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Blocked Tear Ducts

NLDO in Taj

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

Blockage at the end of lacrimal duct

 

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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How can I prevent my child's glasses from getting stronger?

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.

Screen Shot 2015-03-17 at 12.56.21 PM

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.

2012 – Year in Review

It will definitely take me another month to get used to writing 2013 as I sign charts in the office.  Unbelievable how fast 2012 went by.  And, a lot was accomplished in 2012 at Honolulu Eye Clinic.  Here’s a little recap of our favorite moments/accomplishments of 2012!

1. Our office renovation was begun and completed (though almost wasn’t completed!).  Amidst a contractor who declared bankruptcy mid-way through our project and the fact that I was coordinating everything while on maternity leave, somehow our renovation was finished.  Click here to see our fist blog about demolition (I was so excited and naive to think things would be completed without a hitch!).  And, click here for the post about the progress.  If you haven’t been in yet for your annual eye exam, here’s a look at the finished office.

2.  Jeff and I made the Best Doctors in Hawaii list and were featured on the cover of Honolulu magazine.  Click here to read about the photoshoot.

3.  We had 2 glasses trunk shows (Gucci/Dior and Fendi/Valentino).  Below are pics from the latest trunk show.

 

4. We were featured in Midweek twice – in the Business Roundtable section and the Doctor in the House section.

5. Taj (my second son), turned one !

6.  We added some amazing staff members to our HEC ohana (Summer, Amalis, Amber, Michelle, Jocelyn, Lauren, and Sam join verteran HEC staff – Lia and Grace).  See how we’ve grown over the past 4 years!

[caption id="attachment_762" align="aligncenter" width="639" caption="September 2009 (one year)"][/caption] [caption id="attachment_761" align="aligncenter" width="640" caption="August 2010 (two years)"][/caption]

 

[caption id="attachment_760" align="aligncenter" width="695" caption="April 2011 (2.5 years)"][/caption] [caption id="attachment_759" align="aligncenter" width="695" caption="April 2012 (3.5 years)"][/caption]

 

[caption id="attachment_763" align="aligncenter" width="695" caption="November 2012 (4.25 years!)"][/caption]

 7.  I published my first textbook on strabismus surgery.

8.  We had 4 cosmetic open house events, including the very successful Mommy Makeover event.  Below are pics from our last one in December – Gold Medal Glam – Beauty for Athletes.

 

9.  421 likes on Facebook.

10.  Judged the Miss Chinatown competition this past fall and met some amazing young leaders in our community.

Thanks to all of our patients, friends and family for your support throughout the year!

Foods for healthier eyes (with recipes!)

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!