Category : Ophthalmology

HomeArchive by Category "Ophthalmology"

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.

 

       .       

 

Fixing lazy eye: Strabismus patient testimonial

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:

[caption id="attachment_1349" align="aligncenter" width="300"]valentine Before strabismus surgery[/caption]

 

[caption id="attachment_1348" align="aligncenter" width="300"]DSC_0061 After strabismus surgery[/caption]

 

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.

Are You Taking Care of Your Contact Lenses?

For this week’s post, we have Dr. Jenifer Bossert, Optometrist and Director of Contact Lens Services at Honolulu Eye Clinic.  She recently appeared on KITV news to discuss serious dangers of improper contact lens storage which could be putting your eyes at risk.

 

In addition to disposing of your contact lenses in a  timely manner, here are a few other things you could consider:

When was the last time you really looked at your contact lens case?

When was the last time you actually replaced your contact lens case?

Did you even know you were supposed to replace it?

Several studies have confirmed that 70% to 82% of cases show contamination from overuse.  And only 26% of patients replace their cases periodically, 48% once per year, and the remainder, never!  Median frequency for cleaning cases was 2-3 times per week and one third cleaned only once per month!

Lens cases are hotbeds for bacteria and fungal colony growth…despite the addition of the Multi-Purpose Solution (MPS) contact lens solutions.  Cases are made from porous plastics.  Over time a “biofilm” coats the inner surface of the case.   This serves as a breeding ground for bacteria.  These bacteria become embedded in the pores of the case itself.  Even IF you properly follow contact lens cleaning and rinsing instructions, these nasty bacteria still find a way to grow.

When present, they can attach themselves to the micropores in the contact lens, multiply, and form this undetectable film on the contact lens, which is then transferred to the eye upon insertion.  These deposits irritate the cornea–the soft clear tissue on the front of the eye—causing the wearer to rub the eye and the eye to appear red.  The back and forth pressure from rubbing makes microscopic scratches on the surface of the eye. These small breaks in the tissue act as open pathways for the bacteria to invade the eye, thereby, increasing your risk for a bacterial infection and/or corneal ulcer.

[caption id="attachment_1246" align="aligncenter" width="446" caption="Recent corneal infection in contact lens wearer at Honolulu Eye Clinic"][/caption]

Your best line of defense is following these instructions EVERY day:

  •  NEVER “top off” and reuse the solution in your case for a second day.
  •  After removing contact lenses, empty the case,  and rinse it with fresh MPS (not water).
  •  Turn it over (to keep the dust out) and let it air dry.
  •  REPLACE the case every 3 months.

Following these simple rules will reduce your risk of case and contact lens contamination.  Please remember that not all contact lens solutions are MPS (i.e. disinfecting) solutions so it is important to read the labels.  Saline is NOT a disinfecting solution.  If you have any questions regarding the proper solutions to use with your particular contact lenses, don’t hesitate to call and ask your doctor or the staff here at the Honolulu Eye Clinic!  We would love to hear from you!

What does my glasses prescription mean anyway?

This is probably one of the most common questions I get.  Even though my husband and I are ophthalmologists (eye surgeons), we still do a large number of glasses and contact lens prescriptions.

Here’s my son, Taj performing his first refraction with the phoropter when he was 1.5 years old. This picture was taken at the Children’s Discovery Center, our equipment in our office is much newer than this!

[caption id="attachment_1179" align="aligncenter" width="695"] Taj adjusting the phoropter[/caption]

Refraction is the term used to describe that process of fine tuning your glasses prescription when you sit behind the phoropter. Everyone gets so nervous when we ask “Better 1 or 2”.  They don’t want to get the answer wrong.  And, the thing is there is no wrong answer.  Your glasses prescription is individualized to suit your needs.  And, most optical shops (like ours) can always redo the lenses for free for three months if you end up getting the glasses and they just don’t seem to work for you, even after giving them a couple weeks.  So, that should take the pressure off.

So, you did it – finished the dreaded “1 or 2” test and your doctor hands you a prescription.  It’s like an ancient language – what does it all mean??? OD, OS, Sphere, Cylinder, Axis, Add??

 

OD and OS

First, OD and OS.  OD stands for oculus dextrous, for those of you who took Latin in high school, which means right eye.  OS stands for oculus sinister, for left eye and OU stands for oculus unitas or both eyes

 

Sphere (Sph)

This refers to the spherical lens necessary to sharpen your vision to 20/20 (if possible for you).  The number is the amount, measured in diopters, needed to correct nearsightedness or farsightedness.  In this example, this patient has a minus in front of the number because he is myopic or nearsighted.  This patient can see near, but not far. Whether the number is plus or minus, the higher the number, the stronger the prescription.

This patient’s eye is a little longer than normal, so the light focuses in front of the retina instead of on it.

Myopic eye diagram

 

A minus spherical lens, or a concave lens, helps focus it onto the retina.

Screen Shot 2015-03-17 at 12.56.21 PM

Here’s another prescription with a plus number in the sphere column, meaning this patient is hyperopic, or farsighted.  That means this person can see far away, but not up close (that’s only for adults).  Though, that’s not entirely accurate – most kids are hyperopic.  As their eyeball elongates, they outgrow this farsightedness – but, their vision is never affected by it because their eye is so flexible it’s able to focus past the farsightedness, giving them 20/20 vision.

This patient is a child and her eye is a little shorter than is normal, so light comes to focus behind the retina.

Screen Shot 2015-03-17 at 12.56.27 PM

A plus spherical lens, or convex lens, helps focus the light onto the retina.

Screen Shot 2015-03-17 at 12.56.44 PM

Cylinder (Cyl)

There are two types of lenses in glasses prescriptions – sphere and cylinder.  Cylindrical lenses are used for correcting astigmatism.  Sometimes new patients come to me and say, “I have…..ASTIGMATISM” (que the scary music).  It’s almost as if it’s a terrible disease (which it’s not).  Astigmatism just means the front of your eye, or the cornea, is shaped more like an egg or football, instead of being perfectly spherical like a ball.

Most people have some astigmatism.  For people with astigmatism, it means that images are slightly stretched horizontally or vertically, like a fun house mirror.  This number can be minus or plus, but practices tend to stick to one sign.  In our office, all our prescriptions are written using minus cylinder.  If you don’t have a number in this column, it means you don’t have any astigmatism.

Axis

Axis refers to the direction or position in which the cylindrical lens is pointed to correct the astigmatism.  It’s measured in degrees.  If your prescription doesn’t have a cylinder number, then it won’t have an axis number either.  Remember high school geometry?  That’s what the axis refers to, just like your old protractor.  Do they still use protractors in high school?  Probably not, I bet there’s some app for that now.

cyl axis

Add

This number is also measured in Diopters and refers to the extra magnifying power needed to help you see up close if you are presbyopic.  Presbyopia is the condition which affects most individuals over the age of 40.  You probably know the signs if you fall into this age group – reading, using your phone, all starts to get a little harder and you have to hold things far away for them to be clear.  That’ presbyopia. If you wear bifocals or progressive glasses, then there will be a number in this column.  Add power is always a plus number and it can range from as low as +0.75 to +4.00 (in rare cases), though the normal add powers are between +1.25-+3.00.

Prism

My patients will have a number in this column.  This is for correcting eye misalignments (strabismus) and reducing double vision.  Depending upon the type of strabismus (eye drift up, out, in or down), the prism will be oriented in different directions to counter the eye misalignment.  Most people do not need prism in their glasses.

And, we’ll close with my favorite pic from the Cat in the Hat – it’s actually very accurate!

Product Spotlight: New Colored Contact Lenses at HEC

Honolulu Eye Clinic is so so excited to be one of the first clinics on the island to carry the new AirOptix Colors Contact lenses.

I’ll admit it – when I was young, there was nothing I wanted more than green eyes.  There was an auntie I used to babysit for down the street.  She was Indian with these gorgeous silver/green eyes and I used to tell my parents – “When I’m 18, I’m going to get colored contact lenses” . I wanted to look like the famous Indian actress (and former Miss Universe), Aishwarya Rai.  That’s her real eye color.

Fast forward to 2008 when we took over Honolulu Eye Clinic.  Finally, I thought, colored contact lenses.  The only option was the Fresh Look colors and alas, try as hard as I could, I could not get those contacts on to my eyes.  I thought it was just my inexperience wearing contact lenses, since I don’t wear glasses and have never needed contacts.  But, even when I had our stellar staff put them on for me, they were incredibly uncomfortable and moved all over the place on my eye.  On top of that, they blurred my vision.  I finally checked my corneal measurements and realized that my corneas were too flat for the standard size that the Fresh Look colors come in.  So, I resigned myself to having brown eyes (OK, I’m being a bit melodramatic).

But, just last month, Alcon introduced AirOptix Colors and it’s a contact lens I can actually wear!  The fit is comfortable – much less movement and drying than the previous iterations.  The Dk constant (which is just a measurement of how much oxygen the lens transmits) for the AirOptix is 6 times more than the Fresh Look Colors.

And, the colors are so much more natural.  My husband does not care for the fake, artificial colors of Fresh Look and these new AirOptix ones just make your eyes pop but in a subtle manner.  They have a 3 in 1 color technology, which enhances your natural eye color (instead of just covering it).  The outer ring defines and intensifes your eyes.  The primary color enhances your eye color and the inner ring adds depth and natural richness.  The colors are are on both surfaces of the contact lenses, which makes the color more life-like.

Here a pic of me wearing the green (subtle).

[caption id="attachment_1143" align="aligncenter" width="695" caption="Air Optix Colors in Green"][/caption]

 

 

[caption id="attachment_1139" align="aligncenter" width="259" caption="AirOptix in Gray"][/caption]

 

I hate taking selfies.

And, last one of me wearing just one green contact lens.

[caption id="attachment_1142" align="aligncenter" width="300" caption="Green contact in right eye and normal in left eye"][/caption]

Here’s some of my staff. Sam has beautiful blue eyes.  But, she likes to change it up,so she’s wearing a hazel contact lens in her right eye.

 

Sofie is wearing hazel on the left side.  Wouldn’t you just kill for those lashes?

And, last our optician, Becca who has beautiful brown eyes, but likes to play with the gray contact lenses.


The Air Optix website has a fun virtual studio, but nothing is as good as actually trying on the contacts on your eyes.  Please call us if you would like to try the new Air Optix colors.  They are monthly lenses and currently come in plano (no power in the lens) and minus powers (nearsighted).  The plus powers are supposed to come out by the end of the year, though they are not yet available.

Keep Your Eyes Healthy: Make-up Safety

We all do it – use make-up even when a nagging feeling tells you that you should probably toss it.  I know, it hurts to throw away your $30 tube of mascara, just because it’s been three months.  What’s the harm?  And, I’m pretty pake (that’s cheap for any readers who aren’t from Hawaii), so I think back in med school, I’d use the same mascara for a year.  But,now I know better.  Microbial organisms are present on your lashes and they can flourish in tubes and bottles when given the chance. Serious eye infections can occur, so I’m listing some guidelines to follow with eye make-up.

1. Toss your mascara every three months

You’ve probably read this in your beauty magazine or blog, but where did this magic 3 month number come from?  A study done almost 40 years ago in a very reputable ophthalmology journal showed that bacterial and fungal growth was found in 36% of mascara tubes after 3 months.  So, now ophthalmologists make the recommendation to discard your mascara after 3 months.

Like I said, I know this one is painful.  A little tube of Diorshow costs over $28 (I used to love this mascara) and I totally didn’t used to do what I knew in my heart was the right thing to do – throw it away after 3 months.  Think about it, you double dip your mascara wand and there are numerous normal bacteria on your lashes.  Once you apply your mascara, you’re putting that cespool of bacteria back into a liquid/gel bottle and sealing it tight.  That means staph and strep are growing and replicating inside your mascara tube.  Convinced now?  If not, here’s another great little fact – one study found that almost 80% of mascara samples contained Staph aureus and 13% contained Pseudomonas.  Pseudomonas is a terrible bacteria that is responsible for this below:

OK, so, I don’t think there’s ever been a reported case of Pseudomonas infection from mascara, however, that picture will probably convince you to dispose of your mascara in a timely fashion!

Once the mascara starts to smell funny, change in consistency and become clumpy or dry, then you know it’s time to dispose of it.  There are a lot of less expensive mascaras out there which work really well.  And, then you won’t feel so bad to throw it away.  Also, be conscious of the expiration date.  Before I wrote this blog post, I didn’t even realize mascaras had expiration dates – but here it is.  This is from the back of my Fiberwig mascara.

If you look closely, it actually states 6 months, but don’t do it – stick to the 3 month guideline to be safe.

 

2.  Don’t share mascara or eyeliner

Anything that it’s in gel/liquid form can harbor bacteria more than powder form.  Therefore, don’t share!  If I get my make-up done by a make-up artist, I always bring my own gel liner and mascara.  Perhaps that’s being too careful, but I have no idea how long that tube has been open, even if they use a clean, disposable applicator each time.   Honestly, probably the best thing to do is to avoid the samples at make-up counters all together.

3.  Dispose of eye make-up after an eye infection

If you get conjunctivitis (pink eye), even if it resolves with antibiotic drops, you must throw away your eye make-up, at the very least your mascara.  Adenovirus particles can live on the surfaces of inanimate objects for upwards of one month .  And, you likely had the infection even before you started manifesting symptoms.  So it’s not good enough to just stop using the products when you have the conjunctivitis and the resume use once the pink eye improves.

One question I get asked often is if a patient can wear make-up if they have blepharitis.  Blepharitis is not an eye infection.  It’s inflammation of the eyelids, so technically, you can continue using your make-up with blepharitis.  However, there are certain types of make-up which are non-clogging and may be better tolerated by people with blepharitis.   Cosmetics may say “non-comedogenic” but that doesn’t necessarily mean they are oil-free.   AND, blepharitis can be caused by staph – remember, there’s a lot of staph just hanging out on your skin and lashes.   So, if you have the severe form of blepharitis – staph marginal disease – then check with your ophthalmologist regarding make-up use.

4.  Eye shadows (powder form) are good for 1-2 years, but don’t forget to clean your brushes

I have a bit of an eyeshadow addiction.  It started when I moved here to Hawaii.  I would get my make-up done at the MAC counter before our photos for our Honolulu magazine ad and have to buy $50 worth of makeup.  There’s just something so pretty about all the colors.  Anyway, here is the embarassing picture of the contents of my make-up drawer.  I own one eyeliner, one blush and a million pots of shadow.

Thankfully, since most eye shadows are powders, they carry much less risk of bacterial infection.  So, I’m safe to indulge my eye shadow addiction.  Though, now that I pulled out all my eye shadows, I see some in this pile from my days in NYC, which was 8 years ago!  Guess those are going in the trash now.  Another thing is even if eye shadow is safe for 2 years,  people often neglect to clean their make-up brushes and these can harbor bacteria.  I clean my brushes with MAC cleaner.  I’ll also use baby shampoo for a real deep clean as well.

5.  Remove make-up before sleeping (even if you have lash extensions).

This is a great time to review some standard eyelid cleaning techniques.  I see a lot of blepharitis in my adult patients, especially in women who wear lash extensions.  They have the extensions and then wear make-up, but they are so worried about losing their precious extensions, that they don’t clean their eyelids properly.  This almost always results in blepharitis.  Washing your eyebrows and eyelids with antibacterial shampoo (Johnson & Johnson’s baby shampoo is what I prefer) can help control blepharitis.  Put a small bit of dilute baby shampoo on your ring finger and suds right on to the lid margin for 30 seconds on each eye.

 

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.

Gotta Love What You Do

I just did a recent article for Midweek about pink eye.  Feel free to check it out – I just talk about prevention and treatment of conjunctivitis.  But, that’s not the topic of this post.  The Midweek writer’s first question to me was “What got you interested in pediatric ophthalmology?”.   I’m lucky enough that this question is such a non-brainer.  Is there anything better than restoring sight to a child? Complex surgery or a simple pair of glasses – both are so important in the developing vision of children.  That question made me think about one of our my first patients here in Hawaii.  I worked for a year after my fellowship as an attending at Boston Children’s Hospital. but there I was surrounded by senior physicians.  If I needed help on a case, or advice, they were there to assist.  When I moved out here with my husband 6 years ago, it was, honestly a bit terrifying.  I had lost my safety net and I had to build a practice from the ground up, somehow convincing parents that despite looking young and inexperienced, that I actually was a capable surgeon.

Niko was just a 6 year old boy when he came into see me my first month practicing at Honolulu Eye Clinic.

He had previously been living in California and had recently moved to Hawaii.  His mom had noted that he squinted a lot.   Niko was a smart little boy, but he had real trouble with the eye chart.  When I dilated his eyes, I discovered cataractsin both eyes.  A lot of people are often surprised that children and even babies can get cataracts.  It’s obviously much more rare than in adults, but it does occur.   I met with Niko and his sweet mom, Louise and told them that we should schedule surgery for Niko.

[caption id="attachment_1050" align="aligncenter" width="695" caption="Marking Niko's eye for surgery in the pre-op area"][/caption]

This is what Niko’s mom wrote about her experience:

We first found out about a vision problem when Nikolas and I were reunited in Hawaii after a year of separation due to an illness of mine. He spent kindergarten year in San Jose California with my parents and siblings while I received treatment.While in San Jose he complained about not being able to see the board at school towards the end of the school year. When I picked him up and brought him back to Hawaii I decided to take him for a complete physical and suggested to the clinic physician for an eye exam as well.  They tested his eyes and we discovered that he couldn’t read most of the letters. The optometrist doing the exam referred us to Dr. Wong. He said that Niko may have cataracts. I was shocked and worried because he had just turned 6 yrs old.
 
Dr. Wong and her staff were so warm and welcoming. Even before we stepped into the clinic, I had already spoken to her on the phone several times. She told me about herself and her experience that gave me such relief to have found someone that can help my sons condition.  She performed surgery first on the right eye about 4 wks later and the left eye another 4 wks after that. The surgeries went well and Niko mentioned that everything so much brighter than before on the way to school a few days after. I was moved to tears of joy.
He now wears bifocal glasses that he loves and thrives in school. He is always excited to see Dr. Wong and her loving staff for regular check ups. He even mentioned to me several times that when he grows up he wants to become an eye doctor just like Dr. Wong so he can also help others see better.
 

Niko gave me this card.  Six years later, I still keep this card at my house.

After surgery, Niko’s first words to me were “I  can finally see the clock in school!”  His vision improved to 20/20 in each eye.

Each time he came for his post-operative visit, Niko would show off his latest dance moves for my staff.  I mean, seriously, is there anything better than getting that letter from a Mom or this card from a six year old?  He got cute bifocal glasses which he proudly wore all the time.

And, now 6 years later, Niko is an aspiring actor and model!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I know pediatric ophthalmology is not one of the “sexy” subspecialties of ophthalmology.  Everyone wants to do Cornea or Cataract with all the fun laser cataract machines or Retina with the cool new macular degeneration drugs that are coming out.  But, peds/strabismus has its HUGE rewards and I for one, cannot think of anything else I’d rather do.

 

 

Multivitamins and Cataracts

I’ll admit it – I eat gummy vitamins.  It’s the only way I can get myself to remember to take my prenatal vitamins and since I am nursing, it is extremely important for the nutrition of my child.  The beneficial effects of multi-vitamins are numerous – calcium for your bones, omega 3 fatty acids for neurologic development.   Patients routinely ask me if a multivitamin will help prevent the onset of cataracts.  Previous studies which have shown that vitamins can help prevent the progression of macular degeneration, never actually demonstrated that vitamins decrease the incidence of cataracts.  The Age Related Eye Disease Study (AREDS) showed that taking daily high doses of vitamins C and E, beta-carotene, zinc and copper can slow down the progress of age-related macular degeneration (AMD).   These are the vitamins that say “Eye Health” at Costco. One of my previous posts was about this protective effect of anti-oxidants and macular degneneration.  But, what about cataracts?  Well, first – what is a cataract?

A cataract is a clouding of the normally clear lens within your eye, which results in blurred or distorted vision. The lens helps to focus light onto the retina, the part of the eye similar to the film in a camera.  Light enters the eye through the cornea, passes through the natural crystalline lens and is accurately focused onto the retina, providing a crisp, clear image.

 

 

 

 

 

 

 

 

 

 

Cataracts are most often found in older patients but they can occur in people of any age. They can progress until eventually there is significant loss of vision, and neither diet, nor medications, will make the cataract go away. Surgery is required to improve vision.  Some people mistakenly think that a cataract is a growth in the eye and that surgery entails “cleaning the cataract out.”.  That’s not quite the case.  The cataract is removed with laser or ultrasound power and replaced with an artificial lens.

However, a new study examined a group of almost 15,000 male physicians , over the age of 50 and followed them over an average of 11 years.  The study was well designed, it was a prospective, double blind, randomized, placebo controlled trial, done at Brigham Women’s Hospital and Harvard Medical School. Half took a common daily multivitamin, as well as vitamin C, vitamin E and beta carotene supplements. The other half took a placebo.  Researches then followed the patients to assess if they developed cataracts or macular degeneration.  They found a roughly 9% decrease in incidence in the development of cataracts in the group who took the vitamins compared to placebo.  Nine percent may not seem like a lot, but when you think about the fact that over 22 million people in the United States alone have cataracts, that 9% translates to roughly 2 million people who may not get cataracts if taking these multivitamins.  On a world wide scale, it is estimated that cataracts cause 51% of blindness, affecting about 20 million people.  And, though cataracts are treatable, many people in developing countries do not have access to surgical care.  A simple multivitamin could make a huge difference in these lives, either delaying the onset or progression of cataracts

Lash Extensions – the long and short of it

Many of you remember when I wanted to take “The Latisse Challenge” last year.  I was planning on using Latisse and taking weekly photographs of my lash growth.  But, since I was breast feeding my second son, I decided against doing it (Latisse is not FDA approved in pregnant or nursing moms).  And, since I got very quickly pregnant with Arya after ceasing nursing Taj, I really have never had the chance to try Latisse.  I have been jealously checking out  all of the people around me with their gorgeous eyelashes.  Even both my boys have lashes that Kim Kardashian would covet.

 

[caption id="attachment_958" align="aligncenter" width="695" caption="My Boys"][/caption]

To top it off, I have suffered from madarosis with pregnancy.  Madarosis is the medical term for loss of eyelashes and eyebrows.

There can be many different reasons for it – inflammation such as caused by infections, blepharitis, or even allergy.  Or it can be a sign of a systemic disease or condition, toxicity from medications, nutritional disorders, autoimmune disorder (lupus), tumors, hyperthyroidism or hypothyroidism, or traction (did you know that a lash curler can cause lash loss??).  For me, I think it’s been a combination of hormones and my lash curler.  The skimpier my lashes got, the more I tried to make every lash count – so I started curling them which really made things worse.  Oh, and I’m a notorious eye rubber.  I get bad allergies and I never remember to take my Pataday drops and just end up pulling and stretching my eyelid skin, which is never a good thing.

All of this lead me to try lash extensions.  Several of my friends have them and they are super popular here in Hawaii.  Many of my patients ask me about them and I wanted to try it out.  The licensing for lash extensions varies state to state.  In Hawaii, an aesthetician or cosmetologist can be licensed to apply lash extensions, even currently no classes or lectures are taught about lashes in these two fields.  Therefore, anyone can do lashes and you should make sure that the person you choose for your lash extensions does not skimp on the type glue, types of lashes and is diligent with their application.  After all, this is a non-surgeon using crazy glue and sharp instruments approximately 1 mm from your eye!  The American Academy of Ophthalmology cautions about the dangers of lash extensions.  They warn about:

  • Infection of the cornea
  • Infection or swelling of the eyelid
  • Permanent or temporary loss of lashes

I went to a lady who was highly recommended.  The process of lash extensions involves gluing, with cyanoacrylate glue (Dermabond – the same type of skin glue doctors sometimes use instead of stitches), lashes on to the base of your natural lashes.  I have since learned that there are a few different types of lashes – synthetic, silk and mink.  For mink lashes, think the Kardashians or Beyonce.

The adhesive should not be adherent to your eyelid skin.  The first time I had the lashes done, I liked their look and did not have difficulty with them.

The typical lash cycle consists of 4 different phases, and most women have between 100-200 upper lashes on each eye.

 

Therefore, even though it takes a full 3 months to cycle through your lashes, most women will want to get their lash extensions filled in every 3-4 weeks.  I went back for my fill=in and asked for more noticeable lashes.  One thing to note is that I had my baby 3 months ago.  This is important because, as many of you mamas out there know, like clockwork, right around the 3-4 month mark, all that luscious hair on your head that the baby hormones were promoting starts to fall out.  Same is true for your lashes.  Unfortunately, the lash lady saw that I had baby fine lashes, since I was shedding a lot of lashes due to the hormones, and applied extra glue to make the lashes stick better.  The fumes from the glue caused my eyes to tear throughout the entire process. The end result was that the lashes were too heavy and caused most of my real lashes to fall out.  Even though I’m an ophthalmologist, it didn’t occur to me to check the ingredients of the glue used.

 

[caption id="attachment_950" align="aligncenter" width="417" caption="Lash extensions glued to multiple of my lashes with excess glue at base"][/caption]

I looked online for studies regarding lash growth and lash extensions.  You might be scared yourself to try lash extensions because you’ve heard “it causes your lashes to fall out”.  In reality, no study has actually been performed to support or deny this assertion.  But, there are risks associated with lash extensions – irritation, inflammation, infection, allergic reaction and even madarosis.  Some of you may remember Kristin Chenowith showing up on David Leterman wearing huge sunglasses because of an allergic reaction from her lash extensions.

 

Long and short of it, I started developing irritation and redness of my upper eyelid skin from the lash extensions – I wanted them off.  I almost attempted to pull them off myself, but I knew that would result in more missing lashes.

So, I tried another lash stylist (is that what they are called?) who had been highly recommended by another friend.  Kristin Wood of the Kristin Wood salon.  She spent an hour and a half carefully removing all of the excess glue at the base of my lashes and the few errant lashes remaining.  At the conclusion, my upper lids were swollen and red and she advised me to wait  to get new lash extensions until my eyelids had healed.

[caption id="attachment_952" align="aligncenter" width="417" caption="Redness and swelling at base of lashes after lash removal"][/caption]

I knew that was the right call, so I came back in two weeks and she worked her magic.

[caption id="attachment_954" align="aligncenter" width="417" caption="New lashes!"][/caption]

 

One week later, only two of my lashes have fallen out.  The lashes are longer and feel much lighter than my previous ones.  When I touch them, they don’t feel stiff, but soft like my own lashes.  However, most people in the lash industry will admit that lash extensions do cause your natural lashes to fall out more quickly.  So, what should you do to avoid complications from lash extensions?  The FDA and American Academy of Ophthalmology offers the following advice:

  • Check the ingredients of the glue to make sure you are not allergic to it
  • If you have an eye infection or the skin around the eyes is inflamed, avoid lash extensions (as I did initially)
  • Make sure that the technician applying your lashes wears gloves and practices proper hygiene
  • Ensure that the aesthetician is properly certified and working at a reputable place.

If you develop an infection from the lash extensions, resist the urge to pull them out yourself.  Go to an ophthalmologist for treatment. An ophthalmologist can prescribe an antibiotic or antiobiotic/steroid ointment.  The lashes will fall out over the period of about six weeks and with it, the glue should also fall out in that time.

Also, beware of a lash stylist who tells you not to get your lashes wet at all.  Usually, you shouldn’t get them wet the first 24 hours, but after this, you should clean your lashes and remove make-up with an oil-free make-up remover.  Kristin advised to perform the same baby shampoo lid scrubs that I recommend to my patients with blepharitis to prevent build-up of protein and oil (and this was before she knew I was an ophthalmologist!)

So, what do I think of lash extensions?  I had one experience which seems to echo everything that the Academy of Ophthalmology warns about – glue on the base of the eyelid skin, allergic reaction and lashes that were too heavy for my natural lash to sustain, thus causing traction madarosis.  And, I had a great experience with another lash stylish with no complications.  So, the choice is yours – lashes, Latisse, good old fashioned mascara, whatever you choose, be safe and make your eye health your top priority, don’t just look for a good deal.