Do you suffer from acne? Bumps on your eyelids can be a sign

21 01 2014

zitDo you suffer with zits or chronic acne on your face or elsewhere on your body?  Are you obsessed with having and maintaining clear skin?  If you don’t already know, a zit or a pimple on your skin happens when the oils in your pores are trapped, built up and harden.  Your ‘pores’ on your skin are actually called sebaceous glands and are oil producing glands that give your skin the glowing complexion.  Irregular production and secretion of these oils can be caused by dirt from your hands and makeup and lack of proper cleaning of your skin from dead tissue or built up debris.  When these glands, or pores, become obstructed the skin tissue becomes inflamed turning red swollen and sometimes painful.  This inflammation is the body’s response to local trauma.  Now this isn’t the trauma caused from a hit or a poke, but microtrauma induced by the trapped oil and debris pushing on the surrounding wall of the gland and skin.  Some people with certain skin types have a strong inflammatory response which in biology is known as the triple response (of Lewis) which consists of:

  1. Red spot: due to small capillary dilatation
  2. Flare: redness in the surrounding area due to arteriolar dilatation
  3. Wheal: due to leakage of fluid from capillaries and venules

Those with a stronger response will be more likely to have stubborn acne that has limited responses to commercial products.  These cases usually require a skin specialist (dermatologist) to treat it medically.  People with eczema, asthma, psoriasis and rosacea (to name a few) are known to have a hypersensitive triple response.

meibglandNow that you understand what causes a pimple, you should also know that those sebaceous glands found on your skin are also found in your eyelid and are slightly modified to secrete oils for the eye’s surface.  Each eyelid contains 20-40 of these glands and have a very specialized function.  These glands are called meibomian glands and react the same way the pores on your skin react to debris, dirt, bacteria and general trauma.  What’s different about this area of the body however is that your eyelid is constantly moving and wiping away environmental debris from the ocular surface.  If you are a contact lens wearer, then it is also rubbing the plastic of the contact as well causing friction on the inner eyelid.  Considering what we know about trauma and what it does to our glands, imagine that this microtrauma happens every time you blink, every time you apply make up, every time you wear a contact lens and every time your eye is exposed to environmental debris.  That is pretty much every minute of every day!   The average human blinks seven to ten thousand times a day and for those people that have a heightened inflammatory response are more susceptible to the meibomian glands becoming obstructed which can lead to an eyelid pimple otherwise known as a stye.  These styes can get very large if untreated and become chalazion or an eyelid cyst which can in some cases require surgery.  Interestingly, a stye only happens when the blockage has gotten large enough to become visible to the human eye.  The blockage usually starts long before it becomes visible externally.

Unfortunately though, these meibomian glands are few and once blocked or inflamed can quickly become dysfunctional and die off. happysad The eyelid surface is uniquely situated close to the eyelash follicles.  Naturally occurring bacteria often accumulate in high numbers in this area due to built up dead skin, makeup and environmental debris.  This surface cannot be cleaned by commercial products with the precision required without causing harm to the eye (cleanser in the eye, removal pads can abrade the cornea, etc.).  Also the inner eyelid tissue known as the wiper is too sensitive to touch or use retail cleaning agents on without causing pain and or damage.  Basically this tissue is never really cleaned and these glands are under constant burden.

Your eyelid glands are just like your skin glands and need clinical attention to keep them functional and prevent meibomian gland dysfunction which causes up to 86% of dry eye disease patients.  In many cases it is a preventable condition, but only recently has clinical periocular hygiene emerged as a new effective maintenance treatment.  Using special dyes and instruments, the eyelid surface and glands can be treated comfortably in your eye doctor’s office.   New advances in this area allow even the most hardened blockages to be melted using prescribed heat and pressure simultaneously (LipiFlow thermal pulsation) in non-surgical painless procedure.

Bumps on your eyelid are exactly the same as pimples on your face, however the consequence of not treating it or preventing it are potentially vision threatening.  If left untreated eventual gland death can occur decreasing the stability and vitality of your tearfilm.  This puts the entire surface of the eye at risk for infection, chronic inflammation and even scarring of the conjunctiva or cornea.

Experts from around the world have now recognized meibomian gland dysfunction as being perhaps the most pervasive cause of dry eye disease around the planet.  These tiny delicate pores have a huge impact on our visual health.  Talk to your eye doctor about your glands and be proactive.  Having dedicated my career to the ocular surface and spending the last 2 years specifically developing treatments in this area, my advice is:  don’t let the symptoms start!

In good health,

Dr. Richard Maharaj OD, FAAO

Cinical Director,

eyeLABS Optometry and Center for Ocular Surface Disease

twitter: @eyelabsinc


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!

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.

twitter: @eyelabsinc

25.8 Million US with Diabetes vs. 23 Million with Dry Eye Disease

16 05 2013

In June 2012, eyeLABS center for Ocular Surface Disease became the first optometry clinic in Canada to offer LipiFlow Thermal pulsation treatment – the only FDA approved treatment for evaporative dry eye.  eyeLABS is a unique facility because we don’t sell glasses – we manage the ocular surface of patients far and wide and we do so with an array of options that allows for a customized approach to managing a very complex disease – Dry Eye Disease.

eyeLABS year 1 clinical results:

Looking  just over 100 eyes treated using a combination of LipiFlow, lid management techniques, and medicine we have achieved a 90% rate of significant improvement in clinical signs and patient symptoms, 8% with mild to moderate improvement and 2% minimal to no change.  This was defined in our clinical study by validated patient symptom scores, gland scores, corneal staining, tear film break up time and visual acuity.  As a result we continue to educate as many physicians and patients as possible about the shift in approach of managing dry eye from exclusively cornea to the eyelids and glands.

Prevalence of DED vs. Diabetes

According to NDEP (National Diabetes Education Program) there are 25.8 million Americans living with diabetes.  According to a Marketscope 2011 Comprehensive Report on the Global Dry Eye Products, there are 23 million patients living with Dry Eye Disease.  Of course the comparison in the impact of two diseases on the body isn’t fair, but the impact on quality of life (QoL) is eerily similar.  A 2012 study examining 87 dry eye patients and 71 healthy volunteers found that vision-related QoL in dry eye patients was impaired and was correlated with anxiety and depression( Li, M Invest Ophthalmol Vis Sci. 2012 Aug 17).  Countless studies examining QoL within the diabetic subset show strong correlations to anxiety and depression due to the daily burden of medicine, monitoring and management.

Dry eye is too often dismissed by physicians as insignificant and ‘not as important’ as other ocular ailments like cataracts or glaucoma and patients have become embarrassed to mention it.  In fact, when eyeLABS Dry Eye Clinic patients were surveyed, the most common reason for not talking about dry eye with other doctor was embarrassment.  Embarrassment that their doctor wouldn’t think it was important.  Interestingly all patients reported social anxiety about the cosmetic appearance of their red eyes to colleagues, family, friends etc. and had sought out medical attention to treat the anxiety as a result.  eyepicture

The social impact of these two diseases are  far-reaching.  Given that the prevalence of the disease is near equivalent why is it that dry eye is swept under the rug?  It is possible that medical options of dry eye have been limited and expert agreement on the cause is divided has resulted in doctor’s complacency towards this growing epidemic.

Being in the position that I’m in seeing dry eye and ocular surface day in day out I can say that this condition does deserve attention and undivided attention at that.  My patients are physicians, teachers, celebrities, pilots, mothers, fathers and and they have all opened up about the anxiety that dry eye has caused them.  One might assume that those listed above are ‘professionals’ and would never leave the disease to take over their lives but many  patients have even considered suicide prior to having treatment because of how limited their lives had become.   For the first time they have had relief and I feel grateful for the opportunity to change their lives.

When one considers the impact of a disease on mental health, the mental health should be then considered a co-morbidity.  Diabetes, Dry Eye Disease and many other ailments all have the common denominator on reduction in quality of life and an increase in depressive and anxious tendencies.  Almost 50 million Americans share this common denominator between diabetes and dry eye, but those with dry eye don’t have nearly as many resources for dealing with their condition.  Considering the success I’ve had with my patients in this last year, I submit that we can do a better.

In good health,

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

twitter: @eyelabsinc

CBS The Doctors, featuring LipiFlow

6 05 2013

Click here  to view CBS, The Doctors – featuring LipiFlow

On May 6th 2013, CBS aired an episode of The Doctors, which highlights the revolutionary LipiFlow Treatment to the masses. eyeLABS is proud to be the first optometry clinic in Canada to offer LipiFlow treatment in an environment that is exclusively dedicated to the ocular surface – not LASIK, or other refractive surgery – just dry eye. Call 905-456-9333 or visit to see if you are a candidate.

Got Dry Eye ?

12 12 2012


100 million people globally suffer with dry eye. Lid disease has been shown to be a major culprit behind dry eye.

Getting Closure: Exposing the Eyelid Overbite

28 11 2012

Blinking has always been known to have 2 purposes: 1) to clear away debris from the tear film and 2) to replenish the tear film to allow the cornea to remain a clear optical surface.  When we sleep, conventional wisdom suggests that the eyelids meet halfway and form a seal that prevents exposure of the cornea throughout the night.  Nocturnal lagophthalmos is an anatomical state whereby the superior and inferior lids fail to meet resulting in exposure of the conjunctival and corneal surfaces at night.  These patients typically present with symptoms of persistent dry eyes, recurrent corneal erosions, and often have a psychological impact due to constant questioning of their red eyes by family, friends and co-workers alike.   There is evidence that suggests that in the general population 1.4% of patients have some form of lagophthalmos.

A deeper look at the finer anatomical structures of the eyelid suggest that our blinks have a different purpose, and in fact may not be as efficient at closing the gap on our dry eyes.

Figure 1. Gross anatomy of the eyelid

The lids meeting is contingent on the anatomical reach of of lids, but as important is the seal created by the meeting of the superior and inferior line of Marx (LOM).   With reduction in lid laxity with age, changes in lid tension by blepharoplasty and less frequent and deliberate blinking with computer/smartphone/tablet use this ‘seal’ is not always present.  The result is an eyelid overbite, where the upper eyelid falls slightly anterior to the lower eyelid causing the LOM’s to miss each other and therefore no true touching of the upper lid to the lower lid.  An often overlooked function of the blink is to create a negative pressure to draw meibum or oil out of the meibomian glands (MG) when the lids touch.  If they don’t touch, then this negative pressure cannot stimulate expression of the oil from the gland and will create an oil deficient eye, susceptible to evaporative dry eye (EDE).  Over time, inactivity or reduced activity of the MG will result in stagnation of meibum and MGD ensues. Clinically, we can see this in various degrees within the symptomatic patient, however the asymptomatic patient has signs as well.

How can a practitioner determine if the lids are meeting microscopically?  Using a slit lamp and looking for smile staining on the cornea/conjunctiva  means looking for chronic signs of exposure, which aren’t always there in the early stages.  There is an onset of physiological changes within every disease and a simple use of a transilluminator will reveal a very telling sign.  Dr. Donald Korb OD FAAO, has used this technique in practice for years and it is now incorporated into every consultation I see in my dry eye clinic.  The example below demonstrates  the ‘light leakage’ sign indicating a break in the seal of a blink.  On SLE, this patient appears to have good closure and no obvious staining patterns were associate, however she presented with severe dry eye symptoms but normal aqueous production.  On identification of the broken seal, she was tested for non-obvious MGD (NOMGD) and lid wiper epitheliopathy (LWE) which was confirmed.

Figure 2. Leaking Light – sign of incomplete lid seal between upper and lower eyelid

This is the eye-equivalent of an overbite and is a telling indicator of exposure and potential future MG dysfunction.  These patients benefit from exposure therapy such as moisture chamber goggles, hyper-viscous topical agents at night, manual lid expression and regular assessment of the lid wiper and line of Marx for epithelial changes and accumulation.  Compression on the lid of  these patients should be done with caution as fine debris can enter the broken seal and abrade the cornea as well patients should be educated on corneal warpage post compression.

The micro anatomy and complex coordination of a blink can and in fact does break down with age, cosmetic surgery and with environmental factors.  Closer evaluation of the lid surface as it relates to chronic disease progression doesn’t require symptoms to be present.  The role of the primary eye care physician is to provide front-line care which helps in the prevention of eye disease.  Dry eye, having a population of 100 million globally , as stated by TFOS in 2011 may have it’s roots firmly planted in the lid.

In good health,

Dr. Richard Maharaj OD, FAAO