Why Our Kids Can’t See…

 

Two words: myopia and amblyopia.

Amblyopia

My daughter recently had her 18-month check-up at the pediatrician’s office and at the end of the exam, the doctor mentioned her dental health and the importance of a dental exam but made no mention her ocular health or the need for an eye exam. Being an eye doctor as I am, I inquired why they did not recommend eye exams? With a puzzled looked, my pediatrician, whom we love dearly, mentioned they will not regularly refer a child for an eye exam unless a problem is noted on their (rather limited) ocular evaluation. On that note, I took the opportunity to review with our doctor the need for early intervention as there are subtle defects that cause visual loss and if left untreated cause permanent vision loss. He probably didn’t enjoy the lecture in the middle of his morning schedule but he seemed to understand and took it in stride.

Eye exams are crucial for detecting small discrepancies in vision that could leave a lifetime blur if not corrected early. While pediatricians do an excellent job in the primary care of a child, their ability to diagnosis subtle eye turns and refractive error is limited. This is not due to any fault of their own—they are not trained to find visual deficits as small as those that can cause permanent visual loss.

The sneakiest of the bunch is amblyopia—the leading cause of vision loss in children. Amblyopia also is known by the terrible term “lazy eye,” is decreased vision in one or both eyes not due to ocular pathology but by a poor connection of the eye to the brain. During development, both eyes need to see clearly and focus together. If there is an eye turn (strabismus) or blurred vision due to uncorrected nearsightedness or farsightedness, the eye will not make a strong connection with the brain and will have permanently reduced vision if left untreated.

Ever notice those cute little babies in eyeglasses? Not all of them presented with eye turns. Although an eye turn is obvious to parents and will raise suspicion to have it checked, it is a difference in refractive error (i.e. glasses prescription) between each eye that can fly under the radar and cause amblyopia.

Fortunately, we can treat amblyopia but it has to be caught early. After the age of 5, the rate of successful intervention starts to decline due to the hardwiring of the brain.

To prevent amblyopia and other risks to your child’s vision and health, the standard of care for your child’s first eye exams is at age 1. Yes! Even at 12 months, we can pick up, not only refractive errors but congenital variants and cancers such as retinoblastoma.

Myopia

Myopia, also known as nearsightedness, has increased substantially in the US and has effectively doubled in the last 3 decades. This is a pandemic, meaning not just in the US, but worldwide.  Recent research attributes a number of factors to this including the usual suspects like genetics, but also the increased near activity of children (think tablet and iPad use) and reduced outdoor activity. Researchers believe the problem lies in not extending focus beyond near objects and the absence of natural light. You can read more on this on our ”Nearsightedness– Can We Defeat It?” (create hyperlink) blog post.

Through ongoing research, a number of treatments that slow the progression of myopia have been developed and we do have those available at Carolina Eye Doctors.

We can intervene and treat in a number of ways. Two of the most effective treatments are through pharmaceutical and optical pathways. The Atropine for the Treatment Of Myopia (ATOM) study and the Low-Concentration Atropine for Myopia Progression (LAMP) Study have shown that using low concentration atropine eye drops can significantly reduce myopia progression.

Another tool we have to substantially reduce progression is corneal refractive therapy (CRT). This treatment falls under the term “orthokeratology” which entails application of a gas permeable contact lens. This lens is worn overnight to induce temporary changes in corneal curvature, allowing for clear daytime vision without glasses or contact lenses. Although these lenses were designed for the correction of refractive error, studies have shown a secondary advantage of slowing myopic progression. So it’s a great two-for-one benefit.

Take-Home Message

While two of the most common causes of children being unable to see (myopia and amblyopia) can be treated, they first must be diagnosed. And the earlier the better. We recommend eye exams at 6-12 months of age, age 3, just before they enter the first grade — at about age 5 or 6—and every year thereafter. Visual conditions are the leading cause of poor learning and classroom performance. Caught early, they can be diagnosed and treated, optimizing your child for learning and preventing common educational delays.

Eye Health – The Key to Squaring the Healthspan Curve 

Eye Health – The Key to Squaring the Healthspan Curve 

With the birth of our first child, I started thinking about longevity and how to make my life last as long as possible. Not just long, but healthy.

This is the concept of lifespan vs. healthspan. Your lifespan is the length or “span” of your life. Healthspan is the length of time in your life that you’re healthy enough to get the most out of it. The idea being that lifespan doesn’t matter much if you are too sick or disabled to enjoy it.

 

We Need to Square the Healthspan Curve

Healthspan Curve

Check out the graph here. As we get older, and time goes on, our health slowly deteriorates. “Squaring the curve” means keeping healthy and active through the years and only at the end of your life, just before you die, does your health decline quickly. The line becomes more of a square than a curve.

However morbid, the idea is that you make the most of the years you have.

The three principals crucial to squaring the curve (as well as achieving long life) are good nutrition, sleep and exercise. You get these three right, and you’re on your way not only to a long lifespan but a squared healthspan as well.

 

Your Eyes and Vision – Crucial to Squaring The Curve

Maintaining your eye and vision health may be the most critical aspect in squaring the healthspan curve. If you lose your vision, your quality of life suffers incredibly. Losing your eyesight in the last 10 to 20 years of your life will dramatically impact what you are able to get out of it.

 

What To Do

The 3 principals to keep your eyes healthy (besides the aforementioned nutrition, sleep and exercise) are:

  1. Don’t smoke. Easy enough to say but hard to do if you’re a lifelong smoker. But quitting is a twofer. Because no smoking is a real close #4 on the health principles above and has been linked to everything from cataract to macular degeneration, quitting gives you double the benefit to your eyes AND your overall health.
  2. Wear sunglasses. Along the same lines as smoking, sunlight can damage your eyes just the same- by creating free radicals and instigating oxidative damage. The high energy of UV light causes damage to the retina that eventually leads to macular degeneration- the number one cause of blindness in those over 65 years of age in the United States.
  3. Get an eye exam. The problem with eye disease is that it is slow, without symptoms and only noticeable when it is too late to treat adequately. There are two poster children for this- glaucoma and dry eye disease. Both need to be caught early and, if they are, can be treated before they cause blindness with the former and unrelenting pain in the latter.

Of all your senses vision is the most important and, indeed for many, almost as important as life itself. Keep it healthy and it will go a long way in squaring your healthspan. Ignore it, disregard it or take it for granted and, unfortunately, it will catch up with you down the line.

Dr. Tarbett’s Thoughts As The White House Eye Doctor

After spending 9 years as the eye doctor for the White House Medical Unit (WHMU), I’ve been asked a lot of questions. One of the most common is, “What do you think is going on there now?” I’m assuming they’re wondering this because the current administration is rather unconventional with a non-establishment president, unorthodox methods and, of course, the tweets. Truth is, the WHMU is probably running exactly the same as it always has – like a well-oiled machine. The White House Medical Unit is tasked with providing healthcare to the President, the First Family, Cabinet members and other government officials. Most of the WHMU staff is military, following regimented protocols and procedures. So, while across West Executive Avenue it might be chaos, the clinic is running smoothly.

The fact is, all presidents are in the news. All the time. There always seems to be high stakes and drama, no matter who is in office. During my 9 years there, it was Bush and the Iraq War, Obama and Obamacare. Now it is Trump and the Wall. There is always a focus on the White House, but you can be sure the military will continue to run the White House’s medical care with the consistent precision it runs all operations. And as far as the WHMU goes, I can tell you, the folks there will always be professional, dedicated and focused on providing the best care.

I was not in the military and will never hold that honored title of “Old Soldier.” I was a civilian and became the White House eye doctor (or the more official term, “Optometry Consultant to the White House Medical Unit”) probably as a matter of luck as much as proficiency in my profession. The majority of my career I spent at Walter Reed Army Medical Center. Before it closed and combined with the National Naval MedicalCenter (creating the Walter Reed National Military Medical Center), Walter Reed had “Ward 72,” a VIP suite that would care for high ranking military and civilian officers of our government. The White House Medical Unit doctors and I would provide eye care for these folks, and so I got to know the WHMU staff pretty well. And when the outgoing White House eye doctor and my boss recommended me for the job, they offered me the position, which I gratefully accepted.

My time at the White House covered the years 2006-2015, the tail end of the Bush administration and the bulk of the Obama administration. I got along great with both presidents and hope, in time, to share some memories and stories. I have admiration for both and a great appreciation for the office of the President Of The United States. No matter who holds it, it is a never-ending beat-down of second-guessing, derision and ridicule, and to occupy the office takes a fortitude that I respect, even though I may not agree with everything being done. Abraham Lincoln, one of our greatest presidents who took tremendous punishment from all sides, was summed up best by a quote from abolitionist leader Frederick Douglass: “Viewed from the genuine abolition ground, Mr. Lincoln seemed tardy, cold, dull, and indifferent; but measuring him by the sentiment of his country, a sentiment he was bound as a statesman to consult, he was swift, zealous, radical, and determined.”

Sometimes, it takes time and perspective to fully understand a President’s contributions and place in history. I’m just honored that I could meet and serve a couple of those remarkable men and, through my small role, help them be their best so they could serve our country.

A Dry Eye Discussion with Dr. Garcia

If your eyes have been feeling a little more gritty, sandy or dry than usual, you’re not the only one. As we get cozy inside and turn on our heaters, the humidity and moisture our eyes love starts to drop. Irritation then starts to kick in making dry eyes a symptom we hear on a daily basis.

If you have ever been diagnosed with dry eyes you know it can be much more uncomfortable than it sounds. Dryness is not as benign as one would think. The cornea is the only organ in our whole body without blood vessels and it relies both on the quantity and quality of our tears to provide adequate hydration, oxygen and nutrients. If the cornea is not properly hydrated, decreased vision, persistent redness and ocular discomfort occurs.

Tear chemistry

diagram of the tear film layersTears are made of three components.

The lipid/oil layer
Where our eyelashes insert into our eyelid there are about 30 tiny little oil producing glands called meibomian glands. They secrete the oil or lipids necessary to prevent our tears from evaporating.

The aqueous/water layer
Our lacrimal glands provide the foundation for the middle layer- the aqueous or water layer. This layer contains all the nutrients, such as salts and minerals, our eyes need to maintain a clear and comfortable surface.

The mucin Layer
The inner most layer is made of a mucus that acts as glue to keep the tears on the cornea and maintain a smooth and consistent tear surface.

What’s going on?

While there are many known causes for dry eye including environmental and hormonal factors, we now know the majority of dry eye can be divided into two categories- Evaporative Dry Eye and Aqueous Deficient Dry Eye. The majority of dry eye patients suffer from Evaporative Dry Eye, related to a deficiency in the oil production of the meibomian gland.
As mentioned, the oil maintains the integrity of the tears and if there is not enough of it, the tears will break up quickly and evaporate, leaving the burning, gritty irritation of “dry eye.” Most concerning, if the meibomian glands are placed under long term stress they will stop producing oil. This results in the year over year worsening of symptoms due to the chronic and progressive nature of dry eye disease.

What can we do?

Thanks to advances in ocular imaging we can perform meibomography with the Oculus which allows us to directly image the meibomian glands and assess the precise level of damage. Imaged at the top are healthy long straight and narrow meibomian glands, similar to the keys on a piano. Below is worsening of Evaporative Dry Eye where the glands have started to regress and stop producing the nutrient rich oils.

In addition to the Oculus meibomography, additional tests such as how fast tears break-up and evaporate, how much inflammation is present on the ocular surface and the volume of tear fluid can be analyzed to thoroughly evaluate the physiology of your tears.

After all data and information is gathered a treatment plan can be tailored to supplement your individual needs. Our end goal is to restore a normal and stable tear film. Patients should be aware that artificial tears most often only provide temporary relief. Fully restorative treatments may require prescription eye drops, supplemental nutraceuticals or in office treatments to properly manage dry eye disease.

Time is of the essence

No matter the current stage of the condition, it is important to identify the problem and treat it accordingly to prevent the condition from further progression and worsening of symptoms. If you suffer from Dry Eye Disease it is time to take a deeper look, schedule an appointment for your dry eye work-up today.

Dr. Tarbett Talks Visual Fallout in Concussion

Brain injury was known as a silent epidemic in the 1990’s but not so anymore. Whether it be a concussion-related to a sports injury or a motor vehicle accident; a fall or a blast injury in our military service members, we are aware of brain injury much more these days.

Approximately 50% of the brain’s neural circuitry is dedicated to vision and 75% of patients sustaining a TBI will experience visual symptoms. While a headache will be the most common symptom, blurred vision, double vision and light sensitivity will be close behind.

Common Terms

The three terms used to describe brain injury are a concussion, mild traumatic brain injury (mTBI) and, most recently, chronic traumatic encephalopathy (CTE). This terminology can be confusing, as concussion and mTBI are used interchangeably by medical professionals. However, it has been suggested that concussion and mTBI should be separate entities with concussion referring to a neurological syndrome involving head trauma and subsequent symptoms, while mTBI is an identifiable injury to brain tissue. However, telling the difference between the two is difficult given our most common screening and neuroimaging techniques are not sensitive enough to detect the microscopic changes that occur in brain injury. CTE has driven much discussion recently due to its notoriety in sports-related concussion. CTE is a progressive, pathological deterioration of the brain caused by repetitive head trauma.

Visual Problems

Blurred and double vision typically result from poor eye tracking and focusing of the eyes. This has been termed “oculomotor dysfunction” and affects approximately 30% to 50% of patients that have had a concussion. Visual testing in brain injury patients will include evaluating eye muscle movement, the ability of the eye to focus from distance to near and how the eyes work together as a team.

Light sensitivity is one of the more unique symptoms of brain injury. Theories of why it occurs are still being developed. One of the most common theories involves special retinal cells termed “retinal ganglion cells” that may detect light and feed directly to a pain center in the brain. In brain injury, this pathway is altered allowing too much signal to reach the pain center.

Dizziness or imbalance commonly occur after brain injury. This is due to disruption of the vestibular system which is what is responsible for your balance and how your eye tracks moving objects. Research suggests vestibular and vision therapy that involves gaze stabilization improves recovery time.

As community awareness of brain injury increases, we can sooner diagnose and manage the visual problems it creates and improve the lives of our patients.

 

 

Tarbett, AK. Caring for Patients with Brain Injury. Review of Optometry. July 2017. 72-78.Goldstein M. Traumatic brain injury: a silent epidemic. Ann Neurol. 1990;27:327.
Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21:375-378.
Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths – United States, 2007 and 2013. MMWR Surveill Summ. 2017;66:1-16.
Traumatic Brain Injury In The United States: Epidemiology and Rehabilitation. CDC Report to Congress. 2015.
Brahm KD, Wilgenburg HM, Kirby J, Ingalla S, Chang CY, Goodrich GL. Visual impairment and dysfunction in combat-injured servicemembers with traumatic brain injury. Optom Vis Sci. 2009;86:817-825.

What’s Up With Blue Light?

Wherever we go blue light is bound to follow. Blue light is produced by the ever-present LED- Light Emitting Diode. The LED is what illuminates our phones and computer screens, and has now also made it into our homes with LED light bulbs. LED lights are smaller, more efficient and more durable than other lighting so it is no wonder they are all around us. The problem is that the dominant wavelength emitted from LEDs is around 482nm—the blue wavelength of light in the visible light spectrum.

The two big concerns I have with blue light is the higher energy that is packed in those shorter wavelengths and the fact that blue light disrupts or our sleep cycle. 

Light comes to our eyes in waves, more precisely electromagnetic waves. The visible spectrum being wavelengths from approximately 380-780 nanometers (1 billionth of a meter). And if you remember your ROY G. BIV, going from longest wavelength to shortest with the “V” as in “Violet” at 380nm. Shorter than 380nm is the dreaded ultraviolet light that we cannot see but contains tremendous energy that causes sunburns and ultimately disruption in DNA that leads to cancerous growths. Because blue light is near that end of the spectrum, we worry about excessive amounts of it reaching the delicate tissues of the eyes. While some studies indicate that blue wavelengths can damage the retina, there has not been any evidence that the blue light emitted from our phones and computers cause long-term damage.

The main reason we recommend blue light protection is due to computer-related eye strain and the disruption blue light has on our circadian rhythm. This has been borne out in research. Blue light emanating from the computer screen has been shown to cause variances in our focusing system. With an eye that is constantly trying to find the right focus, it causes the eyes to fatigue quicker and eye strain during computer use.  Exposure to blue light has also been shown to hinder our ability to fall asleep and get needed deep REM sleep, leaving us fatigued and unproductive. The theory is that blue light suppresses melatonin, the hormone that helps regulate sleep.  Melatonin not only regulates sleep but is also one of most potent cancer-fighting hormones in the body with a strong appetite for gobbling up free radicals that cause cancerous change. 

While the jury is still out on permanent tissue damage from blue light, I believe there is enough evidence that blue light can be harmful to sleep thus affecting your overall systemic health.

To prevent sleep disruption from blue light you can try to avoid using digital devices especially before bedtime, but lenses or coatings that filter the light solve the problem. 

We recommend blue light protection with DuraVision® BlueProtect from Zeiss for our heavy computer users especially if they are using digital devices before bedtime.

Chang A, Aeschbach D, Duffy J, Czeisler C. Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proceedings of the National Academy of Sciences, 2015 Jan 27;112(4):1232-37.
Graef K and Schaeffel, F.  Control of accommodation by longitudinal chromatic aberration and blue cones.  J of Vis. 2012;12(1):14. 
Hanifin J, Brainard G. Photoreception for circadian, neuroendocrine, and neurobehavioral regulation. J Phys Anthro. 2007;26(2);87-94.
Karbownik M, Garcia J, Lewinski A, Reiter R. Carcinogen-induced, free radical-mediated reduction in microsomal membrane fluidity: reversal by indole-3-propionic acid. J. Bioenerg. Biomembr. 2001;33:73–8.
Lissoni P, Barni S, Ardizzoia A et al. A randomized study with the pineal hormone melatonin versus supportive care alone in patients with brain metastases due to solid neoplasms. Cancer. 1994;(73):699–701. 
Dauchy R, Xiang S, Mao L, et al. Circadian and melatonin disruption by exposure to light at night drives intrinsic resistance to tamoxifen therapy in breast cancer. Cancer  Research. 2014 Aug 1;74(15). Retrieved from cancerres.aacrjournals.org on April 19, 2015.
Ham, W. T., Jr., Ruffolo, J. J., Jr., Mueller, H. A., & Guerry, D., III.  (1980).  The nature of retinal radiation damage: dependence on wavelength, power level and exposure time; the quantitative dimensions of intense light damage as obtained from animal studies, Section II.  Applied Research, 20, 1005-1111.
Hao, W., & Fong, H. K. (1996).  Blue and ultraviolet light-absorbing opsin from the retinal pigment epithelium.  Biochemistry, 35, 6251-6256.

ACCORD Study Data Confirm Dr. Tarbett’s Original Research

Recently retinal specialists from Wake Forest and the University of North Carolina have confirmed the findings of Dr. Tarbett’s original research on thiazolidinediones (TZDs) and diabetic macular edema published in 2011.

Data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye Study, a large multicenter study, funded by the National Eye Institute, was analyzed and found no associated risk of macular edema when using TZDs to treat diabetes. Thiazolidinediones such as Pioglitazone (ACTOS®) and rosiglitazone (AVANDIA®) are used to control blood sugar in type 2 diabetes by improving insulin sensitivity. After a number of earlier studies and case reports suggesting a link between diabetic macular edema and use of TZDs, Dr. Tarbett designed and conducted a study at Walter Reed Army Medical Center using optical coherence tomography to evaluate patients on TZDs. The macula is the center part of the retina that allows for fine visual acuity. Optical Coherence tomography is a new technique that allows more precise measurement of swelling, or edema, in the retina from blood vessels damaged by diabetes. Dr. Tarbett’s team of researchers were the first to use OCT technology in the study of TZDs and diabetic macular edema. As in the ACCORD study, no association was found between diabetic macular edema and TZDs.

Carolina Eye Doctors continues to use the same technology every day to evaluate the retinal health of our diabetic patients. Carolina Eye Doctors joins The American Optometric Association and American Academy of Ophthalmology in recommending yearly eye exams for all patients with diabetes.

Nearsightedness– Can we Defeat It?

Myopia, also known as nearsightedness, is booming. Its prevalence in the US has doubled in the last 3 decades with 42% of the US population now nearsighted and fully half of the population expected to be nearsighted by 2050.

What can we do?

A simple and effective solution–get children outdoors. The evidence continues to grow showing increased outdoor sports activities reduce and delay the onset of myopia. This may have a dramatic effect on a child’s vision over the course of their lifetime.

By reducing the degree of nearsightedness, a person’s glasses prescription, retinal detachment and other sight threatening conditions are all drastically reduced.

The jury is still out on the cause for this finding but possible candidates are children indoors are exposed to more near activities that don’t extend their focus beyond the walls of their indoor environment and absence of natural light. There is no specific recommendation on the amount of outdoor activity time although one study showed that outdoor recess time at school was enough to make a difference.

One Caveat: if a child is already nearsighted, increased outdoor activity has not been associated with reducing progression. We need to get children outdoors early before the onset of nearsightedness. For children that are nearsighted now there are a number of treatments that have proven effective at reducing progression and all should be considered in a child with nearsightedness. Come see us– we can help.

Below are studies for further reference.

Wu et al.: Outdoor Activity during Class Recess Reduces Myopia Onset and Progression in School Children (Ophthalmology 2013;120:1080-1085)
Jonnes LA Sinnott LT Mutti DO Parental history of myopia, sports and outdoor activities, and future myopia. Invest Ophthalmol Vis Sic. 2007; 48:3524-3532.
Guggenheim JA Northstone K Mc Mahon G Time outdoors and physcial activity as predictors of incident myopia in childhood: aprospective chort study. Invest Ophthalmol Vis Sci. 2012;532856-2865.
Deng L Gwiazda J Thorn F. Children’s refractions and visual activites in the school year and summer. Optom Vis Sci 2010:87:406-413.
Dirani M Tong L Gazzard G Outdoor activity and myopia in Singapore teenage children. Br J Ophthalmol. 2009;93:997-1000.
Ip JM Saw SM Rose KA ROle of near work in myopia findings in a sample of Australian school children. Invest Opthalmol Vis Sci. 2008:49;2903-2910.
Mutti DO Mitchell GL Moeschberger ML Parental myopia, near work, school achievement, and children’s refractive error. Invest Ophthalmol Vis Sci. 2002;43:3633-3640.

 

Carolina Eye Doctors