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The Laura Dowling Experience
Beyond 20/20: An Ophthalmologist's Guide to Eye Health and Surgery
Ophthalmic surgeon Dr. Micheál O'Rourke takes us through the fascinating world of eye health, sharing insights from cataracts and macular degeneration to aesthetic procedures and vision preservation.
• Eyes constantly move and blink even during sleep, requiring high energy and thin skin for optimal function
• Cataracts are an inevitable part of aging, involving protein misalignment in the lens requiring surgical removal and prosthetic lens replacement
• Macular degeneration comes in dry (less treatable) and wet (treatable with injections) forms that affect central vision but preserve peripheral sight
• Blepharoplasty (eyelid surgery) is becoming popular at younger ages, removing excess skin around the eyes for a refreshed appearance
• Women experience a dramatic drop in tear production during menopause, making HRT one of the most effective treatments for menopausal dry eye
• Increased screen time reduces our blink rate and contributes to vision problems including the evolutionary shift toward myopia in children
• Thyroid eye disease primarily affects young women, causing protruding eyes and altered appearance that can be addressed with surgery
• Eye floaters result from changes in the eye's jelly-like vitreous humor and should be evaluated if they suddenly increase or appear with flashing lights
• The eye cannot be temporarily removed during surgery as once believed, as nerve tissue damage is permanent
For more eye health insights, follow proper eye protection practices, get regular check-ups, and be aware of symptoms that might indicate serious conditions.
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I know that you do a little bit of eye aesthetics 50% of your conversation is eye to eye, and if there's a slight discrepancy in terms of the eyelid position, your brain can pick that up quite quickly as being abnormal.
Speaker 1:Is that like the lazy eye? You know there's always a kid in the class with the lazy eye.
Speaker 2:That is when the brain is developing your vision, and one eye has a blurred vision. The other eye is the better vision, so your brain forgets about the blurred vision so that you have one good eye and then the eye can move in or it can move out. And to correct the vision problem, initially with glasses and then a patch, if needs be, to give the weaker eye more strength in order to work more.
Speaker 1:So you put the patch in the good eye.
Speaker 2:Now, if you keep the patch on the good eye indefinitely, that eye will go blind. Will it go blind? Yeah, so if you have no stimulus to your eye before the age of seven, the vision doesn't develop.
Speaker 1:You were talking about the blepharoplasty. It's the droopy eyelid really, isn't it?
Speaker 2:Blepharoplasty is becoming a really increasing trend. Younger and younger. It's the excess skin, where you have this fold of skin, that comes over and it will even touch off the lashes and you will get quite an aged appearance. Even a small change with a blepharoplasty surgery will give a much younger appearance to the eyes, which is quite remarkable.
Speaker 1:And are you just taking a little slice of the skin and then you're sewing it back together?
Speaker 2:Would it?
Speaker 1:take too much.
Speaker 2:If you do take too much, it is very hard to put it back Undercorrect rather than overcorrect.
Speaker 1:I underdose all the time in the past. Underdose, don't overdose. Welcome back to the Lower Downing Experience podcast, where each week, I bring you insightful and inspiring guests that will open your mind and empower your life. Today, I'm joined by ophthalmicmic surgeon Mr Michal O'Rourke, fora fascinating deep dive into eye health. We cover everything from glaucoma and macular degeneration to thyroid disease and dry eyes, menopausal eyes, lazy eye surgery, blepharoplasty and treating common eye infections. I found this conversation absolutely brilliant. I genuinely feel so much more educated afterwards and I know you will too and you will also learn about the importance of our eyes.
Speaker 1:Before we get into today's episode, I would love to ask you for a little favour. If you like this podcast and I know so many of you do you could really help me out by giving it a nice rating, sharing it with your friends and subscribing to the podcast. It may not seem like a big deal, but actually this really helps to keep the podcast high up in the charts, and that means that I can keep bringing you brilliant guests who are insightful, inspiring and full of wisdom that we can all learn from. Thanks a million. Now let's get to it. This episode was produced by podcatseditingcom. These guys have taken my podcast production to the next level. Check them out at podcatseditingcom. Tell them Laura Dowling sent you and they might even do your first podcast free of charge.
Speaker 1:Michal, it is a pleasure to have you on thanks very much to talk all about eyes yes, all eyes I have to put my hand up. I do not like eyes as in, I like looking at nice eyes. But in the pharmacy the girls always knew if someone came in with a gunky eye they'd deliberately go laura come out yeah and I go out and someone with a bit of pus in their eye or a red bloodshot eye oh my goodness.
Speaker 2:Yeah, I think it's probably normal not to like eyes, but somebody has to study them and as ophthalmologists we study them front to back, in and out, and know quite a lot, I would hope, about a small area, which I think is quite nice to know in detail one specific area rather than knowing somewhat about a large area. So that's, I suppose, what is my interest in eyes and why I went into it, is to know back to front everything about eyes in that particular context of just one area. Obviously it does seed into other parts of the body, which is interesting, but the patients really aren't ours or they're not owned by ophthalmology. We can consult and we can help in terms of the diagnosis, but overall they belong to another specialty and we are involved in their care. That way, with eyes we know just our little area and we keep to that, and that only.
Speaker 1:And what made you interested in eyes, apart from knowing about one little thing very specifically, what got you interested in eyes when you're going through med school or junior doc?
Speaker 2:Well, I suppose we have a pair, so it's two little things really, but I liked Like balls. They are eyeballs, yes, I would say. In college I was particularly inspired by the professor in Trinity at the time, lorraine Cassidy, who seemed to be on a different league than other teachers. She really loved her job and she was very interested in patients, the holistic care, their families and just some of the diagnosis not being that good in terms of other diseases that can be going on, like neurological problems, and displaying all of that in a very compassionate way to the extent that I think she really made me feel this is an exciting job to be in. She also wore, you know, a very fashionable black skirt and a black blazer, came in with a Louis Vuitton handbag and threw it down the lecture table for the first lecture and I think everybody felt this was on a different level than what we'd been experiencing before and I think that was the initial spark that I felt a bit more pulled in.
Speaker 2:You can go through rotations in college and through the hospital and you can feel you're not really part of the team, you're just going in and out. But I organized through her an observership down in London for that summer for Moorfields and then I think it just became my thing is what I was mostly interested in. So even within eyes, there are numerous parts of the eye that we study on fellowship level, be it oculoplastics, which is what I do cornea, glaucoma, retina. So there's so many different areas that they do cross over. All right, but we are becoming more and more so specialised. We know more about our little area within the area and less about the general stuff. So, yeah, it does fit the need. For anybody who's a bit OCD type A and wants to know just about their little niche, I think yeah.
Speaker 1:And what are Ocuplastics?
Speaker 2:So I did all the general ophthalmology training, which predominantly focuses on cataract surgery and delivering that at a safe and a high level, and then you get experience in the subspecialties. So that's at the end of our training. What we come out with Fellowship then would be subspecialties. So oculoplastics is the plastic surgery around the eye and it sounds like a small area, but the intricacy of the anatomy means you have to understand how different vectors work, for example with the eyelid, how it functions.
Speaker 2:You can't just put a skin graft on and it'll take like it might take elsewhere why, so the skin around the eye is the thinnest of anywhere in the body that might go so crappy as we get older exactly. The other thinnest area, believe it or not, is the testicles as in, it's as thin yeah, apparently. So, oh, really. And why is that? It's because we blink even in our sleep. So so our eyelids are constantly moving, so it needs to have a low weight and for the muscle to have high mitochondrial function in order for us to blink. So our eyes never stop moving, even when we're asleep.
Speaker 1:What does high mitochondrial function mean?
Speaker 2:It means that there's a lot of the energy part of the cell around the eye in order for us to keep it functioning, so you need a lot of oxygen to your eyes. The blood flow through the eye is quite high relative to the size of the organ and the weight of the tissue and constantly, even in our sleep, as I was saying, we still see images. The eye constantly moves, even when you're sleeping with small movements of the eye. If you ever watch somebody sleeping in a not crazy way, you will see that there's slight little movements over and back and all of that needs energy constantly to maintain the function. It's the fight or flight response as well. So if there's a loud bang outside, you automatically turn to it, your eyes turn to it and it's one of the first responses that we don't even have control of is to look and to see. We don't really understand how important our sight is until it's gone.
Speaker 2:And I would say those who have adapted in later years to loss of vision it's extremely difficult to do and kudos to them for doing so well and adapting with, whether it be the white stick or the dog, or even just knowing your way around your environment. If you close your eyes and it's black. What can you function to do? And then the other population, being the children or the younger younger born without sight, they may not know any different, so they have a different set of adaptation skills, rather than what the adult would be and even within what I would do day to day. Some of it is orbital tissue as well, so orbital as a subspecialty. Removing an eye that's not seeing or is painful and blind, and the trauma that a person goes through, for example, with that, is not insignificant in terms of their life and what the impact is.
Speaker 1:Do you normally have to remove an eye because of an injury or for cancer, or what would be the reasons why you'd need to remove an eye?
Speaker 2:So the main reason would be if the eye is not seeing and it's painful, so it's not of any use and it's never going to see. And that can be due to a number of conditions, such as a vein occlusion in the back of the eye. It becomes ischemic or there's no oxygen through and it starts to get new blood vessels the same as, for example, a diabetic eye would be and then it starts to bleed in itself and it becomes more and more painful because of that cycle that keeps going. If there's a tumor in the eye, for certain melanomas for example, the eye has to be removed intact so that the tumor doesn't seed outside. But it can happen at any stage in a person's life, from trauma, and that can be a child all the way up to you know, your end years.
Speaker 2:And it is of the utmost important, if a person has lost one eye for vision, that they would wear safety goggles etc for any type of DIY work. It sounds intuitive, but those safety checks that are there are because there's an increased risk of damage to your fellow eye. If you have no vision in one eye and that's a small number, but I always advise them no DIY, get somebody else to do it, or if you're walking in the street, get somebody to walk on the side that has the poor vision or no vision on that side. So I have been working on a project with a guy recently who has lost one eye through a previous trauma retinal detachment, numerous surgeries and he was struggling to come to terms with the whole procedure. That's there.
Speaker 2:There isn't very much psychological support and for him this was a big ordeal. To lose his eye was the same as having to lose his limb. And we're working on a podcast, actually a series, so patients will give their details of their story, their background, and each one will be maybe a couple of minutes long and it's so that if you are going through that process, you'll be able to listen and hear that somebody else has come out the other side, that they're functioning well, they're living well and living normally and, in particular, for parents and for children as well, if that is the case, that they can have a full and normal, happy life with an implant as the second eye.
Speaker 1:Is the implant there? It's like a prosthetic eye. You take it in and out and you have to clean it every day, is that?
Speaker 2:it.
Speaker 1:Yeah, do they ever look real though?
Speaker 2:I think this is one area that we could advance more in, and 3D printing is very useful. They have some studies looking at that and it's not in use fully just yet. I think it's not a big industry. There's not enough collective financial interest behind it, and also what the ocularist will do. So that's the person who will make the prosthesis. They will take molds, they will shape the prosthesis for the front and then they hand paint it to look like the other side.
Speaker 2:So that is in itself an art. It's a fine skill that somebody acquires, and we don't have very many of them in Ireland either. It is something that's probably dying out as a skill and I think would be very useful if we had more as also to do the psychological part of it as well. You know, not just the physical side. So the prosthesis is the bit that stays in front.
Speaker 2:Behind that is an implant which takes the volume of the eye that's been removed and that can be made from acrylic, which is quite light. The way I do that procedure is I put a sclera wrap which is somebody who has died and donated their eye. The white or the sclera part is then turned inside out. So that is on the acrylic ball and then the muscles are sewn onto the sclera. So you will get a little bit of movement, but overall the idea is looking straight ahead. The eyes are aligned, looking left or right, but overall the idea is looking straight ahead. The eyes are aligned, looking left or right. You won't have alignment of the eye, and that's as good as we can get at the moment.
Speaker 1:Wow. So what are the main things that you see in your practice? You know what are the main things that go wrong with eyes. You did mention cataracts, yeah, so maybe explain to people what cataracts are, why they occur and is the surgery really easy?
Speaker 2:Yes, are why they occur, and is the surgery really easy? Yes, cataracts is. It's an inevitability as you get older.
Speaker 1:Oh, Jesus is it.
Speaker 2:Now, not everybody who has a cataract needs to have a surgery. So it's a normal aging process in the lens. If it gets to a certain point where your vision isn't clear or you're not managing with your vision and that is a little bit down to interpretation of the patient and what they can manage with and deal with Then you have a cataract operation done which removes the lens and puts in a prosthetic lens. That lens is of a fixed focal length, so it's measured before you have your operation and we know what power lens to put in to give you good distance vision.
Speaker 1:So what is a cataract, though? What is happening to the lens?
Speaker 2:So the proteins that are usually well aligned start to become misaligned and it's like an onion. It's one of the few parts of our body that continues to grow during life. So every year a new layer is put down and therefore it becomes cloudy. As more and more layers are put down, it's like looking through a frosted glass rather than looking through a clear glass, and as it grows the thickness will increase. Patients will often describe initially glare, so difficulty between evening and nighttime vision, so that low light or dusk vision, halos around objects or not being able to see the bus numbers, not being able to see the writing on the TV, and not correctable with glasses. So if that's the case and there's a cataract, then it's a cataract. Operation is the only way to treat a cloudy lens.
Speaker 1:And will an optician be able to diagnose a cataract when you go into your optician?
Speaker 2:Yeah, and it's a yellowish color, as opposed to when a baby is born. It's like looking through a glass of water clear and you can sometimes see at the back of the lens what's called a posterior subcapsular cataract, which is mostly related to steroid use, for example, and a complication of steroids is often developing cataract, and it's interesting to see the different types that are there. Now, the surgery is still the same. It still needs to be replaced and a new lens put in and that gives you the good distance vision, as I was saying, near vision, then being different again, so being able to focus up close. You need the readers. That's essentially what the surgery is. It's about maybe 20 minutes, half an hour. We can now do it with drop anesthetic on the eye, so it doesn't even need to have any anesthetic injected around the eye. You're lying flat, you're looking straight up at the microscope light and you have to stay reasonably still.
Speaker 1:Oh, jesus, but can you feel you poking around? Okay, so I couldn't deal with that now. I'd have to have a general anaesthetic. I hear anyone touch my eyes. I can manage eyebrow plucking right.
Speaker 2:Okay.
Speaker 1:But anyone else touching anywhere near my eyes, I absolutely. It's literally like someone's. I feel someone's going to claw them out. It's a horrible feeling. Will there be many people like me?
Speaker 2:Yes to claw them out. So it's a horrible feeling. Will there be many people like me? Yes, there's lots, as I can often tell by trying to examine people. When they are they're closing their eyes or they're squeezing their eyes, or often the mouth is open as opposed to the eyes being open, and it's a normal response. Nobody likes having their eyes touched and they're very much innervated, very heavily, according to the need for the eye to repair itself if there's a trauma. So the front of the eye, the cornea, has a dense innervation which means if you touch it you get this very heightened response to pull back I'm squirming while you're talking If you get a scratch in the eye yeah you get pain which makes the eye water and that produces factors which help the eye heal itself.
Speaker 2:So there is a cycle there as to why it's innervated like that and so heavily, and I think it's completely normal to be squeamish about eyes. I mean, I don't, I wouldn't like if somebody put their finger in my eye either.
Speaker 2:So okay I don't think that anybody would be happy with that, but I would hope that I'm a bit more used to being around eyes and at least putting patients at ease about what we're going to do. Which often is the biggest factor regarding a surgery is the fear of the unknown and that increasing your anxiety and then, once the anxiety is up, it just is a cycle of perpetuating things into crisis stage.
Speaker 2:A bit of sedation is often helpful for a cat, so it would be even through the drip actually um and nice. The worst, the worst is, some people get, will get sedation and they can flip so they can get disinhibited. And that's why we have excellent anesthetic colleagues who will just monitor things as we're going through it, because it's very important to stay still as possible for the cataract operation. We're operating under the microscope, so a tiny, tiny change in the hand position is a big position change under the microscope. So we're talking about blades that are 2.3 millimeters in diameter, a lens being injected through that size of an incision, self-sealing wounds, and the surgery itself is a little bit.
Speaker 2:I think of it like a computer game. So you do one stage, you do one and then you get through that, you go on to the next step and then the next step and get through everything and you're to the end. And it is definitely a skill to be learned over a period of years as a trainee. And, as I was saying about the stages, if you get an error in the first stage then it makes it quite tricky for the rest of it. So the parts of the eye are only a few micrometers in thickness, so so you can imagine a small force would burst through that. So we have to be cognizant of the fact that you know, although we're looking down the microscope and it is magnified, in reality these are tiny organs and any damage to your vision obviously long-term implications for that.
Speaker 1:So and when you say looking down the microscope, do you have goggles, special microscope, goggles on.
Speaker 2:There's usually a microscope which is mounted on the ceiling and we would bring that in place over the patient and that will give us a full view of what's called the anterior chamber. So, from the cornea to the back of the lens, you can magnify, you can change your illumination, you can go up down, you can visualize anything that's straight in front of you, and then the second lens is put on to look at the back of the eye. If you're doing retinal surgery but the microscope is necessary for intraocular surgery in order to see the tissues clearly, for what I would do with oculoplastics, then that is differently. We're on the outside, so I would put loops on for magnification to get my stitches more in focus, because they are small, but it's not at the same level as would be needed inside in the eye okay, wow are you less squeamish now?
Speaker 1:um, I still a bit. No, it's just, it's interesting to hear, but it's quite mathematical. I'd say, do you have to x-ray people's eyes or take a picture of their eyes and measure them and then go to the drawing board and do your cross multiplication to make sure you don't mess things up?
Speaker 2:We're a bit more advanced than that. We don't have the 12x12 tables anymore, we're not there with our calculator with log cause and sign. We talk about AI and the advances that are there, but in ophthalmology I think we're very progressive with technology. To do a cataract operation and measure the lens that is needed, there is a scan done of the length of the eye and then there's various formula based on the power of your cornea which will spit out a number at the end of what lens power to put in.
Speaker 1:What do you mean? The power of your cornea? What does that mean?
Speaker 2:So the power of the cornea is the steepness as regards to one axis versus the other, so it's like a rugby ball, so it's steep in one axis, more curved in one axis than the other, and that will bend the light as it's coming through a certain amount. The lens will bend it more and it has to meet at the same point in the retina so you get an image. It'll stimulate the light cells in the retina, which is then traveling back to the brain. So you get an interpretation of the image. And if that doesn't happen, for example if you're short or long sighted, the image is in front of or behind the retina, so it's out of focus and blurred. And with the measurements of the eye, measurement of the power of the cornea and a few X, y and Z numbers that various people have come up with, we get a power of the lens that is the correct one to put in to give you the perfect distance vision.
Speaker 1:Is it every lens made to measure, then? Or do you have just all these random lenses?
Speaker 2:So it's about. It's as near as and as accurate, as you wouldn't know the difference between. You know a 20.05 and a 20.1. So the next they're in 0.5 gradients of diopters it is very accurate.
Speaker 1:We own it language diopters.
Speaker 2:Also, refractive laser is even more at a higher level of getting all your measurements beforehand and it goes into the computer or the machine which will spit out the treatment that's necessary. So this is AI at its early stages in terms of getting all the information together, processing it and you knowing. If the patient has this power lens in, they will get clear vision. So, yeah, that's how we calculate what lens to go in and for each person. It'll be maybe slightly different between left and right, or your lens power will be slightly different than mine, but it depends on also the length of the eye. So if you're short-sighted and all of that, or long-sighted, fractions of a millimeter will make a difference. So the eye is about 21, 22 millimeters and we can measure up to 25 millimeters. It doesn't sound like a big difference, but that is a myopic eye, which is a long eye which is short-sighted. So those two millimeters of a difference goes from normal to short-sighted. So those two millimeters of a difference goes from normal to short-sighted. So, yeah, fractions.
Speaker 1:Do robotics play a big part in the surgeries that you do, or in your work? Or do you see them? Could they take over?
Speaker 2:So I hope that it's not a case of taking over. I don't think they will. I think they'll assist us. I think we have a lot of it in place already. We just aren't calling it ai um, I don't know very much ai robotics for cataract surgery per se. Um, it is like a computer game, as I was saying. So maybe they will. We've used in different parts of the surgery that laser will be done to make your wounds or to make a different part of opening the lens bag, but that hasn't become mainstream just yet. I think it's a bit expensive to introduce, so I think we'll be doing the cataracts for quite a while to come.
Speaker 1:Yeah, and then is there is there surgery? Is there robotics where you would like the computer game? You're doing the levers and the robots doing it, but you're looking at what the robot's doing because it can be more precise.
Speaker 2:So, I think that will come in. At the moment, I don't know of any surgery being done by robotics for eye surgery In the same way as, for example, it would be for urology and for prostate surgery. It seems to be one of the areas that's really taken off. I think it is only a matter of time when we live with the robots and we help each other, rather than them taking over and us becoming extinct. I think that robotics would be very useful for certain parts of eye surgery, particularly the retina. Where it's fractions of millimeters for example, peeling a membrane at the back of the eye that can cause the retina to pucker, and when you do, when you peel the membrane you allow it to relax, so you allow the puckering of the retina then to flatten back.
Speaker 2:So your distorted image that you were getting when the retina was all bunched up is then refocused into the normal clear image when the retina is flat.
Speaker 1:Why would a retina become puckered into the normal clear image?
Speaker 2:when the retina is flat. Why would a retina become puckered? So that can happen after inflammation in the eye, or it can happen for some unknown reason that we can't quantify as well, but it will give you like a distortion in your vision, rather than the letters being particularly absent on a Snellen chart or the vision chart, and once you release that, it's like the puckering of like a galvanized roof. Then it flattens out and the image becomes clear again. So that would be the retinal surgeons that look at the back of the eye, which is far away from my bit in the front okay, so you deal mainly with the front.
Speaker 1:Yeah, could you do the back?
Speaker 2:so during training we would have rotated through, got experience in terms of what the different diseases were. I feel retina is a bit outside my comfort zone, even after three or four years as a consultant, where we're so into our own little niche area. I'm very happy to do all of that in our own niche that we forget about the rest of it.
Speaker 1:Okay.
Speaker 2:And I think it is becoming very specialised in ophthalmology. Oculoplastics is again a very surgical part. It's the plastic surgery around the eyelids front of the eye, and the eyelids function to close and to open open so we can see close, to protect the eye. It sounds like a very simple and basic thing. Anatomically and structurally they are quite complex and it's not just a sheet of tissue. It has to move in a particular way and it has to function in a particular way in order to maintain our vision.
Speaker 2:And each part of the eye, in its own right, has to function 100% for us to get a clear vision and get a clear picture. If it doesn't, then the vision is distorted and you can't see. So each part of it, in terms of what the light goes through it, has to focus on the back of the eye or the retina, or else to change the light into an image in the brain. And it's great that we have a spare one just in case, because if anything happens your cornea, for example you can't see, it's like looking through a cloudy window or the glass is scratched. That can happen for any of the multiple reasons, including dryness, which sounds again simple, but you know, dry eye can lead to the cornea not being clear.
Speaker 1:Is the cornea, the first part, the front of the eye.
Speaker 2:Yeah, it's like a bow window or a bay window in the front and that is quite complicated from an evolutionary point of view. It has five different layers and corneal grafts is the way to treat if you have a major corneal problem which is replacing your corneal tissue with a donor's tissue.
Speaker 1:And is that donor always dead?
Speaker 2:Yeah, so we get our. I think we still get our corneal tissue from an American tissue bank and you know they are expensive. They are different than what would be an organ transplant because the immune system in the eye again is a bit different than elsewhere. So the risk of a corneal graft rejection is quite low. You don't need to be on systemic immunosuppression or heavy tablet immunosuppression that you would be if you have a lung transplant or if you have a liver transplant or a kidney transplant. The immune system being behind a blood ocular barrier, the same as the brain is behind the brain barrier, it protects it from eating itself in a way with autoimmune conditions.
Speaker 1:So it's primitive in a way but highly evolved in another way so does it have to be from a fresh, dead donor, or does it keep it frozen or in the fridge it's transferred?
Speaker 2:maintained, I think, at a particular temperature.
Speaker 1:Okay.
Speaker 2:And anybody who would donate their eye. There would be the sclera.
Speaker 1:Where's the sclera?
Speaker 2:The sclera is the white part which is the very thick protective part. It's very rigid tissue and if you were to get a bang to your eye, that is what prevents any penetration or perforation through.
Speaker 1:I can't even look at yourself at that risk.
Speaker 2:I think it's one of the firmest tissues anywhere in the body and it's akin to the lining of the brain, because the eye is evolved from the brain. It's an outgrowth of the brain. So when we talk about three layers protecting, it's the same three layers that are protecting the brain itself. The cornea, then, is that clear part in the front. So I would imagine the same three layers that are protecting the brain itself. The cornea, then, is that clear part in the front. So I would imagine the same person's donated tissue is used for a scleral tissue to be donated or a corneal tissue to be donated somewhere else.
Speaker 1:So any part of the eye can be donated and it can be put into another person and it won't have that immune response that other tissues do when you ask the question about always.
Speaker 2:Always is never always. So inside in the eye there's a lot of pigmented tissue and that isn't ever transplanted into another person. It won't help the person see it. You can't connect up the cables from a donor eye to the optic nerve.
Speaker 1:Okay, so that can't be done.
Speaker 2:Unfortunately we have nothing at the moment that will make a retina work or a donor retina transplanted into somebody In an actual fact. It's probably not a good idea because autoimmune problems can happen if that was to leak out or you have somebody else's uveal tissue inside in your eye and there is one condition called sympathetic ophthalmia, whereby the uveal tissue escapes from outside the eye and it goes into your systemic circulation and because your body doesn't recognize it as being your own it's usually behind the gate of the blood ocular barrier then you get an autoimmune response and it starts attacking your good eye god and the body's amazing, isn't it?
Speaker 2:so I think, when you put it under stress, absolutely, and when you're trying to study eyes, in particular in their steady state, and you realize what is needed for us just to see, yeah, um, it's highly complicated and complex, and I think we probably don't understand most of it insofar as we haven't been able to, you know, reproduce it in another human if they had issues with their own eye, the. It's also fascinating about what you see and what I see, and are they the same thing? And what we call yellow, what I call yellow, is that the same? What you see?
Speaker 2:as yellow, but it's how our brain has learned, with our eyes, to put a name on something that is yellow.
Speaker 1:Yeah, so talk to me about colorblindness, then in that sense that is yellow.
Speaker 2:Yeah, so talk to me about colorblindness then. In that sense, so colorblindness is hereditary, and I've always found it a difficult concept to explain, because if somebody is colorblind, they can't see that color, so they just see something else instead. And it's always come down to the fact of again what I was saying about what you see as a color and what I see as a color. We're calling it the same thing because that's what our brain has adapted to or what we call that color, but it may not necessarily be exactly the same.
Speaker 1:But is it not that you know? I know so. My brother's a pilot and one of his friends wanted to be a pilot and he failed at the first attempt. Because he failed the colorblind test, because apparently they can't distinguish between red and green, is that not it?
Speaker 2:yes, brown you'd imagine red and green being stop and go yeah, being very important colors, so for example, at traffic lights. You distinguish them because of their position on the traffic yeah but you don't see them as different colours, right? And there are even more rare types where the person can see a different spectrum of colour as well, a fourth spectrum, I think.
Speaker 1:My God, it's like the Matrix.
Speaker 2:And how do you know that you're different? Yeah, unless.
Speaker 1:And that's it. You see, he's going through life not even realising, and he thinks he can go and be a pilot, and then he just although the fashion sense might have been a bit between red and greens, this is it, this is it, but isn't it that's interesting, isn't it so? Do they just see brown, or variations of brown, and that's why can't they? Is it other colours they can't see, or is it like we don't know?
Speaker 2:Well, you know, there's the three primary colours.
Speaker 1:Yeah.
Speaker 2:But then there's the mixing of each of those.
Speaker 1:So what are the three primary?
Speaker 2:colours I can't remember.
Speaker 1:Are they red, green and orange, or are they? I'm going to look this up, we're going to look it up Red, yellow and blue. Okay, so they can't really. Can they not distinguish between those? Maybe, because look when they're, am I wearing? It's a bit gray, you need a bit of vanish there. I tried it.
Speaker 2:But yeah, so the the concept of color I think is very interesting and I suppose, even as you see a baby develop and you see them having very, very primitive vision to start off with and then they start to smile because they start seeing more of the world how that develops over the first few years of life, and how much we depend on vision for everything that we do. And if you don't have that, the adaptations that are necessary to get by, if you think of what you did today, how much of that would you be able to do tomorrow if you lost your vision straight away? And I have come across some absolutely remarkable people in clinic who have the most amazing skills to adapt, so they would have a guide dog who seems to be a part of them, will be something that they can rely on and depend on to cross the road in busy traffic and comes into the clinic and just sits down underneath your desk until the patient is ready. And they will be able to sense when the patient is finished, when they stand up, when they put down their hand for to call them, etc. And then other technology advancements like using voice dictate on your phone, which is not that amazing of an invention. Now we all use that, but a few years ago I remember seeing a guy who knew by texting on his phone he was able to type without being able to see the pad for the letters and he was the fastest typist I have ever seen. It was just the questions were coming out as if you would say them.
Speaker 2:So and he has done an undergrad, he's done a master's and there is certainly an uphill struggle there in university to, I suppose, get the same that an able-bodied person or a normal vision person would have. And important, that those people have the exact same access to whatever they need and extra that they need in order to be able to have a, you know, a complete and full life, the same as if they didn't have that condition. I think, unfortunately, in in ophthalmology we don't tend to see the patients who have lost their vision. It's like as if there's nothing we can do for them. So therefore, we don't tend to see them back in clinic every year and there's a whole demographic of those patients that as ophthalmologists we don't come across and we don't have their issues in mind. And there's a lot to be advocated for for those patients, and there are some very good groups who do that, I think for children.
Speaker 1:So I know that you do a little bit of eye aesthetics down in the IDI. So what do people come in to you for?
Speaker 2:So, blepharoplasty.
Speaker 1:Is that what it's called? So your eyes are a bit hooded.
Speaker 2:We're on the other extreme.
Speaker 1:Want to freshen me up a bit.
Speaker 2:So aesthetics around the eye are important because when you have a conversation with somebody, 50% of your conversation is eye to eye and there have been various psychological studies looking at this, graphing your eye movements, where on a person's face we actually look. So you look at the eyes and a person's mouth back to their eyes, again looking away. But about 50% is eye-to-eye contact and if there's a slight discrepancy in terms of the eyelid position, one versus the other or what would be considered to be normal, your brain is so finely adapted that it can pick that up quite quickly.
Speaker 2:So if you imagine, 50 of our day we're looking at somebody's eyes yeah if there is one that is slightly tautic, which means it's slightly droopy, or the lid is higher, as might be in thyroid eye disease, we can pick that up in our brain as being abnormal is that like the lazy eye.
Speaker 1:You know there's always a kid in the class of the lazy eye wasn't there?
Speaker 2:there's always, there's always, yeah, yeah so that is when the brain, in conjunction with the eyes, is developing your vision and one eye has a blurred vision, for whatever reason. The other eye is the better vision. So your brain forgets about the blurred vision, so that you have one good eye for vision. And when it forgets about it, then the eye can move in or it can move out, and that's called a squint. And what the correction is is to correct the vision problem, initially with glasses and then a patch, if needs be, to give the weaker eye more strength in order to work more.
Speaker 1:So you put the patch on the good eye.
Speaker 2:Put the patch on the good eye Now. If you keep the patch on the good eye, Put the patch on the good eye Now. If you keep the patch on the good eye indefinitely, that eye will go blind. Will it go blind? Yeah, so if you have no stimulus to your eye before the age of seven, the vision doesn't develop.
Speaker 1:Really.
Speaker 2:And that can be for as short as you know two weeks on a very young baby and up to the age of about seven. It would be more time, but for a very young baby, if you were to put a patch on the eye, the brain does not develop vision.
Speaker 1:Or if the baby is in darkness the whole time. Oh my goodness.
Speaker 2:So it's the same as if you have a limb if you don't use your hand, if it's just, if it's tied, when you get to a certain age of it could six months it's not going to know how to function and the brain that is getting those messages is going to forget about it. So that's you know. Neuroplasticity in the brain is the opposite of that. So when you put a patch on and then you're making the weaker eye to work more, then the brain is getting the stimulus for that part of the brain to develop. After about the age of seven you don't have the same facility to do that, but in adulthood, if you were to lose vision in one eye and you only have the weaker eye, the brain will pressurize itself to give you a slightly better vision, but not 100%, which shows that we do have some neuroplasticity even into our adult years, and things can adapt and change.
Speaker 1:Sorry, I totally took you on a tangent there. I was like lazy, I was totally different or like you were talking about the blepharoplasty, so the kind of it's the droopy eyelid, really isn't it?
Speaker 2:Yeah, so it's the excess skin where you have this fold of skin that comes over and it will even touch off the lashes. It causes the upper eyelid to feel quite heavy, particularly at the end of the day, and you will get quite an aged appearance to the eye itself. So even a small change with a blepharoplasty surgery which will remove the excess skin and sometimes the fat that's in the pocket just inside here, right beside the nose, Opening that up will give a much more refreshed look, a younger, youthful appearance to the eyes, which is quite remarkable when you see pre-op picture and a post-op picture six weeks later that it can be quite dramatic to see, is it really obvious, though?
Speaker 1:Is it like I know she's been done, my mijo?
Speaker 2:The biggest compliment that I can get is nobody noticed I've had surgery. Okay, and that's the aim of the game really is, as one patient remarked recently, everybody thinks I've had my hair done differently or I've changed my makeup. So you don't want to be dramatically changing, you don't want to change the shape of the eye or anything to do with changing the face. It has to be subtle and it has to be just a small refinement and a week down time for the upper lid and you should be pretty much back to yourself and are you just taking a little slice of the skin and then you're sewing it back together?
Speaker 2:Would you take too much. So I would hopefully be able to measure how much to take after all my years of training, because if you do take too much, it is very hard to put it back. So you're talking about skin grafts and then the eyes open, the eye dries out. It's very uncomfortable. My teaching has always been under-correct rather than over-correct. You can always go and take more if needs be.
Speaker 1:I like it, michal, I like your style. I underdose all the time in the practice. Underdose, don't overdose. Exactly, it's a good term Subtherapeutic.
Speaker 2:And you know scars and that can happen, but in general it's no problem to go and take a little bit extra. It takes about three months to be fully in its resting position, shall we say, after a surgery. So that's all the swelling and everything to be fully gone. There's a dramatic improvement in the first five days and then at a week you should be pretty much back to work. Stitches come out then and people don't really notice maybe at the start as the swelling goes down even more. Then it's a steady state after about three months.
Speaker 2:So the distance between the lashes and the skin crease in the Angelina Jolie eye, as I always give as the perfect example of eyes, is what creates that youthful appearance. So if you have hooding where the excess skin is covering that, that makes the eyes look aged and dated. I don't know who does her eyes, but has she had them done? So I was looking recently at something on Google and she does have the most amazing eyes in terms of the shape, the symmetry, even the color of her eyes, and that distance between lashes and the skin crease line being open makes the eyes look a lot more youthful maybe than her years would suggest. So I mean she's had a good surgeon surgeon. It's been very subtle and we're questioning did she have it done or not? So that's the real.
Speaker 2:That's the reason yes, so that's upper blepharoplasty, and then for lower is a different ball game. It's a different surgery.
Speaker 1:Is it a?
Speaker 2:lot messier, so lower is more about moving fat around yes, okay so septum, which usually keeps the fat back. As you get older it becomes stretchy and it balloons forward into little pockets, usually medially on the inside, central, and then laterally on the outside.
Speaker 1:You're talking about the septum of your nose.
Speaker 2:No, septum of the eye. I've forgotten about the nose, you see, because I eye I I've forgotten about the nose, you see, because I only do eyes. Now, there you go. So there's a septum which, like a fibrous tissue and that is so it's behind your eyelid skin and it goes from around the orbit itself to the rim of the orbit and that is it's like a bag or a sack lining that is very fibrous and it keeps the fat from bulging forward. But, like everything, as we get older it becomes stretchy and it loses its strength and as the fat then starts to bulge, you will see these little pockets developing. The extreme example would be thyroid eye disease, where you get a disease which increases the amount of fat being produced around the eye and that dramatically then pushes the eye forward, or it'll push a lot of fat forward and that's where you get excess fat being produced.
Speaker 2:In normal aging it's a case of the septum is not being able to hold the fat back, and what we do now, as opposed to previous blepharoplasty surgery where they would take skin from the lower lid, we now allow the fat to reposition itself and to fill in where there's a defect in volume. So generally there's a volume loss around the rim of the orbit inferiorly. There's a line there that you get what's called a double hump. So you get the first hump is the fat. The second hump is the cheek the normal cheek, and that double hump is an aged. Look. To get rid of that, we release the double hump and we allow the fat to spill over into that area and it gives a nice smooth contour.
Speaker 1:But how do you know where it's going to go and stay?
Speaker 2:So we bring the middle fat pad down on a stitch down to here and that's there for a week.
Speaker 1:He's touching the below his eyelid and then he's touching then his chin. So you take the Cheek. Cheek, sorry, oh my God if I had to bring it down to your chin.
Speaker 2:You'd be like what kind of that would?
Speaker 1:be interesting. So you bring the fat pad down and you stitch it down a bit further.
Speaker 2:So allow it to spill forward by itself, not on tension, not pulling it. So Not on tension, not pulling it.
Speaker 1:So you're not talking about spilling forward like a fluid, just you're talking about it coming forward. It's like lobules.
Speaker 2:Okay, yeah so a very yellow color, and once you open the septum it will spill like as how would you describe it? Expanding foam Exactly.
Speaker 1:Okay, I think I'm nearly an ophthalmologist, I think so Next week maybe. Next week IDI.
Speaker 2:So you allow that, then underneath most of the tissue of the cheek, to come down and that will allow it to disperse under that area. With one stitch down in the cheek, not the chin, then you bring that out onto the skin and it stays there for a week and that's to keep it in that position and it really is allowing the volume to be replaced that you have lost with years of life, which happens so depressing, isn't it?
Speaker 1:Did you lie flat on your back for a week, then in bed?
Speaker 2:So for lower lip left there is a bit of downtime, with swelling more bruising than the upper. There's a lot of ice packs to keep you busy as well, which is to minimize the swelling. Upper. There's a lot of ice packs to keep you busy as well, which is to minimize the swelling, and all of that kind of turns a corner around day five and then you start to notice the swelling is improving. The lymphatics which drain that around the eye aren't very well developed, so that's why it takes a little bit longer than usual surgery elsewhere. But what you get after that is the volume deficiency that was there giving the age look is reversed. That is a long-term solution. So this isn't a case of it works for three months or six months. It resets the baseline to a new or youthful look.
Speaker 1:It's like you're six months again.
Speaker 2:Exactly Turn it back that far.
Speaker 1:Fabulous. And then does that get rid of the dark circles? Is that what dark circles are?
Speaker 2:Dark circles are quite tricky to treat. They're caused by a shadow from where the light falls on that side of the nose. Really, if you have good lighting, you don't tend to get as many dark circles. But what you're seeing there is the blood vessels or the muscle underneath being very vascularized. That is shining through the very thin skin that's there, as I was saying, the thinnest skin of anywhere in the body. So you're really seeing very well vascularized muscle through a very thin sheet of skin and that is difficult to reverse. You can use filler sometimes, but in most cases dark circles aren't always treatable, particularly if they're right in beside the nose, in the medial one. We can release the medial fat and allow that to spill over a little bit. But filler is mainly the way that can be treated in specific circumstances. It depends on the patient and how much of a dark circle they have and where it is exactly. A good night's sleep is also very useful a bit of concealer, yes.
Speaker 1:And then there's always this thing where have you ever seen it like? I've it so where women's eyes may be fantastic. They've always had the bleph, yeah, but then it's very hard to get the entire face looking as useful as it was. You know, the eyes might look good, but then the jowls yeah.
Speaker 2:And is it a case of once you start doing something like, if you start doing the bleph, then you're suddenly going Jesus, my eyes don't match my jowls and I have to get them done? Yeah, I think, firstly, it's important to keep it in perspective, and cosmetic surgery is completely elective. It is when you might want it at a specific time in your life. So the I suppose the idea of getting your eyes done and not getting anything else done it can look, exactly like you're saying, a little bit odd in terms of the overall appearance. So I would imagine it can get a bit addictive as well.
Speaker 1:If you've had one area done, you want a second area and it's important to have somebody maybe to tell you enough is enough, or have a surgeon that will tell you this doesn't work for you and you wouldn't do just a a double job, like where you do the upper eyelid and then you just like pull the pull the chakras up, not yet, but I think a lot of the techniques are similar.
Speaker 2:What we're trying to do is reverse gravity, really, and everything falls down with gravity over time. As you know, that's the way that we age.
Speaker 1:I've even seen those replications of what happens behind your skin and your face over time. So the muscles waste as well, and then the bones shift. And then you get that kind of sunken feeling, so you can't just lift your bones up.
Speaker 2:No, and I think even with the best facelift, you look at the overall person. Best facelift, you look at the overall person. Quite often the giveaway sign is the person's hands, where you can't do very much in terms of turning the years back, or a very youthful face, and the way a person dresses is you know they have to be all keeping together. So, yeah, I think that the reversing time is useful for some people in terms of trying to gain confidence. I would always say if it's something that bothers you, then go ahead and do it, but that has to be within reason, and there's a lot of information out there about cosmetic surgery. There's a lot of places you can get it done in the world which may not be as safe or as reputable as what we're doing here in Ireland, and I have no problem saying have you seen some botched jobs?
Speaker 2:Yeah, taking too much skin around the eye would be something that we have seen before. It's difficult then to explain to the patient that it was overdone, and they generally won't go back to the country where they had the surgery done. So that is tricky, because then you're repairing a hot mess, really, and trying to get them into a good position so that their eyes are protected, which is the main function.
Speaker 1:Because if their eyelids don't close, that can cause the drying out of the eye and lead to other problems.
Speaker 2:Tell me about the lady that was in hospital who hadn't told the yeah, I mean cosmetic work, Botox fillers, and I think you know we had our eyes opened about medications being imported in incorrectly and used incorrectly. But the lovely lady who was getting ready for a wedding a neighbor's wedding and decided to treat herself to some Botox and some filler ended up in hospital where she was being investigated for neurological problems related to eye movement disorders, which was really the botox infiltrating around the eye to the muscles. This isn't new. I think every ophthalmologist would have seen this, and it's a like a confounding of various muscles being paralyzed a little bit, but not fully. It doesn't fit with any pattern, mri scans, normal. But she did confide in me that she had her Botox done by maybe somebody who wasn't trained in it and her filler was also maybe a little bit overdone as well. So I would say not to go down that route of it all possible.
Speaker 1:And did she eventually get it fixed?
Speaker 2:So Botox wears off after the three months anyway which is a great thing, that if you're not happy, I would say not to go down that route of it all possible and did she eventually get it fixed? So Botox wears off after the three months anyway, which is a great thing that if you're not happy with it, it'll always be gone. Filler, I think that's going to stay with her in her lips for a long time you can get it dissolved.
Speaker 1:I think she was happy with her fuller lips, so yeah, she'll have that for a while. We're going to circle back now to actually eye conditions and the main ones that you see. So I know that we dealt with cataracts there. Can you tell me how ophthalmologists actually? Sorry, just tell us a little bit. What's the difference between an ophthalmologist and an optician?
Speaker 2:An optician is somebody who goes to college for four years and they learn in terms of eye diseases and also their main focus is on refraction and prescribing glasses, contact lenses and the skills involved in that. An ophthalmologist would be an eye doctor, so has done a medical degree, and then this is their specialty afterwards, which would be the same as doing dermatology, gastroenterology, any of the specialties. So we're coming at it from a very different angle than what an optician would be, and I suppose we're keeping it in context then as well of knowing the medicine from the entire body as opposed to just that particular organ. But yeah, we work well together. We have to. You know we're in different aspects of the team.
Speaker 2:There's orthoptists also. Just to complicate things a bit more. They look after the eye muscles in particular if you have a lazy eye or a squint and that is not available in Ireland to do as a course at the moment, but it's done in the UK and then they will work here. And then we have our photographers, which are so vital for a lot of what we do. We document so many things with photography in the clinic and we get scans done by the photographer, including fluorescein scans, which look at the retina, fluorescein scans which look at the retina, oct, which is infrared, looking at the macula and the optic nerve. And yeah, we rely a lot on technology and on scans as well.
Speaker 1:So opticians you mainly go to for reading glasses and that, but they can. Can they die? So if they see something in the back of the eye, could they see what you see in terms of, oh, this person probably has diabetes. Do they have to refer them on to you then?
Speaker 2:There's a lot of screening that they would do and refer onwards then for assessment if they feel it's not normal. A lot of the opticians will have an OCT at their practice, so it's useful to have done.
Speaker 1:What's an OCT?
Speaker 2:An OCT is an infrared imaging of the retina and it takes very, very fine pictures. It assimilates them together into a 3D picture and you can look at the retinal layers in real time and see if there's something like macular degeneration, which would be inflammation in the retina fluid, if it needs injections, treatment, anti-vegetarian treatment and that. So it's a very, very refined technology to look at a small but very important functioning tissue. But they're on the high street, they're available, you can pop in and you can get your glasses done two for one and you can also get your OCT done for a little bit extra and another image of the back of the eye for a little bit extra. So a lot of what they will be doing is screening.
Speaker 1:You touched on macular degeneration there. Can you explain what that is? Because a proportion of people would have come into the pharmacy and they would have been buying the likes of macuShield. Is there evidence for that?
Speaker 2:So the evidence is coming from large population studies finding a deficiency in a particular component and then trying to replace that. So lutein was big in the press at that stage and it still is, or occupied as well?
Speaker 2:yeah, and omega-3. All of these help. Your healthy diet is not just at that time that you have the disease, it's for years and years before that. Macular degeneration is two types of the dry type and the wet type. The dry type is you get excess components of the normal functioning of the eye being distributed in the retina and you get an inflammatory response to that. With the dry type, unfortunately, we can't go and scrape that off and give you normal vision again, so the best we can do is to halt it and to hopefully stop it from progressing with things like MacuShield. I think you would need a lot of patients to be on that treatment to see some benefit.
Speaker 1:As in numbers, to treat Exactly.
Speaker 2:Okay, yeah, and that's coming from, I think from American studies.
Speaker 1:Okay.
Speaker 2:The wet type is, you get an inflammatory response that exudes fluid within the layers of the retina. So, from a mechanical point of view, where the retina is yay, thickness, if you get fluid it's distributed wider. So again, you're not actually focusing the light onto the cells that it should be, it becomes distorted and you get a distorted image in the very center of your vision, which is what you need to see, to read, to see people's faces. It's where all the action is at, is the macula, and you can still see in the periphery. You're not going to go blind from that, but the most of what you will need your vision for is now reduced, so quite debilitating is now reduced, so quite debilitating.
Speaker 2:And the treatment is with anti-VEGF injections. They're given into the eye as an injection. So as the patient, I'm sure the first injection is quite difficult to have. Numbing drops on and you get the patient to look up in a particular way and you're going four millimeters back from the cornea and it is a needle into the eye Injection in and then out straight away. So I would think if I weren't even squeamish about eyes, that would be something that's difficult to have done. It works. They're repeated three months and then you just see how the patient responds.
Speaker 1:So what does it do to the fluid?
Speaker 2:So it turns off the inflammatory response you don't drain the fluid. So because the tissues are so finely aligned, if you were to go in with an operation and try and drain that, you'd probably do more damage to the tissues around that we can't take the eye out. That's a myth that some people will think. But we can't unplug it and put it back in. It has to remain in the optic nerve.
Speaker 1:Is some eye surgery, not where you take the eye out, and it's still attached to the optic nerve no is that a myth?
Speaker 2:that is an absolute myth.
Speaker 1:Yes, so you never take the eye out like it's kind of hanging from the optic nerve no, unfortunately.
Speaker 2:That would be great if we could yeah but for orbital surgery, for example, we have to work around the back of the eye, take the bone off on the side here in order to get access or go through the sinuses in here so how, in the name of how do we all think that sorry? How do?
Speaker 1:I think that after all this, time.
Speaker 2:I'm not sure where that came from.
Speaker 1:Actually do you know where it comes from? It comes, I think, cartoons, where the eyes drop out.
Speaker 2:I think if we could, it would be fantastic.
Speaker 1:It would make my job a lot easier.
Speaker 2:It means the optic nerve would be like a spring or we could unplug your eye, give plug in another eye and it would still work, but it doesn't, unfortunately.
Speaker 1:So it's because my mind is blown.
Speaker 2:That's going into a reel that you can't do that it's because the nerve, nerve tissue, once it's damaged, it's damaged and if it regenerates it will do so very slowly. It would hopefully reattach to the other part of the nerve, but it may not do and there's nothing in terms of stem cells or anything at the moment that we have that will regenerate a nerve okay when it's gone, it's gone and even within a few minutes.
Speaker 2:If the oxygen goes to the optic nerve, your vision won't come back. So it's critical as the brain you know exactly the same type of tissue. It needs oxygen at all times.
Speaker 1:So the wet macular generation, it is treatable, and can they get their vision back as normal, or is it always going to be a bit sketchy?
Speaker 2:So you can get your vision back as normal. Treat it early and frequently with the injections. Often by the time somebody gets their way to maybe an optician first and then referral on or to an ophthalmologist. It's been there for a little while. So you have damage done to the layers of the retina, they've stretched and when you put them back into their normal configuration they may not function exactly as before. But the prognosis with treatment is pretty good but not for the dry not for the dry and for the wet type as well.
Speaker 2:We don't often know when to stop the treatment because it'll work for a period of time, so the the half life of the drug must be three months, I'll say that yeah, so it's one every month for three months.
Speaker 2:Yeah, so it's one every month for three months, oh okay, yeah, and then you give it time to see has that turned off the stimulus? Some patients will need maintenance treatment, so it might be every 8, 10, 12 weeks they get a scan done. If there's fluid there then they get another treatment and you're extending their interval between each treatment to see will that maintain their vision? But a lot of people with wet macular degeneration are driving. They're functioning well and I suppose, just to emphasize again, even with the worst possible macular degeneration, your peripheral vision, your side vision, is still the same. It's your central vision, which is what we need a lot, but you're not blind with that condition.
Speaker 1:So can we talk a little bit about dry eye? Actually, because a lot of menopausal women so your middle-aged female followers is going to shoot up after this podcast. So I get a lot of ladies and they're menopausal and they have dry eye. What is the best thing for them to do? Is it the theolos and the hylos and all them, or what?
Speaker 2:So I think the best thing is HRT. It is something that will. It's something that will, for the majority, be get their symptoms under control or even get rid of all their symptoms. And it shows the importance of hormonal factors on our tears and on our eyes, because, you know, everything comes back to the eyes today, With dry eye, it's often multifactorial. So the amount of tears that you produce goes down every year. For a man, you know, it's kind of a linear descent all the way. For a woman, at menopausal time plummet, yes, cliff edge, and then you're down further and then it still continues to deteriorate over the next rest of your life. So we don't have any way to stimulate the eye to produce more tears. They've looked at very intriguing methods like putting something up your nose which will stimulate, like as if you're pulling a nose hair and make your eye water, but that's as advanced as it has gotten. We can't stimulate the lacrimal gland to make more tears, so therefore we have to try and keep the tears that are there. There's one licensed drug for dry eye and that's iCurvus, which is topical cyclosporine, and it works to maintain what you have. It doesn't reverse and based on the fact that there's an autoimmune component or immune response to that. It stings a lot as well, so it can be quite sore. For about 50% of people they won't stay on it.
Speaker 2:Blepharitis, rosacea, myeloma and gland dysfunction various parts of the same problem. It has to do with your ability to keep tears on the surface of the eye, so like you would put on a glass of water. If you put a layer of oil or fat on top, the water won't evaporate through the fat or the oil and that's the way our tears have evolved. There's a layer of fat or oil on the very surface which comes from the glands at the base of the eyelash, and that fatty layer means that the water stays on the surface of the eye. So if you don't have that, if your meibomian glands aren't functioning properly or you have blepharitis which blocks them, then the water just evaporates very quickly and we can check that at the slit lamp. Put a drop of fluorescein on which is orange, look with the blue light and we can see how quickly then the orange evaporates. And if you're putting drops onto the surface of the eye, you're just putting more water on. You're not essentially addressing things like blepharitis, which need hot compresses.
Speaker 1:Is the hot compresses to break up the oil kind of that's clogging, make it more like liquid.
Speaker 2:So it'll come out and massaging and, interestingly, ipl has had good effect from studies in the States. So IPL for rosacea anti-inflammatory for blood vessels on the very surface of the skin is proving to be anti-inflammatory for the eyelid margin as well. That's not even treating right up to the base of the lashes. This is going near the eyelid but not onto where the lashes are, and that's an overall improvement in your skin quality from IPL. That's the latest buzz for dry eye. It won't get you off all the drops or the treatment, but it might minimize them.
Speaker 2:And I think you know if you're doing half an hour every day with baby shampoo, cotton buds, hot water, messing around with that. There are the other options which are readily available now much easier the Scope products or the Thea products, pre-packaged open you clean with the eyelid margin tissue, you throw it away and it just is a lot more convenient and easy to use. I think, egg cups, baby shampoo, cotton buds all of that it's tedious. What's the?
Speaker 1:thing about baby shampoo.
Speaker 2:Why is it the thing that they say instead of just normal shampoo or soap, it doesn't sting your eyes, so the same as for babies if it gets into their eyes, it won't sting.
Speaker 1:Okay, and you're just scrubbing off the blockage. Is that what you're doing?
Speaker 2:So if you see it up close, it's actually a bit gross to see the amount of dry skin that accumulates at the base of the eyelashes. What the detergent does is it makes it softer. So then when you wipe, it just removes everything. There's probably an overgrowth of bacteria as well. If you put somebody on antibiotic ointment it will help, but then a few weeks later it comes back again. And there's a particular bug called Demodex, which is the most ugliest looking thing ever when you see it under the microscope. That doesn't like tea tree oil fully enough, so some of the wipes are impregnated with tea tree oil and the bug just runs the opposite direction.
Speaker 1:But we're not telling you to put tea tree oil into your eyes. No, we do not.
Speaker 2:Burn the corny eyes. There'll be an increase in tea tree oil-related injuries.
Speaker 1:Okay. So I know you say HRT is the best option, but in the absence of that, what's the best? Eye drop.
Speaker 2:Is it like the Lacrydu, the real thick ointmentment, or is it the hyaloforte or the theolos? Like I know, the hyaloforte and theolos are similar but yeah, they're different, different companies essentially. So the drops come in everything from water all the way up to vaseline, which is lacryloop, yeah, and the one you use last thing at night is vaseline, because you're not seeing. So if you get up during the night, just be wary of that that you will have to wipe it out yeah, because the lacquer lube can.
Speaker 1:It can blur your vision absolutely considerably, even the following day.
Speaker 2:It's like putting vaseline onto the surface of the eye.
Speaker 2:It's very, very thick yeah but it protects the eye in terms of drying out. There's everything in the middle then, from more like jelly to completely water drops and the water will stay only a short period of time in the eye. It's like having a fire and squirting a little bit of water on it. You know it doesn't get to the base of the problem, but it'll make it a little bit better. And then jelly being longer on the surface of the eye but will blur your vision.
Speaker 2:So, it's that balance of what you need at that particular time. So screen time is something that we're all doing more and more of and that is very impactful for dry, in that it is affecting the blink. The number of times per minute or you know that we blink is lessened by being on screen, so we have a staring appearance. When we're working on screens, we forget to blink.
Speaker 2:So one thing is to remind yourself or to take breaks, and what the american academy of Ophthalmology suggests is this 20-20-20 rule, so every 20 minutes right 20 second break and you look into the distance for 20 feet and that will relax the muscles in the eye and it gives your eye just a break from that stare that we it's a normal response to being on screens is is reduced blink rate, and if we could just remind ourselves to do that, or to work less on screens, then it would be very helpful for dry eye as well.
Speaker 1:What about for vision? Are they saying that kids are becoming short-sighted now because they're staring at screens and they're not out playing?
Speaker 2:and looking at the distance Exactly, and that's from studying evolution and the Darwin days. This is something that has really just skyrocketed very quickly from one generation to the next, over maybe about three generations, particularly in Asian countries where a lot of focus on bookwork not being outside in the playground playing a lot of focus on education and we're all, with more and more education, becoming short-sighted. So being short-sighted means you can read a book up close. It's very, very good vision for near work, but you can't read in the distance and our eyes are evolving for close-up work rapidly.
Speaker 1:But is it that the person's eyes singularly is? We're not like giving birth to people.
Speaker 2:No, yeah, okay, okay, but the rate at which it happens and you can't plug them out and put them in again. The rate at which it's happening is astonishing really.
Speaker 1:Yeah.
Speaker 2:So the number of kids now becoming high myopes, which is the risk being retinal detachment or problems with your retina in later years.
Speaker 1:Sorry, why was your retina detached? Because you're myopic.
Speaker 2:Everything is stretched in the eye, so the tissue is more stretched in the back of the eye, so your risk of having a tear or a break is higher, and we're talking about millimeters of a difference here.
Speaker 1:And is that because? So why is it stretched? Because you're looking at something close up all the time, so it's stretching.
Speaker 2:So the eye is becoming longer, the stimulus being close up work because we get a good, clear vision when we are looking at something up close.
Speaker 1:if you're myopic, All my physics is coming back to me now.
Speaker 2:I remember it all now, and coming back to me now I remember it all now and there's various ways to try and slow that down.
Speaker 2:In fact, Ian Flitcroft, who is a colleague of mine at the Matter has gotten a very prestigious award recently for his work in this, Nominated as one of the top 100 ophthalmologists in the world for his research in myopia, which is looking at atropine drops to dilate the pupil so that the eye is forced to do more work for up close rather than just being able to accommodate and look up close, and he's been working on that for years and years and is one of the world leaders in the area. A drop once a week atropine and my nephew was on this can have side effects. Atropine is a very old drug but in a diluted form it's very safe to use.
Speaker 1:they also particularly if it's just on the, on a topical use. Yeah, you're not like.
Speaker 2:Yeah, my nephew did get weak and vomiting and all that, which I think was a bit overlay, of psychos, you know, psychosomatic on top of it.
Speaker 1:All in his head. All in his head so to speak, like all you menopausal women. It's all in your head. You don't dry out at all. Exactly.
Speaker 2:You're just making things up. There's also special glasses which have. I'm not exactly sure how they work, but they do slow down the rate at which the myopia is progressing. Again, we don't know when to stop. What age do you stop these?
Speaker 1:Yeah.
Speaker 2:And are you going to get a regression back into some level of high myopia again?
Speaker 1:So how can we help our kids then that are on screens more than they should be? We just take it off them and send them outside.
Speaker 2:Yeah.
Speaker 1:Into the distance. Go off there now and look at the Dublin Mountains view.
Speaker 2:Which is easy for me to say when.
Speaker 1:I don't have kids, I know.
Speaker 2:But yeah, grab the iPad, throw them outside. Yeah, and back in my day.
Speaker 1:I know, I know. So they're sick of hearing that.
Speaker 2:But you do see more and more kids on and this is where I'm going to rant a bit but on the screens, particularly iPads. It's a way, I suppose, of keeping them entertained and having that stimulus there so that you can have maybe a little downtime to yourself and is necessary to have your own protected time. But being on them constantly is not a good idea. Kids now have phones, younger and younger. I know that for me your phone is kind of part of your arm really at this stage. If you don't have it, you get that phantom phone thing where you feel your, your phone is vibrating in your pocket when it's not oh, do you have it really bad, I know?
Speaker 1:yeah, where is it now turned?
Speaker 2:off and that kind of separation, anxiety from not being able to communicate but using our vision for close-up work constantly has shown that is the reason why the myopia is progressing. And yet laser surgery is an option in your 20s or whatever, to get rid of glasses. But this is on a different level of being minus eight, minus 12, which is very high myopia, so very long stretched eye tissues being more stretched and higher risk of problems.
Speaker 1:Jesus. Okay, tell me about laser surgery and how successful are they and do they cause dry eye?
Speaker 2:So they can do. It's usually the same as with blepharoplasty actually Anything that disrupts the innervation to the front of the eye. So any incision where nerves may be going through it takes about three months for that to heal, so that you can get worse dry eye at the start and then it should recover pretty much after the three months mark. If you have dry eye to start with, then that can tip you into something that's not comfortable.
Speaker 2:Laser surgery is a very refined procedure Measurements beforehand of your cornea power, front and back, the axis and the length of the eye. What's needed to correct that? It's very, very precise. It lifts a flap on the surface of the epithelium of the cornea. It will burn the stroma of the cornea, a certain shape, to re-bend the light into the correct way for your eye, and then the flap goes back down on top of that and I had laser surgery done when I was about 28 and I would say by far one of the best things that I have ever done. Because glasses free can be out in the rain, you don't have to be worried about contact lenses or them becoming drier, falling out. It's a one-off treatment and it's very successful in terms of vision. There's risk with everything, but the risks are quite, you know, quite low and once your vision is stable, mid-20s onwards, it's a an excellent procedure to have done to correct for that. It doesn't get you out of readers okay, 40s 50s.
Speaker 2:So that's, that's another process that happens in the aging eye.
Speaker 1:Okay, so for me now I started wearing readers. Just no, it's not very bad.
Speaker 2:How many pairs of readers do you have Just?
Speaker 1:one.
Speaker 2:Because you know if you don't wear them all the time.
Speaker 1:No, I don't. Then I don't wear them most of the time actually.
Speaker 2:And do you forget where you left them?
Speaker 1:All the time. Where the fuck are they?
Speaker 2:Yeah.
Speaker 1:Jesus. And then they're always somewhere shoved to the bottom of some bag somewhere. So no, I don't wear them all the time. And then some. The only reason I got them was because I figured I had a headache. I thought I was having a lot of headaches, so I went and got them and the headaches have gone, so maybe the psycho-synaptic 50% placebo. But I went to the opticians and they gave me I think I was plus one or something, or maybe it was less, maybe it was 0.5.
Speaker 2:So that'd be very low in terms of magnifying power.
Speaker 1:Okay.
Speaker 2:Most people plus three would be where they would settle their prescription at, and it tends to be not so much that your eyes get weaker, but you like. Having the glasses on. It makes it a bit clearer. So that's your brain is adapting to. This is a nice, clear image. Therefore, when you're reading, again you want that clear image and you want to put the glasses on. It's not necessarily that your eyes are getting worse or that you will eventually need to wear them all the time For reading. From the age of about 40 up to 50, that power will progressively increase because your ability of your lens in the eye to get fat or to get thin as you're looking near and distance. The muscles age and they don't do that anymore.
Speaker 1:Is it? The muscles just harden a bit and they can't stretch as much. Yeah, so he told you. Now, nearly not the smallest.
Speaker 2:The lens then is a fixed focal length and that's for the distance, and the glasses then are for reading. You can be short-sighted, just to make it a bit more complicated, and you take off your glasses for reading and that has to do with if you're minus two and a half, or we'll say minus three, and then you take off your glasses, you're still minus three. So you get good near vision, and that's why my hopes again were adapted for near vision. I always suggest go into the news agent that sells glasses, get the newspaper and put on the pair that gives you the clearest vision and it'll be plus one to start, or 0.5 plus two plus three, and it usually stabilizes about plus three plus 3.5, and they're essentially magnifiers that will give you the near vision.
Speaker 2:You can go to the opticians you know, as you should, for your screening every year, every two years, but you'd tend to lose the glasses quite quickly if you don't have them on you all the time yeah so for the sake of two euro at your local news agent or maybe it's a bit more than five euro you can get one pair of glasses and get them in different colors and leave them around the house, or whatever yeah because you're lost without them once you do get used to them, and it's that, just the fact that your brain likes the clear image and that it's what it's telling you to reach out, so you're better off.
Speaker 1:Yeah, because, like when I got them at first and I put them on, I was like whoa this is mad and, but I didn't realize, obviously because I was used to reading it not so clear, yeah, but it's not even that it's clearer, it's more that it's bigger yeah, and sharper, yeah.
Speaker 2:Sharper is the sharpness, black print is just more defined and the white background the contrast between them.
Speaker 1:But should I not use them as much, because then your brain gets used to them, or should you use them?
Speaker 2:No, I think you should use them.
Speaker 1:You should use them okay.
Speaker 2:I would be firmly advocating for their use. The type of lenses that aren't useful are the blue tint computer screen lenses that were very much, I think, in fashion around the time of COVID and working from home. So there hasn't been any evidence to say that they protect your eyes. So that's a little bit of a placebo effect, I believe, and everybody was buying them at one stage. So, yeah, we just followed the sheep in front. I haven't seen any evidence for their use from a scientific point of view.
Speaker 1:Should people go to an optician or an ophthalmologist to get their eyes tested regularly, like one would a dentist, or one would maybe they go to their GP? And get their blood work done all the time, so it depends on.
Speaker 2:I suppose if you have symptoms, absolutely you need to have your eyes checked. If your vision is deteriorating or sudden changes in vision or pain in the eye would necessitate a different type of referral. The opticians are readily available on, you know, most high streets and they are covered also by PRSI. To have a screening check done every two years is it necessary? So I think if we're young and healthy and fit and our vision is fine, you don't need to go every two years. In more senior years, when there are various diseases that can happen at that stage in life, for example glaucoma, which is very important to pick up at an early stage it is very useful to have the screening done.
Speaker 1:But it's done by an optician. They only go to you when there's a problem. You don't screen, okay.
Speaker 2:Yeah, so the screening programs that we have well, yeah, but no Expensive and the, as I was saying, the availability of an optician is hugely beneficial. You can have an appointment the same day on any main street in Ireland with an optician. I would imagine. The screening process for diabetic eye disease is very well formulated in Ireland and it works exceptionally well and I think that's down to those who set it up. It's probably one of the best in the world really for patients who have diabetes. So the foresight to take patients who have diabetes so the foresight to take patients who have diabetes out of our clinics where we were just screening them and they were taking up quite a lot of time, has been transformed into photograph screening, which is done by non-medical trained and it's pattern recognition. So they will look at the photograph, they will see if there's changes there and then they go on to the next stage.
Speaker 1:So that is, for anyone that is diabetic. They automatically go into this program diabetic screening and you are testing their eyes for neuropathy and all of that thing, because your eye can degenerate with type 1 and type 2 diabetes Exactly.
Speaker 2:And the other population that was not in screening until recently, I think, is those who were pregnant with diabetes. They were removed and they were screened separately. So now I think there have been changes to introduce that within the screening. So the difference, of course, type 1, sudden onset autoimmune problem your sugars go off straight away and usually a child becoming sick and it's identified the issue with your sugar control. Then it takes about 10 years if you had poor glycemic control in order to get retinal changes or renal changes or neuropathy. So it's a very different condition to type 2, where you could have that for many years.
Speaker 2:And you don't even know, you don't even know, and some patients with type 2 may present with eye problems or we will ask the GP to check their sugars fasting sugars and when we see them, with a particular retinal problem. So it's interesting that that has been going on for that long. We see retinal changes because we can see them. It is something that we can measure, but there's probably other vascular changes that are going on that we don't measure or can't measure and the link between retinal disease and, for example, cns issues like vascular dementia is being looked at through AI, through the examination of huge numbers of retinas that we do for screening. The issue about, I suppose, screening for eye conditions is that, as the Department of Health or the HSE, it has to be worth their while, and glaucoma doesn't meet that criteria just yet because it's not common enough.
Speaker 1:So tell people what glaucoma is.
Speaker 2:So very common standard exam question. Glaucoma is an optic neuropathy, which means it's a nerve problem. The optic nerve at the back of the eye, which is the cable that goes back to the brain, has been damaged, mostly by pressure higher than it should be in the eye. This isn't related to blood pressure, it's a very different pressure. So it's the fluid in the eye is pressing on the nerve too much and therefore the nerve starts to die off. And why does it do that? It's thought to be overproduction, or else the fluid isn't draining out as it should, and that's the way.
Speaker 2:The drugs that are for glaucoma that's how they work is both of those. And then there's also surgery as well, which will do very similar in terms of drainage. There's definitely a hereditary component. There is a genetic component with even, you know, different racial backgrounds will have a higher risk. There's trauma that can cause it as well. Even if it's many years ago, it can affect the drainage from the fluid. And then there's the randomness of we don't know why that person got that condition. I always find it a little bit tricky to diagnose, and once you diagnose the person with glaucoma, generally they're on treatment for the rest of their life.
Speaker 1:And you can't tell by looking at them, because their eye isn't bulging with the pressure, is it?
Speaker 2:So it will be normal. Pressure is less than 21. It could be 25, it could be 35. The pressure goes up to 70.
Speaker 2:That we can measure and that is severe pain in your eye yeah but it could be hovering around 35 for a few years and then the nerve, instead of being a nice pink color, starts to go white color and we can measure the amount of damage done to your nerve by doing a visual field test.
Speaker 2:So this isn't letters on the chart. So it's a little bit of a false sense of security in that you can read all the letters in the chart but you can't actually see on the outside of your visual field, because that's where the nerves are damaged and just checking vision isn't going to be a screening test for glaucoma. So you check the pressure, that's one thing. Then you would do a visual field which measures the optic nerve function and then you would look at the optic nerve as well and see is that normal or abnormal? And based on the probability of each of those, you will say, yes, the patient has glaucoma or they don't. Once you start the drops drops, then they're usually on them for life and it's very difficult to stop the drops because the aim is to reduce the pressure. That's what we can use for treatment. Some of the drops have lovely side effects so they can be remarketed into various products, which is happening at the moment.
Speaker 1:To make your lashes grow longer, yes, but that's an issue because I see that on TikTok. I've seen it before and actually I had a patient who was using her dad's glaucoma drops because it really gave her thick lashes.
Speaker 2:It can also cause the fat around the eye to become atrophied.
Speaker 1:Yes.
Speaker 2:So you get a hollowed out appearance.
Speaker 1:You're. In essence, then, what you're doing is you're draining the fluid out of your eye more than it should be, and actually it can have that.
Speaker 2:Yeah, and also it can change the pigment inside in the eye so it can change the color of your eye. So the worst being a patient who has glaucoma and one eye only and they're put on a prostaglandin because the lashes grow very long, the eye color can change and then it just looks different than the other side. So there are newer medications or sorry, they're not medications, they're more products, I suppose you would call them which Vicky at IDI recently is trying to grow her lashes longer. One of them, I think, is called Latrice, where you will put the serum onto your lashes and it directly will stimulate them to grow, and I believe it works very well. That is a weaker type of prostaglandin, so it doesn't have the same side effects as what the glaucoma drops would. It's not going to be as effective in terms of the lash growth, but I think it does work to strengthen the lashes. I don't know again what happens when you stop it, do they?
Speaker 2:fall out but, you know, from a medical point of view very useful. For example, patients who have radiotherapy around the eye for various conditions which can affect the lashes, or even blepharitis very common condition where you have inflammation in the lash face. Often the lashes become quite weak and they will fall out, and as a man we probably don't consider that as much. But if you're putting mascara on your eyelashes every day for most of your life and then you don't put it on, it can change the way that your eyes look and the shape and that. So these are important things to get right as well they are.
Speaker 1:Are there any other eye conditions that are important to you to discuss that we've missed um so I just want to make sure that we haven't left anything off the table.
Speaker 2:In particular, I suppose what I do in the non-aesthetic side would be thyroid eye disease is a big component of what I do.
Speaker 1:Oh yeah.
Speaker 2:And I know that you had, you know, some discussions about thyroid function and that recently it's a very debilitating condition predominantly affecting younger females Men when they get it, it's one in 10 and it tends to be very much worse disease, but the majority would be females 20s, 30s. Your thyroid function going off, you feel terrible, you can't sleep, you're agitated, you're sweating, you get palpitations and then your eyes start to bulge, you don't recognize yourself in the mirror and your facial appearance completely changing because of this medical problem. There is often a lag in terms of getting it diagnosed and in particular, I think slightly older females may put it down to perimenopausal symptoms and that not having your thyroid checked is, you know it's a very common condition that needs to be checked, you know, usually by the GP and very easy to do. Just to check your thyroid checked is. You know it's a very common condition that needs to be checked, you know, usually by the GP and very easy to do. Just to check your thyroid function For thyroid abnormalities.
Speaker 2:We would always check the antibodies as well to see is it Graves' disease, which is the eye disease, plus your thyroid dysfunction, the eye disease? It goes on for about 18 months. So we know at 18 months that that's it. It's not going to progress anymore. The damage that's done is done.
Speaker 1:Can you not stop it, though, in its tracks?
Speaker 2:So we can stop, but we can't reverse.
Speaker 1:So you can't reverse the bulging eyes.
Speaker 2:So it'll sometimes get a bit better, but the damage that's at presentation generally stays like that until the 18 months and then we can intervene with surgery to rehabilitate, to get you looking more like what you would be. There are medications that are there in the States which are made by Horizon. It's called tepritumumab, igf-1 receptor antagonist. There was a lot of noise about this when it came out initially. We don't have it here because of the prohibitively high cost. It's about $200,000 to give 10 treatments, which is the recommended treatment. Is it as?
Speaker 1:good, as they said, though.
Speaker 2:It isn't. Is the?
Speaker 1:short answer.
Speaker 2:So we thought this was amazing. It's going to reverse it, but it actually causes hearing loss in a certain percentage of people. So it's irreversible hearing loss. And also again, at the finish of your treatment, some people regress again. So 10 treatments isn't enough. There's newer studies coming out and different medications with very similar structure which are on trial around the world at the moment and hopefully we should have something in the next few years that will stabilize it and even reverse. The surgery is quite invasive. So for orbital decompression, I would remove the bone on the outside and break into the sinuses on the inside, and it's creating more space for the fat and muscle to move into. It's not removing fat or muscle that has been enlarged, it's just create more space.
Speaker 1:So the fat and the muscle? That's what happens with the thyroid eye disease. It's just the fat and muscle get bigger.
Speaker 2:yeah, yeah so it's thought to be like the lock and key component of the enzyme into the receptor. So the antibody, the thyroid antibody, is the same shape as a receptor in the fat and the muscle and it inappropriately locks into that and it stimulates it to grow at a much higher rate than would be usual. So there's nowhere for the eye to go except forward and all that extra fat and muscle size can give problems like double vision. The one eye can be more than the other, so it can be quite asymmetrical. But the main thing is that you have this very altered appearance and I've had patients where I asked them to bring a photograph and you know it's a consultation and they're not recognizable now compared to what they were before.
Speaker 2:There's three stages of the surgery. The first one is the decompression. The second is muscle surgery, if they need that, and then the third one is something like the blepharoplasty which we do for aesthetic reasons, for medical reasons. It's done for thyroid patients to remove the skin and the fat or they might have one eyelid very high compared to the other, so it's dropping that lid to get symmetry.
Speaker 1:And how do you drop that? Do you need to use a graft to make that?
Speaker 2:So we recess the muscle that opens your lid to a certain extent and that's graded so the patient is awake. Obviously they're numb to the area, but we're asking them to open and close so that we can get the height and the contour right. So when you have a droopy lid, we shorten the muscle, bring it up. When you have the eyelid too high, we recess the muscle to allow it to drop down a bit. Okay, I would say that thyroid patients are the happiest after they've had their surgery compared to any other cohort, because it's not noticeable that they have this condition anymore.
Speaker 2:If you are walking down the street and there's a person coming the opposite direction with thyroid disease, it's one of those immediately you recognize this as Graves' disease and I think for that cohort you're young, you're working, you might be looking at relationships, kids, all of that it's going to be hugely influential in terms of your self-confidence and how you present yourself and even job interviews, etc. That it can be quite debilitating for patients of that age group. Smoking is also the biggest risk factor. So no smoking, no vaping, okay.
Speaker 1:A lot of people have little floaters in their eyes. What does that mean?
Speaker 2:So floaters are changes in the jelly. The jelly is the structure that keeps the back of the eye as it is and there can be little protein deposits that are there or they can be. If the jelly collapses in on itself, then you will get part of the bag moving around. So as you get older it's not as firm as it used to be. Like everything, like everything, everything.
Speaker 1:Have a few bits and bobs that aren't as firm as they used to be. We won't ask you to list them.
Speaker 2:No, we'll be here all day. But the part of the retina is kept in place by having that jelly to lean on. So you can get a retinal tear. For example, if you have a floater, especially if you're having flashing lights, that is the jelly stimulating the retina by a very basic means of just touching it. Your brain sees it as light. So therefore the jelly is touching off the retina and the retina, being wet tissue paper, can just come away and tear and then you can get a detachment.
Speaker 2:So floaters, if you had them for a long time, they're very stable. If they're changing then you should go in and have that checked out. Or if you're getting flashing lights with it, more so if you're short-sighted again, your eye is longer, so the tissues are more likely to tear or to stretch. It's a very, very common problem. Tends to be worse if you're dehydrated. So if you've had a few drinks the night before following morning, people tend to have floaters, especially looking at a white background or a white wall. If they follow your vision as well, that means they're still in the jelly.
Speaker 2:They're moving around, okay whereas if they're just in one position, it could be more associated with a tear.
Speaker 1:When someone comes in with pink eye or when they have a little bit of pus in their eye or whatever. There's now talk about pharmacists being able to prescribe the chloramycetin drops like they do over in the UK, and that's all fine and well and good. But does that kind of conjunctivitis? Is it self-limiting, and will it eventually get rid of itself?
Speaker 2:Well, it won't. If it's gonorrhea or chlamydia, for definite, this is very true, but a lot of that is bacterial overgrowth dropping into the surface of the eye. Roline, which I think every pharmacist seems to love and loves dispensing, is quite toxic on the surface of the eye. It's a detergent. It is very useful for a particular type of infection, but for the majority of cases it won't work. For bacterial and Brolin makes it.
Speaker 1:It's more of an antiseptic, isn't it?
Speaker 2:Yeah, it's for a contact lens protozoan infection which is called acanthamoeba, so it's very specific for that. It is very uncomfortable on the eye after a few days because of the way it works, you know. So not one to be, I suppose, reaching for the shelf. I would say Chloramphenicol. I think there's absolutely no problem with pharmacists giving out chloramphenicol. It's an excellent antibiotic. We don't have an issue with resistance because it's only working on the surface of the eye as an antibiotic given in ICU setting not done anymore because of the potential side effects but it's not absorbed and if you're worried about absorption you can block off your tear duct for about two minutes and it limits that as well.
Speaker 1:Why would you be worried about absorption?
Speaker 2:So the side effects of chloramphenicol are I think it can cause your platelets to go down and it can cause bleeding, but can?
Speaker 2:it do that in a drop, yeah, yeah anything that you're worried about absorption, and there can be a lot of absorption in the surface of the eye, but if you block off anything down here, that means it just stays on the surface so he's pressing his tear duct there for anyone that's just listening that's okay, that's blocking off your tear duct will stop it being exactly um but is it self-limiting like will they generally okay, so take away the vanidia and the syphilis or the gonorrhea.
Speaker 2:Sorry, the gonorrhea, I think. If it's a viral, then yes, it is definitely self-limiting and the typical pattern is when I first, a few days later, goes to the second eye, you feel a bit cold and fluey and wretched and somebody else has at home, or there's a kid in a creche and they have a snotty nose or a chest infection. So anything viral like that doesn't need antibiotics. What you need is to not touch the eye, because that gets it on your hands and it spreads it, using things like separate towels, changing pillowcases, all of that practical stuff that helps to limit it.
Speaker 1:But it's boiled cooled water cleaning the eye boiled water it depends on how you do it.
Speaker 2:So if you use the same face cloths as everybody else, is that would definitely be disposable and helpful. Yes, okay, boiled water will just remove anything like residue that accumulates from your tears there. It's not going to treat the viral infection, but you can be quite sick with that. It can give you a nasty, sore throat, it can give you a chest infection and you can feel fluey with a viral infection like that.
Speaker 1:So are most of those conjunctivitis eye infections? Are most of them actually viral?
Speaker 2:Yeah, the majority would be and spread. You cough when you're on the bus and you're touching the handle or whatever, and then somebody else comes along and does the same, so it spreads very quickly.
Speaker 1:I know some poor parents in crash you know they are not there in a crash their kid's in crash. The kid's come back from a crash with an eye infection and they're told your kid can't come back into the crash until it's gone they've got the bloody eye infection here and she's like it's only an eye infection.
Speaker 2:It's like wildfire isn't it. Yeah, some of that can be watery eye from a blocked tear duct in a baby as well, which is within my ream, and I do some paed oculoplastics as well, which it's nice to be able to help the younger population with the stresses of sometimes parents who are very well-meaning, obviously, and everybody's there advocating to do their best, but it is pediatric care is different than adult care and what I'm doing surgery wise is always general anesthetic.
Speaker 2:So where I was talking earlier about patient having their eyes open, getting them to look up and down, we can't do that for a child yeah so sometimes there's a little bit of unknown in terms of outcome or less guaranteed that it'll be exactly as bang on as it would be with an adult, or what we could get a bang on because you can't give them directions about looking up, looking down, all the rest, yeah, and they're asleep, so you're hoping that, where you set the eyelid position, for example, that's going to be like that when they wake up.
Speaker 2:And there's so many factors involved with that, including anesthesia medications that they've had how weak the muscle was and all that. But it's extremely rewarding to be working with kids. You can make a big impact and a lifelong impact on a child's for the rest of their life. For example, a ptosis where the lid is slightly droopy. It can be a source of bullying and I would always suggest that the surgery, if it's done, before the age of five, before they go to primary or secondary, before the age of about 12, just so that there is no everybody wants to look the same or to fit in and there's nothing different that can cause something to be picked on or to be bullied.
Speaker 2:And again it's about, I suppose, quality of life and improving that for that age group. The pediatric work is something that I learned in Melbourne in the Royal Children's Hospital where and I set that up in Crumlin when I came back from Australia it's like Mohammed in the mountain, so all these kids were being sent out from Crumlin whereas I went there for a session per week. I did a clinic one week and theatre the other week, and it just made sense that these kids who may have complex medical needs have their surgery done in that hospital rather than them all being sent out to, for example, the Eye and Ear, which may not have the same pediatric facilities. And you still do some privately.
Speaker 2:I think it's very much the skill set that I have as an adult transfers to the smaller faces or the younger faces, whereas a pediatric ophthalmologist would not have the exact same oculoplastic skills or trained at that level. Not have the exact same oculoplastic skills or trained at that level. And it's nice to see the kids grow actually, because I've had kids from the last three years where they were the youngest I think was 10 weeks when I operated on and saw him recently with his own ego and his own personality shining through. So that's quite rewarding when you see that.
Speaker 1:Yeah, well, my brother is a paediatrician, as you know, and he just said he loves dealing with kids because his pain is ours dealing with adults.
Speaker 2:Yeah, I can definitely see that. But also I see the various stages of the children's mentality. Usually I feel about the age of three, four or five. The ego is huge. They won't let you put an eye dressing on or an iPad it's automatically pulled off. Whereas up to that age they will tolerate things like that and then they get more sense after that and then teenagers are just their own thing.
Speaker 1:So teenagers are a different beast. Dm3 good luck with that. I know, can I just ask you, is A different beast. Good luck with that. Can I just ask you is excessive eye watering a sign that there's dry eye there as well, but it's just not sticking.
Speaker 2:Yeah, so dry eye and watery eye are not just there's too much tears or there's too little tears. Quite often, as you're saying, you get a reflex. If there's dryness, you're getting more water being produced, but it's not staying on the surface, so it's not, it's not efficiently being made. If there's a blockage in the outflow of the tears, then that is another cause of watering. So that is something that I would do as part of my surgical skill set endoscopically up through the nose, creating a new passageway for the tears to drain through what? Yeah, that's for the next day. So a DCR surgery is dacryocystorhinostomy, which means new passageway into the nose for the tears, essentially. So the little tubes.
Speaker 1:The Latin translation Exactly Okay.
Speaker 2:The little tubes are about two millimeters in diameter. So if you have a stricture, if you have a blockage, then that's it done. It can't be reopened. Or if it even is reopened, it won't stay reopened because it's a stricture or a scar that's there. So we bypass that by going directly into the nose and the procedure is as an ENT surgeon would do a scope or a camera up the nose. We remove some of the bone overlying the sac and then we intubate the native system and allow it to drain in and bypass where the blockage is.
Speaker 2:So nobody dies from a watery eye, nobody goes blind, but it is very annoying if you have a watery eye and it impacts on everything from driving to the game of golf. You know which is a big deal when you can't, when you're not as good as you used to be at golf. So doing that is, I suppose, quite reflective of what we do as ophthalmologists. We're're all about quality of life, improving the patient's quality of life. We're not very much about saving lives, although we do work with other specialties to make the diagnosis and to help completing that diagnosis.
Speaker 2:A lot of what we do is improving the patient's overall quality of life and vision related quality of life and also the conditions around the eye as well. That can be quite debilitating. There has been studies shown that the impact of a cataract operation on a patient is far more than having a bowel surgery to have your cancer removed. And while there are different components of the patient's health, we can make quite a big impact by restoring vision on the patient's overall experience. So we're not out there at the front line thumping on chests or keeping the heart going.
Speaker 2:You're silently and quietly in the background nodding to each other going we are improving quality of life Exactly and making the eyes look more youthful yeah, oh yeah.
Speaker 1:And actually on that, can I ask you, do you ever get people coming up to you going no mijo, what do I need? Secretly? They want you to tell them that they're just perfect, but then you, you tell them the truth was this like earlier? So you tell them the truth and they're good, they take the hump my standard response is you don't need anything done.
Speaker 2:But if you did and this is what I think I've become more used to critiquing. Anybody who comes to me for a consultation doesn't come to be told you're perfect the way you are. There's some issue that they have that they want to explore. So as we age, yes, there's more skin around the eye. I think blepharoplasty is becoming a really increasing trend younger and younger.
Speaker 1:How young are you talking?
Speaker 2:So I think probably 35 down. It depends on. I suppose it depends on what the patient is experiencing. If there's an obsessional trend towards something that's not very obvious, surgery is not going to fix that. That's a totally different mind game. But if there is excess skin there and the surgery would fix that and it can be done safely and the surgeon is on the same plane as the patient in terms of what they can offer and what's achievable, then by all means I think you can go ahead and get it done.
Speaker 1:You better get it done earlier rather than later.
Speaker 2:I think you get it done when you'll get the most out of it. So people are socializing in their 20s, 30s, 40s, 50s, maybe not as much in 60s and in their 80s. Would you get a blepharoplasty done at 80? It depends on how much you go out and socialize or how much it's bothering you. But you will get more out of it if you get it done in your 30s, 40s and that's, I suppose, the trend that's there now is that there's more people getting it done earlier. You might need a second bleph done in your 60s, but it resets the baseline after the first one is done.
Speaker 2:So yeah, I mean I would have patients coming who are in their 30s and want to have it done and if they meet the criteria and they know what can be an offer and risks, then by all means it's something that we would look at and proceed with, particularly upper lid, and a lot of it is being hereditary. As Katrina asked in the clinic do you see your mom or your dad when she puts up the mirror? So you see the trends coming through. And the patient earlier today said she got her dad's genes herself and her sister. She can see it. Her other two sisters got her mum's genes, which is more youthful looking. There's nothing we can do about that.
Speaker 1:No.
Speaker 2:But surgery will help ease the pain.
Speaker 1:So you never give unsolicited advice. Drunk at a wedding, go up to someone and say I don't know what.
Speaker 2:Now it's not our duty. I can't remember if I did, but we're all a bit obsessional about our own appearance. We're our own worst critics. And I would say after surgery the surgeon is the other worst critic, because what we can see is not often what it is. And being able to stand back from it and say it's actually quite good, it looks symmetrical. You compare it to the pre-op photographs, it's a lot better. And I then get into the conversation with the patient about the episode of Father Ted where there was a slight dent in the car and he kept going with the hammer and by the end of it it was amazing. You couldn't see anything, but maybe the glass from the windscreen yeah um, if you keep going, you won't get a good result.
Speaker 2:At a certain stage you have to say that's good, that's better than it was, and perfection is the enemy of good. So you have to stand back from it and just give the overall impression and the overall appearance, rather than keep going with small minute details. You can always find, you know, that little piece there is not as good as it was or there's a little wrinkle there. But nothing is symmetrical in our body and perfection is impossible. So I think we get things better and keep going at that level rather than perfection.
Speaker 1:Okay. Is there a trend in the likes of Japan and China to get eye surgery done to open up their eyes?
Speaker 2:Yeah, so I had one experience of this where a parent brought their kid, so they had moved from China to Ireland and she wanted the kid to have surgery to change the eyelid appearance. So I did go through the consultation and I found myself near the 20 minute mark thinking this isn't anything but aesthetic surgery and the child can't consent for that. They may not want that if they had their mindset from later years. So there is a trend there trying to become more like the Western side.
Speaker 1:Is that because? Do we have a fold in our eyelid that they don't?
Speaker 2:And they can have the double crease also, which their skin crease is lower, the shape is different and they can also get a double layer of lashes more frequently, or also a little extra piece of skin in the lower lid which folds forward.
Speaker 1:You just pinched it over there and I'm oh, that reaction.
Speaker 2:All of those are what makes up the normal appearance of the Asian eye. It was like in the UK for a period of time there was a trend to have dimples. So you just have to be very careful what you're offering. If somebody really wants that done and it's impacting on them and you feel it's not a psychological overlay or there's going to be something else next week, if they don't have that, or if they have it done or not, then you can offer something that will make them happier or more comfortable in themselves. It's not something that I do. I think that there are some colleagues who are asian background in ireland and they probably have more insight into it, but it was only for that one incident with the mom and the child, which I thought was quite an unusual experience.
Speaker 1:How old was the child? Roughly Eight, oh, my goodness Okay.
Speaker 2:So sometimes the hardest thing is to say no.
Speaker 1:Yeah.
Speaker 2:But you have to be able to stand back and look at the overall picture and just say I don't think this is in the best interest for everybody and like that with eyelid surgery, if I don't think this is going to work in terms of the patient's opinion, is not what I can offer. So what they want and what's on offer by me, if they don't meet, then we're at different levels.
Speaker 1:Okay.
Speaker 2:So that's when you say I don't think this is the surgery for you or what I can offer, or this type of surgery is for you, and you can sometimes get somebody to do that and you would wonder how much consent is involved and how much explanation is involved in the overall procedure. Because that's what I see my role as, in particular for elective cosmetic surgery going through the risks, what can happen and the patient needing to be informed of what is safe surgery and what is achievable. Not overselling. It's not a product that you buy on the shelf. You know. This is a skill that I can transfer to the patient to give them this change in their appearance and the patient knowing that there is a percentage of patients that could potentially have complications with that, as with any surgery, and guarantees aren't always 100%.
Speaker 1:Okay, what advice would you give young people today?
Speaker 2:I thought I was young.
Speaker 1:People a little bit younger than you, and it doesn't need to be. I don't mean kids necessarily. It's whatever advice you might give a young person, a young me-hole.
Speaker 2:I would say follow your instincts and travel. I think travel is the best way to open your mind and to experience other cultures and also appreciate what you have then and what's the meaning of life, I don't know.
Speaker 1:Experience other cultures and also appreciate what you have, then and what's the meaning of life?
Speaker 2:I don't know. I will have to stay on that one. You know we talk about heaven and what comes after life. I think it's important to maybe recognize that this could be heaven and this is good, and we shouldn't be waiting for something extra to happen. Live in the moment and live in the now is more important than waiting.
Speaker 1:Micheál, what a pleasure it was to talk to you. I could have gone on all day, but I didn't know why you were so interesting. Thank you so much for your time.
Speaker 2:You're very welcome, thank you Thank you.