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.

EHR Flawed and Open to Fraud

I am not concerned which name you use for medical records, but the opportunity for fraud and misuse of our medical records is becoming part of the medical problem in rising costs. I have not seen many great articles about this problem, but the NY Times is one of the better articles. The other problem I am seeing very little about is the electronic theft of many medical records from doctors' offices and hospitals.

The federal government is spending more than $22 billion to encourage hospitals and doctors to adopt electronic health records (EHRs). You would think that with this money would come some safeguards to prevent inflating costs and over billing. This is the second report issued in two months by the Office of the Inspector General (OIG) for the Health and Human Services Department, but to date, no one shows any concern.

According to the report, the government has directed very little attention to prevent fraud and other abuses of EHRs. Medicare has not changed how it detects fraud and has provided its contractors with limited guidance. The OIG report was critical of the copy and paste function available in many of the largest electronic health record systems. The result, some critics say, is that hospitals and doctors are overcharging Medicare for the care they are providing. The report did not estimate the amount of fraud that may be occurring, but earlier government estimates have said it could run in the hundreds of millions of dollars. Although the amount is a fraction of the trillions of dollars spent annually on health care, the lack of safeguards at a time when the new technology is becoming pervasive could allow the fraud to balloon.

In the prior report, the OIG found that three-quarters of the hospitals it surveyed had no formal policy for the use of copy and paste for electronic records. Of course, Medicare officials said preventing fraud is a top priority. This has been a statement that has been overused year after year and fraud continues. We always hear about it when a big fraud case is stopped, but we seldom hear about other fraud being stopped much less prevented.

I am not reassured by their statement that they are developing better instructions for their contractors. Then they dispute the OIG recommendation about how contractors should detect fraud. Apparently, if as hospital says it has something in place, the hospital should not be inspected. I say this is when inspection becomes necessary as they are probably hiding something. From my short stint as an auditor, I know this was generally true.

I find the statement by Linda E. Fishman, a senior executive for public policy at the American Hospital Association even more suspicious. When she says, “Hospitals already have strong safeguards,” she is just attempting to close the door when the horses have already gone.

The one statement I do believe is this by Dr. Ashish K. Jha, professor of health policy at the Harvard School of Public Health, who states, “As much as electronic records have the potential to provide better care, many are disappointed in the current technology. The boosters of electronic health records spent a lot of years overhyping and overselling it.”

Please read the NY Times article.

Medical Research May Now Be Beyond Redemption

The source of this blog is a Scottish General Practitioner, Dr. Malcolm Kendrick. What he says is very true and I would agree with him. He states that medicine today is heading in the wrong direction with over-diagnosis and over-treatment. In other words, polypharmacy is becoming a massive problem.

This is driven mainly by the pharmaceutical industry – an industry that wants to see the entire population of the world taking medication every day and forever. He clearly says that the industry has grabbed hold of medical research and twisted it to their own ends.

I would caution that in reading his blog, many spellings are not American, but British spellings. He quotes an article from the British Medical Journal (BMJ) and adds comments to avoid copyright quarrels. I will encourage you to read his blog, as I will summarize for my understanding. Dr. Kendrick says this about the BMJ - they are the only major journal that seems keen to criticize the industry.

Evidence based medicine (EBM) was opposite the drug industry in the 1990's. Doctors could ward off an army of pharmaceutical representatives because their promotional material was devoid of evidence. About the turn of the century, the drug industry realized that EBM was an opportunity rather than a threat, and when published in a prestigious journal was worth more than thousands of sales reps.

Today, without evidence, there is no seat at the guideline table. This is now the elephant in the room because the drug industry controls and funds most research. The drug industry and EBM have set about legitimizing illegitimate diagnoses and then widening drug indications. Today doctors can prescribe a pill for every ill.

The 66 percent increase in prescription in one decade in England does not reflect a true increase in burden of illness or an ageing population, just polypharmacy supposedly based on evidence. The drug industry’s corporate mission is to make us all sick, regardless of how well we feel.

Clinical research in now corrupt and the promotion is passed off as postgraduate education. I suspect that medical schools will be the next area for expansion to recruit doctors in the formative years. Then when they graduate, they will promote polypharmacy.

Dr. Kendrick says we are at a crisis point. Medical research today is almost beyond redemption. I know he is talking about England, but this applies to the United States as well and the drug industry has bought their way into most research and is strongly influencing doctors in their prescribing habits. When we have the American Association of Clinical Endocrinologists training the drug reps how to promote drugs more effectively, most officers of the ADA and AACE having large conflicts of interest as well as many of our doctors getting paid for speaking, and promoting different medications by the drug industry, what are we to think.

Frozen Shoulder – Diabetes Related?

This is a topic I have been requested to write about by a reader, but since I have been fortunate not to have this problem, I will be pulling information from several sources. Basically, at present, there is little known as to the cause and often this cannot be determined. Yes, they know what happens – inflammation and the arm is stiff and difficult to move freely.

Most of the time there is no cause for frozen shoulder, but the risk factors include:

• Cervical disk disease of the neck
• Diabetes
• Shoulder injury
• Shoulder surgery
• Open heart surgery
• Thyroid problems

These are the most known and there may be other reasons for frozen shoulder or adhesive capsulitis as it is medically named. I think that the Mayo Clinic oversimplifies when they declare - “Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so that it can move more freely.”

The U.S. National Library of Medicine gives the main symptoms as:

• Decreased motion of the shoulder
• Pain
• Stiffness

Frozen shoulder without any known cause starts with pain. The pain prevents you from moving your arm. Lack of movement leads to stiffness and then even less motion. Over time, you become unable to do movements such as reaching over your head or behind you.

Frozen shoulder occurs:

• After surgery or injury.
• Most often in people 40 to 70 years old.
• More often in women, especially in postmenopausal women, than in men.
• Most often in people with chronic diseases.

A doctor will normally ask you for symptoms and examine your shoulder and let you demonstrate the range of motion. Often the doctor will make a diagnosis when you are unable to rotate your shoulder. Some doctors will x-ray the shoulder and others will use an MRI to look for inflammation. X-rays are used to eliminate other problems, such as arthritis.

Treatment will also vary by the doctor. Many doctors will only treat the pain with nonsteroidal anti-inflammatory medications (NSAIDs). Others will treat with steroid injections and refer you to physical therapy, which often improves your motion.  I can only trust that it takes a few weeks to see improvement and up to nine months for a complete recovery. Physical therapy can be intense and needs to be done every day. Some have said that if left untreated, the frozen shoulder often becomes healed within two years with little loss of motion.

Risk factors for frozen shoulder, such as diabetes or thyroid problems, should also be treated. Surgery is recommended if nonsurgical treatment does not work. Shoulder arthroscopy is done under anesthesia and scar tissue is released to bring the shoulder through a full range of motion. This surgery may also be used to cut tight ligaments and remove the scar tissue. Pain blocks are given so participation in physical therapy is not hampered.

People with diabetes that maintain excellent management are less likely to get frozen shoulder, but some still do even with excellent management. Always contact your doctor if you develop shoulder pain that limits your range of motion. Early treatment and physical therapy helps prevent stiffness.

Tom Ross at Not Medicated Yet published a blog review of his episodes with frozen shoulder on January 13, 2014. You may also wish to read a 2004 blog by David Mendosa.

Pharmacists Now Doing More for People With Diabetes

I must admit my feeling about the help that pharmacists are providing to people with diabetes is very positive. Pharmacists are stepping up their public relations (PR), putting their activities into action, and doing a lot more for all people with diabetes than certified diabetes educators (CDEs) have done in a long time.

This action started five years ago in a hunt for the cause of hypoglycemia in the 11 hospitals in the BJC HealthCare system according to Paul Milligan, PharmD, medication safety officer at BJC HealthCare in St. Louis, Missouri. First they realized that adverse drug events were responsible of 20 percent of the preventable harm that occurred in their system. Next they lead a multidisciplinary mission to reduce them.

What they discovered was that 77 percent of the adverse events were caused by severe hypoglycemia. Dr. Milligan described this as a hidden epidemic that was not on anybody's radar. This was discovered by working with each hospitals informatics department to track the origin of drug events. That revelation presented particular challenges. Hypoglycemia has assorted and complex root causes - from prescribing, to drug administration, to patient compliance, to food issues, to equipment variances. Dr. Milligan explained that the population available to study was very large — about a third of the patients in the system had diabetes.

This was not what they had expected, but because clinicians mainly focus on the primary reason the patient is admitted to the hospital, and diabetes is often secondary.  Making the problem even more complex was when pharmacists teamed up with physicians, nurses, dietitians, and diabetes educators to study the problem at 11 hospitals in the BJC system. This team discovered that each hospital had a different primary root cause for the hypoglycemia. At one hospital, the 3 people delivering the food, testing the blood, and delivering the insulin came in at different times, so could not perform their actions simultaneously, which is preferable. At another hospital, admitted patients were getting fewer calories than they did at home, but were receiving the same medication dose, which caused blood sugar to drop.

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Once the root causes were determined, the team developed procedures customized to each hospital. That was one key to BJC's success, because they didn't try to implement one standard list across all the hospitals. We dealt with the biggest problem at each hospital, and sometimes only on the problem floors. You get a big impact and bigger buy-in if staff can see direct results.

“Elizabeth Pratt, DNP, RN, from Barnes-Jewish Hospital, which is part of BJC HealthCare, said some of the problem was a lack of awareness among clinicians about hypoglycemic trends in patients and a lack of automated triggers that would alert clinicians to monitor glucose levels.”

"With heightened awareness and an alert system, we're able to recognize those people earlier, have a multidisciplinary discussion with the nurses, pharmacists, and physicians," and ask whether the regimen should be adjusted, she said.

Now that the initial problems are under control, Dr. Pratt has taken over maintenance of the program, system-wide. In 2014, the program will be expanded to include the prevention and treatment of hyperglycemia, she reported.

Now, instead of an average 138 such events per month, the system averages in the 30s, said Paul Milligan, PharmD, medication safety officer at BJC HealthCare in St. Louis, Missouri. The team has been credited with preventing more than 2100 hypoglycemic events, which saved 8127 inpatient days and more than $7 million in hospital costs.