April 1, 2017
My family and I went on a winter vacation to Kauai last month. I can’t remember when was the last time that we went on a week-long vacation together. It was so relaxing; sleeping in, soaking up some sun, and most of all, spending unhurried time with the kids. The twins are deathly afraid of water and they have never submerged themselves in any pool past their necks. Even the ordinary hair washing at bath time is still a struggle. Maybe it was the Aloha magic but it was good to see them work up the courage and plunge their little heads into the water. My son Theo was the first to do that and I just loved seeing his face beam with a sense of achievement when he popped out of the water.
My wife went with some friends to hike the famous Kalalau Trail along the Na Pali coast in the northern part of Kauai. For that 48 hours, I watched six kids ranging from fourteen to three and a half. Luckily, the pool, the beach and the sun kept them pretty happy and tired. The seven of us did go on a road trip to the Kilauea Point Wildlife Refuge and Lighthouse. It was the best deal in Kauai – five bucks for all seven of us to get in as 15 and under go free!! We also visited the breathtakingly beautiful Hanalei Bay. We were body surfing in paradise.
The highlight on this trip for me was sea kayaking and whale watching on the Southern coast of Kauai. I kayak at least a few times each year but always in calm water. Sea kayaking in the open Pacific Ocean is a whole different experience. Members of our tour group all rode in these sit-on-top tandem ocean kayaks with holes in the bottoms. (Yes, holes in the hull for splashed over water to drain out). I felt very exposed and elevated compared to the regular sit-in kayak that I am accustomed to. The sea was rough and we were mercilessly pummeled up and down by the strong winds and large swells. I felt like I was riding a roller coaster in Disneyland. Pretty soon though, the feeling of being small and scared drifting in this vast ocean dissipated. My partner and I learned to be nimble and paddled with the waves. Our little kayaks speedily glided through the choppy sea to within hundred feet of a humpback whale when it sprayed from its blow hole. It was a glorious sight and all worth it.
With the strong winds blowing at me, my eyes got a bit dry and my contact lenses were less than comfortable. I started to wonder if marine animals can get dry eye too. One would think they wouldn’t since their eyes are constantly bathe in water. What I learn is that cetaceans like whales and dolphins actually produce a thick layer of tears, almost in the consistency of a gel, to protect their corneas from the salt in the water. Abnormalities of their tear glands can affect this tear gel, exposing the corneas to surface breakdown and infections in a manner similar to human with dry eye. Dolphins in captivity who are exposed to high concentration of chlorine in the water are also know to produce mucus discharge and put them at risk for dry eye and corneal infections.
Dry eye is one of the most common ocular conditions that I see in the office. Studies showed that the prevalence of dry eye can be as high as 34% in some populations. Dry eye affects women more commonly then men and the incidence also increases sharply with age. The tear film actually has the greatest optical power than any ocular surface such that irregularities in this layer can potentially degrade the retinal image by up to 80%. The visual consequences of dry eye are far-ranging and can affect numerous aspects of daily living.
The human tear film is far more complex than salt water. It has three main components: water, lipids and mucin along with a host of other substances such as electrolytes, antibodies, growth factors and anti-inflammatory molecules. The water component is produced largely by the lacrimal gland located in the lateral aspect of the eye socket. The lipid component serves to restrict tear film evaporation and is produced by the meibomian glands located along the margin of the eyelids. The mucins control the thickness and stability of the tear film and are manufactured by specialized cells called the goblet cells on the surface coating of the eye (conjunctiva). Even a subtle imbalance of any of these three components can potentially cause dry eye. And as such, the diagnosis of dry eyes can be challenging and there is no single test that can be used to establish the diagnosis.
Tear film osmolarity is one of the newer modalities that may help to identify early dry eye disease. It is often increased in dry eye patients because of decreased aqueous tear production or increased evaporation as a result of a poor lipid layer. An osmolarity reading greater than 308mOsms/L is generally considered diagnostic for dry eyes. Interestingly, the tear osmolarity of bottlenose dolphin, at 470mOsms/L, is a lot higher than ours or other terrestrial mammals, presumably an adaption to their salt water environment.
Ocular surface inflammation appears to play an important role in the worsening of chronic dry eyes. While topical steroids can be used in some acute situations with dry eyes, they are not good options for long-term therapy because of the associated side effects of cataracts and glaucoma. Restasis (cyclosporine) is another anti-inflammatory drop that has been very helpful in the management of dry eyes. Cyclosporine works by blocking the release of proinflammatory molecules from activated T-cells in the conjunctiva. Most recently, Xiidra (Lifitegrast) appears as a promising anti-inflammatory drug by inhibiting the binding of two molecules (intercellular adhesion molecule-1 and lymphocyte function-associated antigen-1) that are responsible for T-cell activation and recruitment.
We are committed to be a center of excellence for dry eye management and we are pleased to be able to offer our patients the latest diagnostic and treatment modalities for dry eye disease. If you are experiencing symptoms of dry eye and they are interfering with your quality of life, please do not hesitate to give us a call.
January 1, 2017
Seeing Our Own Mind
In addition to getting plenty of sleep, I make it a habit to meditate the night before or the morning of my surgery days. I found this routine to be incredibly helpful in allowing me to singularly focus on the intricacies of eye surgery and on the patient before me. I had my first “formal” meditation training serendipitously some eighteen years ago while traveling through Edinburgh, Scotland during the Military Tattoo Festival (Think marching men in kilts and bagpipes, not sure why it is called a tattoo). The short meditation course stood out from the many events and street performances during the festival and I decided to give it a try. The instructor asked us to direct our attention to our breaths, feeling the rise and fall of our diaphragms and the air going in and out of our nostrils. Invariably, distracting thoughts will come, acknowledge them, let them pass and get back to your breaths. “Think of your mind as a clear blue sky and the thoughts are like clouds passing through”, he said. While the military tattoo performance at the Edinburgh castle was a sight to see, what stuck with me were the hour-long meditation instructions.
Since that chance encounter, I have been meditating on and off on a very irregular basis. Between my work and the kids, finding fifteen minutes to sit quietly on the mat feels like a luxury. Doing it well is a whole different matter. Of the 15 minutes of practice, 10 of which might be filled with random thoughts about a patient, my daughter not doing well in school, vacations, what to get my wife for Christmas etc etc. I read several guidebooks, attended a number of meditation meet-ups, chatted with experienced meditators and trusted that I was doing it “right”. For many years, I thought that the ultimate goal is to have no intrusive thoughts at all. Being a perfectionist, I beat myself up for it when I did. It was only recently that I had a breakthrough. The goal I have now is to watch myself, almost as a third person looking into my own mind. When distracting thoughts come in, I can catch myself and not react to it or judge it. The overall effect is that I am more aware of the present moment and my senses are more acute. Through my meager meditative practice, I noticed that I can see each step of my surgery more clearly. It is almost like a slow-motion replay. I can sense my instruments better in my hands and I am more aware of my posture. As a result, I stay fresh throughout my surgery day and I am less fatigue at the end of it. If and when a complication occurs, I can handle it better because my attention is unencumbered by emotional and judgemental overtones. In other words, I am acutely aware of my own mind. I am “mindful” of any distracting streams of consciousness and let them pass instead of them taking hold of me. This same mindfulness also allows me to be more present with my patients on my clinic days. I take a meditative deep breath before walking into the room to greet each patient. The breath acts as a reset button for my mind. The etch a sketch is swiped clean and a new drawing begins anew.
At least for me, the purpose of meditation practice is to cultivate mindfulness. There is nothing magical about sitting crossed-legged on a mat. You can do it sitting on a chair and I sometimes do it walking in the parking lot to Costco. And while meditation has its roots in Buddhism, it can easily be done without any religious or spiritual connotations. The best known method in the secular meditation category is perhaps MBSR (Mindfulness-Based Stress Reduction) developed by Dr. Jon Kabat-Zinn at the University of Massachusetts Medical Center which is designed to teach awareness of thoughts, feelings and body sensations. Since this method is standardized and reproducible, it can be used in clinical trials and allow doctors to test the beneficial effects of meditations. As a result of the pioneering work by Dr. Kabat-Zinn and many others, meditations or mindfulness training has been shown to clinically reduce stress, anxiety and depression, improve subjective well-being and mood, enhance executive function and decrease emotional interference in cognitive tasks. Meditations have also been found to be efficacious in the treatment of a whole host of medical conditions including psoriasis, chronic pain, fibromyalgia, hypertension and arthritis. It has also been shown to boost the body response to vaccinations and to reduce the relapse rate for major depression.
For health care professionals, meditations are also associated with significant decreases in depression and anxiety as well as increases in empathy. They reported less burnout and emotional exhaustion, better connection and less depersonalization with their patients and ultimately less diagnostic errors and possibly improved outcomes for patients.
As an ophthalmologist, I am fascinated by the fact that I subjectively see better after a session of mindfulness meditation. Subjects who participated in MBSR course or week-long meditation retreat also reported that they see the world with fresh revitalized eyes. Colors seem more bright and intense and generally more pleasure in seeing. I concur with that but as a scientist, how do I prove that?
Two recent studies may shed light on this particular issue. A group of investigators (ophthalmologists and psychiatrists) from Spain published in the August 2016 issue of Mindfulness that experienced Zen meditations, when compared to non-meditators, have significant better visual acuity in normal, high and low contrast levels as well as better contrast sensitivity vision (the ability to perceive different shades of gray). The improvement in theses visual function, however, does not appear to be correlated with improved retinal thickness suggesting that it is facilitated by enhanced brain function.
A second study from the October 2016 issue of Consciousness and Cognition reported that cultivated mindfulness is associated with improved attention and sensorimotor control. They looked at 30 experienced meditators and 30 non meditators and studied their ability to track objects with an infrared camera on their eyes. The Smooth Pursuit eye movement of meditators is significantly less choppy when compared to non-meditators when the target is moving at a velocity of 12 degrees per second. To test for visual attention, the investigators presented a target in the periphery of the subject’s vision and asked them to look away from it in the opposite direction (Antisaccades). Meditators as a group show less variability in this attention task compared to the non-meditators. Interestingly, the frontal part of the brain has been known to control smooth pursuit. This is the same area of the brain in which meditation has been implicated to have a potential lasting effect especially for those who meditate regularly.
These two studies are by no means conclusive but judging from the many health benefits that mindfulness training can bring, I am not surprised that vision can be improved, directly or indirectly by meditation. I am not suggesting that meditation can cure blindness. However, seeing our own mind is indeed a powerful tool for us as doctors and for our patients as well. Try it and I would love to hear your experience.
October 1, 2016
Screenings for the Young and the Old
I turned the big 50 this year!! I explicitly asked my wife not to do anything special and my birthday was passed unceremoniously with a nice dinner and chocolate cake at home with the kids. I “celebrated” this milestone by running the Vancouver marathon in May which I did when I was forty. Nobody in the right mind would think of 26.2 miles of pain and sweat as a form of celebration. I guess it is a male ego thing; still trying to prove that I am in my prime. In the end, I ran it faster by one hour and ten minutes compared to a decade ago. It was a sweet personal victory after six months of daily training in preparation for this race. I gorged myself with the amazing Chinese food and dessert crepes in Vancouver as my reward. It was all worth it.
While I feel great at my age, my family doctor reminded me that I am no spring chicken when I went for my regular check-up two weeks ago. He checked my PSA (prostatic surface antigen), cholesterol, thyroid function which I all passed in flying colors. I dreaded, however, the obligatory colonoscopy screening at 50 for colon polyps and cancer. They say that doctors make the worst patients. It is true. I rationalized the many reasons why I do not need a colonoscopy. Lack of family history, good health etcetera, etcetera. My family physician offered me a new screening test called Cologuard which detect for DNA fragments in stool sample for colon cancer. The idea was so very appealing to me. No need to take two days off from work, no drinking that awful colonics as a prep, no pain, no risk! Why not? On further research though, it does not appear that I can take this short cut.
First off, my insurance carrier won’t cover for it. They considered it experimental and it will cost me over $600 every three years, the recommended testing interval. Secondly, while the test has a very high sensitivity (92%) and specificity (90%) for colon cancer, the detection rate for polyps, the precursors to colorectal cancer, is much lower (69%).
What do these numbers mean? For every test that we doctors administer, we have to consider the sensitivity and the specificity of the test. Sensitivity means the likelihood of the test in correctly identifying those with the disease and specificity means the likelihood of the test in correctly identifying those without the disease. Obviously, a test that is 100% sensitive and 100% specific would be ideal but that is often not achievable. A test that has a high sensitivity and low specificity meant that it is very good at picking up the disease but many of those that are tested positive may actually be free of the disease (false positives). This might cause unnecessary emotional burden or further unnecessary investigations (and potential harm) for the patient. On the other hand, a test that has a low sensitivity might simply miss the boat. So, the Cologuard, as a one-time screening test for colon polyps may miss it 31% of the time. In three to five-year time, can a polyp potentially turn into a deadly cancer? Unlikely but possible. Not taking any chance, I will bite the bullet and go the colonoscopy route.
We screen for colon cancer because the early stages of the disease, which is curable, is usually without any symptoms. In the same token, children with eye conditions or risk factors that can lead to permanent visual loss (amblyopia) are not easily identifiable. They cannot express their visual difficulty and they simply don’t know what the norm is. That is why we need to do vision screening in young children to identify those eye conditions that are potentially treatable when they are young but irreversible by age nine. The screening method is dependent on the age of the child. The first screening is often done at the nursery when the pediatricians check the overall structure of the eyes, the pupils and the red reflex (the light reflex that is reflected from the back on the eye). By six months of age, when the eyes are expected to be straight, the corneal light reflexes can be checked. In this test, we are looking at the light reflection on the surface of the cornea when the baby focuses on a light source. Normally, the corneal light reflexes should be smacked in the center of the pupils.
By three years of age, many children are cooperative enough for visual acuity testing with a picture chart set at 10 feet. It is recommended that if a child fails or is unable to cooperate for visual acuity testing at age three, a second attempt should be made within six months at the primary care doctor’s office. For a four year-old, a second attempt should be made within one month. If retesting is impossible or inconclusive, then the child should be referred for a comprehensive eye examination by an eye care professional like me who is experienced in taking care of children.
My twins just turned three this summer and they had their first visual acuity testing at their well-child check-up. The nurses lined them up 10 feet from the eye chart and they could not correctly identify the pictures on the 20/40 line. OMG!! I panicked and took them to my office the next weekend and thoroughly checked their eyes in and out. They turned out just fine with normal eye sight for their age. Well, I definitely did not follow the official guidelines for my children. I made an emotional decision, not a scientific one. I am often asked by parents if their children who have no eye issue need to be seen by me for a regular check-up. Generally, the answer is no. They should be screened first by the family doctors and the pediatricians. West of the Puget Sound, I am the only ophthalmologist who has additional fellowship training for pediatric eye care. My office simply does not have the capacity to see all the children in this county. While they happen to be “free” for my twins, comprehensive eye exams are not inexpensive either. Our health care dollars can be spent more rationally and effectively with a sensitive vision screening program. Nevertheless, if a child has known risk factors for eye disease, if there is a family history of pediatric eye disease, or if a child has signs or symptoms suspicious for a vision problem, it is reasonable and appropriate for a child to have a comprehensive eye examination by me.
The ideal screening program for any medical condition should be safe, non-invasive, inexpensive, easy to preform and operator independent. Compared to colonoscopy, the traditional vision screening program is far safer and cheaper. However, it may not be highly specific. Like the twins, many of the kids that I see who failed vision screening turn out just fine. How can we do better? Can we eliminate the subjectivity of an uncooperative child?
In the past decade, great strides have been made in the development of photoscreeners. These are special cameras that use the red reflex to help identify risk factors for poor vision and to detect for other abnormalities in the eyes (cataracts, for example). It is fast and easy to learn and is now widely used in primary care offices and in community group screenings. A print out or a picture can be provided to the parents as to the reasons for the referral to an eye doctor. Our local Bremerton Lions club has been very active in this cause and it was a great pleasure working with them to find the right photoscreener that fits their needs.
To keep us healthy throughout life, we do screenings for the young and the old for a whole range of conditions. It is important to remember that screening is a single measurement of one aspect of your health at a single point in time. Check with your doctor if there is any doubt so to the result of a screening test. Your overall sense of well-being and confidence in a healthy future should always be our ultimate objective
June 24, 2016
Independence Day, 1776
Every year, I take a father and daughter trip with my oldest daughter, Claire. The twins take up so much of my time and attention that it is easy to lose connection with a teenager. This year, we went to the Big Apple. We walked for miles through Central Park, window-shopped on Madison Ave, swung through several museums, and climbed to the top of Empire State Building. We got to talk, argue and share the experience of being in the greatest city in the world. The highlight of our trip was Hamilton. This hit Broadway musical just won eleven Tony Awards and the genius of Hamilton composer, creator and star Lin-Manuel Miranda was definitely on full display during the show. It traced the life of Alexander Hamilton as an orphan in the West Indies, how he immigrated to New York, studied law at King’s College (now Columbia) and rose to become the right hand man for General George Washington and a founding father of this country. The music was smart, clever and catchy with a fine mix of hip-hop, rap, rock and show tunes. The cast was multi-ethic while the costumes and stage designs were appropriately 18th century with 21st century accents. The overall effect, both visually and musically, rendered the story of Alexander Hamilton to be accessible, alive, relevant and highly entertaining.
Miranda apparently picked up a copy of the book Hamilton by Ron Chernow at an airport during a vacation break and was inspired to transform it to a musical. I have never been a history buff and how Miranda could visualize music and dramas from the somewhat dry 800 pages book was beyond my imagination. Nonetheless, I was inspired to learn more about the life of Hamilton and the founding of this country. What struck me the most about Hamilton was his foreboding sense of self-doubt due to this humble upbringing and his immigrant status to the United States. Instead of being crippled by it, his insecurity fueled him to work harder, try harder and always with a fierce urgency that he was running out of time. As an immigrant with modest parentage, I can certainly identify with that drive. The show ended in a beautiful song “Who lives, who dies, who tells your story,” a meditation on legacy and time, still rings in my ear and mind.
Hamilton made me realize that history is not a static thing. Looking at it from a fresh and contemporary perspective, it can be absolutely fascinating. In a few short weeks, we will celebrate the 240th birthday of this country and in a few months, we will elect the 45th President. Given the current political discourse, it is worthwhile to reflect on the ideals on which this country was founded and celebrate what unite us as Americans. No celebration of July Fourth, however, is not complete without fireworks. Have you ever wondered why we commemorate Independence Day with fireworks each year? Apparently our second president started it. In a letter to his wife Abigail on July 3, 1776, John Adams declared that that the signing of the Declaration of Independence should be a “great anniversary Festival” and “solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.” The next year, the Philadelphia Congress was all over it. In the evening of July 4, 1777, the city of Philadelphia was beautifully illuminated with a grand exhibition of fireworks which began and ended with 13 rounds of rockets to symbolize the 13 states. The tradition stuck ever since. As much as I desire to unleash my pyrotechnic fixation as every other American on the Fourth each year, I am somewhat apprehensive of them because of their potential for eye injury.
Firework related injuries spike each year around July Fourth. Of the 10,500 firework injuries that required treatment in the emergency rooms in 2014, as reported by The U.S. Consumer Product Safety Commission , 70,000 (67%) occurred within the one month period between June 20 to July 20, 2014.
The hands and fingers were, not surprisingly, the most common body part to be damaged, accounting for 36% of all the injuries. The eyes, were the second most common on the hit list – a whopping 19%. The victims were mostly male (76%) and young (35 % were less than 15 year old). A consortium of international studies also showed that bystanders were almost as likely (47%) to be injured as the individuals that set off the fireworks.
Ophthalmologists hate being on call on July Fourth as they are often swamped. Corneal abrasions (42%) and contusions (26%) are what we most commonly see. While they can be quite painful, they are fortunately temporary and patients generally recover without any long-term problems. However, life-changing permanent damage such as rupture of the eyeball, retinal detachment, chemical and thermal burns, intraocular foreign body, can occur in up to 18% of cases. Four percent of fireworks-related ocular trauma required enucleation (removal of the eye) – a chilling fact for a seemingly benign summer fun.
Firecrackers are the worst offender, causing 25% of all fireworks-related ocular injuries. They blast off in unpredictable trajectory, with an uncanny ability to land on the eyes. It is mind boggling to me why people will wear safety googles for house cleaning but they would not wear them to set off firecrackers.
In the same token, parents are more apt to let their children play with sparklers than to allow them to light their birthday candles. Sparklers can burn at 2000 degrees Fahrenheit, 10 times hotter than boiling water. Children holding them directly in front of their face are at high risk of thermal burns to their eyes. Bottle rockets and roman candles are two other types of fireworks that have a high incidence of ocular trauma.
The American Academy of Ophthalmology advises that the best way to avoid a potentially blinding fireworks injury is by attending a professional public fireworks show rather than purchasing fireworks for home use.
For those who attend professional fireworks displays and/or live in communities surrounding the shows:
- Respect safety barriers at fireworks shows and view fireworks from at least 500 feet away.
- Do not touch unexploded fireworks; instead, immediately contact local fire or police departments to help.
For those who decide to purchase consumer fireworks because they live in states where they are legal, the Academy recommends the following safety tips to prevent eye injuries:
- Never let young children play with fireworks of any type, even sparklers.
- People who handle fireworks should always wear protective eyewear that meets the parameters set by the American National Standards Institute and ensure that all bystanders are also wearing eye protection.
- Leave the lighting of professional-grade fireworks to trained pyrotechnicians.
If an eye injury from fireworks occurs, remember:
- Seek medical attention immediately.
- Do not rub your eyes.
- Do not rinse your eyes.
- Do not apply pressure.
- Do not remove any objects that are stuck in the eye.
- Do not apply ointments or take any blood-thinning pain medications such as aspirin or ibuprofen.
Alexander Hamilton died in a duel with then vice-president Aaron Burr. He was 49. He knew first-hand the risk of a duel – having personally attended the duel between Colonel John Laurens and General Charles Lee. Hamilton’s first son, Philip, was also killed in a duel with George Ecker in an effort to defend his father’s honor. Duels were commonly practiced for men to settle their disputes in Hamilton’s time. He was honorable. Apparently he didn’t even point his gun at Aaron Burr. His death seemed absolutely senseless from a modern perspective. History does not need to repeat itself. Just because a practice is common does not mean that it is not senseless. Losing eyesight from fireworks is equally senseless. So, learn from history. Have a safe and happy Fourth of July!
April 9, 2016
Some might claim that compassion and empathy cannot be taught
One of my greatest pleasures is reading fiction. A good novel can be as exhilarating as a roller coaster ride, as beautiful as a rain forest in dawn’s light, and as wretched as a sick puppy. On a cold rainy day when I am not in the office, there is nothing more I rather do than to curl up with a new book. For the past seventeen years, I have been a member of a book group with three other physicians and their spouses. We are a diverse group – different upbringings, religious beliefs and political affiliations – joined only by our love of literature and medicine. We love books from foreign lands as they transport us to exotic places and times and give us a glimpse of the cultures and histories. We learned much about India from V.S. Naipual, Virkam Seth, Arundhati Roy and the great Salman Rushdie. We explored South Africa through the eyes of Nadine Gordimer and J.M. Coetzee. And we blitzed through Latin America with Gabriel Marquez, Juan Gabriel Vasquez and Isabel Allende. Out of the nearly one hundred books that we have read, two really resonated with me as an ophthalmologist: Blindness by Jose Saramago and All The Light We Cannot See by Anthony Doerr.
In Blindness, an epidemic of “white” blindness broke out in an unnamed city. An ophthalmologist who saw the first patient who was blind from this mysterious condition became affected too. All those afflicted were quarantined and sent to an overcrowded asylum. Living conditions quickly degenerated and along with it, basic human decency. Saramago brilliantly used physical blindness as a vehicle to moral blindness. “Fighting has always been, more or less, a form of blindness.” he noted. While physical blindness is largely out of our control, moral blindness is entirely voluntary: “blindness is a private matter between a person and the eyes with which he or she was born.” In the end, the mysterious blindness spontaneously resolved and those who survived the ordeal left the asylum irrevocably changed: “I don’t think we did go blind, I think we are blind, Blind but seeing, Blind people who can see, but do not see.” Saramago’s style is haunting. His characters have no names and one paragraph can go on for pages with scant commas and punctuations. This novel still haunts me even though I read it sixteen years ago. What is my role as an ophthalmologist to the spirit of a patient who has gone blind physically? Am I failing my art if I let that human spirit go dim too? Is it an equal failure to my patients who see perfectly fine but blind to the beauty around him?
I read All The Light We Cannot See last year after a patient, a retired librarian, recommended it to me. Doerr beautifully interlaced the lives of two young characters during World War II, a French girl (Marie –Laure) who went blind from congenital cataract at the age of six and a German orphan boy (Werner) who had a special talent with radio repair which earned him a place at Hitler’s youth academy. Just as light can physically alternate between a wave form and a particle form, Doerr alternated between the two characters chapter by chapter until their lives converged in Saint Malo, France in the last days of the Nazis campaign. To me, this book is about humans trying to do good to one another, even in the worst circumstances and light is the metaphor of this pure goodness. Doerr possess perhaps the best ability to describe blindness in literature. He wrote: “What is blindness? Where there should be a wall, her hands find nothing. Where there should be nothing, a table leg gouges her shin. Cars growl in the streets; leaves whisper in the sky; blood rustles through her inner ears. In the stairwell, in the kitchen, even beside her bed, grown-up voices speak of despair He also aptly depicted the hyper acute senses experienced by blind persons: “To shut your eyes is to guess nothing of blindness. Beneath your world of skies and faces and buildings exists a rawer and older world, a place where surface planes disintegrate and sounds ribbon in shoals through the air. Marie-Laure can sit in an attic high above the street and hear lilies rustling in marshes two miles away….” For an ophthalmologist, his words are pure gems.
Reading eye related journal articles is a whole different matter. Most scientific journal articles are written in a dry, formulaic, passive voice that is sure to put the readers into deep slumber. However, when a great article comes along, its brilliance can shine through like a gem beneath a dull luster. One such article was just published last week in the March 2017 issue of Nature entitled “Lens Regeneration Using Endogenous Stem Cells With Gain Of Visual Function” by a group of investigators from UC San Diego and China.
Stem cells are special cells that retain the capacity to differentiate into various cell types. These investigators found that the stem cells in the lens are located on the front surface of the lens, just underneath the anterior capsule. When these stem cells migrate to the equator of the lens, they start to differentiate into clear lens fiber in a highly organized pattern to form the crystalline lens. Several factors such as PAX6, SOX2 and BMI-1 appeared to play an important role in the proper functioning of these stem cells and to prevent cataract formation.
Traditionally, when we remove cataracts, whether in infants or adults, we first create a round opening of about 5.0mm in the anterior capsule to gain access to the cataract. This approach would therefore destroy most or all of the stem cells in the lens. These investigators devised a new method in removing cataracts by creating a small openingg of 1.5mm in the peripheral part of the lens, thereby preserving the stem cells. With this new method, they observed that the stem cells can regenerate a functioning lens in rabbit by seven weeks and in young monkey by five months.
Encouraged by the animal studies, the same group of investigators also tested this new cataract technique in 12 human infants afflicted with congenital cataracts in both eyes and compared it to 25 infants with congenital cataracts removed in the traditional technique. Three months after surgery, a functioning lens was regenerated in the experimental group and nearly all the lens remained clear (95.8%) at six months without any other significant complications. These regenerated lenses have the ability to accommodate – varying focus depending on the image distance which cannot be accomplished with an artificial lens implant even if one were put in an infant. Additionally, these regenerated lens are expected to grow with the child as opposed to a static implant.
This is a fascinating article and its potential impact on eye care can be huge as over 20 million cataract patients undergo surgery each year. The same stem cells have been shown to be active in adults suggesting that lens regeneration may be a possibility in the elderly population. However, age-related adult cataracts tend to be much harder in consistency and will be difficult to remove through a small opening. Collateral damage to the stem cells may also occur with prolonged surgery times or ultrasound energy.
Lens regeneration may be a subject of science fiction just a decade ago but is now a definite reality. The power of science to transform our lives is immense and concrete. I believe, however, that the transformative power of arts is equally potent, albeit more subtle. Some might claim that compassion and empathy cannot be taught. They are something that one is born with. I disagree. I think that compassion and empathy can be learned through arts and that is one way that arts can save lives. A gifted writer can develop characters that are so real and palpable that we might as well posse them. We feel his pain, joy, anxiety, regrets, longings etc – that is real empathy. I know what blindness is and its many causes. But it is the genius of Saramago and Doerr that helps me understand what blindness feel like. It helps me understand the person who is sitting on my exam chair or lying on my operating table. That’s a pretty powerful tool and that is why I’ll keep reading good fiction.
January 5, 2016
My Professional Treasure Chest
They bring meaning to my work and remind me of the true privilege of being a physician.
Have you noticed that we stopped writing in Christmas cards these days? We are sending them but we hardly write in them anymore. The majority of the Christmas cards that I received from my friends and relatives in the past few years are photo collages of their lives in that year. Their beautiful babies and children are prominently featured and their family vacations are highlighted on the neatly organized and professionally printed card. A few brave souls included close-up pictures of themselves and it is nice to see that they too have put on a few pounds and going gray on their temples. There is, however, not a square inch of real estate on the card where one can write a few words. Perhaps social media has taken over that function. Who writes anymore anyway? We only type. Perhaps I am old fashioned in that way. But it really touches me when folks take the time to write a personalized message on the card. So, there are two Christmas cards that really stand out in my mind this year. Both are from my patients. One featured an artistic rendering of a Christmas in the country scene with snow covered barns, windmill, barren trees against a gray sky. The inscription was simple, red inked Season’s Greetings. What she wrote, however, was golden: “Dr. Cheung, Thank you so much for giving me a much better view in my life.” This card came from an elderly lady with advanced cataract and cornea scarring in both eyes. I successfully removed her cataract in one eye two years ago and restored her vision in the fellow eye this year. The second card came from a young mother who experienced double vision when she looked down at her infant daughter while nursing her. I performed eye muscle surgery to realign her eyes a few months ago and she can now see her world in unison. Her card has a simple and elegant paper silhouette design of a dove above a silver dusted window. In it she wrote: “Thank you for fixing my eyes and improved my life.”
These two cards brought great joy to me and I am sure to keep them in my professional treasure chest. They bring meaning to my work and remind me of the true privilege of being a physician. We all seek meaningful human connections, whether you are a doctor or a patient. These connections help heal the patients and at the same time gratify and invigorate the physicians. I think that technologies have a great potential of bringing people together but the greatest challenge lies in making those connections meaningful. Technology can help us print high-resolution brightly glossed Christmas cards that conveniently fulfill our needs and obligations to send such cards but the effect they have on the intended recipients is pale in comparison to ones that are simple but thoughtfully worded.
In healthcare, I am constantly mindful of how technology can depersonalize the patients’ experience. Take electronic health records (EHR) as an example. EHR is supposed to improve efficiency, reduce cost and reduce medical errors. Sadly, none of that turns out to be correct. Don’t get me wrong, I am not against the technology. In fact, I am one of the early adopters of EHR technology, having used one in my practice for over ten years. However, the way we have to use it, as dictated by our government, depersonalizes the doctors-patients experience. Patients’ unique complaints and symptoms are reduced to a required series of check boxes. Volumes of data are collected but the most relevant ones are buried in the haystack. Doctors spend far more time looking at the computer screens than at their patients, as they are busy checking all the boxes. The human connection is lost. The patient does not feel cared for and neither is the doctor gratified. I am not advocating a return of the paper chart but a different application and emphasis of the EHR technology. Unless citizens and providers collectively make a concerted effort to change our governmental policy on EHR, I am afraid that it will develop in the direction to push doctors and patients further apart rather than bringing them closer.
In ophthalmology, I see great potential in femtosecond laser assisted cataract surgery and I am pleased to be offering this new technology in Kitsap County beginning March 2016. Femtosecond means one quadrillionth (10 -15) of a second. These ultrashort pulses of infrared laser energy cause photodisruption of transparent eye tissues such as the cornea, the front surface of the cataract (anterior capsule) as well as the cataract lens itself. The laser energy creates a very small spot of free electrons and ionized molecules in the eye tissues followed by an acoustic shockwave that expands into a cavitation bubble. Successive and rapid application of these tiny laser spots can effectively cleave the eye tissue in a highly precise manner. Even the most skilled surgeon with the sharpest blade cannot compete with the precision and reproducibility of this laser. The result is a very clean and sturdy entrance wound that shapes like a step of stair in the cornea and a perfectly circular and well centered opening of the anterior capsule.
The femtosecond laser is also used to softened and divide the cataract lens into manageable pieces. Traditionally, this is done with ultrasound energy but the energy can spill over and damage the back surface of the cornea and the supporting structure of the cataract lens. This collateral damage can result in clouding of the cornea, dropped lens fragment or instability of the lens implant. With the use of the femtosecond laser, collateral damages are greatly reduced because less ultrasound energy is needed. The effect on the patient is better visual outcome and faster recovery. Patients with a history of early Fuch’s cornea dystrophy are particularly good candidates for femtosecond laser assisted cataract surgery.
At our surgery center, we use the Alcon LenSx femtosecond laser system. What impresses me the most about this laser system is the ability to customize the treatment parameters based on the unique characteristics of each individual’s eye. A separate scanning laser creates a detail image of the cornea and lens and adjustments can be easily made based on this real-time image. I can then plan each patient’s procedure in much greater details that were previously unavailable. For example, the laser can be programmed to treat pre-existing corneal astigmatism during the cataract procedure. This can greatly improve the patient’s uncorrected vision (without glasses) after cataract surgery.
Not all patients are good candidates for femtosecond laser assisted cataract surgery. A suction cup is placed on the eye for the delivery of the laser energy. Patients with deep orbits or those who are unable to lie flat may pose challenges in using this interface. In addition, patients with small pupils or advanced corneal diseases may be restricted from some or all steps of the laser applications.
As 2015 is drawing to a close, it is high time to reflect on why we are doing what we are doing. Our mission is to help the whole family see a brighter future. It is nice to know from our patients that they have a much better view in life because of our care. It appears that we are on the right track! Surely, technologies can fix eyes and help people see. Technologies, however, cannot be applied appropriately without a sound doctor-patient relationship. When patients feel cared for, they not only see brighter, they see a brighter future. We will strive to do that in 2016 and in the years to come.
October 5, 2015
Rest and Relaxation
One of the more challenging cases that I had to operate on after I returned from my vacation…
This summer came early and with a bang. As the Okanagon fires finally died down, the last days of summer unceremoniously slipped passed us. The fall chill is in the morning air and the sky is brilliantly clear again. Autumn is my busiest season with children going back to school and needing their eyes checked. Summer, however, is for rest and relaxation and I try to take a week or two off each year to spend time with the family. We kicked off this summer with a visit to Grandma in San Diego in late June. Grandma was proud to show off her grandbabies and we were proud that they survived the plane rides with minimal screams and fuss. The highlight in July was of course the twins second birthday. Forty people (many little ones and their parents) descended on our backyard in a three-hour window of sunshine. I honestly did not know how we would have entertained our guests had it rained. The toddlers loudly ran, jumped, wrestled, and blew bubbles while dads, me included, looked on nonchalantly and drank sangria. When I unsuccessfully tried to teach Elise to blow the birthday candles, a gust of wind swiftly did the job for her and a few rain drops followed suit. The adults rushed to gather their hyperkinetic, hyperglycemic children, threw them in their SUVs and the party was over in a hurry.
The grand finale of our summer was a trip to the Oregon coast. We stayed at a friend’s cabin in Netarts, not too far from Tillamook. The children had so much fun running on the sandy beach and splashing all wet in little tide pools. We flew kites, kayaked in the bay and did a few good hikes in the surrounding area. I could feel all my tensions melt away as I watched the sunset against the backdrop of the Three Arch Rocks. I came back feeling refreshed and recharged; ready to tackle the challenges of a medical practice.
Americans are hard workers. Fifteen percent of our citizens report taking no time off each year. On average, Americans get sixteen paid vacations days annually in addition to federal holidays. Compare that to France where workers receive five weeks of paid vacation per year. It is not uncommon for French physicians to close up their offices in the month of August in Paris. As much as I enjoyed my vacations, I have no plan to savor life like my French colleagues. I do, however, think that vacations of moderate duration are important as they prevent burnouts, renew creativity and refocus professional priorities.
Rest and relaxation are vital to our general well-being and to normal functioning. The same goes for our eyes. Our eye muscles need to contract AND relax appropriately and synchronously for the two eyes to track together. One of the more challenging cases that I had to operate on after I returned from my vacation was a nice lady with Grave’s disease. This is an autoimmune condition in which the immune system goes haywire and starts to attack the thyroid gland, the eye muscles and other orbital tissues. As a result, the eye muscles become stiff and unable to relax. The fatty tissue behind the eyes can also become swollen and pushes the eyes out of the socket. In extreme cases, the optic nerve can become damaged because the swollen fatty tissues and eye muscles cannot expand against the bony orbit and in turn press on the optic nerve which runs in the center of the cone-shaped orbit.
Patients with Grave’s disease often times experience ocular discomfort because the cornea is more exposed and the lids may not completely cover the eyes when they sleep. The eye surface becomes dry and irritated. Patients are most commonly referred to my office because of uncontrolled double vision. We all have six eye muscles in each eye, one in-turner (medial rectus), one out-turner (lateral rectus), one down-turner (inferior rectus), one up-turner (superior rectus), one in-rotator (superior oblique) and one out-rotator (inferior oblique). These muscles coordinated with each other to allow the two eyes to track together. In Graves, the muscle that are most commonly affected is the down-turner, followed by the in-turner and the up-turner. The muscles become really tight and hold the eye in its field of action. As a result, the eyes are locked down and in, often asymmetrically between the two eyes. The eyes, therefore, point to different directions and the brain cannot put the two images together, resulting in double vision.
Treatment of Grave’s disease involves controlling the thyroid hormone abnormalities which often times improves the eye problems as well. Approximately ten percent of patients with Grave’s require orbital decompression in which small pieces of the orbital bones are removed to create space for the swollen tissues to expand. Another ten percent of patients have double vision because of the tight eye muscles or because the muscle positions are changed after their orbital surgeries. Typically, we wait for a least six months when the active phase of the disease subside before operating on the muscles to realign the eyes.
Another common scenario that causes eye misalignment and double vision is stroke. Small blood vessels in the brain that supply the control centers of the eye muscles may be clogged by cholesterol plaques. Lacking stimulation from the brain, the involved eye muscle will become weak or even completely paralyzed. For example, a small stroke in the brainstem where the nucleus of the sixth nerve resides will weaken the out-turner muscle. The in-turner muscle, without an opposing force from the out-turner muscle, will turn the eye in. Over time, the in-tuner muscle will become tight. Even when the brain recovers and the out-turner muscle regains strength, the in-turner muscle cannot relax and the eye will remain crossed. Botox to the in-tuner muscle may help to balance the forces between the two muscles but eye muscle surgery is the definitive treatment.
Relaxing a tight muscle, either from Grave’s or from a stroke, is achieved by a recession in which the involved muscle is secured by sutures and reset it further back along the wall of the eye. This effectively decreases the pull that it exerts on the eye. To watch me perform a recession, you may click here. Eye muscle can also be strengthened by a resection in which a segment of the muscle is removed and reattached it to the same place on the wall of the eye. The shortened muscle is tighter and can therefore pull on the eye more. A newer technique in strengthening eye muscle is by folding a segment of the muscle onto itself to make it shorter. This technique, called plication, has the advantage of preserving the blood vessels on the eye muscles and is potentially reversible. We have used this technique on a series of patients and have been impressed with the results.
We are a center of excellence in caring for adults experiencing double vision from Grave’s, Oculomotor palsy, Myasthenia Gravis, Orbital fracture and unresolved childhood strabismus. In most cases, we can medically manage the double vision with prisms. Temporary stick-on prisms are particular helpful for those patients who are recovering from a stroke and in planning for surgery. For those patients that ultimately require surgery, we utilize the latest adjustable suture technique to maximize successful outcome. Our surgery center employs anesthesia protocols to allow patients to recover rapidly after strabismus surgery. Once the patient regains full consciousness, we can further refine the positions of the muscles by loosening or tightening the sutures to achieve single binocular vision. With this approach, our success rate is over 90% for eye muscle realignment. Our goal is to help patients with double vision to rest easy, relax so they can focus their energies on the joys and challenges of their lives.
June 26, 2015
The human brain is a fascinating organ
I just returned from a trip to Hong Kong to visit my mother. It was a quick turnaround; left on Thursday and back on Tuesday. I am still reeling from jet lag, which is why I am writing this blog at 3:00 AM waiting for the melatonin to kick in.
Mother has advanced Alzheimer and Parkinson, an unfortunate combo which rendered her to bed except for her doctor visits. Physically, she has recovered well from her stomach cancer surgery a year ago and now relies exclusively on tube feeding. She has a bed sore that is slowly healing, thanks to improved nutrition. Mentally, however, she appears to be slipping further and further away. I showed her pictures of the twins and I think she recognized them as her grandchildren. She would grin from cheek to cheek in one minute and stare into blank space in another. Her eyes were open but her mind was locked up inside a deep recess within her cranium. Among the millions of neurons that are tangled into a ball of yarn by her disease, a few pathways remain intact but dormant, waiting to be activated under the right conditions. I stumbled upon such as occasion when I was up at 1:00 AM, being jet lagged in that time zone. Her eyes were open and bright and she tracked me as soon as I stepped into her room. I asked her if she knew who I was and she answered unequivocally, yes. We talked about her father, a Western-trained doctor who was sent to a labor camp during the Cultural Revolution. We talked about her mother, her seven siblings and her arduous journey from China to Hong Kong. As I tried to help her to retrieve her distant memory, mom’s speech became more slurred but rapid. She then launched into a monologue as if to give me one last life lesson with all her remaining power of articulation. Tears streamed down my face as one more lesson from mother to son went unheard. Mom stopped speaking and looked visibly upset. She reached out to me with her tremulous hand and at that instance; I knew my mom was still there somewhere.
The human brain is a fascinating organ. Conventional wisdom believes that the human brain, once it reaches its natural maturity, has limited ability to regenerate if it is struck by diseases such as Alzheimer, stroke or trauma. But conventional wisdom is just that, conventional; and just plain wrong sometimes. New research findings from multiple disciplines suggest that the brain has the potential to heal and regain function more than previously thought. In my field, amblyopia, or commonly known as lazy eye, is a prime example. Amblyopia is the reduction of visual acuity caused by abnormal interaction between the two eyes during the critical period of visual development. There is usually a good eye and a bad eye. The bad eye produces a less clear image because of refractive errors (near-sightedness, far-sightedness or astigmatism), strabismus (misalignment of the eyes) or cloudy media (congenital cataract, for example). It is thought that the two eyes compete for neural connections in the occipital cortex (the back part of the brain) and this game is usually over by nine years of age when that part of the brain becomes relatively mature. When the two eyes are in equal footing, the connections to the brain are pretty balanced and they work together to afford us binocular vision and depth perception. When there is a good and a bad eye, the connections to the bad eye was thought to be under developed or even withered away in severe cases. Recent research, however, showed that at least for most forms of amblyopia, the pathways from the bad eye to the brain are actually intact, they are just dormant. The good eye is not cooperating with the bad eye but in fact working against it by suppressing its signals from coming through.
For centuries, the mainstay of treatment for amblyopia is to patch the good eye or blur the good eye with a dilating eye drop called atropine. The rationale is straight forward, we penalize the good eye so that the weak eye can re-establish connections with the brain. While these treatment modalities are generally effective, depending on the age of the patients, 15-50% of children failed to obtain normal acuity even after extended period of treatment. Furthermore, about a quarter of children lose acuity in the amblyopic eye once the treatment is stopped. This give us pause as to whether our conventional thinking is entirely correct. The traditional paradigm is punitive – hold back the good eye to prop up the bad eye. A new approach is to encourage the two eyes to cooperate with each other in order to restore binocular vision which we are naturally endowed with. I found this idea to be very exciting and I am proud that we are a center that participates in a trial supported by the National Eye Institute and administered through the Pediatric Eye Diseases Investigator Group.
In this trial, called Amblyopia Treatment Study #18, we compare patching the good eye two hours per day to playing one hour per day of a Tetris-like or falling block games on an iPad. The subject wears red/green glasses with the green filter over amblyopic eye. Some boxes are only visible to the good eye through the red lens, other boxes are only visible to the amblyopic eye through the green lens. Image contrast begins at 20% in the fellow eye and 100% in the amblyopic eye. Every day, the software adjust the contrast level based on an algorithm of performance and duration of play from the previous day in order to promote the weak eye while maintain cooperation between the two eyes.
Children who are five to less than seventeen years old with amblyopic eye vision 20/40 to 20/200 are eligible to participate in the study. Those who qualified will be randomly assigned to either patching 2 hours per day or to playing the iPad game an hour a day by the study center. We have no control over the assignment but those children who are randomly chosen to the patching group will be offered the opportunity to try the iPad treatment for sixteen weeks. Patches will be provided free of charge as will the iPad and the red/green glasses, which need to be returned at the end of the study. Visual acuity will be assessed at 4, 8, 12 and 16 weeks. Parents will be reimbursed for travel and other visit-related expenses throughout the duration of the study.
Please tell your friends and family about our study. The success (or lack thereof) of any sound medical treatment, be it for Alzheimer or Amblyopia, is dependent on subject participation. We all benefit from the current acceptable forms of treatment because someone else with the same condition participated in some study some time ago. When we take time to become a subject in a study, we are paying it forward – to help those who are in the same boat that follows us. It is an exercise of kindness, the most important lesson that I learned from mom.
I am writing to let you know that we are in the process of consolidating our Bainbridge and Silverdale offices. The expansion of our Silverdale location has just been completed and the Bainbridge office will be closing on April 15, 2015.
While this was a difficult decision, I am excited about the improvements at the Silverdale office which were designed to make your visit to our clinic an even more pleasant experience. We have added two fully equipped examination lanes and have expanded our lobby space, which will allow us to further reduce our already short
wait times. We have also replaced our server and all our computer terminals to ensure the highest security of your private health information.
Our brand new ocular imaging suite will allow us to take high-resolution images of virtually every part of your eye. The latest Zeiss Cirrus HD-OCT (Optical Coherence Tomography) that we purchased can capture 67 million data points of your macula, the most precious part of your retina, in 1.8 seconds. What this means to you as our patient is the most precise and technological advanced eye care delivered in the most efficient manner. Glaucoma follow-up that previously took two visits can now be easily accomplished in one short appointment.
We realize that the consolidation of our locations may pose an inconvenience to you, and for that we fully apologize. If you have purchased eyewear from Eyeland Optical, rest assured that we will continue to honor your warranty and service your glasses from our Silverdale office. To reduce excess inventory, we will have a frame sale beginning on April 1, when all items will be reduced by at least 50%. Keep us in mind if you are looking for a new pair of glasses or sunglasses this spring.
On a personal note, I am looking forward to simplifying my professional life somewhat so I can have more time to spend with my young twins. It is hard to believe that they are already eighteen months old and quickly becoming active toddlers. Daddy playtime is a lot more fun; and as an older father, I want to play an active part in each of their lives now to help shape their development.
Thanks again for your support and for entrusting your vision, the most noble of all senses, to me and my staff. We look forward to seeing you at our Silverdale office and are confident that you will enjoy the benefits of the consolidation. We can assure you that you will find the same standard of personal eye care that you have come to expect from us at Bainbridge Eye Physicians over the past eight years.
Jason C. Cheung, MD
February 2, 2015
Cats have nine lives
Have you ever wonder why human have round pupils and cats have oval ones?
We got a new cat. His name is Smudge, aka Prince. Technically, he is my almost-thirteen-year-old daughter’s cat. It was her idea; something new for the New Year and I thought it would be a good way for her to develop more responsibility. I have a feeling, however, that I will be doing the lion share of the litter box clean up.
Smudge is a really sweet cat. He is gentle with our eighteen-month-old twins, even when he was poked by their little fingers. He also gets along fine with my wife’s cat Shiva who made it quite clear that she will remain the first cat. Shiva hisses at Smudge often and he basically just learned to mind his own business. Good survival strategy for a male in a household.
Smudge’s favorite spot during the day is the twins’ changing table by the window. He loves to lounge there to bathe in the light. His shiny beautiful coat is all black except for a few reddish brown spots, hence the name Smudge. Smudge has a distinctive hoarse low-pitched cry. At night, he meows and yowls incessantly to be let out only to return punctually at 6:20 each morning. His eyes are green and expressive with vertically oval pupils. Have you ever wonder why human have round pupils and cats have oval ones? The conventional thinking is that a slit-like or vertically oval pupils can dilate faster – an adaptation to cats’ nocturnal activities. This explanation never sits well with me since normal human pupils can react to light or darkness pretty darn fast too. Another explanation that makes more sense to me is that a vertical pupil provides a better focus on the horizontal plane which can be very helpful to carnivorous animals such as cats. In contrast, herbivorous animals tend to have horizontally oval pupils because when they lowered then heads to graze, the pupils will then be oriented vertically to allow them better focus on the horizontal plane for approaching predators.
Yet, more recent studies suggest that the slit pupils in cats had evolved to compensate for their large lenses in which the peripheral parts of the lens have a different focal length than the center. This multifocal lens can cause color aberration but the slit pupil help to reduce the color distortion and allows cats to have all colors in sharp focus in one plane on the retina.
A misstep in the development of the human eye can result in a cat-like oval pupil too. In the developing embryo, the primitive eye first appears as a thick pancake at 25 days of gestation. The pancake then starts to fold into an upside down taco and the gap is called the embryonic fissure. The fissure is there to allow blood vessels to grow into the developing eye. Beginning around the second month of gestation, the two lips of the fissure meet and fuse, first in the mid-region of the eye and then zippers forward and backward to complete the globe. Incomplete closure results in a coloboma and the extent of the defect and its visual consequences vary depending on the degree of the zipper malfunction. An isolated small coloboma in the front part of the eye may produce a cat’s eye like this picture. The affected patient may have a little bit more glare and photosensitivity but still enjoys 20/20 vision. In contrast, a large coloboma in the back part of the eye involving the retina and the optic nerve like this second picture can have a devastating effect on vision. Retinal detachment may develop from the edge of a retinal coloboma, further compromising the patient’s vision.
Coloboma can affect one of both eyes and can be inherited. A child with a severe coloboma may have a parent with a very subtle coloboma that was never recognized before. Coloboma may be accompanied by multiple systemic abnormalities in a patient in what is known as the CHARGE association. This includes: Heart defect, choanal Atresia, mental Retardation, Genitourinary abnormalities and Ear abnormalities. Therefore, a good physical exam by the pediatricians (and appropriate testing if indicated) is required when a young child is identified with an ocular coloboma.
Back to Smudge. I worry about him out there in the night when he is exposed to cold, wind and potentially dangerous wild life such as raccoons who pay homage to our home frequently. Somehow, he likes it out there and he comes back unscathed every morning. They say that cats have nine lives. I wonder why the number nine. Nine is a lucky number in Chinese culture. So I guess cats are just inherently lucky. Another legend has it that the ancient Egyptian Sun God, Atum-Ra, took the form of a cat when he visited the underworld. Atum-Ra also gave birth to eight other gods; so he was nine lives packed into one. Ancient Egyptians also believed that cats have divine properties and perhaps that’s where the nine lives legend began.
There is no doubt in my mind that cats have only one life but their ability to dodge death is phenomenal. Watch a cat fall from high places, it almost always land on its feet. Their smallness, agility, and keen sense of balance allow them to constantly reposition themselves in difficult or even life-threatening situations. If I have to choose an animal to represent my practice, it would be a cat. I have been in practice in Kitsap County since 1998. I was in two group practices before opening my own office in Silverdale in 2002. We added the Bainbridge office in 2007 and moved our Silverdale office in 2012. I am happy to announce that we are in the process of expanding our Silverdale location and we will be consolidating our two offices into one in April. This was done mostly in response to the changing technological needs in the practice of ophthalmology and we are acquiring several pieces of new equipment so we can continue to deliver efficient and state-of-the art eye care to our patients. These new technologies are expensive and we cannot afford them in both of our existing offices. We also did not feel right to deliver different level of care between the two locations, hence the need to consolidate.
The practice of medicine is evolving rapidly, at a pace faster than anything I have ever witnessed since I have been a doctor. The direction of the change, I am afraid, is not all positive. Small physician offices, which formed the cornerstone of the delivery of health care in this country for decades, are being bought out by hospitals. Governmental regulatory efforts and technological burden are the main factors that drive this change. Unfortunately, health care administered by a mammoth institution tends to lack the personal touch. Patients become customers or numbers. Physicians are monitored by administrators who track how many minutes they spend with their patients in the name of efficiency. Doctors stop looking into their patients eyes and turn their gazes to the computer screens in order to enter data required by the government. I, along with many other physicians, am saddened by this process. It really takes the fun out of our profession. To me, the art of medicine is about building positive relationships. While science and technology cure diseases, how a patient feels healed and how he or she feels cared for is through positive relationships and experiences with the doctors, nurses and the front desk staff. This I feel is the biggest disconnection in today’s medicine. While a tiger is big and strong, it won’t curl up cozily next to you on a sofa like Smudge. Unless you are a circus animal tamer, it is pretty hard to form a relationship with a tiger. To keep the personal touch in my office, I hope to stay small like a cat while striving for technological excellence. I also hope that our small practice can remain nimble like a cat so that we can land on our feet when we pull through this turbulent time.
October 25, 2014
Do Not Go Gently Into That Good Night
My wife and I just ran the Victoria half marathon this morning. The weather was perfect for running with a mild chill in the crisp autumn air under a slightly over-casted sky. The course was mercifully flat and pleasing to the eyes too. We began in downtown Victoria where the glorious British Columbia Parliament Building was still glowing in the pre-dawn light. We then wound through a beautiful public park, a quaint British-accented neighborhood and finally hugged along the shore as we approached the finish line. Local residents and musicians came out in droves to cheer us on. The positive energy was palpable and I was reasonably happy with my result. I ran this course four years ago and had my personal best here. This time around, I am seven minutes slower than my last. Granted, I did not train as rigorously as my last because of the twins but I cannot help to wonder if aging is finally catching up to me. As an ophthalmologist, I am not immune from the aging effect on my own eyes. Now that I have passed my mid-forties, bifocal glasses have become a necessity of daily life. This natural decline in our ability to focus up close is called presbyopia.
Accomodation is the process by which the lens in our eyes becomes more round and increases its focusing power to bring light from near objects onto our retina. In humans, the lens is held within a capsular bag which in turn is suspended within a circular muscle (ciliary muscle) by tiny fibers called zonules. One theory of accomodation proposes that when the ciliary muscle contracts, the tension on the zonules is relaxed and the elastic lens becomes more curved and powerful. Presbyopia is the normal progressive loss of accomodation due to the loss of the elasticity of the lens. In other words, the aging lens is less pliable to the contractive forces of the ciliary muscle. The ciliary muscle appears to get weaker too with age with more connective tissue and less muscular fibers on microscopic studies. However, stiffening of the lens is the most important causative factor to presbyopia.
Like many middle age folks, I dislike wearing bifocal glasses. My vision is excellent with them but I hate having something over my face all the time. I love contact lens for distance but my near vision suffers due to presbyopia with the regular monofocal contact lens. I experimented with monovision, in which my dominant right eye was corrected for distance and my left eye was corrected for near vision. This approach caused me and many others a slight headache which improved with time. However, I lost some depth perception with this method and for my work, this was not a viable option. Recently, I have great success with multifocal contact lens, thanks to the encouragement of my associate, Dr. Dixita Patel, the contact lens specialist in our practice.
There are two classes of contact lens that help to ameliorate presbyopia. The first class (alternating vision) is similar in design and function to regular bifocal spectacles in which there is one segment for distance and one segment for near. The retina receives light from one image location at a time: distance or near. The other class that I personally preferred is called simultaneous vision bifocal contact lens which sends light to the retina from both distance and near at the same time. The design of this class of contact lens may utilize diffractive technology in which concentric grooves on the back surface of the lens split light rays into two focal groups: near and far. I found that contrast is diminished with this kind of contact lens becausedistance targets are washed out by light coming from the near and vice versa. However, this is very tolerable and I have come to love them and wear them now on a daily basis.
This same diffractive technology is also used in the design of multifocal intraocular implants for patients undergoing cataract surgery. I have been very impressed by the AcrySofReStor multifocal lens implant, manufactured by Alcon. The central 3.6 mm of this lens contains diffractive grating and providesexcellent near and distance vision. The peripheral part of the lens is distant-dominant and most important in low-light conditions. In one study, 78% of patients who received this lensimplant in both eyes never needed glasses six months after surgery and 20% of the study patients required glasses sometimes. Intermediate vision is also very good with the newer +3.00 add version of the Restor Lens but halos, glare and decrease in contrast, particularly in low light conditions, may be problematic for some patients. Not all patients with cataracts are good candidate for this exciting lens technology and I would be happy to discuss your individual needs if you are interested in this lens for your cataract surgery.
Modern medicine has provided us with some amazing technologies to counter the physiologic effects of aging. They don’t stop us from realizing that we are getting old though. The best antidote to that, I think, is to live a life that is purposeful and keep doing what we love and enjoy. When I did my first full marathon in Vancouver in 2006, I crossed the finish line with a runner that was in his eighties. It was his 107th marathon and he sure made an indelible impression on me. Aging is just a little speed bump for us to hop over along the path of life. I plan to keep on running even though I am a bit slower now and my right knee hurts on occasion. I also plan to keep on operating even though I have to constantly adjust the focusing foot pedal of the microscope now as the accomodative amplitude in my own eyes weans.
I am reminded of the first few lines of a poem by Dylan Thomas:
Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.
This month, I celebrated the lives of two amazing local physician: Doctor Robert Bright, a family physician and Doctor Terry Olsen, an ophthalmologist. They were models of caring and commitment which we, the “young” physicians should strive to emulate. They did not go gently into that good night. They both enjoyed long and successful practice and they never stopped caring for their patients. May they rest in peace now.
August 8, 2014
We celebrated the twins’ first birthday last week. The little bit of caffeine in the chocolate cake woke them up from sleep two to three times that night. It goes to show that they are still sensitive little creatures but by and large, they are healthy and happy babies. The weeks in the neonatal intensive care unit is now a distant memory and the nagging fear that something will go wrong with their health faded away. Bringing them from low-birth-weight premies to babbling and crawling babies gives my wife and I a great sense of accomplishment. Most of all though, this landmark is a time to pause and reflect on how truly fortunate and blessed we are.
I run with the twins often in their bright orange double “Bob” stroller. Our usual route from our home takes us through a beautiful half-mile stretch of road that has multiple speed bumps and a speed limit of 15mph. I am often surprised to see that drivers slowed their cars down even more just to get a glimpse of the twins. Invariably, the twins bring a smile to their faces. They can melt the most taciturn face into a smirk or even joy. I wonder why that is. Is it because the twins are just so darn cute, like one would smile when you see a puppy pile? I think it is more than that. I think babies remind us of the infinite possibilities that once lay ahead each of us. That sense of hope and innocence is rekindled in a place deep within us when we meet a baby and that is why they are blessings to us all.
I mentioned the twins often in this blog but my oldest daughter Claire is an equal blessing to me. She is now twelve and a great big sister to the twins. It is interesting to be a father to two children who are utterly dependent on you while another child is desperately trying to become independent from you. Claire is already showing the tell-tale signs of a teenager: rolling her eyes when I try to teach her anything, dramatizing every incident at school to an apocalyptic ending and pushing boundaries in her socialization with friends, girls and BOYS included. Last month, I noticed a good -sized pimple on the tip of Claire’s nose and I offered to remove it for her. She declined. I jokingly said that the pimple is a distraction when boys try to look at her and that comment earned me a punch in my abdomen. Raising twin babies is in some ways easier. I might be sleep deprived but it sure hurts less.
A pimple on the nose may engender the wrath of a pre-teen daughter but a pimple in the eyelids is no laughing matter either. Along the margin of the eyelids, there are glands that produce oil which is an essential component of the tear film that coats the surface of our eyes. When these glands produce too much oil, they can get clogged up. The oil is then extruded into the surrounding eyelid tissues which elicits an inflammatory reaction to produce a chalazion. A stye or hordeolum is an acute infection of these plugged up glands, usually located in the front part of the eyelid. It can be quite painful. As opposed to a stye, a chalazion is more akin to a pimple and represents a chronic local inflammation and is generally painless. It is usually located in the deeper area of the eyelid and it may secondarily cause an exuberant growth of scar tissue and small blood vessels mass known as pyogenic granuloma on the internal surface of the eyelid.
Chalazion generally does not interfere with vision but a large persistent chalazion may indent on the cornea to cause astigmatism. The patient may then experience blurry vision as a result of the induced astigmatism and amblyopia (lazy eye) has been reported due to chalazion in children. It is my clinical impression, as well as others that Hispanic children tend to get chalazion more frequently and recurrently. It is unclear whether there is a genetic or dietary component here. Interestingly, dietary supplementation of omega-3 fatty acids such as fish oil has been shown to change the composition of the oil produced in the eyelid glands. This may, at least in theory, reduce the likelihood of occurrence of a chalazion. Controversy exists as to whether fish oil intake is linked to prostate cancer in men. While fish oil is good for many things such as dry eyes, blepharitis and cardiovascular health in general, men might need to balance that against their individual risk factors of developing prostate cancer.
The first line of treatment for a chalazion or a stye is hot compresses. The heat and the mechanical motion of rubbing the lid margin help to melt open the plugged up glands to allow it to drain. A combination of antibiotic and steroid eye ointment may provide added benefits. I usually recommend medical therapy for at least two weeks before surgical intervention. Surgery, however, is relatively low-risk and can be done as an in-office procedure for adults. It involves flipping the eyelid outwards with a clamp and an incision is made on the internal surface of the eyelid to drain the pus out. We often remove a small piece of the tissue and leave the incision open to allow it to continue to drain. Antibiotic ointment and a patch are applied which can be removed in couple of hours.
An alternative to surgical drainage is injection of a steroid suspension to the lesion. I tend to recommend this treatment when the lesion is small and indurated without a lot of pus in it. Patients with dark skin may develop whitening of the eyelid skin in the area where it is injected and I try to avoid this method for these individuals. In kids, either method poses a risk of damaging the eyeball and therefore we have to do them under general anesthesia.
If left untreated, many chalazia will eventual go away. Rarely, an untreated stye or chalazion can become infected and the infection can extend to the entire eyelid and possibly into the eye socket. Even more uncommon is the occurrence of eyelid gland cancer that can masquerade as a chalazion. For these reasons, medical attention should always be sought for unresolved or recurrent chalazion.
May 1, 2014
The TSA of an Eye Exam
I just returned from a three-day trip to Hong Kong with my family. The sole purpose of the trip was for my six-month old twins to meet my mother whose health has been declining. Her mind is slipping away from Alzheimer’s and her body is ravaged by Parkinson’s and stomach cancer. It was a bittersweet journey, as it was the first and probably the last time for them to meet. My mom had several relatively lucid intervals per day, each lasting no more than fifteen minutes. During one such interval, I asked my mom if my son Theo looked like me when I was a baby. Without missing a beat, she nodded yes. It was priceless, knowing that she understood my question and who the twins are. The sixteen hour journey and four sleepless nights were all worth it.
On our way back from Hong Kong, I was pleasantly struck by how easy it was to go through the airport security there. No undressing my belt and shoes in public. The babies were wheeled through the metal detector in their car seats and stroller. It was a breeze. In contrast, going through TSA in Seattle was a bear. They actually asked us to remove the twins out of their car seats along with every little toy dangling from the handle bar of their car seats. The car seats were then scanned, as was the stroller. Thankfully, they didn’t body scan the twins or asked us to taste the bottles of formula milk.
This difference in experience in airport security screening reminded me of a clinical encounter that I had several weeks ago in my office. The patient was a middle age man who came in with some flashes and floaters. He hesitated with the dilated fundus exam because he had to go back to work after his visit. He asked why I could not just take a picture of his retina which was what his previous eye doctor did. I explained to him the importance of a good retina exam through a dilated pupil and there is really no substitute for it. Luckily, he relented and sure enough, he had an early retinal tear and was successfully treated with a laser and prevented the development of a full blown retinal detachment.
The dilated fundus exam is an integral part of any comprehensive eye examination. It is the most effective way to screen for glaucoma and retinal conditions such as macular degeneration and diabetic retinopathy. An annual dilated fundus exam is recommended for individuals 65 years and older. Without dilation of the pupils by drops, the pupils can constrict to 2 mm or even smaller with light stimulation in some people. It is impossible to accurately assess the retina through such a small opening and many retinal conditions, particularly those that affect the peripheral retina such as retinal tear, will be missed. A retinal camera can provide some clue to retinal pathologies in the central part of the retina but it is practically useless for the peripheral retina. As a screening tool, not only is the retinal camera not sensitive enough, it is also not cost effective. The patients often incur an additional cost because it may not be covered by their insurance.
When the pupils are dilated with drops to 5 mm or more, an ophthalmologist can accurately assess the lens for any cataract formation. The optic nerve can be visualized to look for signs of early glaucoma or swelling due to increased pressure in the brain. The macula, the central part of the retina, where there is the highest density of photoreceptors, can also be carefully examined for early signs of macular degeneration or diabetic hemorrhages. The blood vessels can be assessed for high blood pressure damages and we can also look for tumors and retinal thinning or defect in the periphery.
In children, a dilated fundus exam is also paramount for those at risk or suspected to have retinoblastoma. Without a good exam of all parts of the retina, this cancer of the eye can extend through the optic nerve into the brain and is potentially lethal. The pupils of premature babies are also frequently and safely dilated to detect for retinopathy of prematurity – abnormal blood vessels development in premature retina that can lead to retinal detachment and permanent blindness.
In adults, we typically use agents that will keep the pupils dilated for four hours. Near vision will remain blurred during this time because both the pupil dilating muscle (the iris dilators) and the focusing muscle (the ciliary muscle) are affected by these agents. In children, because of their tremendous focusing power, we often use stronger agents to temporarily paralyze the focusing muscle. Doing so will give us the most accurate glasses prescription in children. The trade of, however, is that the near vision may remain blurred for a day.
The side effects for dilating the pupilsare generally mild and tolerable. Blurred near vision and light sensitivity are the most common complaints. Allergic reactions to dilating agents may result in red eyes, rash or swelling of the eyelids but they are transient. Small children can occasionally become sleepy after dilation. Very rarely, dilation may precipitate an angle-closure glaucoma attack for those individuals with anatomic narrow angles.
The dilated fundus exam is akin to TSA screening. It is time-consuming, inconvenient and the yield is generally low. In low risk population without any symptoms, the rate of detection of clinically significant fundus lesions is estimated to be about 1 to 3 %. I have yet to meet a patient that enjoys the dilated fundus exam. I dreaded having my own pupils dilated six months ago and the previous one was done about six years ago. I also have yet to meet a traveler that sings TSA praises. However, if I have to choose, I would pick a dilated fundus exam over a retinal camera and the TSA over the Hong Kong airport security over and over again. The consequences of not doing a proper screening-another terrorist attack or blindness- are unimaginable.
January 17, 2014
New Year’s Resolution
Happy New Year! I wish you all a healthy and prosperous 2014. New Year is a mark in time that prompts us to reflect on our past achievements and set goals for the future. Like many of you, I set a number of resolutions each New Year, many of which I failed to keep. For 2014, again, I stand to lose a few pounds by reining in my uncontrollable urge for dark chocolate, be a more patient father and a more understanding husband, and to commit to reading every eye journal that arrives on my desk each month. Reasonable and achievable goals? Yes, indeed they are. A 250 IQ or Herculean strength is not a prerequisite for reaching these goals but they do require me to develop good habits to have a reasonable chance of success. And that is the rub: good habits can be just as powerful, if not more so, than any superhuman trait. In health, creating good habits can lead us away from diseases, even those that we might be genetically predisposed to.
For example, one of the most common eye conditions that I see in my practice is blepharitis – inflammation along the eyelid margin. Patients with blepharitis complain of burning irritation in both eyes, often with crusty mattering that sticks to the eyelids in the morning. Redness in the eye and on the eyelids and a gritty sensation are often present. The causes of blepharitis are multiple but the main culprit is excess oil production by the glands along the eyelid margin that can lead to bacteria overgrowth which in turn can produce toxins to further irritate the eyes. While medications such as erythromycin ointment, azithromycin eye drops, and in severe cases, topical steroids and oral tetracyclines can be very helpful, the most important aspect in the management of blepharitis is daily lid hygiene – cleaning the eyelids with a hot wash cloth with or without a dab of baby shampoo. A process that takes 20 seconds or less but very few patients do it consistently once the acute phase of the disease is over. I must admit, I have blepharitis and I don’t do the cleaning regularly and you won’t believe how many times a day I have to give this spiel to patients (and therefore to myself)!! If only I can develop this HABIT, my eyes will feel and look so much better.
Perhaps the most common eye “disorder” that we see in our office is myopia, or nearsightedness. Myopia is a mismatch between the refractive elements of the eye (the lens and the cornea) and the length of the eye such that images are brought into focus in front of the retina. Usually, this is because the length of the eye is too long (axial myopia). Myopia can easily be corrected by glasses, contact lens or refractive surgery but severe myopia can predispose patients to the development of retinal detachment, glaucoma and cataract. Genetics plays a strong role in myopia and parents who are highly myopic themselves are particularly concerned about how fast myopia is progressing in their children. They often ask me what they can do to prevent or slow down their nearsightedness. Are there effective medicine or exercise? Can special glasses or contact lens work? Recently, three clinical trials showed that there is no quick fix for myopia. The Correction of Myopia Evaluation Trial (COMET), the Contact Lens and Myopia Progression study (CLAMP) and the Atropine for the Treatment of Myopia (ATOM) respectively showed that progressive spectacle lens, hard contact lens and atropine drops provide no or marginal benefits in slowing down myopia. Interestingly, two separate studies, one conducted in Taiwan and one in Denmark showed that children in those countries who are encouraged to play outdoors showed significant benefit in halting myopia progression. The mechanism of this benefit is unclear at this time. One theory is that indoor artificial lighting and light stimuli such as those from computer monitors, tablets, smart phones and video games are particularly rich in red light. The unbalanced stimulation to the red cones may in turn mediate signals that stimulate axial growth of the eye. Supporting this theory is the recent finding by a group of UW vision scientists that one form of inherited myopia is caused by defects in the red and green cones due to mutations in these visual pigment genes. This same group of investigators is now looking into the effect of wearing red/green glasses on myopia.
Over the holidays, I have been reading The Power of Habit by Charles Duhigg. The science behind habit formation is fascinating and the stories on how people transformed their lives by developing good habits are very moving. It appears that to curtail myopia, parents need to stow away the electronic gadgets that they just bought for their children over Christmas and develop the habits of taking them outdoors and play. I understand this simple message as a physician but also realize that as a father, this is not so easy to do in our fast paced world. “All our life, so far as it has definite form, is but a mass of habits” so wrote William James in 1892. In health, as in life, developing good habits is the key to success – whether it is for blepharitis, myopia or obesity. May that be my ultimate resolution for the New Year.
November 9, 2013
Only time will tell
The twins continue to thrive since my last blog entry. They stayed at the Swedish neonatal intensive care unit for a little over two weeks , mostly for feeding and growing. Except for their small sizes, they appeared otherwise healthy to us and to their doctors. They have roughly tripled in size in three months – they literally jumped on the growth curves. Elise was less than one percentile at birth and is now running at 14%. Theo is a tank in comparison, approaching 69% tile. Babies like my twins who were premature and growth restricted in utero are at risks of a host of medical problems including cerebral palsy, attention deficit disorder, autism, asthma, reflux …… all sound very scary as a father. While the logical and medical side of my brain tells me that there is no evidence of any of these conditions, there is still an underlying tinge of fear. Only time will tell.
That’s the thing about physicians prognosticating. It is an educated guess based on statistics but there is no way we can tell whether YOUR child, YOUR spouse, or MY child will be free of a particular aliment. In pediatrics, we develop milestones to help us gauge the development of a baby, make better predictions and to intervene when necessary if the baby falls significantly off the trajectory.
For example, misalignment of the eyes is very common in early infancy. Approximately, 75% of neonates have wandering eyes, 25% have straight eyes and a very small percentage have crossed eyes. Look at Elise and Theo in these pictures.
Their left eyes appear crossed but their daddy is not freaking out – yet. This is still within the norm, particularly if it is intermittent. By three months of age (corrected for prematurity), most normal infants will have straight eyes. If their eyes remain crossed by then, I would be calling my associate, Dr. Barrall. For now, patience is the best course of action. In fact, the congenital esotropia observational study confirmed in 2002 that small degree of crossed eye (less than 40 prism diopter) identified at less than 20 weeks of age frequently resolves without any treatment.
Parents often wanted to know how much their baby is seeing. Is it 20/40? What is normal? That is actually not a good milestone to gauge visual development in an infant. It is neither accurate nor practical. How much a baby “sees” depends on how we measure it.When measured using sophisticated electrodes attached to the scalp (Visual Evoked Potential) while the baby observes a reversing pattern on a monitor, the acuity of a full term newborn is estimated to be 20/100 to 20/200. The acuity typically increases rapidly between one to three months and approaches 20/80 by 4 months. VEP tends to overestimate acuity in infants and some babies can measure close to 20/20 by 6 months with this method. However, this is a very time consuming way to measure acuity and it is subject to many variables such as the alertness and attention span of the baby. In clinical practice, this is rarely done unless other alarming signs such as nystagmus (jiggling eye movements), extreme light sensitivity and poor visual attention are also present.
Another common myth is that newborns can only focus up to about 10 inches from their faces. Most infants are born far-sighted (hyperopic), which means that it is easier for them to see things far away than at up close. Optically speaking, in a relaxed, unaccomodated hyperopic eye, there is no clear focal point from infinity to the cornea. Accommodation –the contraction of the focusing muscles in the eye, is generally believed to be poor or absent until three to four months of age. Therefore, the neonates will have a defocused image at all distances but they tend to look at things at about 10 inches because that is where their objects of interest are located – the parent’s faces or the approaching mothers breasts or bottles.
The physical characteristics of the structure of the eyes are good milestones and reference points for eye doctors. At birth, the average corneal diameter of a full term infant is 9.8 mm just 2.0 mm shy of the adult value of 11.7mm. A large cornea and loss of clarity of the cornea will raise concerns for congenital glaucoma, a rare but potentially devastating eye disease. The front to back diameter of the newborn eye (axial length) is about 16mm, compared to the adult value of 23mm. The most rapid growth phase occurs in the first 18 months of life when the white wall of the eye (the sclera) drastically expands. The color part of the eye, the iris, becomes darker after birth as pigments accumulate in the cells and the meshwork of this lacy structure. In Caucasians, the eye color is typically set by six months of age.
What about at the other spectrum of life? We don’t typically look at developmental milestones in seniors as they are done growing. However, we can look for markers to monitor degeneration and predict the time course of a disease. Ultimately, however, only time will tell.
In the eye, for example, genetic testing is now commercially available for age related macular degeneration (AMD). Using the DNA from a mouth swab, the Retna Gene test can evaluate the risk of a patient with the dry form of the disease progressing to the advanced, wet form of the disease. While it does not change what we can do for those patients identified as high risks, the test can educate and impart on the patients the importance of periodic follow up. This test is now available at our offices for those patients who fit the criteria.
The most dreaded neuro-degenerative disease in the senior population is, of course, Alzheimer’s. My mother was diagnosed with early-onset Alzheimer’s five years ago. She now lives in Hong Kong and it has been difficult to watch her slowly decline from a distance. I am not sure if she would understand who the twins are when she finally meets them. I also know that it will be a matter of time when she would no longer recognize my voice when I call. A glimmer of hope now exists for early detection and possibly treatment for Alzheimer’s. The hallmark of Alzheimer’s disease is the deposition of an amyloid protein in the brain causing the neurons to tangle. This same amyloid protein also accumulates in the retina and if we can measure the level of amyloid in the eye, we might be able to correlate with the disease in the brain. Researchers recently identify a compound, Curcumin, a derivative of turmeric or curry, which binds to the amyloid protein. This Curcumin molecule also naturally fluoresces and by measuring the amount of fluorescent light coming from the retina using a specialized camera, scientists can deduce the amount of amyloid protein in the eye and by extension, in the brain, after the patient ingests a dose of Curcumin. Since there is still no effective cure for Alzheimer’s disease at this time, it is our hope that early detection can allow for a more effective treatment before the neurons turn into plaques and tangles with the amyloid protein deposition.
As physicians, we are often frustrated by the limited effective options we can offer our patients with chronic diseases such as Alzheimer’s or Cerebral palsy. We tried our best to educate and reassure our patients, but we all know that the outcome is unknown and only time will tell. Reflecting on my experience as a father and as a son, I think that a little bit of hand-holding from a caring physician can go a long way even in the face of a terminal condition. I like to think of chronic disease as a long journey and as your doctor, my role in these situations is to travel the distance with you, offer guidance when appropriate and take a little burden off you when needed. While only time can tell the ultimate destination of this journey, it goes a heck a lot faster when we walk hand-in-hand.
August 5, 2013
Life’s greatest journey
The twins are here!! We were blessed by the arrival of Elise and Theo on Friday, July 26 at 2:03pm. Elise sneezed at the world andstarted crying. Theo came one minute later and met the world with a bang, kicking and screaming despite his small size of 4 pounds and 10 ounces. They were delivered by C-section at 34 weeks and 2 days of gestation because Elise was growing poorly. Her birth weight was 3 pounds and 8 ounces, less than 5 percentile for babies of that age.
Fortunately, they are doing well in the neonatal intensive care unit, breathing on their own and started feeding already. Elise, in particular, is a voracious eater. Guess she is trying to catch up with her brother. We expect them to be at the NICU for three to four weeks before returning home. My wife is also recovering well from the operation and very happy and eager to be a new mother.
It has been a tough and long journey. At 23 weeks and 2 days of gestation, during a routine ultrasound appointment, my wife was found to have a very weak cervix. She was immediately admitted to the hospital for bed rest and for monitoring of preterm labor. If the twins were delivered at that point, their survival rate was less than 30% and even if they lived, they would face multiple serious medical problems, one of which is blindness. It was a very dark time for me and my wife and as an ophthalmologist, the thought that my own children may be blind was almost impossible to bear.
How do extremely premature infants develop blindness? In the developing eye, the blood vessels in the retina grow from the optic nerve in the back of the eye at 16 weeks of gestation and emanate forward to the front (peripheral) part of the retina. Normally, the vessels reach the nasal peripheral retina by eight months and the temporal (the side close to the ears) peripheral retina by ten months. In premature infants, these developing blood vessels have not reached the peripheral retina to supply it with oxygen. The relative lack of oxygen causes the retina to produce a hormone called VEGF (vascular endothelial growth factor) which in turns stimulate the blood vessels to grow towards it. Unfortunately, high level of VEGF can stimulate both normal and abnormal blood vessels (neovascularization) growth. The neovascularization is leaky and fluid can track under the retina to cause it to detach which mayresult in blindness. VEGF, in addition, can stimulate the cells in the vitreous jelly to grow like scar tissue which in turn can pull on the retina, causing it to detach. This proliferation of abnormal blood vessels and scar tissue in the retina of the premature infants is called Retinopathy of Prematurity (ROP) and is one of the leading causes of blindness in children in this country.
Premature infants younger than 30 weeks of gestation and/or weighing less than 1500 grams (3 pounds and5 ounces) are at risk for developing ROP and require screening by an ophthalmologist who is experienced in this condition. Most ROP exams on infants are done while they are still in the NICU but they can also be done in the office after the babies are discharged. In our office, we instill an eye drop to dilate the pupils of the baby who is tightly swaddle by a blanket. A parent will gently hold the baby’s body while my assistant keeps the head still. I will then put a numbing eye drop in the eyes and a speculum to keep the eye lids open. I then look into the eyes with an indirect ophthalmolscope to evaluate if there in any ROP and if so, the extent, severity and location of the disease. If the disease reaches certain threshold, treatment would be recommended.
In the past, treatment of ROP involved using a freezing probe (CRYO) to burn the peripheral retina that is devoid of blood vessels. The CRYO-ROP trial, published in the late 1980’s, showed a 40% decrease in unfavorable structural outcomes and a 30% decrease in unfavorable visual acuity in treated eyes, compared with observed eyes after 15 years of follow up. However, even with cryotherapy, 44% of children with threshold ROP had vision worse than 20/200 at 10 years of follow up.
Laser has largely replaced cryotherapy as the main treatment modality for ROP. In early 2000’s, the ET-ROP trials demonstrated that Earlier Treatment with laser for high risk ROP prior to reaching threshold disease was beneficial. However, laser treatment can potentially cause cataract, irregular pupils due to scarring of the iris to the lens, and loss of peripheral vision.
Most recently, based on the latest understanding of the science behind ROP, Bevacizumab (Avastin) was used for the treatment of ROP. Bevacizumab is an anti-VEGF molecule, it blocks the effect of VEGF on the developing retina. This medication has been used extensively in other eye diseases such as macular degeneration and diabetic retinopathy to stop abnormal blood vessels growth. In fact, a randomized, controlled, multicenter trial called BEAT-ROP demonstrated that BevacizumabEliminates the AngiogenicThreat of ROP and was superior to laser for the treatment of the most aggressive form of ROP that involves the posterior (central) aspect of the retina. In addition, peripheral retinal vascularization continued as normal in the Bevacizumab group but not in the laser group. While Bevacizumab injection shows great promise as a treatment for ROP, we need to continue to monitor for possible side effects on other body systems of a developing baby. Late recurrences of ROP had been observed in eyes injected with Bevacizumab which underlies the importance of long-term follow up for these babies.
Fortunately, my wife was able to hang in there for 11 weeks to the point that Theo and Elise’s age and weight put them at low risk for developing ROP or other serious medical problems such as bleeding in the brain. As an ER physician and a very active person, it was very tough for her to stay in bed for that period of time. We are most grateful for the medical care and attention that we received at Swedish Medical Center. The perinatologists and nurses at the Antepartum unit and the neonatologists and nurses at the NICU were truly superb. Since my wife and I are very healthy people, we are rarely on the receiving end of the medical system. We realized how fortunate we are to live in a time with tremendous technological progress in medicine. Without the ultrasound monitoring, this pregnancy would probably be lost forty years ago. Yet, as human beings, what we crave most in time of sickness, is not technology but human touch. I was reminded of this important fact while in the NICU where the nurses encouraged us to have “kangaroo care” with the twins. We laid skin-to-skin with the babies and it was amazing to see how their heart rates and respiratory rates improved without any medication. In the weeks that we were in the hospital, my wife and I poured through the medical literature on incompetent cervix and intrauterine growth restriction, hoping to allay our fears. It didn’t. It only created more questions and worries. What reassured us the most were the caring touches of the nurses and the honest and open discussions with the doctors. And when I saw two teams of highly skilled NICU personnel standing by in the operating room to receiveour twins just before the surgeons cut into my wife’s abdomen; despite the huge pang of fear in me, I strangely knew that Elise and Theo will be okay.
May 1, 2013
I have some very amazing and exciting news to share. My wife and I are pregnant, with twins!!! We just had our 20-week prenatal ultrasound appointment last week, and here are some photos for me to brag about. One of them, the boy, is destined to be a yoga master. He is practicing the plow pose in utero, far more flexible than his old man.
The other twin, the girl, is a bit more subdue. She appears to be reclining in a chaise lounge, posing as a model in a classic Italian painting.
I am predicting trouble and she will make my hair much grayer than it is now.
The ultrasonographer who took these photos was very kind and highly skilled. Knowing that we are both physicians, she asked us if there was anything specific that we wanted to see. As the ophthalmologist, I, of course, said eyes. And there they are: the developing eyes of my boy within his orbits in axial cross section. The two tiny bright spots within the circles of darkness are the developing lens!
The fetal development of the human eyes is a highly complex and fascinating process. The first sign of the developing eyes occurs at 22 days of gestation as a thickening of the embryo’s surface at the widest part of the head. This thickening then enlarges and balloons outwards into a C-shaped cup but remains connected to the rest of the head through a tubular stalk. At 28 days, another thickening on the surface develops and this will become the baby’s lens when it eventually pinches off from the surface and moves into the center of the C-shaped developing eye.
Do you know that the eye is the first part of the body to development pigment? By the second month of gestation, pigment granules (melanin) begin to appear in the retina. The pigment helps guide the traffic pattern of the nerve fibers from the eye to the brain. That is why patients with albinism have abnormal optic nerve conduction and their vision is usually abnormal. In the second month, eyelid folds and the eye muscles that move the eyeballs also start to develop. The eyelids meet and fuse by the third month and they begin to separate by the fifth. This is the stage where the twins are now.
Sometimes, knowing too much may not be a blessing. Over the years, I have seen enough as to what can go wrong in this miraculous process that keeps me up at night about the twins. While the majority of cataracts that I see in my office occur in the senior population, babies and children can develop cataract too. In fact, I just removed one from a delightful five year old girl yesterday. There are many causes of pediatric cataracts, any misstep along the development process as outlined above can cause a cataract. In addition, infections, inflammation, trauma, metabolic diseases can all cause cataracts among the youngs. Genetics is an important factor too. Inherited cataracts are most commonly transmitted to the offsprings in an autosomal fashion, that is, the baby has a 50/50 chance of inheriting and developing the cataract from the parents. Often time, when I see a cataract in a child, I can also find one in the parents. The parents are just lucky that they have a mild form of the disease.
Removing a cataract in a young child or infant is technically more challenging than in an adult. The wall of the eye in an infant is very soft and the eye has a tendency to collapse when we enter the eye to remove the cataract. The capsule that surrounds the cataract lens is also far more elastic than in adults. It is much more likely to rip when we open the capsule to gain access to the cataract. The size of the eye, of course, is much smaller. Manipulating instruments or placing an intraocular implant is awkward within this tight space and experience really counts in these cases.
In adult cataract surgery, an intraocular implant is almost always placed to replace the eye’s natural lens. In a young child, since the eye is still growing, an implant that produces a sharp image at the time of the surgery will not be the right one for the child in several years. An alternative is contact lens, which power can be changed to match the growing eye. Putting a contact lens in an infant, however, is not an easy matter and may create a fair amount of parental stress. To compare these two options, a multicenter randomized clinical trial was conducted for infants less than 6 months of age with cataract in one eye. The Infant Aphakia Treatment Study Group found that the visual outcome at one- year of age is the same for the contact lens and the implant groups, although the babies that received the implant had more complications and require more additional surgeries than the contact lens group.
Perhaps the most difficult aspect of taking care of a child with congenital cataract for both the doctor and the parents is amblyopia. Amblyopia is reduced vision in one or both eyes due to form deprivation or abnormal interaction between the two eyes. Children with cataract in one eye and a normal fellow eye are at highest risk of developing amblyopia in the affected eye. In these children, the neural pathway from the eye with the cataract to the brain is underdeveloped compared to the fellow eye. Even when the cataract is removed and a good image is obtained with contact lens or implant, this disadvantage in the neuro-circuitry still persists. The only way that this can be reversed is by penalizing the good eye by putting a patch over it or by putting a drop in to blur that eye. Patching the good eye is not fun for the child or the parents. To make matter worse, this treatment is only effective in the first few years of life when the brain is still amenable to be changed. Once that window of opportunity is over, no amount of patching, drops, glasses or implants can make a substantial difference in the visual outcome for the child.
Delivering this kind of bad news to parents is never easy and we doctors strive to do this in a way that is compassionate and informative at the same time. Being a father helps me put my doctor self in the parents’ shoes – to really know how it feels to receive the diagnosis and the prognosis. Three months after my first daughter, Claire, was born, I saw a baby girl in my office with a cataract in one eye. She was the same age as my daughter and just as angelic. As I was explaining to the mother the risks and potential complications of the surgery, she started to cry. While I had gone through that with parents many, many times before and I am generally not an emotional person, I too was struck with an overwhelming sense of grief and loss and tears began to roll down my cheeks. I thought of Claire as the patient in the room and the realization that her life would be very different than what I imagined for her. It was the best lesson in empathy and I firmly believe that I am a better doctor because I am a father. I am so looking forward to fatherhood again with the twins. They will make my life immensely richer, both personally and professionally.
February 11, 2013
An Inspiration and a Beginning
Hello!! Welcome to my blog. This is the first time I write a blog and it is not common for physicians to have a blog on their professional websites. I hope to use this forum to educate the public and my patients about eyes and vision through my own lens. The opinions expressed in this blog are solely my own personal experiences and perspectives on eye care. They have not been peer reviewed in scientific journals or tested in a laboratory. They are simply my take on things from the latest advances in ophthalmology to the day-to-day practice of medicine. They do offer you, the reader, a glimpse of who I am as a physician and to garner your trust in me as your Eye M.D. Let’s begin our journey.
This past Wednesday evening, I had the pleasure of entertaining Dr. G and his wife at my home. Dr. G is a retired ophthalmologist and emeritus professor from the Chicago area. He sought me out to be his cataract surgeon several years ago after he moved to Bainbridge Island. It was a real honor for me to be his doctor and his surgery went perfectly. We kept in touch over the years and he enthusiastically shared with me his eye mission trips to Burma each time he came in for his follow up visits. My staff would save up expired medications and supplies for him to take on his trips and he is always very appreciative of them. Dr. G’s wife came in couple of weeks ago for her eye check and told me about his most recent trip to Burma in December. Since my wife Danielle and I have been talking about traveling to Burma in the near future, we decided to invite them over for dinner.
For the dinner, I prepared a salad with lotus root, Napa cabbage and chili-lime vinaigrette, a steamed Chilean Sea Bass, a stir fry baby bok choy and shitake mushrooms and some steamed Bhutanese red rice. I thought I did a pretty good job on the food but Dr. G’s slide show of his Burma mission trips was truly the highlight of the evening.
Burma, also known as Myanmar, is a Southeast Asian country with a population of 60 million. It has been under military rule since the early 60’s but democratic reforms have been forthcoming since 2008, allowing foreigners like Dr. G better access into the country. While the country is rich in precious stone, oil and gas, the per capita health expenditure is less than US $2.50. Needless to say, eye care is scarce and a group of Australian ophthalmologists developed an eye hospital there with the mission of treating reversible blindness. Dr. G was one of the volunteer surgeons who traveled there to provide expert eye care for free.
Cataract is by far the most common cause of reversible blindness in the developing world. A cataract is the clouding of the crystalline lens in the eye. The most common type of cataract is called Nuclear Sclerosis and is related to aging. In this type of cataract, the center of the lens turns yellow to brown, blocking light from entering the eye, causing diminution of vision. The picture below showed a very advanced cataract that Dr. G saw in Burma. Cataracts rarely progressed to this stage in the United States because of good access to quality eye care and eye surgeons in our country. However, just because you have been diagnosed with a cataract does not mean that you have to have it removed right away. For seniors with MILD nuclear sclerosis cataracts, a change of your glasses prescriptions may be all that is necessary. Wearing sunglasses to protect the eye’s lens from harmful UV light exposure may also slow down the progression of cataracts. Medications, supplements or eye exercises cannot prevent or cure cataracts. When your vision is so poor that it can no longer be improved with glasses AND your daily activities are affected, that is the time to consider cataract surgery.
Back to Dr. G. In the two weeks that he was there, his waiting room looked like this each morning. He would then operate for hours to accommodate all the patients that traveled for miles to see him. The equipment available to him was poor and he had to create a large incision (13mm) to extract the entire cataract lens in one piece in a technique known as extracapsular cataract extraction. The most advanced technique in cataract surgery that I practiced involved making a 2.65 mm incision that requires no suture. The cataract is then broken down into pieces using an ultrasound, the pieces are removed by suction, and a folded implant is then inserted and unfolded inside the eye. This technique, small-incisional phacoemulsification with new technology intraocular lens, allows for much faster restoration of the vision. It is, however, much more costly and not practicable in a setting like Burma.
While the full recovery of Dr. G’s Burmese patients might take some time, he was gratified by the stunned and joyous expression of each of his patient’s face on the day after the surgery. He felt privileged to have made a significant positive impact on their lives and these trips have brought meaning to his life’s work. My wife (an ER doctor) and I long to join Dr. G on one of his mission trips but we might have to wait a year or two because of our young children.
The morning after my dinner with Dr. G, I operated on six patients with visually significant cataracts. I reflected on our discussions about the different techniques and approaches to cataract surgery and I was inspired by the common mission of our work. Restoring sight is a noble cause. While operating in the US might be less “exotic” than in Burma, and we are constantly burdened by insurance companies and government regulatory restrictions; the end effect to me as a surgeon is still the same: it is truly a privilege to bring vision back for my patients. The following day, I was equally gratified by the joyous expression of my patients face when I removed their eye patches and they read 20/25 to 20/20 without glasses. Patients often thank me for the miraculous gift of restoring their sight. The truth is, they have given me a gift that is equally miraculous: a sense of purpose and meaning in my work.