There are only a few things more frustrating than dealing with constantly burning, itching and irritated eyes. Coworkers and friends ask if you have been crying or are sick. You look tired. Contacts are hard to put in. Figuring out what is causing the chronic irritation can be incredibly frustrating. As a cornea and dry eye expert, I see this type of situation daily: patients who have tried endless drops, have been to multiple doctors, and still find no relief. Curious whether you have dry eye syndrome (DES)? There are a few questions you should ask yourself:
- Do you have a sensitivity to light?
- Do you have burning/stinging of your eyes?
- Do you feel a gritty or scratchy sensation?
- Do your eyes get watery and teared up?
- Does your vision improve with artificial tears?
- Do you find your vision quality fluctuates when blinking?
- Do you have red/infected eyes?
If you answered yes to some of these questions, you may have DES.
Dry eye syndrome is typically caused by an imbalance in the liquid film that covers the ocular surface. It may be caused by an underproduction of tears or a chemical imbalance that prevents the tear film from functioning properly. Typical symptoms can include itching, burning, tearing, foreign-body sensation, redness, blurry vision or episodes of excessive tearing. Many factors affect the health of the ocular surface, including diet, co-existing medical conditions (such as a thyroid disease, Sjögren’s disease, or rheumatoid arthritis), medications, anatomical abnormalities, hormones, and environmental conditions such as high or low humidity and temperatures.
It is important to properly diagnose the underlying cause of dry eye and provide customized treatment with maximum benefit for each patient. I personalize each treatment to every individual and the specific cause of their symptoms. I believe that performing a thorough workup to initially establish the cause of the dry eye is a crucial first step prior to initiating treatment. During this workup, there are specific tests including tear breakup time, Schirmer’s test (amount of tear production) and inflammatory mediators in the tear film.
Treatment then involves addressing the underlying cause. I typically begin with the most conservative and mild approach and slowly add on treatments to determine the minimal amount of treatments needed for the optimum effect. I usually begin with preserved and nonpreserved artificial tears (that come in individual vials), add thicker drops, including those with carboxymethylcellulose, add gel, ointment, prescription drops, and punctal plugs. Below is a description of each of the types of treatments in more detail:
Punctal Plugs
There are two puncta in each eye, one in the upper and one in the lower lid, and the puncta connect to the canalicular and nasolacrimal duct. The tears drain through this system. By occluding the puncta with punctual plugs, we are essentially blocking the drain and allowing the tears to stay on the surface of the eye and thus lubricate it for longer. This improves comfort and minimizes the amount of artificial tears needed throughout the day. Think of this as putting a stopper in the sink drain to allow the fluid to stay on the surface of the eye longer. Punctal plugs are tiny (two by four mm) inserts placed in the office at the slit lamp. The procedure is not painful at all, and you can continue your day-to-day activities afterward. There are two kinds: silicone plugs that are permanent (but may be removed) and collagen plugs, which are absorbed over about three months. If collagen plugs improve symptoms, we replace them. We typically start with two plugs and then proceed to four if there is a benefit. A more permanent solution includes electrocautery of the puncta, which permanently closes the puncta.
Autologous Serum Tears
More aggressive treatments include autologous serum tears, in which a patient’s blood is drawn and centrifuged to separate the liquid and cellular components of the blood and is then turned into tears that are refrigerated for three months. Autologous serum tears are well-tolerated and are composed of substances that artificial tears cannot replicate, such as immunoglobulins, vitamin A, fibronectin and growth factors that promote corneal health. Current indications for autologous serum tears include Sjögren’s syndrome, dry eye, several types of keratitis as well as ocular graft-versus-host disease. They can be costly and time-intensive initially but can greatly help the right patient.
Custom Lenses
There are several lens devices, such as scleral lenses and specifically the PROSE lens system that provides relief to certain patients. PROSE devices are made out of highly gas-permeable hard plastic that allows oxygen to reach the cornea. They are designed to create a space between the prosthetic device and the eye that is filled with sterile saline. The liquid remains in the reservoir, providing constant lubrication by bathing the eye in a pool of artificial tears.
Another common condition is “epiphora,” or tears pouring down the cheek. This can be the result of various conditions, such as reflex tearing from ocular surface disease, tear hypersecretion, lid abnormalities or nasolacrimal duct obstruction. Reflex tearing is tearing in response to dry eye and an irregular surface. To determine whether there is an obstruction anywhere along the punctal, canalicular or nasolacrimal duct, we irrigate the system through each of the four puncta with saline solution. Obstructions can be partial, intermittent or complete. This procedure is safe and painless and is both diagnostic (it gives us information regarding the location and type of obstruction) and therapeutic (it can open the obstruction partially and improve symptoms). Treatments for obstructions include drops, procedures, and oculoplastic surgery.
Glaucoma
Sunday, 05 July 2020
Glaucoma means injury to the optic nerve in the back of the eye usually caused by elevated eye pressure. This optic nerve damage causes diminished peripheral vision over time. Because the changes are gradual and initially subtle, many individuals do not realize that they have glaucoma until they have experienced significant abd permanent loss of vision. It is therefore, important to be examined by an opthtalmologist on a regular basis to be checked for glaucoma as well as other conditions that can be treated successfuly if caught early.
The artical below provides a nice summary of the different types of glaucoma as well as their diagnoses and treatments.
Glaucoma
Dry Eyes
Monday, 18 May 2020
Everyone experiences dry eyes once in a while. For some individuals, however, this can be a chronic condiition. The article below offers a great review of the causes of dry eyes, the ways in which dryness can be diagnosed and measured, and the many available treatments.
Dry Eye
Floaters
Wednesday, 08 April 2020
Floaters represent densities in the vitreous jelly that fills our eyes. As we age, the vitreous starts to shrink. Eventually the this process could cause the vitreous to pull away from the retina in the back of the eye and fold in on itself. This fold in the jelly is what is perceived as the floater. Very rarely, this can be associated with tears in the retina. The appearence of sparks of light in the periphery or a dark curtain sweeping in front of the vision is associated with an increased risk of retinal tears. All new onset floaters should be evaluated by an ophthalmologist. Although flaoters can be annoying, they are usually innocuous and become less noticeable over time.
This artical provides a more comprehensive review of the causes and management of floaters.
Floaters
This is an important message from The American Academy of Ophthalmology about the coronavirus.
Surprising Ties Between Coronavirus and the Eyes
Cataracts
Friday, 28 February 2020
There is a common misconception that cataracts represent opaque membranes growing in the eye when in reality they are the eye's natural lenses that become cloudy as we age. Cataract surgery is usually performed when this clouding effects our quality of life. The procedure involves using ultrasound or a combination of laser and ultrasound to dissolve the cataract. A lens implant is then inserted into the eye to replace the cloudy natural lens that was removed.
The link below offers a great overview of the cataracts and modern cataract surgery.
Cataracts
This is a great overvew from the American Academy of Ophthalmology on the causes, signs, symptoms, and treatments of styes and chalazia.
Stye and Chalazion
The prominent Moorfields hospital in London working with Google’s DeepMind to approve Artificial Intelligence to detect eye disease with remarkable 95% accuracy... now if only the bots could counsel patients and perform surgery...
Full articles here: https://www.google.com/amp/s/www.bloomberg.com/amp/news/articles/2018-08-13/google-s-deepmind-to-create-product-to-spot-sight-threatening-disease
https://www.wired.co.uk/article/deepmind-moorfields-ai-eye-nhs
https://www.bbc.com/news/health-44924948
Uncovering The Aesthetics Of PRK & LASIK Eye Surgery
The Cosmetic Factor in PRK & LASIK Eye Surgery Procedures
Link to original article: https://www.thecosmetictourist.com/home/2018/7/24/uncovering-the-aesthetics-of-prk-lasik-eye-surgery
When someone mentions cosmetic surgery, you could be forgiven for not immediately thinking about PRK (Photorefractive Keratectomy) & LASIK eye surgery. After all, they are both laser surgery procedures on your eyes, to correct problems such as nearsightedness, farsightedness, and astigmatism.
But if you’re inclined to look a little further down the road, having PRK & LASIK surgery could be considered major cosmetic procedures. After you have had either of these laser eye surgeries, you should no longer need to wear glasses or worry about drooping eyelids from extended use of contact lenses.
For someone who wears glasses everyday, having LASIK & PRK eye surgery can result in huge, and long lasting positive effects on their life, all through the aesthetical change to their overall image that can occur when they leave their glasses behind.
To write this article The Cosmetic Tourist got together with Ophthalmologist, Dr. Yuna Rapoport, MD. From her Manhattan practice, Dr. Rapoport performs refractive, cornea, and cataract surgical procedures, as well as teaching residents in at Mt. Sinai New York Eye and Ear Infirmary.
Laser Vision Correction Surgery; Both Practical And Aesthetic
Dr. Rapoport explains that both LASIK and PRK are laser eye surgery procedures that reshape the surface of your eye to correct your vision. Listing the reasons behind having these eye procedures in greater detail;
“For you to see clearly, light rays must travel through your cornea and lens. The cornea and lens refract the light so it lands on the retina. The retina turns light into signals that travel to your brain and become images.
With refractive errors, the shape of your cornea or lens keeps light from bending properly. When light is not focused on the retina as it should be, your vision is blurry.”
With both LASIK and PRK eye procedures, a laser is used to change the shape of your cornea, which improves the way light rays are focused on the retina. Once this has been achieved, you are able to fully enjoy the aesthetical changes brought about by eye lens surgery.
PRK Or LASIK, Which Procedure Is Right For Me?
So what exactly is the difference between PRK and LASIK eye surgery? Dr. Rapoport says that for those who have high prescriptions to correct their eyes, or those with thinner corneas, or other eye abnormalities;
“...may not be candidates for LASIK but are candidates for PRK.”
LASIK and PRK Evaluation with Dr. Rapoport
For anyone who is wondering which procedure they would qualify, don’t worry, as Dr. Rapoport points out that every potential patient will have to partake in;
“...a thorough evaluation and multiple tests [that] are required to assess whether you qualify for either.”
The doctor goes on to explain that some patients may choose PRK or LASIK for other reasons, such as occupational or contact lens intolerance.
Fundamental Requirements Needed For PRK & LASIK Eye Surgery Procedures
Before you can truly get excited about the potential aesthetical results of having either of these laser eye surgery procedures, you need to meet certain requirements. Dr. Rapoport lists the most important ones as:
- You should be 18 years or older (ideally, over 21 years old, when vision is more likely to have stopped changing)
- Your eye prescription should not have changed in the last year.
- Your refractive error (prescription) must be one that can be treated with LASIK/PRK.
- Your corneas need to be healthy and your overall eye health must be good.
Of course there is always the flip side to meeting these requirements, with a rather hefty list of major reasons why someone would not be a good candidate for either of these eye lens surgery procedures;
- Unstable (changing) refractive error
- Extreme levels of myopia, hyperopia or astigmatism
- Skin or other disease that can affect healing
- A history of excessive scarring
- Severe dry eye
- Corneas that are too thin
- Cornea abrasions or disease
- Advanced glaucoma
- A cataract affecting vision
- Uncontrolled diabetes
- Pregnant or nursing women
- Keratoconus (cone-shaped cornea)
- Family history of a corneal transplant/corneal disease
There are of course many other considerations that come with getting laser eye surgery, such as ceasing all contact lense use some weeks before your procedure is scheduled (Like any cosmetic or elective surgical procedure, your PRK/LASIK eye center should supply you with thorough instructions upon scheduling).
Dr. Rapoport’s Lowdown On Each Eye Surgery Procedure
So having made it through the prerequisites, and committing to having laser eye surgery, what comes next? Where are the procedures performed, and what you can expect whilst the procedure is being performed;
“Both LASIK and PRK are performed at a laser center or in an office ... No systemic anesthesia is required [for either procedure].”
Dr. Rapoport expands in some detail about the LASIK procedure;
“During LASIK surgery, your eye is first numbed with eye drops. An eyelid holder is placed on your eye to keep you from blinking. A suction ring is then applied to the eye to raise the eye pressure and keep it from moving. The IntraLase laser is then used to create a paper-thin corneal flap. The flap is then opened like the page of a book to expose tissue just below the corneal surface.
Next, the excimer laser is used to remove ultra-thin layers from the cornea to reshape it. The laser will have been pre-programmed with specific measurements for your eye. Finally, the flap is placed back into its original position and the edges are smoothed down. The flap attaches on its own in two to three minutes, where it will heal in place.
A see-through shield is placed over the eye, which you sleep with for a few days. The day of the procedure, you should plan to go home and take a nap or relax after the surgery. Your eyes may feel scratchy or like they are burning for a couple of days. Recovery after LASIK surgery typically requires a few days.”
Moving on, Dr. Rapoport describes the slightly differing PRK procedure as;
“PRK surgery is similar to LASIK but does not require the creation of a corneal flap. Instead, the epithelium (the top layer) is first removed. The laser, which has been preprogrammed with information from your specific measurements, then reshapes the cornea by gently removing the epithelial tissue on the exposed cornea. A drop called mitomycin C is placed onto the cornea for a brief time to prevent postoperative haze (cloudiness).
A bandage contact lens is then placed over the eye and is removed in the office at three to seven days once the top layer has healed. PRK has a longer recovery period than LASIK, of up to 30 days.”
The Aesthetic Results Of LASIK And PRK Eye Surgery
The Cosmetic Effects of LASIK
With both procedures leading to the same final postoperative visual outcome, you can expect the same aesthetical results from whichever laser eye surgery you are recommended to have.
Dr. Rapoport says the biggest change is that after eye surgery you are able to see fully, and all of the time;
“Imagine being able to wake up in the middle of the night, or in the morning and be able to see. No more fumbling for glasses, no more spilling contact solution from the contact case, and no more being uncomfortable at the beach or pool with glasses.”
With massive lifestyle changes such as these, it comes as no surprise that 92-98% of patients who undergo LASIK and PRK eye surgery are completely satisfied with the results.
Positive feedback from Dr. Rapoport’s own patients include not having to wear or decide which glasses frames to purchase, and the ability to to fall asleep without having to worry about removing contact lenses or breaking their glasses.
The doctor also mentions additional aesthetical effects from surgery that include whiter, clearer eyes due to the lack of irritation, and eye allergies (mainly encountered with contact lense users). Another point, that all glasses wearers will recognise as a big deal, is the added benefit of not having to push glasses back up your nose.
Final Words Of Advice From A Top Rated Ophthalmologist
When wrapping up our interview with Dr. Rapoport, we asked her if there were any tips she could pass on for anyone interested in laser eye surgery, particularly with concerns about the safety of the procedures.
She was keen to point out that LASIK and PRK eye surgeries have been researched thoroughly in South America and Europe since the 1980’s, whilst in the US, the procedures were FDA approved by 1995.
“The technology has improved tremendously and this completely laser procedure can correct custom irregularities and higher order aberrations, resulting in a vision that is of a better quality than either with glasses or contacts.”
Dr. Rapoport stressed the importance of thoroughly researching your choice of doctor;
“It is crucial to choose an ophthalmologist who performs customized imaging and testing to ensure you have the safest and most precise treatment, like we do at Eastside Eye Surgeons”.
Additionally, she says, a very in-depth discussion should be held regarding possible treatments, including distance correction, near correction and monovision;
“Monovision is a great option for patients who want to have their vision corrected for both distance and for near vision without any glasses at all, not even reading glasses!”
In monovision your dominant eye is corrected for distance and your non dominant eye corrected for near sight.
Whilst this procedure may sound like it could cause overall vision problems, Dr. Rapoport says that;
“Your brain learns to adjust and to use the two eyes together”. However, in some patients, it is better to try out monovision as a trial with contact lenses first.
A Little About Ophthalmologist Yuna Rapoport, MD
Dr. Yuna Rapoport, MD
Yuna Rapoport received her MD from the honors program at Northwestern University Feinberg School of Medicine, completed ophthalmology residency at Vanderbilt University, and completed an extra year of fellowship at Harvard Medical School. She performs refractive, cornea, and cataract surgery.
Her work regarding advances in eye care treatments has been published in many leading medical journals and presented at major ophthalmologic meetings. She is on staff and teaches trainees at New York Eye and Ear Infirmary and Mt. Sinai St. Luke’s Roosevelt.
When we asked the doctor for any final thoughts for our article, she reiterated one of the main thoughts that we wanted to explore when we first contacted her and asked for a collaboration on laser eye surgery;
“When performed in appropriate patients, LASIK and PRK can have a huge effect on individuals self image past, present and future.”
There are only a few things more frustrating than dealing with constantly burning, itching and irritated eyes. Coworkers and friends ask if you have been crying or are sick. You look tired. Contacts are hard to put in. Figuring out what is causing the chronic irritation can be incredibly frustrating. As a cornea and dry eye expert, I see this type of situation daily: patients who have tried endless drops, have been to multiple doctors, and still find no relief. Curious whether you have dry eye syndrome (DES)? There are a few questions you should ask yourself:
- Do you have a sensitivity to light?
- Do you have burning/stinging of your eyes?
- Do you feel a gritty or scratchy sensation?
- Do your eyes get watery and teared up?
- Does your vision improve with artificial tears?
- Do you find your vision quality fluctuates when blinking?
- Do you have red/infected eyes?
If you answered yes to some of these questions, you may have DES.
Dry eye syndrome is typically caused by an imbalance in the liquid film that covers the ocular surface. It may be caused by an underproduction of tears or a chemical imbalance that prevents the tear film from functioning properly. Typical symptoms can include itching, burning, tearing, foreign-body sensation, redness, blurry vision or episodes of excessive tearing. Many factors affect the health of the ocular surface, including diet, co-existing medical conditions (such as a thyroid disease, Sjögren’s disease, or rheumatoid arthritis), medications, anatomical abnormalities, hormones, and environmental conditions such as high or low humidity and temperatures.
It is important to properly diagnose the underlying cause of dry eye and provide customized treatment with maximum benefit for each patient. I personalize each treatment to every individual and the specific cause of their symptoms. I believe that performing a thorough workup to initially establish the cause of the dry eye is a crucial first step prior to initiating treatment. During this workup, there are specific tests including tear breakup time, Schirmer’s test (amount of tear production) and inflammatory mediators in the tear film.
Treatment then involves addressing the underlying cause. I typically begin with the most conservative and mild approach and slowly add on treatments to determine the minimal amount of treatments needed for the optimum effect. I usually begin with preserved and nonpreserved artificial tears (that come in individual vials), add thicker drops, including those with carboxymethylcellulose, add gel, ointment, prescription drops, and punctal plugs. Below is a description of each of the types of treatments in more detail:
Punctal Plugs
There are two puncta in each eye, one in the upper and one in the lower lid, and the puncta connect to the canalicular and nasolacrimal duct. The tears drain through this system. By occluding the puncta with punctual plugs, we are essentially blocking the drain and allowing the tears to stay on the surface of the eye and thus lubricate it for longer. This improves comfort and minimizes the amount of artificial tears needed throughout the day. Think of this as putting a stopper in the sink drain to allow the fluid to stay on the surface of the eye longer. Punctal plugs are tiny (two by four mm) inserts placed in the office at the slit lamp. The procedure is not painful at all, and you can continue your day-to-day activities afterward. There are two kinds: silicone plugs that are permanent (but may be removed) and collagen plugs, which are absorbed over about three months. If collagen plugs improve symptoms, we replace them. We typically start with two plugs and then proceed to four if there is a benefit. A more permanent solution includes electrocautery of the puncta, which permanently closes the puncta.
Autologous Serum Tears
More aggressive treatments include autologous serum tears, in which a patient’s blood is drawn and centrifuged to separate the liquid and cellular components of the blood and is then turned into tears that are refrigerated for three months. Autologous serum tears are well-tolerated and are composed of substances that artificial tears cannot replicate, such as immunoglobulins, vitamin A, fibronectin and growth factors that promote corneal health. Current indications for autologous serum tears include Sjögren’s syndrome, dry eye, several types of keratitis as well as ocular graft-versus-host disease. They can be costly and time-intensive initially but can greatly help the right patient.
Custom Lenses
There are several lens devices, such as scleral lenses and specifically the PROSE lens system that provides relief to certain patients. PROSE devices are made out of highly gas-permeable hard plastic that allows oxygen to reach the cornea. They are designed to create a space between the prosthetic device and the eye that is filled with sterile saline. The liquid remains in the reservoir, providing constant lubrication by bathing the eye in a pool of artificial tears.
Another common condition is “epiphora,” or tears pouring down the cheek. This can be the result of various conditions, such as reflex tearing from ocular surface disease, tear hypersecretion, lid abnormalities or nasolacrimal duct obstruction. Reflex tearing is tearing in response to dry eye and an irregular surface. To determine whether there is an obstruction anywhere along the punctal, canalicular or nasolacrimal duct, we irrigate the system through each of the four puncta with saline solution. Obstructions can be partial, intermittent or complete. This procedure is safe and painless and is both diagnostic (it gives us information regarding the location and type of obstruction) and therapeutic (it can open the obstruction partially and improve symptoms). Treatments for obstructions include drops, procedures, and oculoplastic surgery.
