save your eyes by learning from my mistakes

Before graduate school, I did not expect I would ever be one of those people who
have to worry about their eyes going bad. Nor for that matter did my mother. My eyes were better than "perfect" one 20/15, the other 20/10, far and moderate, good enough near. I had access to quality medical advice (even regular friends in Harvard Medical School).


But... they are now a serious problem, and much worse for my mother.  There are important lessons learned.

One lesson was already out there -- don't be too proud to use sunglasses a lot when outdoors in UV. Don't think it doesn't apply to you. Certainly, WHENEVER you would use sunblock you should also use good sunglasses! Most people don't die of skin cancer, and people do need some sun on their skin, but in the US today MOST people end up needing cataract surgery ... and I now suspect that the minority who don't get it still suffer from the effects. Yes, it takes many years to evolve, but if I had been aware years ago of what I would encounter in my 60's (and of how the majority experiences as bad or worse), I would have taken the trouble. Costco sells extremely comfortable and effective sunglasses for about $40 now, which also help with issues of glare in ordinary vision anyway. It's not as if you have to wear them 24 hours a day or when sitting behind thick glass windows which block UV! The analogy to sunburn is helpful.

So my main problem right now is catarcts. My mother's is macular degeneration. Hers is much worse I know that UV slowly degrades the lens of the eye, and I now know more than I ever wanted to know about that condition.  But can UV also damage the retina, a more fundamental problem, not so solvable today?   I have heard her horror stories... but not studied that aspect as much.

But there are other lessons learned, somewhat more technical. I had a great discussion with Luda about this subject this morning, and it reminded me once again how lucky I am to be married to someone who understands so much, even though some of our discussions are so intense they can be downright scary to small children who overhear.

Where do I start with these technical things?

Let me start with heresy... whenever I think for myself and apply real intelligence, I end up believing something which is heresy to the world around me. Usually not simple-minded left-wing or right-wing heresies -- something more like what Gore once called "the radical middle." (More can be said about Gore but not here and now.)

The heresy here -- from both theory and experience, I really believe in adaptation.
I believe that eyes adapt to their environment much more than most doctors believe possible, even without considering the esoteric things which also affect vision.

At a certain point when going to Harvard (grad school and undergraduate), I ended up pouring huge amounts of energy and focus into starting at things near to my eyes -- computer printouts especially for debugging, but also some of the world's first CRT monitors and books. All much more, much more continuously than I did in high school, even in the courses I took at Princeton and Penn while I was in high school, because the latter was easier and more in balance with a lifestyle which got me out of doors (in the sun!) much more. Not so much UV at Harvard, but UV is not the only problem for eyes. I was rather shocked how radically and quickly my vision changed... STILL just as strong in resolution, but far more myopic in distance. From moderate to far sighted to myopic.
My far vision was still good enough for driving without glasses (and was tested of course regularly in past years!), but shifting form 20/10 to 20/30 for distance was a shock. It was some consolation that I could read small print no one else could.

OK, I really have to introduce some technical words here to be coherent. For each eye, there are two main variables we need to be aware of -- RESOLUTION (what you lose from cataracts and form macular degeneration) and FOCUS or FOCAL LENGTH. Until about 3 to 4 years ago, I always had spectacular resolution, more pixels I could see per solid angle of images coming into my eyes.
But at Harvard, my FOCAL LENGTH changed dramatically, from far to near, because of the way
I put energy into things near to my eyes, causing my system to adapt. Adaptation is not really a bad thing; "nature" wants us to be good at the things we actually care about doing.

But: was it really just 3 to 4 years ago that I started to get a resolution problem as well?

In fact, maybe 15 years ago, it got to be dicey whether I should drive with only 20/30 far distance.
I could still pass some of the DMV tests, but with effort, and in fact test results started to become unpredictable. I did go out and get "-2" glasses for driving.

Some people said: "Oh, now you have glasses. Why don't you just wear them all the time?"

Ouch! No way. Glasses CHANGE focal length; they do not help or hurt RESOLUTION.
It would have made my vision much worse if I just wore them all the time -- and I had friends who had experienced exactly that kind of worsening of vision! It's important to understand what is going on here.

SOME optical systems, like telescopes or binoculars or magnifying glasses, DO help with resolution. For example, if a telescope is "30X", that means that you get 30 times as much resolution -- like an array of 30 by 30 pixels coming to from a place where before only one pixel would get through. But the glasses they sell at the optometrist to wear on your face are all just "1X" -- no magnification. What they do is change focal length. They change what the distance is that you can see best from your eyes, the distance which comes into focus on your retina. My "-2" glasses for myopic people would "bring a far object closer." That doesn't mean I would get more pixels of resolution in seeing far cars as I drive; rather, I could bring the pixels I see into focus better. But if an object is CLOSER to my eyes than their present (short) focal length, it would actually bring them OUT of focus, and push my adaptation to be even more myopic! And it would hurt. My first optometrist was wise in prescribing glasses a bit weaker than "the optimum for far vision" for me, because he still wanted me to be able to feel pressure in myself to focus better at a longer focal length... when helps a little in adaptation to keep from absolute myopia.

 Does EVERYONE adapt like that? Is it important for everyone to consider what they are doing with their eyes when they spend too many hours looking at computer screens?  Well, some people adapt more than others. A long story.

But then about 3 to 4 years ago, I made another serious mistake, with another lesson learned.
As my resolution started to get a whole lot worse, due to cataracts (which I did not even think about at first!), I started to move my head closer to the computer screen, and move books or reports closer to my eyes, to get the intense and complete images I was used to using, a major part of scientific work. This caused the myopia to get worse, as well as cataracts! By last year, when I had a real professional eye exam, I needed a new prescription, -5, and my eyes were even then only CORRECTABLE to 20/30! I knew I needed an eye exam, because I could tell the vision was getting worse, and I started seeing "rainbows" around bright lights outside at night.

So now... I realize that the reduction in resolution probably occurred much earlier than that, a steady quiet blurring due to slow chemistry changes in the lens (NOT a disease like a germ!). If you ever see rainbows the way I did... you should know that you DO have a major degradation in resolution of vision due to UV damage. You already should feel bad that you did not use sunglasses much more... and should change immediately if you don't want it to get worse!

But here was my further mistake 3 to 4 years ago, which I saw clearly only this morning.
At Costco, I had seen simple reading glasses available without prescription, for "+2". I remember looking at them and thinking: "Those are not for me. Why don;t they have something cheap and easy like that for people like me, who are myopic and need more like -2? These are for the more stereotypical old people, who become more farsighted with age and need close objects to 'look' further, the exact opposite of what I need." But in fact, once I started having the resolution problem, I should have bought a pair of those glasses, and made a resolution: "Whenever I focus a lot on something a foot in front of my eyes or closer, I will wear these glasses, both to make it easier and to prevent more radical adaptation to more extreme myopia." +2 glasses would not be enough; HOW TO USE THEM was also crucial.

But here I am now. What now?

Last year, my (new high-level) optometrist said that my cataracts are only stage 2. Bieng correctable to 20/30 is truly awful, as are the constraints now which affect so much of my life... but I am still far better off than most people my age, and MUCH better off than my mother (who passed her 90th birthday a few years ago). Following standard advice, he advised against cataract surgery, because I still lead a relatively normal life (and can read, albeit in bright light less than a foot from my eyes),
and because there are some risks involved even now. (The greatest part of my mother's vision problems now are actually due to incompetent laser surgery they tried on her a few years ago!
Being a nice person, she did not sue for malpractice,  though I sure think she could have, from how she and my brother describe it.) Bad as it is, maybe I'm better off than most people, who end up having cataract surgery even despite the cautious practice of today.

Last year, being a perpetual skeptic, I looked further into these tradeoffs, with lots of literature search on the web.  It was hard to work my way around the "$25 per click" on serious medical journal articles, but I found ways. In the end, I learned that most cataract surgeries end up with something not much better than what I had last year, AND a continued rate of degeneration due to UV... just fine for folks who die in two years anyway, but very bad news for people who might live longer.  But I also learned that some research has also been successful.

This year -- it seems that there is just one specific TYPE of replacement lens, the EnVista system
from Bausch and Lomb, which offers real hope to people in my situation. They say it is "the only IOL certified by FDA to be glistening free," free from the main source of deterioration of vision of people AFTER they get cataracts. (There is also a common complication which is reduced in probability.)    Most people don't get that kind of IOL when they have cataract surgery; they are calm and relaxed and trust the normal medical process, and get screwed, sometimes very badly.
(The same thing happened to my mother when she first needed stents for her heart; I wish I had screamed louder for her to get the new kind which do not deteriorate as fast!) I hope my new optometrist whom I see today (the previous guy having moved on) is more up to date here --
and ironically, I trust him MORE because one of the "medical expose" sites says he got money from Bausch and Lomb related to Envista.  (I learned about EnVista quite independently form my own searches.) This IOL is still just a few years on the wider market, and one never knows for sure... but the high success and reduced risk observed so far augur well.  EnVista is NOT one of those "premium multifocal " lenses that some people pay extra for (not covered by insurance), but it sounds as if it leads to results like the vision I had before at the best, which is more than good enough.

Will I schedule cataract surgery at the meeting today, or not? I still don't know, but it seems quite possible.

===============

By the way... on adaptation, Luda asked me about the mechanism. I said:
"It's like what we discussed with Karl Pribram, whose last serious book discussed the visual system in great detail. We discussed it even more in person. There is tendency for people to naively ASSUME that there is a bottom-up hierarchy here, from molecules to cells in the retina to signals in the retina, to the thalamus, to layers in the cortex, all upwards. But in fact top-down FEEDBACK
from layer to layer is really essential to the basic facts of life, at all levels. The levels INTERACT.
(Oh do I know more about these details!)."

"The adaptation mechanism is stronger in some folks than ever. Let's discuss the various experiments on cats reared in darkness, and on the calcification of the pineal/epithalamus complex...." We did.

How much will the higher part of my visual system suffer if I POSTPONE the cataract surgery?
No one knows. Is it like weight, where it's easy to slide and harder and lengthier to come back?
That's certainly a factor in my decision.

TBD. But for you... try to avoid such situations!

Best of luck,

    Paul

Also, I should have added -- I saw the TV ads for OcuVite when I was beginning to worry. I checked into the claims, and ended up instead buying a little orange plastic jar of Lutein and Zeaannthin (sp?) from Costco. So now every day I take prilosec, grape seed extract, zeananthin and baby aspirin in the morning,,, except sometimes just prilosec. The evidence on l&z is encouraging, but not decisive; it wasn't decisive for me. If only I had worn sunglasses more, when I was younger! Cataracts are a slow process of decay, and maybe my vision would have remained stronger even at 40 and at 50 if I had started earlier with the basic sunglasses, with the rule about always using them whenever one would use sunblock. But I didn't use sunblock much back then either; back then, I wish I had used sunglasses at least when outside for more than 15 minutes between 10AM and 2PM, adjusted when peak sun is not noon.

I suppose UV is not the only possible cause of erosion, and folks who lack lutein in their diet may need that too, but simple sunglasses are the main thing.


=============================================================

Next day: lots of stuff happened at the doctor's visit, lots could be seen. As usual, some things can be posted and some I'd feel uncomfortable discussing even here.

The information packet and the video they showed me were somewhat disquieting. Maybe the video is available on the web, somewhere like u-tube.  (By the way, I took notes from my earlier days of scouring the web for information and trying to assemble a picture of this stuff. A posting by Slonin, a cataract surgeon describing his own experience, was very lucid and encouraging to me this past week,
along with the reports on EnVista, Envista MX60 in particular.)

The video really stressed the issue of multifocal (and accomodative) new plastic lenses to replace the lens on your eye, versus classical or monofocal lenses like EnVista.  For years, I felt somewhat limited by the way my eyes CHOSE to go near (go myopic) and thus be worse with far vision,
BUT DOES THIS TRADEOFF become much worse with classical plastic lenses? I hadn't really thought about that. I thought the problem was bad enough in my younger years, but I could live with it if my resolution returned to what it used to be; after all, I could drive without glasses back at age 40, even though I was myopic, because of my good visual resolution.  Slonin seemed happy. I sure hope it's that good, but I do worry a bit now. Was all the warning in that video just a way to push people to buy the more expensive multifocal lenses? I hope so. I don't plan to buy multifocals in any case, not so much because of the price tag ($7,000-$8,000  FROM ME, beyond what insurance would pay), but because I already decided against them based on what I saw in the literature on risk and deterioration. If the focal length problem is worse than I realized... the only effect is to make me wonder whether I made the right decision to start this process, and to damp down my hopes for how much better things will be after the cataract operations. But should I really waste energy on either of these things, when it is do far along? ... HEY FOLKS, AGAIN, YOU DON'T WANT TO BE HERE if all it takes is sunglasses from an earlier age!

Luda asks: is it really that simple? Why is it that half the US has cataract surgery by age 60 and almost all by 70? (Since I am 70 and could have gotten by easily without it, as of last week, could it be that no one is escaping this?) Well, what fraction of the US population uses effective sunglasses so much as I NOW do?

The sunglasses story reminds me of the trichinosis ("triganosis") story from when I was young,
in the year 1950. I remember talking with a neighbor, another young kid, about the warnings we had from adults never to eat raw hot dogs. "If you do, you really might get trigonosis. You don't really want to do THAT!"  One of us said -- "Hey, if was that bad... how many kids eat raw hot dogs at least a few times, and how many stories do you hear of kids struggling with an awful disease besides the other stuff we know about?" (We all had seen polio stories and evidence about polio and smallpox.)
So many years later, I bumped into a brief story... "About 30% of the population did get trichonosis then. The main symptoms are lethargy, inability to work well and focus.." Wow! If I had seen THAT back then... but fortunately, I listened and avoided raw hotdogs... I forget whether always or almost always. I avoided marijuana 100% clearly and distinctly, but about raw hotdogs at age 3, I forget.)

There are similar stories about kappa waves produced by the brain, and calcification of pineal/epithalamus system... but back to eyeballs.

I was surprised that the main menu presented to us in the information package was a choice of four options -- three laser-based and highlighted, and a traditional surgery option covered by insurance at the bottom of the list, so innocuous that Luda and I both didn't really notice it until a final meeting with a scheduler whom we peppered with questions. I hadn't seen a lot of stuff on cataract surgery by laser when I did my web search earlier on issues important to me (like how much my vision might start deteriorating again after the surgery!). Yesterday, after the doctor's appointment, I searched on that, and was relieved to read that it didn't sound necessary for folks like me.  I am on course now for the simple traditional cataract surgery covered by insurance. I probably won't back out because of fear about a focal length problem, but that's the main alternative.

Focal length -- three options for each eye: "near, far and middle." Lots of discussion about having one eye one choice, and another eye the other, to reduce the need for using glasses for the rest of my life after surgery -- with encouragement for lots of tests and a trial period using contact lenses to make sure it doesn't scramble the brain. Well, even before college, I had one eye more far (the right) and one more middle/near (the left), and my brain seems adaptable enough in this realm. So maybe I will go left-near and right-middle this time.

Regarding near versus far -- I was amused by the "lifestyle questionnaire": "which is more important to you, reading or golf?"   Not a hard question! If the worst thing that happens is that I will still need glasses when driving or reading someone's equations projected onto a conference screen, that will be reassuring. But they also listed computers as "middle," not near, so I need to check. It may be that "near, near" would work better. A nasty choice, really, but unavoidable for folks like me who put a premium on issues like risk and future deterioration.

Yesterday the doctor and his assistants did lots and lots of tests. (Some details I may include only in my journal version of this, on private hard disk.) Thank god, none of the scary painful squirting I remember from some quick glaucoma tests  in other places earlier. But four sets of eye drops in each eye by the end of the visit. Cornea in great shape, still much better than average; none of the bending or astigmatism which would have put me in a totally different category, requiring other choices and costs. Likewise the macula, despite the experience of my mother and her brother. (That was partly genetic, but they were also both more "sun worshippers" than I was. I'm glad I don't need to nail down all of what I don't know about that condition.) Likewise the retina itself.

The doctor was somewhat puzzled that everything but the transparency of the lens was in such good condition, because there WAS evidence (secondary, and then definite by test) that my left optic nerve is enlarged. The left eye became my dominant eye by the time I was in college, perhaps because it specialized in what I put the most energy into. (Long ago, at Chestnut Hill Academy, K-12 time, they did a pubic test of which eye was dominant, for the whole middle school, and I really confused them by not being consistent. Yesterday I was consistent. That was not self-consciousness at work in either case. My mother was once a great shot with a rifle, because being right-handed and left eyed worked well for that task.)

But all the usual explanations failed -- and there was no evidence of any need for anything but the traditional lens stuff.  He warned that deterioration of optic nerve or neural pathway would be irreversible. An assistant warned that deterioration or the surface cells of the cornea would also be irreversible. To her, I mentioned the research on blueberries for the brain proper, but confessed I know nothing about how that plays out in the eye.  So what is my enlarged dominant optic nerve doing? No sign of deterioration as such...

So next week, another preliminary appointment -- one more test they couldn't do yesterday, and lots of measurement "to let us know what your options ARE for lenses." The minimum for the traditional approach, and I sure hope I will not end up just squeezed out altogether.

If not, then a day at Fairfax Hospital later for the right eye, then another day for the left eye, with two additional postoperative visits. FIVE visits to come! The doctor's office is only 0.4 miles walking from a metro station (Greensboro), and how much should I keep putting a burden on Luda driving me back and forth?

All for now.

===========

Wait, there is a technical issue worth noting.

For any set of eyes... there is a focal length, an optimal distance for seeing objects. For example, I imagine it was 20 feet or more when I was young, maybe one to three feet now. Probably there is a formula somewhere which converts cryptic numbers like the "-5" for my glasses prescription to a statement of how far away an object should be for me to have best possible vision.

At that optimal distance, I have a certain amount of resolution -- how many pixels I see per solid angle of visual field.

A key question for everyone is: how much resolution do you lose when the object is NOT at the optimal distance form your unassisted eyes? For example, if it is twice as far away, or if it is half the distance, how much does your resolution suffer? More precisely, what are the "half resolution ratios?" What is the ratio x such that you only get half the resolution (actually, 1/4 as many pixels) when the object is located at a distance of x times that optimal ratio?  (There is a far x, objects so far you only get half the resolution, and a near x.)

WHAT I WISH I HAD is data on how "x" WILL CHANGE after EnVista is implanted into my eye,
VERSUS what it was before. HOW MUCH sacrifice will cataract surgery result in? I see lots of noisy words about how small the problem is and how big the problem is, but I don't see
useful clear numbers like this anywhere, in anything I have found. It is really sad to be in such total ignorance about something which could be quantified (and spelled out in plain English).

=======================

Aug 12, home from a second appointment to PREPARE for cataract surgery.

I was amazed just now... when I googled on

envista focal length near far,

the first hit was to this blog post! Some stuff is easier find than others on the wbe.

Tay -- more tests: a fancy machine (no squirts!) to evaluate glaucoma (not there), another to measure geometry of my eye for surgery purposes, and a final vision check with my glasses to verify it has indeed deteriorated as much as it seemed last week. Ten feet away from an eye chart, with my full strength glasses on,  in the chair I could only get to 20/20 with right eye and 20/50 with left, as before. (Later Luda noted that the glasses were dirty, and set for vision more than ten feet. Standing up with cleaned glasses, I could do better... but not SO much better. It is also posisble my eyes -- especially left -- are MORE myopic how than when I got the rescription, because of how I have kep reading closer to my face.)

Then the consultation with the doctor. He himself had -6 to -7 glasses, stronger than my driving glasses, and wears them all day. If he too reads a lot, I wonder whether wearing them all day explains why his myopia may be more severe than mine?

He said he could do envista, no problem at all, though he never has yet. They go with standard acrylon IOLs. I promised to email him some of the things I found on the web arguing strongly against that, and in favor of Envista.

More serious --0 the near versus intermediate versus far choice. An awful conundrum.
Most folks just get far, no problem. But I still remember the questionnaire asking which is more important to me -- reading versus playing golf. I guess I'm not most people. I told the final person, the surgical consultant, I really wanted more information. Since they have to special order envista, they really needed a definite choice before scheduling surgery. I asked... are there any real NUMBERS here, not juts fuzzy stuff that I don't trust? She looked and looked, and found a page from the material they had on CrystalLens (another Bausch and Lomb product, more expensive, multifocal.)
"Ignore the lens name.... see what near intermediate and far are, 20 inches to 20 feet is intermediate. "
Violating the strong recommendation to choose far... I chose intermediate for the right eye, nondominant. Surgery is now scheduled for the right eye for September 24.

Before that... what a mess! I must get a physical from my GP by then, to qualify for surgery. (Well, he wanted to see me again anyway.) They scheduled an appointment for "preop clearance" with a retinal specialist as well. Three types of eye drops to take before that surgery. An appoint scheduled the day after and a week after the operation. Another one-month visit will need to be scheduled. The left eye is not scheduled; I will see what I see through the right eye, and choose for the left based on that experience. Numbers are hard to find to assist that decision, but actually seeing what intermediate is myself should help a lot.

Will my vision really be better or worse after this? It seems to make sense, but right now I still have qualms.

========================================

Then: Mon, Aug 17: today they will do a check of my retina in a ret8ina specialist, to verify I am ready for cataract surgery.

Should I keep taking the lutein and zeanxanthin pills we get from Costco, which have much more of those special nutrients than the popular OcuVite? On a quick google search ... yes, like sunglasses, those too help prevent cataracts and macular degeneration both. For example, see:

 http://www.ncbi.nlm.nih.gov/pubmed/21646979

Yes, UV light contributes a lot to macular degeneration as well as cataracts.
It is no coincidence thar the really heavy sunworshippers in my mother's family ended up with
that condition. MODERATE sun exposure and lots of outdoor activity were good for my health...
 but I wish I had used both the protections, sunglasses an lutein/zeantantin (sp?) along with that.

A few days ago, on my final testing for cataract surgery, the doctor asked for my sources on Envista. I sent him:

Here are just a few of the many sources I read which pushed me towards going ahead with cataract surgery, and towards EnVista.

Last year, Dr. Friedlander said that with eyes correctable to 20/30, it would be better not to do the surgery, or wait... though he recommended I come back in a year in case of further deterioration. And so, last year, I read through many sources. (My eyes were good enough to do that, last year and this year!) I was especially interested in risks of deterioration of the IOL over many years. Do I still need to use sunglasses religiously?

My initial search was discouraging, and argued against surgery for me, as Friedlander said:

http://www.iolsafety.com/issues-under-discussion/glistenings

There were many other similar stories, when people looked really seriously at statistics on deterioration over many years. But then I found some good news with new materials:

http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/content/tags/bausch-lomb/new-generation-iol-glistening-free?page=full

http://www.ncbi.nlm.nih.gov/pubmed/20656166

http://www.ncbi.nlm.nih.gov/pubmed/22727297

http://www.nature.com/eye/journal/v16/n3/full/6700066a.html

http://www.bausch.com/ecp/our-products/cataract-surgery/lens-systems/envista-iol#.Vc4CZvlVhBc

http://www.ophthalmologymanagement.com/articleviewer.aspx?articleID=109185

I said to Luda -- I'm not the kind of person who would normally buy a new line of car in the year of introduction. But if the logic looks right, and it is on the road for three or four years, it makes sense to me.  There are risks either way, with or without the surgery, but going ahead still seems like the right way to go. I look forward to being able to really see the television in our living room (about 10 feet from the couch), people's faces, and the computer screen without my having to lean forward and train my eyes to be even more myopic. Thank you very much for helping me.

Best regards,

  Paul

P.S. I am also very grateful to Irina for responding to my plea for real numbers in print to help me decide on focal length. I have pretty good web skills, but I have yet to find anything as clear as the page she showed us from the CrystalLens package, actually DEFINING "near," "intermediate" and "far."  CrystalLens, like EnVista a Bausch and Lomb product, certainly sounds good -- but reliability even more than cost pushed me more towards EnVista.

==============

Update September 4:

Have had two additional preop visits to OTHER doctors -- requested by the opthamologist, maybe required by insurance companies. The retina doctor was very, very nice -- and warned that I am lucky that I don't need HER kind of more challenging laser eye surgery. (I guess I shouldn't overestimate the risk of laser cataract surgery, even though my mother had a bad experience with the other kind of laser eye surgery; but I am not opting for it.)

At Quaker meeting last week, a woman said (like many others) -- yes, it is great, and routine, just 15 to 20 minutes actual operation. She was very satisfied -- and had it twice. Twice? Oops. So I guess it was good I held out for the IOL which shows best promise of NOT deteriorating. But even so, also good I have decided not to give up sunglasses even after the operation.

And it does really hit me the implication that I am so strongly left-eyed though right handed, when I was more both-side-eyed back around 8th grade. I guess I really have cultivated right brain kinds of strengths at least since my "new foundation" since age 15.