Month: September 2022
Help! My Cornea Keeps Breaking
A case of recurrent corneal erosion
Transcript for those of you who would rather read:
A middle aged female patient came in, referred by one of the ophthalmologists in our practice for dry eye treatment. She said, ‘Oh I did not know that you were an optometrist, I thought you were a dry eye specialist.’ This statement assumes that an optometrist cannot be a dry eye specialist. That is plainly wrong. However, I can only imagine that she is not alone here and it may represent a popular misconception. Contrary to what the public think, an optometrist does not only prescribe glasses or contact lenses, though these are certainly the bread and butter in our jobs. An optometrist can diagnose and treat most eye diseases, and many of us develop specialties such as dry eye, medically necessary contact lenses, low vision, vision therapy and pediatrics. For dry eye, there are probably more specialists that are optometrists than ophthalmologists. I may do another video in future about how to select the right eye doctor based on your needs and visual complaints.
I said, ‘dry eye is a specialty that both optometrists and ophthalmologists can do. Tell me your problem and I’ll see if I can help you.’
Though she did have chronic dry eye in both eyes, it’s her left eye that she was mostly worried about. (You can learn more about dry eye in my previous video and blogs and I have linked them below in the video description. )
She initially had an injury of the left cornea 8 months ago because of using CPAP mask while sleeping, since then it had happened again and again, to the point she had to discontinue using CPAP. The cornea is the clear tissue on the surface of the eye and good vision relies on clear and healthy corneas. Dry eye and injury can both make this tissue sick and result in pain, tearing and poor vision.
Her first ophthalmologist performed a procedure to remove the faulty superficial layer of the cornea and put a bandage contact lens in to protect the eye. Unfortunately that resulted in a corneal ulcer, for which she had to go to the emergency room of a famous eye hospital in a different city. A corneal ulcer is an infection of the cornea, which can lead to permanent vision loss if untreated. One of the risk factors of developing corneal ulcer is wearing contact lenses, and some of the contact lens related corneal ulcers can be difficult to treat, especially with delayed treatment.
With intensive antibiotic eye drop treatment, the corneal ulcer resolved. But her nightmare of the cornea injury continued, she was having almost weekly recurrent corneal erosions in the left eye, waking up with eye pain. She could not sleep well and was afraid to open her eyes in the morning.
So what is recurrent corneal erosion, or RCE? This is typically a tear of the superficial layer of the cornea, initially often from an injury, but subsequently can happen spontaneously. It often happens when people wake up in the morning, because a sudden opening movement of the eyelid can open up a previously weak spot in the cornea. In addition, many people have dry eyes overnight for various reasons, such as incomplete closure of eyelids, having heat or air conditioner on, using a cpap machine, etc. Having dry eyes predisposes the opening of the healed wound again. As a result, waking up with severe pain, tearing and light sensitivity in the eye is a common complaint for those with RCEs.
How do you treat RCEs? First, it is imperative to keep dry eye under control, for the reason mentioned above. This is also the reason my patient’s ophthalmologist referred her for dry eye treatment. Second, special attention should be given to the enticing factor of the cornea wound. In her case, it would be the overnight incomplete eyelid closure and possibly the eye touching pillow or other things physically.
She had already tried ointment at night which did not prevent RCE from happening. She used artificial tears during the day, but the relief was only temporary. She was not doing any warm compress because she needed to boil her eye mask for some minutes to reactivate it each time. She did take fish oil capsules. The fish oil and the stopping of her amitriptyline medication were the only things that seemed to be helpful to her. Yes, certain medications can cause dry eye and again you can find more information in my link below. She was using steroid drops while her cornea was healing but she could not use that forever due to side effects such as cataract and glaucoma. She tried various goggles but reported that when they moved at night she sometimes found her eye touching various parts of the goggles, which could make things worse.
Careful examination of her eyes showed that she had meibomian gland dysfunction and ocular rosacea, which were contributing factors to dry eye. More information about these conditions can also be found in my previous blogs with the link below.
Based on her past treatment, I recommended that for dry eye and MGD, she continue the artificial tears 4 times a day, but should buy a much easier to use eye mask which can be simply heated up in the microwave before use. She would need to do warm compress twice with 5 min each time daily. She would continue the fish oil, which was beneficial to dry eye. She could start restasis twice daily, this being an FDA-approved eye drop for chronic dry eye, but with the caveat that it could take up to 3 months to be effective, and it only worked in a small percentage of dry eye patients. In future, if her dry eye is still not controlled well, she would benefit from intense pulsed light therapy, which is unfortunately very expensive and not covered by insurance.
For RCE, I recommended that she use a large amount of ointment in the left eye at night, and put an eye shield on to prevent things from getting onto or into the eye. Some studies suggest that doxycycline can prevent corneal breakdown and reduce the frequency of RCE. So I prescribed that to her. She did have stomach upset previously when taking it for Lyme’s disease, but this was a reduced dosage and we will monitor GI side effects closely.
Patient was very thankful and I hope she got better. Long-term management is required for both RCE and dry eye. That’s it for now. Let me know your thoughts and comments. See you next time!
Links for dry eye and MGD: https://bostoneyeblink.com/2016/06/28/why-are-your-eyes-dry/
ocular rosacea: https://bostoneyeblink.com/2019/12/12/another-treatment-for-dry-eye-doxycycline/
systemic medications that are associated with dry eye: https://bostoneyeblink.com/2019/11/02/when-drugs-cause-dry-eye/
Secret to Stopping Myopia
I will share a secret that can lead to complete myopia prevention in this video. It’s simple, but not many people among the general public know about it. It sounds simple, but in reality is extremely hard to achieve.
If you don’t want to watch the video, here is the transcript.
Secret to stopping myopia
Hello, this is Dr. Ding. I am an eye doctor and today I would like to tell you the secret to stopping myopia.
Myopia affects 1 in 3 people on this planet, and people with myopia have increased risks of a host of eye diseases that may lead to blindness. No, it is not merely an inconvenience of glasses or contact lenses that can be fixed by lasik surgery later. It is a fundamental change to the eyeball that permanently changes the anatomy and robustness of the eyes that no lasik can fix. Lasik may make you lose those glasses, but your eyes are nonetheless the same ones with the increased risk of macular degeneration, retinal detachment, cataract and glaucoma. These are conditions that glasses, contact lenses, or lasik can not fix.
So now you know that myopia is bad, but why is myopia so prevalent?
We can blame some of this on our parents. Some of them have genes that make it easier for people to develop myopia. For example, if parents both have myopia, then their kids will have a much higher chance of developing myopia as well. It’s a bit like tall parents will give birth to kids who will become tall adults eventually. Unfortunately, we really don’t have a way to choose our parents or our genes at this moment. So let’s find out what else is the problem.
For hundreds of thousands of years, humans lived as hunter gatherers and/or farmers, which means a lot of time spent outdoors.
And up until some two thousand years ago, humans did not really read. Computers came out only in the last century, as well as ipads and smartphones. With modern education and lifestyle, it has become the norm to spend the majority of wake time reading, writing, or looking at things at an arm’s length, most often in a room.
And this is a big problem for our eyes. Human eyes are supposed to be emmetropic or just right by stopping growing after 6-8 years of age. However, the constant near work and lack of exposure to high intensity, full-spectrum natural light keep sending signals to our eyes to continue to grow, which leads to myopia. As a result, children’s eyes develop myopia which continues to progress up till early adulthood. In fact, this high stress and demand we put on our eyes make myopia grow even in people’s 30’s and 40’s.
The sad thing about myopia is that it is not reversible, which means that once it forms, it does not reverse. It’s just like when you grow to be 6 feet tall, you don’t just shrink to 5 feet.
The sadder thing about myopia is that it will continue to progress if nothing is done to stop the eye from growing.
The saddest thing about myopia is that it happens so early in life that the people who have this happen to them, AKA children, are too young to be able to make a decision to live differently to make a difference. It is up to the parents, the teachers, the school and the society to tell them, hey, this is hurting your eyes and we have to do something to stop your eyes from getting bad or worse.
So what can parents do? First, we need to know that normal growth or kids’ eyes rely on a good amount of outdoor activities daily. Numerous studies have shown that 2 hours of outdoor activities daily prevent myopia from happening in the first place, and slow down myopia progression once it starts.
What is so special about the outside? We don’t know for sure, but most likely it’s the enormous amount of light outside vs the comparably much dimmer artificial light inside a room. For example, on a bright sunny day, the light unit outside is up to 100,000 lux, even on a cloudy day it is about 5,000 lux, whereas in a well-lit room it is typically around 1,000 lux. In addition, natural light consists of a continuous spectrum of the visible light, whereas most artificial light sources have a different light spectrum.
Another factor could be the openness of the outside environment. Unless closed, our eyes are constantly focusing on objects and scenes. This is done automatically without you trying. So your eyes have more chances to focus on things that are much farther away outside than inside a room.
Back to parents’ responsibility of giving kids outdoor time. This has to happen early and consistently. You don’t start bringing your kids outside when they are 6 or 7, you start doing that when they are 1 or 2. Remember it’s the bright natural light that’s beneficial and not the exercises themselves, so working out inside a gym will not help their eyes, but walking or even sitting in the sun will do.
Sure please put on sunglasses or a hat to avoid UV damage to their eyes, but even when protected by sunglasses the eye still sees much more light than inside a house.
Again it is the bright natural light that is beneficial, so taking them to the park when it’s dark or really cloudy or raining will not help. It may be good for other things but not for myopia prevention.
What can schools do to help kids prevent myopia? Let’s face it, kids spend the majority of their day time at school, when the natural light is the best. So make recess count, make every child go out to the field during recess. Better yet, increase the time of recess. Maybe teach some classes outside. Promote walking to school and not driving. Build more windows to classrooms.
What can our society do to help children’s eyes? Educate parents, teachers and children. Let everyone know about this ‘secret’. Promote this on social media, on TV and on radio. Make policies that mandate 2 hour of daily outdoor activities for schools, preschools and daycares. Screen children for vision problems. Subsidize health plans to allow children to have free eye exams. Give working parents special time off once in a while during the day to spend time with their children outside. Foster a culture that favors activities outside as an essential part of healthy living.
There it is, the secret. It seems so simple, yet it is so hard to do. It is in every way against our modern lifestyle and civilization, where sitting in front of a computer all day long is the mode of productivity and success. Yet we simply have to do it, because after all, what is more important than our children’s vision and health?
Boston Eye Blink 