Menu Part 10 Retinal Reports from the 2007 AAO Meeting

During the 2007 American Academy of Ophthalmology (AAO) Meeting, and the Subspecialty Days preceding it, especially Retina 2007, I received briefs about the meetings from both Ophthalmology Times and Ocular Surgery News. Using these briefs, I was able to prepare comprehensive writeups of both the two-day Retina 2007 presentations and retinal highlights from the opening day of the main meeting. These writeups were presented in a series of three reports:

1. Retina 2007 Subspecialty Meeting Presentations – Day One

Highlights included:

Updates:

● 2-Year results of the PrONTO Study (intravitreal injections of Lucentis with OCT diagnoses for guided further treatment);

● ANCHOR Update – Lucentis vs. PDT with Visudyne;

● Avastin vs. Lucentis – A discussion of the economic and moral dilemma of using approved Lucentis vs. off-label Avastin;

● Avastin’s Impact – Despite lack of clinical data;


New Treatments for AMD:

● VEGF Trap – discussions of the CLEAR-IT AMD 1 and CLEAR-It AMD 2 trials;

● Topical Therapies – discussions of various topical treatments

- TargeGen’s 801 kinase inhibitor
- CoMentis’ ATG2
- Ocucure’s OC-10X
- Othera’s OT-551
- Glaxo-Smith-Kline’s Pazopanib

● New Developments in posterior segment drug delivery – a discussion of potetial solid implants, such as Retisert and Vitrasert from Bausch & Lomb, and a subretinal implant system from SurModics called I-vation.

And, finally, an interview with Dr. Judah Folkman, the father of anti-angiogenic agents, and the keynote speaker for the opening session of the AAO Meeting.


2. Retina 2007 Subspecialty Meeting Presentations – Day Two

Highlights included:

● A discussion of Dr. Susan Desmond-Hellmann’s (Genentech’s President, Product Development) presentation to the Retina 2007 assembly and her Q&A session;

● Sub-Retinal Implants for treating retinitis pigmentosa;

● Retinopathy of Prematurity – Anti-VEGF therapy is on the horizon;

● Spectral Domain Optical Coherence Tomography advances; and,

● New Non-Thermal Laser for Retinal Treatment – a brief discussion of the Ellex 2RT Therapy.


3. More Retinal Treatment News from the 2007 AAO – Day Three

● More from Retina 2007
- A Comparison of Lucentis vs. Avastin;
- An Update on the CATT Study;
- Additional information about the Ellex 2RT laser treatment.

● Retinal-related Information from the Main AAO Meeting
- The keynote address by Dr. Judah Folkman;
- An overview of intravitreal drugs for treating diabetic retinopathy; and,
- Intravitreal therapy for vein-occlusive disease.

Drawing Inside and Quieting Roger Cole on Savasana Part 2 Rerun

Drawing Inside by Melina Meza

Here is the second excerpt from the interview that Leslie Howard did in 2008 with yoga teacher Roger Cole. In this excerpt he talks about his own practice of Savasana, compares seated meditation with Savasana, and gives his recommendations for setting up and practicing the pose. 

 Leslie: Have you had any special experiences with the pose, either in your own practice or with students?  

Roger: Not really. There isn’t one that stands out for me. Restorative asana experiences—Ssavasana being one of them—many times I have had resting poses or Savasana in which I just really feel like this is exactly what I need and what everyone needs—everyone needs to do this sometime. Take the time when you would not ordinarily be sleeping, and lie down and just stop. It is different from seated meditation. Seated mediastion is wonderful in its own way. In Savasana and the other more reclining poses, the brain just shuts off. In the seated pose you are very, very alert. Seated meditation is really good for this deep realization in which you you see the connection between things. In Savasana it is more like you are drawing inside and quieting, and you are observing the quietness. There is a lot less activity in Savasana.  

Leslie: Do you always practice Savasana in your own practice?

Roger: Ideally, yes but in reality no.   

Leslie: When you take the time to do it, what is your preferred method?

Roger: First of all, I am very big on restorative poses and sometimes I will substitute a restorative pose for Savasana. Now ideally Savasana is the last pose because it is the most neutral; no part of the body is elevated over the other, nothing is particularly stretching, especially if you support the arms and stuff. So if I had the ideal Savasana, I would be almost completely neutral, with maybe a little elbow flexion so I could stay longer, maybe padding under the head not to lift the head but to make it not hurt. I personally don’t need padding under the knees but padding under the heels so that the heels don’t hurt. So I make it comfortable. 

The other thing that a lot of people don’t realize about Savasana and other restorative poses is that temperature is extremely important. You get cold. And if you get cold it is just not a relaxing experience. So I am very conscious of the room temperature, and if you need to be covered with a blanket in Savasana and other restorative poses, you need to cover the hands and feet. Don’t just cover the trunk and have the hands and feet sticking out. So in my practice of Savasana ideally it would be the last pose even if I do a lot of other restorative poses. But in reality there is a time limit so if I end up staying in another pose longer well than Savasana gets shortened. Same thing when I am teaching; ideally I would like to put it at the end of every class but sometimes I just run out of time.   

Leslie: Are there any special circumstances or conditions for which you think Savasana is particularly valuable? 

Roger: One of things is that Savasana is the quickest, most generic pose. When it comes time to relax, just lie down. You can do it on a bed, which is actually very important. Bedrooms are set up with a bed so you can lie on them. Of course they have blankets and such, but the availability of having a space to do it is extremely important. If you just lie down on a dirty floor you might not relax, or if its cold or too light or in a traffic area, the bed takes care of all that. Of course, it is a little soft but its there and its available. 

In a yoga class situation, with students that have never done yoga you don’t what to do some strange thing with them in Savasana, maybe with support under the knees because that is very non threatening and it’s very intuitive. So, it’s got a lot of benefit. It doesn’t have a lot of the problems of being uncomfortable or they can’t hold it or their knees hurt or whatever. But if you are going to put people in it a long time, you are going to have to prop them up. So I think it would be particularly valuable for quick relaxation. Also, some kind of relaxation is valuable, but it doesn’t always have to be specifically Savasana. 

You asked me if there were times Savasana should be avoided. So with some kinds of back pain, such as when people have a facet joint injury, it’s too much back bend, but you can modify the pose. Generally it is a pretty easy pose to do. Also if the nose is congested, prop them up and it can be used to drain the nose. 

What about emotionally? Emotionally if someone has had a trauma, like after an earthquake or something like that or a terrorist attack, people are often afraid to close their eyes, to lie there with their eyes closed is very frightening. Also I have had a couple of deaf students and they don’t like to close their eyes because once they close their eyes in Savasana, they don’t know what is going on in the world, although they will do it. They can hear enough through their hearing aid to know when there is shuffling around, but it’s a little tricky. 

So in those instances Savasana with eyes open is a good pose and if their eyes close, apparently they have gotten over it. 

Leslie Howard is an Oakland-based yoga teacher, specializing in all things pelvic. She leads workshops and trainings nationally and internationally, and is the director of the 200 hour Deep Yoga program at Piedmont Yoga. With a state certification in massage, she also practices cranial sacral therapy. To learn more about Leslie, visit: www.lesliehowardyoga.com.  

Roger Cole, Ph.D. is an internationally recognized, certified Iyengar yoga teacher trained  at the Iyengar Yoga Institutes in San Francisco and Pune, India. He is also an accomplished scientist educated at Stanford University and the University of California, with specialties in the science of relaxation, sleep, and circadian rhythms. Roger has taught yoga since 1975. He has authored dozens of articles on yoga teaching, practice, biology and therapeutics, including Yoga Journal's Anatomy Column, Master Class Column and Ask Our Expert Column, Yoga International's Asana Solutions Column, and special feature articles on the prevention of yoga injuries, the physiology of stress, relief from back pain, and the science of keeping your balance. He has trained thousands of yoga teachers and taught yoga as a healing art to physicians, physical therapists, medical students and patients. He offers weekly classes in Del Mar, California, and conducts workshops throughout the U.S. and abroad. His specialties include yoga teacher training, yoga anatomy, yoga physiology, restorative yoga, and promotion of better sleep. See rogercoleyoga.com for more information.

Subscribe to Yoga for Healthy Aging by Email ° Follow Yoga for Healthy Aging on Facebook ° Join this site with Google Friend Connect

Summary of Part 1 of The Mindfulness Workbook for OCD by Jon Hershfield and Tom Corboy

New Harbinger Publications offered to send a review copy of The Mindfulness Workbook for OCD by Jon Hershfield and Tom Corboy(2013).  Since I was in the middle of taking a mindfulness class, it was interesting to read this book with specific connections to OCD.

I am familiar with the writing of Jon Hershfield, as he was the moderator of the online support group PureO for many years, and he had a way of describing obsessive thoughts and ways to face them that was very helpful.

Part 1 covers definition of mindfulness and cognitive behavioral therapy(CBT) terms.

The authors define mindfulness as, "the state of acknowledging and accepting whatever is happening in the present moment exactly as it is(p. 8)."  In my experience, when I have an anxious thought or sensation, I race way ahead of the present moment in trying to figure out what it is or what it means.

The authors argue that, "The problem of OCD isn't that you think too much.  It's that you confuse the intensity, volume or visibility of your thoughts with their importance(p. 12)."  Practicing hanging in there with the intensity or stickiness of the thoughts can allow your mindful self to choose what you want to do with your life, rather than listening to the loudest voice.

The book provides a cognitive behavioral therapy background on distortions of thinking that you can identify in your own thoughts, not as a way to "solve" or "figure out" the thoughts, but to practice seeing them as thoughts.  One of the things that really helped me when I was in therapy for OCD was writing down my thoughts as they happened, as if it were a transcript, but then labeling the distortions in the margin, so I got better at identifying what my mind was up to.

One such distortion is Catastrophizing/Predicting/Jumping to Conclusions.  Accepting I can't predict the future is a bedrock of mindfulness.   As scary as the uncertainty can be, the racing ahead brings forth even more fear.

The book does an overview of Exposure and Response Prevention therapy, and the use of Imaginal Exposure Scripts, another component that helped me in therapy.

Part 2 of the book addresses mindfulness and CBT for specific obsessions with a 3 step process.

1. Acceptance of the presence of OCD thoughts and feelings.  You are accepting that the thoughts are there, not any meaning that you attribute to those thoughts.
2. Assessment using CBT to assess the value of the OCD thoughts, as a nonpartial observer, labeling possible distortions, and returning to the present.
3. Action using behavioral skills to expose yourself to OCD thoughts in order to habituate to them and overcome your fears.

I suspect many readers will turn immediately to Part 2 in hopes of clues to particular obsessions, as the authors say, "The reason we separate obsessions into categories is that for every obsessive-compulsive cycle, there's a way to break it.  There's a way in, and knowing the way in is important  When you understand the mechanics of an obsession can identify the compulsions that hold it in place, you can begin the process of letting both of them go(p. 84)."

I will discuss some of these chapters in future posts, as well as some thoughts on the book as a whole.  

Part 3 The Limits of Research in Making a Decision about Medication

It's 2002, and the psychiatrist who put me on his waiting list finally called to schedule an appointment. I sat in a leather chair, feeling like a willow trembling with the slightest breeze. He was a soft spoken man in his 50's, and he paused after I spoke as if to absorb what I said before responding. He concurred that I had a diagnosis of OCD, and felt medication could help me, and that perhaps after a year or so, my mind would "reset" itself and I would be able to taper off.

He proposed Celexa because it was new and not supposed to have sexual side effects. OCD thinking had seriously stunted my ability to approach anything near intimacy with my husband, and we had just started making some progress because of working my therapist, who I will call Molly. I was terrified of sexual side effects, and this was a major obstacle to my taking medication. I'd read numerous articles on the subject from the medical literature, plus enough posts on internet bulletin boards to fuel up my obsessing to the flammable point.

His assurance to me was that if I did have sexual side effects, he would put me on another drug, Wellbutrin, and this would correct the problem. As much as I liked this doctor, his solution was like something from a farce. Take one woman who is very afraid of taking medication, and tell her that a drug will solve any problems created by the first drug. . .

But I still knew that I couldn't go on the way I had been, with rituals consuming a lot of my time and energy. I told him I would need to think about it. I believe I did something actual thinking at the time. This is an important distinction. Obsessing and compulsively looking up medical articles is not the same thing as thinking about something, or problem-solving.

I'd read enough to know that some people were helped by SSRI antidepressants, and that the only way to know if they would help me was to try one. This is incredibly difficult for someone who hoards information to accept, that some things have to be experienced rather than researched, that sometimes you need to make a decision, and you will never have enough information to make a perfect decision. But I was on my way to making a decision.

Related Posts:
Part 1: OCD and Medication Decisions
Part 2: Starting Medication While Struggling
Part 4: My First Prescription for SSRI's
Part5: Feeling in the Jaw: Side effects
Part 6: Being on Medication & OCD Weeping
Part 7: Wanting to Get off my Medication
Part 7.5: Built on Sinking Sand: OCD and Health Anxiety

Holding It All Together Part 1 Ligaments

by Baxter

Knee Joint (with ligaments)

As I was prepping for my upcoming workshop this Saturday on Yoga and the Musculoskeletal System out in Brentwood, CA (see Brentwood Yoga Center Workshops for registration information), I decided to look back at my old blog posts to see what I had written regarding tendons and ligaments, two of the main structures we’ll be talking about this weekend. And much to my surprise, I found that I had not yet addressed these basic and vital topics. So today I thought I’d begin a discussion on ligaments, anticipating that I’ll come back to tendons again in the future.

Let’s begin by looking at some basic definitions for these two structures. Both ligaments and tendons are composed of something anatomists call “connective tissue,” which is a collection of tissue types that often serve the function of keeping our different body structures together, and include such diverse tissues as the above tendons and ligaments, as well as fascia, intervertebral discs, cartilage in the ears and nose, cartilage coating the ends of bones and others. Connective tissues, depending on what their function in the body is, will either be more or less elastic by virtue of the proportions of the components that make up connective tissue: collagen and/or elastin fibers, which float in a semi-fluid gel called ground substance. According to Mel Robin, in his book A Physiological Handbook for Teachers of Yogasana, connective tissue works as a mechanical support or binder for other tissues, allows for food and waste from cells to move in and out, acts as a lubricant and is the body’s glue. 

So what then are the structures that ligaments glue together and what are the unique features of ligaments? Ligaments are specialized connective tissue that binds bones to bones. They keep the bones of your joints in close proximity so they don’t dislocate (which sometimes still can happen, in the shoulder joints, for example), and they allow for a certain amount of passive movement in some directions and restrict movement in others.  In fact, restraining movement is one of the main functions of ligaments. They happen to be high in collagen fibers and low in elastin fibers, which makes ligaments strong, but not very flexible. According to David Coulter in his book Anatomy of Hatha Yoga ligaments are:

“...made up of tough, ropey, densely packed inelastic connective tissue fibers, with only a few cells interspersed between large packets of fibers.”

Usually, the amount of stretch that can take place in a ligament is very minor, only around 4%, but there are exceptions, such as ligaments in the cervical spine region, which have been found to stretch up to 200%! In contrast, those around the knee joint have very little elastin, so are much more rigid to provide more stability to the joint. This can have relevance for our yoga practice. As an example, deep flexion (forward bending) of the neck as in Shoulderstand will not permanently overstretch the neck ligaments. But deep flexion (bending) of the knee as in Supta Virasana has to be approached cautiously and mindfully so as to not overstretch the supporting ligaments of the knee. If the ligaments are overstretched, they will not return to their original length and will be permanently loose and ineffective in stabilizing the knee. In general, you want to focus on stretching the muscle and not the ligaments in your yoga practice.

Another reason to avoid overstretching or, even worse, tearing a ligament, is that ligaments have a poor blood supply. Due to this poor supply, getting repair cells into an injured ligament and taking away the waste and injured material is more difficult, and healing is therefore slow. Also, ligaments have very few cells—which are the things that have to be stimulated in an injury to produce more fibers and fluid—and this contributes to slow healing as well. 

Those out there who have injured the ligaments at the side of the knee joint, the collateral ligaments, via sports like soccer or football, can attest to the long healing times I am referring to here. When we sprain a ligament, not only do we experience some pain and swelling, but the area also seems looser and more prone to re-injury. A ligament sprain that almost everyone has experienced at one time or another like this is the outer ankle.

It seems that one of the safest ways to stretch your tight muscles, and avoid stretching your supportive yet rigid ligaments, is via moderate intensity, slow, held stretches. Warmer muscles and ligaments seem to do this more healthily then cold ones, so I like to move slowly and mindfully in and out of a position a few times to warm up the tissues, and then follow that up with a more sustained hold. And the good news regarding safe stretching is that our nervous system warns us as we approach the kind of overstretch that could tear our ligaments (and tendons) through pain (which can have a whole range of variety and intensity), trembling or weakness. This is yet another reason to pay close attention to the sensations that arise as you perform your asanas. Also important is the location of the sensations, as those arising in the mid-length of the muscles is much more acceptable than sensations occurring right over joints. You might hang in there a bit longer in the first instance and come out of a stretch promptly in the latter!  

Next time, I’ll discuss tendons, which share some similarities with ligaments, but have some unique functions as well.

Subscribe to Yoga for Healthy Aging by Email ° Follow Yoga for Healthy Aging on Facebook ° Join this site with Google Friend Connect

When to Transition to a Gentler Practice Part 2

by Nina

Hidden Waterfall by Brad Gibson

"At ninety-three, he could still perform difficult asanas--including variations on the headstand many younger "masters" could not. When he was ninety-five, however, he fell and broke his hip. Because of the reputation of Krishnamacharya, several leading surgeons offered to operate—but he would have none of it. Instead, he rigged up pulleys and ropes by his bed and began to experiment with new Yogic techniques for his own rehabilitation. Within two months he was able to walk, but the loss of full freedom of movement depressed him." —from Health, Healing and Beyond by T.K.V. Desikachar (about his father Krishnamacharya)

In Baxter’s post yesterday When to Transition to a Gentler Practice, he quoted a letter we received from a reader asking for advice about when to transition to a gentler asana practice. This is not the first time we’ve received such a question; in fact, this is probably the most frequent question we get here on Yoga for Healthy Aging. I suspect that most people with this question are hoping for some kind of formula from us, saying for example, if you can no longer do x, y, and z poses, it is time for your transition or most people should make the transition by age 65. But as I said to Baxter, I really feel that if you are asking the question, it’s not time yet. Because when the time comes, you will know it. Maybe you will be like Krishnamacharya, who had to change when he was 95. Or maybe you will need to transition much earlier, the way I did.

In my forties I had a rather strong, what I like to call “semi-fancy” asana practice. I took an advanced yoga class, did challenging poses like arm balances, full Lotus, advanced backbends, etc., practiced about two hours a day, and did long inversions almost every day (including a ten-minute headstand with variations and a ten minute Shoulderstand). I quite enjoyed the athleticism of my practice, and the feeling of strength and physical wellbeing it brought to me. By my fifties, however, I developed certain physical problems, probably brought on by menopause, which forced me to change my practice. Mild arthritis in my right hip meant that I could no longer do Lotus or even half Lotus and that I had to start using props in certain other poses. And two rounds of frozen shoulder (who knew you could get it more than once?) temporarily restricted my range of motion in my shoulder so that I was very limited in what I could do with my upper body, and after the frozen shoulders abated, I was never able to get my full range of motion back (though I’m still flexible in that area, compared to some).

I practiced asana throughout all these difficulties, adapting my practice as my restrictions increased and then decreased. While my shoulder was frozen, I couldn’t even do Downward-Facing Dog pose, much less Headstand, Handstand, or Upward Bow pose. So my practice was by nature very gentle. After I got better, I began to gradually ease my way back into the poses I couldn’t do with my temporary injury, and I’m still working on getting back to where I was (realizing, of course, that I may never get there).

When I was able to do Headstand again, I made a conscious decision not to do it as often or as long as I used to. I felt that it was a pose I enjoyed so much, I didn’t want to risk losing it again, and I knew that both Headstand and Shoulderstand would be pretty hard on my neck. So I decided to practice it only about twice a week and only for about 5 minutes each time, instead of the way I used to practice it. I had absolutely no scientific evidence that this was a good idea, and it was not suggested to me by any of my teachers, it was just a feeling I decided to follow. And it can’t hurt to be cautious, right? Removing the long inversions from my practice also made it shorter, so now my practice is more in the 1 1/2 hour range (and sometimes shorter, if I’m tired). As it happens, I never had to leave my regular (intermediate) yoga class. That’s partly because I know how to make modifications to my poses (or do alternatives) when there is something I can’t do. But it’s also because my teacher has been very supportive and understanding. (Once he said something about me—thank you, Donald—that I’ll never forget: “Nina never gives up!”)

The point is, my transition has been a very organic process, in which I’ve responded to signals from my body (some rather loud, others perhaps not) and made adaptations along the way. It hasn’t all been a one-way process, either. During times of difficulty, my practice was very gentle, and when I was more able, I returned to a stronger practice. And I also know, the transition process is not over yet. Who knows what the future holds. Will I be still be doing Headstand at 95 like Krishnamacharya? Or will I have to give it up much earlier?

Baxter, too, has gone through a similar process, with physical problems (including a touch of hip arthritis) prompting him to modify his practice. And that’s how I think it will turn out for most of you, dear readers. Perhaps you will have an injury or illness that forces you to change your practice, either temporarily or permanently. Or perhaps you will simply reach a point (who knows at what age?) when you can just no longer do the poses you used to be able to do or get through an entire class the way you used to, and you’ll know deep down inside that now is that time for a change. Like the future, this process is both inevitable and completely unpredictable. But it is your own body that will guide you through it.

Subscribe to Yoga for Healthy Aging by Email ° Follow Yoga for Healthy Aging on Facebook ° Join this site with Google Friend Connect