Thursday, December 17, 2015

Second Cataract Surgery: January 6, 2016

Although the focus of this blog are issues associated with lipids and heart health, I'd like to bring in other topics as well, in particular, the choices one needs to weigh in choosing the best sight strategy for the kind of lens you choose to embed.

One can go for maximum distance vision in both eyes. But then one almost surely will need reading glasses.

Or one can go for the new "multi" lens, which go for both distance and reading. As with many other compromises, you don't get the best distance or reading correction. At least that's been the story on the street.

Or one can go for "mono-vision" (as I did). This choice takes off from the natural distribution of function your eyes already have. One eye tends to do the "up close" work, the other eye, the distance work. In my case, my left eye naturally gravitates to closer reading, my right eye is my distance eye. My optometrist and I discussed this and set this up with my last several contact lens prescriptions.

Instead of correcting both eyes to 20-20, he corrected my left eye to about 20-40, so that it was easy to read. He adjusted the right eye to the full 20-20 for distance. This worked very well. I could read small text (say on my iPhone) without reading glasses or even squinting. While driving, the brain combined the two different corrections into something like 20-20 (at least during the day). This worked very well and the idea was to continue it with similar embedded lenses when I had cataract surgery.

But cataract surgeries don't typically happen together. The cataract in my left (reading) eye matured faster than the one in my right (distance) eye. So the idea was embed a "reading" lens in that eye.

But I've left out the issue of astigmatism. Both eyes have some astigmatism, which needs to be corrected in some way. My left eye was a candidate for a "toric" implant, a lens which corrects vision, including astigmatism, but costs extra.

My surgeon, who is also a lasik specialist, suggested that he could embed a regular lens and adjust for astigmatism through lasik surgery  at the time of the implant. The idea was to come up with about 20-40 in the left eye to continue my strategy of mono-vision.. This translated to a "backing off" about 1.25 diopters. (There is not necessarily a one-to-one correspondence to the 20-20, 20-30, 20-40, etc. and the diopters of correction. 1.25, 1.50, 1.75, etc. This needs to be actually tested in a standard refraction exam at your optometrist.)

Long story made short is this: while my left eye started out at 20-40, it has continued to "back off" until, almost a year later, it is 20-80. This is no problem of course in terms of reading, but I do feel some strain in combining distance vision, say while reading labels in a museum or driving at night. On a bright day, because the aperture of the iris is contracted, you get the same "depth of field" advantage as you do with a camera, so that my left eye may be even 20-30 at that time and the illusion of a full correction in both eyes is very strong.

The optometrist at the surgeon's office said something like, "The original target was 1.50 but I see that it is 1.75 or more..." I thought the original target was 1.25 (about 20-40) and was afraid the result was more like 20-100 in that dark room, but it was later tested at 20-80, which I think corresponds to 1.75.

In retrospect, I probably should have had a toric lens for my left eye. But my current status is within the acceptable window - as I attested at the office visit.

For the future, however, especially if the left eye backs off further (a real 20-100), then I would get a contact lens for it. The question is then, "At what correction"? From a discussion with my regular optometrist, it would have to have at least 0.5 diopter correction to be worth it. For me, that would mean, I think, a 20-40 "net" correction in that eye.

The question then becomes, does that compromise reading vision. If so, it doesn't appear to be worth it. My optometrist was able to simulate what it would be to have this. I really liked how it helped my distance vision (in the relatively dark room). But I was slightly put off by how I would have to slightly distance (extend out further) my iPhone for optimum reading. A close call.

In the meantime, the surgeon is going for "the best distance" in my right eye and I will get the toric lens. ($$)

Bottom line, after the surgery  and things settle. I'll revisit this.

New Component: Diet

The Scramble
I had an hour-plus meeting with my new endocrinologist's dietitian. Our shared philosophy: "Eat as much as you want, but eat the right foods." Here I remember my experience in China vividly. I ate as much as I wanted, but still lost five pounds a month. At the end of my longest stay there - three months - I lost fifteen pounds. The trick, of course, is to do it here.

She gave me four pages of recommendations, about which I'll be posting in the future. I'd like to highlight here, however, the "Scramble."

This is a variation. I started with  about a half sliced white onion, garlic, part of a sliced yellow pepper, and some sliced green onions. To those I added some already stir-fried ground turkey (just an ounce or so). When those were cooked (but not over-cooked) I poured in enough egg whites (from TJ's) to cover, then waited for that to solidify. I added some chili flakes to warm things up, and some pepper. And just a little fish sauce in place of salt. I then rolled up the scramble, cut it in two and placed it on halves of a round flat bread that I had toasted. Awesome!

Wednesday, December 16, 2015

Tests Pending for February 2016 Assessment

Seeing my new endocrinologist has led to a variety of tests and consultations to establish diagnoses that my previous doctors suspected and prescribed for without necessarily testing for. For example, my excellent Kaiser doctor suspected that I might have "fatty liver syndrome" (NASH) but didn't test specifically for it, or made his judgment on the more standard tests. He also suspected some "insulin resistance" and talked of my being "pre-diabetic".  But my A1c test was typically normal, so those diagnoses were put on the back burner after attaining and holding a good lipid profile.

Often heard, "Yes it would be nice to have additional tests results, but because they would not change your treatment regime, there is no need to do them." A follow-up heart scan was not indicated because it wouldn't tell us anything we don't already know - and are treating for. (In addition, it would introduce additional radiation, something I did not need after the IMRT treatments at RCOG in Georgia for my prostate cancer.) The VAP test is expensive, and the results would be interesting, but they would not affect what we are already doing for treatment.And so on. I've continued to take my medications, exercise, and eat reasonably well.

Yet ferritin levels continue to be high. A younger family member has had two strokes. A cousin died in her forties from atherosclerosis. My Dad had this disease as well and suffered at least one very bad stroke. So it is perhaps not surprising that my new endocrinologist is specifically testing for these assumed diagnoses.

I've consulted a second specialist for the NASH - "fatty liver syndrome." There are a set of labs which are grouped under this heading "NASH". I've taken the test and will get the results back when the specialists reports back to my endocrinologist.

In January, I'll take the "VAP" lipid profile (equivalent to the Berkeley Labs lipid panel), then meet with my new endocrinologist. The VAP panel will help diagnose the "small-LDL-trait" - where one's LDL is small and gritty rather than large and buoyant. It is perhaps the best predictor of stroke. The smaller and grittier, the greater is the likelihood of a stroke or some other heart incident.

In the meantime, I've started shifting to the foods recommended by the dietitian in my endocrinologist's office. I'm intrigued with the possibilities. The idea is not to eat less food, but to eat different food. The result should be weight loss, the last piece of the puzzle. I am enthusiastic because this has worked for me in China where I lose 5 pounds/month eating all I want. More about this in a separate posting.

I'm taking milk-thistle, a supplement which is supposed to detoxify my liver. We will see from the VAP and liver tests in late January where this helps ferritin levels, or the slightly high/low scores of my liver enzymes.(See this earlier post.)  I'll have an ultrasound of my liver before Christmas to see whether there are any anomalies there. More about these tests later.

Nor have my kidneys escaped notice, though I haven't identified any tests specifically directed at them.

It is likely that the ferritin, NASH, insulin resistance, small-LDL-trait (and throw in Hyperlipoproteinemia Type IIb see this) are all part of the same syndrome that can be addressed by essentially the same medications, loss of 15 pounds, and a shift of diet.

Tuesday, December 1, 2015

Heart Scan Scores: Then and Now

November and December have and will be filled with a variety of tests, on which I'll be commenting shortly. But I've had a second heart scan and can compare the results to those of the Orange County scan from January, 2010. (The January, 2010 is in the middle, designated with "OC". The November, 2015 score is on the right, designated "MI" for "Millennial Imaging" where the scan was performed.)

First note that the actual number of lesions went down from 10 to 8. (This may, of course, be an artifact owing to different equipment.) Note also that the Calcium Score for the Left Anterior Descending Artery (LAD) actually went down from 283 to 258.2, although the number lesions is the same.  (Again, this could be because of different equipment.)   

For the Right Coronary Artery (RCA), however, although the number of lesions went down from 5 to 3, the score increased from 552 to 654.4. 

While it's my belief that these scores are in "standard form," Orange County included an additional interpretation from 0-100:

0-20 Low
21-40 Moderate
41-70 High
71-100 Very High

On this scale, OC assigned a number of 58, which falls the "High" category.

I am naturally curious about whether this initial risk has changed.  If proportions hold, this risk would increase about 8% in proportion to the increase from 835 to 903.6 or 63, which is still in the "High" category,  but not quite in the "Very High" category. Of course, risk assignment is tricky and may not be linear.

So how do I interpret the two scores, five years apart? I would not make too much of the "fewer" lesions. I am more mindful of the 8% increase in the total  score. I am appreciative of the 9% diminution of the LAD score. I was hopeful that this would be across the board. But this is offset by at nearly 16% jump in the RCA score.  

Still, if the proportions hold, then I would remain in the "High" category and am - in some sense at least - holding my own. One assumes it would be worse without my efforts over the past five years, very likely slipping into the "Very High" category.  But click here for my cardiologist's take five years ago. His thalium stress test actually looks at the blood going through these arteries.  His comment, "no obstruction."

That is, of course, the problem. I am asymptomatic. I am trying to guard against something that statistically could well happen. It goes back to indirect measurements. We don't see the plaque, we see the calcium in a calcium scan. We do see the blood moving in a thalium stress test. "No obstruction" he said.

# of Lesions OC
Calcium Score OC
# of Lesions MI
Calcium Score MI