Finally a safe line of cosmetics for eyes

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Finally a safe line of cosmetics for those of you who have dry eye or wear contact lenses!
When you wear any eye cosmetics, mascara, eye liner, eye shadows, etc, these inevitably get into your eyes and I can see them in your tears, on your cornea and conjunctiva when you come in for eye exams. There are dozens of ingredients commonly used in cosmetics that will damage your cornea, your meibomian glands, get absorbed onto your contact lenses and cause irritation. I’ve been advising my dry eye patients and especially those who wear contact lenses to stay away from cosmetics, because of their accumulative toxic effects on the ocular surface. I feel bad that my patients cannot enjoy good, comfortable vision and look beautiful at the same time.

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But no longer! My long-time colleagues (and experts on dry eye) have developed a brand new line of eye cosmetics, banning the common toxic ingredients found in mainstream cosmetics, using a formula that has been tested by ophthalmologists and dermatologists to be safe and well tolerated by people who have dry eye and who wear contact lenses.
So now I’m happy to let my patients know that you can finally be healthy and beautiful at the same time.

Click the link eyesarethestory.com/bostoneyeblink to purchase any products on eyesarethestory.com and you will get an extra 10% off through Boston Eye Blink. Once you receive the product, send pictures of them with purchasing receipt to email: BostonEyeBlink@gmail.com and in a month you will receive a rebate of 10% off of your purchasing price.

For your first time purchase online using the code: winkwink to get a 20% off.

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2020 CAPSULE COLLECTION

 

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EYE PROOF FACIAL CLEANSER

 

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EYE PROOF FACIAL SERUM

 

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EYE PROOF LIQUID LINER

 

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EYE PROOF MASCARA TRIO SET

 

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EYE PROOF REFRESHING TOWELETTES

 

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TRINACRIA COLLECTION V.1

FDA approves new OTC allergy eye drops

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Allergy season is coming. Millions of Americans will suffer from itchy and watery eyes shortly. The current treatment of itchy eyes can be done by only two types of OTC products, one is ketotifen- based, such as zaditor or allaway. Ketotifen has anti-histamine as well as mast cell stabilizer activity, and works generally well for itchy eyes. The other type is pheniramine- based, such as Visine-A and Opcon-A. This one only has anti-histamine activity. In addition, Visine-A contains a vasoconstrictor, which may temporarily relieves redness but over long-term may cause worsening red eyes.

For many patients, ketotifen may not be enough to relieve their itchiness. In such cases I often prescribe patanol or pataday (olopatadine 0.1% and 0.2% respectively). These usually work very well, and quite safe and well- tolerated, though patients have to come to see a doctor to get prescription.

Now FDA just approved patanol and pataday as OTC, and may be available as early as March 2, 2020. (news link https://www.mdmag.com/medical-news/pataday-fda-approves-prescription-allergy-eye-drops-over-the-counter-alcon)

This is great news. As patients no longer have to wait for weeks before getting an appointment from an eye doctor’s office. If your eyes are itchy, just go to the pharmacy to pick up some ketotifen or patanol if the former does not work for you. This will also reduce cost from health care system and reduce work productivity lost due to going to doctors’ offices. Of course I bet it will be expensive, but having easy access is the key point here. And hopefully generics become available in future to make it more affordable for consumers.

I see fluid coming up in my eye

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Another case by Juan Ding, OD PhD

A young gentleman in his 20s came in complaining of poor vision in his left eye which worsened for the past 2 weeks, particularly that it bothered him to see ‘fluid seeping up’ in his left eye vision happening a few times in the past two weeks. No it is not seeing fluid in his left eye in a mirror, it is seeing that with his left eye.

He grew up in a middle east country, had congenital cataract and cataract surgery both eyes. When he was a young kid, he unfortunately had an injury to his left eye that made him completely blind in that eye. He wears a prosthetic shell in the right eye. After removing the shell, it is obvious that this eye has gone – it is withered (phthisis bulbi), with a white membrane (pannus) over the entire cornea. Importantly, there is no sign of infection in this eye, and it does not hurt.

The left eye had only hand motion vision, meaning he can see hand moving in front of his eye but no details. This eye also shows back and forth shaking (nystagmus), which sometimes happens with poor vision from a very early age. Eye pressure is 10, which is normal. There are a lot of cells (4+) in the anterior chamber, which means very severe inflammation. The pupil is irregular and completely stuck to the artificial lens behind (posterior synechiae). The dilation drops could not dilate the pupil at all, so I was not able to see anything behind. Additionally, there appears to be a white membrane on the artificial lens, further blocking any view to the back. Unfortunately in my small eye clinic we do not have B scan to check if there is any retinal detachment.

Further questioning did not yield much more useful information. The patient was aware that he did not see well out of the left eye, but he did not know why, and could not produce any previous medical record.

Given the finding, I prescribed steroid drops for inflammation, and atropine, a strong dilating drop to break the sticky pupil. I made an appointment for him to see our uveitis specialist in 2 weeks, hopefully the pupil will be dilated then for her to see.

The patient walked in to see another eye doctor of our department 6 days later, complaining that his sx did not improve with the drops. In this visit, his eye pressure went up to 29, which was attributed to steroid response. He was given timolol to lower eye pressure

One day later he walked in again, complaining seeing everything white with the dilating drops. His eye pressure in the left eye now became 5. This time the access doctor happened to be the uveitis specialist. She found still the same amount of inflammation that I saw, and found funnel retinal detachment (this is retina detached almost entirely except for the optic nerve head position, causing a funnel shape on ultrasound, as shown below) on B scan. She increased steroid dosage and referred him to our retinal surgeon.

funnel RD from web

image: Ultrasound scan showing a funnel retinal detachment (source: https://imagebank.asrs.org/file/1431/open-funnel-retinal-detachment). This is not my patient.

 

Weeks later, as I checked back the medical record to see how he’s doing. I found out that he went to Mass Eye and Ear (MEEI) in Boston. From their notes, it appears that he used to see eye doctors there, diagnosed with chronic funnel retinal detachment in 2015, but lost to follow up subsequently.

So the mystery is solved. His chronic retinal detachment is most likely the cause of his uveitis (eye inflammation), and bleeding in the vitreous (found on B scan at MEEI) would be the cause of worsening vision recently, and seeing ‘fluid going up’ in his vision.

Retinal surgeons at MEEI plan to do surgery for him, though the prognosis for vision is poor due to chronic macula off retinal detachment.

It is sad to see a young person who already is blind in one eye to lose vision in the other eye. Infants need to be screened for conditions such as congenital cataract. It is already late if you notice nystagmus. Fortunately this is done routinely in newborns and well visits by pediatricians. Eye injuries should be prevented, especially for boys. And if you already have a serious eye condition, like retinal detachment, please follow up with your eye doctor.

Seeing a bluish green spot in the right eye

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By Juan Ding, OD, PhD

Case of the day series

A college student walked in for an urgent visit for seeing a bluish green spot in her right eye constantly for 1 week. She went to Colorado last week and did a lot of hiking, taking many photos everyday, enjoying nature. On the last day of the trip, she started seeing a bluish green spot in the right eye, more obvious in the bright background, but it’s there even after closing eyes. She was very scared and went to the local ER, where they did an ultrasound of the eye and found no retinal detachment, but did not know what’s wrong. After getting back to MA, she could not get an appointment with her regular eye doctor, and being the holiday season it’s busy everywhere. Fortunately her PCP at Umass directed her to our open access clinic.

Her vision is normal, 20/20 in each eye. Everything from the front to the back of both eyes are normal. I found no retinal detachment, not even vitreous floaters.

She asked, “Am I crazy? Am I imagining things?”

What do you do next?

Knowing too well that clinical exam has its limitations, I asked her to take an OCT photo. This is looking at the retina in cross sections, like virtually dissection the retina. There is a very small dot in the right eye, just temporal to the fovea, where the photoreceptor outer segment now shows a small defect (Figure 1). Amsler grid shows a matching scotoma nasal to the fixation.

solar retinopathy

Figure 1. OCT of macula cross section. Red arrow points to the lesion at the photoreceptor outer segment level (ellipsoid zone).

 

So I told her that she’s not crazy, a retinal lesion really exists to perfectly account for her seeing the spot.

But what caused it?

Solar retinopathy is the first thing that comes to mind. She denied looking directly at the sun. also denied exposure to laser including laser pen or in a science project. Then she mentioned that during daily hiking, she did spend a lot of time looking at camera screen which could be very bright due to reflecting sunlight. This seems to be the most plausible explanation for now.

I told her that solar retinopathy may get well on its own in weeks to months. It may also be irreversible. At any rate, there is no treatment for this. So we will monitor again in a few months.

Another treatment for dry eye – azithromycin

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by Juan Ding, OD, PhD

I talked earlier about an off label treatment of dry eye and Meibomian gland dysfunction (MGD), doxycycline; and today I will talk about another off label use of azithromycin (AZM) to treat MGD.

AZM is a macrolide type of antibiotic that has a unique characteristic, to promote lipid accumulation in cells. This works well in MGD, because the Meibomian gland cells work by producing and storing lipid and then releasing it to the tear film. With this additional help, my coworkers and I found that the Meibomian gland cells produce more fat 1. And these effects are unique as doxycycline and other tetracyclines do not have this benefit 2. Other scientists found that AZM significant improves dry eye symptoms and work slightly better than doxycycline 3. Further, the dosage and usage is easier with AZM, which is used for 500 mg on the first day and then 250 mg/day for a further 4 days, whereas doxycycline was used for 100 mg twice a day for 7 days and then 100 mg/day for a further 21 days 3.

AZM also exists in an eye drop format, for example, azasite (1% AZM ophthalmic solution). This also works well for MGD and dry eye, though it’s quite expensive and sometimes not covered by insurance.

Side effects of AZM include diarrhea or loose stools, nausea, abdominal pain, stomach upset, vomiting, constipation, dizziness, etc. it is safe to use during pregnancy and breastfeeding.

I prefer the AZM eye drop, which works more targeted to the ocular surface without systemic side effect. Due to its cost, I typically use it only in patients with MGD and blepharitis (inflammation of the eyelid margin) that have failed other treatments. I have had some very grateful patients who report they can finally open their eyes or that their eyes are no longer constantly red. The usage of this of course requires a prescription and supervision under a qualified physician.

I wish they make this cheaper and make an ointment form of this.

References:

 

  1. Liu Y, Kam WR, Ding J, Sullivan DA. Effect of azithromycin on lipid accumulation in immortalized human meibomian gland epithelial cells. JAMA Ophthalmol. Feb 2014;132(2):226-228.
  2. Liu Y, Kam WR, Ding J, Sullivan DA. Can tetracycline antibiotics duplicate the ability of azithromycin to stimulate human meibomian gland epithelial cell differentiation? Cornea. Mar 2015;34(3):342-346.
  3. De Benedetti G, Vaiano AS. Oral azithromycin and oral doxycycline for the treatment of Meibomian gland dysfunction: A 9-month comparative case series. Indian J. Ophthalmol. Apr 2019;67(4):464-471.

 

Another treatment for dry eye – doxycycline

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The other day a 57 year old woman came in, with a very common complaint, dry eye.

She had dry eye symptoms for a few years previously. Last year, due to Lyme’s disease (infection by Borrelia bacterium which is spread by ticks), her doctor prescribed doxycycline for 14 days. After that, she enjoyed dry-eye free days for almost 8 months, until now when the symptoms are back to haunt her. She tried a few artificial tears which helped only a few minutes. She would really like to have another prescription of doxycycline.

On examination, she has Meibomian gland dysfunction (MGD; here’s my previous article on MGD) and dilated blood vessels on the lid margin suspicious for ocular rosacea. She’s never been diagnosed with rosacea before and denies cheeks turning red.

We know that MGD is a major cause of dry eye, and ocular rosacea (a type of inflammation of the eyelids) will make dry eye worse. In fact, doxycycline has been used off-label to treat MGD and ocular rosacea. In one study, for MGD patients treated with doxycycline for 30 days, about 70% of patients showed some level of improvement after one or multiple (up to three times) treatments 1.

Therefore, for certain patients who failed conventional warm compress and lid hygiene treatment for MGD, it may be worthwhile to try doxycycline

Of course, doxycycline has several side effects, and should be taken with some caution. Many of the side effects are related to the gastrointestinal health, such as loss of appetite, nausea and vomiting, diarrhea. People may also get sensitivity to the sun, so sun protection while using this medication is recommended. Lastly it may also cause discoloring of teeth, while reversible in adults, may be permanent in kids, so it should not be used in children younger than 8 years of age. Fortunately not too many 8 year olds have MGD or dry eye. Doxycycline also should not be used during pregnancy.

Next time I will talk about an even better alternative drug for MGD. If you read the reference below, you will guess what it is.

 

References

  1. De Benedetti G, Vaiano AS. Oral azithromycin and oral doxycycline for the treatment of Meibomian gland dysfunction: A 9-month comparative case series. Indian J. Ophthalmol. 2019;67(4):464-471.

 

Annoying floaters, where do they come from? And what should you do about them?

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By Juan Ding, OD, PhD

 

I discussed previously floaters in a young woman, in her case (link here) the floaters came from inflammation of her eyes, which is not a common condition. Today I want to talk about the “common” or “regular” floaters that almost everyone has or will have.

I will start with two patients I saw yesterday. A 68 year old gentleman was on the airplane to Arizona to buy a house when he noticed a big floater following him everywhere in the right eye. It had been 5 days now and wouldn’t go away. His vision was the same, but he was very concerned and came to my walk-in clinic. One of my old patients, a 75 year old woman, who saw me 6 months ago for her annual eye exam, made an urgent appointment due to a similar complaint, big floater that suddenly showed up 3 days ago. As she’s an avid reader and knitter, this floater was quite annoying with her near work.

In both patients, I diagnosed them with posterior vitreous detachment (PVD). This is a common age-related eye condition, and happens in 60% of those in their 60s, and by age 90, 90% of people would have developed PVD. This may start in one eye and eventually the other eye would develop it also.

Vitreous is the big jelly occupying the bulk of our eyeball (Figure 1A. Please pardon my poor drawing techniques). On the backside of the vitreous is the critically important tissue- retina. Vitreous and retina are normally attached to each other. It provides structural support of the eyeball and nutrients to the retina. When we were born, the vitreous is typically a single solid piece. With age, the jelly gradually forms liquefied pockets here and there with protein strands floating around. This could happen at any age. So young people also may complain about seeing floaters, but typically small floaters that don’t interfere with vision. You may notice these in a bright uniform background such as the blue sky or a white computer screen. I personally have noticed my floaters since age 8.

As the vitreous becomes ‘weaker and weaker’, it will eventually lose its contact with the retina in multiple locations. The last location that this happens is usually close to the center of our vision, near the optic nerve. The moment that it pulls away from the optic nerve, it leaves a ring-shaped residue (Figure 1B), which floats around to annoy you. Since this is much larger, you will notice it more, and many people become very symptomatic and seek medical attention. Some people also experiences brief flashes of light lasting a second or two, and this is due to the vitreous pulling on the retina.

PVD

Figure 1. Normal vitreous and posterior vitreous detachment (PVD).  A. Normal vitreous is a jelly substance that attaches to the underlying retina. B. in PVD, the vitreous detaches from the optic nerve, forming a large floater.

The whole process is actually a normal age-related phenomenon, much like wrinkled skin or gray hair. However, one caveat- when the vitreous detaches, it sometimes pulls a piece of retina with it, causing a retinal tear and even retinal detachment. Fortunately this terrible incident happens in only 7% of those experiencing PVD 1, though some studies find this number to be 22% 2. Still, if you are experiencing a new floater, you should go to your eye doctor for a dilated eye exam immediately, because if you do have a retinal tear, it needs to be fixed within 24 hours.

Further, with a new PVD, the risk of retinal tear or detachment is still high within the next 4-6 weeks, so you should have a repeated dilated eye exam in about 4-6 weeks’ time even if no new symptoms come up. At any time, if you notice new floaters, flashes or light, or have a change in vision or losing a part of your visual field, you should seek immediate medical attention.

So what do you do with a PVD? If there is no retinal tear or detachment that come with it, you can rest assured. Your brain will eventually adapt to the floater and ignore it, though this may take quite a few months. Some very few people who are bothered by floaters and find it interfering with their normal life after even 6 months, a laser can be done to break up the big floater into smaller pieces so that you won’t notice them. Alternatively a vitrectomy surgery can be done to remove the vitreous; however, the surgery is invasive and carries the risk of having infection of the whole eye or developing new retinal detachment. You should talk to your retinal specialist if you are absolutely interested in removing the floaters.

If there is indeed a retinal tear discovered, a retinal specialist will treat this immediately with a laser to seal off the tear. Or if the tear is extensive, a surgery can be done to repair the detached retina.

Fortunately, both of my patients only had PVD and no retinal tear or detachment. I asked them to follow up with our retinal specialist in 4 weeks, and return to clinic immediately if new floaters, flashes or light, or change in vision happened to them.

Summary questions:

  • Can PVD cause retinal tear or retinal detachment?
    • Yes it may in a small subset of people. So always go to your eye doctor immediately if you notice new floaters or flashes of light.
  • How long will I see those annoying floaters?
    • Depends on individual, some may see them for up to 6 months.
  • Is there anything I can do if the floaters really bother me?
    • Please wait at least 6 months for your brain to ignore them. If they persist beyond that and bother you immensely, talk with a retinal specialist for laser or vitrectomy treatment. But be aware of risks of these treatments.

References

 

  1. Byer NE. Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment. Ophthalmology. Sep 1994;101(9):1503-1513; discussion 1513-1504.
  2. Uhr JH, Obeid A, Wibbelsman TD, et al. Delayed Retinal Breaks and Detachments after Acute Posterior Vitreous Detachment. Ophthalmology. Oct 23 2019.

 

FDA approves first contact lens indicated to control myopia in children

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Even though OrthoK lenses have been used to slow myopia progression for many years with great effect, last Friday was the first time FDA approved of a contact lens that slows myopia. This is a center distance, multifocal soft daily disposable contact lens to be used in kids 8-12 years of age for myopia control.

https://www.fda.gov/news-events/press-announcements/fda-approves-first-contact-lens-indicated-slow-progression-nearsightedness-children

MiSight lens has been used already in Australia and several other countries, it is now officially approved by the US FDA.

This is good news for kids with myopia, as in addition to orthoK lenses (see my previous articles on OK lens and myopia: Ortho K: why do it and is it risky? and Oh oh myopia), we now have a soft daily lens that does a similar job.

The pros of OK lens: wear at night, lens free during the day (good for activities including swimming)

The pros of Misight: comfortable as a soft lens; since disposed of after a day, risk of infection is lower (But don’t wear it when swimming or taking a shower).

 

What, an eye AND ear problem?

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by Juan Ding, OD, PhD

A 70 year old Asian male complained of eye pain and redness in both eyes, in addition, left ear was swollen and mildly painful, and not hearing too well. He was found to have episcleritis (inflammation of a deeper layer in the white part of the eye) in both eyes and iritis (inflammation of the iris) in the left eye. Combination of these symptoms are suspicious of a condition called relapsing polychondritis (RP). This is an autoimmune disease that targets the cartilage tissue of the body, for example the ear, nose, and the trachea. Eye inflammation can also occur. Since it’s autoimmune in nature, the treatment would be anti-inflammatory, using for example corticosteroids and non-steroidal antiinflammatory drugs (NSAIDs). If necessary, some disease modifying agent such as methotrexate can also be used. He was started on naproxen 500 mg twice daily, as well as an NSAID and steroid eye drops, and his symptoms went away. So in the end he did not need to take methotrexate.

He also had a hx of latent tuberculosis (TB). latent TB means a person has been infected with tuberculosis in the past, but does not show any active sign of disease, such as coughing, fever and night sweats. However, latent TB can cause inflammation in any part of the eye, including the episclera and the iris. So in this case, he is also seeing an infectious disease specialist. Since his eye and ear symptoms resolved on NSAIDs and steroids, it was thought that TB was not the cause, but he was treated with isoniazid for 9 months for latent TB without incidence.

Lastly, although RP frequently causes ears to be red and swollen, it does not typically cause hearing loss. His hearing loss was considered to be another cause. He was treated for 1 month after onset of hearing loss (and ear pain) for a viral etiology with valtrex and prednisone, but did not recover hearing.

So the moral of this case is, if they have inflammation of both eyes and ears, don’t just treat the eye, and think a common underlying etiology.

5 years later, patient came back to see me, his eyes are quiet, as his ears. He does report occasional eye sensation reminiscent of past iritis, but always responds well to the prednisolone drops that he’s instructed to use as needed which he used a few times a month. He is currently not taking any medications for RP and doing well. I asked him to come back in 3 months to check eye pressure and check eye inflammation, and that if a flare up happens come right back. Hopefully the relapsing nature of this disease will not recur.