I'm Dr.

Ray Christensen, faculty member from the department of family medicine and biiobehavioral health at the University of Minnesota Medical School Duth campus.

I'm also a family physician at the Gateway Family Health Clinic in Moose Lake.

I'm your host for our episode tonight on eye problems, including cataracts, glaucoma, macular degeneration, and other vision concerns.

Remember, the success of this program is very dependent on you, the viewer.

So, please call in your questions or send them in our email address to our email address at pbsnorth.org.

Our panelists this evening include Dr.

Dr.

Cole Swiston, opthalmologist and glaucom glaucoma specialist from Essentia in Duth and Dr.

Todd Britain, a surgical opthalmologist from Ralph Eye Care in Duth.

Our UMD medical student phone volunteers tonight are Nick Whitman from Brainard, Minnesota, Madlin Guler from Pelican Rapids, Minnesota, and Dne Nelson from Glendon, Minnesota.

And now on to tonight's program on eye problems again including cataracts, glaucoma, macular degeneration, other vision concerns.

If you have them, please call in.

Dr.

Britain, welcome back.

Uh, can you tell us a little bit about your practice?

Yeah, so I I work at Ralph Eye Care in Hermantown and we provide comprehensive eye care for all ages.

Um I see patients of all types and treat all um ocular conditions.

My primary focus surgically is on cataract surgery and eyelid surgery.

And Dr.

Swiston, you work over at Essentia.

Uh tell us a little bit about your practice at Essentia.

Sure.

So like Dr.

Dr.

Britain, I I see a lot of comprehensive eye care, but I have a subsp specialty for glaucoma care, both medical and surgical management and then a little bit of a a niche in uh complex eye surgery as well.

Um, so I've been at Essentia for a year and a half kind of building that practice up.

Um, and it's been going good so far.

As a start, do you want to talk to us a little bit about glaucoma, what it is?

Sure.

Um, so glaucoma can sound quite scary and complex, but it boils down to uh just nerve damage.

And uh the nerve that gets damaged is the big one that comes off the back of the eye, the optic nerve.

And what generally drives that damage is high eye pressure, which can be caused by a number of different things, but as the nerve gets damaged, you usually lose your peripheral vision.

So from the outside in.

And that's what's scary about it is that you really don't know that your pressure is high.

and you don't know that you're losing peripheral vision because it's not part of the vision we use dayto-day.

So, it's something that needs to be screened for and detected by an eye doctor.

Um, and we can't reverse the nerve damage once it's happened.

We can only slow it down or stop it.

And we do so by lowering eye pressure, which we can do with eye drops, lasers, and surgery, or a combination of those.

Um, and that's my my bread and butter and what I see every day.

I'm I'm sure there's a a lot of variations and levels in this.

Todd, I'm sure you're taking care of a lot of glaucoma also.

So, you're more of a general opthalmologist.

Is that a fair discussion point?

That's correct.

So, when you when what for glaucoma, what kind of things do you do?

Yeah, for glaucoma, um I provide um uh laser surgery.

Um we're often doing laser surgery as first line uh treatment now for lowering the pressure in certain types of glaucoma you know primarily on open angle uh glaucoma um I do a lot of uh combined surgery with cataract surgery to lower the pressure um you know and also you know medical management you know with drops what's the difference between open angle and closed angle yeah it has to has to do with the um the the drain within the eye.

Um, in some patients the the drain isn't as functional as it should be, but it is fully open and that's what we call open angle uh glaucoma.

Um the eye is constantly producing fluid and if that fluid can't uh leave the eye um the pressure increases within the eye and that is uh in contrast to um narrow angle uh glaucoma where um the actual drain is narrower than it should be and that's what's preventing the the fluid from leaving the eye and the the two are treated in in different ways.

So Cole, this this kind of brings us to where you are.

We we've got the basics on this.

Where do you step in with the specialty the glaucoma specialty part?

What uh tell tell us a little bit more.

Sure.

Yeah.

I I I mean glaucoma is so common throughout the US that uh it can't be managed strictly by glaucoma specialists.

There's a horde of optometrists, general opthalmologists who do a wonderful job taking care of it.

Uh but there are points where uh the laser is not covering it or the drops aren't covering it.

Uh and then you kind of need to increase that care.

Um so patients are referred to me when their glaucoma is you know progressing or getting worse despite the best efforts um of those caring for it.

And that's when I step in usually with uh likely a surgery and there's a realm of glaucoma surgeries out there from minimally invasive which Dr.

written talked about and combines with cataract surgery.

So, we do quite a bit of that, but then there's some more invasive and therefore more effective glaucoma surgeries as well.

Um, from tube shunts and bypass procedures and strong lasers.

There's there's quite a few different options and this is one of those fields that's expanding almost faster than we can keep up with it.

Um, and so it's always helpful to to to meet and form a relationship with that doc that's going to be doing the surgery because you you may very well not just need that one.

You may need subsequent because it's a unfortunately a lifelong disease and it's incurable.

It's just something that we can manage and treat.

What age do we and either of you can answer this what age do you start when does it begin?

Is it a does it start in childhood or in young adolescence or is it an older person's kind of problem?

I I wish it was that simple because you you can come out of the womb and have congenital glaucoma and be born with it and you can develop it as a juvenile and you can develop it as an adult, but by far the most common risk factor is is age as well as family history and then just high eye pressure.

So in general, you're going to see more of it in the fifth, sixth, seventh decades of life for sure.

Switching gears kind of Todd, what is Shoggrren's disease with the eye?

Yeah, Shogun's disease is an autoimmune condition.

Um, I p primarily see patients with Shoggrren's disease who are having problems with dry eyes.

That's when they are typically referred to me.

um can affect other um parts of the body um including the salivary uh glands.

So in addition to dry eyes uh shoggens patients also have dry mouth.

Um where my care usually takes place is in treating the dry eyes.

Um with shogrinss we'll start with uh lubricating drops um warm compresses over the eyelids and anti-inflammatory medications.

There are a a couple that are out on the market that can be effective.

I think we probably need to move to cataracts.

Um Cole, what are cataracts?

Yeah, it's uh it's common.

We all we all die, we all pay taxes, and we all get cataracts, unfortunately.

So, within the center of the eye, you have an Eminemshaped lens, and when you are born, that is crystal clear, and that gives you a lot of the focusing power of the eye.

But uh in everyone as we age, it just gets cloudy over time and that dulls out the vision, makes it harder to see detail and color and then can give you a lot of glare at night with night driving.

Um and it can be accelerated in its development by a few different things.

Diabetes, smoking, trauma, a lot of UV exposure, steroid medications.

Uh, and when it gets to the point where that vision just isn't good enough, that's usually the time when you'll get referred to a a surgical opthalmologist for management and cataract.

So, there's this question sitting here, how do you know when it's time and either one of you take that one?

Yeah, it's it can be tough sometimes.

Um, because it does sneak up on people so slowly.

Um, I think probably one of the number one symptoms that people notice is glare.

And we always ask about glare with night driving.

Um, you know, especially in this part of the country, it's impossible to not drive in the dark during the winter months.

Um, so patients will notice that oncoming headlights are more bothersome.

Uh, for those of us who try to avoid driving at night, um, you you may not notice that.

Um, so what you may notice more is that you need more light in the house in order to see well.

um you might find that you're switching out light bulbs, you know, trying to get the brighter lights to see better.

And then what we see um on our exams, uh we'll we'll start to see a shift in the glasses prescription.

Um oddly enough, a lot of patients will become more nearsighted, you know, as the cataracts progress.

So, we'll see that shift in their prescription and eventually there will come a time where we can't correct the vision with the glasses and people are bothered by it.

And that's how we decide, you know, when it's time for cataract surgery.

Most patients, they have an idea, you know, especially when you reach that age range and you're having breakfast with your friends and they tell you all of their symptoms and they tell you that they just had cataract surgery.

It's the way to get the yellow out.

Exactly.

Works pretty well.

I think it is one of those things that people tend to put off, right?

It's like you didn't realize how bad it was and then you probably hear all the time like I I can't believe how well I see after I got it taken care of.

Definitely.

Yeah.

I think the classic thing is we we do um we do cataract surgery on one eye at a time.

And so we always hear from patients, you know, between the the first surgery and the second surgery, wow, you know, my my eye that you operated on, it's it's bright white and my other eye is yellow.

You know, because they're doing the you know, we call it the oneeyed salute where they're covering one eye, covering the other eye, and they notice that difference.

Yeah.

Or I can see all the dirt in my house now.

So, one of you tell me a little bit how how does a cataract surgery work?

I've been through it.

Uh there there's there aren't any stitches.

It was very really quite simple and straightforward.

Um tell tell how does what do you do?

Yeah.

So, modern cataract surgery is is pretty slick.

Um I I don't like to call it easy because I feel like patients get the the sense that there can never be anything that goes wrong.

But as far as a surgery, it is very routine, very straightforward.

Uh generally you come into the surgery center and get just a little bit of sedation.

So your the edge is taken off and a micro incision like a 2 millimeter incision is made in the eye and then that cloudy lens is suctioned out with a special machine and then replaced with an artificial clear lens that lasts the rest of your life.

And if you're going to remember anything from that process, it's just going to be some really bright and what's often described as psychedelic lights.

Uh, and then the recovery is generally very quick, too.

You your vision comes back in the first few days.

Your eye is just a little bit scratchy, and you use some drops generally to help the eye heal.

But as far as surgery goes, I have patients who come in who have gone through heart procedures, joint procedures, and then it's it's just like a walk in the park compared to those.

It is.

That's true.

We kind of touched on autoimmune earlier.

I think Todd it was you that had done that.

There is a question here.

How dangerous is an autoimmune condition on the eye?

We touched on shoggrrens a little bit.

Sure.

Yeah, that's um yeah, it can really depend on the on the condition.

Um, I think primarily with autoimmune conditions, what we worry about is inflammation within the eye.

Just as you can have inflammation elsewhere in the body with an autoimmune condition, um, we generally classify inflammation within the eye as uvitis.

And inflammation within the eye can can affect all all different layers of the eye from the most anterior portion of the eye all the way back to the posterior portion of the eye.

Um our our job as um as opthalmologists is to um treat the eye and also you know think about um the patient's overall health and make sure that um we're doing the right things to to further look into the cause you know of the inflammation.

Um, and that can include things like sending a patient for blood work, um, sending a patient for um, imaging, MRIs, uh, CTS, um, and just working through the condition in order to to treat it um, as best we can.

As a family physician, I've always appreciated having you guys around when it comes to taking care of uvitis and some of those.

Then there's others, too.

Cole, are there any upcoming breakthroughs in macular degeneration treatments?

So, I think maybe tell us what macular degeneration.

We probably should start there.

Sure.

So, you hear it all the time and you probably see ads on TV.

The the macula when we're talking about macular degeneration is the part of the retina in the back of the eye is that's your centermost vision.

So, the macula is responsible for that, you know, re reading a book type vision.

And uh it's just just what it describes.

It slowly degenerates.

You have these junk products that build up in the macula.

And uh it's classified into these two broad categories.

So there's dry macular degeneration and then there's wet macular degeneration.

So traditionally dry macular degeneration we haven't really had good treatments for.

There's been a formulation of vitamins that's pretty extensively studied that is called a-s vitamins and those are usually recommended to just slow down the progression but it can never be reversed.

Now admittedly I'm not a retinal specialist but I know that um the latest kind of holy grail is to try to find some sort of injection or medication that can be put in the eye to reverse that dry macular degeneration.

And I believe there is one on the market now uh that reverses some of the atrophy associated with it.

Um and I I don't administer that medication, but I know that's something that's coming down the pipeline within the world of wet macular degeneration.

Um fortunately or unfortunately, there is a treatment for it, but that treatment is injections in the eye and usually doesn't reverse the the swelling or the or the wet part of that degeneration, but does keep it at bay.

And I think there's always kind of new medications coming down.

Um whether or not any of those work better than the other, I think kind of remains to be seen.

Todd, can medications like Lysinopril cause eye pain?

And I'm pulling my mind.

I don't think so.

Personally, for my for my family medicine aspect, no, I I don't know of any side effects from Lysin Pro.

Another one that another question that's kind of recurring through here too is are are there are there medications I'll stay with you Todd on this one.

Are there medications that that we should be taking to protect our eyes?

And I think you started out a little bit with the dry eyes and probably some drops but uh are there's vitamins and all these things that are on television.

Any guidance?

Yeah, I think um or either one of you.

help.

Yeah.

One one that I'll commonly recommend for um for patients who have a strong family history of macular degeneration who may not want to take the the aids vitamins which are designed for patients who actually have macular degeneration.

Uh would be luteine and zeazanthine.

Uh these are craftenoids.

Um they've been shown to increase the layers within the macula that are affected by macular degeneration.

um these uh you know these nutrients are they're they're showing up more and more in multivitamins.

So if you take a multivitamin you may already be taking it.

Um you can also increase the foods that you eat that contain luteine and zeazanthine.

Um these foods, you know, think of anything that's orange, including eggs.

You know, egg yolks actually have a lot of luteine and zeazanthine in them.

Um, in general though, I think, you know, if you can do things that are good for the heart and good for the brain, then it's going to be good for the eyes, you know, because there's a lot of crossover there.

The question that comes up is the Mediterranean diet also and carrots.

So, when I was a little kid, way back on the farm, carrots were good for your eyes.

Is that still the That's what you're saying, basically.

Yeah.

Um, one of the other ones that had come up in the questioning was Ocuite.

Uh, is that helpful?

I I believe Ocuite is just a a brand name or a different type of this A-Reds vitamin which contains the lutein zeizanthine that's recommended for macular degeneration.

In the world of glaucoma, there's been some data now to show that a a cousin of niacin called nicotinomide um is helpful in kind of preserving nerve function.

So I recommend it universally for my patients with really advanced glaucoma just to get what we can out of that remaining nerve.

But if I was diagnosed with early glaucoma, I'd be taking 3,000 milligrams of nicotinomide every day for sure.

Interesting.

Uh, the other one that comes up with new things is, and I think we touched on dry eyes before, is there anything new?

And this person's from the Hibbing area like glasses, but then there's this other one that there's another something else that's being advertised with the little thing by the eye.

Uh, is there another drug uh, a drop that you can use, MIE or something on Mayo?

Mayo.

Yeah.

Yeah.

So mayo is um an oilier drop that you can use.

So um to kind of think about how these medications work, you have to think about why our eyes are dry.

Um so our eyes are dry mainly because of two reasons.

Um either you're not making the tears like you should or the tears evaporate really quickly.

Um one reason why your tears can evaporate really quickly is you don't have a really good oil layer uh within your tear film.

And so Mayabbo is designed to target that.

Um so it's an oilier drop, stays on the eye longer.

Um I've I've had good success with it.

Um ask you that.

I haven't actually described it.

I was curious.

Yeah, it works.

It works quite well.

Um I'll use it for a lot of patients.

Um you know, who where I really think their tears are evaporating quickly.

It's worked well for some of my patients with Parkinson's uh disease because uh Parkinson's patients, they don't they don't blink as much as they should.

Um and so their their eyes are more prone to drying out because the tears evaporate.

So the Maybos worked really well for me with that.

Um another treatment that's been successful for us is um radio frequency um to the eyelids.

Um it's a treatment it's called forma.

Um and so this also targets the oil glands within the eyelids, opens them up more.

Um usually patients require about three treatments and um it's it's been quite effective.

So is Maybo pricey?

It is.

Yeah, it can be depending on insurance coverage.

Cole, does a family history of age does a how does a family history age and Graves disease influence glaucoma?

Is there anything on the risk?

I don't know of anything on that one.

So I guess to to understand the question are those three related are are Graves disease and age related to glaucoma or do I was interpreting as does age affect and we know that affects glaucoma right does Graves disease um generally no um so Graves disease just as an introduction is u a disease of the thyroid and for whatever reason the antibodies in that case that uh attack the thyroid end up attacking the tissue around in the eye and the eye can bulge out and swell.

So rarely if there was enough bulging it could press on the nerve and cause damage just as glaucoma would but not generally.

Todd a person asking uh shed some light on a branched retinal vein occlusion.

I'm not familiar with that one.

Sure.

Yeah.

So a branch retinal vein occlusion is an occlusion of um a small vein uh within the retina.

Um the the reason it often occurs is the um the retinal veins and arteries cross and they cross within um a sheath that co coats both of them and the um the artery often presses on the vein and pinches it off.

Um, so you can think of the vein as being like a garden hose, you know, and it has blood traveling through it and that blood can no longer travel through the vein, so it spills out into the retina causing swelling.

Um, is sometimes treated with injections uh to get that swelling to go away.

And then we try to manage the underlying risk factors which tend to be high blood pressure um diabetes obesity.

Um but with with good treatment um the prognosis tends to be tends to be good.

There's a question of too much success.

This person has had cataract surgery and gets too much light.

I I've not heard that before.

Yeah.

I I I tend to hear sometimes at least in the early period that uh folks are a little bit light sensitive.

Now I' I've generally found over time that that fades away.

I don't know if you have different experience with that.

Yeah, I do find that it gets better.

I think some of it is just that that change from having a cataract to now having a lens that's completely clear, right?

Um but it it does tend to get better.

Um, eye scratch is couple three days not getting better.

Suggestions go get seen.

Yeah.

Um, this person was thinking about milk and lavender oil and so on.

I think it that's not where I would go with it.

I think that person needs to have a look at the eye.

Yeah.

Tough to know if it actually is a scratch, right?

It could be could be a number of things and you don't want to treat it with the wrong thing.

uh stints in the eye because of eye pressure and pressure gets too low afterwards.

Can that happen with glaucoma?

Yeah, it's it's it's rare um after some of these minimally invasive stints to have too low of pressure.

Um it's also rare but a little bit more common after a bigger glaucoma surgery.

Uh can be kind of indicative of something else going on in the eye as well.

Um generally low pressure is fixable.

Uh whatever ideology that is possibility of dry eyes and not able to use drops because of arthritis.

I don't know anything about that one personally.

So I assume they're looking for alternatives to drops.

Yeah.

Um so warm compress, you know, is helpful.

You again applying heat to the eyelids to treat the dryness.

I usually recommend um 10 minutes once or twice a day.

And then there's actually an an artificial tier spray uh which I've used for some patients where um it's it's an interesting product.

They spray uh the lubricating medication onto their closed eyelids.

So that can be you know easier for patients with arthritis.

Time is running away from us.

Gentlemen, this has been a really great discussion.

I've I've enjoyed the the back and forth and uh there's been a lot of information passed.

I hope that the public enjoyed it.

I want to thank our panelists, Dr.

Todd Britain and Dr.

Cole Swiston.

Please join Doctors on Call next week where Dr.

Christa Quite and a panel discussion will occur on cancer including prevention, diagnosing sta staging, grading, and treatment with panels from around the region.

And if you're looking for more tips, tricks, and cons conversation about health and wellness in the Northland, make sure to check it out on Northland Balance on PBS North YouTube channel.

Thank you so much for watching and joining us for season 44.

All right, on Doctors on Call.

Good night.