News and Stories
InSight, the Coastal Eye Specialists newsletter, is mailed to our active patients free of charge approximately three times a year. InSight contains educational information about eye health, as well as news about eye care and our office. If you wish to be added to or removed from the InSight mailing list, please call (805) 983-0700, or e-mail us.
Cataract Surgery Reduces Auto Crashes, Saves Lives
Close Monitoring of Peripheral Vision
Coastal Eye Scores High in National Satisfaction Survey
Dr. Marquez Leads Tri-County Optometrists
Dr. Wan Again Named One of the ‘Best Doctors in America’
Get Your Eyes Screened at Age 40
A Hazard of the Elements
Multifocal Contacts a Good Option for Some, not All, Patients
New Approaches to Treating Glaucoma
‘Now My Eyesight is Unbelievable’
Recycling Old Glasses
Technology Offers Spectacular 3-D Views of Inner Eye
Close Monitoring of Peripheral Vision Is Important for Glaucoma Patients
You might call it the eye test that patients love to hate.
Frustrating though it may be for patients to take, the visual field (“peripheral vision”) test continues to prove its value in diagnosing and monitoring eye disease. And now, researchers have confirmed the value of close and frequent monitoring of the visual field in glaucoma patients.
Investigators at UCLA’s Jules Stein Eye Institute found that increasing the frequency of visual field testing leads to the earlier detection of progression (worsening) of glaucoma. The study was published recently in the journal, Archives of Ophthalmology.
Glaucoma, often called “the sneak thief of sight,” is an insidious eye disease that can damage the optic nerve and lead to vision loss and even blindness. The eye pressure is often, but not always, high in glaucoma. One of the hallmarks of glaucoma in its mid to late stages is a gradual diminishing of peripheral vision — defects in side vision. These are often unnoticed by patients until it is almost too late.
Why the Visual Field Test is Invaluable
Visual field testing evaluates the patient’s peripheral vision while looking straight ahead. The detection of defects can confirm the presence of glaucoma, and worsening of the defects over time indicates that the glaucoma is getting worse, prompting doctors to adjust the treatment plan.
Patients taking the test are instructed to push a button whenever they detect spots of light around the periphery of their vision.
When doctors are administering the test, they are looking for vision thresholds. Each point in the peripheral vision has a different threshold, which is the level of brightness at which the spot of light is detected. This normally varies with the position in the field of vision, as well as age and other factors. However, normal ranges for the threshold at each point are known. So when a patient can’t see a light at a particular point until it’s much brighter than normal, it suggests there is a problem in the visual system corresponding to that point.
Or if a glaucoma patient, for example, sees the light at a given point at a certain level of brightness, and then a year later doesn’t see the light at that point until it is much brighter, it suggests that the glaucoma has caused further damage to the nerve over that time.
Not So Simple or Easy
The visual field test sounds simple, but it is not necessarily so. The flashes of light vary in location and in brightness and are difficult to keep up with as they appear and disappear rapidly.
Patients generally do not like to take the test, observes Dr. Lee Wan, Coastal Eye Medical Director. “They tend to get frustrated because everybody who takes the test wants to see all the lights. If you don’t see a light, you think you missed something, you failed or did something wrong. We try to reassure patients that’s not the case. You’re not supposed to see all the lights. You’re supposed to see only the ones above the threshold of your vision at each point. Most patients actually do very well taking the test, even though they might feel they’re not doing the job because they’re not seeing all the lights they think they should.”
Because the loss of peripheral vision indicates that the glaucoma has already caused nerve damage, the test is not the ideal tool to detect glaucoma at its earliest stages, says Dr. Wan. “Ideally we would like to be able to catch glaucoma before the peripheral vision starts to go. But once we start to see defects, we know that the glaucoma is really threatening the vision, and we have serious work to do.”
The recent study, Dr. Wan notes, “reminds us that even though patients dislike the test, frequent evaluation of the visual field is a critical part of catching glaucoma before it gets too far. And if patients will just remember they aren’t supposed to see all the lights, and just relax and do their best, the test is not hard. It can even be kind of fun; kids who play video games get it right away.”
Although visual field testing is employed most often for glaucoma, it is also used to detect, confirm or monitor other conditions that affect the visual system, such as strokes, brain tumors, multiple sclerosis, or drug toxicity. All of these can affect the peripheral vision in characteristic ways, making the visual field an important test in diagnosing and monitoring these patients.
One Tool among Several
Dr. Wan points out that visual field testing is but one method available to monitor glaucoma progression today. The visual field test flags changes in visual function. Doctors also diagnose and monitor glaucoma by looking at the eye’s structure, specifically looking at the health of the optic nerve and watching for signs of damage.
Today, doctors have an incredible technological tool known as the OCT, an advanced imaging device that provides spectacular scans of the nerve and other parts of the eye. The latest-generation OCT used at Coastal Eye uses sophisticated eye tracking to provide an incredibly clear image that can be repeated in the exact same spot each time. So any changes — even subtle ones — in the optic nerve can be detected from scan to scan and help doctors plan the treatment strategy for the patient.
Recycling Old Glasses at Coastal Eye for a Great Cause
Did you know that millions of needy men, women and children in developing nations are pushed deeper into poverty every year by vision problems?
The World Health Organization estimates that 153 million people have uncorrected refractive errors (nearsightedness, farsightedness or astigmatism). Most of these impairments are quickly diagnosed and easy to treat with corrective lenses.
A worldwide humanitarian effort by Lions Clubs International — called Lions Recycle for Sight — is helping meet this critical need so that adults can work productively, children can read and seniors can remain independent. The program recycles used glasses donated by people who no longer need them.
Coastal Eye Specialists collects eyeglasses that patients wish to donate, and turns them over to local Lions Clubs representatives, who pick them up
periodically.
From there, the glasses go to a Lions Eyeglass Recycling Center, where volunteers sort and clean them, determine the prescription and package them for distribution worldwide. While the glasses may not exactly match a third world patient’s prescription, the benefit of having glasses even close to their needs can be life-changing.
“It feels really good to know that we can play a role in helping someone in need, not just with their vision problems but with eyewear,” said Coastal Eye optician Lisa Casas.
Coastal Eye Specialists is currently offering a discount on new glasses with a donation of old glasses in wearable condition for recycling.
New Approaches to Treating Glaucoma 
As promising new surgical procedures become available, eye surgeons today are beginning to take a fresh look at the challenge of controlling glaucoma — the insidious eye disease that can damage the optic nerve and lead to vision loss and even blindness.
One such surgical option is canaloplasty, which is being shown safe and effective and can be offered earlier in the disease process than conventional glaucoma surgery. For many patients, it can replace the need for eyedrops and/or laser treatment, the standard early and mid-stage glaucoma treatments. Canaloplasty carries with it less risk than trabeculectomy, the conventional glaucoma surgery that is usually reserved for the advanced stages of the disease.
“This is a new way of looking at glaucoma surgery,” says Dr. Lee Wan, Coastal Eye’s Medical Director. Dr. Wan has begun to offer canaloplasty to selected patients.
‘The Sneak Thief of Sight’
Often called “the sneak thief of sight,” glaucoma is a leading cause of blindness. The most common type of the disease, called primary open-angle glaucoma, has no noticeable signs or symptoms in its beginning or even mid-stages. Early diagnosis and treatment are essential to minimize or prevent optic nerve damage and consequent vision loss.
For reasons that are not completely understood, increased pressure within the eye (intraocular pressure or IOP) is usually associated with the optic nerve damage — and vision loss — of glaucoma. The pressure comes from a buildup of aqueous humor, a fluid naturally produced in the front of the eye to nourish the tissues. The fluid normally exits the eye through a drainage system. When the drainage system does not work properly, the pressure builds up within the eye and is associated with damage to the optic nerve. So in most glaucoma treatment — including eyedrops, laser and glaucoma surgery — the basic objective is to reduce the pressure within the eye by improving drainage of the fluid. Traditional glaucoma surgery, which involves creating a drain either with a tube or a procedure known as a trabeculectomy, bypasses the normal faulty drainage system to keep the IOP down.
How and Why Canaloplasty Works
With canaloplasty, the surgeon stretches open the eye’s natural drainage canal, which runs around the edge of the cornea. This is where the fluid normally seeps out and is absorbed by the body. Doctors believe that in glaucoma, there is some blockage in this system.
The drainage canal is very tiny, around the size of a hair. The surgeon inserts a tiny catheter into the canal to dilate it and stretch it open. The catheter is then removed and a thin suture is placed to keep the canal stretched open.
With the eye’s natural drainage system opened, the pressure inside the eye is usually lowered. Canaloplasty has helped many glaucoma patients reduce their intraocular pressure and dependence on medications.
“We tell patients that this is almost like angioplasty for the heart,” says Dr. Wan. “If you have a blockage in your heart vessel, they catheterize it and put a stent in there to keep it open. That’s what this is, except that we use a tiny suture to keep the canal open after it’s stretched by the catheter. We think this is safer, just as angioplasty is safer than open heart bypass surgery where a new vessel has to be grafted to bypass the blocked vessel.”
When the Procedure Might be Recommended
Eyedrops have been the gold standard in glaucoma treatment for generations. They remain safe and effective for many patients. But eyedrops are not perfect, Dr. Wan points out. Eyedrops are expensive. They can be inconvenient or difficult for patients to use regularly, especially when multiple drops and complex regimens are required. They tend to irritate the eyes. Doctors are not even sure sometimes that the drops are doing their job consistently around the clock. In addition, several studies have found that a significant minority of patients don’t take the drops as prescribed.
“What’s changing now is that we’re starting to think of these newer procedures such as canaloplasty as something we could do in place of eyedrops rather than waiting for someone who has completely failed with all the glaucoma drops,” says Dr. Wan.
Whether an individual patient is a candidate for canaloplasty depends on a number of issues that must be considered, including personal risk factors, stage and progression of the disease including condition of the optic nerve, etc. As with any surgical procedure, benefits must be weighed against risks.
Dr. Wan says some patients with elevated eye pressure show no evidence of damage to the optic nerve and are best treated non-aggressively with one or two drops. They may do fine with that regimen. “So I wouldn’t necessarily recommend surgery to those patients. But for the patient who is showing signs of damage to the optic nerve and is getting worse, we may offer canaloplasty relatively early on in the process rather keeping surgery as a last resort only, as we used to do with the more invasive traditional procedures.”
Outdoor workers and recreation and sports enthusiasts in Ventura County know all too well how bright sunshine, and dry, dusty, windy conditions can irritate the eyes.
These forces of nature are also implicated in the development of a very common eye condition in this area — pterygium.
A pterygium is a non-cancerous overgrowth of the clear, thin tissue that covers over the white part of the eye, called the conjunctiva. Usually, a pterygium by itself is not vision-threatening. But if it grows too large it can create astigmatism, distort the vision and even block the vision if it encroaches too far across on the cornea. A pterygium usually begins in the corner of the eye closest to the nose and grows toward the center of the eye.
Pterygia are twice as likely to occur in men than women. The growths tend to show up more frequently in certain ethnic populations such as Hispanics, Filipinos, and Japanese, but they can and do occur in anyone. People who are outdoors in the sun a lot, such as surfers and farmworkers, are at high risk. Usually, the first symptoms that prompt a visit to the eye doctor are persistently red, irritated, itchy, swollen eyes.
Some cases will respond to treatment with artificial tears, and sometimes the prescription drop Restasis®, to improve the lubrication of the eye. Dry eyes are a major contributor to pterygia. Patients are advised to wear wide-brimmed hats or caps and sunglasses outdoors and to protect their eyes as much as possible from exposure to irritants such as ultraviolet light, wind, smoke or chemicals.
Medical treatment can often alleviate the symptoms from a pterygium, but does not get rid of the growth. if the patient does not respond to medical treatment, and the growth becomes too aggressive and bothersome, surgical removal is a very effective option.
Surgical Removal of Pterygia
Dr. Lee Wan, Medical Director at Coastal Eye, frequently performs surgery to remove pterygia. Done in an outpatient surgery center, the procedure basically involves peeling the growth off the eye. He also has to remove some of the surrounding inflamed tissue and scar that contributes to the growth.
However, with removal alone, there is a high likelihood that the pterygium will grow back. In fact, in his patient population, Dr. Wan estimates the recurrence rate with simple excision approaches 50 percent. That’s because there is nothing there to keep the pterygium from growing back into the same area.
To prevent regrowth of the pterygium, Dr. Wan places a graft over the white of the eye from which the pterygium was removed.
In most cases, this is an autograft, meaning that the graft tissue comes from healthy conjunctiva from underneath the patient’s own eyelid, which is healthy tissue that is normally protected by the eyelid from the elements.
In some cases, the graft is performed using amniotic membrane. This is typically done for patients who perhaps do not have good tissue of their own to harvest, or if there is another medical reason to avoid using an autograft. This amniotic membrane is healthy donor tissue from a placenta — very thin, clear, non-inflammatory, and quick to heal, much like the conjunctiva itself.
Grafts enable the eye to heal faster and reduce the risk of recurrence. In addition, the surgery can be done using a tissue glue rather than sutures to hold the graft in place while it is healing. “The combination of a graft along with tissue glue and sutureless surgery makes the healing much more comfortable and quick. Usually the patient is back to normal activities in a week or so,” says Dr. Wan.
He estimates that the use of grafts and glue reduces the chance of recurrence to about 5 percent. “Some of the pterygia will grow back no matter what, but the majority won’t,” he says, “especially if the patients protect their eyes and don’t keep doing what they were doing before that made the pterygium develop in the first place. Protection from the sun, wind, and dryness is critical.”
Get Your Eyes Screened at Age 40
Early detection is the best medicine. The earlier doctors catch a sign or symptom of eye disease, the more likely it can be treated effectively, and vision preserved.
That’s why the American Academy of Ophthalmology now recommends that adults, even those with no signs or risk factors for eye disease, get a baseline eye disease screening examination around age 40. This is the time when early signs of disease and changes in vision may start to occur. Based on results of the examination, the eye doctor can recommend the appropriate intervals for follow-up exams.
For individuals at any age with symptoms of eye disease or who are at risk for eye problems — such as those with a family history of eye disease, diabetes or high blood pressure — the Academy recommends a visit to the eye doctor to determine how frequently their eyes should be examined. These recommendations do not replace other visits to the eye doctor to treat ongoing disease or injuries, or for vision testing for eyeglasses or contact lenses.
Around age 40, a number of vision-threatening eye diseases can start to appear. “There are some individuals who never see an eye doctor because they feel they have good vision and have no problems with their eyes,” says Dr. Lee Wan, Coastal Eye Medical Director. “Yet they could have a condition like glaucoma, which doesn’t cause any symptoms at all in its early stages. Or they could have diabetes or other medical problems that could show up in the eye, even when the vision is good.”
Age 40 is also the time when presbyopia — the normal, age-related decline in the ability to focus up close — sets in for most people. “One of our concerns is that if someone is getting blurry vision at that age, we can’t simply assume that they just need reading glasses,” says Dr. Wan. “There’s a possibility they have other eye conditions that need attention. So I think this screening recommendation is a good one.”
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