October 5, 2015
Rest and Relaxation
One of the more challenging cases that I had to operate on after I returned from my vacation…
This summer came early and with a bang. As the Okanagon fires finally died down, the last days of summer unceremoniously slipped passed us. The fall chill is in the morning air and the sky is brilliantly clear again. Autumn is my busiest season with children going back to school and needing their eyes checked. Summer, however, is for rest and relaxation and I try to take a week or two off each year to spend time with the family. We kicked off this summer with a visit to Grandma in San Diego in late June. Grandma was proud to show off her grandbabies and we were proud that they survived the plane rides with minimal screams and fuss. The highlight in July was of course the twins second birthday. Forty people (many little ones and their parents) descended on our backyard in a three-hour window of sunshine. I honestly did not know how we would have entertained our guests had it rained. The toddlers loudly ran, jumped, wrestled, and blew bubbles while dads, me included, looked on nonchalantly and drank sangria. When I unsuccessfully tried to teach Elise to blow the birthday candles, a gust of wind swiftly did the job for her and a few rain drops followed suit. The adults rushed to gather their hyperkinetic, hyperglycemic children, threw them in their SUVs and the party was over in a hurry.
The grand finale of our summer was a trip to the Oregon coast. We stayed at a friend’s cabin in Netarts, not too far from Tillamook. The children had so much fun running on the sandy beach and splashing all wet in little tide pools. We flew kites, kayaked in the bay and did a few good hikes in the surrounding area. I could feel all my tensions melt away as I watched the sunset against the backdrop of the Three Arch Rocks. I came back feeling refreshed and recharged; ready to tackle the challenges of a medical practice.
Americans are hard workers. Fifteen percent of our citizens report taking no time off each year. On average, Americans get sixteen paid vacations days annually in addition to federal holidays. Compare that to France where workers receive five weeks of paid vacation per year. It is not uncommon for French physicians to close up their offices in the month of August in Paris. As much as I enjoyed my vacations, I have no plan to savor life like my French colleagues. I do, however, think that vacations of moderate duration are important as they prevent burnouts, renew creativity and refocus professional priorities.
Rest and relaxation are vital to our general well-being and to normal functioning. The same goes for our eyes. Our eye muscles need to contract AND relax appropriately and synchronously for the two eyes to track together. One of the more challenging cases that I had to operate on after I returned from my vacation was a nice lady with Grave’s disease. This is an autoimmune condition in which the immune system goes haywire and starts to attack the thyroid gland, the eye muscles and other orbital tissues. As a result, the eye muscles become stiff and unable to relax. The fatty tissue behind the eyes can also become swollen and pushes the eyes out of the socket. In extreme cases, the optic nerve can become damaged because the swollen fatty tissues and eye muscles cannot expand against the bony orbit and in turn press on the optic nerve which runs in the center of the cone-shaped orbit.
Patients with Grave’s disease often times experience ocular discomfort because the cornea is more exposed and the lids may not completely cover the eyes when they sleep. The eye surface becomes dry and irritated. Patients are most commonly referred to my office because of uncontrolled double vision. We all have six eye muscles in each eye, one in-turner (medial rectus), one out-turner (lateral rectus), one down-turner (inferior rectus), one up-turner (superior rectus), one in-rotator (superior oblique) and one out-rotator (inferior oblique). These muscles coordinated with each other to allow the two eyes to track together. In Graves, the muscle that are most commonly affected is the down-turner, followed by the in-turner and the up-turner. The muscles become really tight and hold the eye in its field of action. As a result, the eyes are locked down and in, often asymmetrically between the two eyes. The eyes, therefore, point to different directions and the brain cannot put the two images together, resulting in double vision.
Treatment of Grave’s disease involves controlling the thyroid hormone abnormalities which often times improves the eye problems as well. Approximately ten percent of patients with Grave’s require orbital decompression in which small pieces of the orbital bones are removed to create space for the swollen tissues to expand. Another ten percent of patients have double vision because of the tight eye muscles or because the muscle positions are changed after their orbital surgeries. Typically, we wait for a least six months when the active phase of the disease subside before operating on the muscles to realign the eyes.
Another common scenario that causes eye misalignment and double vision is stroke. Small blood vessels in the brain that supply the control centers of the eye muscles may be clogged by cholesterol plaques. Lacking stimulation from the brain, the involved eye muscle will become weak or even completely paralyzed. For example, a small stroke in the brainstem where the nucleus of the sixth nerve resides will weaken the out-turner muscle. The in-turner muscle, without an opposing force from the out-turner muscle, will turn the eye in. Over time, the in-tuner muscle will become tight. Even when the brain recovers and the out-turner muscle regains strength, the in-turner muscle cannot relax and the eye will remain crossed. Botox to the in-tuner muscle may help to balance the forces between the two muscles but eye muscle surgery is the definitive treatment.
Relaxing a tight muscle, either from Grave’s or from a stroke, is achieved by a recessionin which the involved muscle is secured by sutures and reset it further back along the wall of the eye. This effectively decreases the pull that it exerts on the eye. To watch me perform a recession, you may click here. Eye muscle can also be strengthened by a resection in which a segment of the muscle is removed and reattached it to the same place on the wall of the eye. The shortened muscle is tighter and can therefore pull on the eye more. A newer technique in strengthening eye muscle is by folding a segment of the muscle onto itself to make it shorter. This technique, called plication, has the advantage of preserving the blood vessels on the eye muscles and is potentially reversible. We have used this technique on a series of patients and have been impressed with the results.
We are a center of excellence in caring for adults experiencing double vision from Grave’s, Oculomotor palsy, Myasthenia Gravis, Orbital fracture and unresolved childhood strabismus. In most cases, we can medically manage the double vision with prisms. Temporary stick-on prisms are particular helpful for those patients who are recovering from a stroke and in planning for surgery. For those patients that ultimately require surgery, we utilize the latest adjustable suture technique to maximize successful outcome. Our surgery center employs anesthesia protocols to allow patients to recover rapidly after strabismus surgery. Once the patient regains full consciousness, we can further refine the positions of the muscles by loosening or tightening the sutures to achieve single binocular vision. With this approach, our success rate is over 90% for eye muscle realignment. Our goal is to help patients with double vision to rest easy, relax so they can focus their energies on the joys and challenges of their lives.