Dr. James Santoro joined hosts Shannon O’Kelley, Physical Therapist and President of Integrated Rehabilitation Group, and Maury Eskenazi, radio personality from Fox Sports radio on Health Matters radio, KRKO 1380am, with thanks to Integrated Rehabilitation Group physical and hand therapy. He talked about eye health and glaucoma.
Read the transcript of Dr. Santoro's talk on eye health and glaucoma or listen here
Health Matters: Joining us is James Santoro optometrist from The Everett Clinic. Now, optometrist, are you the guy that does the glasses, or is that an ophthalmologist? That's my first question, what's the difference?
Dr. Santoro: In the State of Washington we are referred to as optometric physicians, so we are primary medical care, so we do the primary vision exam, comprehensive vision exam, but also we look at the medical side of things. So, for example, on a typical day for me I would see a diabetic patient that may have diabetic retinopathy problems in the back of their eyes and their retina from the diabetes. Or, I could get a call from a Walk-In Clinic with something in somebody's eye that I need to remove. Now, if it requires a surgical procedure inside the eye, that is when we have our group in our ophthalmology unit, our ophthalmologists.
Health Matters: Now, you would dilate my eyes, then.
Dr. Santoro: Absolutely.
Health Matters: In optometry school, you basically do four years of undergrad, then 2-3 years of grad school for optometry?
Dr. Santoro: Actually, it is the four-year program for undergrad to get your bachelor's degree, and then it is a four-year medical program, and then there is the opportunity to advance for certification or advanced certification beyond the four years.
Health Matters: Do you have an area of specialty?
Dr. Santoro: I have an advanced certification in the medical procedure as far as treatment and diagnosis of the medical condition of the eye.
Health Matters: Let's talk about the eye, because I think people need to really appreciate the anatomy and some of the challenges that the eye presents to diagnose, treat, and particularly glaucoma?.
Dr. Santoro: Glaucoma is a painless eye disease with damaging vision loss that can occur without proper diagnosis and management. A lot of times we will look at the back of the eyes, the optic nerve, and glaucoma is a disease of the optic nerve. Glaucoma is one of the progressive eye diseases of the optic nerve, but, glaucoma doesn't just begin at that back of the eye. At the front of the eye, the cornea is a clear dome of the eye, transparent tissue of several layers, but just behind that, as we move inside the eye, just behind the cornea we have the anterior chamber, and that is a critical structure in the front of the eye. It is a clear liquid, but it's so critical that liquid has to be produced at a certain rate. It has to also go out or outflow of the eye at an equal rate. If that rate is compromised, the pressure goes up in many cases. That's a risk factor for glaucoma. As we move into the eye, then we go into the center, as we call the center circle of the iris, or the colored iris, or the pupil. If we open up that pupil, that's an opening to the eye. A lot of times, patients ask, "Why do we need to have the eye dilated?", and I will say, "Look, we are going to dilate your eye, we are going to open up to the pupil." "It's akin to me looking in a room with the door opened versus looking in a room with the door closed through a peephole." I will be able to see really the structures inside the eye, and directly behind the colored part of the eye, the iris, is the lens, and that's a critical structure of the eye, but also a critical structure for cataracts and cloudiness in the eye as we age. Eighty percent of our eye is made up of a fluid called vitreous, vitreous humor, which is 99% water, and, that has other symptoms and types of conditions like floaters that can occur. Then, we get to the back of the eye, the retina, which really gets to the central part, the macula the optic nerve. We get light impulses that come into our eye and through that optic nerve. That's what's so critical about glaucoma, through that main nerve in the back of the eye the light impulses are converted to electrical signals they go through a visual pathway to the brain. We see with our brain. A lot of patients will ask, "How large is my eye?", and I will describe the eye as about an inch in diameter from front to back. A ping pong ball is about 1½ inches, so I just say, "It's about two-thirds the size of a ping pong ball." And, in the eye, from birth to infancy the length from the front to the back does increase, so at birth it's usually around 18 mm in length, and then in infants around 19.5 mm, and then in our adult life the axial length or the length from the front to the back is between 24 and 25 mm. So, there is a lot of dynamic in the eye.
Health Matters: So, the way you see, then, is you have light that comes in through your eyes, it is refracted back onto the retina area where all the receptors or cells are, and that light stimuli is converted to electrical, then the brain reads it through the optic nerve, and then that happens, I mean, really fast and all the time, and there is so much stimuli coming in there it is pretty incredible?
Dr. Santoro: It's pretty incredible, and you look at that optic nerve where that conversion takes place it’s a bundle of nerve fibers, and think, if slowly a few of those fibers start to die off, then slowly die off, and slowly die off, and that's when visual field loss can be very subtle. On a day-to-day activity, a patient may not even notice that visual field loss, but then as it increases and more and more fibers die off and signals are not being transmitted to the brain, that's when we have the visual field loss.
Health Matters: You are talking about glaucoma, then, in that situation. Tell us about glaucoma and how it affects the optic nerve. Doesn't it cause the dying of the optic nerve?
Dr. Santoro: It does. Glaucoma is damage to the optic nerve. The optic nerve is so critical to our eyesight. What we watch in glaucoma is the pressure of the eye. We watch for elevated eye pressure. We have to inspect the angle of the eye in the front of the eye to make sure that circulation is flowing properly.
Health Matters: The front of the eye that you talked about, that fluid has to drain in and drain out. If that fluid builds up because it is not draining out, that pressure damages the optic nerve by impeding blood flow to the nerve tissue? Is that what is going on?
Dr. Santoro: It's damaging the structure of the nerve, and it has been proven that by lowering that pressure, we can slowdown the progression of the damage or killing off of the eye nerve.
Dr. Santoro: Each eye nerve transfers information to the visual pathway.
Health Matters: How would I know if I am getting glaucoma or have glaucoma?
Dr. Santoro: You would not know. There is no pain. We call it the "painless eye disease,” a "sneak thief of sight." Knowing that you're going to be at a higher risk when you are in your 40s and have your eye pressure tested, that's a critical test. And a visual field test.
Dr. Santoro: We dilate the eye. We look at the angle at the front part of the eye and the back of the eye. When we see there is suspect to the color of the nerve, the shape of the blood vessels we'll take a visual field test, and do another test that is a computerized picture of the eye. It is called an OCT.
Health Matters: Is that the one where you can actually see areas where cells have died?
Dr. Santoro: You bet. You see what is called the retinal pigment layers and other layers of the retina that you will see either die off or are thinning. We can't cure glaucoma, at least not yet, but we know if we can diagnose and manage the disease we can prevent further visual field loss, so the OCT will show us any microscopic change that's going on.
Health Matters: What's causing that glaucoma?
Dr. Santoro: The primary glaucoma is called open-angle glaucoma and the cause and etiology is unknown, but we have risk factors. Here are some risk factors. Adult onset, anyone over 40 is a risk factor. Elevated eye pressure. African or Hispanic ancestry. High myopia for open-angle glaucoma. Thinning of a cornea.
Health Matters: When you say myopia…
Dr. Santoro: Myopia is near-sighted. Near-sighted is the inability to see far, so you have to put glasses on to drive or glasses on to see distance. Family history is also a major risk factor. Men and women are equally affected by glaucoma.
Dr. Santoro: And, there is secondary glaucoma. I'll give you a case recently presented to the clinic that was a diabetic case. A patient comes in as a diabetic, referred from Primary Care as a diabetic patient for a diabetic retinopathy. This patient had glaucoma and didn't know it. That's another factor that we look at, that a systemic disease like diabetes can actually have glaucoma. In fact, 1 in 5 diabetic patients are at risk for glaucoma.
Health Matters: When you’re 40+, how often would you recommend to have your eyes checked?
Dr. Santoro: On the initial visit, if everything is normal, your pressures are checked inside, you have a dilated fundus or dilated retina exam and everything is normal, we'll say we'll see you in two years.
Dr. Santoro: Now, when we get into a case where we suspect glaucoma or a glaucoma is under care, we are going to see them more often, and especially if they are under treatment.
Health Matters: So, what's the difference, between glaucoma versus cataract?
Dr. Santoro: The difference is a cataract is a treatable condition, if you want to say curable, by removing that cloudy lens and implanting an artificial lens.
Health Matters: What is the etiology of a cataract? Just age?
Dr. Santoro: That is one of the risk factors, of course, age. And sun exposure, environmental factors can cause cataracts. Medication can cause cataracts. A patient that may be on a steroid for long term, or a long period of time will have and will experience a cataract. These are cataracts that aren't reversible, so we monitor.
Health Matters: What's the age that cataracts are showing up?
Dr. Santoro: I always tell the patient when you feel your lifestyle has changed (it could be driving at night, playing golf, any activity) then we may want to treat that. If you drop off that 20:40 line, that's where we're going to discuss further about a cataract procedure. You know what's interesting, that we implant cataracts which actually have a multifocal implant.
Health Matters: That's amazing. So, you can do a cataract transplant and then the person is completely off glasses?
Dr. Santoro: That is correct. Usually you won't perform two eyes at the same time. Normally, by just the natural progression, one eye will be cloudier than the other. So, you would treat one eye at a time, and then 3-4 months later the other eye. What we have found is that, not only does it give the quality of vision, but the patient will report, "I see colors better." Their whole life changes.
Health Matters: Real quickly, as we wrap this up, tell us quick home remedies. If you get something in your eye, what's the best way to get it out?
Dr. Santoro: You want to flush your eye as soon as you can. And whether it's chemical especially, but anything in the eye, you flush that eye and you call and get seen in one of our Walk-In Clinics, which will call one of us who be on call.
Health Matters: Perfect. Thanks so much James Santoro, optometrist at The Everett Clinic. Of course, for more information, to make an appointment, or to know more stuff, everettclinic.com is what you go to.