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.