20/20 isn’t everything: See why every child MUST have a comprehensive eye exam to prepare for school

17 10 2013

Dr. Richard Maharaj and Dr. Chris Schell demonstrate some common vision problems that children struggle with everyday in the classroom. A very important message on why comprehensive eye examinations (not a vision screening) must happen for each child prior to (or at the very least, as soon as possible) school age. Vision screenings are well-intentioned, but as shown in the video, may miss these subtle diagnoses and give parents a false sense of security. Their little eyes are starting a 12+ year marathon which will serve the basis of learning.  You wouldn’t run a real marathon without preparing your muscles and endurance would you?  Why do we assume newly developing eyes should be treated with less concern or preparation.  See a Doctor of Optometry for a comprehensive eye examination.


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


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