A Child’s Vision: How important is it to you

19 08 2013

Only 14% of children under 6 in Canada have had a comprehensive eye exam yet 80% of learning is visual. In preparation for a 12+ cycle of education is this how do we equip our kids? We should expect more. Many common learning disabilities have been shown to be hidden undiagnosed visual dysfunction. Schedule your child’s eye exam today!

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Counterknowledge: Is Dry Eye a Disease or a Syndrome?

5 08 2013

The answer:  IT IS A DISEASE!

Language is important and how we treat a medical ailment depends very much on what we call it.  Terminologies like disorders, syndromes and diseases get mixed up and misused and interchanged depending on the literature or even the medical professional you are speaking to.   Defining a condition correctly will change the attitude of the patient suffering from it and the doctor treating it.  Brampton-20130205-00310Dry eye is one such disease that has been misrepresented as a syndrome in many arenas but let’s take a look at the definition of a disease versus a syndrome.

Syndrome:  a collection of signs and symptoms known to frequently appear together but without a known cause.  This grouping generally characterizes a disease or disease process

Disease:  a morbid entity characterized usually by at least two of these criteria:

  1. Recognized etiologic agent (cause)
  2. Identifiable group of signs and symptoms
  3. Consistent anatomic alterations

Dry eye disease, also known as Keratoconjunctivitis Sicca, is the term used by the internationally recognized Tear Film and Ocular Surface Society (TFOS).  It has very clear and identifiable signs and symptoms, anatomical changes are both diagnostic and prognostic of the disease itself.  The cause, or etiology, of dry eye is an often debated subject but as a culmination of decades of scientific study, it is well agreed that it can be distilled into one or a combination of aqueous deficiency, lipid or oil deficiency and/or cicatricial (scarring).  It is also generally accepted that dry eye is an inflammatory disease, which is why the majority of pipeline drugs are targeting inhibition of specific inflammatory pathways.

Why is this conversation relevant?  Too often a ‘syndrome’ get’s swept under the rug or trivialized by medicine and pop culture.  We are swift to group symptoms together and call it a syndrome which may be reason enough to take this side-stepping approach.  However when a real and clearly defined condition affects over 25 million US adults and over 100 million people world wide, AND science has elicited cause and effect then it should become an imperative to give it ‘disease’ status; not to scare or induce fear, but to appropriately identify and manage the process.

The next time you meet someone that has dry eye disease (DED), don’t define that person by the disease but rather understand the impact that it has had on her/his life.  Ask them how many doctor’s have actually given it the attention it deserves.

In a survey of 100 patients at eyeLABS Center for Ocular Surface Diseases, the average number of eye physicians/doctors the patient had consulted for DED was 3 prior to seeing me.  I intend to be their last.

sidenoteSideNote: The Ocular Surface is Skin – Treat it that way

Dry Eye Disease is a skin condition, not unlike many dermatological conditions.  The lid surface, meibomian glands and corneal tissue are variations of epithelium and sebaceous glands which will age, like the dermis does.  The lengths of cosmetics, creams, lotions and potions for the skin can help to preserve our skin, but what about the eye?  The science at eyeLABS is founded in ocular surface skin preservation and sustenance.  Lid Margin Debridement (click here for related article) and clinical gland expression provides a basis for the spectrum of treatment options and maintenance procedures available at our clinic.  Contact lens wearers in particular should actively seek these types of treatments out as they are more likely to develop lid related inflammatory conditions (lid wiper epitheliopathy) that directly impact the glands, cornea and therefore dry eye disease progression.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





Be Proactive on Reducing Wrinkles – add comfort to your eyes!

25 07 2013

“Epidermal atrophy and structural changes observed in the Dermal-Epidermal Junction with aging may be, by some extent, related to daily and repetitive skin deformations all along the life span”

Skin Res Technol. 2013 Jun 25

Translation:  Wrinkles and the aging skin are related to constant stretching and relaxing of the skin.  This may sound like common sense, yet patients everywhere still engage in life behaviours that are known to hasten wrinkle formation.   Smoking, tanning, high sugar diets all are big contributors to the aging skin but while changing your habits may take some work, why not eliminate some factors that are out of your everyday control.

crowsfeet

Squinting your eyes – a very common ocular reflex to external factors such as bright light, blurry vision and ocular discomfort.  Because it’s a reflex it is not considered a bad habit, but rather a mechanism your body employs to protect the ocular surface and or enhance vision when stimulated by the above factors.  Here are some very easy steps to reduce your stimuli to squint:

  1. Wear corrective eye wear when needed – this is by far the easiest step to take to avoid squinting.  It has the added benefit of clearing your visual world.
  2. Wear your sunglasses – UV exposure worsens this cause of squint because it can accelerate the aging skin.  If you’ve ever lost your sunglasses and spent even a lunch hour without them, you’ll likely have a headache all afternoon.
  3. Treat your ocular surface keeping it wet and comfortable – Dry Eye Disease (DED) is a leading cause of eye discomfort.  When left untreated the natural course of this disease will worsen leading to further eye muscle contraction.

The treatment options for dry eye have changed dramatically as experts world wide agree that meibomian (oil) gland dysfunction (MGD) may be the leading cause of dry eye in the world (TFOS 2011).  Knowing the mechanism behind this condition allows it’s treatment to be more targeted and therefore more effective.  Each of the four eyelids are home to the 20 to 40 oil glands and optimal functioning is achieved when the glands are absent of any obstruction and the lid surface is properly cleared of debris and devitalized epithelium.  The eyelid margin (the area behind your eyelashes towards the eye) is the only area of our bodies that doesn’t get cleaned regularly or thoroughly and because of its proximity to the cornea is a dangerous place to try to clean at home with q-tips, brushes or wipes.  Corneal scratches can become infected and are extremely painful.  Also, over the counter cleansers are still insufficient to removed devitalized skin and debris which can only be seen under microscopic examination with ophthalmic vital dye staining.LOM_mgo

eyeLABS Center for Ocular Surface Disease offers an array of services to treat and maintain your glands and lids for optimal functioning:

  • Lid Margin Debridement – and exfoliative process for the eyelid surface
  • BlephEx – a microdermal exfoliation of the eyelid surfaces and eyelash roots
  • LipiFlow Theramal Pulsation – the only FDA approved treatment for MGD.
  • Topical and Oral Medicines – although we focus on enhancing your body’s natural functioning there are cases that require specific medicine to treat underlying inflammation and/or infection

In this way, we can limit your stimulus to squint and help you widen those eyes and lose the wrinkles!  Instead of spending countless dollars on Botox and fillers, be proactive and prevent unnecessary “epidermal atrophy,” also known as wrinkles!

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Center for Ocular Surface Disease

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





eyeLABS featured on CTV: Dry Eye Clinic

19 07 2013

eyeLABS  was featured on CTV with Dr. Maharaj and fellow patients discussing the disease of dry eye and the merits of effective treatments focused on the eyelid.  LipiFlow, Lid Margin Debridement, and other therapies are found under one unique roof at eyeLABS center for ocular surface disease.  Click here or the image below to watch the CTV segment:  

CTVRMpic

Meibomian gland dysfunction is a commonly overlooked disease entity and can be inconspicuous even under microscopic examination.  Clinical expression by your optometrist or ophthalmologist is the only true way to identify blocked glands.  These glands, once blocked, will eventually atrophy or die which can lead to permanent scarring of the glands inner architecture.

The image below is a scale commonly used at eyeLABS to classify the severity of meibomian gland atrophy (Meibo-Scale).  It is important that patients and doctors intervene early enough in the disease to prevent natural progression, which is certain if left untreated.  Eye drops do little other than cover up the symptoms.  Clinical clearing of the gland is the most effective treatment and LipiFlow Thermal Pulsation is the only FDA approved therapy for MGD.

meiboscale

Dr. Maharaj has treated patients from across the country and has profoundly changed lives by offering ground breaking procedures like LipiFlow and creating new and innovative maintenance therapies like his signature Lid Debridement technique.  eyeLABS is an instruction facility for doctors in training and Dr. Maharaj has trained other LipiFlow doctors at other Toronto clinics in its use and advances in the treatment of Dry Eye Disease.

If you know someone who complains of even mild ocular discomfort with or without contacts, watery and or burning eyes then do them a favour and refer them for therapy they deserve.

eyeLABS center for ocular surface disease is a referral based clinic.  Call 905-456-9333 or Fax referrals to 905-456-9332 to book a consultation.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Center for Ocular Surface Disease

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





Leaving a Legacy – The passing of Dr. William Samis

13 06 2013

The Montreal Gazette April 30th 1975On June 12th 2013, we lost a very good man and a groundbreaking surgeon – Dr. William Samis.  In 1975, he became  the first ophthalmologist in Ontario to perform phacoemulsification surgery for cataract patients and one of the first in the world to adopt this then groundbreaking technique and associated lens implants.  Indeed a visionary, he cultivated an environment which bred future leaders in the his field.  I joined his practice (partnered with Dr. Steve Arshinoff MD) in 2005 and was touched by his generosity as a human being, his style and sense of humour.  Unbeknownst to him, I absorbed a great deal from this man as an eye doctor and as a person through his words of wisdom and through the eyes of his patients, many of which I adopted after he stopped seeing patients from being ill 2 years ago.  Each an everyone would comment on his candor and caliber as a friend first, and a physician second and every last one would sing his praises as a surgeon decades after having had cataract surgery by his hands.

I like to think I’ve learned even an ounce of what this man had taught me and the many surgeons who walked through his doors or were privileged enough to have learned their surgical skills as his resident.

I have a hard time accepting that he is gone, however I have a harder time believing that for 6 years I was able to work closely with a true game changer – an individual who literally transformed modern eye surgery to make it faster, safer while producing better outcomes.    Some people wish to win a lottery – I believe I did.

My deepest sympathies go out to his family, his wife Jane, and dear friend and colleague Dr. Steve Arshinoff.  We were all in the presence of greatness.

RM





eyeLABS Turns 1: Happy Birthday!

4 06 2013

I just wanted to take a moment to thank my colleagues, patients, friends and family for supporting this exciting new clinic.  Today we officially turn 1.  This marks the beginning of a new year with new opportunities to treat and learn from patients and to evolve as eye care evolves.  eyeLABS has been fortunate to receive the accolades from the professional community with a growing group of referring doctors from both far and near.  Most importantly the patients that have entered our doors and who’s lives we’ve changed in the last year have demonstrated to me, my wonderful staff and colleagues alike that indeed we are changing the surface of the eye for the better.  Thank you so much!

 

As always –

 

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





Eye on Eyes: Irlen Syndrome, VEGF inibitors and a TED talk to guide better science

25 05 2013

Dear Readers:

This edition is a shift from the regular.  In conversations with colleagues and optometry forums I’ve decided to share some of the current conversations being had in optometry, ophthalmology and in medicine.  In this edition, I discuss Alberta’s Bill 204 which is a pending act that brings vision therapy and behavioural optometry into the spotlight.   Retina online published an interesting look at the incidence of nonfatal MI’s and how VEGF inhibitors may increase patient risk.  Finally, for those that know me know my frustration with faulty science and ‘counterknowledge,’  I share a video and encourage practitioners of all disciplines to look at Ben Goldacre’s TED talk on the subject.

In good health,

RM

Irlen Syndrome Testing Act Bill 204 in Alberta Legislature Second Reading

My friend and colleague Dr. Chris Schell (http://www.optometristbarrie.ca/) brought up an interesting piece of legislation in the Alberta government with respect to early learners eye screening.  This bill, also known as the Irlen Syndrome Testing Act, will call for School Boards to make available screeners for Irlen syndrome (including scotopic sensitivity syndrome and visual disturbance syndrome).

Section 3 is quoted below:

3(1) A teacher who recognizes symptoms of Irlen Syndrome in a student must recommend to the parents or guardian of the student that he or she be tested for Irlen Syndrome.

(2) Upon receiving written consent from the parent or guardian of a student, that student must be tested by a screener who is made available by a board under section 2.

(3) If a screener determines that the student may have Irlen Syndrome, the screener must advise the parent or guardian and indicate what corrective measures may be undertaken and if additional testing is required.

This bill is certainly an interesting step in the broader acceptance of vision therapy, however the increasing information on Irlen Syndrome  calls into question the syndrome itself.  Schiemann et al. has demonstrated that there is significant overlap in symptoms of Irlen syndrome patients and the majority (95%) have unresolved binocular vision and refractive anomalies (J Am Optom Assoc, 1990).  The ‘success’ of Irlen filters may be in fact indicative of  more specific binocular vision syndrome and the improvement by filtered lenses may be more of a provocative test than a treatment in my opinion.  So although the bill is well intentioned, I fear the shoulder’s that it is being rested on.

Click here to See Bill 204

Myocardial Infarctions following Intravitreal VEGF Inhibition
(Retina Online Vol 9 No. 5)

The authors of the following study sought to determine the risk of thromboembolic and gastrointestinal bleeding events in the 12 months after injections of bevacizumab or ranibizumab compared with photodynamic therapy (PDT) and a nontreated community sample.

They examined hospital and death records for 1,267 patients treated with vascular endothelial growth factor (VEGF) inhibitor and 399 patients treated with photodynamic therapy (PDT) attending Western Australian eye clinics from 2002 to 2008, and 1,763 community controls, aged ≥50 years. They also analyzed hospital records from 1995 to 2009 for history of myocardial infarction (MI), stroke and gastrointestinal bleeding before treatment. They searched records for evidence of these events in the 12 months after treatment.

The 12-month MI rate was higher for VEGF inhibitor patients than PDT and the community group (1.9/100 vs. 0.8 and 0.7, respectively), the authors reported. They observed no differences between patients treated with bevacizumab and ranibizumab, and the noted that the adjusted MI rate was 2.3 times greater than the community group (95% confidence interval, 1.2–4.5) and PDT rate (95% confidence interval, 0.7–7.7). The 12-month MI risk did not increase with the number of injections administered (hazard ratio, 0.9; 95% confidence interval, 0.5–1.5). Stroke and gastrointestinal bleeding did not differ between any exposure groups.

Although all of the adverse events examined were rare, patients treated with VEGF inhibitors were significantly more likely to experience fatal or nonfatal MI than the community group, the study authors determined. This increased risk may be related to the underlying age-related macular degeneration or vascular endothelial growth factor inhibitor use itself.

Source: Kemp A, Preen DB, Morlet N, et al. Myocardial infarction after intravitreal vascular endothelial growth factor inhibitors: a whole population study. Retina. 2013;33(5):920–927.

 Bad Science – a TED talk on Practicing Mindful  Medicine and Steering Clear of Counter-science

“It was the MMR story that finally made me crack,” begins the Bad Science manifesto, referring to the sensationalized — and now-refuted — link between vaccines and autism. With that sentence Ben Goldacre fired the starting shot of a crusade waged from the pages of The Guardian from 2003 to 2011, on an addictive twitter feed, and in bestselling books, including Bad Science and his latest, Bad Pharma, which puts the $600 billion global pharmaceutical industry under the microscope. What he reveals is a fascinating, terrifying mess.

Click the image to view


TEDBENGOLDACRE