Eyedolatry: August 2015

Corneal Pannus: A Photographic Review

When I'm examining the front surface of the eye in the slit lamp microscope, I'm carefully evaluating your eyelids, lashes, conjunctiva, and cornea. The cornea is the clear tissue that acts as the window for light entering your eye -- because it is clear light penetrates unobstructed through your pupil and onto the retina for visual processing. But when the cornea is not clear, this can greatly impact vision and ocular health long term. Scars, corneal degenerative conditions, inflammatory events, or oxygen deprivation can all permanently cloud the cornea. These areas of cloudiness generally aren't reversible, but if it has happened already to you, it's your doctor's job to make sure that you know everything you need to do to prevent further corneal opacification (cloudiness). A real common finding I see in the exam chair looks like this:

The above picture shows pannus caused by contact lens overwear/abuse.

Do you see that whitened spot at the bottom of the cornea? There are little blood vessels inside which you can faintly see within the whitened portion. This is a mild case of corneal pannus, about 1 mm in size which is what I will often see in my patients. Pannus is growth of vascularized tissue within the otherwise avascular cornea -- to make that simpler, you have blood vessels growing into your cornea which causes a cloudy/whitened area within a tissue that is ideally perfectly clear for maximum light penetration.

What Causes Pannus?

Oxygen Deprivation From Contact Lens Wear: When you wear contact lenses, the material each lens is made from has a certain number of oxygen particles that can pass through the material in a given time. This breathability score is called Dk/t and a quick google search can tell you what the oxygen transmission is for your current contact lens brand. Most of today's most popular multiple wear lenses have really high Dk/t scores -- many over 100 units which is very highly breathable. But if you don't throw your lenses away at the appropriate time, or you sleep in your contact lenses when you don't have the proper lens to do so, you are risking starving your cornea of that vital oxygen it needs. If the body let's your cornea starve for oxygen underneath your lenses, your cornea will die -- that means blindness! Instead, it tries to save you by shooting blood vessels from the conjunctiva or the white of the eye into the cornea to help get by, but the result is pannus -- a permanent cloudy place that you will never be able to see through again. When your doctor sees pannus they know that your contact lens habits aren't working for you -- that means changing to a higher oxygen lens material, changing your wear schedule, or if severe enough you may have to permanently change to glasses wear only.

Much more severe pannus in a patient with limbal stem cell deficiency via
Chronic Inflammation: Not all of my patients with pannus are contact lens abusers. Many of them suffer from chronic inflammatory conditions like dry eye, previous severe viral infections of the cornea, or injuries like burns. Pannus is like scar tissue, showing areas that have been damaged by acute events or chronic irritation. What's going on in dry eye that could cause this kind of damage? Your tear film is the cornea's only protection from the harsh outer world -- ceiling fans, vents, bright sun, staring at the computer or your cell phone for hours at a time. It's a hard world out there. When you don't have an adequate tear film, your cornea is exposed to these harsh environments, and additionally the tissue begins to become inflamed. Dry eyes are red and irritated because of the inflammation they are associated with -- the lower tear volume on your eye's surface means an excessive amount of inflammatory mediators hanging out on the eye. Their job is to trigger your eyes to start watering to put moisture onto the eye when it is needed, but with that watering comes more inflammatory mediators and you enter a feedback circle of continuous eye irritation. When I see pannus in a patient with ocular rosacea or dry eye, it means that we need to significantly increase lubrication with eye drops or gels, and it's probably a great time to consider a topical anti-inflammatory like Restasis or pulses with steroids like Lotemax or Alrex.

The big take home is that when your doctor sees pannus, they know that the surface of your eye is in need of a change. We can't get rid of pannus with today's medicine -- it's a scar that will always alert your doctor that your eyes need special care. But with the proper intervention your doctor can help keep pannus from spreading into larger and larger areas and having greater detrimental affects on your vision.

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Glaucoma Drops Repurposed to Reduce Under Eye Bags

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You've probably heard of Latisse, the eyelash growing serum that was discovered when glaucoma patients taking prostaglandin analogue eye drops had the desirable side effect of longer, thicker eyelashes. But there's new research showing that not only can prostaglandins make your eyelashes fuller, they can also penetrate the skin and reduce under eye puffiness too. XAF5 is a topical ocular ointment made by Topokine Theraeutics derived from prostaglandins that specifically targets under eye bags. XAF5 breaks down subcuntaneous (under the skin) eyelid fat that causes those pesky puffy under eye bags, or steatoblepharon in the dermatological world. The ointment works by penetrating through the skin and binding to fat cells, shrinking them in size and also preventing new fat cell formation.

The Data

Under eye bags are prolapsed pockets of the orbital fat that
surrounds your eye in the socket. via

90 patients between the ages of 40 and 70 applied XAF5 as a topical cream to their eyelids for ten weeks. The level of eyelid bags were graded on a 1 to 4 scale (called the Lower Eyelid Steatoblepharon Severity scale). The results: "just under half" of treated patients experienced a 1 point improvement in their eyelid puffiness on the LESS scale after ten weeks of treatment. The patients also reported a change in their appearance: 75% of patients reported improved appearance and 85% said they were satisfied with the treatment.

Potential Side Effects

The makers of XAF5 report they are using "a different" prostaglandin than that found in Latisse, one they claim won't cause darkening to the eye or eyelid skin which is a known side effect of Latisse. Another possible side effect of shrinking the fat around our eyelids is creating a sunken globe appearance as the eye settles deeper into the orbital socket. This side effect is sometimes seen with glaucoma patients taking prostaglandins, and is what tipped researchers off initially that the medication could be repurposed for cosmetic use. Researchers report that if a sunken eye appearance does develop, the results will reverse once XAF5 is discontinued. The most common reported side effect with XAF5 application was skin redness, which occurred in 18% of users. Phase 3 clinical trials will be forthcoming.

Right and left photos above show the same patient who had been using prostaglandin glaucoma eye drops for 7 years on the right eye only. Note the picture on the left shows longer eyelashes and reduced orbital fat with a more sunken globe appearance as compared to the picture on the right which is of his untreated eye. via

Looking for doctor recommended ways to treat under eye puffiness and dark circles until XAF5 becomes available for prescription? Check out this post for the best at home treatments and products available now.

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Five Things You Didn't Know About Pink Eye

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1. You probably don't have a bacterial infection. If you've been diagnosed with pink eye (acute conjunctivitis) the far and away most likely cause of your infection is a virus. Research suggests that as much as 80% of acute conjunctivitis episodes are viral. Bacterial conjunctivitis is significantly less likely, which is why the use of antibiotics when diagnosed with pink eye is very controversial (using antibiotics when you don't have bacterial infections increases the risk of resistant bacterial strains).

2. Yes, you should see an EYE doctor. Your eye doctor can tell the difference between viral, bacterial, and other types of conjunctivitis, but getting the proper diagnosis elsewhere will be a challenge. A 2008 review study reported that in primary care facilities conjunctivitis is correctly diagnosed less than 50% of the time. In order to determine the nature of your eye infection, a doctor needs specialized equipment that just won't be found at your primary care or urgent care facility. The good news: your eye doctor can tell which type of infection you have by using the slit lamp microscope and sodium fluorescein dye staining to assess the conjunctiva and cornea. They may even have a test for viral ocular infections called AdenoPlus that confirms adenovirus strains found in many viral infections with a quick n-office sample. Head to this post to learn more about the difference between the appearance of viral and bacterial conjunctivitis.

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Viral infections classically have follicular reactions in the palpebral conjunctiva. With a slit lamp microscope your eye doctor can tell the difference between follicles (a lymphatic reaction) seen here above, versus papillae (an allergic or bacterial sensitivity reaction) seen below that is more classic for allergies or bacterial conjunctivitis. Can you see the difference?

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3. If you are feeling miserable, puffy, and swollen during your battle with pink eye, you aren't being dramatic! This MRI of a patient with viral conjunctivitis in his right eye shows there is significant swelling of the soft tissue around the eye's orbit. The top and bottom eyelids, the lacrimal gland (which rests just under your eyebrow), and the nasolacrimal duct (the eye's drainage system) all show marked inflammation on this imaging. No wonder viral conjunctivitis feels so miserable. Due to the significant swelling seen on this imaging, doctors consider treating the symptoms of viral conjunctivitis with steroid eye drops more warranted in patients with significant complaints.

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4. You'll get better (eventually) without treatment. Viral conjunctivitis infections are typically self-limiting, resolving full within 1-2 weeks. Your body's immune system fights off the infection just like when you have a common viral cold. That's why the most common treatments for conjunctivitis involve cool compresses and frequent artificial tear use. The infection itself is highly contagious, so frequent handwashing and avoiding directly touching others for the first 7 days is the best way to prevent spreading the virus to family, friends, coworkers, and your other eye. Because the symptoms can be so severe (see Bob Costas' epic pink eye debacle from the 2014 Winter Olympics as a case in point), many doctors do offer treatment with topical steroids to reduce the swelling and redness, but these drops won't fight the viral infection or make you less contagious in any way. Additionally, treating viral infections with antibiotics won't help treat the virus you have, but some doctors will prescribe these if they feel your risk for a secondary bacterial infection is high (lowered immune system, patients at risk, etc).

Many people wondered why Bob Costas didn't get treatment for his eye infection and missed a good amount of his Olympic broadcasts. Viral infections have no anti-viral treatment so he was forced to wait it out, but perhaps steroid eye drops would have made him more comfortable during the ordeal. via

5. Not all viruses are created equal, and not all are self-resolving. In 1.8 to 2.3% of acute red eye infections, the underlying culprit is the highly dangerous herpes simplex virus. This type of viral infection does necessitate prompt treatment -- permanent corneal damage and blindness is a possibility. So how do you know if you have the more common, self-limiting viral conjunctivitis that just needs palliative treatment, or this much more aggressive viral infection? This is where a trip to your eye doctor is essential! Herpetic infections typically have tell-tale corneal and eyelid lesions that will allow your doctor to prescribe the proper medication. If you have scabby, crusty lesions along your eyelid or face or blurry vision and a concurrent red eye, you need to see a doctor immediately!!

Herpes Simplex Keratitis has tell-tale corneal dendritic lesions that your eye doctor can find when they use sodium fluorescein dye staining. Just one of the tools that your eye doctor has the probably won't be found at urgent care. via

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MyDay: New Daily Disposable Contact Lens Review

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For the last few years if you wanted the ultimate contact lens for all day comfort, you've probably been wearing Dailies Total 1. There have been several new lenses to launch since then, but in my opinion none of them came close to competing with Dailies Total 1... until now. CooperVision's new MyDay daily disposable lens offers fantastic comfort and clarity, and will definitely become an active competitor to Dailies Total 1's current spot on the top of the contact lens heap.

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The Lens:

MyDay is a silicon hydrogel daily disposable lens, meaning it has higher oxygen transmissibility than many other daily disposable lenses on the market. This is a great health point for people with previous history of eye infections or corneal neovascularization or scarring from prior contact lens issues. The health benefits of this higher breathability puts this lens in a top lens safety category with Dailies Total 1 and Acuvue TruEye. The lens material itself is incredibly thin and lubricious -- when placed on your eye it truly does have that "I don't feel like I'm wearing contact lenses" feel.

Base Curve: 8.4 mm

Diameter: 14.2 mm

Power Range: +6.00 to -10.00

Dk/t: 100

Head to head this lens fits very similar to Dailies Total 1 with a steeper base curve and typically very little movement on the eye with blink (creating excellent comfort). A big pro for MyDay is that it is available in plus powers; Dailies Total 1 is still currently only available in -0.50 to -10.00. Another real advantage to MyDay is its' aspheric optic design, meaning that the lens corrects for the average cornea's "higher order" aberrations -- irregularities that bend and bounce light, disrupting the crispness and clarity of your vision. Corneas with low amounts of astigmatism or corneal irregularity could potentially achieve better vision in a lens with aspheric optics. Update: I wore this night driving recently on a dimly lit highway and was really impressed with the quality of my vision compared to my other two favorite contact lenses for comfort, Dailies Total 1 and Acuvue 1 Day Moist. Just remember, aspheric optical designs can give better vision to some by adjusting for the normal light bouncing aberrations coming off an average cornea , but if your cornea is not average, then it may not give you noticeable vision changes.

My Review:

If you read my rave reviews about Dailies Total 1 back in 2013, you know what a big fan I am. I honestly didn't think that my contact lens wearing experience would be matched by any new product. But in my personal wearing experience, MyDay was at least as good on comfort, and just a little better on clarity than Dailies Total 1. The lens stayed comfortable well into my 16 hours of wear, and I never had to use moisturizing drops or manipulate the lens under my eyelids to rehydrate. I found the lens material to feel very similar to Dailies Total 1, so if you are someone who had difficulty with removing Dailies Total 1 lenses, it is possible that you may have the same experience with MyDay. Both of these lenses have low modulus materials (meaning they are very flexible and bend to the shape they are touching) and very high lubricity -- your fingers will glide right over them if they are wet when you try to remove the lens. You also won't be able to easily slide the lens around on your eye -- your fingers are more likely to slide on the lens surface than you are to move the lens around without the proper amount of force. If you are having difficulty with removal it is best to let your doctor know so they can help teach you the proper technique for removing these more "slippery" lenses. The real pro to this more lubricious lens texture is that on your eye, your eyelids will glide right over the lens surface too, meaning that you will have that fantastic "am I wearing a contact lens??" feeling.

I thought the "Instantly Forgettable" marketing campaign is a cute touch -- and at least in my experience, it definitely held true :) via

I tried to think of at least one potential con about the lens, and the only thing that really comes to mind is that the handling tint is really faint. It will be a challenge to see the edges of this lens (especially if you have a high prescription!) to determine if the lens is inside out, and it will be hard to spot this lens if you drop it by mistake.

Because of the very low material modulus, the lens should properly fit a variety of corneal curvatures despite the steeper base curve. Lower modulus materials drape and form easily to surrounding surfaces, meaning that even though the lens comes in only one base curve and diameter, it can potentially properly fit many different corneal shapes and curvatures. Your doctor will carefully assess to make sure this lens is a proper fit for your cornea during your contact lens evaluation.

Have you tried MyDay yet? I'd love to hear your opinions and thoughts about this exciting new product!

I am not affiliated with CooperVision in any way, and this is not a sponsored post. All opinions provided are from my own personal wearing experience.

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