Another Hockey Eye Injury... Vincent Lecavalier

Somebody out there really wants us to take note of how easy it is for hockey players to sustain serious injuries in and around the eye.

Two weeks ago...
I wrote about Manny Malhotra's injured left eye and the many potential complications that can arise from taking a puck to the eye. The blog managed to gain a bit of attention and I was very fortunate last week to have the opportunity to speak on both the CTV evening news and RJ1200 morning show about Manny's injury and the importance of protective eye wear.

Here's the link for CTV evening news report on Manny:
http://www.ctvbc.ctv.ca/servlet/an/local/CTVNews/20110329/bc_malhotra_eye_surgery_110329/20110329?hub=BritishColumbiaHome

Manny was seen by a world renowned eye specialist in New York and underwent surgery last week. All reports say the surgery went well. Now we just have to wait and see how well his body can repair itself. If all goes well, I would expect to see #27 back winning faceoffs for the Canucks next season.

This week...
Another big name player gets a scare. Vincent Lecavalier of the Tampa Bay Lightning was hit in the face by a high stick in yesterday's game against Chicago. Vinnie left the game and didn't return because he "couldn't see out of his right eye". Early reports say Lecavalier suffered a scratched cornea (corneal abrasion) and also needed some stitches around his eye.

Corneal abrasions can vary significantly in severity. Small abrasions can be caused by simply rubbing your eyes. These are usually mild and do not affect vision. Larger abrasions (such as those sustained from getting hit by a puck or a stick) can cause blurry vision for weeks and potentially leave scars which can permanently affect vision. The cornea is one the most sensitive areas on the body so abrasions tend to be quite painful.

To best view a corneal abrasion, a yellow dye is usually instilled on the eye to help highlight the affected area.

A few days earlier...

Shawn Thornton of the Boston Bruins needed 40 (yes, FORTY) stitches to close a gash just over his right eye after he literally fell into the skate of another player. Coincidentally, this was against the Blackhawks as well. Although Thornton did not sustain any eye injuries, you can see from the picture just how close it was.

So here's the big question: What is the connection between these two injuries?
Answer: Neither Lecavalier nor Thornton were wearing a visor!

Someone please tell me again why players think its not important...
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Eye on Manny Malhotra

OUCH! That's the first thought that came to mind when I saw the injury Manny Malhotra sustained during last week's game against Colorado. Not the average ouch "that looks like it hurts"... it was a more serious OUCH! "I hope its not a detached retina".

Manny suffered a blow to the eye and eye socket (orbit) by a deflected puck. Any injuries to the eye can have a lot of different and potentially serious consequences. While the blood dripping from his brow was enough to make some people think the worst, its actually the stuff you don't see that is most concerning.

The Canucks just announced today that Manny will not be returning to play for the rest of the season (including playoffs). Based on this report, its a safe bet that this problem is a lot more serious than a few stitches a couple of Tylenol tablets. However, the Canucks would not report on what exactly Malhotra's current condition is.

Since the Canucks won't tell us, let's talk about some possibilities...

Detached Retina - The retina is a thin film that lines the inside of our eyes and is reposible for receiving images before they are sent to the brain. Compression of the eyeball causes the retina to lose shape and detach. Retinal detachments do not cause any pain.

Cataract - Trauma can cause changes to the lens inside the eye. It becomes clouded and makes vision blurry. Very dense cataracts can cause the pupil to look white rather than the usual black.

Glaucoma - Damage to the nerve (Optic nerve) that sends signals from the retina to the brain. The drainage system inside the eye can be damaged (Angle recession glaucoma) due to impact or blocked by blood building up inside the eye (hyphema, see image below). This causes pressure inside the eye to increase and compress the optic nerve.

Corneal abrasion - The cornea is a clear dome at the front of the eye. It is very fragile and can be easily scratched or scraped. Very painful and can leave a permanent scar.

Orbital bone fracture - The eye socket is formed by mutiple little bones. Breaking any one of these can result in different complications including sinus leakage, trapped eye muscles, and nerve damage.

All the conditions mentioned above can lead to partial or complete, temporary or permanent loss of vision in the affected eye.

A Few Other Notable Eye Injuries in Recent Years

Mattias Ohlund (1999)-
Injury: Hyphema, cataract, glaucoma
Treatment: Multiple surgeries, has a small tube permanently implanted to allow fluid to drain from his eye
Missed: 2 months

Bryan Berard (2000)-
Injury: Detached retina and cataract, legally blind in right eye
Treatment: 7 surgeries
Missed: One and a half seasons

Steve Yzerman (2004)-
Injury: Broken orbital bone and scratched cornea
Treatment: Surgery
Missed: 2004 playoffs and 2004 World Cup

Mats Sundin (2005) -

Injury: Broken orbital bone

Missed: 1 month

Can you guess what all of these players (including Manny) had in common? Drum roll, please...
Answer: None of them were wearing a visor on their helmet.

So why, in a sport that is based around a 3-inch disk of solid rubber flying through the air at 100 mph and careening in different directions within the blink of an eye, doesn't the NHL make it mandatory to have some sort of eye protection?

Bryan Berard said AFTER returning from his injury "We're pro athletes, and the choice should be ours."

I guess thats why...

For the rest of us NON-professional athelets, please try to use protective eyewear whenever possible!!
--

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Lil' Wayne and Cataracts

"You can't see me baby boy, you got them cataracts" - Lil' Wayne in Best Rapper Alive

Who said rap music is bad for you? I think its educational! Lil' Wayne may not know exactly what a cataract is, but he definitely has the right idea.

A cataract is the clouding of the lens that is inside the eye. As the lens becomes more clouded, vision becomes blurred due to light being blocked or scattered. This is the same lens that we use to focus at near objects. The same lens that stops working around the age of 45 and forces people to start wearing reading glasses (Presbyopia).

Everyone will develop cataracts at some point in their lives if they live long enough. How much and how fast depends on the individual and the environment. Medical conditions like diabetes can cause cataracts to develop faster. Sunlight is the main environmental factor. So, grab those sunglasses!

Congenital cataracts - It is possible to be born with a cataract. I recently saw a 5 year old boy who had a cataract in one eye. Another reason why kids should have regular eye exams.

Traumatic cataracts - Getting hit in the eye can cause a cataract. Wear protective lenses whenever possible!

How do you treat cataracts?
The only treatment is removal. The cloudy lens is removed and new clear plastic lens is inserted in its place. The surgery takes about 10 minutes per eye and requires an incision less than half a millimeter in size!

Who knows, maybe next week Kanye West will rap about Macular Degeneration... Stay posted!

"I spent a G on these frames, but my vision is priceless" - Lil' Wayne

Snoop Doc and Dr. Dre, OD

"Got some bubba, give me that. I need it for my cataracts." - Snoop Dogg in "Kush" by Dr. Dre.

While I applaud Mr. Snoop D-O-double-G for his awareness of ocular disease and the potential for using marijuana as treatment, there are some things that we need to straighten out.

Firstly, yes, marijuana can be prescribed for certain medical conditions. BUT! It's use is very limited and strictly regulated. In the medical field, its uses are mostly limited to patients who are being treated for cancer, severe pain, or terminal illnesses. In cancer patients it is used as an anti-emetic (decrease vomiting) and to increase appetite during chemotherapy.

A couple of weeks ago, I received a text from an old friend... "Are there any diseases of the eye that marijuana can be legally prescribed for?" Yes, old friend, yes there are. But, unfortunately, nothing I can help you with :)

The only eye disease that marijuana could be helpful for is glaucoma (not cataracts, Snoop!). Glaucoma is a disease in which the optic nerve (in the back of the eye) is damaged and can result in loss of peripheral vision (and blindness, in severe cases). It usually only presents in older patients, age 55 and up. High intra-ocular pressure is thought to be one of the main causes of damage to the nerve. This is why we do the Air Puff Test.

Marijuana can reduce the intra-ocular pressure a little. But in order for it to be effective, a patient would need to smoke very frequently, as much as every 3 hours. While some people may consider that cutting back compared to their daily norm, its not exactly what I would call effective dosing. Especially when one little eye drop once a day can be twice as effective as smoking 4 joints a day. I'm just sayin!

As always, comments and questions are welcome. Check yearly, see clearly!

Special thanks to Dr. H. Khangura, MD

Vodka Eyeballing: Let's Stop Talking About It

Google Search: vodka eyeball. 1,060,000 results (0.52 seconds). Wow, that is an absurd number of results for a practice that doesn't even exist (as long as you don't count the 5 people in world who do not, unlike the rest of us, suffer the burden of common sense and have actually attempted it).

What is it? Apparently, it is a "recent trend" that is popular with college students as a way to get drunk faster. The process is simple. Pour the vodka onto your eyeball.

Have you seen these people? It got the feeling they were auditioning for a spot in the next Jackass movie. Hey, why don't you guys try snorting wasabi or go bull fighting blindfolded? That might get you the gig.

Anyway, for almost a year now, stories of this nonsensical behaviour have been spiraling out of control. Although it has been covered by every possible news and media outlet multiple times, no one can put a finger on where it began and who is actually doing it (other than the aforementioned 5 people, lets call them the Fabulous Five!). This fiasco was created purely by the media and perpetuated by the upset parents who have been watching the reports and then calling their kids who are probably too busy taking regular vodka shots to even understand what Mommy and Daddy and talking about.

I know what you're going to say. "Harbir, you're just adding to it and fueling the fire by writing this blog!". Erroneous! Erroneous, I say! The sole intention of this blog is to stop people from talking about this fictitious form of alcohol consumption and concentrate on more meaningful and consequential topics of discussion such as How Trevor Linden Sold Out.

Now, to answer the questions that are likely circling your minds.

#1) Does it work? No.

Imagine putting an eye drop into your eye. Now put a second drop right after. And now a third. What happens? It spills over. Each individual drop from an eye drop bottle is approximately 0.05ml. And your eye can't handle more than a few drops.

1 ounce of fluid (vodka, in this case) = 30 ml. So, less than 0.1% of the alcohol in an eyeball shot will stay in your eye. Furthermore, an even smaller amount will actually be absorbed.

#2) Does it hurt? Since I am not one of the Fabulous Five, my answer is purely presumptive. Yes.

#3) Is it dangerous? Yes.

Alcohol can cause breakdown of the epithelium (outer covering) of the cornea and conjunctiva thus leaving the ocular surface susceptible to insults such as corneal abrasions, keratitis, conjuctivitis, and infections.

Vodka Eyballing. Lets Stop Talking About It.

"If you think metaphorical beer goggles are bad, imagine what literal vodka goggles will make you do!" -Stephen Colbert

 

How Trevor Linden Sold Out: The Prequel

OK, OK, I get it... People in Vancouver loooooove Trevor Linden. I know, I'm from here. So I expected a few people to be a little ticked off with me for recently writing a blog titled "How Trevor Linden Sold Out".

But, like any great story, there is always a pre-story; the prequel that provides you with greater insight into the original saga and how things came to be. Batman had Batman Begins. James Bond had Casino Royale. And Star Wars had (however unfortunately) Episodes 1, 2, and 3. This, my friends, is the Hobbit to my Lord of the Rings.

It all started in 2007. A company named clearly contacts (aka coastal contacts) that sells contact lenses online, had a lawsuit filed against them in BC Supreme Court because they were breaking the law by not requiring their customers to present valid prescriptions before ordering contacts. The law in all Canadian provinces and US states is that all patients must have a valid prescription and the online company must confirm it with the eye care professional who provides it.

This rule is in place to help prevent the misuse and incorrect fitting of contact lenses which can lead to serious, potentially vision threatening complications.

In 2009, the courts made a decision. clearly contacts must start abiding by the law OR have it changed. They decided to pursue the latter.

Abracadabra...

In 2010, Health Minister Kevin Falcon created new legislation that allowed online sales without the requirement of a prescription from an eye care professional. I can hear the gasps... He did what?? He changed the rules, with no regard for public health, to suit the needs of one corporation.

Apparently, Health Minister Falcon believed that buying contacts and glasses for cheaper was in the public's best interest, but having regular eye health examinations was not. Are these the types of decisions a HEALTH minister is supposed to be making?

MLA Adrian Dix put it well when he said "Health Minister Kevin Falcon will lower eye care standards to satisfy the commercial interests of one company, ignoring the open opposition from the Canadian National Institute of the Blind, physicians, and several health professional bodies..."

How is it possible that British Columbia is the only place in North America that is satisfied with these third world standards of health care? We often refer to American health care as an example of a flawed system, one that does not promote wellness and disease prevention. But now Americans (and other Canadians) are looking at us and wondering how or why we would possibly allow our standards to be lowered in such a way. The answer, my friends, is money.

That last point to resonates quite loudly in recent news articles which shed light on some large endorsements that the "honorable" Kevin Flacon has been receiving from a certain online company. *Cough* clearly contacts *Cough*
http://www.news1130.com/news/local/article/173102--falcon-may-be-too-cozy-with-business-community

By the way, this person is planning on becoming the next Premier of British Columbia.

So, What About Trevor Linden?
Our captain joined clearly contacts as their spokesperson early in 2010. Please refer to the original conversation of How Trevor Linden Sold Out for more information.

Someone recently said to me "...that's what celebrities and athletes do. Companies give them money to promote their product, and they do it... what's the big deal?"

Is that not the definition of selling out? Doing something ethically questionable for money. Especially when the very thing you are promoting is ultimately causing a decline in the overall well being and quality of care in the same community that has raised you and embraced you as its hero and idol.

My Life in 3D

I can't seem to take a breath these days without hearing something about 3D movies, 3D TVs, and now even 3D Nintendo games. A lot of time, effort, and resourses have been directed toward this market and it really seems to picking up steam. Personally, I don't see what all the fuss is about. I watched Avatar in 3D and I was not impressed.

I "see" you, Jake Sully.

Whether you believe in intelligent design or evolution, God or Charles Darwin, no matter how we got here, its pretty amazing to think that we are naturally born with the ability to see our world in 3 dimensions (well, at least most of us are). And that's without the sweet red-green glasses that Biff's friend, 3-D, wore in Back to the Future (I know you remember him).

How does it all work?
The basic premise behind 3D is that each eye is viewing a slightly different image. You can experience this by simply holding your finger up in front of you and looking at it with one eye open. When you switch to the other eye, you'll notice a little shift in the background. The two images are put together by the brain, allowing us to perceive depth. This is called Stereopsis or stereoscopic vision.

The "old school" way to present images in the 3D was to project two slightly mis-aligned images on to a screen, one image with more red and one with more green (called Anaglyphic 3D). Then, of course, you wear the super cool red-green glasses and voila! The red lens would see the red image and the green sees the green. Your brain does the rest.

These days, its a little more advanced. 3D cameras use two side-by-side lenses to shoot two separate images, basically imitating the way our eyes work. Glasses are still required, but now they have polarized lenses (they look a little like sunglasses), which allow each eye to view separate images without using the red-green.


Is it just me, or does this remind you of Johnny 5 from Short Circuit?



TVs are currently being developed to allow for 3D viewing without glasses. The way most of these TVs work is by putting something called a lenticular lens over the front screen of the TV. This lens basically splits the images from the TV into two directions, so each eye sees something slightly different. To give you an example of what a lenticular lens or screen looks like, its a little like those holographic stickers or posters that have little grooves on them. They show you different images as you change the angle or walk by. Apparently a lot of work is still required for these sets.

What better example could I use?

Is it dangerous?
Nintendo is coming out with a new version of their hand held game system called the Nintendo 3DS. Surprisingly, they have take some initiative and warned consumers that these little devices may not be appropriate for children under the age of 6. But, when the device was analyzed by the American Optometric Association, it was decided that they were not harmful.

In fact, that is generally the case with most 3D devices. If the person using the device has a fully developed, normally functioning visual system, there shouldn't been too many negative side effects. HOWEVER, there are some situations in which people may have mild problems with ocular alignment (in most cases the patient doesn't know about these problems). When these visual systems are stressed by the work of viewing 3D images, they may experience strain and possibly double vision. Visit your eye doctor to see if these issuses can be resolved.

There are a few people out there who will never be able to experience the luxury of upgrading their lowly 2 dimensional programming to 3D. These are people who have significant eye turns or big differences in prescription between their eyes. Generally these people have amblyopia or lazy eye, so they are unable use both eyes together to see stereoscopically.

Luckily they're not missing out on much. At least I don't think so :)

Thanks for reading. Please feel free to pass this information on to anyone who might find it interesting. As usual, questions and comments are welcome.

What Parents Should Not Do: An Eye Doctor's Perspective

I was initially going to break this topic into multiple segments. Each would described my experience with a different young patient (and his or her parents). Instead, to my surprise, I recently encountered a 6 year old boy whose mother unfortunately embodied all of the poor tendencies that doctors try their hardest to discourage.

To maintain the annonymity of this dynamic duo, let's call the boy John and his mother Jane.

Jane brought John in for his eye exam and mentioned that he had (not so recently) lost his glasses and may need another pair.

As I entered the exam room, I immediately noticed that, while he fiddled with all of my instruments as his mother sat idle, little John's left eye had an outward turn (aka Exotropia). I took my seat and asked Jane about the eye turn. She responded very casually with "Oh yes, his dad and his older brother both have the same thing. Its no big deal." No big deal?? I controlled my initial urge to scold this mother of two and I politely suggested to Jane that this is something we will need to discuss at the end of the exam.

Next came the refraction. Trying to determine John's glasses prescription was about as easy as teaching my dad how to use the bluetooth function on his phone (not easy). Both tasks required a lot of patience and reiteration of instructions. At the end of it all, I was able to improve John's vision with a prescription that involved a lot of astigmatism, but he still was not seeing as well as I would have liked. Especially with the left eye.

While we normally aim to have our patients seeing 20/20 with both eyes, John was only seeing 20/40 with the right eye and 20/60 with the left.

What we are seeing here is the development of  amblyopia, or a lazy eye. Basically, if the brain is receiving a blurry image or double vision, it will start to shut the blurry (or turned eye) off in an effort to make vision more comfortable.

This process occurs at a young age. In fact, after the age of 8 it is very difficult to recover the quality of vision that is lost. And the older the patient gets, the harder it is. Eventually, no amount of glasses, contacts, or lasers will help. From this point on, it is a problem with the brain and not the eyes.

In John's case, because of the high prescription in both eyes, he is at risk of both eyes becoming lazy.

Luckily he is still young and with aggressive therapy, I am confident that most, if not all, of his vision can be recovered.

But what is required? The first step is a pair of glasses with the full prescription worn every waking moment of the day. The second, is the use of a patch. It is worn over the right eye (the one that is not turned) for a certain number of hours a day to force the left eye back into action. If the eye turn is not resolving, surgery to help straighten the eye is a possibilty.

After discussing all of this with Jane, she conceded that she was provided most of this information by another optometrist a couple of years earlier. In fact, that eye doctor had also scheduled a follow up visit a couple of months after the initial exam. But, since her older son and husband have similar problems and are "doing fine", she figured that it was "no big deal" and didn't follow up. I was really beginning to lose my patience with Jane's nonchalant attitude towards her young son's vision.

After all of the things I had just finished explaining to her, Jane asked if it was ok not to get the glasses yet. She was hoping to let John decide when he was older if he wanted to wear glasses or get laser surgery. That way she didn't feel like she was forcing it on him. What??

NO THAT IS NOT OK. AND IT IS A BIG DEAL!

When your child's vision is at stake, its a big deal. When his aptitude to read and learn is affected, its a big deal. When his ability to see and experience the world is degraded, its a big deal! How could anything be more important???

While Jane is an extreme example, there are a lot of people who exhibit this type of behaviour to a lesser degree. For as long as I can remember, as a student and now as a doctor, I have watched far too many people carry a complacent disposition regarding their health. Too often, I've heard people say "its no big deal" or "it'll get better". I'm guilty of it myself. But, if there is one situation in which I can't ever imagine having that kind of attitude, it is when a child's health is in question.

In British Columbia, annual eye exams are free for all children under the age of 19. If there's one thing our government is doing right, this is it.

So bring your kids in. We'll be happy to see them :)

Reading in the Dark is Bad for Your Eyes

Myth or truth?

I get asked about this almost every day at work. Will it make my eyes worse? Is it why my eyes feel tired? Should I turn the lights up? No. Probably. Yes.

Our eyes have to work to focus every time we are reading or looking at things up close. It's called accomodation. Little muscles inside the eye cause the little lens inside the eye to change shape so near objects come into focus.

It doesn't take a genius to figure out that things are harder to see in the dark. So, in the dark, the stimulus for accomodation is decreased and our eyes lose focus.

Our eyes will continually lose focus and then re-focus causing them to fatigue and strain.

There is a little myth to it though. Your eyes won't "get worse" from reading in the dark. By this I mean there won't be any change in prescription or need for stronger glasses.

Botox

Most people have heard of botox therapy for cosmetic purposes to get rid of wrinkles. But what exactly is botox and what else is it used for?

Botox = Botulinum Toxin AKA one of the strongest neurotoxins known to man, which is produced by the bacteria Clostridium botulinum.

Basically, it causes complete paralysis of all muscles it comes into contact with and can be lethal if it somehow enters the bloodstream.

Botulinum toxin is so potent that a dose as small as 100-200 nanograms can be lethal to an average human (one nanogram is one billionth of a gram). 4kg of the stuff would be enough to wipe out the entire world's population!!
But Botox has some real Medical Uses:

In Eye Care:Blepharospasms - Spasms of the muscles that control blinking (uncontrolled twitching or blinking)
Strabismus - Eye turns due to over-action of muscles that control eye movement

The effects of Botox last about 4-6 months, so patients would need to have multiple injections per year.