Eye Disease – Thyroid Eye Disease

The ophthalmologist included a lot of material in the email he sent me and the images were not the most usable. I talked to him about that. He said he was aware they might not be, but hoped that they would not be unusable. I told him that I would talk about the images that show in Google search. I asked him why he did not cover thyroid eye disease and he said probably because he does not have any patients with the disease. He thanked me for wanting to cover it and said it does happen in small numbers for people with type 2 diabetes, but more often for people with type 1 diabetes.

Some people refer to this as bulging eyes, but should not. Thyroid eye disease (TED) is a disease marked by swelling of the muscles and fatty tissues surrounding the eyeball within the eye socket. This causes the eyeball to be pushed forward and causes various eye symptoms. Treatment is done to protect the eye while the disease runs its course. This often means artificial tears, medicines, and in some cases, surgery. Thyroid eye disease is usually associated with an abnormality of the thyroid gland, which needs to be treated.

“TED is sometimes called other names such as thyroid ophthalmopathy, dysthyroid eye disease, Graves' ophthalmopathy or ophthalmic Graves' disease.” Autoimmune thyroid disease happens when the body's antibodies attack the thyroid gland. In some people, these same antibodies also attack the tissues surrounding the eyeball.

TED is a rare condition and affects about 16 women and 3 men in every 100,000 people each year. Most of the people have an overactive thyroid gland and have an underlying autoimmune condition. It generally happens in middle age and some people carry genes that make it likely that they will have thyroid eye disease.

Symptoms are caused by the tissues of the eye socket swelling and pushing the eyeball forward:

• “The front of your eyes can get red and irritated as the sensitive cornea is less well covered or lubricated by the eyelids.
• The front of your eyes may feel (and be) dry if the tear-producing gland (the lacrimal gland) has been affected.
• Your eyes may ache.
• Your eyes may look more bulgy, giving you a staring appearance.
• You may get double vision (diplopia) as the muscles become too swollen to work properly.
• In advanced disease, your vision may become blurred and colors can appear less vivid.

The two eyeballs are not always equally affected. You may have other non-eye symptoms due to the abnormal thyroid gland.”

Diagnosis of TED can be done in several ways:

#1. An eye exam if you already have a diagnosis of a thyroid gland problem.

#2. A blood test named thyroid function tests which determines how well your thyroid

gland is functioning or more specialized blood tests to measure the antibodies in your blood.

#3. Thyroid scans to see how actively the thyroid gland is working and sometimes an MRI, which will show which tissues have been most affected.

#4. They can also assess your general sight, how well your see colors, and how your peripheral vision is. They may also carry our an eye movement test to see how the eye muscles have been affected. These assessments will often be repeated throughout the course of the disease.

If left untreated, the inflammation will gradually heal itself; however, the symptoms caused by the swelling may remain because some of tissues have been stretched to the point they will not return to their original form. Treatment is done to limit the damage done during the inflammation.

Medicines may be used, such as artificial tears, which are ocular lubricants, and this may be sufficient in the early stages. As the disease progresses, steroids such as prednisolone may be used. Omeprazole, a medicine that protects the stomach lining may be used to counteract the side effects of steroids.

In about five out of 100 people with TED, the disease is severe enough to require surgery is required. Several types of surgery can be accomplished:

1. Decompression – creates a space within the orbit for the inflamed tissues to spread into for relieving pressure on the optic nerve.
2. Surgery on the orbit to allow the eyeballs to settle back into the sockets.
3. Surgery to the stretched muscles or to the lids to allow return to normal.

There are other treatments available and you may read about them here.

Here are a few tips that you can do to help yourself:

• “We know that one thing that makes this disease worse is smoking. If you do smoke, see your GP about getting help to stop.
• Sleeping propped up will help reduce the puffiness (congestion) around the eyes.
• You may find bright light uncomfortable. Sunglasses will help.
• If you are a driver, let the DVLA know if you experience double vision. This is a legal requirement. Usually, they will contact your ophthalmologist for a report. If the double vision is well controlled with prisms, you may be declared fit to drive.”

Most people with TED do not develop permanent complications; however, when TED is severe, the person is older, a person smokes, and in people with diabetes, complications cannot be ruled out. Some possible complications include:

1. “Complications from the disease

• Damage to the clear window of the eye (the cornea).
• Permanent squint or double vision.
• Damage to the nerve of the eye, resulting in poor vision or color appreciation.
• Unsightly appearance.

2. Complications from treatment

• Side effects from the immunosuppressive medicines.
• Side-effects from the surgery:
  • New double vision (about 15 in 100 people with TED).
  • Loss of vision (less than 1 in 1,000 people with TED).
  • There are some other very rare complications that your surgeon will talk you through.”

Thyroid Eye Disease is a drawn-out illness. The inflamed period generally lasts months to about two years. For most people it will be a mild disease needing lubricants and regular assessments only. It fades away by itself. For those who have a more severe disease, the outlook depends on how early it is diagnosed and how intensive the treatment is. About 1 in 4 people will end up with reduced eyesight.

Eye Disease – Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is one of the eye diseases that does not have diabetes as a risk factor. Yet many people with diabetes may still develop AMD. AMD damages, and then destroys, central vision, your straight ahead finely detailed vision. AMD takes two forms, wet and dry, with 90 percent of cases being dry. The remaining 10 percent are wet, a more advanced form of AMD. Wet AMD is more damaging, causing about 90 percent of serious vision loss.

Starting with the highest risk, the people most at risk are:

• People over age of 60
• People that smoke
• Have a family history of AMD
• Are white Caucasian and female
• Have high blood pressure
• Are obese

AMD is painless. It may worsen slowly or rapidly. Dry AMD may affect central vision within a few years. Wet AMD can cause sudden and dramatic changes in vision. In either case, early detection and treatment are keys to slowing vision loss.

See your eye doctor right away if you notice any of the following:

Straight lines appearing wavy, a symptom of wet AMD

Blurred central vision, the most common dry AMD symptom

Trouble seeing things in the distance

Problems seeing colors correctly

Difficulty seeing details, like faces or words on a page

Dark or "blank" spots blocking your central vision

Wet AMD treatment may include:

• Special drug injections – this is by far the most common treatment
• Laser surgery
• Photodynamic therapy

Dry AMD treatment is aimed at monitoring or slowing the progression of the disease. Vision loss from advanced dry AMD cannot be prevented. But, taking certain dietary supplements may help stabilize the disease in some patients. One large study has shown that taking high doses of the antioxidants vitamin C, vitamin E, lutein, and zeaxanthin, along with zinc may help slow AMD progression in cases of:

• Intermediate AMD
• High risk of progressing to advanced AMD
• Advanced AMD in just one eye

However, this regimen did not prevent AMD onset or slow its progression in early-stage disease.

These preventive steps may help keep AMD at bay:

• Eat more leafy green vegetables and fish.
• Maintain a healthy weight and exercise regularly.
• Don't smoke.
• Check your blood pressure regularly. Get treatment if your blood pressure is too high.

AMD is detected by using a comprehensive dilated exam. The exam may include any or several of the following:

1. Visual acuity test – the eye chart measures how well you see at distances.
2. Dilated eye exam – this allows your eye doctor to see the back of your eye. He/she then uses a special magnifying lens to look at your retina and optic nerve for signs of AMD and other eye problems.
3. Amsler grid – your eye doctor may ask you to look at an Amsler grid to help determine if lines in the grid disappear or appear wavy, which is an indication of AMD.
4. Fluorescein angiogram – this test is performed by an ophthalmologist in which a fluorescent dye is injected into your arm. Pictures are then taken as the dye passes through the blood vessels in the eye. This helps see leaking blood vessels, which occurs in Wet AMD.
5. Optical coherence tomography (OCT) – this is similar to ultrasound, but uses light waves to capture high-resolution images of any tissues that light can penetrate, such as the eyes.

The key here is early detection and keeping your appointments to give the eye doctor the best odds for helping you. Please read this.

Eye Disease – Diabetic Retinopathy

I have written about two of the three eye diseases that people with diabetes are at risk to develop – cataracts and glaucoma. Now it is diabetes retinopathy. Many authors just use the term diabetic eye disease for retinopathy, cataracts, and glaucoma. Diabetic retinopathy is the most common eye disease in people with diabetes. It affects over 5 million Americans aged 18 and older. Usually both eyes develop the disease. Diabetic retinopathy progresses in four stages.

The four stages of diabetic retinopathy are:

1. Mild Nonproliferative Retinopathy. At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina's tiny blood vessels.
2. Moderate Nonproliferative Retinopathy. As the disease progresses, some blood vessels that nourish the retina are blocked.
3. Severe Nonproliferative Retinopathy. Many more blood vessels are blocked, depriving several areas of the retina with their blood supply. These areas of the retina send signals to the body to grow new blood vessels for nourishment.
4. Proliferative Retinopathy. At this advanced stage, the signals sent by the retina for nourishment trigger the growth of new blood vessels. This condition is called proliferative retinopathy. These new blood vessels are abnormal and fragile. They grow along the retina and along the surface of the clear, vitreous gel, that fills the inside of the eye. By themselves, these blood vessels do not cause symptoms or vision loss. However, they have thin, fragile walls. If they leak blood, severe vision loss and even blindness can result.

This tells you how important glycemic management is to preventing retinopathy. Damaged blood vessels can cause vision loss and blindness in two ways. First, fluid leaks into the center of the retina, named the macula. The fluid causes the macula to swell, blurring vision. Second, in proliferative retinopathy, new and abnormal blood vessels grow and can cause vision to blur by leaking blood into the center of the eye. This can cause scar tissue and lead to retinal detachment.

Everyone with diabetes, regardless of type, is at risk for retinopathy. The longer you have had diabetes, the more your risk becomes. The National Eye Institute says up to 45 percent of Americans diagnosed with diabetes have some form of diabetic retinopathy.

Identifying yourself as being at risk for proliferative retinopathy is macular swelling that can develop without and with symptoms. Vision can remain unaffected as the eye disease progresses. Your risk of vision loss is high. This is one reason you should have annual eye exams and why they are necessary. If you thought getting a diabetes diagnosis because you had no symptoms, diabetic retinopathy may go unnoticed before taking action. This again is the reason for having an annual eye exam and more often if needed. Vision is not something to delay until it is noticeably affected and then treatment may be less effective.

See your eye doctor right away if you notice any of these symptoms:

• Blurred vision – this is very common in people with diabetes who have unmanaged blood sugar levels even without the presence of retinopathy.
• "Floaters" that swim in and out of your vision in one eye that last longer than a few days. These may be ordinary harmless floaters, but don't take chances. If you have diabetes especially, floaters may be the sign of bleeding in the back of the eye. New floaters are always a reason for seeing an eye doctor, especially when you have diabetes.

Two treatments are used for diabetes retinopathy:

1. "Scatter" laser treatment (pan-retinal photocoagulation) is effective for treating new blood vessels before or after they begin to bleed. Severe bleeding may be treated with a surgical procedure (vitrectomy) by removing blood from the center of the eye.
2. "Focal" laser treatment may be done to stabilize vision. This therapy may reduce vision loss by up to 50 percent.

These laser treatments may reduce the risk of serious vision loss and blindness, but they cannot cure diabetic eye disease. They cannot bring back lost vision or prevent future vision loss.

Read my blog here about the Johns Hopkins study, where less than half of the adults who are losing their vision to diabetes claim they have not been informed by a doctor that diabetes could damage their eyesight. This is more than the third that don't obtain proper vision care. It is obvious that many people with diabetes do not see their eye doctors when they have diabetes. This is another reason for anyone with diabetes to have an annual dilated eye exam. Once there are noticed changes in their eyes, then people may need their eyes examined more frequently.

Managing your blood glucose levels carefully and your blood pressure within the normal range will help as well. Always follow your doctor's recommendations regarding medication, diet, and exercise.

Eye Disease - Glaucoma

Unfortunately, glaucoma is a group of related eye diseases that can cause blindness. Diabetes is one of the risks for glaucoma. Symptoms don't appear until glaucoma has already damaged the optic nerve. Intraocular pressure is usually associated with optic nerve damage. The common type of glaucoma is primary open-angle glaucoma and the causes are not understood. Glaucoma can develop without an increase in eye pressure.

People at risk can include anyone, but the following are at higher risk:

1. People who are over the age of 60
2. People of Mexican-American descent
3. All African-Americans and especially those with high eye pressure, corneal thinness, or optic nerve problems
4. People who have had a severe eye injury
5. People with certain medical conditions, such as diabetes
6. People with a family history of glaucoma
7. A person who has increased eye pressure

Often people do not have any symptoms until vision is almost gone. As the vision decreases, the person with glaucoma may notice progressive vision loss, including:

1. Developing blurry vision
2. Narrowed side or peripheral vision
3. Focusing problems
4. A halo effect around lights, which typically occurs at extreme eye pressures and acute glaucoma attacks

There is no cure for glaucoma and once vision is lost, it cannot be restored. Early detection and treatment can often protect you from severe vision loss. Glaucoma treatment may include:

• Eye drops or pills that help reduce pressure in the eye
• Several kinds of laser treatments to decrease eye pressure or to compensate for narrow angle or peripheral glaucoma
• Surgery to create a new opening for pressure causing fluid to drain from the eye

There are three types of glaucoma.

1. Open-angle glaucoma is the most common form in the United States. In this type of glaucoma, the optic nerve is damaged bit by bit. This slowly leads to loss of eyesight. One eye may be affected more than the other eye.
2. Closed-angle glaucoma is less common. About 10% of all glaucoma cases in the United States are closed-angle. In this type of glaucoma, the colored part of the eye (iris) and the lens block movement of fluid between the chambers of your eye. This causes pressure to build up and the iris to press on the drainage system of the eye. A related type is sudden (acute) closed-angle glaucoma. It is often an emergency. If you get this acute form, you will need medical care right away to prevent permanent damage to your eye.
3. Congenital glaucoma is a rare form of glaucoma that some infants have at birth. Some children and young adults can also get a type of the disease.

Early finding and treating glaucoma is important to prevent blindness. If you are at high risk for the disease, be sure to be checked by an eye specialist, an ophthalmologist, even if you have no symptoms.

If you are using medicine to treat glaucoma, take your medicine every day as directed. If you don't take your medicine, the eye pressure will increase and this may be causing permanent vision loss.

If your have lost some vision because of glaucoma, your eye doctor can refer you for low-vision services. Low-vision aids can help you make the most of your remaining vision.

Have regular eye exams every two years until age 60 and then every year afterward. I say age 50, as this is important for all eye diseases, unless you suspect vision loss, then get an appointment as soon as possible. The key to preventing glaucoma is to maintain normal eye pressure. What eye pressure level is "normal" for you? Only an eye doctor can determine this.

Remember, reducing eye pressure is the only known way to slow or stop the progression of vision loss from glaucoma. Only your eye doctor may notice high eye pressure or determine that you are at high risk for developing glaucoma. You may be asked to use eye drops or visit the doctor more often. In some people who are at risk for glaucoma, eye drop treatment can reduce the risk by about 50 percent.

What ever you do, always follow directions. If you don't trust your eye doctor, find another eye doctor if one is available.

Eye Disease - Cataracts

Cataracts used to be the most common eye problem I saw among the elderly, but I don't know if it is true any longer. When your eye's normally clear lens becomes cloudy, you have developed a cataract. Often it will start in one eye, but will eventually develop in both eyes. Cataracts are small at first and may not affect vision, but the denser they become; the more they will affect your vision. I know this as I am in the early stages and my ophthalmologist has given me a clear warning to keep my appointments. This I intend to do.

Risk factors for cataracts include:

• Most cataracts are due to aging
• Diseases, like diabetes
• Eye injury or trauma
• Eye surgery for another problem
• Inheritance or pregnancy-related causes
• Overexposure of the eyes to the sun's damaging ultraviolet rays
• Smoking
• Certain medications

The most common cataract symptoms include:

• Blurred or cloudy vision
• Faded colors
• Increased glare from headlights, lamps, or sunlight
• Poor night vision
• Multiple images in a single eye, or double vision
• Frequent prescription changes for your eyeglasses or contact lenses

For early cataracts, these steps may help:

• Obtaining a new prescription for eyeglasses or contact lenses
• Using brighter lighting
• Using magnifying lenses
• Wearing sunglasses

You may help delay cataract development by avoiding overexposure to sunlight, wearing sunglasses with ultraviolet protection, and a wide-brimmed hat. These don't help everyone, but may be worth the effort. If your everyday activities are hindered by cataracts, your optometrist or ophthalmologist will probably recommend surgery. Don't go into a panic, as surgical cataract removal is one of the safest, most common, and most effective types of surgery. Delaying cataract surgery until it interferes with your quality of life is the recommended step and won't harm your eyes.

When you choose to have surgery, you will be referred to an ophthalmologist who can perform the surgery, if you don't already have one. As part of the procedure, the eye surgeon removes the cloudy lens and replaces it with an artificial clear lens. If both eyes are in need of surgery, one eye will be done first. A month or two later, the surgery on the second eye will be performed.

Be sure you follow the instructions you receive very carefully and contact the surgeon if something does not seem correct. Very seldom will there be a problem, but by following instructions, problems will generally not happen. I know I will be facing this in a few years, so I will write about it when it happens. If you are interested, use the Google search engine and type in cataracts. After a list comes up, near the top of the page, there will be the word 'Images' (normally the second word from the left) and click on this for images showing cataracts.

Joint January Meeting

Our January meeting started with Dr. Tom (previously shown as our local doctor) addressing both groups. First, he thanked our group for the impromptu meeting earlier and expressed his thanks to Sue for bringing her relative to be tested and having her depression brought under control without the need for depression drugs. He then turned to his group and told them that thanks to this group including you, many of you will now be tested for different vitamin and mineral deficiencies that would not otherwise be considered deficient.

Next, he explained that the last few months had been intensive and he thanked us for the research we do and to his group, he asked if any of them might be interested in research. Only one person expressed any desire and he was asked to meet with us after the meeting was over.

Tim had been setting up the projector for this Oregon State University website. Dr. Tom said he wanted to start with vitamin B12 and the foods area first within B12. When Tim scrolled to Food Sources, Dr. Tom took time to read it aloud and then emphasized how important the last sentence in the first paragraph should be to everyone. It says, “Individuals over the age of 50 should obtain their vitamin B12 in supplements or fortified foods like fortified cereal because of the increased likelihood of food-bound vitamin B12 malabsorption.”

Then Tim brought up the University of Maryland Medical Center website and scrolled down to the Dietary Sources, which reads, “Vitamin B12 is found only in animal foods. Good dietary sources include fish, shellfish, dairy products, organ meats -- particularly liver and kidney-- eggs, beef, and pork.” Dr. Tom said he understands people that do not like organ meats, as they are not his favorites either. He thanked Tim for doing this as he felt both sources were important. Tim stated that both URLs would be included in the email sent about the meeting.

Dr. Tom then explained that for anyone over the age of 50 that might have fatigue or other problems discussed on either site should not be afraid to ask for the test to determine if they might have a deficiency. He would do the test and felt it was important for people to consider before doing anything about supplements. Then he emphasized that this was important for their doctor to know because of the medication conflicts between vitamin B12 and certain prescription medications, as shown at the bottom of my blog..

After some discussion, Dr. Tom called attention to the Age-Related Macular Degeneration section and told people to read this on both sites. Then he introduced the ophthalmologist and said he would talk about vision and some of the common problems for people with diabetes.

The eye doctor thanked Dr. Tom and then thanked me for inviting him to speak about problems for diabetes affecting eyesight. He explained that I had provided him with my blog on vision and the related websites and this helped explain much of what he would be covering. Next he asked if everyone had diabetes or pre-diabetes. All hands went up and he asked how many had their eyes checked within the last year. Only 16 kept their hands up. He asked if there were some that had eye exam in the last two years – only two.

Then he addressed the seven that had not raised their hands asking how many of them were on Medicare and four raised their hand. He then stated that the American Diabetes Association guidelines stated that two years was now the recommended time between appointments. He said this is not good and you should see your eye doctor for a dilated eye examination at least annually if you are over 50 years of age and annually if certain conditions exist before age 50. With some eye problems, an exam every six months is recommended.

He then asked Tim to start the slides, which showed the eye, and he pointed out what he would be able to see in a dilated eye exam. Some of the slides showed what age-related macular degeneration (AMD) looked like. Then he moved on to cataracts and had several slides showing different aspects of their development. Then he had slides showing what glaucoma looked like. He then concluded with retinopathy and how this looked in the eye exam.

He concluded that of those present, that were his patients, none had retinopathy, several had early stages of cataracts, two were being treated for AMD, and only one had early glaucoma. He then had Tim show the last three slides, which showed advanced glaucoma, cataracts, and AMD. Anyone with these stages can be diagnosed as legally blind. The good news is by discovering them early; treatment can prevent this from happening or delay the serious problem of blindness.

He concluded by saying everyone over the age of 50 should have a dilated eye exam on an annual basis if they have diabetes. Medicare does cover most of the cost and will pay for most treatments. He finished that his office will work with people that are not covered by insurance and do their best for them in getting them help. Discussion and questions followed and he took a few people aside to talk privately with them. The meeting ended and the Dr. Tom asked several of us to talk with the one interested in doing research.

The eye doctor asked if I would be writing more blogs on the eye diseases and I said I was thinking seriously about this. Since he has my address and email address he asked which format I would prefer. I said email if he didn't mind. He indicated that he had several URLs that he would send me and if I could use them he would send several images as well. We agreed and the meeting was over.

Blood Pressure Now Has New Guidelines

With the new guidelines for blood pressure (BP), I may need to talk to my doctor. My BP has been staying about 120 (systolic) over 60 (diastolic) for the last year. I don't feel dizzy when I stand up or when I get out of bed, so I don't feel any urgency to consider a change in BP medications. However, the new guidelines are much higher than my current medications are allowing me.

There are many articles and blogs now being published on the new guidelines. The first I will use is a blog by Joslin Communications and the second is a blog by Dr. Kernisan. The Joslin blog is for people with diabetes and Dr. Kernisan is about for caregivers of the elderly. I urge you to read both blogs.

Joslin Communications

The new 2014 guidelines by the National Institute of Health (Eighth Joint National Committee (JNC 8)) offer a series of changes from JNC7, which was last issued in 2003. “For those with diabetes who are older than 18 years of age, the JNC8 guidelines are in agreement with those recently issued by the American Diabetes Association. JNC8 recommends aiming for a goal blood pressure of 140mmHg systolic and 90mmHg diastolic and to use pharmacological agents if the blood pressure equals or exceeds this level.”

JNC8 based its guidelines on evidence on clinical studies that showed lower BP levels in older adults did not provide any clinical benefit. “The American Heart Association is concerned that liberalizing the goal for those older than 60 could lead to more heart disease as the consequences of high blood pressure develop over years and the studies cited by the JNC8 were not long enough to detect the damage caused by higher blood pressure levels.” At least I can agree with the AHA on this.

Blog by Dr. Leslie Kernisan – for caregivers

I must note that while I don't completely agree (See AHA statement above) she does have some good points to consider. She says, “Experts made the noteworthy decision to modify the blood pressure (BP) treatment target for adults aged 60 or older to less than 150/90—a change from the previous goal of less than 140/90 for the elderly demographic, set forth in the 2003 BP guidelines. In addition, people with diabetes or kidney disease are now advised to aim for a BP of less than 140/90, as opposed to the previous recommendation of less than 130/80.”

Dr. Kernisan advises caregivers to check their loved one's BP with a high-quality BP machine at home. She says to check their BP at the same time of day for 3 to 7 days in a row. She does recommend checking twice a day if possible. She lists a few things to keep in mind and I will quote them.

• “BP is constantly changing within the body, so a series of measurements will give you a more accurate idea of where your loved one's BP usually falls.
• Home-based BP checks have been shown to correlate better with a person's true BP than occasional office-based BP checks.
• If your loved one has recently had a fall, or if their systolic BP is less than 120, consider checking their BP both sitting and standing. If BP is dropping a lot when they stand, you'll want to ask their doctor to address this.”

She also knows patients and advises caregivers to check the actual pill bottles on a regular basis. She also cautions caregivers not to rely on a medication list provided by the doctor's office. Some doctors will keep increasing the dosage of BP medication when the real problem is that the patient hasn't been taking the pills.

If you are a caregiver, please read to the bottom of her blog as she has a free Q & A call on this topic and registration is required. She provides the link for this.