Giant Eyeball Sculpture for Chicago

This story today from CNN:

http://www.cnn.com/2010/TRAVEL/06/07/chicago.eyeball.sculpture/index.html?hpt=C2

I say bring on this giant eyeball sculpture.  I am keeping my eyes on this plan, and I hope the folks in Illinois see it through.

Drinking vodka through your eyes?

http://www.dailymail.co.uk/news/article-1278583/Young-people-drinking-neat-vodka-EYE-quick-buzz.html

Thanks to a friend who sent me this link, I first became aware of a shocking new trend: obtaining an "instant buzz" by pouring vodka into the eye.  Really, Britannia?  I know the British university crowd likes to party (yeah, baby, yeah!), but for heavens' sake, spare the bloody cornea!  Or use tea, like descent Englishmen.  Peer pressure to perform vodka "eyeballing" has not yet hit the frat scene in the U.S. (surprisingly), and I am crossing my fingers and eyes that it never will.

Alcohol, especially in high concentrations (such as 40 proof vodka), separates the external layers of the cornea (the epithelium) from the eye and causes painful corneal abrasions.  If deep enough, the abrasions may lead to permanent corneal scarring, irregular astigmatism, and consequently blurry vision and pain *for life*!

The only instance in which we use alcohol on the cornea is at the time of a refractive surgical procedure, such as PRK.  We purposefully create a corneal abrasion in order to allow laser to reach the deeper layers of the cornea and permanently mold it into its new shape.  As a safety measure to prevent haze (a.k.a. scarring) from occurring, a chemotherapeutic drug (Mitomycin C) is applied to the eye.  The wounded cornea is then babied some more with a contact lens that allows for more comfortable and faster healing.  So, other than  PRK, America, please refrain from proofing your eyes with alcohol.  Put your vodka where your mouth is.

Iridology Uncovered

Did you know an extensive branch of alternative medicine is based on the interpretation of nooks and crannies in the iris?  It is called iridology, and has amassed a considerable cultish following.  Iridologists believe that alterations in iris texture, color, and structure can portend imminent changes in one's physical, mental, and spiritual well-being.  Much like augors who read the future in the entrails of sacrificial animals or coffee dregs, iridologists claim to portend "tissue weaknesses, inflammation or toxicity in organs or tissues". They use magnifying loops and a penlight (sometimes a video camera) to document their findings, while referring to iris maps such as this one, originally developed by Bernard Jensen in 1981 (from http://www.truevitality.com.au/wp-content/uploads/2009/08/iridology-eyechart.jpg)

Although I like to give everyone the benefit of the doubt, even when it comes to quacks, I came upon an interesting site entitled "Confessions of a Former Iridologist"  that convinced me otherwise (http://www.quackwatch.org/01QuackeryRelatedTopics/confessions.html).  Mr. Mather is a recovering iridologist who expresses dissenting views (infidel!) on the profession he once held at high esteem. His apprenticeship in western medicine and appreciation for evidence-based proof led him to re-examine the field using controlled conditions. He concluded that "not only did the light placement affect the appearance of structures; the slow draining of the batteries in the penlight changed the appearance of the eye color" and that iridology, therefore, has "no basis in real anatomy and physiology and . . . failed well-done trials and studies."  Still, the Iridology charts would make for cool coasters.



http://www.herbsbylisa.com/iridology.html http://www.truevitality.com.au/wp-content/uploads/2009/08/iridology-eyechart.jpg

Twitch Hunt

We all experience the lid twitch every now and then.  The upper or lower eyelid begins to intermittently spasm, and it seems the whole world can see it.  "I look like I have Tourette's," we think to ourselves.  In fact eyelid twitch, also known as eyelid myokymia, is almost imperceptible to others.  At least once a week, I see a handful of patients who rush in because their eyelids are doing the lambada.  If severe enough, eyelid myokymia may cause your world to seemingly bounce up and down as well (oscillopsia).

Why does this happen?  Essentially, the orbicularis muscle of the eye (in charge of opening and closing your eyelids) contracts rapidly in response to misbehaving nerves.  This usually occurs intermittently for a period of days, weeks, or even months.  Although extremely irritating, eyelid myokymia is benign (but if it lasts more than three months, call your eye doc).  It is triggered by such quotidian factors as inadequate sleep, fatigue, excessive caffeine, and emotional stress or anger.

Do you live in a large metropolitan area?  Do you down a grande latte mocaccino in your way to work?  Are you employed by the mafia or the CIA?  Or, are you leading a covert double-life and secretly hording a second family in Pennsylvania?  If you answered yes to any of the above, the lid twitch can happen to you at any moment.  Although there is no medicinal cure for it, eyelid myokymia improves with a good night's sleep, relaxation, and positive thinking.  Try to chillax with a glass of wine and a good Ingmar Bergman movie, or read the Seven Habits of Highly Effective People -- if nothing else it will help put you to sleep.


Walsh and Hoyt's clinical neuro-ophthalmology By Neil R. Miller, Frank Burton Walsh, William Fletcher Hoyt. 6th edition. Page 1216.

White Cadillacs

Cataracts, the bread and butter of ophthalmic surgery, are often referred to by the old folks as "Cadillacs."  That's fine by me, because there are about as many types of cataracts as there are Cadillacs: white, black, brown, front-loaded, back-loaded, with spikes on the sides. . . Unlike Cadillacs, though, cataracts never went out of style.  Everyone gets cataracts at some point, if s/he lives long enough.

Cataracts are opacified lenses.  Like a camera, your eye has a lens that sits in a bag ("capsule") behind the iris.  All your life, it works hard, changing shape to focus near and far objects, allow color and light to come through, and filter UV rays.  When you turn forty, the lens gets a little rusty and starts having difficulty focusing at near (like an old tire, it looses its flexibility).  And then, sometime after that  -- there is a sixty year range -- the lens begins to cloud up and transmit vision poorly.  Color vision is diminished (blues and greens take on a yellow-orange tinge), objects appear fuzzier, and people experience more glare.  Chemically speaking, the proteins in the lens morph into water-insoluble molecules and the lens medium becomes opaque.  Time to take it to the shop and trade it in for a new one!

In cataract surgery, we use tiny instruments, some ultrasound power, and a little pump to remove the old cataract.  Then we replace it with a shiny new lens implant that we place in the same bag that once held the cataract.  Of course, there are different models.  The standard government issued lens implants give you good vision at one specified distance (near or far).  The suped-up ones ("premium lenses") give you good vision at near and far, decrease night glare, or correct for astigmatism.  They do not come with heated seats, but you can get ones with tinted windows (the SN series by Alcon) and others that decrease the blurry vision you may get at night.  Of course, you should read the small print (or if you can't see small print anymore, get a magnifier), and make sure you understand the side-effects associated with the premium lenses (glare, cost, decreased contrast).

Being the most commonly performed surgery in America today, cataract extraction is now perfected to an art-form.  It can be done suturelessly, painlessly, and rapidly.  And we throw in an oil change.

UV and You

On a recent trip to SoHo, I witnessed sunglasses adorned with "100% UV protection" stickers sold for as low as $1.00. And would you believe it, they were also Coco Chanels, Guccis, and Dolce and Gabanas! OK, so the manufacturer labels may have been fictitious, but what about the Ultraviolet (UV) protection? Chances are these glasses really do filter UV rays, though the only way to be certain is to have them measured by an optician. Multiple studies have demonstrated that the price of sunglasses has little bearing on their ability to filter UV light, so don't rush to dismiss the bargain glasses.

UV filtration standards are assigned by continental jurisdiction: Australian, European, or American. The US standard is the lowest (land of the free!) We allow 1% UV transmittance of wavelengths up to 400 nm (Hence the UV 400 stickers), while the Europeans are a little more selective in awarding wavelengths VISAs (up to 380 nm). Our mates down-under fall somewhere in between. There is no enforcement of these standards in the US, so the presence of UV stickers may be misleading.

But what’s so bad about a little sunny delight for the eyes anyway?

UV rays may inflict damage in several layers of the eye cake. Too much UV exposure can cause squamous or basal cell carcinomas to crop up on the eyelids. Likewise, squamous cell carcinoma may develop on the skin of the eyeball (the conjunctiva) and spread onto the cornea. More commonly, chronic UV exposure may result in a growth called “pterygium” to spread over the cornea. Pterygium is Greek for “little wing,” which describes perfectly the shape of this flightless lesion. If these growths are detained on conjunctival territory, they look like little stumps and are fondly named “pinguecula.” Folks who spend their life outdoors are more prone to these conditions: farmers, sailors, the crew of Jersey Shore.

Intense UV exposure may also lead to corneal inflammation (keratitis) and cause a sterile conjunctivitis when the surface cells (epithilium) die off. Welders and DNA lab-workers or those who seek “perma-tans” in their friendly neighborhood spas also fall victim to this ultraviolet infliction.

Sun gazers (usually these folks are high on something, and it's not vitamin D) can damage their retinas with solar rays. The retinas of sober individuals who stare at solar eclipses may also be burned by the sun. The diagnosis “solar retinopathy” is not an eco-friendly energy solution, but rather a transient loss of central vision for one to twelve months!

Finally, some believe excess sun may play a role in the development of cataracts and macular degeneration, though far stronger genetic factors contribute to these entities.

In conclusion, the benefits of sun protection cannot be overstated. Thanks to role models such as Bon Jovi, Paris Hilton, and David Hasselhoff, these accessories are also considered really cool.  Right?

Color me Bad

I once asked a colleague of mine whether he was color blind, and he replied with great agitation that he was not color blind, but color deficient!  Defensive, are we?  Color perception is one of the great wonders of the human eye. Our retinas house a high-tech built-in imaging system that consists of 90 million rod and 4.5 million cone sensors.  Rods are in charge of night vision, peripheral vision, and large movements.  The cones, being more refined, take care of daylight vision, fine details, central vision, and color.

As you may remember from your physics days of yore, color is a wavelength of light that is reflected by an object.  And, like old technicolor televisions, we have three cone types capable of perceiving three color wavelengths: green, blue, and red.  This makes us trichromats.  Allegedly, there are individuals who have a fourth cone type, and they are called tetrachromats. (Although a tetrachromatic retina is exceedingly rare amongst humans, people immediately think they are tetras when they first read about it.)  Because the human lens filters out most ultraviolet light, we do not perceive it, but there have been reports of aphakic patients (patients without a lens) who see into the ultraviolet spectrum (!)

Many different forms of hereditary color deficiency and color blindness exist, and they usually have to do with either complete absence of one (or more) type of cone, or a reduced sensitivity of one cone type.  The most common type of color deficiency (red-green) is due to a reduced sensitivity of the green cones in affected individuals.  Because most of the genes that code for vision are on the X chromosome, males are much more likely to suffer from color deficiency and females are much more likely to be tetrachromats.  Seven to ten percent of males are color deficient (which explains why some dress the way they do).  Other reasons for deficient color perception are acquired causes related to optic nerve and retinal health.

But, it's not all bad news for color deficient folks.  Studies conducted by the military have shown an evolutionary advantage to color deficiency: the ability to see through camouflage.  Was GI Joe color deficient?  Maybe so.

Eye Contact: taking care of your contact lenses

As a cornea specialist, I see a fair amount of corneal ulcers, contact lens overwear, and allergic reactions to contact lenses or solutions.  I have always believed first time contact lens wearers should take an exam, much like the driver's ed test.  If only patients would obtain a license to wear contacts, corneas around the world would be healthier, and eyeballs will breath a sigh of relief.  But the FDA has so far ignored my fringe opinions on the subject.  So, here are my top ten tips for good contact lens care:

10. Never sleep with your contacts in.  No ifs ands or buts!
9. Always clean your lenses at night.  The best types of cleaning solutions to minimize allergic reactions and infections are Clear Care or Aeosept.  These solutions are hydrogen peroxide based -- this acid kills most living organisms and bubbles out into water by morning (virtually preservative-free). Please read the instructions carefully before using the product!  You cannot put the solution directly in your eye before it is neutralized into water.
8. Limit contact lens wear to 8 hours a day or fewer.
7. If you are too lazy to clean your contacts at night, consider daily wear contacts that you may carelessly fling out of your eyes at night.
6. For those whose corneas show signs of choking out (we call it "neovascularization" or "neo" for you Matrix fans), I recommend lenses with high oxygen diffusion such as O2 Optix from Ciba.
5. For the dry eye folks who have a hard time tolerating contacts, try Acuvue Oasis, which will help keep the eyes better lubricated.
4.  Use preservative-free artificial tears if you are wearing contacts and need a "spot" of lubrication.
3. Never wear contacts that were not fitted for your eyes by an ophthalmologist or optometrist, because damage can occur.
2.  Do not use expired lenses, solutions, or old cases.  Would you drink expired milk?  Why do this to your eyes?
1.  If your contacts irritate your eyes, take them out and see your eye doc!

It's a sign of the seasons: itchy eyes

Cherry blossoms are budding in DC, Central Park is bespeckled with frosty pink and white patches, and tulips are sprouting along Boston’s Comm. Ave. In other words, tissue boxes are making cameos, children are a-sneezing, and our friends and loved ones are rubbing their eyes out. Allergy season is hitting the East Coast full force, and those of us who suffer from the affliction are crying for help.

Signs of ocular allergy include itching, tearing, and red eyes. Interestingly, systemic medicines prescribed for seasonal allergies (such as Claritin D, Allegra, or Benadryl) do not improve ocular allergy symptoms. Usually, topical drops such as Pataday, Elestat, or Bepreve are necessary to curb the irresistible urge to rub. These drops combine anti-histamine action with mast-cell stabilization (mast cells are like time-bombs full of itchy substances).  Mild steroid drops like Alrex may help as well.  If you are uninsured (not for long!), there are a few effective over-the-counter drops too, such as Zaditor or Alway.  The main thing to try and avoid is eye rubbing.  If your eyes are itchy and you rub them, you enable their bad behavior!  The more you rub, the more mast-cells are goaded to release their allergenic explosives.  Putting one of these drops in your eyes is a far better (and more pacifist) way to control your symptoms.  

So, stop and smell the flowers?  Maybe.  Just make sure you are properly equipped.

3-D Films: behind the scenes

Unless you live under a rock or somewhere on Pluto, you have probably seen or at least heard of the film Avatar by now. Perhaps you also watched the Clash of the Titans, or Tim Burton's Alice in Wonderland. Curious about these eye-popping 3-dimensional cinematographic experiences, you may have wondered, how'dey do it?

Films produced for your 3-dimensional watching pleasure depend on special projectors and eye-gear. In everyday life, you are able to perceive the world around you in three dimensions (provided you have fairly good vision in both eyes). This is because your eyes are spaced approximately 6 cm apart, each conveying to your brain a slightly different perspective image from its position on the head. Your brain (nerd) takes these two slightly dissimilar images and fuses them into one three-dimensional picture.

When you watch a conventional film, your brain is unable to appreciate depth of field, because the two eyes send fairly similar information to the brain. However, if the movie projector were to display two slightly dissimilar images to each eye, your brain would be fooled into thinking the film is 3-dimensional. With the RealD technology used in creating Avatar, two slightly dissimilar images are produced as the film's projected light-rays are polarized (oriented) in two opposing directions. Normally light waves bounce randomly in all different ways, but if subjected to a polarizing filter, they will follow in the ordained direction of their filter (clockwise and counterclockwise, in this instance). The opposing polarizing filters on the Avatar projector actually alternate the image light-rays from clockwise to counterclockwise at a rate of 144 times per second! If you were to see both projected images at once, however, the picture would appear fuzzy, not 3-dimensional; so for the low price of $16.50 you are also provided with a pair of 3-D glasses. The right and left lenses on these glasses also contain circular polarizing filters: one oriented clock-wise, the other counter-clockwise. This way, while one eye filters out the clockwise rays the other receives the counterclockwise ones. So each eye sees a slightly different image. These two images are dispatched to your brain, which computes the information into a 3-dimensional picture.  Et, voilá.

Interestingly enough, we use a similar technique in everyday pediatric ophthalmology. With linear polarizing filter glasses (one lens filters only vertical image rays the other only horizontal image rays), children are asked to look at a tablet containing a fly, circles and animals. These images are preprinted on a material that allows light rays to be projected vertically alongside a shadow image that projects horizontally. If the child identifies the correct “3 dimensional” images in the tablet (Titmus test), we know s/he has good binocular vision from both eyes. The test serves as a great screening exam for amblyopia (a condition in which a child does not develop good vision in one or both eyes). It can also be used to assess depth perception in adults.

So, now you know how they work, prepare for an onslaught of 3-D films!

Transplant Surgery

Some folks do not know what an "ophthalmologist" really does. So whenever people mistake me for an optician at Lens Crafters, I proudly announce that I perform transplant surgery.  Put that in your pipe and smoke it, I chuckle to myself.  Because of their unique position in the body, pristine islands in a sea of blood vessels, corneas receive an immunity necklace.  In professional jargon, they are "immunologically privileged", i.e. white blood cells cannot easily reach a corneal transplant and cause its rejection, because the highways to the cornea are unpaved. Therefore, corneas are the only transplanted organs that do not require systemic immunosuppression or blood-typing.  

Forget "I see dead people."  Recipients of corneal transplants see thanks to dead people!  Cadaveric corneas are harvested from deceased individuals who checked the appropriate box at the DMV.  They are then rushed to an institution on Wall Street called, you got it, an eye bank.  In Optisol storage media, they can be stored for approximately seven days before they are delivered to an operating room.  Meanwhile, they undergo rigorous testing to ensure quality and good health.  There are several eye banks in the country and the world, but the oldest one was established right here in New York.  It was founded by Dr. R. Townley Paton, who pioneered and then performed the first corneal transplant in 1905.  He did not establish The Eye Bank for Sight Restoration until 1944, when he was able to procure proper news-press and funding for his unique project.  Dr. Paton's first donor corneas were obtained from deceased inmates on death row at the nearby Sing-Sing prison and later expanded to deceased law-abiding citizens.  As the New York Eye Bank continued to grow and append surgeons, it sprouted 25 branches throughout the country.  Nowadays, 33,000 corneal transplants are performed in the United States each year.

Who needs corneal transplants?  The most common reasons for a transplant are a pointy cornea condition called keratotconus and a swollen cornea condition called bullous keratopathy.  Corneal scars due to trauma, infection or ulcers are also a hot commodity.  Finally, there are congenital conditions that cause the translucent corneal window to opacify.  These too, qualify for transplant surgery.

The procedure of transplantation is relatively simple: (1) cut out a circle of recipient cornea (2) replace missing circle with cookie-cut donor cornea (3) suture new cornea into its new 'hood and wait for it to jive.  The suture material consists of nylon thread, a fraction of a hair-width (it is only visible under a high-power microscope).  Full visual recovery takes about a year, and the cornea usually lasts approximately 15 years before it fails.  In the meanwhile, topical steroid drops are applied to prevent white-cells from reaching the graft.  There is only a 10% rejection rate in most cases, which, if caught in time, can be reversed.  Several years ago, exciting new technology emerged that allowed for partial corneal transplantation in a procedure called Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK).  This surgery forgoes the need for sutures, promises an even lower rejection rate than conventional transplants, and allows for visual recovery within three months!  It is only appropriate for folks with corneal swelling, though.  To learn more about the fascinating history of the New York Eye Bank, check out their website: http://www.eyedonation.org/

What's wrong with Johnny Depp's Eyes

Tim Burton has almost as big an eyeball fetish as Takashi Murakami. Five ophthalmic conditions that make the Mad Hatter's eyes look very odd in Alice and Wonderland:

1. Megalocornea: notice the corneas have very large diameters in comparison to the white of the eye.
2. Anisocoria: The right pupil is slightly larger than the left
3. Hypotropia: The right eyeball is slightly downturned in comparison with the left
4. Sparkly blepharitis: the lower lashes are encrusted with sparklies
5. Sapphire irides: The iris is an unnaturally green color

Stye Town

"Code red, Dr. Keshet to the surgical suite, STAT!"  With great alacrity and concern, a surgery attending once called me to the intensive care unit for a stye consult -- if the patient did not receive clearance for a new pimple that cropped up on his left upper lid, he would be denied life-saving cardiac bypass surgery.  I was bewildered that a little spot of inflammation on the upper lid would prevent a cardiothoracic surgeon from performing a vital procedure, but this true story illustrates the widespread misconceptions about styes.  They are largely misunderstood, and deserve just representation.

Sometimes referred to as a chalazion, a stye is merely a ball of inflammation (a granuloma) surrounding a blocked oil gland.  (Technically, a chalazion occurs anywhere on the eyelid, while a stye occurs on the lid margin.) Unlike infectious processes, styes are not caused by bacteria or other micro-organisms.  The body simply mounts a white cell response to a constipated oil gland.  Styes and chalazia often happen to folks with baseline blepharitis, a.k.a. eyelid inflammation.  If your eyelid margins are a tad reddish, and you notice crusties on the lashes, you probably have blepharitis yourself.

I usually recommend putting a potato in the microwave for a minute or two (or boiling an egg), then wrapping it with a damp washcloth and laying it on the affected eyelid for ten minutes, at least thrice daily.  This technique allows the constipated oil gland to experience relief and release its contents.  The granuloma surrounding it then calls off its siege and disperses.  To help this process along, I usually prescribe a steroid drop.  Steroids assuage inflammatory niduses as diplomatically as Bill Clinton in the Mideast peace talks.  If the stye or chalazion does not resolve within two weeks of treatment, I recommend performing a chalazion excision.  For some reason, this painless procedure (after proper local anesthesia, that is) makes grown men --  especially body builders -- cry like school-girls.  But it is a dirty job, and someone has to clean up their stye.  In order to prevent chalazia from returning, I recommend a daily regimen of warm compresses with a hot washcloth, followed by gentle eyelash scrubbing.  Other possibilities are ointments or drops (like Azasite).

Of course, in my humble opinion, the cardiac patient should have been cleared for surgery, but despite my detailed clinical and histopathological explanation of chalazia to the cardiothoracic attending, he stared at me with disbelief and insisted he could not perform surgery on a patient with an infection.  In conclusion, cardiac surgeons think they are smarter than ophthalmologists. . . but. . . *wink*. . . between you and me the eyeball is a bit more complex than a pump.

Floaters

Last week, I was asked to write about floaters, a complaint that bobs up frequently in my practice. The little black "flies" that suddenly pop up in one's vision are the subject of endless fascination, consternation, and futile swatting motions. Some describe them as strands and spots that appear under bright sunny conditions. Others see them as cobwebs that cannot be Swiffered. If a floater is large enough, it may interfere with vision and require surgery (very rarely).

There are a few different types of floaters, but the most common ones are begotten by the "vitreous body" (sound like an x-men character to you?) In normal young eyes, especially those with myopia (near-sightedness), the strings or spots may represent strands of vitreous in the posterior chamber of the eye. Vitreous is a mysterious substance that is normally attached to several points in the retina as well as the peripheral portion of the lens. Its state of matter is difficult to define, and hovers somewhere between solid and liquid, most closely resembling a blob of snot. As we age (between our 50s to 70s), our vitreous begins to liquefy and, as it does so, detach from the retina. When this happens -- bam -- a floater appears. I once treated a patient who actually drew out the new floater that distressed her. Let me just say that. . .ahem. . . the drawing was x-rated. On dilated exam, I was amused to discover that the NC-17 floater appeared exactly as she had described it -- a shapely posterior vitreous detachment. So, in most instances floaters represent benign entities: either vitreous strands (in the young) or vitreous detachments (in middle-aged individuals).

However, if you see a floater for the first time, you are usually told by your ophthalmologist to present at the office within twenty-four hours. What's the hurry? In a minority of cases, especially in myopes and/or those who recently suffered ocular injury (or surgery), floaters may be caused by retinal tears. Unattended retinal tears can lead to retinal detachments that may cause permanent visual loss. A retinal detachment in which the central portion of the retina (the macula) is still attached must be repaired within forty-eight hours!

The last class of floaters, even rarer than the first two, may be due to non-vitreous substances floating in the posterior chamber (the posterior chamber assumes characteristics of the East River). Those floaters may represent inflammatory cells and debris formed in response to an infection or autoimmune disease. Depending on their etiology, they may be referred to in sophisticated ophthalmic parlance as: "snowballs," "fungus balls," or "haze." Alternately, floaters in diabetics may be caused by bleeding into the vitreous. Those floaters are described as reddish wisps floating in and out of view.

For diagnostic purposes, all of these conditions require a complete dilated exam -- do not kill the messenger! Your pupil gives us a peep-hole view onto your vitreous and retina and the bigger we make it, the better our view of your posterior chamber (so keep it clean).

Takashi Murakami, Eyeball Artist

With today's post, I would like to take a short digression from the clinical world of ophthalmology and step into the enchanting realm of cartoon eyeballs. If ever there had been an artist who captured eyeballs with more passion, humor, and sometimes perversion, it would be the brilliant and beloved Takashi Murakami. Anyone who has ventured out to a Murakami exhibit will no doubt agree that his art gladdens the heart with its bedazzling display of cartoon eyes. Raphael Rubenstein in Art of America writes: "Perhaps not since Dali painted an eye-filled curtain for Hitchcock's Spellbound (1945) has an artist been so ocular obsessed."

I first discovered Murakami at the Museum of Fine Arts in Boston ten years ago. I then payed homage to his exhibits at the Institute of Contemporary Art, The Brooklyn Art Museum, and finally the Guggenheim in Bilbao, Spain. The eyeball galaxies that populate his canvases are irresistable, making his shows (clearly) addictive. A Murakami eyeball pin to adorn the lapel of my white coat: 10 euros. Murakami mushroom painting: $313,000. A trip to Bilbao to see cartoon eyeballs: priceless.

Superflat, Murakami's hallmark style, was inspired by the flat style of Japanese anime. Like Andy Warhol, Murakami strives to create "low art" and sell it as "high art" to the highest bidder. In 2001, Murakami introduced "Wink" to non-museum going masses with enormous multi-eyed balloon sculptures , that hovered delightfully over the crowds in Grand Central terminal. Since then, his work traveled around the world with stunning exhibits, becoming more and more accessible to mainstream culture. To the delight of haute couture, he also collaborated with Marc Jacobs to create the the Cherry Blossom Limited Edition, Multicolore and Eye Love handbag lines.

The critical theorist, Hiroki Azuma thinks the "multitude of eyes" in Murkamai's work "corresponds to the painting's deficiency of space, to its equation of gaze with castration's dysfunction." I do not care for equating gaze with castration's dysfunction (whaaa??), honestly, but I agree eyes are a great way to fill up empty space. So, for a lifetime achievement award for Eyeball Artist of the people, I nominate Takashi Murakami.

Eye Opener on Saint Patty's Day

For the second most sacred day on my Google Calendar, I am delighted to write up a beer introspective. The salubrious effects of alcohol on our cardiovascular system, HDL (good cholesterol) levels, and general well-being are well documented. You have also no doubt heard that too much alcohol may damage your liver and your brain, raise your blood pressure, cause gastroesophageal reflux, increase the rate of certain GI inflammatory conditions and cancers, and give you hella halitosis (bad breath). But how does alcohol affect the windows to your soul?

The most obvious effects of too much beer or wine consumption are noted with conjunctival "injection." Injection is a fancy word for "bloodshot eyes."  The superficial blood vessels in the conjunctiva dilate or enlarge, in response to alcohol.  You will notice your facial skin may redden for the same reason.

Next, I regret to to inform you that, in contrast to its cannaboid competitor, alcohol raises one's intraocular pressure.  This fact is disputed, however by our mates down-under who claim no association between alcohol consumption and elevated intraocular pressure or glaucoma!  Hey, what's good for Aussies is good for us -- take Yellowtail Shiraz, for example.

Eye related trauma is often associated with alcohol, whether it be violent (bar fight in the Bronx) or non-violent (woman walks into coat hanger at Upper East Side party. Woman shows up at ER with coat-hanger in eye). True stories.  According to a six-year study conducted in 28 states by Johns Hopkins' Wilmer Eye Institute, 24% of penetrating eye trauma was linked to alcohol consumption.  Direct corneal exposure to alcoholic beverages can also cause some damage in the form of a chemical abrasion. A hundred-proof Puerto Rican rum, for example, may burn its way to the deeper layers of the cornea and leave permanent scarring. Another true story.

To make things worse for chronic alcoholics, a daily "liquid diet" can cause nutritional deficiency (especially vitamins B1, B12, and Vitamin A), which harms the optic nerve in the eye and leads to irreversible vision loss.  Still, nutritional optic neuropathy is exceedingly rare, and certainly not a leading cause of blindness.

Any good ocular news about our fermented friend? Lets look at the glass half full. In moderation, alcohol does not cause any lasting damages. A study of over 4400 patients in Beijing concluded that: "When adjusted for the systemic parameters of age, gender, rural/urban region, level of education, and smoking, self-reported moderate consumption of alcohol does not have a significant effect on the prevalence of major ocular diseases or the physiologic parameters of intraocular pressure and refractive error." Another Hopkins team went even further and declared that "moderate alcohol use . . . has been reported to be possibly protective against age-related macular degeneration, cataract and diabetic retinopathy[!]"  And on Saint Patrick's Day a little beer binge is a mitzva.

Characteristics and causes of penetrating eye injuries reported to the National Eye Trauma System Registry, 1985-91. Parver LM, Dannenberg AL, Blacklow B, Fowler CJ, Brechner RJ, Tielsch JM. Public Health Rep. 1993 Sep-Oct;108(5):625-32.

Prevalence of alcohol consumption and risk of ocular diseases in a general population: the Beijing Eye Study. Xu L, You QS, Jonas JB. Ophthalmology. 2009 Oct;116(10):1872-9. Epub 2009 Aug 26.

Surv Ophthalmol. 2008 Sep-Oct;53(5):512-25. Alcohol and eye diseases. Wang S, Wang JJ, Wong TY.
J Stud Alcohol. 2001 May;62(3):397-402. Alcohol and eye diseases: a review of epidemiologic studies. Hiratsuka Y, Li G.

Santiago Mission

In this special edition of Eye Spy, I wanted to share some of my experiences with a medical mission to the Dominican Republic. Every March, ILAC (Institute for Latin American Concern) hosts a group of ophthalmologists, opticians, nurses, scrub technicians, administrators, and other volunteers in a small town outside of Santiago. This group, largely from New York, is headed by founder Dr. Robert Della Rocca and loyal recruits who return for one week of volunteer work each year. ILAC's mission is to perform sight-saving surgeries and ocular reconstructive operations for indigent farmers with little to no access to health-care. This year has had the largest showing of volunteers with a team of seventy that settled on Santiago de Cabelleros for the week, paying their own plane fares and accommodations.

Some arrived early to set up the operating rooms, pharmacy, clinics, eye-glass fitting room, and screening areas. In each of three operating rooms, three operating stations were established, so that nine surgeries could proceed simultaneously. U.S. drug companies such as AMO-Abbott, Alcon, Allergan, and Bausch & Lomb donated cataract machines, eye drops, and OR equipment, and some sales representatives even arrived to act as surgical assistants. Thanks to the Peace Corps, we also enjoyed the luxury of computerized booking this year, which streamlined the arrivals in an orderly fashion. Over 200 patients registered daily for screening, many of them already pre-screened in their mountain communities, so that only those necessitating medical attention were triaged to the mission (not just presbyopes in need of reading glasses). In the next few days, we would work in our designated specialties ten- to fourteen-hour days.

The Oculoplastics team performed dozens of reconstructive ocular procedures for patients with blind painful eyes, droopy lids, facial traumas, and burns. They implanted prostheses after careful reconstruction of the ocular sockets with fat grafts from the thighs, and removed tumors and large masses from the lids and orbits. In children, eyelid lesions and droopy lids can lead to life-long vision loss due to amblyopia (normal wiring for the visual system does not develop because the brain is deprived of vision from a young age).

Meanwhile, the pediatric team set cross-eyed children (and even some adults) straight -- the proper term for misaligned eyes is strabismus. This team really put in everything they had and worked from very early in the morning until long after sundown, barely pausing for lunch. Having the eyes properly aligned at a young age, gives children a chance at good vision for life, and helps to prevent amblyopia. Some of the children, having never seen a physician before, were not nearly as scared of us as their American counterparts. For the most part, they were cooperative to perfection and even curious!

As an anterior segment surgeon, I had the pleasure of performing surgery on patients who arrived with bilateral blindness from cataracts so white and dense we called them "coconut cataracts." Anticipating their ability to regain sight, patients danced their way to the operating room, accompanied by claps and singing of family members in the pre-operative area. What a contrast from the anxious waiting areas of American operating rooms! The next day, these country-folk who had not seen better than motions of objects or light, were able to clearly distinguish small letters on the eye chart. They were delighted to be able to see again, and we were even more so (secretly).

In addition to cataracts surgery, I performed pterygium removals (growths on the cornea) so large that they occluded the visual axis. I had never seen pterygia grow so large in the U.S., and was amazed that even access to this relatively simple procedure was not available to these Dominican communities. While removal of this growth in America amounts to no more than a cosmetic procedure for most patients, in the Dominican Republic, it is truly a sight-saving operation.

The screening rooms were an eye-opening experience onto themselves. The amount of pathology that ran through the slit lamps and ophthalmoscopes was astounding. Rare genetic syndromes, uncommon infectious diseases, and other eye afflictions we rarely encounter in training were the norm in the ILAC clinic. Although we were unable to offer help to many of the patients with chronic or congenital illnesses, they were grateful for their care, and blessed us for our efforts.

The spirit of camaraderie ran high amongst the volunteers, and the mission home kept the troops going with home-cooked meals from the kitchen. At night, the crew, together with Peace Corps volunteers, would usually go out for some meringue dancing, dinner, or karaoke at local bodegas or downtown Santiago.  New connections and friendships rapidely formed amongst the nurses, doctors, and technicians. Many of the volunteers are long time participants who began their work with this mission ten or fifteen years ago. Some are sons or daughters of volunteer parents, and were now joining the force on their own. If it were not for the incredible esprit de corps that ran through this enterprise, it would not have survived so many years.

This mission was inspirational for me in so many ways. I consider the ability to restore sight to be truly a godsend.  It made me ever so grateful for my training, the long hours of study and busy call nights. The gratification that came from smiling patients who saw their grandchildren for the first time made it all worthwhile. In the end of the day, though, I could not help but feel we had only touched the tip of the iceberg. We came for one week to help a small community in a rural portion of one country, while hundreds of underdeveloped countries remain bereft of any type of health-care. The thousands of patients for whom surgery was not a sight-saving solution returned to their homes without the hope of regular follow-ups and care for their chronic diseases. Our ability to help seemed so limited in scope in the grand scheme of things, and left me with a feeling of sadness and frustration. I can only hope that for every patient whose quality of life improved as a result of surgery at ILAC, a small window was opened to the world.

Sights and Sounds: Photisms

Have you ever lay in your bed, peacefully clothed in the still darkness of night, when all of a sudden a loud sound startled you and a flash of light or colors appeared momentarily? If so, you may have experienced a synaesthetic phenomenon known as a "photism." Sounds, touch, and taste can elicit transitory visual sensations such colors or light. A few research centers have studied grapheme photisms -- colors or lights induced by the sounds or sights of certain letters, vowels, and numbers. A certain vowel will consistently induce a certain hue of colors, for example in a "color-hearer." Apparently, different languages or speakers may induce different photisms as well. Oftentimes, people with visual loss resulting from optic nerve lesions experience sound-induced photisms. They describe flashes of light, resembling "a flame, a petal of oscillating lines, a kaleidoscope, or an amoeba." One characteristic that is common to all photisms in the visually impaired group is the startle response that provokes them. The ability to experience photisms is poorly understood, but appears to be related to cross-wiring in the thalamus (subcortical portion of the brain involved in processing visual and auditory information). Approximately 1% of the population reports seeing these phenomena, and there has been a genetic basis to its incidence. If a tree falls in the forest and makes a sound, does it also induce a photism?



L. Jacobs et al. Auditory-visual synthesia: sound-induced photisms. Archives of Neurology. 1981; vol 38, Nov 4: 211-216.


Seeing Sounds Or Hearing Colors: Scientists Narrow Search For Genes Associated With Synesthesia. Science Daily. July 26, 2007.


Explanation For Synesthesia? Area Deep Within Brain Plays A Role In Sensory Perception. Science Daily. Sept 24, 2007.

LASIK in the head: or 20/happy

The first question I am usually asked, when I tell folks at cocktail parties that I am an eye doctor is: "so, waddja think about LASIK?" (right before they ask me for advice on treating their cat’s persistent conjunctivitis.) "Is it safe?" My patients consider the option, with trepidation. Well, it is an important decision, and should be discussed seriously with your eye doc.

Let me begin by expounding on the two main refractive surgeries available today: LASIK, and PRK. In LASIK, a thin corneal flap is first created with either a blade or a laser (Intralase or Femtosecond), and then a second laser re-shapes the cornea into the correct prescription. In PRK, laser is applied directly to the surface of the cornea to carve your prescription in. In LASIK, visual recovery is much more rapid, and there is minimal pain following the procedure. For PRK, the wound created on the corneal surface takes a few weeks to heal, resulting in more pain and blurrier vision at first. So, why not opt for LASIK every time?

Whether you are a good candidate for LASIK depends on the shape and thickness of your cornea, as well as your prescription. Generally speaking, the surgery is intended for myopes (people with minus power glasses) in their 20's and 30's, with a stable prescription. Reshaping the cornea requires removal of corneal tissue -- the higher your prescription, the greater the amount of tissue marked for clearance. So, when I determine whether you are a good candidate (don't be offended, it is not personal), I need to make sure your cornea is thick enough for the procedure. Irregular corneas in conditions such as keratoconus (where the cornea is more conical than spherical) are also faux-pas for LASIK, so ophthalmologists obtain a corneal topography before offering the procedure to their patients. A friend of mine from San Diego came to me for LASIK evaluation last year, only to discover to her horror that her corneas were too steep and irregular for LASIK -- she suggested that perhaps they would be more suitable for skiing, topographically speaking. In cases where corneal tissue is too thin for flap creation, or the cornea is mildly irregular, PRK is still a viable refractive surgery option. PRK is also a safer option for boxers, pilots, and bungee jumpers, because flaps may actually become displaced with severe direct trauma to the eyes.

To answer the question of safety more fully, I refer you to Dr. William Mather's multiple articles on the safety of LASIK/PRK over contact lens wear from an infectious and visual perspective. The risk of irreversibly losing vision is much greater over the life-time of patients wearing contacts than those who undergo refractive surgery. Ophthalmologists who use the laser (Intralase) for flap creation also significantly improve the safety profile of this procedure.

Still, there are a few risks or complications that patients must consider before undertaking the procedure. Most if not all of these risks can be predicted pre-operatively in certain patients and treated if they arise. Dry eyes can can get drier as the result of some nerve damage from the laser. It usually improves in 3 months, and must be treated prophylactically in everyone before and after the procedure. Halos are another possible complication, though they usually resolve as well, and occur much less frequently with the strictly laser-driven procedure (Intralase). If the exact prescription is not achieved for the procedure, an "enhancement" can be done to touch up the corneas.

So, are people happy with this surgery overall? Dr. Kerry Solomon conducted a review pooling thousands of patients' responses about their experience with LASIK. This multivariate analysis showed a 95% satisfaction rate with the procedure. In conclusion: 20/happy! If you are considering undergoing LASIK or PRK, make sure you have a fair and balanced evaluation of your corneas by a conscientious ophthalmologist.


Mather WD, Fraunfelder FW. Rich LF. Risk of LASIK Surgery versus Contact Lenses. Archives of Ophthalmology. 2006; 124 (10)


Solomon KD, Fernández de Castro LE, Sandoval HP, Biber JM, Groat B, Neff KD, Ying MS, French JW, Donnenfeld ED, Lindstrom RL; Joint LASIK Study Task Force. LASIK world literature review: quality of life and patient satisfaction. Ophthalmology. 2009 Apr;116(4):691-701.

Tear Jerkers

If I am not watching Hope Floats (with Sandra Bullock) or any movie starring Julia Roberts, why are my eyes tearing? The ophthalmic term for inappropriate tearing is Epiphora. What a beautiful Greek word for such a tragic phenomenon. I had a middle-aged Latino patient once in residency whom I will never forget. "Doctora, I wake up in the morning, I cry, cry, cry; I go to work, I cry, cry, cry; I go outside, I cry, cry, cry," he said to me. Tears were welling in his eyes as he spoke, and I felt great sadness at his predicament. Though he was not depressed, his eyes seemed to water wherever he went. Why?

There are two main reasons for epiphora: (1) a reflexive response to dry eyes, and (2) obstructed tear-ducts that do not drain properly. Obstructed tear ducts are self explanatory: tears build up in the eye and then run down one's face, because the drains are jammed up. The dry eye scenerio is a little more complex. "How can my eyes be DRY, if they are constantly WATERING?" My patients sneer at me with disbelief (sending concerned looks at my medical diploma and furtively eying my license to practice medicine).

The sophisticated and highly sensitive nerves on your cornea have moisture sensors that set off a reflex arc to the brain that then dispatches a message to your eyelids: "release tears, ahoy!" When the cornea becomes dry enough to set off this sprinkler system, tears gush down inappropriately. You may have experienced this phenomenon when the cold, dry winds of the Northeast have blown into helpless corneas, sending tears streaming down your cheeks. Perhaps you also cried with longing for the day you would move to a tropical island (a confounding factor), but I digress.

The way to treat obstructed tear-ducts is by having a dacryocystorhynostomy (duh!), which opens the ducts with silicone tubing and creates an alternative way for tears to drain into the nasal cavity. As for dry eyes, one treats the underlying problem (artificial tears, Restasis, lid hygene, etc.) How does one discern dry eyes from tear-duct obstruction? One squirts sterile water through the ducts at the chairside. If the squirtee can taste water in the back of his/her throat, the duct is open, and the cause is more likely dry eye syndrome. If s/he cannot taste the water, the duct is clogged. Incidently, a couple of my Russian patients requested a vodka substitute for the water in this procedure.

O.K., this is a wrap on epiphora. Put away your box of tissues.

Saturday See-Food Diet

For cocktail hour, make eyeball-tini's using radishes and pimento olives. Stirred, not shaken, at: http://showmevegan.blogspot.com/2008/10/veganmofo-eyeball-martini.html




As an opener, keep your eyes on the taco salad. This delicious recipe was sighted on: http://www.tasteofhome.com/Recipes/Eyeball-Taco-Salad













Next, antipasti! Eyeball pasta is easy to make, and capers can substitute the green pesto irises here. Look for this recipe at:
http://www.bbcgoodfood.com/recipes/12856/eyeball-pasta







For desert, eyeball cupcakes will see to it that your party ends on a sweet note. Recipe found at: http://www.epicurious.com/recipes/food/views/Eyeball-Cupcakes-232942

New Graphic from Eric Hou

I am thrilled to announce that Eye Spy has unveiled a new logo, designed by no other than illustrious cartoon artist, Eric Hou. Eric's brilliant plume captured the essence of this site with a spy, an eye, and a chart in the medical record room. Check out his awesome cartoon store at: http://shop.saltykisses.com/

Put a Plug in It

What can we do you for, if you still suffer from dry eyes symptoms, even after squeezing bottle after bottle of artificial tears onto your eyeballs? To answer my dear reader, Avitalle, on a comment posted 2/17/10, I would like to address the topic of punctal plugs. And my answer to you comes from an age-old idiom: waste not, want not.

Your eyelids serve not only the important function of lubrication (call them cornea squeegies), they also contain a little toilet bowl that drains those tears. This little toilet bowl is called the punctum and it marks the beginning of the tear drainage system. Each one of the four lids contains a little punctum -- take a look at the nasal portion of your eyelid margins in the mirror and you will see these little holes. The puncta (plural form of punctum) drain excess tears by a complex vacuum mechanism that synchronizes perfectly to suck tears down the drain with each blink. Tears are then are emptied into the vast dumping ground of your nasal cavity via the tear ducts. In other words: what the eyelid giveth (tear glands) the eyelid taketh away (puncta). It is a sort of deity, perhaps a dictator, that can make or break your tear film.

If your eyes are as dry as Avitalle's, you are probably not producing enough aqueous to keep the cornea moist. So, it seems only logical to throw a wrench into those puncta and show them who's boss. Plugging up the puncta allows your eyes to keep all the tear volume they naturally produce and then some.

How does it work? Punctal plugs are tiny silicone wonders that can be deployed straight into the punctal opening, where they expand and stay until they fall out (typically 6 months to a year later). Planting the punctal plugs (do I get points for alliteration?) takes approximately a minute a punctum, is completely painless, and can be done in the comfort of your friendly neighborhood eye clinic. Depending on the severity of the symptoms, just the lower, or both upper and lower puncta can be plugged.

Most of my patients are very satisfied with the procedure and return with a healthy tear lake on follow-up. There is a small (but vocal) minority who can feel the plug if they look in its direction (Don't do that!) Rest assured though, the plugs can be removed as easily as they were placed, and they are completely inert otherwise (i.e. they do not elicit any immune response or allergy).

Yoga under Pressure

Yoga is arguably the most popular fitness fad of the decade. It claims entire specialty stores devoted to clothing, accessories, gear, and mats. You can do zen yoga, aerobic yoga, steamy yoga, strrrretchy yoga, pre-natal yoga, and even Wii Yoga. Any yoga may be tailored to fit your lifestyle (and some tailor their lifestyle to squeeze in some yoga). So, can anything that feels so good be so bad. . . for your intra-ocular (eye) pressure?

Sirsana yoga is a type that involves headstands. One study of Sirsana yoga practitioners in India showed a two-fold increase in intra-ocular pressure during head-stands. Without getting too graphic, imagine a two-fold increase in any function of your body! Multiple studies have demonstrated progression of glaucoma in followers of this extreme form of yoga; and many other studies are now underway on the question of yoga and eye pressure.

Consider some of your favorite yoga (or other recreational) positions: downward facing dog, downward forward bend, child pose, the wheel, or even more exotic ones like the camel or the fish. Amidst this zoo of poses, your head is placed below heart-level. Blood gravitates to the head, pressure in the cerebrospinal fluid surrounding the brain increases, and intra-ocular pressure rises in turn. The same fluid that surrounds your brain, encases your optic nerves as well, so it follows that when cerebral pressure rises, the pressure on your eyeballs increases.

Glaucoma is the most common disease of the optic nerve. According to the Glaucoma Research Foundation, it is the leading cause of blindness in African Americans and the second most common cause of blindness world-wide. While the exact mechanism of glaucoma is not well understood, we do know that it is linked to eye pressure. Intra-ocular pressure that is too high for any particular optic nerve will cause glaucoma damage, in most cases irreversibly.

I am not looking to direct the national tide of yoga aficionados back to the elliptical, but as with everything else, use good sense and moderation. If you know you have glaucoma or a family history of glaucoma, reconsider positions that involve prolonged suspension of the head below heart level. For glaucoma folks, yoga may be an extreme sport -- stick to sky diving! Do not forget to pay your friendly neighborhood eye doc a visit for an intra-ocular pressure check and a peer at your optic nerves.

Sunday Morning Art Looking at You

Gabriel Orzco's Under Elephant Foot. Currently on Exhibit at the MoMA, NYC. Eyeballs studded into a Beaucarnea tree trunk.

From Lafayette Square in New Orleans, bronze eye sculptures by Louise Bourgeois serve as benches. This 90 year old artist also created a great eyeball sculpture for the Williams College Campus.

Takashi Murakami's Jellyfish Eyes. Much more on this artist to come on Eye Spy.

Flax or Fiction

No visit to your local Trader Joe's or Whole Foods is replete without a leisurely stroll down flax-seed lane. This natural grain, originally used in the making of cloth and paint (!), now comes in many edible forms: whole seeds, ground seeds (for sprinkling on your corn-flakes or baking), tablets, cereals, breads, power bars, and even muffins. I was first introduced to ground flax-seed ten years ago when my college friend, a devout health-nut, poured it into blueberry-pancake mix. It was part of a Suzanne Summers diet recipe, because of its ability to control satiety and curb hunger, while keeping calories to a minimum.

The two main types of flax-seed, brown and yellow, contain equal amounts of short chain omega-3 fatty acids. You have heard countless tales about the beneficial effects of omega-3 fatty acids on the heart, blood pressure, immune system, and mental health, but did you know omega-3's are great for your eyes as well? Blepharitis, or eyelid inflammation, can benefit from this oil's anti-inflammatory action. Treating eyelid inflammation leads to improvement in dry eye disease (see my post "A Dry Subject," 2/16/10). A large study conducted at the Northwestern Feinberg School of Medicine has shown a 30-36% reduction of blepharitis symptoms in subjects who consumed omega-3 fatty acids as compared with placebo. Dry eye specialists often recommend tablets of flax-seed oil or its aquatic counterpart, fish oil, as part of a dry eye treatment regimen. Italian researchers obtained similar findings (pescatarians that they are). The advantage of flax-seed over fish-oil is apparent to vegetarians as well as those suffering from gastroesophageal reflux disease, otherwise known as fish-burp syndrome. Flax-seed is one of the only non-animal sources of omega-3 fatty acids.

But there are other salubrious benefits to flax-seed. Lignans, a lesser famed but equally loved oil family, have been shown to lower the incidence of cancer (particularly breast cancer) and heart disease. Also, the high fiber content of flax-seed helps to regulate bowel movements in the constipated and presumably lower rates of colon cancer.

Just how much flax seed is enough? Experts recommend supplementing your diet with 1000 to 2000 mg a day of flax-seed. This is most easily accomplished with tablets. You may want to titrate your exact dosage based on the gastrointestinal side-effects. There is some controversy about whether flax-seed causes prostate cancer, but evidence in either direction is scant. If you want to give flax-seed a shot at improving symptoms of dry eye, take it for at least a month and give it a chance to kick into your system.

For some flax-seed recipes, check out: http://www.flaxmatters.com/recipe.home.php

Macsai, MS. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction. Transaction of the American Ophthalmological Society. 2008;106:336-56.

Pinna A et al. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007 Apr;26(3):260-4.

A Dry Subject

Dry eye syndrome, the most common ophthalmic diagnosis today, affects us all sooner or later. Severe dry eye syndrome, also known as keratoconjunctivitis sicca, usually afflicts people with systemic disorders, such as rheumatoid arthritis. One blog entry cannot approach an exhaustive discussion of this topic, so I will start with some "dry science" that is crucial to understanding dry eye disease and its treatment.

All dry eyes are not created equal. The tear film is composed of three main ingredients: aqueous, mucin, and sebum. Much like a soufflé, your tear-film demands exact proportions of these main ingredients to remain stable and form a smooth surface over the cornea. Too much of one ingredient and not enough of another leads to premature break-up (instability) or drying up of the tear film, such that you may feel any one of the following uncomfortable sensations: burning, stabbing pain, itching, foreign body sensation (feeling of sand or eyelash in the eye), and blurry vision. A fourth important factor involved in regulating the tear film is the blink reflex. Most people blink between 6-8 times a minute. A good blink is a complete one (the upper and lower eyelids make contact) and spreads the tear film evenly across the cornea.

Two of the main ingredients in the tear recipe, sebum and aqueous, are released from your eyelid margin (from glands that sit behind your lashes). The third ingredient, mucin, is produced by marshmallow-shaped cells in the gooey skin of the eyeball, the conjunctiva. It then follows that eyelid inflammation will disrupt the production of sebum and aqueous and therefore affect the tear film. In a very common condition known as blepharitis (eyelid inflammation), dry eye syndrome results from faulty sebum or aqueous release. Reduced blinking rates or incomplete blinking also lead to drier eyes, because the tear film coats only those surfaces covered by the blink, leaving the remainder of the cornea high and dry. You may have noticed yourself that when you read a book/Kindle or work on the computer for a prolonged period of time, your eyes begin to burn and your vision blurs. Studies have shown that subjects focusing on these highly visual tasks blink less frequently. A reduced blink reflex means faster tear break-up and discomfort or pain. Why the blurry vision? Being a very powerful refractive surface (a surface that focuses light onto your retina), the tear film must be "just right" (think soufflé) in order to produce clear vision. As soon as it breaks up or dries up, the refractive surface is damaged and the image projected into your eye becomes unfocused and fuzzy.

My patients often ask me, with Nancy Kerriganian alarm and a dearth of tears in their eyes, "why me?!" The reasons for poor blinking and tear-film deficiency are multifactorial. First and foremost among these is aging. As sure as death, taxes, and cataracts, our aqueous tear production decreases with age. Another gender misfortune is female sex, especially as menopause nears and hormones involved in tear film regulation change. Drugs, such as anti-depressants, blood pressure, neurologic, and allergy medicines, contribute to dry eyes. Smoking (you heard it here first!) is bad for you, and interrupts proper tear-film production at its root and with second-hand smoke. Crack cocaine smoking is even worse and can lead to full-fledged corneal abrasions. Sorry to pull the race card, but white folks (you know who you are) with Rosacea, are more prone to blepharitis and, therefore, dry eyes. And, finally, disease states such as Lupus, Rheumatoid Arthritis, and Sjögren's Disease all contribute to dry eyes.

Now that we know the basics of tear production, lets talk about treatments. Depending on the underlying cause of dry eyes, I like to tailor therapy to target the specific problem. For example, if you have eyelid inflammation, I treat your ailing eyelids first, and if you have tear film deficiency I recommend lubricating the ocular surface or stimulating tear production with a prescription drop. If you sleep with your eye-lids slightly ajar (lagophthalmos), I recommend a drop that will keep your corneas moist at night. The corner-stone of dry eye treatment is artificial tears. By this I do not mean Visine, Naphcon-A, or any vasoconstricting drops. In fact, I would recommend you cease and desist use of the aforementioned, if you do. In the next few blog posts I will delve into therapies for different dry eye scenarios and talk about drops, gadgets, supplements, and routines that can help dry eyes feel better.

If you seem to have severe dry eye symptoms and have not found an answer to your predicament in this post, hold on to your seat-belt, I have only reached the tip of the iceberg. Please comment with your particular problem and I will address it in a future post.