Category : Pediatric Ophthalmology

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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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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.

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.

 

 

Preventing Sports-Related Injuries in Kids

I was listening to the radio the other day about the new concussion policy rules that a lot of youth football leagues now have in place.  It started me thinking about the many eye injuries I see as a consequence of sports and trying to increase awareness about these potentially devastating, completely preventable injuries.  I’m a little late – September was Sports Eye Injury Prevention Awareness Month (that doesn’t exactly roll off the tongue, does it?)  But the message is important, even if the name of the month is a bit long.

Below is one of my favorite patients and what happened to him should serve as a cautionary tale for all parents whose children are involved in sports.  This kid was 10 years old, playing baseball and accidentally walked behind the batter.  He was struck in the face with the bat (accidentally) and suffered from numerous fractures of his face, the bones around his eyes and lost vision in the right eye from the trauma.

Dr. Timothy McDevitt was able to repair the fractures in Kaliu’s face and I performed surgery to straighten his eyes.  Here he is post-op.  Click here for his mother’s testimonial about her son’s surgical experience at Honolulu Eye Clinic.


He looks great post-operatively and we were able to make the eye look much more normal. Unfortunately, there was no way to restore his vision in the right eye.  As a mother of 2 young boys, this kind of preventable injury hits close to home.  I always think that an injury like this could have been prevented if all of the children on the baseball field had been required to wear sports goggles (also called recreational spectacles).

One problem I’ve noticed is that often kids (and even their parents) will wear their regular glasses when playing sports.  But, you shouldn’t!   More than 40,000 sports-related eye injuries occur every year.  Blunt trauma, such as a ball hitting the eye cause the majority of these injuries.  Some parents also mistakenly think that the helmets with face shields are enough to project the eyes (like football helmets).  But, this is not true.  Your child’s eyes are still exposed to penetrating sports equipment or fingers! Kids and teens have high rates of sports-related eye injuries because of their wide involvement in athletics in school and their tendency to play aggressively. The types of eye injuries can vary including:

1. Corneal abrasions

2. Bleeding in the eye (hyphema)

3. Fracture of the bones surrounding the eye (orbital fracture)

4.  Retinal detachment, or even rupture of the eye.

 

Depending upon which part of the eye is damaged, permanent vision loss can result and surgery may be required to repair the eye. Wearing eye protection significantly reduces the risk of these injuries by ninety percent!

Recommended Protective Eyewear
Many people mistakenly believe that regular glasses or contacts can protect their eyes. Yet, glasses can break upon impact causing a penetrating injury to the eye and contacts do not protect the eye at all.
The American Society for Testing and Materials (ASTM) has standards for the types of sports goggles to be worn in various sports. All sports goggles should be made from polycarbonate.   Polycarbonate is a high-impact resistant plastic that offers UV protection and can be made in prescription or non-prescription lenses. Regular eyeglasses only have 5 percent of the impact resistance of polycarbonate lenses.  Even though all children’s eye glasses are made from polycarbonate, the frames can still bend and break in the eye, making them unsuitable to wear during sports.

At HEC, we carry Liberty Sport goggles, so I’m most familiar with them, pictured below.

They are a type of protective goggles especially designed to be worn during sports. Fitting most prescriptions, Liberty Sport brand goggles are tested and approved to withstand high impacts. They have very soft padding on the bridge and sides of the frame aimed to protect the bridge of the nose as well as the temples. Their wrap design helps prevent dirt, dust, and even UV rays from damaging the eyeball and the delicate areas surrounding the eye.  Liberty Sport goggles automatically come in the polycarbonate lens material mentioned above and can be ordered clear, or with polarized sunglass lenses, or also with Transitions Lenses (also known as photochromic lenses)–which turn from clear indoors to dark, sunglass-type lens when exposed to UV light outdoors.  They are also designed to fit under sports helmets (baseball, football, etc). And the best part, as mentioned above, is that we can customized them with yours or your child’s glasses prescription in them.  I have some patients that like to wear these as their regular glasses! Of course, they also come in a wide variety of colors and styles.

Whichever type of sports goggles you choose, just make sure that it has polycarbonate lenses and is certified by American Society for Testing and Materials as safety goggles.