Introduction

Dr. Bob: And welcome to The Dr. Bob Show. Thank you so much for taking your time to come
and watch to learn about making your life healthier. We have huge amounts of information on this show. We are going to be predominantly talking about the eye - about visual problems that people have. Are you having a hard time seeing the screen or seeing sort of fuzzy or blurry. Have you got cataracts? Do you have glaucoma? Do you have macular degeneration - aged related macular degeneration? You are going to have it at one time in your life. Is there diabetes or high blood pressure that's involving your eyes? Is something going wrong with your vision other than just far-sightedness or near-sightedness? We will be talking about those things. I have an outstanding guest.

My guest is Dr. Darin Smith. Dr. Smith is a board-certified ophthalmologist, has been on The Dr. Bob Show before and is a great teacher. Later on in the show, we will be talking about treatable causes of fatigue. Why am I fatigued and is there something that I can do about it? New recommendations of the American Heart Association on prevention of heart attacks and strokes and when you watch television when that doctor says, "nurse, get me a CBC and titer cross match and start an IV with D-5W, what do those words really mean? We will be talking about the CBC and so we've got a lot of information for you so that you will learn to be happier and healthier. Before we go into the next segment, be sure you are exercising 20 minutes seven days a week, starting the day off with a breakfast of fruit and fiber, starting the day off with eight hours of wonderful restful sleep and most of all, laughter in your life. Stay tuned. There is a lot of information for you.

Dr. Bob: We are talking with Dr. Darin Smith, board-certified ophthalmologist and Darin, welcome to The Dr. Bob Show.

Dr. Smith: Thanks Bob.

Dr. Bob: Board-certified ophthalmologist. Now, that's an eye doctor but what does that mean?

Dr. Smith: Basically what that is, that's someone who has gone to medical school. I've gone to four years of medical school just like a regular primary care doctor would. And then I did an additional four years of training, specific just to the eye.

Dr. Bob: Four years of eye training. You did yours down at Parkland Hospital down in……

Dr. Smith: Dallas, Texas.

Dr. Bob: In Dallas, Texas.

Dr. Smith: That's right.

Dr. Bob: Great training center for internal medicine, eyes, for just lots of things.

Dr. Smith: It's a busy place.

Dr. Bob: We want to talk about certain eye diseases. I want to go through three or four things. #1: Glaucoma, then cataracts and then macular degeneration. We hear so much about macular degeneration, age related. One treatable form and one another. But let's go to glaucoma first. What is glaucoma?

Dr. Smith: Great question. Basically what glaucoma is, it's a disease of the nerve in the back of the eye, the optic nerve, and usually people who have glaucoma, have an increased pressure in the eye. Everybody has a pressure in the eye. If you didn't, the eye would be like a raisin. And there is a pressure that actually supports the, the structure of the eye. But if that pressure is too high, it can actually damage the nerve in the back of the eye.

Dr. Bob: Because of the pressure.

Dr. Smith: Absolutely.

Dr. Bob: Now why does the pressure get high in the eye.

Dr. Smith: Well, you know, that's a great question. It's very similar to essential hypertension. You know, there's a lot of causes and no one really knows for sure why that pressure goes up usually.

Dr. Bob: Now, are there treatments for glaucoma. Well, first of all, how do you find it?

Dr. Smith: Well, usually we find it on a regular screening. We check. Anytime someone comes in for an eye exam, and that's what I would recommend to any of the viewers, even if they are just trying to get glasses, they should have their pressure checked at every eye exam.

Dr. Bob: How often - when should you begin getting an eye exam? At what age?

Dr. Smith: Well….

Dr. Bob: Yesterday?

Dr. Smith: Yesterday. Yesterday would be a good day.

Dr. Bob: Does it hurt to check the pressure in the eye? I can feel my eyeball. Can I get a good idea if there is too much pressure there?

Dr. Smith: No. No. That's pretty tough. It doesn't really hurt. Sometimes it is a little uncomfortable depending on the methods that's used but it's no big deal.

Dr. Bob: When I go to the eye doctor, he just sort of blows some…..

Dr. Smith: Right.

Dr. Bob: Blows some air in the eye and I don't know how it measures the pressure but my pressure has always been good. And I get my eyes checked once a year. The last time I looked, you've only got two of them.

Dr. Smith: That's right.

Dr. Bob: And they are very important on that yearly exam.

Dr. Smith: Absolutely.

Dr. Bob: If the pressure is too high, what do you do to bring it down? Do you just take some fluid off?

Dr. Smith: Well, you know. Gosh. I guess in extreme, extreme cases but no, usually we are very fortunate now these days. There have been so many advances that you know, it used to be that we would have to do a lot of surgery or even laser but now days, most of it can be adequately controlled just on drops and a lot of time, just one drop a day.

Dr. Bob: Eye drops can make the pupil narrow or big?

Dr. Smith: You know what, there used to be a drop called Palocarpene. These were way back when and they used to make the pupil real small and have a lot of side effects. Fortunately, most of these drops have very few side effects and where that Palocarpene is hardly used anymore.

Dr. Bob: Oh, that's great. Is the treatment pretty successful?

Dr. Smith: Very successful.

Dr. Bob: The pressure that you want the eye to be?

Dr. Smith: Normal pressure is between 10 and 21 for the general population. Now, depending on if the nerve has been damaged from previous glaucoma, then we might want a little lower pressure but that's kind of a general guideline.

Dr. Bob: Can people tell if their glaucoma is coming on? What happens to the eyesight? Bingo?

Dr. Smith: Well, that's the scary thing about glaucoma. It is one of the most common preventable causes of blindness in our country and the key word there is preventable because it is to easy to prevent.

Dr. Bob: Let's go to cataracts.

Dr. Smith: Yes.

Dr. Bob: Now, cataracts is something to do with seeing out of the eyes. What is that Darin?

Dr. Smith: Well, you know, there's a real misconception I think about cataracts as that there is a film or something that is growing on the eye and if we look back and even before we get to the cataract, we have to realize there is actually a lens inside the eyeball and that lens when we were born is nice and clear. And as we grow, that lens gets more dense and more dense and more dense and at some point it becomes a cataract. And so the cataract is actually the natural lens in the eye that started to get cloudy.

Dr. Bob: And then the symptoms, you just sort of get like a fogged up window.

Dr. Smith: That's exactly right.

Dr. Bob: And how, is it dangerous to somebody?

Dr. Smith: Not usually dangerous but it just, it can cause a lot of blurred vision, like you said foggy vision and can interfere with people's livelihood.

Dr. Bob: Now when I see people that have had cataract surgery, I want you to tell me about it. When they say they've had their cataract surgery, they say there's new colors and new vision. They can see things they could never see before. It's like, it's the greatest thing that has ever happened to them. How do you take out the lens in the eye?

Dr. Smith: Well, I tell you what. It's amazing. There have been so many advances over the last even 10 or 20 years on this. What we do now is, we actually do a small incision less than 3 millimeters. Get out a ruler. That's a small tiny incision and what we do is we actually use a little ultrasound device that goes in there, breaks up that cataract into small little pieces and kind of sucks that right out and we just put a lens implant, a clear plastic lens, to replace the cloudy lens that we just took out.

Dr. Bob: The new plastic lens. How long does it last?

Dr. Smith: Forever.

Dr. Bob: Forever. So really, it's a great treatment.

Dr. Smith: Oh, it's wonderful and the ophthalmologist does such a wonderful job at that.

Dr. Bob: Macular degeneration. Now, is that a big problem?

Dr. Smith: It is a real big problem.

Dr. Bob: And that's what we are going to talk about in just a minute. The big problem - macular degeneration. Everybody is going to get macular degeneration if they live long enough. So, let's talk with a patient who had more than one eye problem of which macular degeneration was there also.

A Patient's Experience with a Visual Impairment

Hallerin Hilton Hill: Many people with Cataracts describe their vision as, well, like looking through a fog, not being able to make out details or colors. In fact, that's exactly what Lucy Strunk experienced for years.

Lucy Strunk: Well, it was like I had dark sunglasses on all the time and I couldn't see that detailing of the leaves on the trees or things in a picture.

Hallerin Hilton Hill: After Dr. Darin Smith performed cataract surgery by replacing the lenses in Lucy's eyes, she says her life changed dramatically.

Lucy Strunk: And I was like a little kid with a bag of candy because I have never been able to see. He's my hero. He has fixed my eyes. I can see and I love looking at my eyes. I have never had 20-20 vision even with glasses or contacts and now, I've got 20-20 vision. I can see every little detail on everything. I can even see my wrinkles better.

Hallerin Hilton Hill: For The Dr. Bob Show, I'm Hallerin Hilton Hill.

Dr. Bob: We're talking with Dr. Darrin Smith, board-certified ophthalmologist and we've talk about glaucoma, increased pressure in the eye, easy to find on a routine eye exam. You can't really find it any other way. So, see your ophthalmologist and get your routine eye exam. Cataracts, foggy lens and your ophthalmologist can see that very easily as he looks back into the back of the eye through the lens, he can tell if it's foggy or not.

Dr. Bob: Darin, let's talk about macular degeneration.

Dr. Smith: Yes.

Dr. Bob: Now, first of all, what is the macular and when it degenerates, what happens?

Dr. Smith: Well, you know, we talked about the cataract before, let's go to a little anatomy. The retina, you know, you hear about the retina. That is the back lining of the eye. It basically has all the nerves and blood vessels and what happens is light goes through the eye and is focused right on to the retina. And the macula is the center part of that retina. Kind of like the bull's eye and so the macula is the area that's responsible for the central part of your vision.

Dr. Bob: So, really the main part that I'm looking at right down the middle is where my macula has been receiving pictures.

Dr. Smith: Absolutely. That's exactly right.

Dr. Bob: What happens if it degenerates? What happens to the macula?

Dr. Smith: Well, what happens is through time and like you said earlier, the name of that disease, actually age-related macular degeneration. And what happens is just through time the cells that are responsible for taking care of all that light and all that vision for all those years just kind of wear out and so, the actual retina gets weak right there and unable to take all that light that's focused and sends signals back to the brain for processing.

Dr. Bob: Why do I see some 70 years old or some 80 years old that don't seem to have age-related macular degeneration and yet some people, it starts very commonly at what age?

Dr. Smith: Well, you know, I see a number of people even in their 50's.

Dr. Bob: In their 50's?

Dr. Smith: Sure you can.

Dr. Bob: Is it easy to tell when you are looking at the eye?

Dr. Smith: It is. It is. We just by looking with a special lens onto the retina itself, we can actually tell if there is any there.

Dr. Bob: Now, I know from reading there is a wet and a dry type but I don't know which is the most common and which you treat and all that. Tell me about wet and dry.

Dr. Smith: Well, I tell you what. If you've been watching the news at all, there's been a lot of news about macular degeneration of both types. The dry type is actually the more common fortunately, because it's the less severe. Basically, the distinguishing line of what makes wet wet is that if there is blood in the retina. And so, the dry form of macular degeneration does not have any blood and that's good and that form usually causes mild to moderate vision loss. The wet form, there's been new blood vessels that have actually begun to grow underneath the retina.

Dr. Bob: Do they push it out of the way or do they kill it?

Dr. Smith: Well, they do. It kills it and scars it so what can happen with wet macular degeneration is you end up with a large scar right in the central area of vision and so, everything out in the periphery looks clear but if you were, if I were to have it and I looked at your face, I couldn't see your face.

Dr. Bob: Could you if you turned sideways?

Dr. Smith: A little bit but it's not functional vision.

Dr. Bob: Now, I know with some of the treatment of diabetes on the retina, the blood vessels, you use laser to really stop the bleeding. Can you use laser to stop the formation of those blood vessels?

Dr. Smith: Great question. In fact, that's where a lot of this news has been coming out. Historically, wet macular degeneration had a very poor prognosis and still unfortunately, it really kind of does. But at least now there's, there's new treatment using new lasers that can sometimes halt, reverse that bleeding and actually preserve vision where just actually a couple of years ago, that was totally impossible.

Dr. Bob: Do you zap the blood vessels or do you use something? Is photodynamic therapy (PDT), is that used?

Dr. Smith: That's exactly what I'm talking about.

Dr. Bob: And PDT is something you inject into the arm, goes to the eye and the laser activates it?

Dr. Smith: That's exactly right and what, the reason that's important is because they are able to use a lower energy of the laser where before they just had to laser right on to it and it would cause a scar but now by injecting a dye that is actually activated by the laser, they can lower the energy that they are actually using with the laser and still effect destruction of the blood vessels but try and preserve the retina itself.

Dr. Bob: Laser treatment of the eye. Is that a difficult thing? Does that take a super specialist as an ophthalmologist or do most ophthalmologists do that or do some do it? I don't know.

Dr. Smith: Well, there are, you know, certainly every ophthalmologist does what he or she feels comfortable doing. I think for a lot of the macular degeneration related lasers are done by retina specialists. The more, you mentioned laser for diabetes and that is certainly something that the general ophthalmologist will do a lot of.

Dr. Bob: We've got a couple, we've got one minute here. I want you to just tell me what do you see in the eye if somebody has high blood pressure out of control or you look into the eye and they've got diabetes? Because maybe somebody comes to the eye doctor and they don't know they've got these other problems. Tell me what you see.

Dr. Smith: We see little splotches of blood. We can see real areas of leaky blood vessels from fluid and that's mainly for diabetes. For high blood pressure, we see that little arteries have gotten, get very narrow and actually will call what is called AV nick and we will actually nick off the little veins but they cross over.

Dr. Bob: Is it easy to see?

Dr. Smith: It is easy to see.

Dr. Bob: How much do you love ophthalmology?

Dr. Smith: I love it.

Dr. Bob: Isn't it so wonderful?

Dr. Smith: It is bless beyond belief being a part of it.

Dr. Bob: You know, the first time I looked at a slit lamp under the eye, I said, "Wow," wouldn't that be a fun thing to do and I know why you love it so much. Darin Smith, you're a great teacher. Thank you for coming to The Dr. Bob Show.

Dr. Smith: Thank you Bob.

Dr. Bob: Let's talk a little more about the eye before we go.

Supplemental Commentary

Dr. Tobin Tayler: Hi, I'm Dr. Tayler

Patient: Nice to meet you.

Jane Joseph: If it's been a while since your last eye exam and you're not sure what to expect, here's some comforting news. Some things haven't changed starting with the eye chart.

Dr. Tobin Tayler: The thing that we look at is just an assessment of what we call the central visual acuity which is what you are doing when you read the wall chart.

Jane Joseph: It's been around for over 50 years and still used today as part of the standard, complete eye exam. Something else that hasn't changed. You will still have your eyes dilated during the exam.

Dr. Tobin Tayler: It increases the size of your pupil and that allows us to see a number of structures more clearly that we would never otherwise be able to see. It allows us to see the lens of the eye more completely. To look at things for example like cataracts. And also more importantly, we're able to assess the structures in the back part of the eye, the optic nerve and the retina.

Jane Joseph: Your physician will also look at the size of your pupils.

Dr. Tobin Tayler: For example, differences in the size of the pupils or discrepancies within the size of the pupils can sometimes indicate underlying problems in other areas of the body in some instances.

Jane Joseph: You will also most likely at some point during your exam have a bright light go over both your eyes.

Dr. Tobin Tayler: The way the eyes react to light is a direct reflection of the function of the optic nerve and also to a lesser extent of the retina.

Jane Joseph: One area that may surprise you is that your physician is very interested in pressure of your eyes.

Dr. Tobin Tayler: Your eyeball is just like your tires. They have a pressure inside them and we can measure that pressure with different instruments and the pressure inside the eye has a normal range and abnormalities in that pressure can be due to a number of different problems. For example, most commonly, people know about glaucoma.

Jane Joseph: Glaucoma is a condition of the eye where an increase of pressure can actually lead to vision loss. It's important to catch eye diseases like this early so they can be treated most effectively. A routine eye exam should start at about the age of eight or nine years old and as you get older, it's a good idea to have them every year.

Jane Joseph: For The Dr. Bob Show, I'm Jane Joseph.

Conclusion of Interviews

Dr. Bob: I want to thank Dr. Darin Smith for his wonderful discussions on common causes of blindness. Remember, the key to keeping good eye health is seeing your eye doctor on a yearly basis, getting that yearly eye check, have them measure the pressure on your eyes. They can see if you have cataracts and they will see if you have the wet form of macular degeneration or talk to you about what you can do to improve eye health.

Letters

Letter #1: Dr. Bob, what are some of the treatable causes of fatigue? Why are people so tired - give us some things we can treat and there are several things.

Response #1: I was thinking about thyroid disease. People with hypothyroidism. The thyroid gives us our energy and gives us metabolism. A very easy test, a test called TSH will measure your thyroid and while we are talking about eyes, with hypothyroidism we have loss of our eyebrow on the lateral third of the eyebrow. Hyperthyroidism, overactive, sometimes a whole lot of energy but the thyroid is working so fast and we are going so fast that fatigue is one of the things even with hyperthyroidism. With hypothyroidism frequently we will have a big stare. Actually the eyeball itself protrudes forward. We call it exophthalmus, Grave's disease. So thyroid, eye problems, fatigue.

What other things can cause fatigue? Any kind of chronic illness can cause fatigue. A chronic illness such as chronic hepatitis. Somebody with chronic allergies can have fatigue. Somebody with simple allergic rhinitis can have fatigue and it is treatable. It is treatable with nonsedating antihistamines, intranasal corticosteroids. And with allergic rhinitis we frequently get allergic conjunctivitis, since we are talking about the eyes. Itching and redness and tearing of the eye. There is excellent eye drops for the eyes over-the-counter. Opcon-A would be one. Prescription medications - Patanol, Optivar - excellent eye drops for somebody with allergic rhinitis. Other causes would be a sleep disorder, snoring, sleep apnea, restless leg syndrome, any type of sleep disturbance, can't get to sleep, wake up in the middle of the night and can't go back to sleep. All of those are treatable forms. If you've got a sleep disorder, see a sleep specialist and find out if those causes of fatigue that you have can't be treated.

Anemia where the blood count goes low. We can see that in the eye also. The conjunctiva, the red part of the eye, becomes very very pale. Blood loss can cause anemia or low iron can cause anemia and so, those are some treatable causes of fatigue.

Commentary

Dr. Bob: There are some recent guidelines from the American Heart Association on prevention of heart attacks and stroke. And I thought it would be good to mention those. We know that if we can prevent heart attacks and stroke that we can improve a lot of cost in medicine because sometimes the first stroke or the first heart attack leaves somebody either dead or leaves them with a very poor lifestyle. So, what can we do to prevent stroke or to prevent heart attacks?

Response: Well, there are several things we can do.

#1. Know what your family history is. If you've got some mother or daddy that's got diabetes or they've got high blood pressure or they had hardening of the arteries, high cholesterol, family history passes down from one generation to the other frequently. You know, back in the old days, maybe mom and dad died at an early age. Now we are living to longer ages so it is very important that we know our family history. Some other parts of the guidelines are: get your blood pressure. Know what your blood pressure is starting at age 20 and everytime you see your doctor, know what your blood pressure is. If you've got a family history of high cholesterol, start at age 20 or at an early age knowing what your cholesterol is. Check it every four to five years according to what you and your doctor have. If your blood pressure is high, certainly you need to know what your cholesterol is. Know what the good cholesterol and the bad cholesterol is. Smoking. Not only do we know that smoking is a common cause of heart attacks and stroke, but now we know that second hand smoke does the same thing. So, if you are in the house with a smoker, get that smoker out of the house. They are going to harm your health.

Some of the other guidelines are: aspirin as primary and secondary prevention of stroke and heart attacks. What's primary and secondary? Well, to prevent it from occurring the first time is primary prevention. Baby aspirin. That's one of the new guidelines. After age 40, especially if your risk factors are significant, high blood pressure, diabetes, high cholesterol, sedentary lifestyle, then a baby aspirin a way is what you need to prevent heart attack and stroke and if you've had a heart attack and stroke, certainly heart attack, you need to be taking a baby aspirin a day and talk to your doctor if you've had a stroke about whether you need aspirin. Also, atrial fibrillation. The new guideline says need to definitely be on a blood thinner. 25% of strokes are due to an irregular heart rhythm called atrial fibrillation where we throw a blood clot from the heart to the brain. Atrial fibrillation, blood thinner, DON'T go by without getting that done.

Letter #2: Dr. Bob, what's a CBC? How often have you heard on television the doctor says, "nurse, I need a CBC?

Response #2: A CBC is a complete blood count. Two basic things it tells us. What the red blood cells are like, what the white blood cells are like and the blood platelets that form clotting. Now, the red blood cell tells us if we've got anemia or not. It can be iron deficiency anemia or the red blood cell can be too large, a macrocytic an enlarged red blood cell anemia, they would have a sign that you need vitamin B-12. So, you can have iron deficiency or you can have B-12 or there can be blood loss that can cause anemia and so, a CBC will tell us that.

It tells us about the white counts. When we have an infection in the CBC the white count if it's elevated, is a good sign there is bacteria. If it is actually lower than normal, it may be a viral illness. If the white count is way elevated, it may be a sign of leukemia. Platelets. If you've got easy bruising. If you bleed easy. If you don't stop bleeding. In a CBC it will tell us if you've got adequate platelets and if you have the ability to stop bleeding.

So, a CBC is really something that you and your doctor want to know what your's is. Your doctor can get huge information from that simple complete blood count.

Closing

Dr. Bob: Well, that's all the time that we have for this show. I want to be sure that you are exercising, one of the guidelines of the American Heart Association. They say 30 minutes seven days a week and yes, seven days a week. Sometimes my wife says, "it's hard to exercise seven days a week" but that's what she does. Start the day off with a breakfast of fruit and fiber and if you can get eight hours sleep, you'll perform better, you will be happier, the people around you will be happier and most of all, what is it we like on The Dr. Bob Show, well, it's that laughter in your life. Find a loved one that you can laugh with and have a great time.

If you have a question for Dr. Bob, write to The Dr. Bob Show - 6700 Baum Drive, Suite 1, Knoxville, TN 37919 or send your e-mail to letters at letters@drbobshow.com