Hide the eyes and you hide the person. • People with shifty eyes are untrustworthy. • Droopy eyes say you're tired. • Bloodshot and watery say you're hung over. • Look someone straight in the eye and he knows you mean business. Cast a sidelong glance through lowered lashes and you know what can happen.
When doctors examine our eyes, they gather clues as to what's going on not only with our vision, but with our general health. Diabetes, heart disease and other conditions all can turn up on an eye exam.
Deteriorating vision is one of the most troubling and early signs of aging. From nearsightedness to macular degeneration, the leading cause of blindness in Americans over 65, much can go wrong.
Sagging skin around the eyes can betray your age; it also can be so severe it obstructs vision.
Yet many medical and cosmetic eye problems are preventable or fixable, whether your goal is to see more clearly, or to give others a more youthful impression of yourself.
After age 50, and especially if you wear glass or contacts, an annual eye exam is imperative. Many of the major causes of vision impairment are preventable or treatable with early detection, including:
Presbyopia: Nearsightedness can start younger, but most of us notice we are holding books and newspapers at arm's length in our mid to late 40s. The eye's lens becomes less flexible and can no longer change shape to focus on near objects. Treatment options: nonprescription and prescription eyeglasses, bifocal and trifocal contact lenses, refractive surgery to reshape the cornea, and lens replacement with a synthetic implant.
Cataracts: They affect more than 22 million Americans, and the older you get, the greater your risk. The lens of the eye becomes cloudy and can cause blurry vision, double vision, glare and trouble seeing at night or in low light. Treatment varies from eyeglasses to surgery.
Diabetic retinopathy: Affecting more than 18 million Americans over age 18, the condition arises when excessive blood sugar damages the tiny vessels that nourish the retina. All diabetics should have a comprehensive eye exam each year; the National Institutes of Health says 90 percent of diabetes-related blindness can be prevented by controlling blood sugar, pressure and cholesterol.
Glaucoma: This buildup of pressure in the eye is painless, but it is a leading cause of blindness. "You can lose vision — your side vision — and not even realize it until it's quite far along," said Dr. William Grizzard, a Tampa ophthalmologist and retina specialist. African-Americans over age 40, everyone else over 60 and those with a family history are at highest risk.
Treatment if caught early is simple: daily administration of eyedrops or oral medication.
Age-related macular degeneration: In its most common form, abnormal blood vessels grow on the retina and leak blood, affecting central vision. The change can be so subtle and gradual, it goes undetected for years. "The brain is real good at making sense of the information we get and compensates for the loss of vision in one eye," Grizzard said. "I have patients who didn't know they had it and didn't come in until the other eye was affected." AMD, among the major causes of blindness in those over 60, is treated with laser therapy, medications and miniature telescope implants.
Retinal tear or detachment: When the retina pulls away from the choroid, its source of oxygen and nutrients, there's a risk of permanent vision loss. But people usually can tell when they have a problem, and can save their vision if they get treatment within 24 to 72 hours. Symptoms include a sudden abundance of floaters, specks or strings appearing before your eyes; sudden flashes of light or blurriness; and a shadow or veil over part of the visual field. Surgery or treatment with a freezing probe can preserve vision.
Dry eye: When tears are poor quality or too scant, the result is stinging, burning, redness, eye fatigue, pain and badly blurred vision. Menopausal women are at highest risk. Treatment includes over-the-counter eyedrops or artificial tears, prescription eyedrops such as Restasis, opening blocked glands behind the eyelids, and corneal shields to trap moisture near the eye.
Earlier action on cataracts
Most people wait until their 60s or 70s to have cataract surgery because insurance and Medicare won't pay for cataract removal unless vision is significantly impaired. Then, most plans cover only a standard replacement lens implant, and you will probably still need eyeglasses.
Many baby boomers are willing to pay for a new, high-tech lens implant — refractive lens exchange — when they first start noticing impairment.
"Boomers want to be as free of glasses as possible and have good-quality vision," said Dr. Stephen Updegraff, a refractive eyeive eye surgeon in St. Petersburg and Tampa.
The standard implant, what Updegraff calls the "government issue" lens, is popular with older patients, because Medicare will pay an allowance of $1,633 per eye. (If you're paying cash, it's closer to $2,750 per eye.)
It doesn't cover the pricier multifocal lens implants (ReZoom, Acrysof IQ Toric, Crystalens), which correct for all ranges of vision and, for many people, eliminate the need for eyeglasses. A typical cost per eye is $4,500.
Still, "about 20 percent of patients will have a little blurriness with distance vision, particularly at night, so we do lasik to fine-tune their vision about three months later," Updegraff said.
Some patients who have early cataracts may consider getting what is known as an implantable contact lens (Verisyse, Visian ICL). This thin, flexible lens is inserted through a small incision in the cornea and placed between the iris and the natural lens; it can be removed later if your vision changes. Cost averages between $3,500 to $5,000 per eye.
The cosmetics of older eyes
Susan Rieth didn't like the way her eyelids had changed over the years. Especially after she got into her 60s, the upper lids became puffy and hung down to her eyelashes.
"It didn't interfere with my vision," Rieth said, "but I would get up in the morning, look in the mirror and say, 'Ugh!' " Rieth, 64, an office manager, thought her eyes didn't reflect how young and vibrant she felt inside.
As we age, the muscles around the upper and lower eyelids weaken and the skin stretches, says Tampa plastic surgeon Dr. Dan Greenwald. In the lower lids, the result is what most of us call bags. Upper lids can appear swollen due to excess fat, making them sag. In extreme cases the sagging skin obstructs vision.
Many plastic surgeons say if you're going to do just one thing to look younger, eyelid surgery is the way to go. It's now the third most popular cosmetic surgical procedure, behind breast augmentation and nose reshaping. More than 170,000 cosmetic eyelid surgeries were performed on American women last year; another 30,000 were done on men.
A couple of months ago, Rieth went to Greenwald for blepharoplasty, where an incision is made in the crease of the upper eyelid to remove excess fat and skin. She was at work four days later.
"It was like nothing,'' said Rieth, who had only minor bruising. "You didn't really notice the stitches because they were tiny, tiny in a crease line."
Blepharoplasty runs between $2,500 and $5,000 for both eyes, and generally isn't covered by insurance.
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These days, doctors are taming even more dramatic sagging around the eyes.
Ten years ago, Wilma Lewis of Lutz started noticing that she was developing pouches beneath her eyes. By December of last year they became a real problem.
"When I tried to look down or read the paper all I was seeing was festoons," said Lewis, 68. "They were just in the way all the time."
Festoons or malar mounds, puffy areas that seem to drape across the cheekbones, are fairly common, but difficult to treat. In fact, some traditional cosmetic eye procedures can make them look worse.
Because of her job — she's one of the nice ladies handing out food samples and coupons at Publix and Target — Lewis decided to take action.
"It was embarrassing to go to work with big bags under my eyes," she said.
Surgical removal of the draping, puffy skin is one option, but you must have facial wrinkles to hide the incision scars. An alternative, which Lewis chose, is laser skin resurfacing.
Tampa facial plastic surgeon Adam Scheiner, who treated Lewis, said the laser injures the skin, promoting new cell growth in the area. The new skin is tighter and the puffiness is gone.
Cost ranges from $2,000 to $3,000 for both eyes and there is considerable downtime. "The wound on the face takes two weeks to heal," Scheiner said, "but once you're through it, the results are great."
Lewis agreed. "People say I look like a young teenager."
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If you'd just like a slightly fresher look, nonsurgical alternatives include Botox injections, which can temporarily relax creases between the eyes and on the forehead. Prescription topical creams, chemical peels, microdermabrasion and laser treatments can reduce the effects of sun damage, fine lines and crow's-feet. Expect to pay between $100 and $200 or more per treatment.
The eyes know
Some eye changes are visible only to your doctor. Others you may notice, and could possibly be signs of trouble elsewhere in the body:
• If your eyesight quickly changes, that could be a sign of stroke. Call 911 immediately; stroke is a medical emergency.
• When blood seems to flood the white part of one or both eyes, it may be a sign of high blood pressure.
• If eyes appear to bulge, it could mean an overactive thyroid.
• When the white part of the eye turns pale yellow, this could signal liver disease or (rarely) pancreatic cancer.
• A growing dark spot on the iris or a change in the shape of the pupil may be a sign of melanoma, cancer in the eye.
• Changes in vision and raised areas on the retina may also be a sign of a brain tumor.
Irene Maher can be reached at firstname.lastname@example.org.