Is glaucoma eye-drops compliance that difficult?

Is glaucoma eye-drops compliance that difficult?

A patient's perspective

By Sam Fong, Alpha-C Support Group, Glaucoma Society (Singapore)

Far too many glaucoma patients have lost too much of their sight, much too early and unnecessarily, due to non-compliance on the use of their eye-drops. The correct use of eye-drops is surprising low even among the educated population. What are the reasons?

Eye-drops - a symptom reliever
We take our medicine by habit. Traditionally, eye-drops have been primarily seen as lubricants for dry eyes and to be used as and when required. Very few instructions are given to the user other than the drops should get into the eye. Even if it overflows the eye lids, it is acceptable. After the application, the user feels almost immediate relief from the discomfort. So, the feedback is that eye-drops produce good results and when eye is better, the drops are no longer required. It is also the same with pills. A 3-times-a-day medicine does not mean an 8-hourly cycle - you would often take it after breakfast, after lunch and after dinner, or at your leisure. In most common ailments, medication relieves the symptoms of pain or discomfort while the body's immune-system performs its own auto-healing process. Thus, you can get well, with or without medicine, albeit with a little more suffering along the way. Therefore, a patient's views of medicine are gathered through their common experiences. And, however you take your medicine, you usually do get well eventually!

Glaucoma Eye-drops - a pressure regulator
However, with glaucoma, it is not quite the same story. It is not a common experience and the normal technique does not apply. This is because, when you have glaucoma, your eye’s auto-regulation system has failed. Eye-drops are no longer a symptom-reliever but now acts as a regulator of intra-ocular pressures (IOP) in the eye. You can say it is like the pace-maker used to regulate the heart beat and stopping the pace-maker will cause the faulty heart to function erratically. So it is with the eye. When your application of IOP-lowering eye-drops are stopped or not regular, the unregulated glaucomatous eye pressure may fluctuate diurnally by as much as +10 mmHg from its low.

First, we need to try to understand how glaucoma is treated with the use of eye-drops. Currently, the only available treatment for glaucoma is by lowering the IOP. We can do this by taking medicine in the form of tablets, using eye-drops or by surgery where an alternate drainage path is created for AH (aqueous humor) outflow. It is quite obvious that tablet intake is probably the least effective means for lowering IOP in the eye because the medicine is not directly applied to the eye and that surgery is the most effective because it directly and physically creates a vent in the eye for pressure relief.

No feedback indication
What makes it difficult for the patient to understand the usefulness of the eye-drops is that the pressure in the eye is awfully low. Take a drinking straw and fill it with water to 150mm height and hold it against your arm and you will feel nothing; double it to 300mm water height and again you will feel nothing pressure-wise. This represents the limits of the range of pressures between 11 and 22mmHg. The eye-drops in most instances are trying to regulate the IOP in the patient*s eye within this range and to find a "safe" level required by the patient. And because the patient cannot feel the effects physically, the patient cannot appreciate the usefulness of the eye-drops. The process is unable to provide a system of positive feedback that can be measured by the patient. In the case of diabetes, the patient is able to measure daily his blood-sugar level and gauge his compliance but this is not quite the case with glaucoma. With glaucoma, the patient can only get the performance-feedback at his next clinic visit, which may be 5 to 6 months later.

There are various causes of non-compliance in the use of eye-drops. Broadly we may classify them into two groups:-

1) failing to take prescribed doses at recommended intervals
2) failing to dispense the correct dosage due to wrong techniques

Unclear Prescription Convention
It is traditional in medicine prescription to use the day to represent the interval of dosage and then specify the number of times they have to be taken, often before or after food. Thus this practice is also applied to glaucoma eye-drops - do you apply nightly, twice a day, three times a day, or four times a day? The day is taken as the yardstick. What then about the night? Does one sleep through it without medication? If the patient sleeps 10 hours a day, what happens to the 3 or 4 times a day dosage interval? It is possible in such instances that the eye-drops would have over-regulated the IOP during the wake-hours and under regulated the IOP during the sleep-hours. This can only lead to undesirable results for patients with "spiked-up" IOPs during the night.

If the traditional prescription methods are confusing, then change them. Perhaps it may be better to base the application times on a 24-hour day (inclusive of the night) - applying eye-drops 12 hourly, 8 hourly, or 6 hourly - instead of the 2x, 3x or 4x per day convention. In this way, the time of dosage each day will be the same and much easier to remember. This makes the exact dosage times clearer and helps the patient to be more disciplined. The patient will also have a better idea of the dosage interval and plan ahead. Thus, if adherence to a 6-hourly dosage schedule is not possible for the patient because his work, age, health etc, it would be better that the ophthalmologist prescribe eye-drops which have longer effectiveness. Studies show that greater compliance is seen with lower-dose frequency and falls sharply as the frequency is increased. With once-a-day dosage, 75% of patients use their drops regularly. But, the patients' compliance falls to 40% when the dosage ís increased to a 6-hourly schedule.
Consumption rates of common dosing schedules are around 80% when the drops are taken by patients who are on a once-a-day dose; and falls to 50% when patients are placed on 6-hourly dosages.
Though the consumption rate looks better, the time interval of application has often been compromised. Often non-compliance may be due to:-

• 1) Lack of planning
  2) Forgetfulness
  3) Change of daily schedule
  4) Confusion about instructions
  5) Cost of the medicine

Proper Instilment
However, getting the correct timing for dosing is only one aspect of compliance. The other, which is more difficult to manage, is getting the necessary dosage into the eye where it is required. Here, tablets have the advantage over eye-drops for compliance because the former can be counted but the latter is difficult to measure. An eye-drops dispensing bottle is designed to release one drop-size at a time into the eye. Most eyes are capable of receiving at least 0.8 of a drop-size. Three things can happen to a drop when instilled:-

1) some over-flow the rim of the eye
2) some gets drain out through the tear duct
3) some gets absorbed by the eye - the only useful portion

Depends on Patient, his Patience and Persistence
The objective is to allow as little of (1) and (2) to happen and as much of (3), which is the only useful portion of the eye-drop, to take place. The eye-drop must get to the eye to do its job. How much of the drop is going to be effective depends on the patient, his patience and his persistence. Too little of (3) would result in partial compliance or lack of efficacy. How much of the drop should do useful work i.e. (3) is a chicken-and-egg issue. The test is, if by maximizing the usefulness of the drop will maximize the IOP lowering, the maximum usefulness should logically be targeted. It saves money, it gives less side effects.

Consider a Case Study. Let us say that a control patient needs a 35% IOP reduction to reach the target pressure. Assuming that, with this patient, the prescribed eye-drop is capable of lowering the IOP by 40% if optimal efficacy is practiced but only 20% was obtained due to poor but consistent application. As a result, on examination of the optic nerves and visual field results, the ophthalmologist prescribes to add on another eye-drop so as to lower the IOP further by another 20% and the target IOP was met. Note that this could actually be achieved with the first drop if there was good compliance. Thus, with good compliance, it is possible to reach the target pressure with less cost, a less frequent dosing regime and less side effects. Trying to get everyone to achieve the maximum benefit from the drop may not be practical but some good practices may yield better results than haphazard applications.

Some Good Techniques for Good Compliance
Let us consider some of the better techniques adopted for good compliance. In a workshop study of 20 patients some good practices were introduced and the performance gauged after the next visit. The results of the initial visit and subsequent visit are tabled: The results showed that with proper instructions and practice, the procedures could be taught and learnt by patients.
Let us try to understand how each of these steps helps to improve the procedure of application. Getting the eye-drops properly absorbed by the eye requires time and it varies with different eye-drops and from person to person. Generally, 5 minutes would be sufficient but with the carbonic anhydrase inhibitors (CAI) they might take as much as 10 minutes because of their more waxy and viscous nature. Keeping still for 5 minutes in the tilted head back and the eye gently closed position will keep the drop at optimum instilment mode. Closing the eye gently without blinking and squeezing will improve the dosage. The action of blinking will cause fluid to drain down the tear ducts and together with some of the medicine. Applied pressure-lacrimal puntae, a procedure of applying slight pressure to the inner corner of the eye with the finger, will physically close the tear duct blocking drainage through this channel temporarily. The patient should try to apply drops to one eye at a time instead of both eyes simultaneously if difficulties are experienced in preventing over-flowing. A delay of 1 or 2 minutes between instilment of drops to each eye often helps. Similarly, if more than 1 drop is instilled to the same eye at close interval, a minimum of 5 to 10 minutes between applications will ensure that the second drop does not wash out the first drop.

Even the most conscientious patient forgets or misses the time to take a medication occasionally. But, immediately upon realizing it, he should take the medicine as soon as possible unless the time is so close to the next scheduled medication, that he should skip the dose and carry on according to his normal schedule.

One must safeguard against the folly of being fully compliant just before the next clinic review with the objective of obtaining good IOP readings, with the hope that the ophthalmologist would not increase the dosage of eye-drops and thus save cost. This will not work, as the optic nerves and visual field results will reveal the long-term consistency or inconsistency of eye-drops compliance. But it is only when the patient understands the importance of being consistent, that the patient would want to be compliant.

Conclusion
Finally, the patient should remember that the IOP-lowering eye-drop acts as an IOP regulator. In order that it can function in this role, the interval of application should be regular, as prescribed, and consistently maintained over long periods of time. The ability to apply each dose with maximum effectiveness to the eye will enable maximum benefit to be obtained from each drop and avoid additional medicine. By being compliant the benefits to the patient are:-

1. It will require less eye-drop dosage
2. It will have fewer side-effects
3. It will save you money
4. Most importantly, it will save your SIGHT!

Into counselling

© Australian Institute of Professional Counsellors

Into counselling

Most therapists possess an innate desire to help others, and because of this emotional involvement, sometimes it can be challenging to convert the potential into practical results.

Whilst we’ve tackled the basic premises which can help counsellors enter the market and attract clients, there is still one aspect of the counselling relationship which is indispensable for a counsellor’s success: client satisfaction. But isn’t that a matter of competence and an intrinsic part of being a counsellor?

Yes, it is. Being able to progress clients through to the achievement of their counselling goals has plenty to do with the counsellor’s ability to perform his/her services at the most basic level. However, it is exactly that logical assumption that induces many counsellors to oversee basic communication needs and counselling skills which will be the key for their success as a professional counsellor.

The Counselling Setting

Prior to engaging in the interpersonal communication process, there are basic requirements which will influence the client’s ability to express him/herself, and to make decisions regarding the relationship. These aspects refer to the counselling setting, which in the initial meetings can cause a significant impact in the client’s perception towards the counsellor. In a nutshell, the counsellor should observe the following:
Comfort: a comfortable setting improves client expression of feelings.
Security/Privacy: providing the client with security during a session.
Noise control: ensuring that noise does not affect communication.
Stimuli control: a neutral environment (light colours and decoration).
Supportive environment: a space in which the client can share in their own pace.
Facilities: Amenities, décor and other office facilities are relevant aspects to be observed.

Rules of Engagement

There are certain ‘rules of engagement’ which dictate the likelihood of a counselling relationship being constructive, and these rules apply to any context. For example, if you have just been introduced to someone at a social event, you should initially avoid asking personal questions as that is perceived to be intrusive. These rules are inherited by particular social groups, and following them is the basis for creating a positive profile and developing a receptive attitude from other group members.

In the counselling setting, there is much more necessity in applying such rules. The client is there for a specific purpose, which requires a particular approach to the situation. The client is also likely to be “uneasy” or unsure about what to expect, which increases the ‘risk’ of making a bad impression or not developing good rapport. Finally, there are more urgent ethical guidelines which must be complied within the counselling room, but would be of little relevance in a social setting.

In order to encourage the client to engage in a formal relationship, the counsellor must first avoid the common pitfalls which can make communication difficult. The first and foremost issue to consider in this scenario is the elusive impact of ‘first impressions’ in the eyes of a client. Trust and rapport are emotional keywords in a client’s subconscious, and once they have been negatively ‘red-flagged’ for any reason; it is very unlikely that relationship will move forward. So what can make this occur?

Dodging the Pitfalls

The standard communication pitfalls found in any relationship cover most potential problems of the first couple of meetings. They relate to a range of conscious and subconscious thinking patterns which could create communication gaps between the client and counsellor.

These patterns are based on the each individual’s education, relationships, attitudes, motivational targets, self-confidence levels and a range of other factors. Because the initial stages of a counselling relationship tend to be open and unpredictable, a good strategy to move forward is engaging in prevention: aiming to reduce the probability of communication pitfalls. To prevent this, counsellors must be aware of the common mistakes, or negative patterns, of good communication:

Judging: Criticising, name-calling, diagnosing and praising evaluatively
Sending Solutions: Ordering, threatening, moralising, and advising
Avoiding the Other's Concerns: Diverting, logically arguing, reassuring

The probable outcome of avoiding such pitfalls is establishing grounds for a productive relationship through good rapport and developing a certain level of trust and openness.

The Mindset of the Client

When it comes to interpersonal communication in therapy, being flexible and responsive is one of the most beneficial skills a counsellor can have. Different mindsets and emotional states require a particular approach; and the counsellor’s ability to adjust to a client’s needs is likely to dictate the success of that relationship.

In order to better exemplify the diversity of mindsets which clients may approach counseling with, there are five generic profiles of clients – and respective strategies -to help improve the relationship and enhance client-counsellor rapport.

Profile 1: an emotionally unstable client

The client is emotionally unstable and finding difficulty in expressing him/herself.

Emotionally unstable clients normally require a client-centred approach which enforces the need to establish rapport and trust, and to ensure the client is aware that he or she is in a safe and friendly environment. The client will normally have difficulty in expressing him/herself because he/she is unable or not ready to deal with emotions.

Counselling strategies to establish rapport would include: using self-disclosure to relate to the client’s situation and create an emotional link; creating goals and accountability in order to encourage action from the client; providing transparency and positivity through communication.

Profile 2: an involuntary or skeptical client

The client has been forced to attend to counselling (e.g. legally mandated).

This type of client may be difficult to deal with in the early stages of the relationship. Normally, he or she will be skeptical about the process, and may not acknowledge any need to change. It is important for the therapist to gain respect from the client, and use that respect to establish trust.

One of the most common strategies to gain respect and create responsiveness from the client is to outline the process of counselling: what he or she is there for; what is the structure of the relationship; what are the rights and duties of the client; what might be the expected positive outcomes. Solution-focused strategies are a good way to create a sense of accountability and need for change.

Profile 3: the child

The client is a young child or adolescent.

Dealing with children is always challenging as there is a perceived ‘bigger’ communication gap. The goal for the counsellor is to establish trust using humour; engaging in activities such as games; encouraging a collaborative approach; using self-disclosure and role-playing. These are all common strategies to help improve communication with young clients.

Profile 4: the uncommitted client

Lack of commitment can be a challenging problem in the counselling setting. Normally, a client with little or no commitment has a specific agenda which justifies their attendance at a counselling session (an example would be a husband who was asked by his wife to attend counselling in order to preserve their marriage). Framing and re-framing are good tactics to re-model the way the client perceives the counselling relationship: shifting from the ‘helping’ mode to the collaborative approach. Creating goals and structuring will also motivate the client to go through the necessary stages for change, collect the rewards, and move on with his/her own life.

Profile 5: the demanding client

A demanding client will normally believe that the counsellor will provide answers to his/her problems. They will come to counselling without much resolve to act upon their current situation, and will normally create very unrealistic expectations regarding the counselling relationship and the counsellor.

Again, encouraging accountability, managing expectations and establishing well-planned goals is a good approach. The client should be encouraged to realise that change can only occur from within. Using role-playing, narrative therapy skills, and/or a solution-focused approach to empower and encourage the client may be the key for deriving motivation.

Hopefully, the above strategies assist with providing a firm foundation to establish the client-counsellor relationship.

--ooOOoo--

• © Australian Institute of Professional Counsellors. To republish or reproduce this article, please include this information at the end of the article. For more information about the Institute – please visit www.aipc.net.au/lz. To access our Article Library, visit www.aipc.net.au/articles.
  

Now that I've been told I have glaucoma, what can I expect?

Now that I've been told I have glaucoma, what can I expect?

By George L. Spaeth

"Now that I've been told I have glaucoma, what can I expect? " This question has to enter the mind of every person who has just learned that he or she has glaucoma. It may be a sufficiently frightening question that the person never speaks it aloud. But it's the sort of question that most physicians dread, because it asks for projections that are extremely difficult to make. It asks the ophthalmologist to "play God," and, while physicians may be respected for their knowledge, they are usually aware that they have no unique ability to see into the future. Nevertheless the question is the right one for patients to ask, and it is an essential one for the ophthalmologist to address with a patient.

The first thing that a person who has been told that he or she has glaucoma ought to do is to ask the doctor what he or she means by the word "glaucoma." The word "glaucoma" is still used in so many different ways, and it means so many different things to different people, that the question about what it means for the person to have glaucoma can't really be addressed at all until there's some agreement on what the word "glaucoma" means.

Expect the Unexpected
The first thing that the patient with glaucoma should expect is the unexpected. Some types of glaucoma seem so serious that the physician worries that the affected person is likely to go blind. Other glaucomas seem quite mild, and the doctor may wonder if any treatment is necessary at all. But the patient with what appears to be a serious glaucoma may respond wonderfully to treatment and not have any further significant visual loss, while the one with the seemingly mild glaucoma may end up visually incapacitated because glaucoma in this case proves very resistant to all sorts of treatments.

Does this mean that the individual affected with glaucoma can't make any plans? No. While unexpected things are routine, the changes that occur in most people with glaucoma, once the initial diagnosis has been made and the initial treatment started, usually occur slowly over a period of many years. If the patient is alert and the physician is alert, the different directions in which the glaucoma is going can be spotted, and new and more appropriate projections made.

For example, the first patient mentioned above needs to be counseled at the start that there's a reasonable chance that he will lose his vision due to glaucoma. But as soon as it becomes apparent that the response to treatment is better than expected, a new counseling session is necessary in which the patient comes to understand that he's doing very well and the outlook for the future is far more favorable than had initially been considered. In a similar vein, when it becomes apparent to the physician that the second patient is not responding well to therapy, it's essential to share that information with the patient so the patient have a more accurate idea of where he or she can expect to be 20 years later.

Remain Vigilant
Except for a few types of glaucoma, the tendency for glaucoma to cause continuing damage remains with the person for the rest of the person's life. Thus, the person must not think that he or she is "cured" and stop being vigilant. There's a great difference between being vigilant and being a hypochondriac. To be vigilant means to be alert to warning signs and to exercise appropriate "preventive maintenance." To take care of a car properly does not require that the owner spend an hour a day inspecting the car. It does mean that periodically the car needs to be checked to make sure that the operating systems are working appropriately and that, if they don't seem to be working properly, that they are checked out promptly.

Warning signs that should alert the patient to call the doctor are symptoms of any kind that make the patient wonder if everything is OK. Of course, the most worrisome symptom is any sense that visual function is worse in any way. These symptoms would include:

• a sense that it's harder to get around, an increasing sense of clumsiness



• loss of depth perception



• more difficulty seeing at night



• less ability to distinguish between colors



• haziness of vision that is not corrected by glasses



• a perception that there are certain areas in the person's visual field that are getting worse



• pain in the eyes, especially when it's associated with smoky or misty vision or with rings around lights



• pain or fatigue after close work or when going into dark places such as restaurants or movie theaters



• achy eyes, that feel as though they have some pressure in them, especially when such aches occur repeatedly



• colored haloes around single lights such as street lamps



• a fluctuating sharpness of vision.

It's appropriate for the person to test each eye individually periodically. This need not be time-consuming or threatening. One way, for example, is on the first of each month for the person to check each eye individually to see if there's been a change in the smallest print that the person can read, and to check each eye to see if there's a change in the sense of the visual field, i.e., the awareness of all the things that surround a person. If one uses the same printed material each time to check vision, it becomes immediately apparent if the vision is becoming worse. If one looks at the same general scene, such as at a specific picture on the far side of the wall, then major changes in the visual field are easy to appreciate on repeated testing.

There are, of course, a wide variety of other visual symptoms that indicate that something might be wrong, such as "seeing double" or marked problems with glare. These symptoms, however, usually point to concerns other than glaucoma.

It's also important for the person to be vigilant regarding his or her general health. A person's general health has a profound effect on his or her glaucoma, and the glaucoma can have a profound effect on general health. Changes in the person's sense of well-being, the person's sense of energy, level of general fatigue, stress, and important events in the individual's life should be noted and relayed to the physician.

Prepare for Battle or Be Wary of Treatment?
Eyes that have far-advanced damage have demonstrated that the person's glaucomatous disease is the type that causes damage. Eyes that don't have much damage have demonstrated that they have the type of condition in which damage is much less likely to occur. The person, then, who at a relatively young age is found to have far-advanced glaucoma damage has to be prepared for a real battle. On the other hand, the person who's really doing quite well and isn't showing signs of progressive deterioration is more likely to be damaged by methods used to prevent further damage than he or she is likely to be damaged by the glaucomatous process itself.

Value Your Own Assessment of What You're Feeling
The person with glaucoma has to realize that the system of medical care which has come to be considered to be the best medical care is based on science, and science is based on unbiased, objective measurements which are analyzed in an unbiased, objective way. This means that the concerns of patients, which are never objective, and are always biased, are always considered with skepticism by the scientist. But in fact every individual person is unique and different from every other person. The patient wants a physician to be scientific, objective, and knowledgeable, but the patient must be prepared to do battle with physicians who don't appear to value what the patient feels about himself or herself. For example, when a patient says to the doctor that he's getting worse, by definition the patient is getting worse. The doctor may not be able to find manifestations of that deterioration but that doesn't mean the deterioration isn't occurring. The glaucoma patient, then, must pay a great deal of attention to his own sense of well-being and must be prepared to communicate that convincingly to his or her physician.

Be Ready for Repeated Optic Disc and Visual Field Assessments
The two most important tests done on the glaucoma patient are evaluation of the optic disc and visual field. Patients need to be prepared to have serial, repeated tests of these two functions. The patient also must be prepared for the huge amount of variability that exists between testing sessions and must not conclude that he or she is either getting worse or stable just on the basis of an apparent change in a photograph or on a visual field. The determination of whether a test really does represent a deterioration or an improvement is frequently an extraordinarily difficult determination and should not be made lightly by either the physician or the patient.

Be Prepared to Make Trade-Offs
The person who has a serious glaucoma, in which the optic nerve already has become damaged must realize that he or she is going to have to make trade-offs. Using drops is a nuisance; the vision is temporarily blurred, it's not comfortable to have to leave a meeting to go into the bathroom to use one's drops, it's a nuisance to make sure that one always has one's drop with one, etc. But if one has the type of glaucoma that is going to get worse, and the glaucoma is being controlled with medications, either one uses the drops or the glaucoma gets worse.

The two most important tests done on the glaucoma patient are evaluation of the optic disc and visual field. Patients need to be prepared to have serial, repeated tests of these two functions. The patient also must be prepared for the huge amount of variability that exists between testing sessions and must not conclude that he or she is either getting worse or stable just on the basis of an apparent change in a photograph or on a visual field. The determination of whether a test really does represent a deterioration or an improvement is frequently an extraordinarily difficult determination and should not be made lightly by either the physician or the patient.

Similarly, when glaucoma surgery is done, the eye is not returned to normal. The pressure may be controlled by the surgery, but the surgery usually substitutes one problem of less magnitude for the greater problem of losing vision. It is essential that the patient understand that there will be such trade-offs and it is the job of the patient and physician together to decide how to prioritize the problems so that the patient is most likely to accomplish those things which are of most importance to the patient.

Source: Wills Glaucoma Service

Eye Supplements, Yes or No?

EYE SUPPLEMENTS, YES OR NO?
A PATIENT’S PERSPECTIVE

Sharon Siddique, PhD
All For Eyes Pte Ltd
Singapore

Whether or not to take vitamin and herbal supplements for eye health confronts everyone with low vision. We need to take this issue seriously because there is evidence that certain vitamin and herbal supplements appear to slow down (but not reverse) eye deterioration caused by eye conditions, such as AMD (age-related macular deterioration), glaucoma, and cataracts. It is up to the individual, in consultation with his/her eye doctor, to decide what is appropriate.

Information (as always) is the key. There are basically three approaches. Some believe that it is sufficient to eat a healthy diet, full of the types of foods that provide nutrients for eyes. Others feel that it is sometimes beneficial to supplement (or “top up”) this healthy diet with a selection of vitamins, minerals, and herbs. In Singapore we can also consider various types of TMs (traditional medicines), which include TCM (traditional Chinese medicine) and Ayurveda (traditional Indian medicine).

HEALTHY DIET

A healthy diet for eyes will include several portions of green, yellow, orange and red fruits and vegetables every day. Fortunately for us, Singapore markets have an abundance of greens (kai lan, yu choy, bak choy, Chinese cabbage, bitter gourd. etc), and yellow vegetables - carrots, peppers, squash, pumpkin, tomatoes and yams. Fruits such as papaya, kiwi, various melons, mango, oranges, pomelo, clementines, starfruit, grapes, persimmons, plums, etc. are plentiful. In Singapore, they are not only easily available, they are also relatively cheap.

So if we eat a healthy diet, is there a reason to take supplements? Some say no. But how many of us actually follow the “healthy diet” described above, on a daily basis? If we have to admit that we fall short of this ideal, it may make sense to consider adding certain supplements to our daily health regime. There is a bewildering number of vitamins, and it is easy to get lost in the terminology. Navigating through the information is challenging. Basically, there are Vitamins, Herbs, and Traditional Medicines (TM) to discuss.

VITAMINS

Antioxidants can help our eyesight because they prevent the damaging effects of oxidation, particularly in the retina. Vitamins A, C, and E are the most effective antioxidants. In addition to the vitamins themselves, there are a number of associated natural extracts (called carotenoids and flavonoids) that are found to be rich in these vitamins, and which may be easier for the body to absorb. Finally, Vitamins A, C, and E are more effective when taken together with certain minerals (zinc and, selenium) and other vitamins (particularly the B complex of vitamins).

Vitamin A and Carotenoids

Carotenoids are a class of highly unsaturated yellow to red pigments occurring in plants and animals. They are the natural extracts from which Vitamin A is derived. Three carotonoids most often mentioned in the context of eyes are beta carotene, lutein, and zeaxanthin. Lutein and zeaxanthin appear to be particularly important to eye health. They have been found to be highly concentrated in the macula of healthy retinas and appear to neutralize free radicals generated when ultraviolet and blue light strikes the retina.

Vitamin C and Flavonoids

Vitamin C is a major antioxidant in the lens of the eye. Flavonoids help the body to absorb Vitamin C, and assist in maintaining the intercellular glue (collagen) that strengthens connective tissue throughout the body. They have antioxidant powers and are essential for strong blood vessels, including the sensitive blood vessels of the retina. The most common flavonoid associated with eyes is rutin. Rutin has also been associated with maintaining healthy pressure levels within the eye. Other flavonoids, such as quercetin and the anthocyanidins, may help protect the lens of the eye from cataracts.


VITAMIN E AND MINERALS

Vitamin E functions mainly as an antioxidant. Vitamin E, also known as tocopherol, is a fat-soluble vitamin, so Vitamin E is carried through the body attached to fat. The body stores vitamin E in fat deposits and in the liver. The minerals zinc and selenium help the body absorb Vitamin E. Zinc is required for the function of certain enzymes in the retina that are critical for vision.

The B-Compound vitamins are needed for maintenance of the nervous system, and proper functioning of the cell and its energy metabolism. It is generally recommended that the B vitamins be taken in tandem, as their specific functions are interrelated. Riboflavin (vitamin B2) is manufactured in the body, and is needed to activate vitamin B6 (pyridoxine), which may ease watery eye fatigue and may be helpful in the prevention and treatment of cataracts. The B vitamins include thiamine (B1), Riboflavin (B2), Niacin (B3), Pantothenic acid (B5), Pyridoxine (B6), Biotin (B7), Folic acid (B9), and Cyanocobalamin (B12).


HERBS

Bilberry, a close cousin to the blueberry, has long been widely used in Europe for eye health. Bilberry is rich in fatty acids, flavonoids, iron, zinc, and selenium. During World War II British Royal Air Force pilots reported improved night visual acuity on bombing raids after consuming bilberry jam. Subsequent claims have been made that bilberry extracts result in improved night visual acuity, quicker adjustment to darkness and faster restoration of visual acuity after exposure to glare. Bilberry has been used in the treatment of glaucoma as well.

The herb Eyebright is great for the eyes. Since the Middle Ages, Eyebright has been a popular herbal eyewash. Eyebright's antibiotic and astringent properties tighten membranes and mucus surrounding the eyes, effectively strengthening and improving circulation. Eyebright contains bitters, essential oils, flavonoids, several B vitamins, and Vitamins A, C, D, and E. Today Eyebright is used for relieving eye problems such as eye strain, pink eye and inflamed, irritated and sore eyes Eyebright is also used for cleansing and purifying the blood, therefore stimulating healthy liver functions.

TRADITIONAL MEDICINE (TM)

We are familiar with Bilberry and Eyebright because they are European, and they are therefore much better marketed. With regard to Asian traditional medications, we are barely scratching the surface of fascinating connections and similarities between European, Chinese and Indian TM in general, and, in our case, as applied to eye health. Here are two examples.

In both Chinese and Indian TM, there is a direct relationship between herbs used for the treatment of liver function, and the eyes. Wolfberries, for example, are the Asian cousin of the European bilberry, and are cheap and plentiful in dried form, found in any Chinese medical hall in Singapore. Called "goji" in Chinese, ancient Chinese medical texts extolled wolfberries for strengthening the eyes, liver, and kidneys as well as fortifying the "qi" (chi) or life force. There are also interesting parallels in Indian traditional medicine. Triphala is a composite herbal preparation containing equal proportions of three native Indian fruits, and it is taken for various eye disorders, as well as cleansing the liver.

The turmeric root is also used to support liver function, as well as eye health, in both Ayurvedic (Haridra) and Chinese (jiang huang) herbal medicine. Turmeric protects against the damaging effects of toxins and free radicals. Turmeric, which is a member of the ginger root family, is a deep yellow colour, and is commonly used in Indian cooking. And hence we return to the diet, which, according to Western health directives, should contain plentiful supplies of eye friendly green and yellow vegetables. It is difficult to find anything more intensely yellow than turmeric!

SUMMING UP

We are fortunate to be in Singapore, where off-the-shelf vitamins and supplements have been tested and approved by the Ministry of Health. There are many Western multi-vitamin supplements which are specially formulated for eyes, as well as herbal preparations and traditional medicines. They are available throughout Singapore, and generally contain various combinations of the vitamins and herbs mentioned above. So investigate this interesting subject, and discuss it with your GP and ophthalmologist. It is up to each of us to take responsibility for doing everything possible to preserve our precious gift of sight.

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Read about Dr Sharon Siddique : A Clear Visionary at http://www.glaucoma-singapore.org/LowVision/All4Eyes/ClearVisionary.html

POAG puts pressure on the heart

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Glaucoma explained in Chinese by Allergan

The Importance of Sunglasses: A Patient's Perspective

THE IMPORTANCE OF SUNGLASSES:
A PATIENT’S PERSPECTIVE


Sharon Siddique, PhD
All For Eyes Pte Ltd
Singapore
October 2006


THE SUN’S HARMFUL RAYS

In tropical Singapore we are all aware of the damage that the sun can do to our skin. Protective clothing and sun creams are commonly used to try to prevent sunburn, wrinkles, and skin cancer. Unfortunately, we are much less aware of the damage that strong sunlight can do to our eyes. Too much exposure to ultraviolet (UV) radiation can leave the eyes red, teary, strained, and light sensitive. Just as with the skin, damage is cumulative, and can lead to an increased risk of cataracts and retinal damage, including AMD (age-related macular degeneration).

UV radiation is so potentially dangerous because we literally can’t “see” it. It is composed of invisible, high-energy, light rays from the sun that are found beyond the violet/blue end of the visible spectrum. Our eyes are particularly sensitive to damage from ultraviolet A (AV-A) and ultraviolet B (UV-B) light. Children, the elderly, and those of us with eye problems are particularly at risk.

Children’s eyes are more vulnerable because their pupils are larger, meaning more light enters the eye, and reaches the retina. By the age of 18, studies show that more UV light will have been absorbed by a child's eyes than over the rest of his life. And yet we seldom see Singaporean children using sunglasses. As Singapore’s population ages, we are already seeing the effects of long-term exposure to the sun’s harmful rays as the rates of cataract and AMD increase.

Ultraviolet protection is especially important for people after cataract surgery. Since the lens absorbs UV radiation, individuals who have had cataract surgery are at increased risk of retinal injury from sunlight. This is because although the lens implant contains some UV blocking agents, it does not provide the same degree of protection to the macula as the natural lens. Taking certain medications - such as tetracycline, sulfa drugs, birth control pills, diuretics and tranquilizers – also increases the eye's sensitivity to light, and potential damage.

A good pair of sunglasses should protect against harmful UV light entering the eye. Ask before you purchase. Do the lenses provide both UV-A an UV-B protection? Are the lenses polarized, which ensures that they will reduce reflected glare? Do the frames fit snugly to provide the eyes with maximum protection, particularly over and around the rims of the frames? Sunglasses which are specifically designed to fit-over a normal pair of spectacles may be particularly suitable for many spectacle-dependent Singaporeans.

THE CONFUSING WORLD OF COLOURS

There is a big misconception that the darker the lens, the better the protection. In fact, UV coating is colourless. Clear lenses, with no colour-tint, can still be UV-light blockers, and they are very useful in protecting the eyes from impact, debris, dust, chemicals, or after eye surgery. Clear lenses can be used during low light or nighttime activities, and are particularly effective to reduce glare under fluorescent light.

Most sunglasses come in a bewildering range of colours, from common amber and grey, to yellow, red, green, and even orange and plum. Does this mean, then, that the choice of colour is merely cosmetic? Absolutely not. Different colours absorb or transmit specific wavelengths of light. That is why, for example, when we look through red-coloured lenses, the world looks, well, rosy.

So when and why is the choice of colour important? Those of us with eye problems need to pay particular attention to these “colour codes” because by absorbing and transmitting certain specific wavelengths of light, tinted lenses – also called absorptive lenses - can improve our ability to see. For example, glaucoma-sufferers typically perceive the world as being "too dark." As a result, they may show a preference for yellow lenses, which increase the apparent brightness of objects or surroundings. People with macular degeneration may favour an orange, yellow-orange or plum tint. And people with retinitis pigmentosa may prefer an orange or red tint to reduce glare.

The two most commonly available colours for sunglasses are grey and amber. Grey lenses are described as neutral because they do not enhance contrast or distort colors. Choosing lighter shades of grey can help relieve indoor glare, especially under fluorescent light. In general, grey is soothing, sharpens focus, and provides good glare protection. Grey is often the colour of choice for post-op cataract surgery, glaucoma sufferers, diabetics or people who have had corneal transplants.

Amber tints are known for their “blue blocking", protective effect. There is some evidence that the retina may be more sensitive to blue visible light. Blocking the visible blues eliminates much of the scatter created by the shorter wavelengths of light. The result is an apparent increase in contrast and depth perception. Objects appear more clearly defined, and thus amber tints are popular with skiers, boaters, and pilots. They also provide good contrast enhancement, useful for those with macular degeneration, and retinitis pigmentosa.
Yellow is a powerful a "blue-blocker" because the color keeps blue light from entering the lens. Yellow and orange sunglasses make objects appear sharper, with more contrast, but there is some colour distortion. Both yellow and orange are helpful for reading. Yellow is often the choice of those suffering from retinitis pigmentosa and macular degeneration because it provides maximum brightness and good visual acuity. Yellow glasses are great for relieving eye fatigue from prolonged exposure to computer screens. Orange is even more effective than yellow for intensifying backgrounds, allowing the wearer to see objects more clearly.

For normally sighted people, red is a rather uncomfortable color to look through, but it is recommended for certain eye conditions. Red does cut down on blurred vision caused by blues, greens and yellows. Red lenses are good for medium and lower light conditions because they enahnce contrast. Reds and pinks are great in alleviating computer eyestrain, but there is also a certain amount of color distortion. A light or medium tinted lens is good for day-to-day wear. Dark plum is an excellent dark lens, and provides a high amount of glare relief.

Green is a less commonly found colour, but it offers some color contrast with little or no color distortion. Green is also great for glare protection. Because green allows only low levels of visible light to enter the eye, it is a good colour choice for post-op cataract surgery and glaucoma.

SUMMING UP

A final thing to pay attention to in the confusing world of colours is what is called the VLT (visible light transmission). Some types of sunshades come with a colour and a VLT, expressed in percentage terms. Thus, “40% Amber” means that the tint is amber, and that 40% of the visible light is transmitted through the lens. Sometimes the terms “light” (generally over 70% VLT), “medium” (10% to 69% VLT) and “dark” (below 10% VLT) are indicated.

To maximize visual acuity, select the highest visible light transmission (VLT) which is comfortable, and a colour that “feels” good. There is no one correct fit. It depends very much on the conditions under which the sunglasses are going to be used, and the condition of the eyes. Many people require different filter transmissions for cloudy and bright conditions or for inside versus outside applications. In general, the goal is to achieve the maximum visual acuity, while minimizing eye discomfort and strain.

In sum, sunglasses are an ESSENTIAL part of the proactive patient’s vision tool kit. Choose a pair of sunglasses carefully. Decide under what conditions you are going to be wearing them (inside/outside; bright sunny/hazy conditions). Make sure they fit around your eyes to block out glare, that you have maximized your visual acuity with the tint and VLT, and that they are polarized, scratch-proof, and provide 100% UV-A and UV-B protection. Above all, they should fit comfortably – otherwise you won’t wear them. And remember, often our eyes do warn us that they are under stress by tearing, blurring, redness, dryness, and pain. Learn to listen to them.

The "Dry Eye" Syndrome

WET EYES = DRY EYES?
I went to see my eye doctor at Changi General yesterday, a Monday afternoon of 18th December after I had lunch with my friend Shan Chi. She is a lady and has been my assigned glaucoma doctor since July 2005 -- an adorable ophthalmologist, worth her weight in gold.
Our first discussion was that my eyes tend to tear and sometime the tears would well over the eye lids and run down my cheeks. Looking at my eyes at a distance, she told me that my eyes look dry and that was why I tear. *Are you crazy, doc?*, I thought to myself. No, the doctor is always right and I must check this out.
With this paradox in my hand "crying" out for an explanation, I searched the internet for an answer to satisfy my curiosity. I did a global search on "all symptoms on dry eyes" Here is the explanation:-
Tearing in dry eyes may see m to be perplexing. My eyes are apparently wet yet I have dry eyes. This happens because the eye is not getting sufficient lubrication. The autoimmune system sends a distress signal through our nervous system for more lubrication. This emergency call causes the eye to flood with tears to overcome the dryness. But the generated tears are mainly water with little lubricating properties compared to our normal tears. They are capable of washing out debris but have poor adhesion-lubricating properties. Further, these emergency tears often arrive late, and the eyes need to regenerate more. So even if I *cry me a river*, they are of no help.
Treatment is needed and instilment of formulated artificial tears will help. "Thanks, Doc! And a happy New Year to you" I said. "You take care!" she replied. The door clicked to close.
"So I see: teary eye is the effect; dry eye is the cause."

My friend, Sharon Siddique added:
"I think that the "dry eye" syndrome can also be helped by vitamin/herbal preparations that are ingested. There is a formula called "Bio-Tears" that my ophthalmologist recommends at his clinic. Several patients have had good results, and have been continuing to use it."

Cheers,
Samfong

What is Glaucoma?

Glaucoma: The Sneak Thief of Sight

Early detection and treatment can slow, or even halt the progression of glaucoma.

What is Glaucoma?

Glaucoma is a group of diseases that can lead to damage of the eye's optic nerve and result in blindness. It is caused by increased in intraocular pressure (IOP) resulting either from a malformation or malfunction of the eye's drainage structure.

Glaucoma is frequently referred to as the "Sneak Thief of Sight" because it progresses without obvious symptoms.

What is the optic nerve?

A bundle of more than one million nerve fibers. It connects the retina, the light sensitive layer of tissue at the back of the eye with the brain.

How does glaucoma damage the optic nerve?

Glaucoma can cause damage when the aqueous humor (a fluid that inflates the front of the eye and circulates in a chamber called the anterior chamber) enters the eye but cannot drain properly from the eye. Elevated pressure inside the eye, in turn can cause damage to the optic nerve or the blood vessels in the eye that nourish the optic nerve.

Who is at risk?

Although anyone can get glaucoma, some people are at higher risk than others.

• Everyone over age 40
• People with a family history of glaucoma
• Individuals with other eye diseases which may secondarily result in glaucoma or elevated pressure
• There is a strong prevalence in diabetes

Common types of glaucoma

• Open angle glaucoma (chronic)
• Close angle glaucoma (acute)
• Low-tension or normal-tension glaucoma
• Congenital glaucoma (seen in infants)
• Secondary glaucoma (result of injury or trauma)

Signs & symptoms?

Glaucoma is a insidious disease because it rarely causes symptoms. However, certain types, such as angle closure glaucoma and congenital glaucoma do cause symptoms.

Angle Closure (Emergency)

• Sudden decrease of vision
• Headaches
• Nausea & vormiting
• Glare & light sensivity

Congenital

• Tearing
• Light sensitivity
• Enlargement of the cornea
• Loss of peripheral vision

A person with glaucoma may notice that although he sees things clearly in front of them, they miss objects to the side and out of the corner of their eye.

How is glaucoma detected?

• Visual acuity test
• Visual field charting
• Pupil dilation
• Tonometry

Treatment

A wide variety of treatments are available for reducing the intraocular pressure, the only known effective treatment of glaucoma.

Medicine: Medicines are the most common early treatment for glaucoma. They come in the form of eye-drops and pills.

Laser surgery (also called trabeculoplasty). A special lens is held to your eye. A high energy beam of light is aimed at the lens and reflected onto the meshwork, inside your eye. The laser makes 50-100 evenly spaced burns. These burns stretch the drainage holes in the meshwork. This helps to open the holes and lets fluid drain better through them.

Conventional surgery : A new channel for aqueous humor (fluid) to drain into the blood circulation is created. This will enable the intraocular pressure to be maintained at normal tension.

What can you do to protect your vision?

If you are being treated for glaucoma, be sure to take your glaucoma medicine everyday.Routine eye exams with monitoring of intraocular pressure and visual field examination is done.

Retaining Independence

People who have experienced vision loss from glaucoma can retain independence, productivity divices and techniques to carry out their daily activities. Special lenses and techniques help those who have remaining sight to make the best use.

NB. This article is meant for general information only. Please consult an ophthalmologist for any medical advice.