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This is a topic I’ve been wanting to address on our blog for a while, since it’s so applicable for kids in Hawaii.  Adults often forget what it’s like for young kids, who have a strong prescription in their glasses, what it must be like to swim and snorkel without their glasses.  My kids don’t wear glasses (yet!), though we use them as our glasses models, like below, but if they start to become as nearsighted as some of their relatives, I will certainly look at prescription goggles for them._mg_8748-2jpg

 

I do not recommend prescription goggles for every child.  The majority of children can see well enough without their glasses that the extra expense is not necessary.  But, for a small subset of my patients, they truly can barely function without their glasses and improving their experience in the water, when you’re swimming at least once or twice a week year round like you do in Hawaii, is worth it.

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Since I always send these patient to my Optical shop, since I don’t really know much about the specifics of prescription goggles, I thought it best to consult my optician, Kevin for this post.  Kevin has over 30 years experience working with children and is a certified and licensed optician.  Take it away Kevin.

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Hi everyone, Kevin, friendly neighborhood optician here.  For kids and adults who wear glasses, swimming in the pool or exploring the ocean can be a frustratingly blurry experience. Did you know our optical shop can make prescription swim goggles and scuba masks?

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Even children as young as two years old can enjoy clear vision underwater — while simultaneously being protected from water-borne diseases and parasites, chlorine and saltwater!

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How’s it done?

 

Our optical shop offers two different lens options designed to accommodate virtually any prescription. How?

Similar to over-the-counter reading glasses, we can offer swim goggles inexpensively for those with a lower prescription or one that does not require astigmatic correction. This is accomplished with ready-made spherical prescription lenses which fit into a swim goggle or scuba mask. Since eye doctors do not recommend contact lens use underwater, swim goggles provide premium visual performance and maximum protection.

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For those who require a higher prescription, or prescriptions where astigmatism correction is needed, our swim goggles and scuba masks can be custom-made to fit your individual needs. Add an anti-fog treatment and Transition lenses for superior performance in and out of the water!

We are blessed in Hawaii with lovely weather year-round. Don’t let poor vision keep you from enjoying our island’s underwater beauty.

Consult our optical staff about pricing and availability.

 

As a pediatric ophthalmologist, this question is one of the most common ones I get.   Parents bring their adorable baby in with huge, beautiful blue or green eyes and they themselves have brown eyes.  They want to know if the light colored eyes will “stay.”

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The part of the eye which gives it color is called the iris.  Melanocytes are cells which contain melanin, present in the iris.  The number of melanosomes doesn’t differ between people with different eye colors.  Individuals with brown eyes simply have more melanin in their melanosomes in the irises than individuals with blue eyes.

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My oldest son, with his big brown eyes.

We used to think that eye color was controlled by just one gene and blue eyes were recessive and brown eyes were dominant.  And, that 2 parents with blue eyes could only have a blue eyed baby.  But, that’s not quite true, though uncommon, a brown eyed kid can have 2 blue eyed parents. The inheritance of eye color is much more complicated than previously thought. There are actually 16 different genes responsible for eye color, but the main two sit next to each other on chromosome 15.  These 2 genes control the amount and quality of melanin produced.  When babies are born, the melanocytes do not produce very much melanin.  That’s why a large number of babies have light eyes.  Even my 3 kids have grayish/lighter eyes when they were born.

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My son when he was a couple weeks old, note the lightness of his eyes compared to the previous photo

With time, usually when babies are between 6 months-3 years,  the melanin production increases and then stabilizes.  The melanin in your iris is not affected the way the way the melanin in your skin is (otherwise, everyone’s eyes would become brown when they are in the sun for a prolonged period of time).  After age 3, very little change occurs in the color of eyes.

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My nephew, at six months old who has one lighter eye and one darker eye. Also note his lighter eyes, even though both his parents have brown eyes.

 

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My nephew, now 10 years old. Note how both of his eyes have darkened to a more hazel color.

There are many disorders which can cause a change in iris color later in life.  Some of these are vision threatening, conditions such as albinism, or  and if you notice any change in your child’s eye color past the age of 3, please see your ophthalmologist.

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This young boy was born with one brown eye and one green eye

There are many causes for heterochromia, some of which require urgent evaluation and management, such as possible tumors in the brain or chest (Horner’s syndrome), inflammation of the eye (Fuchs heterochromic iridocyclitis) or even a type of glaucoma.   Some glaucoma medications can also change hazel or green eyes to darken, as can Latisse, the eyelash growth medication (which is based on a glaucoma drop).  Tumors, nevus (moles) of the iris can cause a darkening of the iris, as can a foreign body, This article is an excellent summary of the many causes for different or changing eye colors.  If you notice a difference in color between the 2 eyes, called heterochromia, please also see your pediatric ophthalmologist.

red aloha rupa sig

 

 

First, sorry, I’ve been MIA for a while.  I was on my nice posting schedule and I got hit with the flu back in April when I was attending our national pediatric ophthalmology conference in Vancouver.  It seems as if every time I attend a conference, I get sick – 2 years ago, I had to be ambulanced out of the conference because of what turned out to be kidney stones.  That was a little embarrassing.

Anyway, I don’t usually get sick and I’m pretty sure I had mono.  It was supposed to be a nice time to hang out with my friends from Boston Children’s Hospital, enjoy Vancouver and spend some child-free time with my husband.  Instead, I was in bed with high fevers and a box of tissue. And, though everyone keep telling us how lucky we were because it was so warm in Vancouver, let me tell, 50’s and 60’s does NOT feel warm to a girl who is used to Hawaii sun. Being a physician, of course, I couldn’t actually go get the mono test, but just relied on my skills of self-diagnosis.

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However, the conference was great. I really think it’s important that physicians in Hawaii attend the national conferences.  Jeff and I try to make it a point to do one or two a year.  We’re so isolated out here in the middle of the Pacific Ocean, that I truly think it’s worthwhile to make the trip to the mainland to stay cutting edge in terms of research and surgery.  And, to be honest, I don’t learn the most from the conferences themselves, but I actually learn the most when I’m with a group of senior peds ophthalmologist and I can get their take one of my difficult cases.  I’m not ashamed to ask someone’s advice who has more experience than I do!

Dr. Carolyn Wu on my left and Dr. Alexa Elliott on my right.  Two of my attending when I was a fellow.

Dr. Carolyn Wu on my left and Dr. Alexa Elliott on my right. Two of my attending when I was a fellow.

We had a dinner of all the fellowship alumni from Boston Children’s, which was terrific.  Two former alumni are Chairmen of Peds Ophtho Departments one at Childrens Hospital Philadelphia, and the other at D.C. Children’s, so I was really surrounded by the best and brightest in my field.

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The other neat thing was meeting former fellows who graduated after me.  At least 3 of them immediately recognized me and said “you’re the one with the blocked tear duct blog and video”.  That was kind of cool – though I wish in retrospect that I had taken more effort with filming it.  I am literally holding my iPhone in one hand as I perform the Crigler massage on my squirmy 4 month old son with the other!

Though I spent most of my time in bed at the hotel, recuperating, I did force myself to get out of bed to go biking around Stanley Park with Jeff and then I coughed for like 6 hours straight (it was worth it though). Vancouver is beautiful, I’m hoping the next time I visit, I’ll be in good health!

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So, mono set me back about a month. And, then I’ve literally been scrambling for the past 4 months to catch up.  But, I’m back now, and should resume my regularly scheduled posts.  I’m really aiming for once a week now so keep checking back!

red aloha rupa sig

 

 

 

 

 

 

 
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I’m definitely of the mind set that the more prepared you can make your child for doctor’s appointments, the better they turn out.  So, I thought I’d post about the details of what I do all day, in the hopes that maybe this will help calm the fears of our littlest patients.  I’ve had some parents tell me that they show their kids picture of my Honolulu magazine cover before the appointment and just that simple thing, makes my patients much more comfortable with me.

First up in an any eye exam is to check vision.  Vision should be checked with an actual eye chart for any kid over the age of 3.  Your pediatrician (or his/her nurse) should be doing this at the well child visit.  They may either use an old fashioned wall chart or any one of the number of new vision screeners out there that pediatricians are currently using. I’ve actually found that the Plus Optix screener that couple pediatricians use in the area is very accurate.  When your child comes into our office, we try to immediately escort them into our pediatric waiting room. IMG_6963This way they don’t have to feel antsy about sitting in a grown up chairs in an adult waiting room.  Here, they can play and read until they are called for their appointment.  Then, they are called into the exam room by one of technicians.  The child will sit in the chair (on a parent’s lap if necessary) and we will check vision. We have the children wear special glasses that have a hole on one side to check vision.  We have a pair which has the hole on the other side to check the other eye.Wong(Opt)Shoot42Older kids can check vision like adults, using the paddle.

Then we use a vision testing system which is a computer program.  It’s nice because we can isolate the chart to a single letter and can change the letters on any given line (for any of you guys who try to memorize the chart!).  It also has the advantage of having different types of tests to use based on the age of the kid.  This is why we can usually test any child older than 3 years of age.  Sometimes, we’ve even been able to do 2.5 year olds!

IMG_9161 And, if the kids are too young to know their letters, then we do these shapes or the HOTV letters.

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Some pediatricians still use the chart below to test kids who don’t know their letters.  They are called Allen symbols, but most pediatric ophthalmologists don’t like them because each picture is so unique in shape, that they’re easy to guess.

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Which kid now a days knows that that is a picture of a telephone? I had one patient call it a hot dog! I figured, close enough.

Then, we use special polarized glasses to do a test of 3D vision.

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“Grab the wings of the butterfly”

Then, if the child is older than 12 or 13 years old, I will refract them – that means checking to see if they need a glasses prescription.  That’s the whole “1 or 2 ” test.

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“What’s better – 1 or 2?”

If the kids are younger than 12 years old, then I don’t do this for them.  It’s tough enough for most adults to figure out which is clearer – 1 or 2.  For some reason, this simple question seems to provoke a lot of anxiety.  I check the glasses prescription for younger kids only after dilating their eyes.  Click here to read more about how I can figure out if babies need glasses.

If a child is old enough (at least 4 years old), I will try to examine the front part of the eye at the slit lamp biomicroscope. You’ve probably had this done if you’ve gone to the optometrist or ophthalmologist.  This basically gives me a closer look at the eyelids, conjunctiva, cornea, iris and lens.

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Then, on to the dilating drops.  This is probably what gives children the most anxiety.  I try to minimize this by combing all of the various drops into one spray bottle.  This way, the child doesn’t need to have 3 different drops (even though they may need 3 doses even of the spray).  And, the convenience of the spray is that I can apply it to the child’s eyelashes when their eyes are closed and if I really soak them, then whey they open their eyes, the drops get into their eyes.

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It’s actually quite rare for kids to scream and cry for the drops.  OK, maybe rare is an overstatement – my own oldest son cried when I put drops in his eyes to do his eye exam and that was me putting them in.  This is when the teachers at his preschool kept insisting that he needed glasses because he tilted his head to the side when watching TV or thinking.  And, they knew I was a pediatric ophthalmologist!  “Yeah, I’m pretty sure I’ve checked my son”, I condescendingly thought.  However, add 2 more kids to the crazy mix of our life and I will abashedly admit that I’ve never checked their eyes.  So I guess it wasn’t totally out of the range of possibility that I could miss my kid’s need for glasses.  But, that’s a tangent.

Once the eyes are dilated, I use this crazy thing on my head, called the indirect ophthalmoscope to examine the inside of the eye.  For young kids, I use toys to distract them so I can get a good view inside.  For older kids, I have movies playing to hold their attention (best money I have ever spent when setting up my practice!)

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For the young kids, this is when I check the refraction.  I do this both with an automatic machine (pictured below) and then I double check everything by using a retinoscope as well.

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And, that’s about it.  Of course, they get to choose a toy from our treasure chest on their way out.  I have a lot of kids who don’t want to leave our office.  We have the nicest techs and they are just wonderful with children.  We try to make the experience as pleasant as possible!

FullSizeRenderAnd, no I don’t usually have a professional photographer following me around the clinic.  Almost all of these pictures were taken a freshman in college, right before he graduated from college.  His pics are amazing, for any local moms who want to use him when he comes home for summers and breaks.

 

 

 

There are so many advantages to living in Hawaii – the sun, the outdoor sports, the sense of ohana.

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October in Hawaii! And, just a few blocks from our house on a public access beach – can’t beat that!

 

But, one thing which is not better here than on the mainland is the ALLERGIES!  I have lived in many places – North Carolina, Boston, New York – and my allergies are the absolute worst here in Hawaii.  This year seems to have hit allergy sufferers particularly hard – you may recognize the signs of hay fever – runny nose, clogged sinuses, headaches, coughing and sneezing. One-third of individuals who suffer from allergies also have ocular allergies – dry, itchy and red eyes. Allergic conjunctivitis occurs when the clear layer of tissue lining the eyelids and the white covering of the eyes, becomes inflamed. This causes tearing, discharge (makapiapia), itching, and redness. The most common cause of these symptoms is pollen during hay fever season, however, there are many allergens which can trigger symptoms year round. Cockroaches, dust mites, and animal fur or hair are just a few examples of triggers for sensitive individuals.

Symptoms of allergic conjunctivitis

  • tearing
  • discharge
  • itching 
  • redness

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A severe type of allergic conjunctivitis is called vernal conjunctivitis.  On the mainland, this usually only happens during summer and spring, but here in Hawaii, I see it year round.  So, these poor kids not only suffer from the redness, tearing, itching of typical allergy sufferers, but additional complaints.

Symptoms of vernal conjunctivitis

  • light sensitivity
  • thick pus like discharge
  • bumpy growths on the clear part of the eye or underneath the eyelid
Bumps on the pink part of the lower lid (conjunctiva), also known as papillae

Bumps on the pink part of the lower lid (conjunctiva), also known as papillae

I had one child from Maui who came in because her eye doctor that she needed eyelid surgery for a droopy eyelid.  I could barely examine the poor girl.  She was so light sensitive, she kept her right eye shut constantly and her vision was also terrible in that eye.

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Once I actually was able to flip her upper lid, I saw this.

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Huge bumps underneath her eyelid, just like in vernal conjunctivitis.

So, we started her on treatment.  The most common treatment for vernal conjunctivitis is:

  • Oral antihistamines (Claritin, Zyrtec)
  • Antihistamine drops (Pazeo, Padatay, Lastacaft)
  • Steroid drops to reduce swelling and redness (lotemax, prednisolone acetate, durezol)
  • Cold compresses
  • Avoidance of the allergen

She was also tested for allergies.  Turns out that she was allergic to dogs and cats and she had been visiting her grandmother’s farm every weekend which had tons of animals.  We reduced her visits to the farm, gave her Pataday and lotemax and several weeks later…

Screen Shot 2015-11-03 at 12.55.37 PMHer vision improved to a perfect 20/20 and she was able to open the eye again.   No surgery needed to elevate that upper lid. This was the only dog she could have now – but at least she could see!

Though classic teaching regarding vernal is that it mainly occurs during spring and summer months, I do see it year round here in Hawaii.  And, I can tell when allergens getting bad because all of my patients with vernal conjunctivitis will flare and make appointments in the same few weeks!  The most common allergens in Hawaii are dust mites, mold and cockroaches.  I lived in NYC for 8 years, I thought I was cool with roaches.  But, I tell you, NYC has nothing on Hawaii in terms of the sizes of our cockroach.  It was one of the deals I made with my husband before I moved here – he had to kill all of the roaches.  He gets super annoyed when I wake him up at midnight to tackle yet another flying roach (and I swear our house is clean!).  But a deal is a deal!

 

 

 

 

 

I thought I’d devote a post to those common myths you always hear about the eyes.  I get questions about one of these at least once a week.  It’s hard to do something contrary to the old wives tales you grew up hearing, and sometimes I even have to stop myself from believing something which I know is not true!  My oldest son loves the show Mythbusters and I have to admit, it’s pretty cool, hence the Mythbuster approach to eye myths (without any of the experimentation!).

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So, let’s get started.  Common Eye Myths – which ones are true and which ones are not!

1.  It’s bad to read in the dark.

This is how my son loves to read at night.  All the lights in the room are off and he uses this little bedside Ikea light.

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It actually is not dangerous to read in the dark.  It doesn’t make you need glasses sooner.  It doesn’t tire the eyes out.  There was one study which showed that reading in the dark for adults did affect their comprehension and reading times.  So, it stands to reason, for young readers, it’s best to use high contrast reading material to make it easier for them to read faster and understand what they’re reading.  But, again, not unsafe for they eyes.

MYTH BUSTED

2.  Babies will outgrow cross eyes.

Very rarely, babies can have wandering or crossed eyes when they are born.  Just like they are learning how to use their arms and legs, they have to develop their eye muscles and vision.  However, by the time babies are 4-6 months old, they should be able to use their eyes to focus on faces and toys up close with straight eyes.  It’s actually common for babies younger than 6 months old to have eyes that wander out.  The problem that often happens, is that many babies have real crossed eyes, which do not improve with time, as in my patient below who needed surgery.

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Sometimes, the parents, and even the pediatricians, falsely reassure the parents that this kind of eye crossing will improve.  So, they wait to come to see a pediatric ophthalmologist. This kind of eye crossing, esotropia or strabismus, does not improve with time.  And, actually when babies have esotropia, it is best to operate sooner rather than later.  The sooner your perform surgery, the better the child’s change to maintain or restore their depth perception. Strabismus surgery in infants is not a cosmetic procedure.  There is a lot of misinformation about strabismus surgery.  I remember I was operating on the little baby above (she was 7 months old) and even the Harvard employed anesthesiologist at Boston Children’s was questioning the mom as to why she was having surgery at such a young age!  Thankfully, the mom was extremely well educated on the topic and could set the anesthesiologist straight.

MYTH CONFIRMED (with a caveat)

3.   Sitting too close to the TV is bad for the eyes

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Maybe about once a week, I get a parent in my office who hopefully asks “It’s bad to sit close to the TV, right?” looking meaningfully at Little John in the exam chair.  Except, that it really isn’t.  So, I truthfully answer that sitting close to the TV is not harmful to the eyes or the vision.  No studies have found that it makes kids need glasses faster.  But, your child might be sitting close to the TV because they cannot see it.  It might, in fact, be a sign of nearsightedness in a child.  Your children’s eyes have the ability to focus much better than an adult, so for them, sitting (or standing) close to the TV is comfortable.  I do always add that the American Academy of Pediatrics does recommend restricting screen time (TV, iPad, iPhone, etc) to a maximum of 2 hours a day and only for children older than 2 years of age.

MYTH: BUSTED

4.  A cataract needs to be “ripe” before it can be operated upon.

Using words like “ripe” is an old school way of describing the severity of the cataracts.  Older ophthalmologists wouldn’t operate on a cataract until the cataract was large enough.  But, bear in mind, this was back when you had to be admitted to the hospital for cataract surgery and use sand bags to immobilize your head post-operatively.  Cataract surgery was a big deal.  Nowadays, no one uses that terminology, because with lasers an new intraocular lenses, cataract surgery doesn’t carry the same risks as it did 30 or 40 years ago.  So, really, it comes down to if your cataracts are interfering with your ability to do things you love – drive at night, reading, painting, etc.  If so, then it might be time for you to talk to your ophthalmologist about cataract surgery.   There’s no hard and fast line about when your cataracts are ready to be removed.  It’s all about how they affect your activities of daily living.

MYTH: BUSTED

5.  Wearing glasses will make your eyes dependent on them.

This is the one I am currently struggling with.  As I approach 40, I find it hard to read my iPhone in low lighting conditions.  I have a pair of very low prescription reading glasses (+0.50 sphere).  But, even though they make my quickbooks accounting much easier, I am hesitant to wear them.  Why you may ask?  I love the look of them – in fact, growing up not needing glasses ever, I always wanted glasses.  I adore my Fendis.  But, it’s for the simple fact that even if it’s way deep down, I still succumb to the notion that if I start to wear the reading glasses more regularly, my vision will deteriorate.  That is just not true.  My need for reading glasses will increase every year whether or not I wear glasses now.  Same is true for kids. A lot of parents worry about this dependency as well.  Children’s need for glasses has nothing to do with whether or not they were their glasses.  Genetics, anatomy of the eye are what’s important.

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I don’t like taking selfies

 

MYTH: BUSTED

6.  Crossing your eyes make them stay that way.

An oldie, but a goodie.

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Nope – crossing your eyes will not make them stay that way.  So, kids, cross away to your heart’s content.  Esotropia, or eye crossing, has many different causes.  People can be born with it (congenital esotropia), it can be secondary to being really farsighted (accommodative esotropia), from a blind eye (sensory esotropia), or even from a nerve palsy.  But, not because you do it over and over again.

MYTH: BUSTED

7.  Carrots help prevent you from needing glasses.

I love carrots.  I ate a ton of them growing up.  It was my after school snack with French salad dressing.  And, I don’t wear glasses (well I didn’t for the first 39 years of my life).  But, though carrots are rich in Vitamin A, that doesn’t help you from being nearsighted, farsighted or having astigmatism.

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It is always a good idea to eat a diet rich in vitamins and antioxidants for the overall health of your eyes.  Click here for my blog post about anti-oxidants and your eyes (with recipes)

MYTH: BUSTED

 

Hope you enjoyed our fun mythbusters post!

 

 

 
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a Pediatric Ophthalmologist/Working Mom/Administrator.

As a working Mom, I wear many hats, just as many of my colleagues do.  So, for today’s post, I decided to chart down what I did for a full day from the time I woke up to coming home.  People always ask me how I can manage working with 3 kids and it’s a juggling act.  We’re also super blessed with terrific babysitters who we can really depend upon when we have late days.

5:45 am: Arya is awake.  She likes to reach over from her crib and turn the light on and then calls to us “Mommeeee, Daddeeee”.  Her brother, Taj, who is a very light sleeper, will wake up then and run into her room “I’m coming Arya!”.  It’s very sweet.

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Then, get ready, make my bed (I read somewhere it’s part of starting the day right).  Man, I need some coffee.  I look longingly at my Nespresso.

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Since it’s a surgery day, I don’t drink caffeine, just to make sure I don’t have any jitters when operating.  But, I miss the routine of my coffee.  Gotta remember to buy some decaf pods.  Help get the kids ready for school, etc.  Show the nanny where the stuff for dinner is, so she can prepare it (tacos for kids tonight)

6:45 am: Leave the house.  

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Jeff usually drives and I take care of admin emails.  It gives me time to eat my yogurt.  It’s nice having a chauffeur !

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My chauffeur, Jeff, does not like being photographed.

 

7:05 am: Drop Jeff off at the office and I drive over to the Eye Surgery Center.

7:15 am:  Arrive at Eye Surgery Center, greeted by friendly smiling nurses.  I love this place.

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One of the pre-op nurses at the Surgical Center.

 

7:20 am: Say hello to my patient, mark above his eye with a large S (don’t want to operate on the wrong eye! – don’t worry, I always print a large photo of the patient and place it on the wall in the operating room to remind which muscles I am operating upon), and sign the necessary paperwork.

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Change into my scrubs  and head into the operating room.

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My scrub nurse, Jackie, enjoys 80’s Pop music in the OR just like I do!

 

8:45 am : Surgery is finished.  My second surgery canceled at the last minute, so there was no time to move up another patient.  So, now it’s coffee time! Yes!  I always go to Padovani’s.  It’s a cute little shop 2 doors down from the surgical center in Dole.  They have wonderful hand made gourmet chocolates, delicious cappuccinos and fresh muffins (my favorites are the pineapple and and mango)

Phillipe Padovani, owner and chef.

Phillipe Padovani, owner and chef.

Now, I usually wait about 45 minutes to an hour for the patient to be awake enough to perform suture adjustment on him.  So, I grab my usual bench and get to finalizing some charts on our electronic medical record system, EMA.  Paper charts are still way faster than electronic charting, but at least I don’t have to carry 25 charts with me in my bag.  It’s all on the iPad.  I am WAY behind, as usual

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9:45am-10: Perform suture adjustment.  I’ll do a separate post on this next month, but this is basically when I can fine tune the eye muscle surgery to make sure the eye is aligned exactly where I want it to be post-operatively.  My surgical coordinator in the office, Ronnie, is my scrub assistant in the OR when I operate at Eye Surgery Center and she is fantastic.  A real joy to work alongside.  And, the patients adore her as well.  She assists me with the suture adjustment as well.  I am lucky to have her as part of our team!

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Ronnie, surgical coordinator, scrub assistant and all around awesome girl!

I change and drive Ronnie and I back to the office.

10:30-12 pm.  All the fun, sexy stuff that goes into being a physician and administrator (that’s sarcasm, in case you can’t read into that).  Finish my charting, sign all the paperwork for the company 401K, talk to our financial adviser at Morgan Stanley about the conversion from Nationwide to Mass Mutual, decide upon profit sharing contributions.  Fun, fun, fun!

12-12:45 pm: Reconcile bank statement for July.  Try to locate a missing payroll report from that time period. Did I mention how much fun this stuff is?  Oops – forgot to bring leftovers from dinner to eat.  Thank goodness, one of my staff, Brandi, was kind enough to grab food for me so I can eat while at my desk.  I have the best staff.  But, quickbooks is still not working and syncing with my bank, even after spending 1 hour 38 minutes with them on the phone on my day off.  I’m not in a good mood.

Yes, this is my desk - 2 monitors, an iPad and tons of bank statements.  With a spicy poke!

Yes, this is my desk – 2 monitors, an iPad and tons of bank statements. With a spicy poke!

I’m a very neat person, but my desk at the office is always cluttered.  I think I’m just mid-project all the time.  I remember when they were filming the Hawaii National Bank commercial and they wanted to shoot an action shot of me working at my desk.  I started cleaning my desk and they said “No, no, keep it.  It’s more authentic”.  OK, so now, it’s out there, I have a messy desk.

12:45: First patient is ready for me to see. Steady stream of patients until 3:45.

3:45 pm: My gorgeous girlfriend, Amelia, arrives for our cosmetic event we are having that, yikes, starts in 15 minutes!  We’re having a high tea party with stations for colored contact lenses, Botox, and hair/make-up by Amelia.  And, I have to help get everything set up pronto, though my office manager, Sara, has already done a ton.  I kind of fell into doing Botox about 7 years ago.  I was meeting with Thomas, the rep for Botox to ask about purchasing Botox for medical purposes (strabismus surgery) and he asked if I considered doing cosmetic Botox.  My training in cosmetic Botox was injecting my attendings with the leftover  Botox that we had used for medical reasons (since it has to be thrown away anyway).  And, I do enjoy it – I don’t ever want to be a primary cosmetic surgeon, but it does help people feel happier with how they look.  Most of my patients, are moms of the kids I examine for their eyes!

4-6 pm: Cosmetic event.  It’s a great turnout and all of the guests have a blast.

 

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My friend, Amelia, performing a mini-makeover. Who wouldn’t want to look like this girl?

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Our optician, Joel, doubles as a personal butler.

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Dr. Bossert explains the technology behind the new colored contact lenses

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My friend and I, with our hair styled by Amelia.

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6:10 pm:  Yowser, I was supposed to leave 10 minutes ago for my son’s 1st grade orientation, which got rescheduled at the last minute.  I stuff some sandwiches on a plate and eat while I drive.

6:30-7:10: 1st Grade Orientation.  I’m an hour late.  It started at 5:30, but at least my husband made it there on time.  The kids each drew a picture for us.  Here’s my son’s.

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“Do not feel bad if you come late ”  Uggh.  The guilt of being a working Mom!

7:30 pm: Back at home.  My oldest and youngest are asleep.  But, my middle child takes forever to fall asleep.  He comes out when we get home and asks for a massage.  He’s such a high energy boy, so I started doing nightly massages with essential oil to help calm him down.  Now, he expects it and chooses his scent.  Sorry, future daughter-in-law!

8:00 pm: All kids asleep! I settle in on the couch to do some Netflix binge watching while I do, what else?, finish charts!

 

 

 

I see a lot of styes in my practice as a pediatric ophthalmologist.  Adults and kids get them and they can be slightly painful, tender and look terrible.  Most patients are concerned that styes are an infection (which they are not) and want quick treatment for them.  Usually our adult patients come in for an appointment, having researched online (I admit it, I consult Dr. Google as well), and want the stye cut out.  Sometimes, that’s not am immediate option.

A stye is a term that people use to describe two different medical conditions interchangeably.  Sometimes, people are referring to a hordeolum.  And, sometimes, they mean a chalazion.  What’s the difference?  And, what is a stye anyway?  A chalazion is simply a blocked meibomian gland.  The meibomian glands are these tiny glands that secrete oil for your tears.  The oil is necessary for the proper composition of tears in your eyes and prevents your natural tears from evaporating too quickly.  You have about 40-50 meibomian glands along the upper and lower lids, right on the inside aspect of the lid, located next to the lashes.

Meibomian gland picture jpeg(Side note: you may have noticed that I have black and white diagrams for most of images now.  That’s because I hand draw all of the pictures for the blog so that I am sure I am not mistakenly using any copyrighted images.  So, please do not reproduce these images without my consent)

When the meibomian glands are blocked as in the picture below, people get symptoms of dryness, redness, inflammation, foreign body sensation, burning, itching and stinging.  You can see the oil squeezing out of the glands while the examiner is compressing the eyelid.  I’m going to warn you the next 2 pictures are a little graphic, you might not want to view these if you are eating right now.
The easiest way to unblock these oil glands is by performing hot compresses for 5 minutes twice a day.

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meibomian gland zoom jpeg

 

When a gland gets really obstructed and acutely inflamed, then it is a hordeolum.  It’s red, tender and slightly painful.  Again, it’s not an infection, but think of it almost like a pimple.  When the lid is still hot and red appearing like this, surgical excision should not be performed.  That’s because you can get scarring if it’s operated upon when the eye is inflamed.  Here this little boy who I saw a few months ago with a really large hordeolum on the left upper lid.

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Treatment for this includes hot compresses for 15 minutes three times a day.  Some kids (and adults) dislike doing hot compresses with hot water because of the wetness and the fact that it doesn’t stay hot for the full 15 minutes and must be continuously rewet.  So, often I will recommend  preparing the hot compress by using a clean athletic sock and filling it with one cup of uncooked rice.  You can also add flax seed which takes longer to heat than rice, but is also smoother and stays warmer longer.  Don’t pack it in tightly; leave some room for the grains to move around so that it will more easily conform to the area to be treated.  Use a thick athletic sock so that the grain will not poke through the sock.  Use a rubber band to close the top or if you are using a tube sock, you can knot it.  Place it in the microwave for 30-60 seconds.  Check the temperature on the back of your hand before placing it on your eye.  It should be warm, but not uncomfortably hot.  Place it on your closed eye for 15 minutes three times a day.

I have about 3 of these socks lying around – I use them whenever I feel the earliest start of a stye forming.

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If started early enough, hot compresses will be sufficient to resolve the hordeolum by opening up the oil gland.  Below is a picture of the head of the hordeolum.  Note the beefy red bump on the inner aspect of the lower lid.  The goal is for this to drain with the hot compresses.IMG_7518

 

Sometimes, a combination antibiotic/steroid drop (Tobradex, Maxitrol, Nepolydex) will be started at the same time as the hot compresses.  The steroid helps decrease the amount of inflammation surrounding the blocked oil gland.  The antibiotic helps to combat the bacterial infection of the oil gland.  If these treatments are not sufficient, then the hordeoleum can sometimes progress into a chalazion.  A chalazion is a granuloma – basically when the body has begun to wall off the infection.  Therefore, drops are not as effective in treating chalazion.  Often times, I will recommend omega three supplements or flaxseed oil for multiple chalazion.  And, there has also been some data that reducing milk in your diet may help decrease the incidence of chalazion as well.

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If none of these modalities are effective, then the only treatment left is surgery.  Basically, the chalazion is incised and drained after injecting local anesthetic along the eyelid for pain.  The clamp (pictured below) is used to evert the eyelid to gain better access to the chalazion.

Chalazion clamp applied to lower lid

For adults, this can be an in an office procedure.  For kids, I always do this in the operating room under general anesthesia.  Oral antibiotics are not necessary after the procedure, I only prescribe antibiotic ointment post-operatively.  Usually sutures are also not necessary, since typically the incision is made on the underside of the skin.  If a skin incision needs to be made, then sutures will probably be placed.

 

There you have it – styes and what to do to hopefully prevent them from requiring surgery.

 

 

 

 

I love what I do.  Sometimes, it’s challenging, but it is always rewarding.  Most patients don’t really understand what it is I do, or my training.  I’d say 90% of the people out there don’t even know exactly what an ophthalmologist is!

So, here is summary – I am specialty trained in pediatric ophthalmology and adult strabismus.  This means, I am an eye surgeon as well as an eye doctor.  After medical school, my husband and I both did internships and then proceeded on to our residencies in ophthalmology for 3 years where we learned how to perform eye surgery.  I then went on to finish a fellowship in Boston in pediatric ophthalmology and adult strabismus.  These two are linked together since children often have strabismus, or misaligned eyes (eyes that point in different directions) and the training covers how to address this condition in both kids and adults, as well as other childhood eye diseases – glaucoma, congenital cataracts, blocked tear ducts.  When I was on at Boston Children’s Hospital, I did more pediatric surgeries since there were several senior members of the department who who were expert in adult strabismus (which tends to be more complicated).  However, when I moved to Hawaii, my surgical practice shifted and I started doing more of the more difficult adult strabismus cases.  Both types of rewarding and below is a testimonial from an amazing patient who I had the privilege to meet when he was visiting Hawaii to take care of his sister.  He is a firefighter from NY and hearing his NY accent definitely made me miss the 8 years I spent there.  Crazy to think I’ve been living in Hawaii now almost as long as I lived in Manhattan!

Anyway, here’s a before/after picture of Ed:

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Before strabismus surgery

 

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After strabismus surgery

 

One thing to note is that the procedure is NOT cosmetic surgery.  It is covered by health insurance because it causes double vision in adults or poor vision in children.  Even people who are blind in one eye and it’s wandering out – it is still covered under insurance.  I’m so surprised when patients come to me and say “Doc, I’ve been going to an eye doctor for 30 years and they said nothing could be done for this”  or “My eye doctor told me that medical insurance won’t pay for this surgery”  If you take away one thing from this post, please let it be that strabismus surgery is not a cosmetic procedure and is covered!

Forgive the editing of the video below – it was my first attempt at using iMovie.  And, the music that I dubbed in is actually Jeff, my husband, playing slack key guitar (he’s self-taught, very amazing!)

Strabismus surgery involves tightening or weakening the eye muscles to better align the eyes.  I did the adjustable suture form of strabismus surgery for him.  I do that for all of my adult patients.  Basically, it allows me to fine tune the surgery after the patient has woken up from the general anesthesia.  I can actually pull on long stitches connected to the eye muscle when the patient is awake and adjust the surgery further.  Since pa.  Strabismus surgery is a whole another post that I will get to next week, with some cool pictures!

It was a real honor and privilege that Ed trusted me enough to perform surgery on him when he was out here visiting Hawaii.  I truly enjoyed working with him and I’m so glad he finally had the surgery done.

 
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Why do my child’s glasses keep getting stronger? This is one of the most common questions I encounter in my practice.  I see a patient after they have failed their vision screening exam at their pediatrician’s office and diagnose them with nearsightedness.  The following year, their myopia is worse and the glasses prescription has to be increased.  The year after, same thing happens.  I always reassure parents,”‘This is normal.  Expect the prescription to increase every year until they hit college age”.  But, of course, as a parent, it’s worrisome.   Parents always ask me about TV/video games/foods they can eat, anything that could help “strengthen” their children’s eyes.  Before, I would have to tell them that nothing could be done, it was just genetics.  But, not so anymore!

But, first, let’s just review what is myopia?  Myopia is what most people often call nearsightedness  – you can see up close, but not far away.

 

Myopia is the most common refractive error in kids, and it’s on the rise. My son is obsessed with asking if my husband is nearsighted or farsighted after we read this page in the Cat in the Hat book at bedtime.

 

For myopes, the light rays from the outside world are focused just in front of the retina.  It can be because the eye is a little longer than usual (axial myopia), sometimes for adults, it’s because there is a cataract refracting the light differently.  But, let’s stick to the kids for this discussion.

Myopic eye diagram

So, it makes sense if one parent is myopic, then the child has a good chance of becoming myopic as well.  Eye size is inherited just as hair color, height, etc.  My boys don’t wear glasses for real (though they are modeling them in the picture above), but I should qualify this as a YET.  I am not nearsighted, nor is anyone in my immediate family, however, my husband’s side is a different story.  So, there certainly is a good chance that they may require glasses in the future.

Now, here’s a little throwback to high school physics.  For nearsighted individuals, the lens shape (concave) helps to focus the light on to the retina.

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Now, to the good stuff?  What can be done?  Two new studies have come out which have had some very promising results in terms of decreasing the progression of nearsightedness in kids.

1.  Increase Time Outdoors

One study examined 2000 children in Australia and specifically looked at the type of activities children were doing.  They then followed-up the kids 5- 6 years later to figure out which activities seemed to make a child more nearsighted.

  • Time spent indoors
  • Time spent doing near work (reading, homework, iphone, etc).
  • Family history of nearsightedness

So, what does this mean.  Being outdoors in the sunlight, is protective.  Kids who spent 1-2 hours/day outdoors, were on average a whole diopter less nearsighted than their peers who did not.  That would mean -3.00 prescription instead of a -4.00 prescription. And, the more time kids spent indoors on devices made their myopia worse.

But time spent doing near work, in and of itself, did not cause nearsightedness.  So, the belief that too much time spent on the iPad/iphone will cause a child to need glasses is incorrect.  I am asked this leading question at least daily by parents “Using the iPhone or playing video games is bad for the eyes, right?”  .  They look at me hopefully, expecting me to dispense a lecture to the kids of the dangers of said devices.  But, unfortunately, it’s just not true.  Now, what I do tell them, is that first and foremost, too much time spent on these devices is not great for their brain.  A policy statement issued  by the American Academy of Pediatrics warned about the dangers of attention problems, sleep difficulties and obesity from too much time spent on media devices.  However, there have been no conclusive studies which link media devices with eye or vision problems.  BUT, when kids are playing on these devices, it does make it more difficult to get them outdoors, in the protective UV light and that can make them more nearsighted. So, is it the bright light or the UV light that’s protective?  Well, studies in animals seem to indicate that it might just be bright light which is helpful, though it’s still too early to draw conclusions.  However, I still recommend that kids should always wear protective hats, sunglasses and clothing when outdoors, especially here in Hawaii.

Being myopic is not just a pain for children to wear glasses, it can also have serious consequences in terms of the health of a child’s eye.  People who are myopic have longer eyes than individuals who are not.  That predisposes them to having retinal tears and detachments if their prescription is higher than -6.00 D.   It’s basically because the same amount of retina is being stretched more in a myopic eye than in a normal eye.  This can leads to areas of thinning or tears which can cause retinal detachments.

 

2.  Atropine 0.01%

Another important study assessed the effectiveness of a dilute version of a dilating drop – atropine – in delaying the progression of nearsightedness.  Studies have been done with different strengths of this drop in the past, but as you may know from going to the ophthalmologist, even when dilute, dilating drops can cause side effects, like blurry vision and sensitivity to sunlight.  But, this study looked atropine 0.01%, which is 1/100th the strength we use in the clinic.  When administered daily to kids, it slowed their nearsightedness and also decreased the elongation of their eyeball.  Therefore, they were less at risk for those dangerous retinal tears or detachments.  I now offer these drops to a high select group of patients who have nearsightedness which is worsening quickly.

Schools in China are already applying the outdoor time in an effort to decrease their incidence of nearsightedness.  And, for those kids for whom this preventative treatment is not enough, then there is hope with the atropine drop.  As more studies come out, the research will be even better in helping us slow nearsightedness in our kids.

© 2011 Honolulu Eye Doctor & Mom Suffusion theme by Sayontan Sinha