Work-Mind-Body Balance

Apr 292012

This week’s post was inspired by an amazing event that Hawaii Pacific Health held for female physicians. It was an evening dedicated to restoring balance in our work, personal and family lives. As a working mom, I know sometimes I feel completely overwhelmed by all of my responsibilities -work, motherhood, wifehood (is that even a word?). I want to do it all and I feel guilty when I take a little time for myself. Anyone else feel the same? And, for my friends who stay at home – they’re even in more desperate need for time for themselves.

So, Kapiolani organized this event which had an hour long yoga session, followed by a cooking demonstration by Chef Russell Sui of 3660 On the Rise. The yoga was nice and relaxing. Not hot yoga, where you’re getting all sweaty and trying to get in shape. This was yoga at its purest – good breathing and stretching. I felt invigorated afterwards.

OK, this shot was staged. This is me in my backyard, but I forgot to take pics of the yoga session. Don’t I wish I had the motivation to do yoga by myself in my yard? I’m doing tree pose, but i look more like a leaning pine than a tall, stately oak.

Then, the the fun stuff — the food! Chef Russell Siu is extremely entertaining. He prefaced the demo with the caveat that he was asked to prepare healthy meals. “So, if you are still hungry afterwards, its not my fault!” he said half-jokingly. Throughout the demo, he mentioned places in the recipe he might otherwise want to use butter or cheese, but couldn’t because of the “healthy” limitation. Hmmm…I got the sense he would have far preferred cooking without the healthy limitation. But it was delicious nonetheless.

Here’s my friend, Dr. Deborah Yang, a dermatologist at Kaiser Permanente, and I eagerly awaiting our first course.

And, the Chef himself.

So, on to the meal. Oops – I ate the soup without taking a pic first (I was very hungry after a one hour yoga session after all!). But, here’s the recipe. All recipes are courtesy of 3660 On the Rise.

Chicken Soup

With Cilantro, Onion, Tortillas and Grilled Shrimp
Service for 6 people

Ingredients:

12 ounces chicken breast, small dice
1 each onion, small dice
1/4 cup diced tomatoes in juice
48 ounces chicken stock
1 clove garlic, finely chopped
1/2 tsp. oregano
pinch of cumin
1 each bay leaf
4 wedges of lime on the side
1 each 8 inch corn tortilla, fine julienne, fried
6 each shrimp, 21-25, peeled and deveined
1 clove garlic, finely chopped
4 Tbsp. oil
1/4 tsp. basil
1/4 tsp. oregano

Directions:

Sauté onion with 2 Tbsp. oil in a soup pot until transparent over medium heat. Season chicken with salt and pepper and add to pot and sauté for about 2 minutes.
Add garlic, oregano, cumin and bay leaf and sauté another 1 minute.
Add diced tomatoes and chicken stock and simmer for about 20 minutes over medium heat.
Season with salt and pepper

Shrimp:

Marinate shrimp with 2 Tbsp. oil, basil, garlic and oregano for about 1 hour.
Season with salt and pepper and grill.

I did remember to take a pic of the second course, halfway through (I would be a lousy food blogger, I can’t restrain myself from eating before taking the photograph of the food!). It was delicious as well, though I don’t like tomatoes. I was surprised at how sweet the raw corn was in this meal.

And, here’s the recipe for the chicken pasta.

Grilled Chicken Over Pasta Shells

With Slivered Onions, Cherry Tomatoes, Cucumbers, Kahuku Corn
Basil Vinaigrette
Service for 4 people

Ingredients:

12 ounces chicken breast
1/2 cup slivered red onions
12 each cherry tomatoes, cut in half
2 each cucumbers, Japanese. Medium diced
1 each kahuku corn, kernels only
1 1/2 cups pasta shell, raw
1/4 cup parmesan cheese, grated

Directions:

Marinate chicken breast with 1/2 of the basil vinaigrette for about 2 hours and grill until cooked.
Slice and reserve in a warm area.
Toss rest of ingredients with the basil vinaigrette with half of the parmesan cheese.
Top salad with balance of parmesan cheese and top with the sliced chicken.

Basil Vinaigrette

Ingredients

1/4 cup red wine vinegar
1/4 cup extra virgin olive oil
1/2 cup orange juice
1/4 cup onion, sweet, diced
1 clove garlic
8 leaves basil, fresh
1/2 tsp. orange zest
1/2 tsp. Dijon mustard
1 Tbsp. honey

Directions

Blend all the ingredients in a blender until smooth. Season with salt and pepper.
For a sweeter sauce add more honey.

The next course was a pan seared salmon and was one of my favorites. I think this is easy enough that I could actually make this without a bunch of sous chefs. As you can tell, I enjoyed it and then remembered to take a picture.

But, luckily, a few physicians weren’t able to make it to the event, so there were leftovers, which I brought home for Jeff. Here’s his plate and he just put everything on there at one time, so it has the chicken pasta and the salmon on it. The recipe is below:

Pan Seared Salmon

Orange Honey Jus, Parsley Red Potatoes
Service for 4 people

Ingredients:

4 each salmon fillet, skin off (6 ounces)
2 Tbsp. extra virgin olive oil
1 clove garlic, sliced
4 leaves basil, chiffonade
1 Tbsp. black pepper, cracked

Directions:

Marinate salmon in a ziplock back with above ingredients for about 1 to 2 hours.

Orange Honey Jus

Ingredients

1 cup orange juice
1 tsp. orange zest
1/2 cup white wine
1 Tbsp. shallots, brunoise
2 Tbsp. honey
5 leaves basil, chopped
1/4 cup butter, unsalted

Directions

In a sauce pot over medium heat, add orange juice, orange zest, white wine, shallots, honey and basil.
Reduce mixture by 25%.
Whisk in butter and season with salt and pepper.
Strain through a chinois and keep hot.

I mentioned that the salmon was one of my favorites and that’s because the dessert – a vanilla bean panna cotta was my absolute favorite. Unfortunately, since this was not “healthy”, we were not given the recipe. I don’t even like pannacotta and I thoroughly enjoyed this one.

I love my work – there is nothing I would rather do. Every day I am rewarded. I love the relationship I am able to have with my patients here in Hawaii and I truly enjoy caring for them. I love my boys – I am blessed with 2 wonderful, sweet and healthy sons. But, I’m a firm believer that as a woman, I also need to take more time for myself – whether it’s doing yoga, going out to dinner with my girlfriends, reading, anything that recharges me. When I’ve had that time, then I know I’m a better physician, mother and wife. So, thank you Hawaii Pacific Health and all associated hospitals for such a wonderful event!

Blinking, itching and burning

Ohana, Pediatric Ophthalmology No Responses »

Apr 082012

We live in Hawaii and allergies are a huge problem here compared to the mainland. For 8 years, I lived smack in the middle of Manhattan and the pollution and dirt never caused a problem. But, my first month of living here, the flora and VOG of Hawaii put my allergies on overdrive! And along with allergies and the symptoms you think of runny nose, sneezing, coughing, comes ocular allergies.

In children, allergic conjunctivitis can present like this:

His eyes are only slightly red, but he has a little cough (which isn’t associated with a cold) and a little sneezing and there’s that non-stop blinking.

First, I should back up – what is the conunctiva? It’s the mucous membrane of your eye – the white part and the pink part on the inside of your eyelid.

6 Signs of Allergic Conjunctivitis:

1. Itching

2. Tearing

3. Redness

4. Mucous discharge from the eyes

5. Allergic shiners (look like black eyes underneath the eyes)

Allergic shiners (under the eyes)

6. Blinking

There are many different kinds of allergic conjunctivitis that your eye doctor can diagnose. This is not the same as “pink eye”. There is no infection and it’s not contagious.

Types of allergic conjunctivitis:

- Seasonal or year round (perennial) allergic conjunctivitis - some people are specifically allergic to mangoes or only to VOG

- Vernal conjunctivitis - I see this a lot. Tends to happen in young boys and needs aggressive treatment. These boys will have really red eyes, light sensitivity and are at risk for losing vision in advance stages of the disease.

- Giant papillary conjunctivitis – that’s for all you contact lens wearers out there. If you overwear your contacts, you can develop a reaction to the material, making your eyes red and intolerant to wearing contact lenses.

I am mainly going to discuss seasonal/perennial allergic conjunctivitis in this post.

So, what causes allergies? Allergies are mediated by a type of white blood cell, called a mast cell. It has a special form in the conjunctiva. And, when it gets activated by the thing you’re allergic to (also called the allergen), it releases chemicals. These chemicals, such as histamine and prostaglandins, are what cause symptoms of allergies. They cause blood vessels to become large and leaky, causing redness, swelling and itching.

Here’s the kind of chart that other opthalmologists like to show each other when explaining allergy. I swiped it from my husband’s presentation he had given on allergy.

Allergic response

So, how do we treat allergic conjunctivitis?

Allergen avoidance – this is ideal, but it can be hard in Hawaii. Can’t exactly avoid VOG, and did you know cockroaches are really allergenic? Hard to find a place here without cockroaches. However, I always tell patients to try avoiding touching and rubbing their eyes, which is how a lot of allergens get in the eyes in the first place.
Cold compresses (not warm!) - I know patients sometimes get confused, we tell them warm compresses for this, cold for that. But for allergies, we want cold compresses to make the blood vessels smaller and leak less.
Systemic medications – Benadryl, Claritin (anti-histamine), Zyrtec. These medications are taken orally, and may not be helpful for the eyes at all. In fact, they can often cause dry eye, making the symptoms of allergic conjunctivitis even worse!
Eye drops

Let’s talk about eye drops for allergic conjunctivitis. Many patients will self-treat with over-the-counter drops such as Visine, which constricts the blood vessels and takes away the redness, but does nothing to treat the allergic reaction. Then there are over-the-counter drops such as Visine-A, Naphcon-A, and Opcon-A which have a weak antihistamine. They are safe and effective for short term use, but the preservatives in these drops can be harsh and irritating to the eyes. Also, the effect from these drops lasts only about 2 hours, so patients must overdose themselves in order to get all-day relief.

When I tell patients that they shouldn’t use Visine, they’re always quite surprised. But, it really isn’t the best drop you can use.

There are also some people who use Similasan Eye Allergy homeopathic drops, however there is no scientific evidence that these drops work. In general, most eye doctors discourage the use of these over-the-counter eye drops.

Fortunately, we have some much better prescription drops for allergic conjunctivitis. Pataday, Lastacaft, Bepreve, and Elestat are some of the best drops for allergic conjunctivitis. They not only block histamine’s nasty effects, but also prevent histamine from being released. Pataday and Lastacaft only need to be given once a day. All of these drops are very safe, and can be used long term.

If you have a red eye, you should see your eye doctor – don’t diagnose it yourself. There are many different causes of red eyes which can be dangerous or vision threatening (like uveitis, corneal ulcers, trauma, angle closure glaucoma, corneal abrasions or foreign bodies). There are also many different causes of blinking in children (tic, dry eyes, Tourette syndrome, irritation from eyelashes etc). Get it checked out first!

An Update: Lashes and Tear Ducts

Cosmetic, Pediatric Ophthalmology No Responses »

Mar 292012

Latisse Update

So, after much deliberation, I have decided not to do the Latisse challenge. The reason is because I’m still nursing and Latisse is not FDA approved to be used in pregnant or nursing mothers. I knew that beforehand and I’ve never prescribed it to a patient who is pregnant or nursing, but my overzealousness to have nice lashes almost got the better of me. I figured that the amount of Latisse that is systemically absorbed is quite small. But, when I sat down and really considered it, I realized it just wasn’t worth the risk. Though I’m not a patient person, I would rather wait 6 months and know for sure that I am not harming my baby. The only time I used it was when I posted the video. So, instead I’ve put one of my staff on Latisse and I’ll be posting pics of her every 2 weeksThis is obviously not a picture of my employee’s lashes, but my son, Nikhil has the best lashes, so I just decided to post a pic of him until I get the staff pics uploaded.

Tear Duct Update

On a happy note, Taj’s nasolacrimal duct obstruction has completely resolved. It’s interesting, it appeared to be worsening one day and then all of a sudden there was no discharge, no tearing. So, parents out there – continue the massage, it really does work. I did the Crigler massage much more consistently than the antibiotic ointment or warm compresses.

No more tearing or discharge!

The end is in sight

Office No Responses »

Mar 132012

Our renovation is almost over – thankfully! Thanks to all of our patients who have endured the chaos, mess and cramped temporary reception area as we have renovated over the past 2 months. Our HEC patients are so great – they tolerated sitting on the ground, their charts being misplaced and all sorts of blunders as we tried to cope with seeing patients while renovating.

Of course, the reno was supposed to be done on Feb 1, by the time I returned from maternity leave. And, of course, that didn’t happen. Demolition only began on January 23, so there was no way that it was getting done in a week. We have never renovated anything before and this was certainly a learning experience. Lots of delays, items that we had to make sure were done properly. But, we are getting very excited – the new space will certainly now be large enough to accommodate all of our patients. Below is a sneak peek at the office. We have started using the reception area even though we are still waiting for the granite to be installed and there’s a laundry list of items that still need to be completed. The end is in sight! Anyone out there survived a recent renovation of your home or office?

Even baby Taj is helping clean the new shelves!

Where did you get those lashes? The Latisse Challenge

Where did you get those lashes? The Latisse Challenge Cosmetic No Responses »

Mar 072012

Many of you have probably seen the commercials for Latisse. They originally featured Brooke Shields and now Claire Danes and looks like this:

So, what exactly is Latisse, how does it work and does it actually work?

Latisse is the only FDA approved medication proven to grow lashes longer, thicker and darker. Quite a statement, right? Well, how did they come up with Latisse. Latisse is the brand name for bimatoprost ophthalmic solution 0.03%. And, what exactly is that? Well, it’s the same medicine as Lumigan, a glaucoma drop. And, it’s similar to Xalatan (latanoprost ophthalmic solution) and Travatan (travaprost ophthalmic solution). All three are known as prostaglandin analogues, and are a specific type of glaucoma medicine. Each differs slightly and is made by different manufacturers. Well, we ophthalmologists began prescribing these medicines for glaucoma, we noticed that patients reported that their eyelashes got longer. For men, this was an unwanted side effect. But, someone had the bright idea of repackaging Lumigan (which you can still buy for glaucoma) and selling it as Latisse. Instead of placing the drop in the eye as you would for glaucoma, you place it on the lashes (I’ll get to that later).

So, how does Latisse promote your lashes to grow? Well, that’s kind of unknown. If you go to the Latisse website, you’ll find this diagram. All this tells you is that each hair follicle undergoes a cycle of growth and death. For some reason, Latisse makes the growth phase of lashes longer, but it isn’t known why.

So, on to the third and final, and most important question.

Does Latisse work?

The FDA clinical trials actually proved that lashes did grow significantly with the use of Latisse, after 16 weeks of use. Here are the pics from the clinical trial.

But, I think it’s more impressive when you see pics of real people using Latisse.

This is Christina, my receptionist.

And, here’s Kelley, one of our technicians.

This is what she says about Latisse:

” I started using Latisse about a year ago and have definitely noticed an improvement in the length and fullness of my lashes. I have noticed a slight darkening of the skin on my lash line, but I don’t mind. It looks like I have on a little eye shadow, or perhaps eyeliner, without the hassle of putting it on! I am using less mascara and can even go without it now and still have long, lush looking lashes! I am not the kind of person w ho does anything regularly with my hectic schedule, so it’s difficult for me to remember to use it every day, but I have still gotten excellent results. People compliment me on their beauty when I’m in stores and I always have the same reply, “Thanks, I use Latisse”

And, last, another employee – Shawna. She uses Latisse two to three times a week and these are her lashes.

My mother uses Latisse and she barely uses any cosmetics. She noticed during my wedding when the make-up artist was putting false eyelashes on her that it made her eyes look the way they did when she was young. She commented that the loss of eyelashes as you age is so gradual, you don’t notice it at first. Once she started using Latisse, she saw a dramatic difference within 4 weeks (the label on the box says you’ll see a change in 16 weeks, though most of my patients report seeing an increase in lash growth and thickness even within the first month) and it restored a youthful appearance to her eyes.

Before we discuss how to apply Latisse, I want to briefly review the potential adverse effects of it. It is a medication, which is why only a doctor can prescribe Latisse. And, I do recommend purchasing Latisse from your eye doctor so that they can perform an eye exam on you before and during Latisse use.

Side Effects

Change iris color – this is what most people really worry about and it actually wasn’t shown to happen in the FDA trial at all. But, the glaucoma medicine (when you put the drop in your eye instead of on the lashes) can cause hazel eyes to turn darker brown. Blue eyes remain blue and brown eyes remain brown
Skin pigmentation – if you don’t apply Latisse correctly or put it on the lower lashes (not supposed to), then you may get darkening of the skin of the lower lid. This happened in about 4% of patients
Uveitis – this is inflammation of the eye. This is why I like to do an eye exam on anyone who requests a prescription for Latisse. Many doctors may not and since there are many non-ophthalmologists prescribing Latisse (internists, OB/Gyn, etc, they wouldn’t know how to check for uveitis anyway), it may get missed. However, I like to be careful
Skin irritation or redness
Macular edema – this is swelling of the retina of the eye. Again, this can only be detected by an ophthalmologist or optometrist

How to Apply Latisse

The above is what you’ll find on the Latisse website, but I’ve made a little video to make it easier. Sorry if I seem a bit serious in here, it’s weird talking to yourself in the bathroom.

So, I’m starting the Latisse challenge. Yes, I know it’s not like a marathon challenge or anything really important, but still…For years, I’ve wanted to try Latisse. Honolulu Eye Clinic was one of the first clinics in Hawaii to dispense Latisse, but because I was pregnant with my first son at the time, I was never able to try it (it is contraindicated in pregnant and nursing mothers). But, I will no longer have lash envy of the other women in my office. I’m going to start using Latisse and will post weekly pictures on the blog and you can follow along.

I almost forgot, right now we have a

Buy one box of Latisse, get one free

So, if you’ve ever wanted to try Latisse, hurry on over to Honolulu Eye Clinic, while supplies last. Once we run out of the special, we still offer $25 off each box of Latisse. Yes, Latisse is expensive – $125/ box full price. But, unlike lash extensions, these are your own lashes and they never look artificial. I’ve had many patients tell me that once they reach the length they desire, they are able to taper down to using Latisse a couple times a week instead of daily (again, this is not the FDA recommended use of the product).

Does my child need glasses?

Ohana, Pediatric Ophthalmology No Responses »

Feb 132012

This is probably one of the most common questions I get asked by parents.

How do I know if my child has poor vision?

Usually this question is asked when the children are pre-verbal or if they can’t quite yet read the eye chart. A lot of parents mistakenly think that there is no way to figure out if the infant or toddler needs glasses and that just isn’t true. As parents, there are a couple signs and symptoms you can look out for which may indicate that your child is having difficulty seeing. These might not always mean that your child needs glasses. Sometimes, certain things can be habit (squinting or tilting the head) or sometimes they can mean your child needs glasses or has a more serious eye problem.

- Squinting or tilting the head or face

-Headaches

- Eye crossing or drifting out (strabismus)

-Closes one eye when reading

-Difficulty walking or meeting developmental tasks – I had one little 9 month old girl as a patient, her parents noticed that she wasn’t able to pick up her Cheerios as well as the other babies her age. They brought her in to see me and it turned out that she had strabismus (misalignment of the eyes). I operated on it and within a few weeks, she had taken her first steps. Click here to read the full story of this patient.

-Trouble in school. - Your child’s teacher may comment that your child is inattentive or has trouble with certain tasks.

When should my child’s eyes be examined (or vision tested?)

The American Academy of Pediatrics and American Academy of Ophthalmology recommends that all children have their vision checked at the 4 year old visit at the pediatrician’s office. If your child is premature, has other medical problems, or you have noticed abnormalities, the child can be checked earlier.

A lot of times, parents second guess themselves. You know your child. Please do not listen to anyone (doctor or otherwise) who tells you that your child is too young to have their eyes are examined. This is simply not true. I have caught many problems when examining young babies, because their parents (and their pediatricians) were astute enough to know that something was not right with their kid’s vision. Listen to your instincts – they are often right.

So, on to the second part of the question. You think there might be something wrong with your child’s vision. But, you child is only 1 or 2 years old -surely an exam can’t be done, you wonder? Wrong! I can do a full and complete eye exam on almost any child and examine infants routinely. The nice part of being a pediatric ophthalmologist is that I actually don’t need the patient to really tell me too much of anything. I can take measurements and deduce exactly what needs to be done. So, to the second question:

How does the eye doctor know if my child needs glasses?

Examining a child is different than examining an adult. Obviously, I can’t ask your kid “which is clearer, one or two?” and have them help me decide what glasses to prescribe. But, there are lots of other techniques that a pediatric ophthalmologist uses to figure out what your child is seeing and how well. The most important things I have are toys and a separate waiting room for kids with lots of things to occupy them.

In the exam room, I have movies for kids to watch and lots of patience…and I’m quick. It takes a certain personality to examine kids and those are the people who are typically pediatric ophthalmologists.

For kids, I always perform a comprehensive eye exam. I check vision whenever possible. If the child does not know his letters, then I use a substitute, such as some of the charts below.

If they’re too young to know their shapes, then I will use a toy and cover one eye at a time, testing to see if they follow the toy around. I then check to make sure the eyes are straight by checking the corneal light reflex and cover/uncover test. If the child is old enough, I will use the slit lamp to examine the anterior structures of their eye, but if they are too young, then I will use a strong light and a magnifying glass.

But, how does the doctor check what glasses prescription they need?

I dilate the pupils to relax the focusing muscles of the eye to obtain accurate measurements of refraction. I use a special instrument, called a retinoscope and lenses of different powers, to arrive at the correct prescription.

The nice thing is that I don’t need your child to tell me if his/her vision is blurry, or if they see better with a certain lens. This is the way I can figure out the correct glasses prescription that an infant requires. (I have given glasses to a child as young as 9 months old!). And it also means I can tell when a child just says their vision is blurry to get glasses, but they don’t really need them. By placing the different lenses in front of the child’s eye and using the retinoscope, I look for a certain reflex of light back through the pupil. When the correct lens is in place, the reflex becomes very bright and fills the lens.

And, you might ask -

Why are kids’ eyes dilated?

Children have a large accommodative amplitudes (measurement of the eye’s ability to focus on near objects) and that can change the measurement of the prescription. If a child is not dilated, then a prescription that is more myopic (minus) than necessary may mistakenly be given. That is why it is important that the ophthalmologist or optometrist you take your chid to, should always dilate his/her eyes before determining the glasses prescription. Click here for the handout I give all my patients regarding dilating drops in children.Dilating Drops handout

X games glasses (boys)

Coach glasses (popular with tweens!)

Our Juicy Couture glasses - moms and tweens love them!

And, if your child needs glasses – don’t despair. Often, I have found that parents are more upset about the prospect of the child wearing glasses than the child is themselves. I tell the parents to let the child choose the frames, so that they are happy with the glasses. We have so many new great pediatric frames in our Optical Shop, that 99% of the time the child is able to find something they really like. Almost all of the designer frames in our shop have a 2 year warranty, which is also really important with kids.

My patient below actually chose these super cute frames himself (he’s 3 years old and he knew exactly what he wanted!).

Bottom line, if you, your pediatrician, or your child’s teacher are concerned about your child’s vision, please take your child to see a pediatric ophthalmologist. There is no age too young for an examination.

The demolition has begun!

Office No Responses »

Jan 302012

After many months of planning and delays, our renovation project is now officially underway. For some time now, we have realized that we are outgrowing the current layout of our waiting room and optical shop. Friday was our first day of demolition and it was amazing to see just how fast our entire waiting room, optical shop and reception area could be dismantled! I made sure to emphasize the importance of proper eye protection to the demo crew (do you know how many nails in the eyes we see as ophthalmologists? One is enough!) Don’t worry, we are still open our regular hours.

Here is the way our waiting room/optical shop/reception used to look like. Say goodbye to the teal and mauve color scheme that was so characteristic of the late 80′s/ealy 90′s.

Our old optical shop

Gone is the pink laminate and pink wallpaper! And the stained (despite the fact that we steam cleaned it annually) grey-raspberry-teal carpet? Ripped out! Though in all fairness, everything has held up very well over the last 21 years.

So, you may be asking yourself how do you enter Honolulu Eye Clinic now for your eye exam? We have erected a temporary reception and waiting room. When you come to our usual office door, you’ll be greeted by this sign.

Follow the hallway all the way to the end and you’ll get to the back entrance of our office which leads to our temporary reception desk (this used to be the nursery and will return to Taj once renovations are complete).

The pediatrics waiting room has been converted into the regular waiting room, along with the optical shop.

Our temporary optical shop

We still carry all of the 650+ frames that we used to, they’re just organized in cabinetry now in the smaller space, so don’t worry that you won’t find what you need. Thanks in advance to everyone for their patience while we renovate our office. The new waiting room/optical will have an expanded optical shop and more room at reception to decrease patient wait times to check in and check out.

Foods for healthier eyes (with recipes!)

Ohana, Ophthalmology No Responses »

Jan 242012

Everyone knows that a good diet will help you stay healthy. But eating foods high in certain antioxidants may also help to protect your eyes from reduced vision or even blindness. The antioxidants lutein and zeaxanthin are highly concentrated in the pigment of the macula, the light-sensitive cells in the middle of the eye’s retina.

What exactly is the macula? First, a quick anatomy lesson – think of the retina as the camera film of the eye, located inside in the back. The center part of the retina is called the macula and it is responsible for central vision.

Anatomy of the eye

You may have friends that say “I have macula.” What they mean is they have macular degeneration. Symptoms include:

Shadows, blurriness, or holes in the center of vision.
Straight lines appear wavy.
Trouble seeing details both up close and at a distance.
Difficulty telling colors apart, especially ones close in hue.
Vision can be slow to come back after bright light exposure.

People with severe macular degeneration lose their central vision and see the world as depicted below.

Loss of central vision with macular degeneration

In macular degeneration, there is scarring and bleeding in the macula area of the retina. There is a spectrum of macular degeneration. Some patients who have it do not have any visual symptoms at all. There are two types – dry and wet. The dry form of macular degeneration, is less severe, yet there’s also no real treatment for it. It’s considered the early stage of macular degeneration and the only form of treatment is preventative (no smoking, take vitamins such as Ocuvite, which is available at Costco). The Age-Related Eye Disease Study (AREDS for short) is one of the few studies which proves a beneficial effect of taking a combination of vitamins (Vitamin C, E, beta carotene, zinc and copper) in preventing the progression of macular degeneration.

The wet form, is the more advanced form of macular degeneration. It’s called “wet” because the blood vessels leak and cause bleeding underneath the macula.

Though this is the worse form of macular degeneration to have, there is treatment for it.

Laser treatment used to seal off the leaky blood vessels.
Anti-angiogenesis agents – The newest form of treatment are injections (anti-VEGF) which work by slowing the growth of the leaky blood vessels. Examples of these injections include – Avastin and Lucentis. Typically, these injections must be performed every 1-2 months or the blood vessels will regrow.

Now to the food part. Some research suggests that a diet rich in those antioxidants may be linked to a lower risk for eye diseases. One recent large study found that people whose diets were high in lutein and zeaxanthin were at lower risk of developing age-related macular degeneration (AMD) and of progression to advanced AMD, the vision-threatening form. Another large study found that people with high lutein and zeaxanthin dietary intake were at lower risk for cataracts.

Patients always ask if dietary changes will help improve cataracts and macular degeneration. And, while a healthy diet cannot reverse these changes, it may be able to help prevent macular degeneration and cataracts from becoming significant. Lutein and zeaxanthin are found in dark, green leafy vegetables like spinach, kale and collard greens. The yolks of eggs also contain lutein. The antioxidants are also present in yellow and orange vegetables and fruits, like sweet potatoes, carrots and peaches. National health organizations recommend from five to 13 servings of vegetables and fruits per day, depending on age and gender. One serving equals one cup of salad greens, or one half a cup cooked vegetables or cut fruit, or one medium-size piece of fruit, or six ounces of juice.

So far, the jury is still out as to whether high dietary levels or supplements of these substances prevent or just slow the progression of age-related eye diseases. More than one study has shown that vitamins, minerals and phytonutrients found in food offer advantages that are not available in pill form. Still, eating fresh, whole foods supports a person’s general health, and taking a balanced multivitamin supplement is usually considered a good general health “insurance” practice.

Below are a couple recipes from our family to yours, to maximize your intake of spinach, kale and collard greens.

Now, I am not a huge kale fan, or at least I wasn’t. But, my mother-in-law made this salad and it fast became one of my favorites. The recipe is originally from her friend Joan Namkoong.

Kale Salad

Ingredients:

Fresh kale
Sliced red onion
Kalamata or picholine olives, pitted and halved
Dried cranberries
Walnuts, broken into pieces
Balsamic dressing

Directions:

Use a mixture of regular kale, Red Russian kale, lacinato or other varieties and try to get young (small leaves) kale which is more tender. Remove the leaves from the stems as you wash it; discard stems. Stack the leaves and cut into fine shreds. Use about 1 cup of shredded leaves per person. Place in a salad bowl.

Add the onion, olives, cranberries and walnuts; toss with dressing. You can toss this ahead of time and let it sit – the kale won’t wilt like other salad greens, making this a great salad for a buffet

Balsamic dressing

Ingredients:

½ cup balsamic vinegar
1 cup olive oil
1 tablespoon honey or sugar
2 teaspoons Dijon mustard
1 teaspoon salt
½ teaspoon black pepper

Directions:

Whisk all the ingredients together

Note: 3:1 oil : acid

Below is a recipe for a popular Indian dish you may have tried in an Indian restaurants. This recipe is from my mother.

Saag Paneer (Indian spinach-cheese curry)

: Ingredients for Saag Paneer

Ingredients:

1 bag fresh spinach (frozen spinach can be substituted)
1/2 large onion, chopped
1/2 medium tomato, chopped
2 cloves garlic, chopped
1 inch ginger, finely chopped
1/4 tsp turmeric
1/4 tsp salt
1/2 tsp ground coriander
1/2 tsp ground cumin
1 tsp garam masala
1 Tbsp butter
1 Tbsp oil
1/3 package of paneer, cut into cubes. (Paneer is simply home made cheese and can be bought frozen in any Indian grocery store, if you don’t want to go through the trouble of making it yourself. There’s even one here in Hawaii. Click here for the address.

Directions:

Heat the oil in a large saucepan. Once warm, add the ginger and garlic and cook for one minute. Add the onion and reduce the heat to low, cooking for 5 minutes. Then, add the salt, cumin, coriander, and turmeric to the onion-garlic mixture, cooking for about 2-3 minutes. Next, add the tomato, cooking it for an additional 2-3 minutes until the tomato begins to soften. Add garam masala along with 1/4 cup water and cook for 5 minutes.

Add the spinach with 1 cup of water and saute until the spinach begins to wilt, turning off the heat. Puree the spinach mixture with a hand held blender or remove from heat and blend in a food processor.

In a separate saucepan, heat the butter and paneer, turning constantly so it does not stick to the pan. Add a pinch of turmeric, garam masala and salt to the paneer while frying. When golden brown, turn off the heat and combine the paneer with the spinach mixture.

Kale Smoothie (Our 2 year old drinks this!)

Ingredients:

2 stems of kale
1 cup of orange juice
1 cup of frozen peaches
1 cup of frozen pineapples
1 6 ounce cup of yogurt (we use blueberry because it was in the fridge)
5 ice cubes

Directions:

Blend together and serve

And, see, even our 2 year old likes it!

SkinCeuticals AOX Eye Gel- can make you look like you don’t have a baby keeping you up all night

Cosmetic No Responses »

Jan 122012

So, one more quick Taj related post. I had to share the amazingness of the new SkinCeutical AOX eye gel. I’m usually pretty hesitant to endorse one product over another, but I’ve been so happy with this eye gel, that I had to share it with you all. Everyone has one particular area of their face and body which they wish they could improve. For me, it’s the area under my eyes. I hate when they get swollen and dark…It’s very easy to tell when I’ve had a good night’s sleep (and since I have a newborn, I’m usually not getting too much sleep!). I think it’s all the more obvious since my eyes are large and I feel that the puffiness is even more noticeable. I also get a lot of questions from patients about how best to combat signs of puffiness and dark circles under they eyes.

First, a little bit about the SkinCeuticals line. I like the Skinceuticals products, and they are the only cosmetic products we carry in our clinic, because of the evidence based medicine which supports their claims. There is real science behind their products, published in peer reviewed journals. You may have seen the product in Allure magazine when the Phlorotein CF serum was named “Best of Beauty”. The line really stresses the importance of prevention, prevention, prevention. I now use the phlorotein CF serum (named one of Allure magazine’s top beauty products) which has anti-oxidants (Vitamin C, E and ferrulic acid) that help prevent UV damage and a daily sunscreen. Photoaging is what causes all of the signs we associate with aging and if you minimize the oxidative and free radical damage caused by the sun, then it stands to reason, that you will look better too (in addition to preventing skin cancer).

Before I met the Skinceuticals rep, I pretty much had zero skincare routine. I used Cetaphil moisturizing lotion from Long’s and that was it. My skin was OK, but not amazing. But, living in Hawaii, it is really important to care for your skin and protect it from the UV damage which occurs daily. My mother is 61 years old and looks amazing, so I’m hoping with proper skin care, I can age as amazingly as she has.

My mom and dad with my son, Nikhil

So, back to the AOX Eye Gel. I had just given birth, having been in labor from midnight to 6 am. Obviously, I wasn’t looking my best, which wasn’t really all that important to me on the first day. You’re exhausted, your body aches, and you have a newborn. But, I took a look in the mirror a few hours later and almost didn’t recognize myself. I had HUGE bags under my eyes, the likes of which I have never seen before. The ophthalmologic term is festoons. You can see how swollen my lower eyelids are. I look like I can barely keep my eyes open – I barely could, it had been a hard labor! I can’t believe I am actually posting this picture (note the all important headband – pregnant mothers, don’t forget the headband!).

After labor with my wonderful OB and nurse

Since I work at Queen’s and delivered there, I knew people would be stopping by to offer their congratulations and I needed to improve my appearance slightly (Thanks so much to the Same Day Surgery nurses for the beautiful flowers and to my friends who dropped by). Let’s be real. Of course, it’s about the baby, but I knew there were going to be a lot of pictures taken. And who wants to look back at photos of one of the happiest days in their lives and cringe at the way you look? Jeff was operating the next morning, so I told him to go home to get good rest and not spend the night in the hospital with me and the baby. The plus side of that was that he could bring me my eye gel which I had left at home.

AOX Eye Gel

The skin around your eyes is the thinnest skin in your body. Therefore, it shows signs of accelerated aging and stress more than other areas of your face. In addition, the fat that normally supports your eyes, can prolapse forward causing the eyelids to appear puffy.

AOX Eye Gel:

Prevents signs of aging with a high concentration of pure L-Ascorbic Acid, Ferulic Acid and Phloretin antioxidants
Antioxidants also corrects signs of photodamage including fine lines, wrinkles and improved skin tone
Ruscus Aculeatus (type of plant) supports under-eye circulation to help reduce the appearance of puffiness caused by swelling. It actually causes the blood vessels to become smaller or vasoconstrict.
Caffeine helps improve drainage and congestion of fluids which cause under eye bags

I really think the caffeine and ruscus aculeatus are what you notice immediately when you use it and the antioxidants help prevent future damage. I used it in the morning (I was still in the hospital), put on my headband (a very necessary accessory and should be packed in every pregnant woman’s hospital bag) and slapped on a bit of lipstick. I kid you not, the nurse who came to check on me, right after this picture was taken, gave me a strange look and said “Are you the patient?” That was great!

So, the new eye gel is added to my serum and sunscreen as my skincare regimen. It has become extremely necessary to combat the sleepless nights which accompany a newborn.

Some patients will ask me specifically what I use for my skincare regimen. Everyone’s skin is different, so what is right for me, may not be right for you. My skin tends to be slightly dry and sensitive. So, here’s what I use. And, remember, I am slightly lazy when it comes to my skincare routine.

Cleanser:

I tend to alternate between the Foaming Cleanser and my old stand by of Cetaphil. My mother-in-law gave me the Clarisonic for my birthday, and I love it, but I remember to use it only once a week.

In the mornings, I use:

I use all three of these daily. I love the SkinCeuticals sunscreen, especially the Physical fusion. It has Titanium dioxide and zinc oxide, which area wonderful sunscreens (they’re what lifeguards use on their noses to make them white). I only use sunscreen on my kids with these 2 ingredients because they are what is termed “Physical” sunscreens and have been proven to be the most effective. Obviously, those of you who have seen me in the clinic know that I don’t show up with a completely white face like kabuki make-up and the reason is because the Skinceuticals sunscreen is emulsified and tinted. It isn’t oily feeling and the tint is quite nice. I use this and it looks like I’m wearing powder or foundation, so I can skip that make-up step.

So, there it is. Everything that you wanted to know and more about SkinCeuticals, my vanity after labor and the importance of sun protection. And, if used properly, you may even be able to combat the signs of sleeplessness that come with a baby (or just wake your hubby to do some diaper changes, which Jeff happily does). Have any of you tried any of the SkinCeuticals products? Or do you have your own remedy for sleepless nights and dark, puffy circles under your eyes?

**I do not receive any type of commission or perk for blogging about SkinCeuticals**

What’s that gunk in my newborn’s eye?

Ohana, Pediatric Ophthalmology No Responses »

Jan 052012

Gunk…not exactly a medical term, but a descriptive one nonetheless. Any parents out there reading this are probably familiar with the following scenario. After the trauma of childbirth (for mom, that is), you feel so blessed to hold your child close and the first thing you do is make sure everything on him/her is perfect. Then, a day or two later, you may notice that there’s a lot of mucus in your infant’s eye, maybe even so much to cause it to stick shut. The eye is constantly wet with tears. Is it an infection? Do you need antibiotics?

What I described is a blocked tear duct, or ophthalmologists refer to it as a neonatal lacrimal duct obstruction (NLDO). Both of my sons suffer from this condition. Nikhil is now 2.5 years old and his is much better, but Taj’s is actually pretty bad. The good news is that it isn’t an infection and it isn’t contagious. There are some things that parents can do to help improve matters and lessen the tearing. I wanted to post on this topic since Taj currently has this and I have been treating him at home. Just yesterday, my husband, Dr. Jeff Wong, turned to me and asked “How do you do the massage thing again?” And I thought, if he (a well trained ophthalmologist) can’t remember how to do the massage, then, for sure my patients’ parents may be forgetting as well.

First, what is a blocked tear duct?

The tears are constantly manufactured by glands within the eyelids. After lubricating the eye, the tears normally drain into two small holes (“puncta”) located on the inner corner of the upper and lower eyelids. Look in the mirror and you can find these puncta on your own eyelids. From there, the tears drain into the back of the nose via the tear duct (a.k.a. nasolacrimal duct). This is why we tend to have a runny nose when we cry! Infants with a nasolacrimal duct obstruction typically have a blockage at the most distant end of the duct immediately before it empties into the nose

Clinical Review Fortnightly review: Managing congenital lacrimal obstruction in general practice BMJ 1997;315:293

Approximately six percent of all infants are born with a nasolacrimal duct obstruction (tear duct blockage) affecting one or both eyes. Fortunately, the good news is that at least 90% of these obstructions will clear without treatment within the first year of life.

What are the signs of a blocked tear duct?

As the tears have nowhere to drain, they will well up on the surface of the eye and often overflow onto the eyelashes, lids and cheek. Normally there are bacteria in the tears and now these have nowhere to drain when a blockage is present. These bacteria tend to grow within the tear duct and cause a pus-like discharge from the inner corner of the eye and on the lashes — frequently observed when the child awakens.

It is important that see your pediatrician or pediatric ophthalmologist for a correct diagnosis. There are other serious and vision threatening conditions which can cause tearing in a newborn and those need to be ruled out.

Here’s picture of Taj. See the yellow crusting mucous in the corner of his left eye and on his eyelashes causing them to stick together? Even though it looks troubling, it doesn’t bother him one bit, which is very normal.

So, what can be done?

Since these obstructions resolve by the time the baby is 12 months old, I manage the condition very conservatively. I typically recommend the following:

Crigler massage (see video down below). This is basically massage of the tear duct to get it to open up and create a patent system for the tears to flow. To perform the massage, use your index finger in the corner of the eye, right below the eye and roll the finger downwards over the bony ridge towards the nose. This has been proven to work. Success rates in published studies range anywhere from 30-90%. Do this three times a day. It’s easy, free and doesn’t harm the baby, isn’t that the best treatment? You can see in the video, sometimes it’s tricky performing the massage in an infant (in my case, Taj always seems to think my finger is more food for him). Usually I will use my other hand to stabilize his face, but for the video, it was getting in the way of the shot of Taj’s face, so that’s why he’s moving around so much.

Warm compresses
Antibiotic drops – these will need to be administered by your pediatric ophthalmologist if there is a lot of green-pus discharge. I typically recommend erythromycin ointment and it’s what I’ve been using intermittently on Taj
Breastmilk – This is not a medical recommendation, and I’m going to preface this. A lot of old folklore, Ayurvedic medicine and maybe even your Hawaiian auntie down the street has recommended breastmilk for everything. Breastmilk has a lot of wonderful properties, one of which is that it contains IgA, a type of antibody. The theory is that squirted into the eye, the breastmilk prevents the adhesion of bacteria to the eye and decreases the discharge. I only found one published study as to the effectiveness of breastmilk and because the journal was a bit obscure (Journal of Pediatric Tropical Medicine), I wasn’t able to read the full article to evaluate it. However, I will say that one of the pediatricians who routinely refers to me was always recommending this to her patients and I thought this weird. Yes, I know my background is Indian and I should be down with the Indian home remedies, but I usually require hard published data before I change my practice style. But, Taj’s eye was pretty bad. The antibiotic ointment wasn’t doing too much, so I figured, why not give the breastmilk a try. And, I have to admit, it really improved things for Taj. The swelling and amount of discharge lessened considerably.
Probing and irrigation. This is surgery. I pass tiny smooth wire probes through the tear duct and into the nose, in order to open up the passageway. For adults, we can do this procedure in the office, but obviously a baby is not going to stay still for you to insert long thin metal probes in the eyelids, so this must be done in the operating room under general anesthesia. It only takes about 5 minutes and usually cures the condition. I only do this surgery if the baby is older than 12 months because as I mentioned earlier, 90% of the time, the blockage will clear itself so why put your child through the risk of general anesthesia if not necessary? That being said, this is probably one of the most common procedures that pediatric ophthalmologists perform. It’s very safe and effective. There are no incisions or scarring from this operation and there is no significant post-operative discomfort. Just see here for a post by a patient’s mother about the procedure.

Here is what the probes look like. I start out using the tiniest diameter probe (on the left hand side) and then increase the size, confirming that I’ve opened up the passageway. Sometimes, if the child is older (older than age 2), then I may also insert a silicone tube to keep the duct open. I remove this 3-6 months later. The tube is extremely small and pliable and children do not feel it at all.

So, if your child is like mine – a newborn diagnosed with a lacrimal duct obstruction, don’t worry, 9 times out of 10, this will get better all on its own. It resolved with Nikhil, but, if it doesn’t, the surgery is minimally invasive and painless and that’s a reason to jump with joy.

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1. Itching

2. Tearing

3. Redness

4. Mucous discharge from the eyes

5. Allergic shiners (look like black eyes underneath the eyes)

6. Blinking

Latisse Update

Tear Duct Update

So, what exactly is Latisse, how does it work and does it actually work?

Buy one box of Latisse, get one free

How do I know if my child has poor vision?

When should my child’s eyes be examined (or vision tested?)

How does the eye doctor know if my child needs glasses?

But, how does the doctor check what glasses prescription they need?

Why are kids’ eyes dilated?

Kale Salad

Balsamic dressing

Saag Paneer (Indian spinach-cheese curry)

Kale Smoothie (Our 2 year old drinks this!)

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