Should you take antibiotics with that bump on your eyelid?


Eyelid bumps, sometimes called styes, are very common. They are usually red, sometimes painful, and sometimes will stay there for months. Sometimes these bumps keep coming back. There are two major types of eyelid bumps, one called hordeolum and the other chalazion. Both are caused by blocked oil glands in the eyelid, called meibomian glands. This gland secretes oil through an opening on the eyelid margin (that’s the thin edge at the base of the eye lashes). This oil is really important to keep our tears in good quality (refer to some of my previous posts on meibomian gland and dry eye). When the opening is blocked, the oil backs up inside the gland, and forms a bump. In terms of the hordeolum, this oil content is infected by our normal skin bacterial flora, so this is technically an infection, but it’s often self-limited. In terms of the chalazion, this content undergoes an inflammatory process but not infection. This is one of the reasons that the hordeolum is often painful and chalazion is not.

Regardless, given similar etiology, the treatment is to open up the blocked gland and let the oil flow again. And one effective way to do this is to apply a warm compress on the bump, this allows the content to soften and drain more easily.

However, doctors sometimes prescribe antibiotics, be it an oral pill, or an eye drop or ointment. So the question is: is it necessary to take antibiotics for hordeolum or chalazion?

There is a recent research [1] that retrospectively looked at more than 2,712 cases of these two conditions, some of these were treated with warm compress alone, some with antibiotics alone, and some with warm compress as well as antibiotics. The final outcome shows that all 3 treatments led to a similar rate of resolution, over 70% for chalazion and over 90% for hordeolum. This shows that additional topic antibiotic drops/ointment or oral antibiotics do not really give additional benefit. Warm compress alone works just as well. It’s interesting that antibiotics alone also have a good success rate, though only 1% of patients were treated by this method. 

The limitation is that this is a retrospective study. There is a randomized controlled trial looking at chalazion and found similar outcome: antibiotics do not give additional benefit in addition to warm compress [2].

Given the rampant antibiotic resistance these days, I think it’s reasonable to apply just warm compress and not start antibiotics automatically for every eyelid bump.

References: 

[1] Alsoudi, Amer F. B.S.; Ton, Lauren B.S.; Ashraf, Davin C. M.D.; Idowu, Oluwatobi O. M.D.; Kong, Alan W. B.S.; Wang, Linyan M.D.; Kersten, Robert C. M.D.; Winn, Bryan J. M.D.; Grob, Seanna R. M.D.; Vagefi, M. Reza M.D. Efficacy of Care and Antibiotic Use for Chalazia and Hordeola, Eye & Contact Lens: Science & Clinical Practice: November 8, 2021 – Volume – Issue – doi: 10.1097/ICL.0000000000000859

[2] Wu AY, Gervasio KA, Gergoudis KN, Wei C, Oestreicher JH, Harvey JT. Conservative therapy for chalazia: is it really effective? Acta Ophthalmol. 2018 Jun;96(4):e503-e509. doi: 10.1111/aos.13675. Epub 2018 Jan 16. PMID: 29338124; PMCID: PMC6047938.

Myopia progression in young adults

It is very common to see children develop myopia and get worse over time. We know that adults typically don’t have myopia progression because their eyes have fully developed and stopped growing, just like their height. However, in real life, some young people do have increased prescription numbers year after year. Researchers observed that college students continue to have increased myopia previously in Europe and the US. Now a new study [1] from Australia followed young people for 8 years (20 to 28 years of age) and confirmed this finding.

Among 516 subjects with no myopia, 14% were found to have developed myopia after 8 years. Among 698 subjects with myopia less than 6 diopters, 0.7% were found to have developed high myopia (more than 6 diopters) after 8 years. Among 691 subjects who were included in the progression analysis, 37.8% had myopic shift of 0.50 D or more. On average, the myopic progression was -0.04 D (ranging -0.03 to -0.06) per year, and axial length increase was 0.02 mm (0.014 to 0.025) per year. 

We can see that this is a small myopic shift, but it is a true shift and statistically significant.

So what kind of people are more prone to develop this myopic shift as adults? They found that East Asians were more likely than whites, females were more likely than males, those with myopic parents were more likely than those without myopic parents, and those who spend less time outdoors were more likely to develop more myopia as adults. Interestingly, they used an objective way to evaluate outdoor activities, conjunctival ultraviolet autofluorescence area, as the larger the area, the longer exposure to the sun.

These are also the risk factors of myopia progression in kids. So having myopic parents, being a female, being an East Asian, and spending less time outdoors are just not good in terms of myopia, kids or adults alike. You will notice that no one can change the first 3 risk factors, but the last one is highly modifiable. 

The take home message is that myopia progression can continue into adulthood, though at a much slower rate. And spending more time outside is always a good thing if you don’t want your glasses to get thicker.

Reference: 

[1] Lee SS, Lingham G, Sanfilippo PG, et al. Incidence and Progression of Myopia in Early Adulthood. JAMA Ophthalmol. Published online January 06, 2022. doi:10.1001/jamaophthalmol.2021.5067

Normative database of axial length in children

This article is for eye doctors who use axial length routinely in their myopia control clinic, and certain parents who are curious and/or obsessed with the numbers of their children’s eyes (trust me, I do encounter these parents weekly).

Briefly, axial length is the length of the eyeball, which grows throughout the first 18 years of a person’s life. It is normal for the eyes to grow longer over time until it stabilizes at adulthood. But the growth can be accelerated resulting in long axial length in myopia. Therefore in many eye doctors’ offices, this value is measured to monitor myopia development and record whether myopia control is successful with a given intervention.

Understandably, it is important to have a normative database to evaluate whether a given child’s axial length is normal. Basically, there have been quite a few published articles on typical axial lengths of children of various ages. I have put together data from two recent studies that encompass ages from 3 months to 18 years below. The mean values for a given age are listed, as well as standard deviation. Table 1 is from Florida, USA, on 165 American children (Miami study) [1] and table 2 is from Shanghai, China, on 14,127 Chinese children (Shanghai study) [2]. Obviously the 2nd study is a much larger scale, and I really am very excited about this very new data. The first study, though with much fewer subjects, is quite remarkable as well in my opinion, as it examined kids as early as 3 months, understandably not easy to do and not many other studies were able to look at this age group. So I am keeping these two tables as a reference for my own patients. 

For those who are more visual, Figure 1 and Figure 2 are these numbers plotted in graphs.

Table 1. Axial length of 3 month to 7 years old children (Miami study)

Table 2. Axial length of 4 to 18 years old children (Shanghai study)

Figure 1. Axial length mean (solid line) and 95% confidence interval (dotted lines) in 3 month to 7 years old children (Miami study).

Figure 2. Axial length ranges in 4 to 18 years old children (Shanghai study).

A few things to keep in mind from these data. 

First, these are from two distinct populations. The 3 month to 7 years old study group (Miami study) were children from Miami, FL. No ethnic background information was given in the paper, but one can assume it could be typical from that area. The 4 to 18 years old study group (2nd Shanghai study) were Chinese children. It is well known that Chinese children have longer axial lengths than Caucasions and African descents (and more prevalent myopia rates unfortunately), so we certainly cannot assume that this is inclusive of all possible scenarios. 

Second, you can see that for any given age, there is a wide range of axial lengths in both studies. This tells us that normal is a range, NOT a single number. Do NOT compare the number of your child to your neighbor’s kids. This is not a competition. Also, it has been demonstrated again and again that it is the rate of axial length growth, rather than the absolute number, that better predicts myopia progression. Do not get anxious over one measurement. Monitor the axial length over time to find the trend. 

Lastly, I would still stress that while it is great that we have a normative database for axial length, it is still the gold standard to perform cycloplegic refraction to accurately assess a child’s true refractive error. Axial length measurement is a powerful tool, but it does not and cannot replace cycloplegic refraction.

References:

[1] Miami study: Bach A, Villegas VM, Gold AS, Shi W, Murray TG. Axial length development in children. Int J Ophthalmol. 2019;12(5):815-819. Published 2019 May 18. doi:10.18240/ijo.2019.05.18

[2] Shanghai study: He X, Sankaridurg P, Naduvilath T, Wang J, Xiong S, Weng R, Du L, Chen J, Zou H, Xu X. Normative data and percentile curves for axial length and axial length/corneal curvature in Chinese children and adolescents aged 4-18 years. Br J Ophthalmol. 2021 Sep 16:bjophthalmol-2021-319431. doi: 10.1136/bjophthalmol-2021-319431. Epub ahead of print. PMID: 34531198.

Low dose atropine drops and ortho K combo work better than ortho K alone in myopia control

Many parents ask whether their children should be on both atropine and ortho K to control myopia. There were small studies, some showing better result with the combo treatment. There was also a small scale study that I talked about that showed when ortho k failed to control myopia progression, additional atropine did not help.

Now a new research that analyzed 5 clinical studies involving 341 children revealed that ortho K + low dose atropine worked better than ortho K alone in controlling myopia progression [1]. On average, using the combo treatment results in 0.25 mm axial length elongation compared to about 0.35 mm in ortho K alone after 12 months of treatment. This is a small, but statistically significant finding.  

I think having this data is helpful. When a child has sub-optimal control with ortho K alone, I can recommend adding atropine. If a child has fast progressing myopia and parents are anxious, I can recommend starting with both treatments to maximize the control.

Would you be interested in seeking both treatments together right from the beginning?

Reference:

[1]https://journals.lww.com/claojournal/Fulltext/2021/02000/The_Efficacy_of_Atropine_Combined_With.7.aspx

Cancer chemo drug to treat retinitis pigmentosa?

Recently US FDA granted orphan drug designation of ADX-2191(methotrexate for intravitreal injection) by Aldeyra Therapeutics, Inc for the treatment of retinitis pigmentosa (RP) [1]. RP is a serious genetic condition that leads to retinal cell death and vision loss. It is a rare condition, which is defined as affecting fewer than 200,000 people in the United States. It has no cure, and limited treatment options, and is one of those eye conditions that doctors cannot do much about. So it is great to hear that now a drug is being developed to improve RP. 

What is also surprising is that methotrexate is not a new drug. In fact, it has been around for quite some time now, and primarily used to treat cancer of the blood, bone, lung, breast, head, and neck. It can also treat rheumatoid arthritis and psoriasis. It works by inhibiting cancer cells and certain immune cells to replicate, thereby can be used to treat cancer and certain autoimmune conditions. Now that it is injected into the eyeball for RP, does it mean it inhibits cells to grow and divide in the retina? In RP, retinal cells die, so it does not appear to be helpful to have a drug that further reduces cell duplication. Plus, the retinal cells are already terminally differentiated and do not divide anyways. So how does methotrexate work to help RP?

I am very curious now about this and looked into literature. It turns out it is a brand new mechanism of action of this old drug that renders it effective against RP. Scientists from University of Pittsburgh, University of Cincinnati and National Institute of Health discovered that methotrexate can reduce the misfolding of a protein called rhodopsin that is frequently mutated in RP, without affecting the healthy version of this protein. Rhodopsin is THE molecule to mediate vision in the retina. When it is mutated such as in RP, it folds in the wrong shape, leading to loss of function and death of retinal cells. Methotrexate could help the body’s natural garbage disposal system to work better to clear these wrongly formed proteins, and improved vision in a mouse model of RP [2].

Note this study using mice was published in 2020, and the FDA designation of orphan drug in 2021. The company moved fast!

Of course, orphan drug designation does not mean it’s already approved or will be approved by the FDA eventually for the treatment of RP. Phase 1 clinical trial was being planned and investigated at Mass Eye and Ear/ Harvard Medical School [3]. Hopefully data in humans will give some hope to those with this condition.

References: 

[1] Aldeyra Therapeutics receives Orphan Drug designation from the U.S. Food and Drug Administration for ADX-2191 to treat retinitis pigmentosa. News release. Aldeyra Therapeutics, Inc. Accessed August 4, 2021. https://www.businesswire.com/news/home/20210804005122/en/Aldeyra-Therapeutics-Receives-Orphan-Drug-Designation-from-the-U.S.-Food-and-Drug-Administration-for-ADX-2191-to-Treat-Retinitis-Pigmentosa

[2] Liu X, Feng B, Vats A, Tang H, Seibel W, Swaroop M, Tawa G, Zheng W, Byrne L, Schurdak M, Chen Y. Pharmacological clearance of misfolded rhodopsin for the treatment of RHO-associated retinitis pigmentosa. FASEB J. 2020 Aug;34(8):10146-10167. doi: 10.1096/fj.202000282R. Epub 2020 Jun 14. PMID: 32536017; PMCID: PMC7688577.

[3] https://adisinsight.springer.com/drugs/800053948

10 year use of low dose atropine for myopia control

We know that low dose atropine has been used to control myopia progression for a number of years now. It is still not approved by the US or Chinese FDA partially because long-term safety data are lacking. Previous studies demonstrated 2 years of using to be safe and effective. But myopia control is a long-term thing, maybe up to 10 years if a child starts to develop myopia from an early age (6- 8 years of age). 

Well now there is a study in Taiwan following children using low dose atropine for 10 years. This is a cohort study, no controls, and with only 23 subjects. Every child (that had myopia) was on low dose atropine for the entire 10 years and monitored every 2-4 months to check their refraction and axial length. It is certainly not a controlled or randomised study, and with a low sample size. However, I think it gives us a lot of information in a clinical setting on what to expect once a child is on low dose atropine for myopia control long term.

They also adopted a commonly used clinical approach, stepwise increase in treatment dosage if the treatment effect is not enough. For example, every myopic child started with 0.05% atropine. If a child did well on this, they continued this dosage throughout the 10 year period. If however their myopia continued to progress more than 0.50 D every 6 months, then they were switched to higher concentrations of 0.1%, 0.25%, and until 0.5%. A high concentration of 1% was not used.

In my clinic (and perhaps many others), I usually start with even lower concentration, 0.01%, which has been clinically proven to be effective in myopia control and with the least side effects including pupil dilation, light sensitivity and blurry near vision. I would go up to 0.02% and 0.05% if myopia control is not achieved, and I seldom go higher than 0.05% because at this point the side effect is noticeable and may interfere with normal study and life of a child. Eye doctors in Taiwan are more aggressive in myopia control in terms of using atropine and I thank them for the study. I always wonder whether I should ramp it up, and if higher concentrations are effective, then maybe it’s worth the side effects (and potentially risks of using this for 10 years).

This study answered my question to some degree. First of all, 65% patients were only using 0.05% atropine throughout the study, which means 35% patients did not respond well to the initial low dose. This is a high number. Remember 0.05% is already a higher concentration than the most commonly prescribed 0.01%, and still ⅓ of children do poorly on it. When we encounter children like this (and we will), do we further increase the dosage? In their study they did, and what they discovered was that for those who did not do well in the initial low concentration of atropine, despite the stepwise increase in the atropine concentration, their myopia control was still worse than the kids who responded to the initial low dose atropine. There were vast inter-individual differences, but the mean numbers look like this: the responding kids started with -1.5 D and progressed to -4.7 D after 10 years, whereas the poorly responding kids started with -0.9 D and progressed to -6.6 D. Their study did not have a control, but based on natural history of myopia progression in their population, they predicted about -7.7 D if no myopia control was done at all. So for those that respond to atropine, a reduction of 3 D of myopia over 10 years is quite good, especially it prevents these kids from developing high myopia (more than -6.0 D), which is associated with more retinal related complications. On the other hand, 10 years of high dose atropine in children who were poor responders resulted in only 1 D of myopia reduction, it seemed less worthwhile, considering the burden of using drops daily for 10 years and the side effects associated with dilation. Of course, this is purely based on a mean value, and individuals can be quite different, and for some, maybe 1 D reduction is still something that helps. 

But the lesson here is that if a child responds poorly to low dose atropine, merely increasing the concentration may not be the answer. They may be better off with additional or alternative control methods, such as ortho K lenses or multifocal soft contact lenses. 

Another outcome is that they did not find significant side effects with 10 year use of low dose atropine drops. The study also claimed that the children were not prescribed PALs. That is interesting, considering that atropine at concentration of 0.1% or above will have significant dilation and cycloplegic effects. Given that they used higher concentrations, it can be assumed that 0.01% atropine can also be used without significant side effects for up to 10 years.

So the take home message is that long term use of low dose atropine (10 years) may be safe and effective, but if a child responds poorly to low dose atropine, then they may benefit more from other methods of control. But keep in mind that this is a limited study with small number of patients. We still wait for larger scale and better controlled study.

The study cited in this article:

Chuang, MN., Fang, PC. & Wu, PC. Stepwise low concentration atropine for myopic control: a 10-year cohort study. Sci Rep 11, 17344 (2021). https://doi.org/10.1038/s41598-021-96698-6

Crocodile tears

A man in his 30s came in because he saw flashes of light for 20 minutes two days ago.

He was having very blurry vision and could not focus as well at the time, but it all resolved on its own and he remained symptom-free. After a thorough dilated exam I determined that his retinas were completely normal and his symptoms were most likely from ocular migraine. 

Then he brought up something else completely unrelated. For three years now whenever he ate something his right eye would tear up and it’s always only the right eye. That eye was not red, itchy or painful, it simply teared up a bit. 

He did not have dry eye. And both of his eyes were white and quiet with no sign of tearing at the time. His description sounded almost like crocodile tear syndrome. This is a very rare condition where the nerve that supplies the salivary gland somehow also goes to innovate the lacrimal gland which secretes tears. When he’s having a meal his salivary gland gets a signal to start secreting saliva, and that cross talks to his lacrimal gland which makes his right eye tear up. This often happens after nerve injury when the nerve tries to repair itself and makes an inadvertent mistake. This is called aberrant nerve regeneration. But he denies any facial or head injury. He reports to be completely healthy and taking no medication. 

The treatment for crocodile tear syndrome is to inject Botox into the lacrimal gland so that a part of the gland doesn’t work and therefore not too many tears are produced. In his case this doesn’t really bother him so we will just monitor.

Can you use ortho K lenses and atropine together to control myopia?

We know that ortho K lenses and low dose atropine (0.01%) both can slow down the rate of myopia progression by about 50%. People often wonder whether by combining the two, we can slow down the progression even further.

Here is an article looking at a combo of the two in 73 Chinese children who have very fast myopia progression. They discovered that additional atropine 0.01% did not result in significant difference compared with ortho K lens alone in terms of axial growth.

This is disappointing. However, this study looked at children with fast myopia progression despite using ortho K lenses. Also only a small number of children were evaluated. In addition, this is a retrospective study, meaning authors looked at the data later, rather than a randomized controlled study, so there could be factors stewing the results.

Anyway, we await more studies to see whether the two have synergistic effect.

Reference:

Chen Z, Zhou J, Xue F, et al, Two-year add-on effect of using low concentration atropine in poor responders of orthokeratology in myopic children British Journal of Ophthalmology Published Online First: 11 March 2021. doi: 10.1136/bjophthalmol-2020-317980

Increased myopia among children during COVID-19

Covid-19 has really affected so many aspects of our lives. With all that isolation inside, and the remote learning with digital screens, parents worry about their kids’ health. Many worry this will do great havoc to their eyesight, and they are not wrong.

Research has shown that confinement to home due to covid-19 is associated with an increase in myopia. Scientists have been monitoring the refractive error of 123 535 Chinese children since 2015. While the refractive error was showing a pretty steady trend in kids 6 to 8 years of age from 2015 to 2019, there was a sharp and dramatic change toward myopia in 2020 (Figure 1). Many Chinese children already don’t get enough outdoor activities and spend way too much time studying, and the covid-19 put extra strain in terms of even further decrease of outdoor time and increase of screen time.

Figure 1. Young children show a dramatic increase in myopia in 2020 compared to previous years [1]. Figure from reference [1]

I only hope that with universal vaccination and a good hygiene habit that we have formed during the past year, children will be able to be back to school and enjoy normal outside activities soon. If you think you child may have trouble seeing, please bring them to an eye doctor.

[1] Wang J, Li Y, Musch DC, et al. Progression of Myopia in School-Aged Children After COVID-19 Home Confinement. JAMA Ophthalmol. 2021;139(3):293–300. doi:10.1001/jamaophthalmol.2020.6239

Myopia and anxiety

A friend who is a rehabilitation therapist in China told me some interesting observation he has had while treating myopic children. He noticed that for those children who are more anxious, their myopia progressed faster, versus those who are calmer. So he asked me whether anxiety and other psychological factors may contribute to myopia development and progression.

Now I know that when I was 10 and started becoming myopic, I had a lot of anxiety and depression, for the reason that I could not see the blackboard in class! Every school year we went to the hospital to have physical exam and the vision exam was the most anxiety-inducing. I would squint, guess, and peek at the tumbling E beforehand trying to memorize them. My face became red and my hands sweaty. Yes I am ashamed to admit that I cheated in the vision screening in elementary school to get away with a failed report to the teacher and my parents. Why did I do that? As a child I could not describe it exactly. But I did not want to wear glasses and became different from everyone else. Plus, as a straight A student, a failed test in any form was not acceptable.

More and more I found it difficult to see the board. I would nonchalantly walk up to the board then back to my seat (fortunately I sat in the middle so did not have to walk too long to disturb the other students). I would peek at my desk mate’s notes to see what’s going on. I became afraid of math classes because the numbers were small. Eventually I had to tell my parents that I had trouble seeing the board. I remember feeling ashamed when I had to tell them. It’s as though I contracted a disease that I should not have. Though the science at the time was not clear, at least to me, I knew that I was to blame for becoming near-sighted. I was always reading, day and night. Not necessarily school-related, but I was hooked by fictions, story books, magazines and newspapers, anything that had prints on them. Outside classroom, I would read on my own. During summer and winter vacation, I would still be reading books from the library. My dad who’s a teacher and scholar, was the role model that I took after. He did not stop my prolonged near work. My childhood home was very dark, with rather dim lighting. Plus my dad also had myopia though my mom had hyperopia. Thus odds were really against me and no surprise I was among the early ones in my class to wear glasses. That was in the early 1990s, at age 10 I developed myopia while majority of my classmates were still emmetropic. Today probably majority of kids in a 4th grade classroom are wearing glasses. Times have really changed.

I remember going to the hospital to have my eyes examined. The doctor put eye drops in my eyes, I had to wait for a long time, before someone put a strange-looking frame on my face and showed me a bunch of different lenses. I was asked to read letters on a chart, and I felt strange that I was able to see some tiny letters. I had to say that this cycloplegic trial frame refraction was up to American standard even to this day. Thanks to my small town ophthalmologist, I was finally able to see. I was -2.00 in both eyes that day and I no longer had to walk up to the board to see small prints.

Back to our question on myopia and anxiety. My own experience told me that as a myope without glasses, I definitely felt anxiety. After wearing glasses, my vision was back, but I felt a kind of depression because I had to rely on glasses and I hated having to glasses. I went through all 5 stages of grief: denial, anger, bargaining, depression and acceptance. I thought that if I looked far away long enough, my eyes would be back to normal. I was mad at myself for abusing my eyes without a break on those stupid books. I constantly regret it and promised I would trade in some years of my life in exchange for normal eyesight. I was depressed that I had to wear glasses and looked ugly. Eventually of course I accepted this imperfect aspect of me. After all, there were so many other things that were not perfect so why focus only on myopia?

As an optometrist, myopia is one of the most common conditions we treat. It’s so common we almost consider it ‘normal’, routine and benign. We rarely considered the psychological aspect of myopia, when in reality this condition hit children and adolescents, who are at a vulnerable age.

Now the science part of this article. Research has shown that myopic teenagers had more anxiety than their peers, and boys with myopia had more anxiety than girls with the same condition 1. However, personality profile and psychophysical stress do not seem to play a primary pathogenetic role in myopia 2. So that is good, you can feel tortured by the fact that you need thicker glasses, but the sadness alone does not make your eyesight worse.

References:

1.            Łazarczyk JB, Urban B, Konarzewska B, et al. The differences in level of trait anxiety among girls and boys aged 13-17 years with myopia and emmetropia. BMC Ophthalmol 2016;16:201-201.

2.            Angi M, Rupolo G, De Bertolini C, Bisantis C. Personality, psychophysical stress and myopia progression. Graefe’s Archive for Clinical and Experimental Ophthalmology 1993;231:136-140.