I cut open peoples eyeballs and get paid! AMA!

What does marijuana do to help people with glaucoma?

Great question! Marijuana lowers eye pressure, which is the ONLY treatment we currently have to treat the disease. The problem is that the effect only last 4 hours, so you would have to injest/smoke every 4 hours (even through the night) to have any effect. Its not a recommended treatment at this time, but there are people who do it. We have medications (drops/pills), laser and surgery which are more effective at lowering eye pressure for a longer duration, and so we go that route. There is also the negative effects of smoking that often which you need to consider.

Glaucoma is also a very slowly chaning problem over many years, so it would be hard to maintain that I think.

There is also the negative effects of smoking that often which you need to consider.

But... edibles.

I think there will be a lot more information in the next 5 years on this, now that its going to be legalized in a lot of places.

Marijuana lowers eye pressure, which is the ONLY treatment we currently have to treat the disease.

A few sentences later ...

We have medications (drops/pills), laser and surgery which are more effective at lowering eye pressure

wut?

Sorry, I meant to say, that the only method of treatment that we currently employ in the treatment of glaucoma is to lower eye pressure, we just do it in a bunch of different ways.

How many have you successfully not gouged out to date?

During my residency I did about 2000-3000 ocular procedures and now that I am out on my own I have done about 3000-4000 procedures (1300 cataracts) and none have been gouged out. During residency I did 4 enucleations/eviscerations (removing the eye) for various reasons, but they were not accidental.

This is really eye opening.

Are you going to keep an eye on it?

Clever username btw.

I try.

You must have pupils lining up to see you.

Eye-Eye Captain

Might be too late to catch you but can you outline the process for removing an eyeball for me? Sounds interesting, complex, and kinda dangerous. Can you see the brain while you're removing it?

Its less dramatic then that. First thing I do is a full eye exam to make sure its the correct eye that we are dealing with. Then I mark the eye, then the patient marks the eye. Once they are asleep I will then put on a headset and re-confirm that the correct eye has been identified.

You essentially isolate the muscles, remove them from the globe. Clamp the optic nerve and cut it. Then you use a silicone ball to replace the volume lost from removing the eye ball. This is covered in donor sclera and the muscles are stitched back to this. The outer conjunctiva and tenons are sutured closed and a conformer is put under the lids to maintain that space until a prosthesis can be fit.

Here is a video of an enucleation, there are loads of techniques. http://www.youtube.com/watch?v=dIBh_oCTNvQ (NSFL)

Which vision correction surgery is better: Lasik or PRK?

PRK - No flap created, can be done on thinner corneas. More painful post op, and longer recovery.

LAsik - Faster recovery, negligible pain, thin corneas are a problem.

Depends, I guess. most go with lasik due to the quick recovery.

Have you ever seen a traumatic dislocation of the flap created during Lasik (years post-op)? Is it something else to consider when choosing which procedure to do?

If you are going to do MMA I would probably get PRK. I have heard that fighter pilots need to get PRK as the high G forces can rip the flap off (probably only an ophthalmology tale though).

I haven't seen a flap dislocation many years out, but I know it does happen from time to time.

I can say that it must be REALLY rare to have a dislocation years later. I had Lasik 3 years ago (went from 20/200 in my left eye and 20/80 in my right to 20/13 in both), and have not had a single problem., except for mild night halos if I'm tired. I went through a bad reaction to a roommate's cat about 6 months ago and was constantly rubbing my eyes really hard, without even thinking there might be a problem, and luckily there wasn't.

And thank you for giving people back the gift of sight. When I was in the recovery area after my surgery, I watched a young man walk in to get his surgery (don't know if it was for Lasik or something else). He had a white cane and had his wife and two young children with him. I heard him tell her that he couldn't wait to see her and his kids perfectly for the first time and that if she's a quarter as beautiful as he imagines she is, it will be worth it. A while later he came out, looked at his wife and kids and started crying. He said she was more beautiful than he could have imagined and that their children were the most beautiful children he'd ever seen. The nurse had to quickly teach all of us there how to cry without damaging our eyes post op.

Amazing. Im glad you were helped! Great story.

Just want to say thanks. I coordinate eye donation after death, so we get quite excited when we see any ocular pathology.

No problem! Do you do the harvesting?

No, I just coordinate everything.

Still awesome though.

I am a 25 year old with strabismus. After two failed surgeries as a baby (before 1 year old), my parents were told that there was nothing surgically that could be done to fix my eyes (to restore binocular vision and correct the apparent laziness of the eye that is not "being used" at any given time).

Recently, I've tried to do some research of my own-recognizing that advancements in medicine may have allowed for some procedures that could correct the strabismus. I would love to be able to make eye contact with people confidently without fear that one eye is wandering goofily. I've read some conflicting things, and truly have no idea if it's worth going to see an ophthalmologist to discuss options. And, of course, I don't feel like spending shit tons of money to get a consultation only to be told "sorry Champ, no can do".

So, without offering specific medical advice, do you have any experience with adult strabismus patients? Any advice on whether a consultation may he fruitful? Or any suggestions on whether a consultation should be done with a specialist in strabismus, or any ophthalmologist I can find that might be covered by my insurance?

Thanks!

I can answer this. I have had 7 surgeries throughout my childhood for strabismus. The problem kept recurring. Finally at 31 I went to see an opthalmological surgeon to see what could be done. Sidenote: since 95% of his patients were kids, it was like visiting a pediatrician's office.

There is a type of surgery that is only performed on adults. The surgeon removed the muscles from my eyeballs and reattached them with adjustable sutures. Then immediately after surgery he brought me to his office. I was still groggy from the anesthesia. He pried open my eyelids and I was looking in two different directions. One eye was probably about 20 degees off kilter. It was freaky!

Then he tugged at the sutures on my eyeball. Each time he tugged I felt nauseous. As he cut each suture, my eyeballs started to line up. After each cut, he checked the alignment. It was a bit like aligning the headlights on a car. This step is why they can't do it on kids. A child would not be able to handle it.

Then he bandaged my eyes and sent me home. I was effectively blind for a week. My wife had to do everything for me. Then for the next month I looked like I got into a really bad fight. Both eyes were completely bloodshot. I wore dark sunglasses to avoid scaring passersby.

My eyes have maintained their alignment for ten years. Outwardly no one can tell that I have had strabismus in the past. At the time of surgery I had about a 15 degree deviation, especially when I was tired.

Also if you do not already have stereopsis ("3D" vision or stereo fusion) you will not gain it from this surgery. That part of your brain will not form the necessary connections at your age.

A note on cost: my surgery cost 11K. Since I had already reached my out of pocket max for the year with the birth of my daughter, I paid nothing. The surgery is considered reconstructive, not cosmetic, so your medical insurance should cover it.

Edit: Seek out an opthalmologist who specializes in strabismus surgery. I went to the pediatric eye center at a local university's children's hospital.

Edit 2: Do it! You will gain a renewed confidence. The surgery is worth it.

That's amazing. I've thought about surgery for mine, and while what you describe completely freaks me the fuck out - it sounds like it's worth it. I know my insurance doesn't cover vision therapy or most other surgeries. I guess it's worth checking into again though...

Remember that this is reconstructive surgery like fixing a cleft palate, not "cosmetic" acuity correction surgery such as Lasik. Your insurance should cover it.

The post-surgical adjustment is a bit freaky but you will be so groggy from the anesthesia that it will feel like a dream. Just tough it out, try not to vomit, and arrange to have someone take care of you for a week.

Also called "restorative"

I have read through the comments below and they seem to be spot on. Adult strabismus surgery is possible, you just have to know what you're getting into. definitely go and see an ophthalmologist and if you can see one at a childrens hospital who does strabismus surgery all the time.

Was 'Un Chien Andalou' by Luis Buñuel an influential movie in your life?

[NSFL]

Ill save this for later. I think the hospital IT Dept would likely flag me.

How much watching in monitors a day will affect my eyes?

There are some reports about doing a lot of "near work" can lead to myopia (near sightedness), but besides this I don't think it makes any difference.

I'd like to share from my personal experience. I am 25 years old. My parents always warned me that TVs, GameBoys, etc. might affect my eyes in a negative way. I was and still am a heavy screen user. TVs, Laptops, Smartphones, you name it. To this day my eyesight has not changed. It even got slightly better. I wear glasses at -3.5 on both eyes. And I wear glasses since the age of 4. Well, the last check came out with -3.25 on one eye, which is not a major difference. That's why I said slightly better.

The only thing that I know of is that a lot of near work can lead to nearsightedness. You are -3.5D so you will see great up close. I don't think there are any other problems with screens.

The mods can verify that this guy is an ophthalmologist, and can only assume that he does do the eyeball cutting and that someone pays him.

Done!

I currently don't get paid for my work cutting open people's eyeballs. How would you recommend I go about charging my victi...I mean, patients?

haha nice try dexter.

Seriously though, if you are interested in this kind of stuff you should try to get on the organ harvesting team in your area. you get to fly all over the place and get to learn some cool surgical skills on dead people!

My dad just got cataract surgery. Are there any major risks in having this kind of surgery?

Cataract surgery is both the most common and most successful surgery done in the world. However there are risks to any surgery. I tell all my patients that the biggest thing that I worry about is infection. An infection inside the eye (endophthalmitis) after cataract surgery is basically game over for the eye. That being said, its relatively uncommon (<1 in 1200-2000 cataract surgeries). There are loads of other risks, but they are usually associated with some underlying condition (glaucoma, diabetic retinopathy, etc). I hope he does well!

Hey, thanks for doing this, but I fear it clouded the level of risk more than cleared it. "<1 in 1200-2000"? Was it one or zero?

I wrote it as I would say it I guess. I generally say "Less than 1 in 1200-2000" because its really surgeon specific. As I am new, I don't know my rates of complications, so I quote the general risk. Since I think Im awesome, my risk is probably lower than average..:)

Is there any way one can notice an incoming issue with eyes? For example Glaucoma is caused by too high pressure in the eye, is there a way to notice it, or if there really is an issue, and I notice it by decreased visual performance, is it too late then?

TL;DR: can I notice issues coming, or do I have to get checked on regularly?

Most of the severe eye problems cause blurry vision. If your vision is blurry, and you can't blink it away, I would get an eye exam. The people who do the screening eye exams (for my area its the optometrists), check for all of the other types of eye diseases. Glaucoma is a bit of a problem as it affects the peripheral visual field first, in most cases, and therefore is asymptomatic. The good news is, as long as you don't have a family history of someone having glaucoma at a young age, then you are probably safe. The recommendation for screening eye exams would be every 5 years if you are less than 40.

Hey dude, interesting job!

One question I have is about "floaters"... From what I understand (which isn't much!), floaters are caused by material breaking away from the inside edge of your eye and drifting/hanging around in the fluid inside, causing little black spots to appear in ones vision.

Is there anything that can be done to remove them? Many years ago I was told by a doctor that there are ways, but that they're pretty extreme.

The reason I ask is that about 3 years ago, I just woke up with them in my right eye. They don't really effect me, other than it being harder to focus on things with my right eye. Overall, my vision is pretty strong - I can read this (i.e. font size 10 or so) from about 10-15 feet away without too much trouble, and at for someone in their mid 30's seems quite good - much better than friends, family and colleagues.

The vitreous gel that fills the inside of the eye is made up of collagen. This a stringy material that is found all over our body. As with all collagen, it breaks down with time (wrinkles on the face, etc). The eye is no different. What happens is that you get different densities of the gel inside the eye and when light travels through these areas, on its way to your retina, it gets "disturbed" a bit. I tell people that it casts a tiny shadow on the retina and thats why you see it, although I would expect some physics major to contradict me, but that is easy enough to understand.

That being said, you can have floaters for other reasons too. A bleed in the eye (from diabetic retinopathy or a retinal tear) can cause it. But those are usually hundreds of tiny specs all of a sudden. Autoimmune conditions can cause white blood cells to accumulate in the eye and that can cause floaters too.

Generally we leave floaters alone. The reason being, we don't have a good way to get rid of them. A vitrectomy (surgical removal of the vitreous) is one way, but most people wouldn't do this, due to the fact that there are risks to any surgery. Some people will laser a floater, but it has to be a big one and we usually just break a big one into a bunch of smaller ones. There is an injection Vitrease which is injected into the eye and dissolves the vitreous. this might be an option, but again there are risks and it costs about $4000 I think.

OP please deliver us!

I have floaters present in my right eye, however they don't cause me any grief. They're most aparrent when I look at some venetian blinds. They cause distortion around the parts of the blinds that let the light through. Is there a reason that they're more noticeable there?

yeah floaters are most noticable when looking at a uniform background like a white wall, a snowbank, the sky etc.. Usually just annoying.

What's the texture of the inside of an eyeball like? I imagine it being wet and squishy.

There is a bit of water and a gel which has the consistency of uncooked egg-white.

LASIK or other vision-improving procedures are very expensive, but cataract lens replacement is relatively cheap. Can someone have their lens replaced like they're having cataract surgery instead of using lasers to improve the natural ones they already have?

Yes, its called refractive lens exchange, but if you're doing it for refractive purposes it can cost 3000$/eye. Even though its the same procedure as cataract surgery. Capitalism.

Kerataconus. My sister has it and just had a cornea transplant at 25yrs old. She is recovering and getting her first taste of vision. I couldn't be happier, but want to understand her experiences, both before and after this triumph. What can you tell me about what she has gone / is going through?

Keratoconus is the worst type of astigmatism. Things are totally distorted. A transplant likely would too, but does she wear contact lenses over it? I can't imagine how happy she is. Its really quite rewarding to help people in this way.

How should we take good care of our eyes, to prevent all these scary surgeries and eye problems?

Dont smoke and eat healthy. The same problems that cause heart disease and stroke (cholesterol diabetes high blood pressure) also cause some scarey sudden blindness problems too.

Hello! My roomate/BFF is a scribe. Why are scribes necessary? Do other medical fields have these?

In ophthalmology we generally see a large number of patients in clinic. This would be true for plastics and orthopedics as well. On monday I am seeing the 12 cataract cases Im doing today for a checkup, plus 86 other patients.

A scribe is useful for several reasons, but it basically just comes down to the fact that taking notes is the worst part of the job. It allows you time to talk to the patients without worrying about getting behind. With the introduction of electronic medical records (EMRs) some people can't type fast enough, so a scribe is helpful.

I don't have a scribe, but I do know some who do. They would also write up all your consultation letters too. Saves a ton of time.

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There are several different pay models. Fee for service - payed based on the services you provide. You work more, you get paid more. usually in private practice, and you have overhead (secretary, tech, office lease, equipment etc). Hospital based academic - could be salary. No overhead. Combination of the above. I am in private practice. My practice grossed just shy of 1 million last year, with 1/3 going to overhead (4 employees, rent, equipment etc), 1/3 going to taxes and 1/3 personal drawings (which I pay another % to tax).

I don't know which is better because I never have discussed the $$ with an optometrist. I would think though that Ophthalmology would be better.

I chose ophthalmology because I went to medical school and wanted to do surgery. I never considered optometry. They have a different model I think I am Medicine first - Business second, optoms are generally Business first, medicine second. I think that they have to work hard to make oodles of money as you say, often on evenings and weekends. They also have to "build" a practice of patients, which can take years.

I got lasek surgery when I was 21, and had an issue with dry eyes since then. The place I got it done from kept saying "it'll get better with time" until they were no longer obligated under the contract to do anything about it. Ive seen two eye doctors since then who have done tear tests and have said "its normal you probably always had dry eyes" to which I replied... no... no I didnt, I never had to use eye drops 3 times a day before a giant laser was shined into them.

Any advice? Waking up with burning eyes every morning for 10 years can make you cranky.

Dry eyes are a major problem. Firstly its a constant annoyance, and secondly its not life threatening so most MD's don't take the time to deal with it. When you have lasik the nerves to the cornea are cut and those nerves are responsible, partly, for telling your body when to "wet" your eyes. They generally grow back, but sometimes they don't. This leads to a situation where your body thinks your eyes are wet when they are not.

Dry eye can be treated (not cured) several ways. 1) Drops (starting with thin drops, then thicker gel drops, preservative free drops if you are using them more than 6 times a day) 2) Blocking the lower +/- upper tear duct with a plug. You aren't producing enough tears, so your normal tear drainage system is working against you. 3) environmental changes (humidifier, sunglasses with a foam rim [panoptix or bobster motorcycle glasses]) 4) Restasis or other anti-inflammatory drops 5) Boston PROSE lens for severe dry eyes.

Hi! I'm a med student. What would you say made you want to practice ophthalmology? What can one do to get matched to Ophtho?

I did a cow eye dissection in grade 12 which peaked my interest. Aside from the material, I like the fact that I do both office and OR (and I could do more or one of either depending on the stage of my life). I can work in a small town or in a big city. I can be hospital based or private practice. No one generally dies. And the majority of my patients are really happy and thankful. This is important I think. one of my friends fathers was a psychiatrist and he told her not to do psychiatry because patients never thank you for what you do. not something you necessarily think about, but could wear you down.

I matched to ophtho by doing a research project and by being keen (but not too keen).

What happens if you sneeze?

And you have your eyes open?

Blind. dont do it.

Do you do LASIK? I just had it done and have a few questions.

I don't currently do lasik,(Just too busy) but I have done and been involved with it in the past.

Would you say that eyes have the least room for error for surgery or am I underestimating how robust they are. Do eye balls pop like a water balloon due to internal pressure?

Did you do a dissection on a cows eyeball at school ? Would you recommend teachers do anything specific that could relate to wider lessons eye health and eye surgery?

I tell my colleagues that most of the time (99% of the time) thing go really really well with eye surgery, but the times that it doesn't go well, things are REALLY bad. A death on the table is the worst thing to happen in a lot of surgery, no one gnerally dies in ophthalmology (except of old age) but blinding someone is a terrible feeling. And it leaves this person with an lifelong disabilty.

I first got interested in eyes in Grade 12 when we dissected the cows eye. I was amazed the pupil was a hole, and not a black piece of tissue.

Edited - People die in all fields of medicine. It is very uncommon in ophthalmology, however I do diagnose patients with cancer, life threatening vasculities and other autoimmune diseases. I was being flippant I guess.

Anesthesiologist here. Someone in my group had a patient die after a misadventure with a retrobulbar block. Although rare I think it's disingenuous to say that patients don't die in ophthalmology.

True, I should say they don't generally die.

What made you interested in this subject? Also, what was the most exciting or weird thing that happened while doing this?

I did a cows eye dissection in grade 12, that started the whole interest.

I have some crazy stories related to eyeballs. A common one is people placing superglue bottles in a cabinet where they also keep their artificial tears. This happens WAY more often then you would think. I have seen frying pans rupture globes, police vs convict eye gouging and many more. Im trying to be vague as possible and yet answer your question!

I hesitate to ask but what happens if someone gets superglue in their eye?

Well they freak out, and then their eye gets glued shut. Generally I can peel enough away, but usually you lose some of the epithelial layer of the cornea. The eye feels like a sandy beach for 3-4 days. The lashes generally get pulled too.

I just got a vitrectomy (sp?) done about 2 weeks ago. How long does it take the gas bubble to go away in my eye? Also about how long until my sight gets good enough to give me 3d vision again?

The gas bubble usually last 6 weeks. Don't fly in a plane. Seriously, I have seen 2 people who have tried, not happy campers. I would say it depends on what you had the vitrectomy for. If it was for a retinal detachment it can take up to 1 year to fully heal.

What is your opinion of LASEK (not LASIK)?

I have pretty strong astigmatism, no problem with reading things close up, and treasure my night vision. I'd love to be able to ditch my glasses and contacts but don't wish to end up trading that for a new set of issues (like far-sightedness and decreased night vision etc)

LASEK is basically a slight change in PRK. Its LASIK with a very thin flap. Should be fine. There are always trade-offs. If you are 40+ you will need reading glasses for near work most likely. Less than 40 you should be fine. The night vision is less of a problem in 2014 due to the wider ablation zone and wavefront analysis.

Thanks!

If I don't want what seems to be an inevitable conclusion (eg reading glasses), I guess sticking with my eye glasses (and contacts) is the best solution then?

It seems to be more and more common when I am going out for lunch with colleagues that I discover many cannot read the menu without special eyeglasses or doing some major squinting. While these guys are older than me, I don't consider them old.

unfortunately it happens to everyone.

Is there a way to guarantee 20/20 vision for the rest of my life? By eating certain foods maybe?

I think generally being healthy, making smart choices will give you the best chance. Unfortunately you are kind of stuck with the genetics you currently have. Some people have bad genes, and no matter what they do they will get some sort of problem. This is true for all body parts.

Does LASIK need revision over time?

The curvature of the eye can change over time and so yes, lasik can need to be done again or revised.

Is 25 too late to want to pursue becoming a doctor/surgeon? What advice would you give to an aspiring med student?

Not at all.

Two pieces of advice:

1) Get good grades

2) Don't get bad grades

There are all kinds of forums out there for aspiring medical school students (http://www.studentdoctor.net/)

I'm not OP, but I know of what I speak.

I got a few bad marks at 18 right out of high school, but that does not at all reflect my abilities or who I am academically. Shall I retake those courses? Surely those responsible for acceptance into med school realize that who I was nearly ten years ago is different than who I am today.. right? I was one of those "rushed into college" "undecided" types.. now I work in the OR at a hospital in my city and I want nothing more than to achieve my full potential. Baby steps I suppose..

Some schools only look at your last 2 years, or your best 3 years. Just look around. Also some people will do a masters degree and then the undergrad kind of gets washed.

The oldest guy in my med class was 37 when he started. He was a military guy who decided to do med school. He was great! I think its very possible. The main problems would be $$$ - how much is it going to cost you, and how many years will you be able to work to pay it off?

Medicine is very rewarding , but also gut wrenching sometimes. There are lots of ups and downs. I would say go for it if you thats what you want to do.

25 is not too young at all. Average age of my medschool class on admission was 26

I am myopic. -8.0 and -8.5
I have motes that really bug me, especially in my left eye.
One in particular is usually in the center and hampers my vision.
Is there anything that can be done to fix this?

Also:
- Map-dot-fingerprint Dystrophy
- Lattice Degeneration (no detachment as yet)

Floaters? Very common with myopia. Not much to do about them really. Just keep watching for a shower of new floaters, might mean you have a retinal tear.

MDFD - Not a problem unless you get erosions, then its painful. Lattice - a high number of people with myopia have lattice. If you develop a tear, you should have all the areas of lattice lasered.

What is your opinion on the ReLex eye(or smile) surgery as an alternative to LASIK? I suffer from chronic dry eye and this seems promising although last I heard it wasn't approved by the FDA as of yet.

I don't know much about it, but it sounds like a fine tuning of LASIK.

What are the dangers of leaving your contact lenses in for an extended period of time? Weeks... Months...

Corneal ulcers would be the thing I worry about the most. Development of corneal pannus too, but infections can be blinding. Don't sleep with contact lenses, even if your optometrist says its ok.

I currently have a buckle on my eye from having retina re-attachment surgery. If it wasn't for people like you i would be blind in my right eye. THANK YOU for what you do!

Thanks for posting! I am glad that the technology is available for us to help. I think sometimes I would be pretty useless if I didn't have medicated drops, and an OR to use (ie zombie apocalypse)

Thank you so much for this AMA!

Is it normal for a child with accomodative esotropia, which is successfully being treated with glasses, to temporarily relapse when sick or very tired? I've been repeatedly told this is very normal by our ophthalmologist but it's so unnerving and we're terrified of her developing amblyopia.

Thanks!

Yes! As long as the glasses keep the eye straight most of the time the visual system should develop normally, and the need for glasses generally wears off with age. When you are sick all kinds of things get messed up. You might notice that with the glasses off that the eye seems to turn more than it did before and thats normal too.

What is your favorite position to have sex in.

All of them.

How do you feel about ophthalmic sprays and nebulizers? It is my understanding eye drops are a pretty poor way to apply drugs or artificial tears to eyes, so I'm pretty interested in tech like this and what it could do for the ophthalmic market.

I think that this would be fantastic. A drop is about 30-50ul and the fornix is only 14ul I think, so a lot is waster. A spray or nebulizer would deliver the same volume of medication but waste less. The second problem with bottles is that most of my patients are older, and its hard for them to squeeze the bottle, let alone get it in the eye. I think this type of technology would be beneficial for that too.

How to know if I have strabismus or not ?

I feel like I have, people around may say I don't.

Strabismus can be detected by someone who is trained to measure ocular alignment (orthoptists, optometrist, ophthalmologist). If you have intermittant strabismus you might have double vision. Why do you think you have strabismus? You can try to take a picture of yourself with the flash on, look right into the flash, you will get a reflection on your cornea in the picture. If the location of that reflection is on the same spot of the eye in both eyes, they your eyes are straight. This is only accurate to about 10 degrees or more of misalignment.

http://www.mrcophth.com/mock/mock21/strabismus.jpg (left eye is turning out a bit). Just a googled image. Not a patient of mine.

How much eye juice has squirted onto you?

haha, daily. Liters and liters.

Who was the most famous person you operated on?

Im not in california! I am the new guy in my town so I tend to get all the young patients and local politicians etc. They assume I have "all the answers".

Can you explain macula degeneration and how it's treated. My grandmother is currently losing her vision to it and I don't entirely understand what's happening.

The way I describe this to people is to say that the macula is a very metabolically active area. It needs a lot of energy to do what it does, so in turn it produces a lot of waste products. Normally your body just flushes this away into the blood stream, but in everyone this ability decreases with time. Accumulation of these waste products forms little yellow specs, which we can see, called drusen. Everyone by the age of 90 will have some. A few of these are fine, but if you have too many of these they irritate and damage the retina. This damage causes gradual vision loss in the center of sight. The peripheral vision is not affected. This is called dry macular degeneration. Currently we only have anti-oxidant vitamins to use to help slow the progression.

About 10% of the time your body will recognize this problem and try to fix it by growing new blood vessels. Although good intentioned, it actually causes more problems. The vessels are shitty and grow right in the line of sight. So they bleed and scar and cause a rapid loss of vision. we curently use anti-vegf medication injected into the eye on a monthly basis to treat this. it works very well, but often requires ongoing treatment.

Why does this only affect the fovea and not the periphery? Also what does this have to do with the macula lutea other than both being yellow?

The metabolic demands are greatest in the macula. The macula is just a location, its like saying armpit or something like that. Describes the area between the vascular arcades temporal to the optic nerve head.

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Interesting question. Seems silly, but protecting your eyes in situations where there is the possibility of rupture seems like a good one. Squash balls are perfectly sized to destroy an eye, and I rarely see people wearing protective glasses. I saw a guy who had a tire blow up in his face and he had tiny bits of rubber embedded in his face and eyes, except for a clear patch on his forehead in the shape of safety glasses. They were on his head! Oh well, I know they fog up and are annoying, but they work. If I think of anything else Ill post it.

Don't smoke - bad bad bad for macular degeneration. HAHA. Who doesnt know that smoking is bad your you??

How did you get into your profession? Namely, did you always have a passion for the eye?

I did a dissection of a cow eye in grade 12. Then I did a neuroscience BSc in a vision lab. I pursued ophthalmology from day 1 in medical school. Thats how I guess.

Two days ago, i have been diagnosed with blepharospasm, despite my young age of only 18 years. Have you ever dealt with someone with blepharospasm? If yes, have you injected botox in his or her eyelid-muscles or do you use other ways to "cure" the disease? What do you recommend me to do to prevent further spasms?

yes, I have treated blepharospasm with botox. Sometimes I will arrange for an MRI to be done to make sure that there is nothing irritating the nerves to cause the spasm. I would say that botox is a safe way to treat it, and quite effective. Besides the cost, there really a big downside. Cutting nerves would just cause more problems. Reduce your caffeine intake if that hasn't already been suggested.

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Good question. I think that if you have some light sensitivity they might help, but I don't think that there is any real basis for their use.

Would you recommend laser surgery for presbyopia?

There are some new advances in the treatment of presbyopia, but there are still limitations. I don't think the technology is quite there yet. I personally would want something tried and true before I did it. :)

Mono vision is one way to get around this. Laser one eye for near, and one for far. You lose a bit of depth perception but not much.

Personally I will use reading glasses as long as I can.

Watery eyes. Help me. Only thing I can say that it occurs when I focus on something for too long or a single short sharp main caused to me. It's been like this for years. Sleep deprivation is out, as I've been in good sleeping cycles.

Watery eye can be for a few different reasons. The usual cause is actually dry eyes. Seems counter intuitive, but what happens is that they basal tear secretion is reduced for what ever reason (usually contact lens use) and then the eye dries out. This triggers the lacrimal gland to secrete a large amount of tears, which overwhelms the normal drainage of the eye.

The other possibility is that the tear duct is blocked. Irrigation of the tear duct can easily sort this out. A third option is that there is an irregularity of the lid which causes the tears to spill out rather than go to the nose.

What do you think about the future of treatment (surgical or non) for people with strabismus? Would the use of stem cells be a viable option?

I've had a pretty severe case more or less since birth and my last surgery was over 10 years ago. My understanding is that after a certain age or period of time with the condition, the brain becomes used to it and treatment becomes a dead-end.

Great question. The biggest problem with strabismus is that its not a muscle problem. The problem is further back in the brain and has to do with the control mechanisms that keep the eyes aligned. Imagine riding a horse english style (one rope in each hand). Now imagine that one hand is pulling harder on one rein than the other, the horses head would turn, correct? Ok, now as someone who is asked to fix it, you can't do anything about the rider, you can only change the position of the hands on the ropes, so you either tighten the reins on the other side, or let off some slack on the side that is being pulled harder. The second thing is that the visual system is not fully developed when you are born, in fact it needs visual input to know how to grow properly.

If the eyes are misaligned from an early age, then the control center in the brain that deals with eye alignment doesn't develop. This means that we can adjust the muscles as much as we like, but there is no stimulus to keep them aligned and they will usually drift.

Stem cells seem to be the answer for everything. I don't know of anything at the moment, but they would have to be directed at the brain (rather than the muscles) and there would have to be a period of training where you brain learns to put two images together into one and keep the eyes aligned.

That being said, I will do strabismus sugery on adults for 'restorative' reasons. I just tell them that I dont know how long it will last.

Thanks for the response. When you say "restorative reasons," what does that entail? I'm assuming that you phrase it that way because ocular surgery won't attack the root issue, but will tighten or loosen the respective lateral muscles.

As someone with amblyopic strabismus of both eyes, what kind of surgical options even exist at this point?

I say restorative to distinguish it from cosmetic reasons. If you came to me and said I don't like the way my eyes look, the surgery wouldn't be for cosmetic reasons (ie: I want bigger boobs or a smaller nose), it would be resorative, putting the eyes into a more appropriate position.

Amblyopia can affect both eyes, but thats rare. Do you see well out of both eyes, or better out of one? Eye turns often look like both eyes are turning, especially when they turn out. It depends on what kinds of surgeries you have had in the past. you can always have surgical revisions of the muscles. Its really case dependent.

I focus out of one eye at a time. It is more or less conscious which eye I make dominant, though if I'm not paying attention, my vision defers to my left as dominant. When I am focusing through a given side, that eye will see straight ahead and the other will turn out. The vision in my right eye is slightly better, though it is more frequently the "unused" eye due to it being less comfortable to focus through it than my left. I think that is a byproduct of the surgeries I've had, though. I have very limited capabilities in moving my eyes voluntarily. Vertical movement is nonexistent and even side to side is in millimeters at the most, not counting when my focus is shifted between the two eyes.

Sounds like you have your eyes well understood! When strabismus surgery is done its generally to align the eyes in primary position (IE Looking straight ahead).

Thanks for doing this AMA doc!

If you wear contacts for, say, 20 years, will there be damage done even if you wear them properly? I ask because last year at my yearly exam, the Dr. suggested I start wearing my glasses sooner at night and earlier in the morning, because at the rate I'm going I could have some problems later on.

I didn't ask him to be more specific (like an idiot, I will this year), but what do you think he could be talking about? And I'm not going to claim I've been perfect with my contacts (I got an ulcer once from not taking them out at night, but I NEVER sleep in them anymore), but the fact that he thinks something is developing worries me.

P.S. I've been wearing contacts for about 12 years, not 20.

People react differently to contacts. When you put one on your eye, you reduce the oxygen that can get to the cornea (does not get it from the blood like every other tissue). No matter how high the DQ of the contact lens is, the oxygen is reduced. So to compensate your body will grow new blood vessels to try and help out the corneal oxygenation. This can happen quickly or slowly depending on how your body reacts.

I tell people who have problems with contacts to wear them only when they really need them. So as your doc suggested, on in the morning, off as soon as you get home from school or work. Contact lens holiday on the weekends. Some people I suggest they only wear them when they do sports, or are going on a hot date or things like that.

Dry eye can also be a problem, but I doubt thats what they were talking about.

This is kind of a general medical question too.

How hard is it to maintain a good social life and still perform intricate procedures? There are some days my brain just does not want to work or wake up. I would have some anxiety about performing in those scenarios which is why I'm not a doctor. Do you still drink/smoke/go out late?

Good question. I often have patients ask me first thing in the morning before cataract surgery if I had my coffee yet, to which I reply that if I drink coffee my hands shake like a leaf! So there are some things that I don't do before surgery. Coffee for one. Also going to the gym the night before and doing an arm day is a bad idea, they often leaves me shaky. I never really drank or smoked or went out late much (lame I know). I have 4 kids now so I don't have time for that anyway.

Since Opthalmology is one of the higher paid medical fields, do you find the professionals in this area to be strongly motivated by money or is this a misconception? Do you think this has a negative impact on the quality of practice or patient experience in this field?

I would say that I am currently in a state of disbelief over how much people do in medicine solely motivated by money. I think that ophthalmologist do great work, but there are certain things that are done billing wise which clearly is done only for the extra $$$. I have a lecture on the ethics of medical billing and most of the attendees left feeling dismayed. Ie - There is a problem, It can be identified, but there is no clear way to prevent it.

I think this is true for all areas of medicine, not just ophthalmology. I try to ignore it and treat people based on what they need, not what will pay me the most money.

I might get surgery and have one of these later this year, how big is the risk for a surgery of this kind?

These are very specialised lenses for people who are missing part or all of the iris. I would say that the risks associated with this surgery would be on par with any of the retinal surgeries, a bit more than cataract surgery, but not much. Infection, lens dislocation would be the biggest concerns. Retinal detachment and chronic inflammation would also be on my consent form. I don't do these lenses, mainly because I haven't had the opportunity. Does the lens you are getting need to be sutured in place?

Have you ever had a patient develop a lazy eye after a surgery? Is it common? Is it treatable? (this happened to me)

Usually we do surgery to re-align the eyes after the kids amblyopia has been treated. Sometimes it doesnt work, but I wouldn't say that the surgery caused the lazy eye. Could you give more details? Did you have a cataract or glaucoma when you were a kid?

What are your favorite and least favorite surgeries? What about surgical instruments? I see many that I would not want anywhere near my eyes...

Also, any advise for a surgical technology student?

Interesting. I love doing cataract surgery. Its win win win. I am good at it, so I feel confident doing it. Patients are 9 times out of 10 really really happy. They tell me all kinds of positive things that inflate my ego. I get paid well to do it, and there is an endless stream of work. I don't know if I have a favorite instrument, probably the phaco, but the Utrata Forceps are pretty cool.

Advice - Im not even sure what a surgical technologist does!

Hello! I have been wrestling with a question for years. Should I get surgery or not?

When I was 2 years old, I had an accident involving a sharp point and my cornea. Not a good combination. So, this thing scratched my eye, and whatever that fluid stuff is drained out I think. Now, it is like looking underwater through that eye. My brain decided that the eye wasn't useful, so now my eyes don't line up and the one eye wanders a bit sometimes. I can't wear contacts without a lot of discomfort because my eye is misshapen. Even my pupil is misshapen.

However, I am perfectly fine. I can drive and play sports very well. Reading is no problem. I use the bad eye for peripheral vision only.

My doctor brought up the possibility of getting another surgery to bring my eyes into alignment and maybe better the vision in that one eye. The concern we have, however, is if it doesn't work perfectly, I will have a duplicate image right next to the real image. And this duplicate will be of better clarity (than it currently is), which may be especially distracting.

The current duplicate image only appears (or i only notice it) when I specifically think about it. But at all times I use the eye peripherally.

My doctor did not advise me either way. Please feel free to ask clarifying questions. And if you can't give me an answer that's completely fine, just thought id give it a shot! THANK YOU!!

I always warn people that doing strabismus sugery can lead to double vision. If your eyes are really misaligned, and you see double, its relatively easy to suppress one image. If the images are really close together, but not right on, then the double vision becomes paralyzing.

I would say that surgery has a low likelyhood of success in the long term. your eyes will likely become misaligned again at somepoint in the future. Hard to say how long it will take, but it will likely happen. Really your call, and besides $$ you don't have much to lose.

I want to get corrective eye surgery done (I have astigmatism; something like 1.20/1.25 prescription lenses) but I don't like the idea of laser eye surgery due to how it weakens the eye.

Do you have any other suggested procedures for someone with astigmatism?

To be honest with a prescription of 1.25, youre really not chaning much about the cornea. it does weaken it a bit, but I would be more concerned about -10D or -12 D.

have you had a consultation yet?

Hi! I had a torn and detached retina when I was a kid- it got repaired with a scleral buckle. Im really happy that I can see out of that eye, but the vision isn't perfect (maybe 80% my good eye).

Are there any retina replacements or advanced eye technologies on the horizon that could fix that eye more completely? I would really like to 'see' 3d movies. :(

There is a retinal implant but its in a super low resolution mode right now (ie - seeing the direction a light moves). So no not yet. and 80% is pretty good for having that as a kid! 3D movies are unlikely to work for you, maybe one day though.

Any surgery's you really messed up on?

I had a lady who developed endophthalmitis after cataract surgery. I don't think it was anything I did, but I can't help but feel really bad. As a surgeon you build up a bit of self confidence for every surgery that goes well, and then when you have a complication you get knocked back quite a bit. I haven't had any major intraoperative complications. I have done some lid surgeries to fix drooping, where they come back after and the lids are in the same position.

When you're working do you hear Frank Black from The Pixies screaming "SLICING UP EYEBALLS AAH HA HA HOOO" over and over in your mind?

haha nice one.

Is your getting paid related to the cutting open of people's eyeballs?

I do cataract surgery, and get paid to do it, so yes.

Are you Salvador Dali? WARNING: NSFL

Should I click this at the hospital?? haha..

So I cant really see out of my left eye its all blurry as in if I close my right eye I cant see the keyboard on my note2 (giant screen phone) will lasic help me? Im 25 so I dont think I should be losing my eye sight this early.

Have you had an eye exam to determine the cause? Do you wear glasses? Did you have strabismus as a kid?

If you could give someone one free object, what would it be?

I use a lot of intraocular lenses so i guess I would give that? I have done this several times, when needed.

My father lost his career due to macular degeneration that manifested as a small distorted area right in the center of his vision. Are there any current or upcoming treatments that can deal with that kind of issue?

There are different types of macular degeneration. The most common type is the age related macular degeneration. There are others related to infections, scars, being really nearsighted etc.

We only really have treatment for the wet type of macular degeneration, which is when the body grows new blood vessels to try and heal some sort of area that is "injured". How long ago was your dad diagnosed? how hold was he?

I've considered getting lasik for a long time but I have allergies and afraid of getting dry eye. Would the implantable lenses be a better choice for since the procedure is completely reversible unlike lasik where they cut a nerve and permanently reshape the cornea?

Implantable lenses are ok, but that puts you at risk for worse complications. Depends on your prescription really.

I am in Biology and I just finished a dissection!

Awesome! I was there once!

My sisters Ophthalmologist diagnosed a rarer genetic disorder in me and my sister called Fabry disease.

Yeah this can be seen in the eye for sure. Usually the kidney problems are diagnosed first though. Often I get sent patients to look for the eye findings in fabry's disease, but really they are not visually significant. http://dro.hs.columbia.edu/ced4/corverticillatab.jpg

I have a cataract that isn't anywhere near symmetrical. Any additional problems with surgery for these? How does one go about picking a cataract surgeon who is competent? Is there a particular age at which a surgeon will be most adept but not bored with "this is his xxxx eyeball surgery snooze fest"?

Not really. The only thing would be the end prescription of the eye. We put an artificial lens in to correct the refractive error of the eye. Generally aim for a final refraction of ZERO. However if your other eye is really near sighted or really far sighted this might cause some problems. You could use a contact lens or have the other eye done "earlier" than normal. I would suggest that you go to a surgeon who does at least 300 cataract surgeries per year. If you are too shy to ask how many surgeries they do per year, then pick someone who has been working for 7-10 years. They should be at the peak of their practice. There are always the exceptions (I hope I am one), but that is a general rule. I think RATEMD is a good site as well. I don't really care about bedside manner, I want someone who is surgically competent. Hope that helps.

After PRK, my epithelium grew back with a cloudy haze. After another PRK to fine tune my vision the same thing occurred. We scraped off the epithelium another time to let it grow back again and it healed again with the haze. Why do you suppose that keeps happening?

Basically your body is too good at healing. The organization of the corneal cells is very important to maintain corneal clarity. Lasering it causes inflammation and that results in distortion of the normal corneal matrix. This leads to haze. When the haze is there, what is your visual acuity?

Do you think there will be anything "ground breaking" that comes of the recent finding the sixth layer of the cornea? Also, how much do your techs make? Thanks!

The DUA layer I think is a non finding. I have looked at a lot of corneas under the mircoscope and do not think that there is anything special about this layer. I also asked the chief ocular pathologist of the country to comment on the article I sent him, and he wasn't impressed either.

A tech with no training will make $15/hr in my office. If you get certified (COA, COT etc) from JCAPO then the rate will go up. http://www.jcahpo.org/certification/ I have an orthoptist who works in my office who make 34$/hr.

How do feel about the current trend of general ophthalmologists dying as a field, and along the same vein, the increase of the scope of practice for optometry.

I guess this will be region specific. Where I am, there is a resurgence of general ophthalmologists, but only because there are so many patients. There is a general trend to being more and more specialized, which has its pluses and minuses. Usually means that if the diagnosis is correct that the patient is getting the most up to date care, but this may mean that the patient will have to travel really far to see the specialist.

I have a great relationship with the optometrists in my area. This is not true everywhere. It all comes down to turf and people feeling that they might lose work etc.. I think there is a role for everyone and as long as both parties are honest and work together, that a solution can be found.

very intense work what you do. have you worked with any of the doctors in nepal? i was over there filming with a few last year. such great people and under-appreciated work.

here's some video from my time over there used for the company who does the fundraising to make this possible.

https://www.youtube.com/watch?v=ZAhJZdrMH0E

Awesome work. I haven't done any international work yet, mainly because I think in the eye world anyway, they do a better job at it than I would! Great video.

How did you choose your specialty? Do you think the field of ophthalmology has good prospects for the future? If so, why? Thanks so much for doing this!

Any profession that deals with the elderly is going to be in business for a long time. I chose it based on my interest in eyes, and the flexibility the profession offered.

What's your opinion of the NoonTech Diagnostic Machine? Do you think the next revision will require such precision by the user, or is that half the fun?

Looks terribly painful. I think there will be a machine though that might be placed in a mall that you stick your head into and it will take a picture. this picture will then be send to a specialist to review. This will happen.

You seem frighteningly zealous for a surgeon.

Someone told me that you don't want anyone operating on your eyes who doesn't have all their shirts lined up in their closet.

Since childhood I had incredible bad eye-sight. Without my glasses, I can't see anything which is longer than a few inches away from my face. I have been considering surgery a lot - but here is the downside.

Professionally I am an artist. My entire career, skillsets and experience I have worked very hard on for the last 15 years, entirely rely on my eye-sight. My own eye-doctor told me; that the way you see color will remain the same, however your sense of contrast will change.

I am not sure if you know anything more about this. There are obvious differences between the average person to artists with a trained eye for colors. Contrast is also extremely important when working with visuals.

Right now, I am not sure I dare taking the risk - but on the other hand, but sight is so poor, I could very easily get into life threatening situations in case my glasses break or get lost.

Do you have any experience with this, know similar stories regarding this? - And would it be worth the risk?

I think its important to know what someone does with their time when considering options for surgery. I would tell you that in some professions losing a few degrees of stereo vision (3D vision) wouldn't be a problem, but in my profession I need to see the fine details! So as an artist a small complication for some might be a huge complication for you. I would say to use contacts and glasses as long as you can. It just depends on how much of a risk taker you are. If you are 45+ I would avoid it, as you will need cataract surgery at some point and that will be a better option for you. Have you looked into lasik? You might not even be a candidate with that level of nearsightedness.