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.

 

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.

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.

  1. Laser treatment  used to seal off the leaky blood vessels.
  2. 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.

print recipeKale 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.

print recipeSaag Paneer (Indian spinach-cheese curry)

 

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.

 

print recipeKale 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!

 

 

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**

 

 

 

 

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 (UPDATE: Even my little baby girl had NLDO, so all 3 of my kids had this).  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

Blockage at the end of lacrimal duct

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.IMG_1939

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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