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Medical Forum / General / Vision / May 2008Fuchs's Cornea Dystrophy Questions
About 2 months ago overnight I developed intermittent double vision in both eyes. I went to 3 different eye doctors. The first said cataracts and referred me to a cataract surgeon. The second said I need new glasses which didn't help. The cataract surgeon said Fuchs's Cornea Dystrophy. The cataract surgeon measured cornea thickness 630 right, 645 left, cornea pressure 17 R 15 L, Guttata grade 3 plus, cell count not measured. I am getting the morning fuzzy vision. On a home eye chart morning vision is 20/40 R 20/50 L. In the afternoon it is 20/20 L 20/25 R. I am using Muro eye drops and ointment at night. It seems to clear the vision somewhat. I am a 68 year old male. The cataract surgeon said I have some cataracts, but with the Fuchs's he would not operate. Questions: Is Fuchs's that difficult to diagnose? How common of a condition is it? How likely is the cataract surgeon to have the right diagnosis? Do I need a fourth opinion? Is the onset usually so sudden (overnight)? Given my history and current state what is the likely progression of the disease? Thanks Ray > About 2 months ago overnight I developed intermittent double vision > in both eyes. I went to 3 different eye doctors. The first said [quoted text clipped - 14 lines] > Questions: > Is Fuchs's that difficult to diagnose? Well, the doctor has to look. It also tends to be worse in am and better later in the day, so might have been missed if you had late day appointments. > How common of a condition is it? > How likely is the cataract surgeon to have the right diagnosis? Very likely, esp if he is seeing corneal guttata. Muro is the treatment and since Muro is working, that also confirms the diagnosis. > Do I need a fourth opinion? No > Is the onset usually so sudden (overnight)? Symptoms can onset quickly > Given my history and current state what is the likely progression of > the disease? Hard to predict. Most people do not progress very quickly. Some go on to need a corneal transplant, most don't Judy Just exactly what causes the "morning fuzziness"? Don W. The corneal stroma swells and loses transparency if water isn't actively pumped out. The endothelium contains the pump. When the lids are closed overnight, oxygenation drops. Healthy endothelium has enough reserve to keep the cornea clear overnight. -MT > Just exactly what causes the "morning fuzziness"? > > Don W. Thanks. How might the cornea react to Xalantan with this kind of condition? Also, is the morning "fuzziness" granular or just overall "fuzzy"? (If that is clear?). Don W. > The corneal stroma swells and loses transparency if water isn't actively > pumped out. [quoted text clipped - 10 lines] >> >> Don W. >Thanks. > >How might the cornea react to Xalantan with this kind of condition? > >Also, is the morning "fuzziness" granular or just overall "fuzzy"? (If that >is clear?). For high contrast items such as point source of light or black print on white background it is multiple images. In my case sometimes it is as many as 6 images smeared vertically. For lower contrast it just looks fuzzy. Removing excess water from the cornea with salt water or a hair dryer improves vision. What is Xalantan? >Don W. > [quoted text clipped - 12 lines] >>> >>> Don W. > >Thanks. > [quoted text clipped - 25 lines] > > >>> Don W. Wikipedia says: Latanoprost (pronounced la-TA-noe-prost) ophthalmic solution is a topical medication used for controlling the progression of glaucoma or ocular hypertension, by reducing intraocular pressure. It is a prostaglandin analogue that works by increasing the outflow of aqueous fluid from the eyes. It is also known by the brand name of Xalatan manufactured by Pfizer. Possible side effects: -May cause reddening of the eyes (hyperemia) -May cause blurred vision; -May cause eyelid redness; -May permanently darken eyelashes; -May cause eye discomfort; -May eventually cause permanent darkening of the iris to brown (heterochromia); -May cause a temporary burning sensation during use. -May cause thickening of the eyelashes. -Rarely, herpes simplex keratitis. [http://en.wikipedia.org/wiki/Xalatan] Interesting about too much fluid in the cornea. I always got the impression the it was my cornea (outside) surface that needed a few blinks to become more "optically smooth". How far apart are your multiple images? Degrees, minutes? Those types of multiple images I do not have. Xalatan is a glaucoma drug that reduces eye pressure, namely the anterior chamber (hopefully the posterior tracks), before higher pressure affects the optic nerve, which affects blood flow to the eye. The drug, goes thru the entire cornea (and that would include the endothelium). (As far as I understand it -- no medical type). Don W. PS. What is funny about the usage of that drug is that I squeeze out as much moisture as possible from the eye and then apply the drop. So that I can get the maximum use out of a singular drop. One is advised not to double drop since it tends to wash out the medication from the eye. Interesting, I thought. >>Thanks. >> [quoted text clipped - 27 lines] >>>> >>>> Don W. Sorry for going off topic for a second, but why do some people spell the word 'through' as 'thru'? I mean, if you're going to truncate one word why not just go all out instead of using a half measure. Why not replace the whole post with words like 4 instead of 'for' or 'u' instead of 'you'. Or is this how Americans normally spell the word? I must say, it's much more convenient to say 'thru' instead of 'through' but being a semantic kind of person I can't help but notice these small things where people neglect the rules of standard English. Consistency in speech is always helpful to foreign speakers, too. >Interesting about too much fluid in the cornea. I always got the impression >the it was my cornea (outside) surface that needed a few blinks to become >more "optically smooth". > >How far apart are your multiple images? Degrees, minutes? Those types of >multiple images I do not have. A traffic stop light will have 2 red lights spaced the same distance apart as the distance between amber and red. A cross road (black cross on yellow sign) will have 2 black crosses bars with yellow in between the thickness of a crossbar. From 10 feet a 1/8" green LED will be a series of dots about an inch high. Normal text in a book will have a readable ghost image 1/2 the height of text. I am getting used to it. My corneal pressure is 16, with 12 to 21 normal. >Xalatan is a glaucoma drug that reduces eye pressure, namely the anterior >chamber (hopefully the posterior tracks), before higher pressure affects the [quoted text clipped - 41 lines] >>>>> >>>>> Don W. >>multiple images I do not have. > [quoted text clipped - 7 lines] > > My corneal pressure is 16, with 12 to 21 normal. For a "standard E" (20/20 vision) the subtended angle is 5 minutes or 0.083 degree. Your 1 inch at 10 feet is 0.48 degree. These are remarkable offsets. All caused by deformations in the cornea? (Or in the lens??). Seems like they should be able to nail down the cause. Don W. > degree. Your 1 inch at 10 feet is 0.48 degree. These are remarkable > offsets. All caused by deformations in the cornea? (Or in the lens??). > Seems like they should be able to nail down the cause. It isn't considered useful, because it wouldn't alter the treatment. If the diplopia is lenticular (my vote), his acuity is apparently still too good to expect insurance to cover cataract surgery. If it's corneal, rigid contact lenses would eliminate the diplopia but he probably wouldn't like wearing rigid contacts and no surgeon wants to recommend contacts to a presbyope with symptomatic Fuchs. It would take about two minutes to numb his cornea, pop on a rigid contact lens and prove the origin of the diplopia. But that's not so easy to justify if you have to buy (design, order, wait for) a gas perm contact lens just for a one-shot diagnostic fit. They say "it's academic" meaning "it ain't worth the trouble." -MT >> degree. Your 1 inch at 10 feet is 0.48 degree. These are remarkable >> offsets. All caused by deformations in the cornea? (Or in the lens??). [quoted text clipped - 17 lines] > >-MT I agree. My eyesight is not that bad, I can live with it. The latest medical advice is to wait until it gets worse and they will do cataract surgery and replace the endothelium layer of the cornea at the same time. I am in no hurry to do that. The problem with waiting too long is that blisters will form too many scars on the cornea requiring the replacement of the whole cornea. There are a few scars on the cornea that I can not explain. I am going for a cell count soon which may help to determine how bad the Fuchs is. Thanks for your input. How would Fuchs' and the use of Xalatan (to lower IOP) go together? Complement or complicate the situation?? Don W. >>>multiple images I do not have. >> [quoted text clipped - 14 lines] > >Don W. You are talking about medical people. I have read on the average it takes 6 diagnosis to get it right. That was how many it took to find a torn rotator cuff in my arm. For my vision the first doctor said cataracts, the second said wrong glasses, the third said Fuch's. They all used the same examination procedure. Others with Fuch's have said it took more than 6 doctors to find it. I think it highly likely that I have Fuch's as the major problem and cataracts. I am not sure that with my symptoms that it is a complete explanation. The vision is not as bad as the numbers would suggest because the distortion is only vertical, the vision waxes and wanes and what I described it when it is at its worst. This is a long shot Ray and may not work for you but I had a very similiar vision problem for a number of years. Vertical dipoplia Quite by accident I found that wearing a sleep mask basically eliminated the problem. I have no idea why this worked except to suggest that because I have a orbit deformation(depressed bone) on the side of my good eye, when sleeping my cornea is subject to pressure from the pillow and the mask relieves this. It would take about an hour each morning for this vision problem to recede, until I used the sleep mask. I repeat: it's a long shot and it took a number of weeks for the vision to stabilise. Cheap and good for your sleep anyway so try it. I can't even say with certainty that the sleep mask made the difference but I did go without the sleep mask for a few weeks and the problem returned so I am loathe to try that little experiment again. PS: same problem as you, saw a number of doctors who offered no solution or diagnosis. Mike T., if you would be so kind, I would appreciate your opinion on this wild idea! >>>>multiple images I do not have. >>> [quoted text clipped - 27 lines] > vertical, the vision waxes and wanes and what I described it when it > is at its worst. > Mike T., if you would be so kind, I would appreciate your opinion on this > wild idea! You didn't say specifically that your diplopia was monocular. If that's what you mean then yes, it's certainly reasonable to try a sleep mask. Monocular diplopia can arise from the cornea, where dips and peaks form images that aren't exactly coaxial. It can also arise from the lens, where wedge-shaped areas degrade and their refractive index changes and those areas start to form independent images. As you might imagine, in the first case, corneal molding and surface distortions could be affected by a sleep mask. In the second case, changing the cornea will have no real effect. Fuch's dystrophy doesn't usually cause topographical changes in the cornea without real pain. Ray hasn't described any pain and AFAIK has never had corneal erosions. That, and his age, lead me to suspect that his diplopia is lenticular. If he put on a gas-perm contact lens and the diplopia remained, we could be sure that it's lenticular and would be "cured" by cataract surgery. OTOH, if it's corneal, it will disappear with a rigid contact lens. This isn't worth the trouble unless they're considering surgery or other major treatment. -MT >>>>>multiple images I do not have. >>>> [quoted text clipped - 27 lines] >> vertical, the vision waxes and wanes and what I described it when it >> is at its worst. >> Mike T., if you would be so kind, I would appreciate your opinion on this >> wild idea! > > You didn't say specifically that your diplopia was monocular. If that's > what you mean then yes, it's certainly reasonable to try a sleep mask. Definitely monocular. I can sympathise with Ray because when I was dealing with this problem it proved to be very frustrating. The visual distortion became so severe at times I markedly reduced my driving and I couldn't work for a long time. I have resolved this problem but am stuck with visual confusion, sometimes my brain, particularly when driving, won't resolve the image. Makes for some interesting driving. I have residual binocular vision, strabimus and amblyopia, ptosis in my good idea, optic nerve damage in my bad eye from surgery. My visual acuity in my good eye remains very strong, even as I approach 50 years of age, that is probably a legacy of many years of post surgical visual therapy *when I was very young(4-7 years)*, just young enough to boost VI function perhaps. I still don't need reading glasses but do have v. slight fluctuating myopia. I am an ophthalmologist's nightmare, which probably explains so many have tried to hurry me out the door ... . Thanks Mike. > Monocular diplopia can arise from the cornea, where dips and peaks form > images that aren't exactly coaxial. It can also arise from the lens, where [quoted text clipped - 19 lines] > >>>>>>multiple images I do not have. John, Like "in my good idea". Don W. I vaguely remember you Don. Were you the one involved in a discussion about Stargardts? If so, I hope your treatment for AMD(?) is helping. Nah, that was a typo, rushing too much but I am a terrible proof reader and I hate reading spreadsheets! > John, > > Like "in my good idea". > > Don W. John, what is this "vaguely" stuff?? Yup, it was me, but it was about tossing zinc into some equation. Understand about typo's, but have adopted it! Hope, besides everything else, you are doing ok, status quo on this end. Don W. >I vaguely remember you Don. Were you the one involved in a discussion about >Stargardts? If so, I hope your treatment for AMD(?) is helping. [quoted text clipped - 7 lines] >> >> Don W. Don, I think during our prior discussion I mentioned the below but just in case. This seems to be a promising approach and I hope there have been some follow up studies on this: Ophthalmologica. 2005 May-Jun;219(3):154-66.Click here to Improvement of visual functions and fundus alterations in early age-related macular degeneration treated with a combination of acetyl-L-carnitine, n-3 fatty acids, and coenzyme Q10. The aim of this randomized, double-blind, placebo-controlled clinical trial was to determine the efficacy of a combination of acetyl-L-carnitine, n-3 fatty acids, and coenzyme Q10 (Phototrop) on the visual functions and fundus alterations in early age-related macular degeneration (AMD). One hundred and six patients with a clinical diagnosis of early AMD were randomized to the treated or control groups. The primary efficacy variable was the change in the visual field mean defect (VFMD) from baseline to 12 months of treatment, with secondary efficacy parameters: visual acuity (Snellen chart and ETDRS chart), foveal sensitivity as measured by perimetry, and fundus alterations as evaluated according to the criteria of the International Classification and Grading System for AMD. The mean change in all four parameters of visual functions showed significant improvement in the treated group by the end of the study period. In addition, in the treated group only 1 out of 48 cases (2%) while in the placebo group 9 out of 53 (17%) showed clinically significant (>2.0 dB) worsening in VFMD (p = 0.006, odds ratio: 10.93). Decrease in drusen-covered area of treated eyes was also statistically significant as compared to placebo when either the most affected eyes (p = 0.045) or the less affected eyes (p = 0.017) were considered. These findings strongly suggested that an appropriate combination of compounds which affect mitochondrial lipid metabolism, may improve and subsequently stabilize visual functions, and it may also improve fundus alterations in patients affected by early AMD. PMID: 15947501 [PubMed - indexed for MEDLINE] > John, what is this "vaguely" stuff?? Yup, it was me, but it was about > tossing zinc into some equation. Understand about typo's, but have [quoted text clipped - 14 lines] >>> >>> Don W. Don, Decided to see if there were any follow ups: again good results. Given the high safety profile of these compounds I think anyone with AMD should think seriously about these findings. Ask your doctor. Any bods here who would care to give an opinion? Second abstract from BMC ophthalamo, freely available. Go to pubmed, key in PMID number, follow links on right hand side. I still don't understand why they don't add R Lipoic Acid to the mix. To understand why look up Professor Ames at www.juvenon.com. CF. PNAS, Feb 19,2002, Feeding acetyl-L-carnitine and lipoic acid to old rats significantly improves metabolic function while decreasing oxidative stress Thanks, John. [Metabolic therapy for early treatment of age-related macular degeneration] [Article in Hungarian] Currently, age-related macular degeneration is one of the most common eye diseases causing severe and permanent loss of vision. This disease is estimated to affect approximately 300-500 thousand Hungarians. While earlier no treatment was available, in the recent decade an antioxidant therapy became very popular using combinations of high dosage antioxidant vitamins C, E, beta carotene and zinc. Based on theoretical concepts and mostly in vitro experiences, this combination was thought to be effective through neutralizing reactive oxygen species. According to a large clinical trial (AREDS) it reduced progression of intermediate state disease to advanced state, but did not influence early disease. This original combination, due to potential severe side effects, is not on the market anymore. However, the efficacy of modified formulas has not been proved yet. Recently, the metabolic therapy, a combination of omega-3 fatty acids, coenzyme Q10 and acetyl-L-carnitine has been introduced for treating early age-related macular degeneration through improving mitochondrial dysfunction, specifically improving lipid metabolism and ATP production in the retinal pigment epithelium, improving photoreceptor turnover and reducing generation of reactive oxygen species. According to a pilot study and a randomized, placebo-controlled, double blind clinical trial, both central visual field and visual acuity slightly improved after 3-6 months of treatment and they remained unchanged by the end of the study. The difference was statistically significant as compared to the base line or to controls. These functional changes were accompanied by an improvement in fundus alterations: drusen covered area decreased significantly as compared to the base line or to control. Characteristically, all these changes were more marked in less affected eyes. A prospective case study on long-term treatment confirmed these observations. With an exception that after slight improvement, visual functions remained stable, drusen regression continued for years. Sometimes significant regression of drusen was found even in intermediate and advanced cases. All these findings strongly suggested that the metabolic therapy may be the first choice for treating age-related macular degeneration. Currently, this is the only combination of ingredients corresponding to the recommended daily allowance, and at the same time, which showed clinically proved efficacy. PMID: 18039616 [PubMed - indexed for MEDLINE] TOZAL Study: an open case control study of an oral antioxidant and omega-3 supplement for dry AMD. Vitreo-Retinal Associates of New Jersey, Ridgewood, New Jersey 07450, USA. franciscangemi@aol.com BACKGROUND: The primary objective of this prospective study was to measure the change from baseline in visual function--Best-Corrected Visual Acuity (BCVA) via the Early Treatment Diabetic Retinopathy Study (ETDRS) chart, contrast sensitivity, central 10 degree visual fields and retinal imaging (angiograms and photographs) at 6 months in subjects with atrophic (dry) age-related macular degeneration treated with a targeted nutritional supplement. METHODS: 37 mixed gender patients with a mean age of 76.3 +/- 7.8 years were enrolled at 5 independent study sites and received standard of care with a novel formulation of a nutritional supplement. Results were compared to a placebo cohort constructed from the literature that was matched for inclusion and exclusion criteria. A paired t-test was used to test a null hypothesis and a two-sided alpha level of 0.05 was used to determine statistical significance. RESULTS: 76.7% of subjects receiving the nutritional supplement demonstrated stabilization or improvement of BCVA at 6 months. Subjects gained an average of 0.0541 logMAR or one-half of a line of visual acuity (VA) over the 6-month period. There was a statistically significant improvement in VA from baseline with P = .045. The results provide strong evidence that the treatment being studied produces an improvement in VA. CONCLUSION: Treatment with this unique nutritional supplement increased VA above the expected baseline decrease in the majority of patients in this population with dry macular degeneration. The results of the TOZAL study agree with the LAST and CARMIS studies and are predictive for positive visual acuity outcomes in the AREDS II trial. However, patients will likely require supplementation for longer than 6 months to effect changes in additional visual parameters. PMID: 17324285 [PubMed - indexed for MEDLINE] > Don, > [quoted text clipped - 52 lines] >>>> >>>> Don W. John, Got your references. Will digest. I did get a big kick out of "0.0541 logMAR" for being the results of that one study. I think that is well within the variance of one patient successively reading the chart. Lutein is not mentioned. I do know there is some effort to show increases in macular pigment density by ingestion of this. But.... they don't carry it forward to show changes in visual acuity, far as I can see (hmmm). Thanks, good luck to you in everything. Don W. PS. Yeah, I do get the freebies of off BJO. Am registered. Nice of them. **** > Don, > [quoted text clipped - 153 lines] >>>>> >>>>> Don W. > >Interesting about too much fluid in the cornea. I always got the impression > >the it was my cornea (outside) surface that needed a few blinks to become [quoted text clipped - 58 lines] > > >>>>> Don W. The illusions seen in imperfect sight are very strange and funny. It seems they are completely unique in every single individual, which shows just how many ways a mind at strain can manifest itself on one's vision.
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