Think your eyelids are clean?….REALLY! Introducing Clinical Periocular Hygiene

16 01 2014

Beauty is in the eye of the beholder. Beauty is skin deep. It’s what’s inside that counts.   These phrases gets tossed around, yet people all over the world eyelidmascaraare investing billions into the cosmetic industry now more than ever.  Men and women paint our faces and in particular our eyes to create the smokey, butterfly lashes that magazines and TV tells us we need in order to be ‘current’.   But what is happening to the tissue underneath that paint – what happens after the smoke fades away?  I can tell you from my years of clinical experience and research that the eyes aren’t very forgiving and what you’re not seeing is the decline and deterioration of one of the most important organs in your body.  Your EYES!

So after years of piling pencil liner, mascara, shadow, concealer to and around your eyes, despite your best efforts to remove all of it from the area with cleansers and patented lotions and potions, the eyelid is unfortunately ends up carrying the burden of harboring microscopic bits of make-up debris and builds a breeding ground for bacterial growth which results in an aggressive inflammatory cascade that is so sneaky that the symptoms fail to present themselves until the disease is in full swing.  That disease is LID DISEASE – it encompasses blepharitis, meibomian gland dysfunction, lid wiper epitheliopathy and more generally dry eye disease.

When is the last time you visited your dentist or dental hygienist for a teeth cleaning?  Do you brush your teeth everyday?  This concept of oral debrishygiene is well accepted and widely known that the consequences of not cleaning your teeth can lead to gingivitis and several other oral issues.  The eyelid, both upper and lower, are complex structures that have hair follicles, 2 types of differentiated skin and several glands all that are responsible for keeping your cornea nourished, clear and comfortable;  the windshield wiper of your eye so to speak.  Yet  despite the importance of this structure in keeping your vision clear and protecting the eye from infection and damage, we plaster foreign material that is in some cases toxic to this sensitive tissue and still expect it to last a lifetime?  Well what actually happens is the eye lid skin and glands (known as meibomian glands) go through a process called keratinization and atrophy.  Basically the devitalized skin crusts and grows irregularly over the gland openings as well as within the glands themselves, eventually leading to gland death in the long term.  These glands are responsible for adding the much needed oil your tears need to prevent evaporation of the tears, buffer the friction between cornea and eyelid as well as balance inflammation at the surface of the eye.  When this surface isn’t properly cleared of debris, the keratinization process is started leading to breakdown of this gentle balance that keeps our eyes comfortable and clear.  Some studies have shown that as much as 60% of adults have incomplete eyelid closure when blinking, a process that is meant to assist proper clearance of debris and epithelium from the lid surface.

damageWashing your face and eye area is important to minimize the small particles of makeup debris that can and will transfer into the eye, however the lid margin is an area that without clinical instruments is near impossible to clear with causing damage.  In fact, without specific vital dyes, similar to the ones your dentist uses to highlight plaque on your teeth, damaged tissue is actually very difficult to see even under a microscope.  Don’t be fooled when you look at your lids under a magnifying mirror and think all the make-up is gone or if you cannot see any dead skin build up.

A new innovative area in eye care is emerging to manage this preventable problem.  Dry Eye Disease is reported in scientific literature in as much as 1 in 3 adults in North America.  The problem with that number is many cases of Dry Eye Disease can be prevented by clinical periocular hygiene.  At eyeLABS Center for Ocular Surface Disease, various techniques have been developed and adapted to clean and clear this area with clinical precision and effectiveness.  A comprehensive clinical periocular cleaning is the most effective way to keep this structure healthy and hygienic to date and is a non-surgical treatment for this surface.  As clinical director at eyeLABS, our patients have benefited from  hundreds of clinical hours spent refining our non-surgical periocular techniques as well as developing new ones making our center a first of its kind facility with specialty services in periocular hygeine and treatments.  Lid margin debridement/scaling is a technique used to clear keratinized tissue after being highlighted with specific ophthalmic dyes at the eyelid surface.  Obstructed glands can be cleared which give the oils a clear path to the tear film using various expression instruments with gentle pressure being applied.  In many cases, thermal pulsation is used if the obstruction is too hardened for routine expression to clear.  This 12-minute procedure is the only FDA approved therapy for non-surgical treatment of evaporative dry eye and eyeLABS was the first optometric center in the country to acquire this technology.  Eyelash follicles and roots are known areas where bacteria and mites (Demodex) make a home and can accumulate.  This can lead to inflammation at the eyelash base which worsens the nearby tissue inflammation and damage.  Loss of eyelashes can be a sign of bacterial or mite infestation.  Up to 80% of blepharitis patients have clinically documented Demodex infestation, depite good at home hygiene.  BlephEx is a new treatment method that allows clinical removal and cleaning of this area.

Clinical periocular hygiene is a growing area of non-surgical treatments for the eyelid and periocular region which is a proven effective means of keeping the delicate skin of the inner and outer eyelid healthy and vital to preventing lid disease and maintain good comfortable ocular health. Wear and tear to this area can and does happen without makeup application as well.  Incomplete blinking, contact lens wear, environmental debris, certain medications and health problems (diabetes, thyroid, arthritis) all increase the burden to this area.  Men are just as vulnerable as women to this problem.

Like every new area of medicine, many doctors don’t even know it exists and may prescribe artifical tears, antibiotic drops, lid scrubs or other at home warm compresses and baby shampoo however none of these at home solutions are able to clinically treat this area.  Like brushing your teeth daily (or twice daily), professional grade hygiene is required for proper oral health.  The most effective therapy is a combination of good home hygiene and regular clinical periocular hygiene.  The next time you book a facial to ‘clear your pores’, consider doing your eyes a favour and booking a comprehensive clinical cleaning for your eyes.  They’ll thank you for it!

In good health,

Dr. Richard Maharaj OD, FAAO

Cinical Director,

eyeLABS Optometry and Center for Ocular Surface Disease

twitter: @eyelabsinc

A Tale of Two Cities: Treating the Travelling Corneal Abrasion

12 09 2013

The kids are back in school and hopefully everyone is settling into routines like an old man into  warm bath.  With our kids back to school and hopefully learning with perfect bilaterally corrected vision (having already been comprehensively examined by an optometrist), it’s time for Eye on Eyes readers to do some learning.

The case being shared in this article is not one of an unusual pathology, but the route of management.  It speaks to the capability and compassion of optometrists across the country in helping one patient to feel comforted in a time of uncertainty.  This 62 year old female presented for the second time in 4 months with a left corneal abrasion (see photo).  Image

She had underlying epithelial basement membrane dystrophy and had been using hyperosmotic ointment at night once a week previous to this incident.  On presentation the epithelium had a crescent-shaped break consistent with her fingernail that had accidentally brushed her cornea while rubbing her eyelid.  The surrounding loose epithelium (~3mm) layed above  3+ stromal edema which created a potential for a full circumscribed abrasion with the slightest touch or blink.  She was able to keep her eye closed until coming into the clinic 15 minutes after the incident.

Certainly a worrisome cornea with the potential for infection to set in, however there was no evidence of contamination of the wound and there hadn’t been a lot of time for the eye’s natural flora to cause further insult.  Managing this required wound protection and prophylaxis measures to prevent infection.  The monkey wrench was that this patient was flying to Calgary later the same day and I was left with a potential ulcer, scarring and related vision loss if this wasn’t followed promptly and compliance with my treatment wasn’t followed.

This scenario required some “outside of the box” thinking and in fact outside of the province thinking.  Luckily, my esteemed colleague, classmate and friend Dr. Dwayne Lonsdale who practices near Calgary (North Hill Optometry) was just a facebook message away and was available to follow up and be her on-call travel optometrist while she was in his area.   With the patient’s consent, I sent Dr. Lonsdale ( the above image (taken using my smartphone behind slitlamp) for reference and follow up until she could return to my care back in Toronto.

Once her travel-care was arranged, I placed a bandage contact lens on eye, provided her with  antibiotic topical coverage and Muro 128 qid + ung qhs and sent her safely into the slit lamp of another.  With recurrent corneal abrasions it is important to heal the wound first by protecting it from chronic insult.  In this case repeated mechanical trauma of blinking would cause this epithelium to slide right off and leave an open wound waiting for a biological enemy to invade and infect.  During this time treat with topical antibiotic coverage (4th generation qid) and hyperosmotic agent to reduce edema.

Dr. Lonsdale reported her progress and removed BCL by day 3 and wound recovery was excellent.  BCVA had improved from her initial 20/40- to near 20/20.  Once the wound had closed, a topical antibiotic/steroid was added to reduce inflammation further while retaining coverage.Image

On returning from her trip to see me, her prescribed medications were reduced to hyperosmotic ointment nightly and non-preserved 1% hyaluronic acid to replenish the epithelium.  She is fully recovered and eternally grateful for the care she received at home and while travelling in Canada.  We are discussing options to prevent further RCE by using oral doxycycline combined with hyperosmotic ointment nightly to reduce ocular surface inflammation.

What is interesting here is that without smartphone anterior segment photography, social network communication and the close optometric community that we have, I would not have been comfortable with this patient travelling and would have cautioned her to postpone this trip.  Leaving a BCL on an eye with an open wound with the potential for an opportunist infection and sending her on a plane without confirming receptive eye care on her arrival would be a liability to say the least.  But instead she travelled confidently, she healed and we all learned what is possible when people work together.

Here’s hoping our kids will learn to do the same this year!

In good health,

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

twitter: @eyelabsinc

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.

twitter: @eyelabsinc

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

Just another BRVO?

21 05 2013

A 39 year-old male of South Asian decent reported to the clinic reporting blurry vision in his right eye starting 3-4 days previous.  Vision measured OD 20/50 OS 20/20 (uncorrected – this patients was previously 20/20 OD and OS).  Patient history revealed self reported ‘mild’ hypertension which was not medically managed nor had it been indicated in previous visits with his primary care physician.   IOP was 17 mmHg OD/OS and pupils were normal.  Flurescein angiography study showed no ischemia, however a conservative approach was taken to monitor the macula edema for resolve rather then consider anti-VEGF or therapeutic laser options at the time.

Fundus photo and OCT are shown below OD as well as contrast sensitivity testing.

ODBRVOwMEThe BRVO and to a lesser extent the macular edema is obvious on fundus examination.  On closer inspection though another area off inferiorly and nasal to the disc shows vascular retinopathy in the form of a cotton wool spot and nerve fibre hemorrhages.  This is not associated with the BRVO and signals the chronicity of his systemic hypertension which resulted in an interesting turn of events for this otherwise carefree individual.

Macular edema2ndBRVO

The OCT of the macula  clearly shows the cystic edema associated with this inferior BRVO.  Because of its inferior location this fluid will likely drain away from the macula and be reabsorbed in natural course.

Notice the difference in CS vs. SF curve.  This test was done for monitoring purposes only – it was not a diagnostic test.  It was needed to monitor the quality of his vision in this case as the fluid reduced at his macula.  The retinal surgeon and myself  will rely on this in addition to his objective findings downstream to help in guiding treatment options in the event of poor resolution of edema.


Follow up and Discussion:

From a bird’s eye view, I would say this case is worthy of follow up but not a unique set of findings.  What followed was however very interesting.  I examined this patient on a Thursday.  I called his family doctor but was unable to speak to her.  I sent a report and advised to follow up on his hypertension at next visit which turned out to be the next day.   This patient was very proactive and I would argue, his proactive nature helped to save his own life.   Serial BP testing demonstrated an avg BP of 180/160 and the final measurement of the day climbed past 200/180 sending this patient to the emergency room at the local hospital.  He was admitted to CCU over the next 3 days in an  attempt to urgently reduce his risk of stroking out and to steer this patient away from certain death.  After an intense 3 days his BP had come down to 130/85 in response to his medical therapy and it was maintaining.  The patient reported  that his multiple daily headaches had stopped and his quality of sleep was markedly improved.

I am following him regularly until complete resolution, however I believe there is a lesson learned here.

Better communication – For years, this  man was told he was ‘fine’ but had mild hypertension.  His cultural background supported a holistic approach to managing one’s body.  Through mind and inward discipline he was confident that he was in good health.   He hadn’t followed up regarding the ‘mild’ hypertension for at least 2 years because it wasn’t a concern for his doctor so why should it be a concern for him?   In fairness, there was no way to predict that he would suffer from hypertensive crisis years later so the ‘see your doctor when there’s a problem’ approach seemed prudent here.

My communication as his eye doctor to his family doctor was difficult and I haven’t yet received a report on this potentially critical patient whom I referred for urgent care.    To be clear I don’t believe this to be a problem with this doctor specifically but with the system at large.  This is what I believe needs to change.  How we relay information to each other; whether it is two teenagers tweeting their breakup because of broken communication or a doctor to her or his patient or physicians reporting over the care of a patient we are all too busy, too slavish to outdated protocol, too pre-occupied with all about us to listen.

For this lucky young man, I suspect he is listening to his body more than ever.  He told me he and his wife are finally going to take their honeymoon which is years overdue and will slow things down a little at work.  For the record I am biased to the sense of sight,  but I think we could all do a little better to listen to the world around and within us.

In good health,

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

twitter: @eyelabsinc

Counterknowledge: “I only wear my contacts ‘once in a while’ so I usually replace them every 2 to 3 months”

20 02 2013

Do you drink milk past the expiration date?

Not likely, and if you do you’re probably not happy about it.  Contact lenses are tiny thin pieces of hydrated plastic that, like every other material in the world, are not impervious to getting dirty.  Despite pharmaceutical companies’ best efforts to create the perfect cleaning systems, even the best cleaning agent (hydrogen peroxide based systems) for both contact lens and ocular surface still doesn’t clean everything.  Protein sticks to the contact lens surface and over a period of days to weeks will denature or break down.  This denatured protein does not agree with the ocular surfaces  and can cause a host of complications that may not have immediate symptoms or signs.

17 million people in the US alone have Contact Lens Induce Dry Eye or CLIDE (Ramamoorthy P, 2008).  The peak age of contact lens wearers is in the mid-20’s and Brampton-20130205-00310

How often do you change your oil in your car?  How often do you and your eye doctor discuss  your eyes oil and how it relates to contact lens comfort and every day optical optimization?  Japan is home to the world’s highest number of LASIK surgeries performed at Shinigawa LASIK centers with over 1 million surgeries to date.  In order to optimize visual and surgical clarity each patient undergoes LipiFlow thermal pulsation, a new standard for treating ocular surface disease – specifically dry eye.  In December 2012, Shinigawa set a new standard in LASIK by treating 1000 patients with the LipiFlow system.   This precedent shouldn’t be isolated to those paying for premium refractive surgery.  The amount of money you invest in contact lenses over a lifetime is likely more then you would pay for lasik, so why does the ocular surface not matter as much?

Proper maintenance and therapies for you eyelids, cornea and contact lenses are crucial for comfortable clear vision but the wide and sometimes careless availability of contacts through online stores and big box environments have turned contacts into a commodity and with that comes this pitfall – ‘If I can shop around for the lowest price like a pack of gum then it must not be worth taking care of.  Right?’  But are your eyes a commodity that is as easily replaceable?  If you knew 10 years from now that you wouldn’t be able to tolerate your contact lenses would you do something different today?

Here’s what you can do:

1) Wear single use lenses otherwise known as daily disposables   Get rid of your case and solution and use it once and then toss it.  The healthiest contact lens is no lens at all.  The second healthiest is a daily disposable – sterile fresh lenses in the eye every day.

2) Treat your eyelids well – if you wear make-up, smoke, work in an office or use a computer for more then 4 hours a day then statistically your eyelids and blink are likely to be contributing to lid disease down the road.  Talk to your doctor about ocular surface health and options for maintaining it.  How often do you get a facial?   Your eyelids deserve the same!

3) Don’t shop downwards.  Consider your contact lenses and vision choices the way you would consider LASIK – you would make your decisions based on risk, doctor experience, equipment safety and statistical likelihoods first before looking at price.  Just because you can find them cheap online, does not mean they were created equal.


SideNote: LipiFlow is available in Canada

LipiFlow is the only FDA approved in-office procedure that has demonstrated clinical effectiveness in treating the ocular surface, specifically meibomian gland dysfunction (MGD).  Although offerred to pre-operative patients going through lasik and cataract surgery in large refractive surgery centers, eyeLABS dry eye clinic is dedicated to the ocular surface  and is located in Brampton, Ontario.  A 12-minute non-surgical procedure has provided patients with relief of symptoms for up to 15 months as reported in clinical trials.  Making this available to everyone will make a difference to contact lens wearers and non wearers alike – Dr. Maharaj is the first optometric clinic in North America to acquire this technology.  Call 905-456-9333 to discuss your dry eye options.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

twitter: @eyelabsinc

Counterknowledge: Will wearing my glasses make my eyes worse?

29 01 2013

The answer:  NO!

Countless patients, particularly parents of my pediatric patients, report reduced wearing time or frequency of spectacle wear in order to prevent their eyes from weakening.  Somehow, the urban legend that ‘wearing glasses too much will make my eyes worse’ has perpetuated through the hallows of time and has blossomed into a weed that I and many colleagues are constantly trying to eradicate through education.

Let’s look at an analogy – Does wearing your shoes 2 sizes too big make your feet bigger?  Does not wearing shoes make it easier for you to walk?  Does making it easier for you to walk make your legs weaker?  These all seem like ridiculous questions, but it is this rationale that people rely on when thinking about wearing eye correction.  It just isn’t true or supported by scientific evidence.

Now there is some evidence that a low level of uncorrected nearsightedness (myopia) may be beneficial for close work and not using eye correction for these instances may have a positive impact on myopic progression, however by and large this theory is still being tested.

Some people who have binocular vision development issues require more intensive direction as to when and when NOT to wear glasses.  In these cases your eye doctor will communicate this specifically during your examination.

When parents unilaterally make the choice to reduce the wearing schedule for their kids based on this urban myth,the effects on visual development and subsequent academic performance can be significant.  80% of our learning comes from visual learning and not having optimal vision has far reaching, and a well documented negative impact on educational development.  Often I hear “my child’s eyes are lazy so I just want them to work harder.”  My advice to anyone that has said this or been told this is to really think about this concept.  More importantly, as eye doctors our goal is to use evidence based approaches in tandem with our extensive knowledge of the visual system to make a judgement on how to treat your eyes and vision.  The recommendations of your eye doctor are not made on a whim and are prescribed for your specific visual system based on your exam findings.

Bottom line – Wear them and wear them often.  Give your brain the vision it craves.  The clearer an image is focused on the retina, the better the resolution of the visual stimulus to the brain.  This means that the neural network developing between the photoreceptors in the eye to the optic nerve to your brain is more intricate and allows a better potential for vision.  Some people end up feeling their uncorrected vision becomes worse after wearing glasses for some time.  What is actually happening is your brain is getting used to 20/20 and is preferring it.

  • A quick test:  To know if your vision is truly getting worse try this.  Put your glasses on and stand 6 kitchen tiles away from your digital clock on the microwave or stove.  Cover each eye and read the time.  Use this as your baseline and compare it monthly in exactly the same manner.  If the clock becomes blurry WITH GLASSES ON, then your vision has changed.

To play devil’s advocate I understand that it is conceivable that because your doctor dispenses glasses that you may consider his or her recommendation to wear them self-serving.  If you feel this is the case, then seek out a second opinion and validate (or rule out) your concern.  Steering yours or your child’s visual management based on misinformation is dangerous, no matter how many times you read it on the internet or have friends that ‘have the same eye problem.’  No two eyes are the same – not even your own!

Here are some points to clarify with your doctor when being prescribed glasses:

  • Frequency and Duration: When and for how long should I wear them?
  • Alternatives:  What other vision correction options do I have?  Contact lenses?
  • Adaptation:  What are normal symptoms should I expect when wearing my glasses for the first time?  What is considered abnormal?

sidenoteSideNote: Online shopping

The next time you consider purchasing your eye wear online, consider this:  Who is responsible if something goes wrong?  What value do you place on the service that comes along with your eye wear.  For some, this point may be moot however anyone that has had trouble adapting to the vision of a new pair of glasses or a new snug frame will tell you the value of having your optometrist or optician provide the ophthalmic service is worth it.  If you’re willing to give up service then consider a September 2011 study by a research professor at Pacific University College of Optometry in Oregon that found that 44.8% of eyewear ordered online FAILED at least one parameter of optical or impact testing (Click here to see study).

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

twitter: @eyelabsinc