Blepharitis is the inflammation of the lids. It may have several etiologies and can result in many secondary conditions that are detrimental to ocular health. Patients often present with inflammation and redness of either the anterior, posterior or both areas of the lids. In addition, there is usually debris at the base of the lashes that further clogs the gland openings.

The Blepharitis blocks glandular openings on the lid surface decreasing secretions into the eye. This results in dry eyes with all the secondary complications. As a result, patients most often complain about burning, stinging and excessive tearing. Furthermore, corneal edema will cause photo phobia and blurred vision. Chronic Blepharitis ends in the eye lashes falling out as well.

Seborrheic Dermatitis ( dandruff) causes anterior Blepharitis and usually has a Staphylococcus component. Additional factors such as poor hygiene, poor diet, hormonal changes and even stress will exacerbate the condition. External factors like make up and pollution will also come into play making the patient’s symptoms worse. While bacteria is normally present on the lashes, these other factors permit them to become an abnormally large part of the lid community tipping the balance and increasing toxins in this very sensitive area.

Meibomian Gland Dysfunction causes posterior Blepharitis. These glands produce oils that are required as a component of normal tears. If these glands manufacture faulty oils or don’t secrete a normal volume into the eyes, the ocular surface will suffer and may result in surface damage.

Certain factors will predispose patients toward Blepharitis, such as a weakened immune system, Acne and poor hygiene. Having any or all of these will dramatically increase the likelihood of contracting and the severity of the condition. Furthermore, Blepharitis may result in secondary complications that may be worse then the condition itself. Fungal and bacterial infections, lid spasms, Dacryocystitis ( blocked ducts), Amoeboid infections, styes, and ultimate lid damage are all real possibilities if the condition goes untreated.

Therefore proper diagnosis and treatment is required. Complete therapy includes improving lid hygiene and avoiding external factors like oily make up and hairspray. Lid surfaces must be cleaned with diluted baby shampoo twice per day followed by warm compresses for a minimum of 2 weeks. Lid massages should follow each compress to increase blood flow to the area. In addition, topical ointment like Tobradex often is applied to decrease the inflammation and bacterial flora. If the Meibomian glands are involved then oral antibiotics are usually added to the regimen.

Upon completion of the treatment, maintenance therapy should be performed at least 1-2 times per week indefinitely. Blepharitis often returns and must be carefully monitored. Finally, contact lens wear must be closely followed to prevent additional corneal involvement.

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Herpes is caused by an Epstein-Barr virus and is often confused with other organisms as the etiology of Keratitis. Most often a patient will present with red, painful eyes that can be caused by many things. Careful examination is required to properly diagnose and then treat these individuals.

Herpes Keratitis is usually diagnosed by the dendritic ulcers. They most often appear with a dendritic epithelial pattern that is ulcerated and has branching lines that end with terminal end bulbs. It is extremely painful and causes substantial photo phobia. The problem exists when there is a dendritic appearing lesion that is not well defined. The initial diagnosis may be Herpes, but upon closer examination a few days later the lesion lacks the defining entities that only Herpes Keratitis would have. Treatment must be closely followed and modified accordingly. The use of antiviral meds should reduce the lesions and improve the condition. If this does not occur, then there has been a misdiagnosis and treatment must be changed. Frequently, Acanthamoeba may be the agent that needs to be treated. Initially, the dendritic lesions will appear the same minus the end bulbs, but when the antivirals do not work, antibiotic meds must me introduced as soon as possible. In addition, if any steroids were employed, then they may have exacerbated the Acanthamoeba lesions. Obviously it is always indicated to take a culture at the beginning of treatment, but the condition may require treatment modification prior to getting the lab results back.

In short, always consider that the initial diagnosis may not be correct if the treatment does not fully re mediate the symptoms in a timely fashion. With regard to Herpes Keratitis, consider Acanthamoeba Keratitis as an alternative diagnosis early in the treatment period.

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Glaucoma is a disease that damages the optic nerve inside the eye resulting in blindness if untreated. There is a genetic predisposition for the disorder, but there are other factors that contribute to the type of Glaucoma and severity of the disease.

Routine eye exams should always include a pressure check which is the basic Glaucoma test. The most accurate way of evaluating the intraocular pressure is with the Goldman Applanation method. That requires eye drops and the use of an applanator with a cobalt blue light. The most common method is the non-contact tonometer which is the ” air puff” test. It is easy and quick, but not as accurate as the applanation. If the pressure is close to or above 21 mm, then a closer look is indicated because there is an increased chance that there may be a problem.

The next part of the exam is to look at the optic nerve. Normal nerves should have a yellowish pinkish appearance and the central cup part should not be more then 30% of the overall optic nerve. If it is and there is a vertical elongation to the cup, then additional testing must be done. Next up would be a visual field test. This involves following a light and using ones’ peripheral vision to see other spots. This evaluates the neurological integrity of the nerve. If there are glaucomatous field and nerve changes then there will first be an increase in the natural blind spot followed by arcuate “scotomas” or blind areas surrounding the central vision. These are clear indications of a positive diagnosis of Glaucoma. Confirmation of the disease is made with a GDX, which is an instrument that actually maps out the optic nerve changes and spots areas that are in danger.

There are several types of Glaucoma, the most common type being Chronic Open Angle. There is also a Narrow Angle type which is most common in farsighted patients. Diseases like Diabetes can cause the disorder as well by increasing blood vessel growth into the angle that drains the fluid from the eye. That is most dangerous and is called Neovascular Glaucoma and follows Rubeosis which is blood vessel growth in the iris of the eye. Trauma can cause the disease by recessing the iris resulting in scar tissue. That is called Angle Recession Glaucoma. Finally, there is Pigmentary Glaucoma which results from pigment leaching out of the iris and blocking the drainage area. This has a very strong genetic component and is the most difficult to treat.

The key issue with Glaucoma evaluation is to know the signs of early disease and treating it appropriately. All too often the early signals are missed and damage to the nerve occurs. The increase in pressure results in a decrease in blood flow to the nerve resulting in death to the tissue. Thus, the new treatment methods focus on vascular sparing to keep the blood flowing to the nerve. As a practitioner, even questionable pressures or optic nerves should be tested further and we must not assume that things are normal. Proper follow up is a must and patient compliance must be carefully evaluated.

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Patients often complain of many symptoms that may represent more then one condition. One of the most common difficult differentiations to make is whether it is an allergy or dry eyes.

The symptoms of both disorders are similar and often over lap. They both cause red eyes, may create a burning sensation and both can itch even though we were all taught that only allergies make the eye itch. Tearing and mild discharge are common and frequently the patient will have all of these symptoms and if a poor historian may confuse when, where and how often they suffer. They are however, very different conditions and treatment will only be affective if appropriate for the anomaly.

Each condition has specific pathophysiology. Dry eyes are caused by tear film insufficiency, instability or a poor mixture of the required tear components. If there are glandular irregularities such as Meibomianitis the lipid layer will suffer. This will result in more rapid tear film evaporation. Goblet cells produce Mucin whose function is to bind the tears to the epithelium layer of the cornea. Insufficient quantities of Mucin will result in the tears running of the eye too rapidly. Lacrimal glands produce Aqueous, the water part of the tears. Water represents most of the tears and an insufficient amount obviously has a dramatic affect on the volume of tears. The most accurate method of measuring the aqueous volume is with Fluorophotometry. Blinking mixes all these components up and spreads them out over the cornea. Normal blink rate is once every 5-6 seconds. However, if one stares at a computer that rate will decrease to 10-12 seconds drying the eyes out. Therefore, when someone has dry eyes, forcing a correct blink rate is crucial to successful treatment.

The etiology or cause of dry eyes is also quite varied. Eyes tend to decrease tear production with age or hormonal changes, certain diseases and treatments like for cancer or surgeries such as LASIK. Blepharitis ( lid inflammation) and contact lens wear are also common causes of dry eye.

The pathophysiology of Ocular allergies is quite different. Exposure of a sensitive individual to an allergen will result in the release of antibodies that bind to Mast cells. The mast cells then release histamine that cause the full allergic reaction. The result is itchy, puffy eyes, swollen lids, tearing and discomfort.

Unlike dry eyes, if an individual is not sensitive to an allergen then there will NEVER be a reaction. The key to appropriate treatment is making the correct diagnosis.

Treatment for dry eyes begin with artificial tears several times per day. If that does not help then going after the source is required. New theories include an allergic reaction in the tear producing mechanism and thus prescribing a mild steroid like Lotemax 3 times per day in conjunction with the artificial tears is done. If that still is not adequate, then Restasis which is a reformulation of an old drug Cyclosporin is employed. Cyclosporin is an anti autoimmune drug that has found a new use. Care must be employed when using this medication because any infection that occurs while taking it may be much worse. Therefore, patients must be counseled to stop using it if any disease occurs. Finally, punctal plugs can be inserted to keep tears in the eyes in addition to these treatments. Wet cell eye glasses that trap moisture are not often used, but can be employed as a last resort as well.

Allergy treatment is much simpler. Eye drops that are Antihistamine/Mast cell inhibitors are the best. They attack the source and symptoms of the disease. Comfort is fast and long lasting. The number 1 drug of choice these days is either Pataday or Patanol. I have found that similar drops like Elestat, Optivar and the OTC drops are not as effective. If these medications are not enough to alleviate the condition, then steroid eye drops will do the trick. We start with Lotemax and graduate to the stronger ones if needed.

In short, one must be sure of the diagnosis before starting treatment and then modify it as required.

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A young child runs around in class and is called disruptive, while another student says he doesn’t understand what is on the black board. In another class there is some one who avoids reading and home work and prefers to watch TV very close. Frequently, children like these are classified as poor students, disruptive or behavioral problems. While they may be that way, there is also another possibility.

Avoidance behavior is a normal reaction when something hurts us, or we are uncomfortable performing an act. Children are not in a position to know, or understand that they may have a visual problem that is causing their discomfort. I usually advise a complete eye exam by an Optometrist that is experienced with children and behavioral vision. Unfortunately, well intended parent may take their children to an eye doctor who is not well versed with these visual conditions and may give a clean bill of health to the child. They may see 20/20, but still do not function well under visual stress.

Asthenopia is a condition that describes visual anomalies relating to the visual system, not just the actual eye sight. There is a difference between vision and eye sight. Sight is simply what we see, while vision incorporates sight with how it is interpreted in the brain. So some one may see well, but not function well visually. As with most conditions a problem won’t be found if you don’t look for it.

Frequently found problems with the visual system are Accommodative Infacility (focusing irregularities), Exo or Esophorias ( eye turns), Oculomotor Dysfunctions( eye movement irregularities) and Convergence Insufficiency’s ( inability to turn the eyes in at near to read). Only a complete evaluation of the visual system can uncover these conditions. The symptoms may include double or blurry vision, head aches, difficulty reading due to an inability to follow the line of words smoothly, and poor eye/hand coordination.

Recent studies on Autistic and Hyperactive children have concluded that they may have these conditions secondary to the medications they take for their disorders. Their vision is often 20/20, but they can not function well because of these anomalies. The first step is to diagnose these conditions and the second is to treat them.

The best treatment modality for these visual disorders is Vision Therapy. VT is a therapeutic method that retrains the visual system to function properly. It most often involves working with an eye doctor 2-3 times per week for a period of several months modifying the treatment on a regular basis. While the different conditions must be worked on separately, they are all inter related. Helping one part of the system will affect another. For example, improving the ability to converge will also strengthen the accommodative system. The eye movement will likewise help the eye converge better. All of these will make eye hand coordination better and thus tracking will also improve.

The bottom line is that if a child or adult complains of visual issues despite seeing 20/20, they should be evaluated for these other conditions. Frequently, something else will be found that will improve the situation. Then a “bad” student may become the next star! My wife is a science teacher and she often will find a student that has been given a clean bill of health by their doctor only to be diagnosed later on with an eye condition just described. In addition, hearing should also be tested.

As practitioners we need to think globally in order to give the best possible eye care to our patients.

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A 40 year old male went for a LASIK consultation and was told that he would be a great candidate for the procedure. He had complained prior to surgery that he had very dry eyes and often woke up with painful eyes, but the surgeon told him that he would still do well with the procedure.

During the course of the surgery the flap kept folding over and sticking to itself resulting in multiple wrinkles called striae. When the surgery was over the outer most layer of the cornea appeared to be dry resulting in a mild corneal abrasion. Therefore a bandage contact lens was place on that eye as a protective measure. The patient called the office early the next day complaining of EXTREME pain and light sensitivity and was instructed to come right in. Upon evaluation it was determined that there was a large abrasion resulting in the edge of the flap lifting up. There were also multiple striae in the flap which caused substantial visual decrease.
Since the abrasion was present it was decided to leave the lens on for another 24 hours and to reevaluate the eye the next day. On the next follow up, there were more striae present and the vision was now down to 20/200. To improve the refractive surface and improve the vision, the corneal flap was “re floated” to flatten it out and eliminate the striae. This was accomplished, but during this procedure the entire outer layer of the cornea pealed off. Aside from being extremely painful this further reduced the vision. While the flap was now smooth, it lost the epithelial layer. Another bandage contact lens had to be reapplied until the epithelium grew back.

Two days later the patient returned, still in pain, still blurry. The epithelial layer had regenerated and was beginning to cover the cornea again. Unfortunately, it was also growing under the cornea which required going back into surgery to once again lift the flap to clean out these cells. Once again, the outer layer came off and needed another contact lens. Finally after 10 more days, the epithelium regrew and the pain was eliminated. However, the central cornea was now hazy and the vision was still 20/200. Pred Forte steroid eye drops were prescribed to treat this new problem.

This individual also suffered from severe allergies and constantly had the need to rub his eyes. After fighting the feeling for several weeks, in his sleep he gave in and rubbed his eye …vigorously. Feeling substantial pain he woke up to notice that he could not see out of that eye. Early the next morning he once again returned to the office with a red, painful, blurry eye. An examination disclosed that the cornea flap had been torn off the eye and was no where to be found. With out the flap, there was no hope of helping this cornea and an emergency corneal transplant had to be performed. This was accomplished and many months later the patient had his vision restored with a noticeable degree of astigmatism. He was fit with a custom designed contact lens which restored his vision to 20/30.

While this case scenario is quite unusual and fortunately is a rare occurrence, any one considering refractive surgery must consider that it may occur to them. It may not be as a result of the surgeon or the follow up care, but simply a series of bad side effects that could happen to anyone. In short, all candidates must be aware of all the potential complications and be willing to accept them if they occur.

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Amblyopia is decreased vision in one eye for a non-pathological reason. Most often it is due to either an eye turn or a large difference in prescriptions between the eyes. Regardless of the cause the end result is the same, but can in many cases be corrected if treated early.

Eye turns can fall into several categories. Exotropia is an Outward turn, Esotropia is an Inward turn, Hypotropia is Downward and Hyper tropia is Upward in nature. An often missed anomaly is the Cyclorotation which is a rotation of the eye. It is difficult to see unless the doctor is well trained and experienced in Strabismus ( eye turns). All of these issues will have the same result regardless of the direction of the turn. The reason for the decrease in vision in the turned eye is because that eye will have the image focused on to a part of the retina that has less neuroreceptors resulting in a blurrier image. Therefore, when the Lateral Geniculate Body part of the brain is developing between the ages of birth and 7-10 years old, it does not receive the same stimuli as the other eye. This causes the turned eye to have a permanent reduction in neurological ability to transmit the image to the brain. The Lateral Geniculate Body is a transfer station near the brain stem that functions to send images to the brain. If it is not properly “built” at the time of development it will never be able to supply equal stimuli to the brain. The result is Amblyopia.

The same result will occur if one eye has a very different refractive strength from the other. The eye with the weaker power will be chosen to be the main eye for seeing. This results in the other one becoming Amblyopic for the same reason as before.

The good news is that if diagnosed early both eyes can have normal vision. The only exception would be if one eye has such a prescription that it does not have the same visual ability as the other eye. Extremely high powers spread out the retinal receptors causing a lack of visual ability regardless of the stimulation.

Treatment for Amblyopia includes extensive stimulation of the eye. This is accomplished by patching the good eye forcing the weaker eye to do all the work. Patching may vary from several hours per day to full time. However, it must be noted that the good eye must get stimulation as well or it may lose its’ ability if deprived of work as well. In addition, most experienced practitioners will have a Vision Therapy program in place to additionally stimulate the weaker eye. This may include ocular motility exercises, accommodative or focusing work, and even binocular therapy when the eyes are able to work together. As long as treatment is initiated early enough, the results are usually good. As the child gets older the likelihood for deeply ingrained Amblyopia is much greater and permanent. While teenagers and young adults may not get as good results from Amblyopia therapy, there is often an improvement in their visual functioning. This can make their ability to navigate through the visually demanding work environment more comfortable. So no one is ever to old to be helped. The results will vary and will not be as pronounced as with a young child.

When there is Amblyopia all eye glasses should be made of Polycarbonate safety lenses to protect the better seeing eye. If some thing were to happen to the good eye the patient would have to rely on the “bad” eye. Like wise contact lens wear should be carefully controlled and all extra precautions must be taken for the same reason. In short, when there is the possibility of Amblyopia early aggressive treatment must be initiated for as long as is needed for the best lifetime results.

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Our eye lids serve many functions that are required to keep our eyes healthy and functioning well. Among these important acts are to clean the eyes with blinking, keeping them moist, removing debris, protection and even avoidance. This last function is accomplished when the eye lashes come in contact with foreign matter and warn us of approaching danger.

Unfortunately, the lids are also a prime location for pathology and lid growths due to their constant exposure to UV light and pollution. Most lumps and bumps on the lids are benign and while they may not look pretty they are not dangerous. There are however, some lid lesions that are very serious. Topping the list in the bad category is Squamous cell carcinoma. It grows slowly and painlessly and may take many months before it is even noticed. It often starts as a wart like growth with a keratotic outer layer, but evolves into an ulcer with a fissure centrally. The base of the tumor becomes indurated, red with an ample blood supply and hard edges. It must be excised early on in order to prevent extensive damage to the surrounding tissue. As is grows it may spread to the connective tissue and even the underlying bone. At this point the pain is constant and severe. The greatest danger with Squamous cell carcinoma is that it metastasizes to other body areas. This is accomplished by use of the lymphatic system to the preauricular and sub maxillary lymph nodes. Once this occurs the prognosis for recovery is much less positive. Early treatment will prevent secondary complications and complete elimination of the cancer is possible.

Basal cell carcinoma by contrast is a localized lesion and does not spread throughout the body. It does its’ damage locally. It also is a slow growing tumor and may appear like a little bump at first then changing to a volcano like growth with rounded edges. It frequently bleeds and continues to grow under the skin even as the outer appearance may remain the same. The damage can be quite extensive if not excised early on. Often facial reconstruction must be performed in order to clean out the entire tumor.

As is often the case in medicine, there are other lesions that look serious, but are quite safe and benign. Keratoacanthomas is a prime example. It looks a lot like an early Squamous or Basal cell carcinoma, but is simply a “bump” that is comprised of keratinized tissue and is therefore also confused with an inverted follicular keratosis. Both are benign , but should always be removed and tested to make sure they are these 2 conditions. Only the trained and experienced eye can make that differential diagnosis.

Sarcomas and Malignant Melanomas are usually easier to diagnosis since they have more unique appearances. Obviously both require immediate treatment and follow up care. Other simple lid lesions are Chalazions and Hordeolums commonly known as Styx. They are treated with hot compresses and should resolve in a week or two.

The bottom line is that if there are any bumps or changes on the eye lids all patients should have them evaluated by their eye doctor. It most often is nothing serious, but early treatment for all lid lesions results in better long term eye health and appearance.

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A 50 year old woman calls our office complaining about little spots and fly like things floating in her vision and occasional flashing lights. We tell her to come in as soon as possible and we do a complete eye and retinal exam. She suffers from Vitreous Floaters, a normal condition.

This case scenario is played out many times every month, but should not be ignored if any one experiences these visual disturbances. Vitreous Floaters are small pieces of old retinal tissue that break off of the outer layer of the retina and float around in the jelly of the eye called the Vitreous. In most cases this is a benign condition, but can represent a much more serious condition. These bits of retinal tissue may have come from an area that left a small retinal hole or tear behind and the floater is the result of the tear. In all cases when there are floaters a complete dilated retinal exam must be performed as soon as possible. That is the only way to properly evaluate the retina. When there are flashes of light present as well the level of concern goes up since that may also indicate traction on the retina and can be more serious. If a hole or tear is discovered then usually laser treatment must be done in order to seal the anomaly and prevent further damage.

In some cases vitreous fluid or blood will fill the area where the floater originated resulting in a retinal detachment. This is a much more complicated condition and frequently requires retinal surgery to correct the problem. If left untreated it can result in total blindness in that eye.

Most often, the floaters either dissolve or reattach themselves some where in the eye and are no longer a visual issue. The problem is that over the course of our lives new ones are constantly forming. Thus even if one goes away, a new one is starting. In short, if an individual sees floaters he/she should see the eye doctor as soon as possible to rule out any retinal hole or tear. If there are flashes as well the level of urgency increases. A complete evaluation must include a dilated exam as well.

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Blepharochalasis is the increase in skin above and around the eyes. It typically occurs with increasing age, but may occur in younger folks if there is a genetic predisposition. The skin in this sensitive area becomes loose, flabby with multiple folds making for a tired, aged look. While we are all concerned with our appearance there is a medical concern that accompanies this condition.

As the skin folds increase there are pockets of skin that will remain moist and warm and are a good location for bacterial growth. Thus people with Blepharochalasis are more at risk for contracting skin diseases around their eyes. This of course increases the likelihood of an eye infection secondary to the skin disorder. Extra care must be given to ocular hygiene to prevent these issues. Furthermore, as the skin increases in magnitude it typically droops down and may obscure the line of site. This of course will decrease the visual capabilities and affect one’s ability to see either straight ahead, the superior field of vision or both. Thus, there is a medical need to surgically correct this condition. If the visual field is constricted then insurance will cover the surgical procedure since there is a medical necessity. The procedure to correct this condition is called Blepharoplasty.

There are those individuals that feel that they have taken on an aged appearance because of this condition and want cosmetic surgery despite not being bad enough to be covered by insurance. In today’s world of cosmetic surgery this is a fairly common procedure. The street term for this is the “eye job.” Regardless if it is due to age and must be done for medical purposes or just for cosmetic reasons, there are several serious complications that may arise if not done by a qualified surgeon.

Common side affects include having the eyes appear too wide open or too large because too much skin has been removed. This will lead to the eyes drying out and many secondary complications arising from exposure of the cornea. In addition, there can be damage to the tear producing mechanism resulting in a permanent dry eye condition. Red, burning, painful eyes is not a good trade off for looking better. The eyelids may turn inward following surgery causing a constant brushing of the cornea by the eye lashes. This leads to scarring and decreased vision. There may also be damage to the eye lashes themselves if poorly performed.

The bottom line is that when eye lid surgery is performed it should be done by an Oculo-plastic surgeon with a great deal of experience. This will insure a good aesthetic appearance and normal physiological functioning of the eye.

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