Welcome to our practice. We want to help you preserve the
precious gift of sight. We will do this by striving to provide the best possible
eye care. Your concerns and expectations are important to us. Be sure to share
with us all of your needs so that we can answer your questions and explain your
diagnosis and treatment.
OFFICE HOURS, EMERGENCIES
A staff member
is available to make appointments and answer questions during our regular office
hours Monday through Friday 7:00a.m.- 4:00p.m. Emergencies are seen right away.
After hours, Dr. Munro can be paged by dialing the office, 401-437-0500, and an
answering machine will instruct you on how to contact Dr. Munro or the doctor
who is covering. To page Dr. Munro directly, dial 401-350-0408 (touch tone phone
only). After three beeps, dial your own number and hang up. Dr. Munro will call
you back.
When scheduling appointments, please be aware that your pupils
may be dilated with eye drops. Please bring sunglasses and, although many people
can drive after dilation, we encourage you to bring a driver for your return
from these appointments.
If you are unable to keep your appointment or
are going to be late, please call the office as soon as possible. This courtesy
allows us to be of service to other patients.
DOCTOR-PATIENT
RELATIONSHIP
We want to make a special effort to explain everything
regarding your condition, medicines, treatment, surgery, ect. Do not hesitate to
ask Dr. Munro or the staff any questions. We welcome suggestions or complaints
regarding our service so we can better serve you. If at any time you want a
second opinion, we encourage you to do so. We would be happy to suggest several
specialists and send them details of your condition.
CHARGES AND
INSURANCE
Fees charged in this office are comparable to those charged by
other eye specialists in the area. Please feel free to discuss our fees with our
insurance specialist. Patients are requested to pay for office visits including
co-payments and services not covered by insurance at the time the service is
rendered. Our office does not extend credit. We participate in major insurance
plans. Participation means that we will bill your insurance company and accept
its approved amount as payment in full. You are responsible for the payment of
all non-covered services, co-payments, co-insurances and deductibles. Dr. Munro
participates in:
-Medicare -Blue Cross of Rhode Island -Blue Cross
Plan 65 -United Health Plans -Healthmate Coast to Coast -Health Care
Value Management -Blue CHip -Tufts -Harvard Pilgrim -And many other
insurances
EXAMINATION
A technician will perform preliminary
testing. This certified ophthalmic assistant will start a permanent record and
test your vision. Then Dr. Munro will examine you. When Dr. Munro has finished
his examination, he will discuss the findings with you (and your family or
friends as desired). These findings will include a diagnosis and recommendations
for further testing, medical or surgical treatment.
SURGERY AND
LASER
Dr. Munro specializes in small incision cataract microsurgery,
treatment of glaucoma and other eye diseases. Surgery is performed at East Bay
Surgery Center in Swansea, MA.
Most glaucoma laser eye treatment is
performed in the office. The laser treatment that is used to clear clouded
cataract membranes is perfomed at the East Bay Surgery Center.
Dr. Munro
is one of the first in New England to use the Heidelberg Retinal Tomograph. It
is used for optic nerve imaging for the management of glaucoma.
MEDICAL
QUALIFICATIONS
-Certified by the American Board of
Ophthalmology
-Assistant clinical professor; Brown
University School of Medicine
-Member: American Academy Of
Ophthalmology New England Ophthalmological Society, Rhode Island
Medical Society, American Society of Cataract and Refractive
Surgery
-Medical School - University of
Michigan
-Internship-Philadelphia General
Hospital
-Ophthalmology residency- University of
Pennsylvania
-Cataract & lens implant microsurgery
using no-stitch, self-sealing, small incisions
-Glaucoma
treatment
-Confocal laser scanning tomograph for glaucoma
management
-Two in-office lasers for glaucoma and secondary
cataract treatment
-State of the art diagnostic and therapeutic
equipment
Information on Perscription Glasses/Contact
Lenses
By Dugald H.
Munro, MD
WELCOME
We
are here to meet all of your vision needs in a friendly, professional manner. I
am grateful to have you as my patient and intend to provide the best eye care
available.
REFRACTION
We use an advanced technique of testing for
eyeglasses called the Clinicon method. This way of testing for glasses is
different from most other eye doctors. It makes it easier for you to give the
correct answer to "which is clearer, one or two". You may notice that most of
the time, we test your eyes for new glasses while you have your old glasses on.
The results are put into a computer, giving us numerous optical calculations
about your eyeglasses. Your eyeglasses prescription is printed out on this same
computer program. Our method of eyeglass testing is especially beneficial for
people who have stronger eyeglass prescriptions but is also very good for people
with ordinary prescriptions. We always provide you with two copies of your
eyeglass prescription. One is for your eyeglass-supplier, and the other is for
your records for future use.
EYEGLASSES QUALITY CHECK AND
GUARANTEE
I encourage you to bring your new eyeglasses here, no
appointment necessary, for a free quality control check. Our staff will
determine if your glasses were made to correlate with your prescription.
Likewise, if you ever have a question, concern or problem with your new
prescription glasses, please bring them to us. We will be happy to check them
for you. If any changes to your new eyeglasses are necessary, we will
communicate with your optical supplier. We will see to it that any changes are
done at no charge to you. This is our guarantee of satisfaction for your new
eyeglass prescription.
BIFOCALS AND TRIFOCALS
Flat Top Bifocals
(with a line) provide better reading vision than no-line (progressive) bifocals.
No-line bifocals and trifocals have the advantage of no visible line showing in
the glasses. However, there are several disadvantages to no-line
lenses: No-line lenses are more expensive than lenses with a line. In Dr.
Munro's experience, about 50% of people have difficulty adapting to, or fail
with no-line lenses. Also, it is common for a person to have had success with
their first, second, or third pair of no-line glasses, and not be able to adjust
to the next pair. This can occur if the eyeglass supplier does not center the
lenses correctly in the frames or if they change to a different lens brand (or
different lens manufacturer) than you had in your old glasses which you have
become accustomed to. Opticians can usually determine the brand and lens type of
your old glasses from looking at laser marks on the lenses. If you are buying
new no-line bifocals, be sure the optician orders the same brand and lens type
as your old glasses. No-line lenses have a narrow angle of view for reading
- about one newspaper column's width. When reading print that requires a wide
angle of view such as an 8 1/2 by 11 inch page, you may have to turn your head
back and forth, as you read, to stay in focus. No-line lenses can be
difficult to adjust to because of distortion in the lens that can cause eye
strain and blurred vision when reading. If you are an avid reader, but still
want to wear no-line bifocals, you should consider purchasing either single
vision reading glasses or bifocals-with-a-line to use when you are reading for
long periods of time. If over-the-counter reading glasses are suitable for
you, purchase these for reading (see other side of this pamphlet). Reading
vision is often clearer with inexpensive over-the-counter reading glasses than
with expensive no-line bifocals. Bifocals with a line provide extremely
sharp vision for both near and distance vision. These types of lenses have a
wide angle of view for reading. Most importantly, there is no distortion in the
reading part of these lenses, as there can be with no-line bifocals. If in
doubt, choose bifocals with a line instead of no-line (progressive)
bifocals. Trifocals with a line also provide extremely sharp vision both for
arms-length vision and reading small print. If you have an occupational or other
need to see clearly from two to four feet (such as desk work on computer and at
the same time read small print), and are age 50 or older, trifocals with a line
are an excellent choice.
PLASTIC OR GLASS LENSES
Most current
lenses are made of plastic. Although plastic is substantially lighter than
glass, it tends to scratch more easily; however, you can request scratch
resistance plastic for your lenses. High index of refraction plastic lenses,
which are thinner than regular plastic lenses are also available. These lenses
can cause distortion when looking through the periphery of the lenses and can be
difficult to adapt to in some cases. These lenses are best for people who wear
strong (thick) eyeglasses and want to have thinner lenses.
TINTS AND
SUNGLASSES
Ultraviolet light from the sun is one of the causes of
cataracts and other eye diseases. An ultraviolet absorbing tint is recommended
for everybody and can be requested for both sunglasses and clear lenses. The
ultraviolet coating adds minimal or no noticeable tint, or darkness, to your
clear lenses. A darker sunglass tint is an additional tint and is different
from the ultraviolet absorbing tint. The color and degree of darkness of the
sunglasses, or dark tint, is your choice. You can choose this tint with the
advice of your optician or optometrist when you purchase the
glasses. Anti-reflective lens coating (which is said to decrease glare from
night driving, computer screens, and light) is not recommended. In Dr. Munro's
opinion, it does not significantly reduce glare; in fact, it actually allows
more light to enter the eyes! The one characteristic of these lenses is they
will "reflect less light" to a person who is looking at your glasses. This is
not a visual benefit to you, however it may be a cosmetic advantage.
Furthermore, the coating, with time, causes smudges on the lenses which cannot
be cleaned off. This tint is sold to you at a considerable additional
cost. For sunglasses, Dr. Munro recommends polarized sunglasses. This is the
only sunglass that dramatically reduces the sun's reflection from automobiles
while driving.
OVER-THE-COUNTER (OTC) READING GLASSES
Drug store
reading glasses are useful for people who have only a slight astigmatism, who
have both eyes with similar focus, or who only need some magnification for
reading. The advantage to these magnifiers is that they are inexpensive. The
disadvantages are that they are not suitable for everyone. Wearing these lenses
will not harm your eyes. Keep in mind that the two to three dollar OTC
glasses are usually just as good as the twenty dollar OTC glasses. The
strength of glasses that is commonly available in stores are in the range of
1.25 to 2.75. Glasses strengths of 1.00 or from 3.25 to 4.00 are not commonly
available but you can purchase them on the internet. To do so, go to a search
engine such as Google and search for "reading glasses". You should experiment
by trial and error with different strength glasses so you can determine what
suits you the best. Keep in mind that you need weaker OTC glasses for the
computer than for reading and that you need stronger OTC glasses for fine close
work (or very fine print) than you need for reading ordinary print. For
instance, if you need +1.75 glasses for reading, choose a +1.25 glasses for the
computer and a +2.25 glasses for fine close work such as needle point or for
reading maps. Computer glasses should have full frames as opposed to half
glasses - this makes it easier on you neck.
CONTACT LENSES
Dr.
Munro is able to fit and provide a variety of contact lenses to meet your
individual needs. A staff member will initially instruct you about lens wear,
care and cleaning methods. We primarily dispense Acuvue brand contact lenses (
although, other brands can be ordered upon request) including: * Acuvue 2: a
two week disposable lens. * Acuvue Oasys: a two week disposable lens with
Hydraclear plus technology which provides a moist and smooth feeling lens. *
Acuvue Advance for Astigmatism: a two week disposable lens designed to provide
crisp vision to the astigmatic eye (having an oblong or football-shaped cornea).
This lens includes Hydraclear technology for all day comfort. * Acuvue 2
Colours: a two week disposable lens with a color layer to completely change or
intensify your natural eye color. * Acuvue Bifocal: a two week disposable
lens for patients with Presbyopia ( age-related close focusing problem). The
lens focuses for near and distance at the same time, which eliminates the need
for reading glasses. * Acuvue One Day: a daily disposable lens which offers
better convenience and eliminates the need for cleaning solutions. This lens is
a healthy option, as a clean lens is inserted every morning. * Acuvue One
Day Moist: similar to the Acuvue One Day lens, with a moisture-rich ingredient
added for all day comfort. All of these Acuvue brand contact lenses provide
some level of UV protection for the health of your eyes.
Information on Chalazions
By Dugald H.
Munro, MD
CHALAZION
A chalazion, or more commonly a stye, is a swelling or cyst in the
eyelid.
Symptoms
The symptoms of a chalazion include tenderness,
redness, and swelling of the eyelid. The tenderness usually clears in about one
week and is followed by a lump on the eyelid. This lump may last weeks, months,
or even longer.
If a chalazion is large and on the upper eyelid, it may
cause blurred vision by changing the shape of the eye.
CAUSE
Each
eyelid contains about 30 tiny Meibomian glands. These glands secrete an oily
substance onto the margin of the eyelid. The function of this oily substance is
to help prevent tears from overflowing the eyelid edge.
A chalazion
forms when the drainage duct from an oil gland to the skin becomes blocked. This
causes an oily secretion to accumulate inside the eyelid. Initially,
inflammation occurs and results in tenderness and swelling of the
eyelid.
After about a week the inflammation subsides and a cyst forms
inside the eyelid. This cyst is called a chalazion.
One cause of
chalazion is blepharitis, which is chronic crusting and redness of the eyelid
margins.
If you have blepharitis, it is important to treat it with warm
compresses and lid scrubs to remove the crust on a daily basis. Cleaning these
crusts every day will help prevent new chalazions from forming.
In most
cases, we do not know what causes chalazions. We do know some people have a
tendency to form multiple chalazions in different eyelid locations over the
years.
TREATMENT
1. Warm compresses
Warm compresses
should be applied by placing a warm, wet face cloth over the closed eye for a
few minutes three or four times a day. Re-wet the face cloth frequently to keep
it warm.
Repeat this for one week, or until the tenderness subsides.
2. Prescription eye drops
Dr. Munro may give you a prescription
for antibiotic/anti-inflammatory eye drops. Put this drop in the affected eye,
after the warm compresses, four times a day. Do this for about one week, or
until the tenderness disappears.
Generally, after a week, the tenderness
of the chalazion disappears, and a small hard lump may remain. At this point,
eye drops and warm compresses are not effective.
3. Massage or
expression of glandular material
If the chalazion starts to drain yellow
fluid either through the skin of the eyelid or from the back side of the eyelid,
you should squeeze the lid to express the retained glandular material. Do not do
this if the lump is deep in the eyelid or if you do not see any yellow
drainage.
4. Tincture of time
It is recommended after the initial
eye drops and warm compresses, that you should live with the chalazion and allow
nature to take its course.
If you live with the chalazion and use no
treatment, the following can happen. The chalazion can break open and drain, or
it may gradually dry up. Unfortunately, this can take months or up to a
year.
5. Surgical removal
If none of the above treatments are
effective, Dr. Munro can surgically remove the chalazion in the office. A local
anesthetic is used to numb the eyelid for the procedure.
You should have
someone to drive you home after the surgery.
Dr. Munro does not recommend
chalazion surgery unless the chalazion is large and you have tried the previous
treatments first. Naturally, if the chalazion is bothersome, do not hesitate to
have it removed.
RECURRENT CHALAZIONS
If you have chalazion
surgery, and experience a recurrence in the same location, please let Dr. Munro
know. In this case, a biopsy may be recommended in order to determine if there
is a more serious problem than a chalazion.
Contact Lenses & Giant Papillary
Conjunctivitis
By Dugald H.
Munro, MD
GIANT
PAPILLARY CONJUNCTIVITIS
Giant papillary conjunctivitis (GPC) is an
allergic reaction that occurs in some people who wear contact lenses.
SYMPTOMS
GPC causes red, itchy, dry, irritated eyes in soft
contact lens wearers. The amount of time you are able to wear your contact
lenses is reduced. The contacts do not feel that comfortable. When you put in
new contact lenses, the eyes feel temporally better.
CAUSE
It is
caused by the development of an allergy to the invisible microscopic coating of
tear protein that is deposited on the surface of the contact lenses.
The
eye has a mucus membrane of the same type of tissue as in the nose, throat, and
sinuses. In the eye, this mucus membrane is called the conjunctiva. GPC occurs
in the conjunctiva. The conjunctiva is the lining of the white of the eye and
the inside of the eyelids.
GPC occurs after a person has worn soft
contact lenses successfully for some time, usually months or years.
If
you have nasal allergies (hay fever), the conjunctiva is also affected and your
GPC symptoms will be increased.
TREATMENT
The treatment is aimed
at decreasing protein buildup on the contact lens surface. This is best
accomplished by frequent replacement of the contact lenses.
We recommend
you switch to one-day disposable contact lenses. These are disposed of daily and
new contact lenses are worn every day. This will minimize the tear protein
deposit on the contact lens surface which is causing the allergic reaction.
We fit Acuvue 1-Day disposable contact lenses.
Do not wear
contact lenses over night!
Keep in mind that GPC takes months to clear,
even if you stop wearing contact lenses.
Once you have developed GPC, it
will invariably recur if you return to wearing the same contact lenses for long
periods of time. Be advised that once you have GPC, and have switched to
daily-disposable contact lenses, you cannot go back to wearing the same contact
lens for long periods of time. This will result in a recurrence of
GPC.
Other Treatment
If, after switching to daily-wear contacts,
you still have problems, please make an appointment to see Dr. Munro because
there are prescription eye drops that will help.
Narrow Angle Glaucoma
By Dugald H.
Munro, MD
GLAUCOMA
EXPLAINED
Many people are familiar with the term "glaucoma"; however, few
people comprehend the specifics and seriousness of this eye condition. In all
variations of glaucoma, the fluid circulation through the front part of the eye
is abnormal, which causes increased pressure inside the eye. This can damage the
optic nerve and permanently destroy vision. Glaucoma is rare in young people,
but is a leading cause of blindness in people over 40 years of age.
There
are two major types of glaucoma, open angle and narrow angle. There are two
types of narrow angle glaucoma, acute and chronic.
HIGH RISK
GROUPS
Narrow angle glaucoma can develop in any person at any time of
life, but it tends to occur most commonly in the following groups:
-People who are over 40 years of age.
- People with a family
history of glaucoma. Glaucoma is hereditary to a certain extent. However,
most people with glaucoma are not aware of a family history. - People who
are highly farsighted. - People with cataracts
HOW GLAUCOMA IS
DETECTED
To accurately diagnose glaucoma, we do the following
procedures: 1) Check the eye pressure. 2) Test the field of vision
Glaucoma causes abnormal blind spots in the side vision. An instrument
called a perimeter tests the field of vision and can detect side vision loss
early in the course of the disease. Most people with glaucoma are not aware of
these blind spots in their side vision until the peripheral (side) vision is
severely damaged. 3) Examine the optic nerve Dr. Munro observes and studies
the optic nerve for any sign of glaucoma damage. He also photographs the optic
nerve using an instrument called the Heidelberg Retinal Tomograph. This is a
state of the art device that not only creates an image of the optic nerve, but
measures its topography (shape). These measurements and images become a
baseline. Dr. Munro will compare future measurements with the baseline
measurements to see if there has been any change. 4) Gonioscopy this is an
office test in which Dr. Munro observes the trabecular meshwork, which is the
place where fluid drains out of the eye.
ACUTE NARROW ANGLE
GLAUCOMA
Acute narrow angle glaucoma is a sudden build up of eye pressure
caused by a blockage of fluid flow by the iris. This can result in extremely
high eye pressure and can cause symptoms such as sudden onset of severe eye
pain, headaches, nausea, and blurred vision. If not treated immediately, the
vision damage may be irreversible. The most effective treatment is laser
therapy. This creates a tiny opening in the iris to relieve the blockage and
lower the eye pressure. The creation of this new channel, if performed early
enough, usually saves the vision and prevents future attacks.
CHRONIC
NARROW ANGLE GLAUCOMA
Chronic narrow angle glaucoma is also a buildup of
eye pressure resulting from blockage of fluid flow by the iris. Chronic narrow
angle glaucoma develops slowly and subtly. There are no early warning signs or
symptoms. It can cause extensive damage to the vision before a person is even
aware of its existence. People with this type of glaucoma will usually not
experience any pain or notice a change in vision, until the vision has been
altered severely. At this point, it is too late to repair the damage, but prompt
treatment can preserve the remaining vision. The treatment for chronic narrow
angle glaucoma is laser therapy, the same as for acute narrow angle glaucoma
(above).
FURTHER TREATMENT MAY BE NEEDED
If narrow angle
glaucoma (acute and chronic) is detected very early, the laser treatment is a
cure and no further treatment is required. On the other hand, if the
glaucoma is not treated early enough, permanent damage occurs. In these cases,
even though laser treatment is performed, scar tissue will result in open angle
glaucoma occurring in the eye. In this case, the patient will need to undergo
further treatments to control the glaucoma. The further treatments which may be
needed are: eye drops, additional laser treatments, and possible
surgery.
LASER TREATMENT EXPERIENCE
Office laser treatment only
takes a few minutes. You will experience some light flashes and perhaps a slight
sting, but it is nearly painless. The vision may be blurred for several hours,
but should return to normal the following day or even sooner. There are no
limitations afterward, although driving is prohibited on the day of the laser
treatment. One laser treatment per eye is usually adequate, but in rare cases,
Dr. Munro will recommend more if needed.
If you have narrow angle
glaucoma in one eye, laser treatment is recommended for both eyes to prevent
glaucoma in the fellow eye.
Laser treatment is covered by Medicare and
many other major health insurance plans.
Glaucoma Medications
By Dugald H.
Munro, MD
MEDICAL TREATMENT
OF GLAUCOMA
I have written this pamphlet to help you understand the
benefits and possible side effects of eyedrops and medications used by people
who have glaucoma. With a better understanding, together, we can effect the best
treatment.
HOW TO USE EYE DROPS
a. Tilt head back, open eye and
look up. b. Gently pull lower eyelid down to form a pocket as illustrated on
cover of this pamphlet. c. Place one drop into the formed pocket. If you
think you missed the eye, put a second drop in. d. Gently wipe eyelid with
tissue. e. Hold finger over tear duct as directed below.
LACRIMAL
OCCLUSION
To increase the effectiveness of the eyedrops, do the
following. After you put eyedrops in the eye, wipe eyelids with a tissue.
Immediately thereafter, put your index finger over the inside corner of your eye
and against the side part of your nose. Push gently for one to two minutes.
While doing this, you can be doing other things with your eyes open.
This
will decrease the amount of drug which gets in your body through the tear duct,
thus decreasing systemic side effects. It will also increase the amount of drug
which gets into your eye where the drug is needed. If you are using more than
one eye drop, wait five minutes before you apply the second drop.
SIDE
EFFECTS OF DRUGS USED FOR GLAUCOMA
Xalatan, Travatan, Lumigan Eye
drops
These drops are the most effective of all the eye drops for
lowering the eye pressure and they only have to be used once a day. The
following side effects occur in a low percentage of people; eye redness, foreign
body sensation, itching, eye dryness, tearing, and sensitivity to light. These
drops can cause the eyelashes to grow longer. These side effects are not
considered serious.
Another side effect that occurs in a small percentage
of people, is the color of the eye(s) might be made darker. This is a permanent
change and does not effect the vision, but for some, is a cosmetic problem. If
you notice the color of your eye(s) becoming darker, stop taking the eye drop
and call the office.
These medications are used once a day at bedtime
(Xalatan can be used anytime after 6:00 pm).
Xalatan should be stored in
the refrigerator until it is opened. Once the bottle has been opened, it may be
stored at room temperature as long as you are using the drops daily. Travatan
and Lumigan do not have to be kept in the refrigerater.
These beta
blocker drugs are usually well tolerated by most people. Systemic side effects
include low blood pressure, reduced pulse rate, fatigue, asthma, shortness of
breath, dizziness, depression, impotence and others. These drugs should be
avoided, or used with caution, in people with asthma, emphysema, congestive
heart failure, or those who have slow heart rates.
Trusopt and Azopt Eye
drops
Trusopt and Azopt Eye drops can have side effects, but serious side
effects are rare. These eye drops can cause a bitter taste in the mouth after
putting them in the eyes. These drops can cause stinging or burning immediately
after putting them in the eyes. They can cause redness of the eyes, foreign body
sensation, blurred vision, tearing and dryness. These eye drops are a form of
sulfa, so if you are allergic to sulfa, you cannot take these eye drops. These
drops are used either two times a day (every 12 yours) or three times a day
(every 8 hours).
Alphagan-P and Alphagan Eye drops
Side effects,
which occur in a low percentage of people, include dry mouth, red eyes, burning
and stinging, headache, blurring of vision, foreign body sensation, fatigue, and
allergic reactions. These side effects are not considered serious. Alphagan is
used either two (every 12 hours) or three times a day (every 8 hours).
ALLERGIES
Some eye redness with certain glaucoma medications is
common. However, if your eyes or eyelids become itchy, red, swollen or sore, you
may have a medication allergy. These symptoms should be reported to Dr. Munro.
SIDE EFFECTS
Keep in mind that people can experience systemic
(bodily) side effects caused by eye drops. Please make sure your medical doctor
is aware of all the eye medication you are taking. If you think you are
having side effects or allergies from eye drops, please call Dr. Munro.
Heidelberg Retinal Tomography
By Dugald H.
Munro, MD
HEIDELBERG
RETINAL TOMOGRAPHY
Dr. Munro provides the most up to date state of the
art technology for the management and treatment of glaucoma. He was one of the
first in the country and the first in New England to use HRT for the benefit of
his patients.
The Heidelberg Retinal Tomograph (HRT) is an advanced
medical instrument used for imaging and measuring the optic nerve in glaucoma
patients.
The HRT uses a confocal laser-scanning camera, which enables
it to take a picture of the optic nerve and measure its topography (shape) at
the same time. These measurements are saved and are used as a base line for
future comparison.
HRTs are typically done annually. After the second
set of HRTs is done, a computer compares the two HRT images to determine if
there has been a change in the optic nerve during the previous year.
Our
goal in glaucoma treatment is to preserve the optic nerve over time. In order
for Dr. Munro to know if there has been a change (or no change) in the optic
nerve, precise measurements are necessary for comparison. HRT measurements are
extremely accurate and reproducible. The HRT can detect slight optic nerve
changes even before the patient notices any problem with vision.
WHAT TO
EXPECT WHEN HAVING AN HRT
During this painless test, a patient sits with
his chin and forehead placed against adjustable rests. A technician focuses a
special camera with a red light on the eye and takes three to five pictures per
eye.
The images will be most accurate if you do not move your eyes when
the picture is being taken. During the test, hold very still with both eyes wide
open. The test takes five minutes or less per eye.
GLAUCOMA CAUSES OPTIC
NERVE CHANGE
Glaucoma is basically a disease of the optic nerve. The
optic nerve consists of one million individual nerve fibers that conduct
information from the eye to the brain. As glaucoma advances, optic nerve fibers
are lost permanently, causing a larger ?cup? or topographical depression of the
optic nerve center. When this occurs, the rim of the optic nerve becomes
smaller.
The HRT measures the size and shape of the ?cup? in the optic
nerve as well as the surrounding rim.
Many people have the impression
high eye pressure is the only cause of glaucoma. However, there are many causes
of glaucoma. They include abnormal blood circulation, age, heredity, race, eye
pressure, and other health factors.
SUMMARY
The type and amount of glaucoma
treatment needed depends on whether the optic nerve is remaining stable or
getting worse.
If the follow-up HRT indicates the optic nerve has
remained stable, the present treatment is adequate and no change in the
treatment is recommended.
If the follow-up HRT indicates the optic nerve
has changed for the worse, more treatment is recommended. This may include
additional eye drops, laser surgery, or operative surgery.
Open Angle Glaucoma
By Dugald H.
Munro, MD
OPEN ANGLE
GLAUCOMA EXPLAINED
The cause of glaucoma is increased pressure in the
eye. This occurs because the fluid drainage out of the eye becomes partially
obstructed. Fluid is constantly pumped into the eye (which is a closed system)
so an outflow blockage causes increased pressure within the eye. The increased
pressure can damage the optic nerve in the back of the eye and cause vision
loss.
There is usually no cure for glaucoma; however, early detection
and treatment can preserve vision in almost all cases.
HIGH RISK
GROUPS
Glaucoma can develop in any person at any time in life, although
it is more common in older people. Glaucoma is a leading cause of blindness in
people over 40 years of age. It is found most often in the following
groups:
-Those with a family history of glaucoma
-Those with
diabetes
-African Americans
HOW GLAUCOMA IS DETECTED
To
accurately diagnose glaucoma, the following examinations are done: 1) Measure
the eye pressure. 2) Visual field examination Glaucoma causes abnormal
blind spots in the side vision. This test can detect side vision loss before
people are aware of any loss. 3) Examine the optic nerve Dr. Munro uses a
state of the art instrument called the Heidelberg Retinal Tomograph (HRT) to
photograph and analyze the optic nerve. The HRT creates an image of the optic
nerve and measures its shape. The first HRT test is a base line measurement.
Future HRT tests are compared to the base line in order to detect any possible
change in the optic nerve. 4) Gonioscopy In this test, Dr. Munro observes
the trabecular meshwork. This is where fluid drains out of the eye.
OPEN
ANGLE GLAUCOMA
The most common type of glaucoma is open angle glaucoma.
It has been called "the sneak thief of sight" because it can steal vision while
the person is unaware of any problems. It is dangerous because it progress
gradually without any warning symptoms. This is the reason why fifty percent of
people with glaucoma do not know that they have it. Glaucoma is usually
discovered during a routine eye exam in people who have no visual complaints.
HOW GLAUCOMA IS TREATED
There a three ways to treat glaucoma.
Prescription eye drops, which lower the pressure, are generally recommended
initially. If the eye drops do not control the eye pressure adequately, laser
treatment is advised. If eye drops and laser treatment do not control the eye
pressure, surgical intervention is recommended.
Prescription eye drops
reduce the production of fluid in the eye or increase the drainage of fluid from
the eye, thereby reducing the eye pressure. Laser treatment, called argon
laser trabeculoplasty and selective laser trabeculoplasty, decreases the eye
pressure by making tiny stretch marks near the trabecular meshwork. These
stretch marks allow the thousands of tiny openings in the meshwork to enlarge
which allows more fluid to drain from the eye. This lowers the pressure.
This laser treatment which I do in my office and at East Bay Surgery Center,
is painless and only takes three to four minutes. In four out of five cases it
is very effective in lowering the eye pressure. Sometimes, two laser treatments
per eye are required, done moths or years apart. After the laser treatment the
vision will be slightly blurred for up to an hour. You will be able to drive
after about an hour. The laser treatment has virtually no downside risks and
complications are very unusual. Generally, people who have the laser procedure
must also take eye drops that lower the eye pressure-but not as many eye drops
than if they didn't have the laser treatment. An alternative to laser
treatment is taking additional eye drops. The disadvantages of taking additional
eye drops are more expense, inconvenience, and the possibility of side effects.
If the treatment with medication is not effective, a glaucoma operation,
called trabeculectomy may be necessary. This surgery creates a new opening for
fluid to drain from the eye, therefore lowering the pressure. Very few people
with glaucoma will require this surgery.
Normal Pressure
Glaucoma
In one-third of the people with glaucoma, optic nerve damage can
occur, even though the eye pressure is normal. This condition is called normal
pressure glaucoma. Recent studies have shown this problem is caused by slowed
blood circulation to the optic nerve or high eye pressure spikes which occur in
the middle of the night. This type of glaucoma is very effectively treated by
keeping the eye pressure extra low, with the use of eye drops, laser or
surgery.
THE GOAL OF GLAUCOMA TREATMENT
For the best treatment of
glaucoma, it is essential to have eye exams periodically, typically every three
months. It is also essential to take your prescription drops
regularly. Treatment of glaucoma is done to prevent permanent loss of vision
or blindness in the future. The loss of vision from glaucoma can be prevented
but once lost cannot be restored. This is why it is so important that you take
your eye drops as regularly as prescribed.
If your income is low and you
cannot afford to buy the drops, check with Dr. Munro or his staff and we may be
able to get the drops at a reduced price or free of charge.
Astigmatsim Surgery
By Dugald H.
Munro, M. D.
WHAT CAUSE
ASTIGMATISM?
Astigmatism is caused by an irregular curvature of the
cornea. This causes blurred vision. The cornea is the front-most part of the eye
located over the colored iris. It functions as a lens for focusing light rays to
the back of the eye. Normally, the cornea has a round shape like a basketball.
Astigmatism is caused by the cornea having an oblong shape like a
football.
HOW IS ASTIGMATISM CORRECTED?
Astigmatism causes blurred
vision for both near and distance. It can be corrected by glasses, contact
lenses, incisional surgery, laser surgery, or toric lens implants. Ordinary
cataract surgery does not correct astigmatism. You will need to wear glasses
after cataract surgery if you have astigmatism. Dr. Munro corrects astigmatism
corrected by either a toric lens implant or limbal relaxing incision.
TORIC INTRAOCULAR LENS IMPLANTS
This is a special-order
intraocular lens implant used at the time of cataract surgery, that corrects
astigmatism. It is specialized to your particular needs. The advantage is this
is a more precise method of correcting astigmatism than limbal relaxing
incisions. For large amounts of astigmatism, a toric lens implant can be used in
conjunction with a limbal relaxing incision.
LIMBAL RELAXING
INCISIONS
Incisional surgery to correct astigmatism is called limbal
relaxing incisions. The advantage is it doesn?t require a special implant like
the toric implant so that it can be done in conjunction with an implant that can
correct both near and distance vision without glasses. Dr. Munro performs limbal
relaxing incisions at the time of cataract surgery or in the office.
WHAT
ARE THE POSSIBLE COMPLICATIONS OF ASTIGMATISM SURGERY?
Complications of
astigmatism surgery or toric implants are unlikely. Rarely the astigmatism may
become worse. This is an unusual occurrence and can be corrected by wearing
glasses. There can be other complications which are very unusual.
WILL I
NEED GLASSES AFTER ASTIGMATISM SURGERY?
Patients who have astigmatism
surgery usually are less dependant on the use of eyeglasses. Reading glasses
will probably still be needed unless you choose a special implant designed to
focus for both near and distance. Astigmatism surgery will make it more likely
that you will be able to read clearly with inexpensive over-the-counter reading
glasses after a standard lens implant rather than expensive prescription
glasses. However, because each eye reacts differently to surgery, there is no
guarantee you will not have to wear glasses all the time after limbal relaxing
surgery or toric lens implant surgery.
HOW DOES ASTIGMATIC KERATOTOMY
CORRECT ASTIGMATISM?
Astigmatic keratotomy corrects astigmatism by
changing the curve of the cornea from its abnormal oblong shape (like a
football) to a normal round shape (like a basketball).
DOES HEALTH
INSURANCE COVER ASTIGMATISM SURGERY OR TORIC LENS IMPLANTS?
Health
insurance or Medicare does not cover limbal relaxing incisions. Health insurance
or Medicare only cover a small part of a toric lens implant. Cataract surgery
with a standard lens implant is covered by health insurance and Medicare. You
will be responsible for a $500.00 charge (not covered by health insurance) if
you decide to have a limbal relaxing incision for astigmatism unless you have
chosen an implant* that focuses both for near and distance. In this case, the
limbal relaxing incision is included in the additional charge for the special
lens implant. You will be responsible for an additional charge (not covered
by health insurance) if you choose a toric lens implant. Please decide prior
to cataract surgery if you want astigmatism correction and let Dr. Munro or his
staff know. Dr. Munro can arrange for financing so you can pay for it over
time. *This is not covered by health insurance or medicare.
Intraocular Lens Implant Options
By Dugald H.
Munro, M.D.
IMPLANTS THAT
ALLOW FAR AND NEAR FOCUS WITHOUT GLASSES
There are three lens implants
available that give both reading and distance focus without glasses. A
multifocal implant is a lens that has two different lenses built into a single
implant. There are two of these implants available, the ReSTOR lens and the
ReZoom lens. The third implant is the Crystalens, which is an accommodating
lens. This lens focuses for near and distance like the natural human lens or a
camera lens.
MULTIFOCAL LENS IMPLANTS
Multifocal lenses (ReSTOR
or the ReZoom) simultaneously focus for near and distance. The advantage of the
ReSTOR lens is the near reading vision is the best of the three lenses but
arms-length vision (computer and desk-work range) is not as good as the ReZoom.
The advantage of the ReZoom lens is that arms-length vision is good, but near
reading vision is not as good as the ReSTOR. The disadvantage of both the
ReSTOR and ReZoom lenses is they cause glare and halos when driving at night and
at other times. This will usually partially improve with time. ReSTOR and
ReZoom are not recommended for people who have, or are at risk of developing
macular problems, such as macular degeneration or diabetic retinopathy. The
Crystalens is a lens that accommodates. This means it focuses for near and far
by moving forward and backward in the eye as your gaze goes from near to far. It
has significantly less glare and halos than the ReSTOR or the ReZoom
implants. The disadvantage of the Crystalens is that it is not as good for
reading very small print as the ReSTOR and the ReZoom. You might need to use
weak reading glasses with the Crystalens. You should be able to read medium to
large-size print without glasses.
NEED FOR GLASSES
With ReSTOR,
ReZoom or Crystalens implants, there is no guarantee you will not have to wear
glasses all the time. The goal is to lessen your dependency on glasses, not to
totally eliminate the use of glasses. None of these implants will make your
focus as good as when you were 18 years old.
MONOFOCAL
IMPLANTS
The standard monofocal implants Dr. Munro uses are of extremely
high quality and give extremely good vision. The disadvantage is you will be
more dependant on the use of eyeglasses for reading. These monofocal lens
implants are covered by health insurance and Medicare.
HEALTH
INSURANCE
The ReSTOR, ReZoom, and Crystalens are only partially covered
by Medicare and other health insurances. There will be an additional
out-of-pocket charge to you if you choose one of these lenses. Dr. Munro can
arrange financing so you can pay for these non-covered implants over time. If
you need surgery to correct astigmatism and choose one of the implants that
correct distance and near without glasses, the cost of astigmatism surgery is
included in the additional charge for the implant. Astigmatism surgery
provides sharper vision, without glasses, in people with both monofocal and
multifocal implants. If you have chosen a standard implant, there is an
additional charge for astigmatism surgery that is not covered by your insurance
company. Please read the astigmatism surgery pamphlet. When deciding what
type of implant to have, please factor the cost of a lifetime of buying
eyeglasses into your financial consideration. Please let us know if you want
one of these implants, otherwise a standard implant will be used.
HOW
DOES DR. MUNRO DETERMINE THE POWER OF THE LENS IMPLANT?
We measure the
length of the eye from front to back and the curvature of the cornea using the
Carl-Zeiss-Meditec IOL Master. There are different methods of obtaining these
measurements; however, the IOL Master is considered the most accurate method.
Accurate measurements are important because the increase the chance that you
will see clearly without glasses after surgery. Only 40% of ophthalmologists in
the United States have this instrument.
YAG Laser Capsulotomy
By Dugald H.
Munro, MD
YAG LASER
CAPSULOTOMY
Months or years after successful cataract surgery, a gradual
blurring of vision occurs in a small percentage of people. This is caused by a
cloud which forms on what is called the "capsule". The "capsule" is the part of
the original "human lens", which is left in the eye and holds the lens implant.
A YAG laser is used to clear this cloud in the capsule. This procedure is done
in the office.
THE LASER CAPSULOTOMY EXPERIENCE
You will sit in
front of the laser with your chin and forehead against some rests. No needles or
incisional surgery is required. The laser procedure takes about 3 minutes and is
painless (the capsule contains no nerves, so pain cannot occur). During the
laser treatment, please hold as still as possible. Also, please continuously
press your chin down into the chin rest and your forehead forward against the
forehead rest. This will help stabilize your head so it won't move.
During the procedure you will see some light flashes. Immediately after
the laser treatment, the vision will be temporarily blurred because of the
dilating eye drops used prior to the treatment. It usually takes a number of
hours for the vision to clear after the laser treatment. There is no limitation
to activity after laser treatment. When you leave the office after the laser
treatment, you can resume full activity such as working, exercising, lifting
heavy objects, using your eyes, etc. Do not drive until you feel your vision is
clear enough to drive. Most people start driving within 24 hours.
HOW THE
YAG LASER CLEARS THE CLOUD
Laser light enters the eye through the clear
cornea and clear lens implant. The focus of this light is concentrated at the
capsule. It clears the cloud in the capsule by removing a small part of it. This
clearing is only done in the central area of the capsule. Laser treatment only
has to be done once, because the capsule will not cloud over again.
WHAT
ARE THE COMPLICATIONS TO THIS LASER TREATMENT?
There is a very low rate
of serious complications to this procedure. Retinal detachment is a complication
and occurs in a very low percentage of cases. If it occurs, it can be treated
successfully in most cases.
