VENOUS DISORDERS OF LOWER EXTREMITIES
Recently, President Donald Trump was diagnosed with chronic venous insufficiency of his legs. It was clarified that his condition was not serious and would not affect his duties. This prompted the media to investigate venous disorders of the lower extremities.
The most common are varicose veins – engorged, tortuous, snakelike, prominent veins in the legs. Usually, this is related to defective valves inside the surface veins. Blood is pumped down to the legs through the arteries by the heart. The returning blood must go up against gravity to the heart. This is made possible by squeezing the muscles and their movements and the valves that allow only one way flow toward the heart. When these valves are defective, blood stagnates and backs up in the legs, leading to engorgement of these veins and back pressure is felt in the tissues leading to further consequences.
Some of the risk factors for varicose veins include genetic factors, obesity, long hours of standing/immobility, pregnancy, female sex, pelvic congestion, prior blood clots in the deep veins, use of certain hormone pills and surgery.
Initial symptoms may be just dull ache in the legs, appearance of tortuous veins under the skin, swelling of the leg, numbness, night cramps or itching. Later, the tissues become firm and indurated due to constant fluid accumulation, with discoloration of the skin with dark or bluish patches. Itching and scratching can lead to ulceration and large nonhealing wounds. Other complications can be clotting of the surface veins called superficial thrombophlebitis, bleeding from minimal injuries and chronic lymphedema of the legs.
Initial treatment is by elevation of the legs, compression stockings, weight reduction and regular exercises. When worse, one may resort to interventions to remove or collapse these veins. Blood will continue to go up through the deep system of veins. Previously, most patients needed surgery with long or multiple incisions to remove these veins. Lately, many newer treatment modalities have been introduced. They involve endo-venous procedures in an outpatient setting, using laser, or infra-red heat waves or sclerosants to clot up the vein or glues to seal up the vein. The veins are not removed, but they collapse and clot off.
Deep vein insufficiency (DVI) occurs when the valves inside the deep system of veins in the core of the legs become defective, while the surface veins are functioning well. Most of the blood is normally going through the deep system of veins. This leads to swelling of the legs, aches and pains, loss of elasticity of skin and subcutaneous tissues, skin discolorations and venous ulcer formations. Secondary cluster of varicose veins may be seen on the skin as the blood is finding alternate pathways.
Deep vein thrombosis (DVT) is a more serious condition when a blood clot forms inside the deep veins of the legs. For the blood to remain in liquid form, it must keep circulating. Whenever there is stasis, it tends to clot up. Thus, clots develop in the deep veins of legs when the person is not moving their legs frequently. Such occurrence can happen following or during surgery, being bedridden with illness or disabilities, after injuries and fractures, sitting in the same position during long hours of travel or hospitalization for any serious illness. It can also occur because of clotting disorders or certain medications.
Symptoms of DVT include sudden pain and swelling of one calf or lower extremity. Arterial pulses will be palpable since it is the venous system that gets affected. There will be pain in the calf muscles, aggravated by ankle movements. Ultrasound is the best immediate bedside test that will confirm occlusion of the deep veins with clots. If necessary, a venogram (dye test of the veins) or a CT angiogram are performed.
The danger is that these clots can dislodge and travel toward the heart, and then move into the pulmonary arteries, causing pulmonary embolism (PE). This can be a lethal situation when blood cannot go into the lungs, and the patient suffers from lack of oxygenation and death.
Prevention of DVT is a high priority for all hospitalized patients who are given low dose anticoagulants; intermittent compression stockings and close monitoring are set up. Early ambulation of patients is encouraged. Similarly, people are advised to avoid sitting in the same position for more than two hours at a time while on the road. They are advised to get up and move around. They may also wear compression elastic stockings or take mild anticoagulants in low dosage if at high risk.
Once DVT is diagnosed, immediate full anticoagulation is arranged. Colloquially, the blood thinners can be given orally or via intravenous route. They help prevent new clot formations. At times, special medications to dissolve the clots are needed. More rarely, emergency interventions or even surgery may be necessary as life-saving measures. Such procedure may involve catheter-guided clot dissolution, mechanical removal of the clots, or placement of filter device in the inferior vena cava to trap the clots, to prevent them from moving up to the heart or lungs.
Other venous disorders of lower extremity include perforator vein insufficiency, chronic lymphedema and venous ulcers. Perforator veins are connecting veins between the surface and deep veins. Over a long period of time, they can cause the leg to become swollen and hard with unhealthy skin, pigmentation and ulceration. Venous ulcers are usually on the inner side of the ankle, surrounded by firm to hard skin and subcutaneous tissue, often with pigmentation. They require vigorous local care with debridement, wound care agents, compression stocking or special boots (Unna boot), antibiotics, elevation and surgery to reduce venous pressure by ligation of the incompetent perforator veins. Sometimes, they can lead to large open denuded areas involving a good part of the leg segment requiring long-term wound care.
Venous disorders are problematic with long-term discomfort, disabilities and inconvenience, besides cosmetic concerns. While most of the venous problems of the legs are chronic, DVT can be sudden in onset and become life threatening. Healthy lifestyle and preventive measures are the best recourse.Dr. Venkit S. Iyer, MD, FACS, is a retired General and Vascular Surgeon. He has authored four books – “Decision making in clinical surgery,” “Aging well and reaching beyond,” “The Clinic” and “Geriatrics Handbook.” They are available through Amazon or from the author. His website venkitiyer.com has necessary links and contact information.
GUEST COLUMN
Medicare vs. Medicare Advantage: What You Need to Know Before Enrollment
Every fall, millions of Americans have the chance to review and adjust their healthcare coverage. The Medicare Annual Enrollment Period runs from Oct. 15 through Dec. 7, making it the ideal time to ensure your plan still works for your needs.
Original Medicare is made up of Part A (hospital coverage) and Part B (medical coverage). It gives you the freedom to see any doctor or hospital that accepts Medicare nationwide, but it doesn’t cover everything. Most people add a Part D prescription drug plan, and many also purchase supplemental coverage (Medigap) to help with costs like deductibles and coinsurance.
Medicare Advantage (Part C), on the other hand, bundles your Part A and Part B coverage —and often prescription drugs — into a single plan offered by private insurance companies. Many Medicare Advantage plans also include extras like dental, vision, hearing and wellness benefits. However, they usually work within provider networks, which may limit your choice of doctors and hospitals compared to Original Medicare.
So which option is better? It depends on your health needs, budget, and preferences. Original Medicare may suit those who travel often or want the widest provider access. Medicare Advantage plans may be attractive for people looking for lower upfront costs and added benefits.
The key is that your healthcare needs can change from year to year — and so can the plans. Premiums, drug formularies, provider networks, and coverage details may shift annually. That’s why the annual enrollment period is so important. Taking time to review your current plan and compare it to other options ensures you aren’t paying more than necessary or missing out on benefits that matter to you.
Whether you choose Original Medicare with supplemental coverage or a Medicare Advantage plan, always check your plan each fall to make sure it still meets your medical and financial needs. A little review now can help you avoid unexpected costs and ensure peace of mind in the year ahead.
Hermun Puri, a licensed insurance broker with Exact Medicare, can be reached at (813) 494-7724 or (813) 219-8424.
EYE CARE
Reading Vision Problems? FDA HAS approved a New Eye drop
By Dr. ARUN GULANI
One of the most common frustrations that quietly creeps up after age 40 is this: menus start getting longer arms, phones are held farther away, and fine print suddenly seems to shrink. This natural change is called presbyopia — the gradual loss of near-focusing ability that affects nearly everyone with age.
Until recently, reading glasses, multifocal contacts, or surgical options were the main choices. But now, a newly approved prescription eye drop may offer an additional way to address this daily challenge.
The U.S. Food and Drug Administration has approved Vizz (aceclidine ophthalmic solution 1.44%) for the treatment of age-related blurry near vision in adults with presbyopia. This makes Vizz the second prescription drop of its kind in the U.S., following Vuity (pilocarpine), approved in 2021.
In my experience of having pioneered presbyopia Laser techniques, and also successfully performing custom-designed cataract surgery with presbyopic, multifocal, trifocal and accommodative lens implants, this drop is a non-surgical option for patients with early presbyopia (reading vision) and certainly adds to the choices available for patients.
Vizz works by modulating the pupil size. It causes the pupil to constrict, creating a “pinhole effect” that increases depth of focus, bringing near objects into clearer view while maintaining distance vision. This is similar to how a camera’s small aperture sharpens the entire image.
Clinical studies showed that near vision improvements typically begin within 30 minutes of being instilled and can last up to 10 hours for many users. Side effects are generally mild and include temporary dim vision, mild irritation or headache. Because it acts mainly on the pupil rather than the focusing muscle, it tends to cause fewer shifts in distance vision than older pharmacologic approaches.
Vizz joins a growing class of presbyopia-correcting drops, offering a non-surgical, reversible option for people in the early stages of presbyopia who want more freedom from readers. It does not cure presbyopia, and the effects are temporary, usually lasting for several hours a day. These pharmacologic solutions fit within a larger spectrum of modern presbyopia management. Options now range from glasses and contacts to advanced corneal laser procedures and high-precision lens implant surgeries.
Not every eye or lifestyle is the same. Some patients benefit greatly from these drops, especially those in the early or moderate stages of presbyopia, while others may eventually require surgical or lens-based solutions for stable, long-term results. When I evaluate patients, I consider their daily visual demands, lighting environments, tolerance for temporary changes, and the presence of any other eye conditions such as cataracts, corneal irregularities, or previous surgeries. Drops like Vizz may be an excellent bridge for some patients, or part of a customized plan that evolves over time.
There are a few points to keep in mind. Because the pupil is constricted, some users may notice dimmer vision in low-light settings such as restaurants or night driving. These drops work for hours, not days, and they don’t reverse the natural aging process of the lens. Not everyone achieves the same degree of improvement. And as always, a comprehensive eye exam is essential since blurry near vision can sometimes mask other eye diseases.
The approval of Vizz represents an exciting evolution in presbyopia care. For many entering their 40s and 50s who are not ready for surgery or prefer a temporary, adjustable option, eye drops may offer a simple way to reduce dependence on reading glasses. As technology advances, the future of presbyopia management is no longer limited to one-size-fits-all. Instead, it’s about tailoring solutions to each patient’s eyes, goals, and lifestyle — from drops to lasers to lens implants — giving people more control over how they see and live.
Arun C. Gulani, M.D., M.S., is director and chief surgeon of Gulani Vision Institute in Jacksonville. He can be reached at [email protected] or visit www.gulanivision.com