Eye Care

Acne Rosacea, Rosacea, and Ocular Rosacea are chronic dermatological conditions characterized by acute exacerbations of the skin. It usually presents itself in the fourth to fifth decades of life. Typical signs are persistent redness (erythema), spider vessels (telangiectasias), localized red spots (papules), and white heads (pustules) that affect the cheeks, nose, chin, forehead and neck. An enlarged nose is a classic sign (rhinophyma). Women are twice as likely as men to be diagnosed.

Ocular involvement (Ocular Rosacea) is the most common form of all Rosaceas. Eye symptoms most commonly reported are dryness, tearing, foreign body sensation, and redness. Symptoms are usually greater than clinical findings. Certain eye and eyelids diseases associated with Rosacea include chronic blepharitis (65%), meibomian gland dysfunction (78%), dry eye syndrome, chalazion, hordeolum, corneal and sclera perforations, episcleritis and iritis.

Triggering Factors: Hot drinks, alcoholic beverages, spicy foods, stress, weather changes and sunlight may worsen rosacea. People with rosacea should avoid these triggers because they could cause flushing and blushing, which may become persistent. Sunscreen, wearing hats and avoiding midday sunlight is the best ways to limit sun exposure. No specific diet has been proven to help those with Rosacea. However, it is important for Rosacea patients to find out which foods are your triggers. Keeping a diet diary may be helpful.

Treatment: Since this is a chronic, generalized skin condition, a combination of different treatment regimes have shown to be most beneficial. The mainstay of roscacea treatment is hygiene. Most patients will have meibomian gland dysfunction and blepharitis. Daily warm compress and lid scrubs can drastically reduce outbreaks and reoccurrences. Topical antibiotic with steroids may be required to suppress inflammation. But care should be taken, patients are likely to become steroid addicted because it works so well. Oral medications have been very effective in alleviating patient’s symptoms (3-6 weeks). Also, topical prescription gels, antibiotics or creams for the face have been successful choices. Homepathic remedy, such as Omega-3 supplementation with EPA-enriched flaxseed oil, has been successful too; although, many patients have reported diarrhea with flaxseed oil.

Amblyopia, also referred to as lazy eye, is defined as decreased central vision in one or both eyes, which is not correctable with prescription lenses. Amblyopia is the result of a non-disease process or abnormality that interferes with the normal development of the eyes and visual system.

Development of the visual system begins at birth with normal use of the eyes. Good vision is encouraged to improve as the infant properly utilizes their eyes. The eyes and vision evolve as the child ages, and continue to change through the first decade of life. Any interference with this process can negatively impact potential visual ability.

Amblyopia is caused by several abnormalities. In the case of strabismus, or misalignment of the eyes, the eyes do not work together and one or both eyes may turn in, out, up, or down. Amblyopia may also be caused by vision problems like nearsightedness, farsightedness, and astigmatism. In cases where there is a large degree of difference in visual acuity between the eyes, both eyes may not have equal focusing ability. Therefore, the ‘weaker’ eye may not develop normally, and the child may favor the stronger eye. Rarely, certain types of cataracts or opacities may cause amblyopia.

In each of the previous causes, the brain receives a good, sharp image from one eye, and a blurry or fuzzy image from the other eye. The brain cannot combine the images, and eventually ignores the eye with the poor image. If left uncorrected, this weaker, or lazy eye, will develop amblyopia.

Unless an eye turn is visible, amblyopia often has no symptoms and may go unnoticed by even the most perceptive parents. In the majority of cases, amblyopia must be detected by checking vision and the visual system. In very young children and infants, vision may be estimated by how well they follow a small object with one eye covered. A normal eye will look directly at the object while an amblyopic eye may look to the side.

Once amblyopia has been diagnosed, treatment may consist of a combination of the following:

• Patching of the good eye
• Eye drops to blur the good eye
• Prescription lenses
• Prism
• Vision therapy

Chronic or long-term inflammation of the eyelids is known as blepharitis. It is a common problem affecting people of all ages. Common causes include; poor eyelid hygiene, excess oil produced by glands in the eyelids, a bacterial infection or an allergic reaction. Typical symptoms include a sandy or gritty feeling, dryness or burning, itching and even watering. Typical signs include: scales or flakes along the eyelashes, redness along the eyelid margins and occasional sticking together of the eyelids. Blepharitis usually causes minor discomfort, but can progress to be more severe if left untreated.

Proper Lid Cleaning

Warm Compresses

• Heat a washcloth with warm tap water
• Apply warm washcloth to closed lids for 1-2 minutes.
• Reheat and reapply washcloth repeatedly for 5-15 minutes.

Lids Scrubs

• Heat a washcloth with warm tap water.
• Apply a dime size drop of baby shampoo to the heated washcloth and lather.
• Gently close eyelids and scrub along the lid margins.
• If necessary, carefully clean around the base of the eyelashes with a Q-Tip or corner of washcloth.
• Perform 1-2 times per day for one week, then 2-3 times per week thereafter.

Prescription Ointment, if prescribed

• Perform warm compresses and lid scrubs.
• Squeeze up to a 1⁄4 inch of ointment along inside lower
  eyelids of both eyes
  Gently close eye while looking up, down, left and right to spread the ointment.
• Dab and spread a small amount of extra ointment on the outside of the closed eyelid margins.
• Wait 5 minutes and gently wipe excess ointment off with a tissue or washcloth.
  Ointment will blur vision. Apply just before bedtime.

Dry eye is a chronic and common condition, afflicting about 10 million Americans. It is estimated that almost 75% of people over age 65 will experience dry eye. It occurs in both men and women, although it is most common in pregnant or post-menopausal women.

The tear film is made up of a mucous layer against the eye, a middle aqueous (water) layer, and an outer lipid (oily) layer. All three components are critical for a normal tear film. If any of the three layers are deficient, the eye may suffer symptoms of dryness. The cause is usually an imbalance between tear production and/or tear volume drainage and evaporation.

People with dry eye usually have complaints of burning, stinging, itching, redness of the eyes, “sticky” eyelids, sandy or gritty sensation, foreign body sensation and/or tearing (excessive watering). Tearing with dry eye seems strange at first. This excessive watering is explained by the fact that an underlying dry eye may become irritated, sending a “signal” for increased tear production to “flush-out” the eye. This response is similar to the presence of a foreign body, such as an eyelash or hair, in the eye. Certain conditions can contribute to dry eye symptoms: normal aging, problems with blinking, use of caffeinated products, exposure to tobacco products, computer use, contact lens overwear and some contact lens solutions, environmental factors (dry climate, low humidity, wind exposure or smoke), certain medications (oral contraceptives, antihistamines, antidepressants, antihypertensive to name a few), some medical conditions (arthritis, Sjogren’s syndrome or thyroid dysfunction) and chemical or thermal burns.

Dry eye syndrome can be classified as mild, moderate or severe. The severity and cause(s) of dry eye generally dictates the course of treatment. Your doctor may recommend one or more of the following:

• A humidifier in the home has been found to be helpful for many patients. Due to “hard” tap water in most areas, however, distilled water is usually required.
• A diet rich in essential fatty acids has been shown to help. Fatty acids reduce eyelid inflammation, decrease lacrimal gland apoptosis (programmed tear gland cell death), stimulate tear secretion and thin oil secretions from the eyelids. In short, the underlying causes of dry eye are treated, not just the symptoms. Products such as TheraTears Nutrition may require 1 to 3 months of use before improvement is noted. TheraTears Nutrition contains 187 IU of vitamin E, 1000 mg of flaxseed oil and Omega-3 fatty acids (450 mg of EPA and 300 mg of DHA).
• An artificial tear used with the eyes on a regular basis, 4 times a day or more is best. If the condition is to be treated with artificial tears chronically, it is recommended to use non-preserved artificial tears. Artificial tears without preservatives are packaged in disposable ampules. Artificial tears with preservatives are packaged in bottles.
• Occlusion of the puncta (tear drainage openings), located in each of the four lids, may be completed. This usually involves simple insertion of a punctual plug into one or more of the tear drainage duct openings. The tiny plugs, usually made of silicone or collagen, can be inserted with little or no discomfort and are rarely felt by the patient afterwards. In the unusual case that the patient then has too many tears, the plug can just as easily be removed.
• Restasis is a prescription medication that causes increased tear production for the eyes. It treats an underlying cause of dry eye, not just the symptoms.

Floaters are small cloudy particles that float within the vitreous, the jelly-like fluid that fills the inner portion of the eye. They are comprised of small flecks of protein or other matter that are trapped during the formation of your eyes before birth and remain suspended in the clear fluid of the vitreous. Floaters usually appear as semi-transparent specks of various shapes and sizes. People often describe them as looking like a string, a bug, a spider, a cobweb, a net or even a cotton ball. They can be seen when they fall within your line of sight and cast a shadow on the retina (the light sensitive portion of the eye). Floaters are usually visible when you are looking at a plain-lighted background such as a blue sky or white pages of a book. Deterioration of the vitreous fluid may cause floaters to develop. This can be part of the natural aging process and is often not serious, although it can be very annoying.

With age, the jelly-like vitreous can shrink. Shrinkage can continue and cause the membrane around the vitreous to detach or pull away from the back of the eye. The pulling causes the retinal receptor cells to be stimulated and “fire” by this tugging action. This may result in the perception of light flashes. On rare occasions, vitreous can pull strong enough on the retina to cause a small tear or hole. The damaged part of the retina subsequently does not work properly and a blonde or blurred spot in vision may result. If untreated, retinal tears or holes can continue to worsen sometimes leading to a retinal detachment. Severe vision loss can result if the retina becomes detached. This can be seen as a curtain or loss of peripheral vision.

It is important to have an Optomap Retinal Examination or dilated eye examination if you experience flashes or floaters, or if you become aware of an increase in the number or intensity of flashes or floaters. In a dilated eye examination, your doctor will use a variety of special instruments to look at the vitreous, the retina and the other interior parts of your eyes to determine the causes of the flashes and floaters that you see. Most importantly your doctor will determine if holes or tears are present.

While flashes and floaters can be symptoms of either a vitreous detachment or a retinal detachment, vitreous detachment occurs more frequently and usually requires no treatment. Floaters tend to last longer than flashes. The flashes usually subside after a few weeks and the floaters tend to fade out over several months as they move forward in the eye. Often they do not go away completely. Most people learn to ignore them. Vitreous detachment should be monitored at least annually to determine if it is stable. Flashes and new floaters should be evaluated with an Optomap Retinal Examination or dilated eye examination to determine if any holes or tears are forming.

Approximately 1-3% of contact lens wearers develop GCP, consisting of conjunctival infection, mucous discharge, itching, tear film debris, coated lenses, blurred vision, excess lens movement, and blurred vision. These symptoms may remain minimal or progress to complete lens intolerance. The linings of the upper eyelids are most affected.

GPC begins with the formation of deposits on the surface of the lens. The constant trauma of the blinking lid rubbing on the surface of the lens exposes the deposits to the conjunctival lymphatic system. The antigens associated with the deposits incite an immune response in the conjunctiva. This condition is most commonly associated with failure to replace soft contact lenses as scheduled.

The symptoms increase with increased numbers of deposits, increased size of the contact lens, and increased wearing time, especially overnight wear. Treatment of GPC consists of using medications, for a short duration, that suppress the immune response. It is important to reduce the amount of contact between the deposits and the conjunctiva. Frequent cleaning, frequent replacement, reducing wearing time, and using lenses that resist deposit formation are effective treatments.

Glaucoma is a group of diseases in which the optic nerve becomes damaged. Once damaged, characteristic visual field changes occur. There are many types of glaucoma. Some types are hereditary, while other types are not.

Research indicates two interrelated processes leading to primary open angle glaucoma, the most common type of the disease. First, the eye may produce too much fluid (aqueous humor) for itself. Or second, the eye’s drainage system may be blocked. Either one or both processes may occur causing the inside pressure of the eye (intraocular pressure or IOP) to increase. The pressure builds up enough to squeeze the small blood vessels in the eye. This reduces the circulation of blood and damages the nerves that relay vision. The first nerves to be affected are usually the ones that transmit peripheral or side vision. With most types of glaucoma, pressure increases are so mild that there is no feeling of pressure or pain. Therefore, changes occur so slowly that a person is not usually aware of vision loss.

It was once believed that high IOP was the main cause of this optic nerve damage. Although IOP is clearly a risk factor, we now know that other factors must be involved. People with “normal” IOP can experience vision loss from glaucoma, while people with high “IOP” may not experience vision loss (a condition known as ocular hypertension).

Glaucoma can be difficult to diagnose because it is usually a slow process. Many different tests may be necessary to assist your doctor in establishing a diagnosis. These tests may include but not be limited to the following: tonometry, gonioscopy, ophthalmoscopy, visual fields, and retinal tomographs.

• Tonometry is a test that measures IOP.
• Intraocular pressure varies from one person to the next. With glaucoma, the pressure can vary throughout the day: being normal part-time and high part-time. Several IOP tests are necessary when your eye doctor is suspicious of glaucoma.
• Gonioscopy is a test that evaluates the drainage structures of your eyes. Your doctor will use a special handheld lens and a microscope to see if there are any changes causing glaucoma.
• Ophthalmoscopy allows your doctor to see the retina and optic nerves inside your eyes. The nerves are best viewed with the eyes dilated. Some eyes have a natural appearance that is very similar to eyes with early glaucoma. These eyes need to be watched very carefully for subtle changes. With glaucoma, eyes do change internally.
  Perimetry uses a sophisticated computer to measure and analyze your visual field or peripheral vision. Your doctor will be looking for stable peripheral vision. A decrease my indicate glaucoma. Repeated visual field tests are needed to determine if your peripheral vision is changing.
• Tomography assists with early detection of glaucoma. The Heidelberg Retina Tomograph II (HRT II) uses CAT-scan-like technology to create a detailed 3-D “picture” of the optic nerve head and surrounding tissues. In short, the HRT II informs your doctor if your optic nerves are structurally set up to develop glaucoma.

Your doctor may recommend some or all of these tests when there are risks of glaucoma; such as family history, high or borderline IOP measurements, certain medication usage or questionable appearance of internal eye structures. When these tests are ordered, your doctor is not necessarily saying that you have glaucoma. Your doctor needs more information about your eyes. This information provides baseline data for comparisons when evaluating your eyes in the future. With this information, your doctor will be most accurate in determining whether or not your eyes are developing glaucoma.

Treatment of glaucoma involves lowering the pressure of the eye to prevent further damage. Treatment includes various medications or even surgery to control the IOP. Routine eye examinations are extremely important, because if glaucoma is left untreated, permanent vision loss or blindness occurs.

Oxygen needed by the cornea diffuses from the tears on the corneal surface. Contact lenses create a barrier that reduces the amount of available oxygen. Contact lens wear (especially with a closed lid during sleep) can cause acute hypoxia. If mild, hypoxia produces epithelial edema and temporary blurred vision. If severe, it can cause epithelial cell death.

Contact lens users who over-wear their lenses or fail to replace their lenses may also have chronic or long term hypoxia. Epithelial microcysts produce a mild decrease in vision. It takes several weeks for the microcysts to disappear after dicontinu7ation of the contact lenses. Also, swelling of the cornea may cause temporary or even permanent changes of prescription, usually increased nearsightedness.

With more severe chronic corneal hypoxia there may be neovascularization. Neovascularization is new blood vessel growth. If less than 2 mm it is not visually significant and generally is well tolerated but is a sign of hypoxia and may be a harbinger of more significant problems. Deep stromal neovascularization can occur with significant abuse of contact lenses. Chronic hypoxia can cause decreased corneal sensitivity. That may be the reason why some patients experience decreased comfort with more oxygen-permeable contact lenses.

Chronic hypoxia also leads to thinning of the epithelium, decreased epithelial shedding, increased cell size, and increased binding of bacteria to the corneal surface. The thinner epithelium poses less of a barrier to bacterial penetration. The reduced shedding of epithelial cells allows the attached bacteria to remain on the eye for longer periods of time. The increased binding of bacteria enables greater numbers of bacteria to attach to the epithelial surface. Thus, over-wear of contact lenses greatly increases the risk of eye infections.

Migraine, tension and cluster type headaches are caused by electrical and chemical instability of certain brain centers. These centers regulate blood vessels around the head and the flow of pain messages to the brain. The body’s chemical serotonin is thought to be responsible, but the exact mechanism is not well understood. The headache involves dilated, inflamed blood vessels and tight, aching muscles.

Those who suffer from migraine include 6% of males and 18% of females. Until puberty, migraines are equally common among boys and girls. Females are likely to have their most severe attacks during or just before their menstrual period, due to changes in estrogen. Half of those who have migraines have never been diagnosed. Many migraine sufferers (70-90%) have other family members who have been affected.

People have different experiences during a migraine attack. A “prodome” is a warning several hours or even a day before the attack. A prodome might include mood changes, fatigue, craving, or sensitivity to light or odors. Early in a migraine, 20% of sufferers experience an “aura” or changes in vision such as flashing lights or zigzag lines. This may precede the headache by 20-40 minutes. People can experiences these symptoms without developing a headache. This situation is referred to as an ocular migraine. With the headache, there is often nausea or vomiting, and/or sensitivity to light or noise. The pain is usually severe, throbbing and usually on one side of the head. Light-headedness and dizziness may accompany this pain. The migraine attack may last for hours or days. It usually worsens with activity and can be severe enough to interfere with normal activities.

Fatigue, hormone changes, and especially stress can predispose a person to migraines. The following items may act as “triggers” and set a migraine attack in motion: alcohol, especially red wine, nitrates in processed meats, MSG, NutraSweet, chocolate, aged cheese, whole milk, sour cream, ice cream, citrus, fruits, nuts, onions, peas, certain beans, pickles, sesame seeds, salty foods, yeast, excessive caffeine, lack of caffeine, eyestrain, bright lights, glare, loud noises, weather changes, missed meals, birth control pills and other medications, missed medications and other factors.

For migraine sufferers, a routine healthy diet along with nutritional supplementation, proper routine sleep habits and regular exercise is the best place to start. Whenever a migraine occurs, write down the possible stress triggers that you have been exposed to over the 2-4 hours before the prodome and up to 24 hours before the headache. After several episodes, you see some common elements that may be your triggers. There will probably be several, not just one. Once you know your triggers, you can avoid them, or at least moderate your exposure to them. Also if you can recognize your prodome early, you may be able to prevent the migraine with rest, aspirin or less medication than otherwise. Before starting long-term treatment, it might be beneficial to try to control migraines without medication. Caution should be used with over-the-counter medications such as aspirin and other pain relievers because extended use (greater than 2-3 times per week) can lead to rebound headaches.

Several medications are available that can be taken daily to prevent frequent migraine attacks. There are also medications to help manage the nausea and the pain once a migraine has started. The decision to treat migraine must be based on the frequency, the severity and the duration of the attacks. Your family physician should be consulted for pharmaceutical treatment.