Why does my dry eye cry?

It is a problem with quality not quantity.  Our lacrimal glands make tears that mix with mucous and oil from neighboring oil ( meibomian ) glands to create a sticky mixture for lubricating the eye. If the oil or mucous is deficient, the salty water made in lacrimal glands does not stick to the eyeball and it overflows. I like to give an analogy of windshield wiper fluid. One cannot replace it with water.
So a problem with dry eyes can, in most cases, be addressed by improving the flow of the meibomian glands. These glands open into the eyes through small pores located in  linear fashion just behind and parallel to our lash lines both in the upper and lower eyelids. These pores are tiny and hence easy to get clogged with the oil.
Once you understand the mechanism as stated above you will understand why warm soaks and cleaning the eyelid margins with baby shampoo work. Occassionally the problem is complicated by a chronic inflammation ( redness, swelling) of the eyelids by bacterial infection or by unknown causes. These people need additional brief courses of antibiotic eyedrops or antinflammatory agents (restasis) to curb the inflammation.

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Vision Impossible

One of my patients, who may recognise herself in this article, does not beleive me when I tell her that her eyesight is good and that when her vision is corrected with the help of lenses she reads a 20/20 line without a least bit of hesitation. “ But doctor , I can’t
see” and she holds her head in despair. She is 62 years old and an avid reader.
She had never needed glasses to read and then at the age of 52 she had LASIK
because she liked to see her friends clearly at a party when “of course she
could not use glasses with her fancy party dress”. “Why did you not try contact
lenses” ? I ask. “Well,  because then I would need reading glasses”!! Hoping
that she would get it instantly,  now that she is in the zone, I venture “ That
is what happens with LASIK as well”. “Oh!!”. There is silence and then she gets
it. “ I see”.

LASIK is an excellent surgery when used for right indications, at the right age and
with  right expectations in place. It is a serious medical decision because it
involves undoing something which was meant to be your “normal”. There can be an
argument that by using glasses we are doing the same thing- undoing our normal.
That is true but with surgery we make it permanent and there is no going back
most of the time.

Coming back to my patient, I think the reason she had such a hard time adjusting to her
new vision was the fact that her surgery was at a relatively advanced age. She
had for 52 years enjoyed her reading without needing glasses.Now, even though
she could see her friends clearly from across the room without any visual aids,
it pained her when she fumbled through her purse looking for reading glasses to
jot down a phone number. It is harder for the brain to get used to the new
visual status as we age. And so even though you may be technically  20/20 in the
confines of my office, you wonder about it when you are out there…..

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Last weekend I attended a wetlab in Boston at the Annual Meeting for ASCRS (American Society for Cataract and Refractive Surgery). I learnt how to correct Astigmatism surgically. A lot of you ask me about Astigmatism and I tell you that it is a condition where the eye is not perfectly round like a basketball, but slightly oval like a football. This difference is usually not noticeable to the naked eye, but becomes evident when we make fine measurements of the eye. Hence the correction of astigmatism requires a lens that is curved like a football (in an opposite direction or axis) and not like a basket ball. This analogy is the most often used and I have still not found a simpler way to explain it.


The two common methods by which astigmatism is corrected are optically by the glasses and surgically by LASIK. I explained the optical correction by the basket ball analogy. LASIK is when you reshape the front curvature of the eye by laser in such a way that it reverses the “football effect”.

What I learnt in Boston is different. Here I learnt the use of a diamond knife to reshape the front of the eye and make it more like a basketball. This method is commonly employed when a patient needs a trip to the operating room for cataract surgery. The surgeon uses this time to correct the astigmatism as well because the eye is already anaesthetized and the microscope is available. This helps the patient to be less dependent on glasses after a cataract surgery.

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When should my child have his first eye exam?

This is a question I often hear from parents when I prescribe glasses to their child and they have other kids who potentially may need glasses as well. There are many reasons why a child should have an eye exam. A child learns from her environment and if she does not see she does not learn. Sometimes the image that an eye perceives is distorted only to a slight degree and the child is able to make educated guesses about what is written on the classroom board. This leads to frequent mistakes. Eyes are extension of the brain. The images are received in the eye but processed in the brain. Seeing is a learning process like language. A barrier of any sort will disrupt the process of “learning to see”. The barriers can be distorted images that result from the eye being defocused or misaligned ( cross eyes or wandering eyes) or there can be an eye disease like cataract or very rarely a tumor that can interrupt passage of the light inside the eye. If any of these things disrupt the image formation in early childhood, the eye develops a condition called amblyopia. This is also commonly referred as “lazy eye”. Fortunately, most of the time this is reversible if corrected within the first six to ten years of life. Treatment is either by glasses, drops, patching or surgery depending upon the underlying condition.

Eye exam for children


The first eye exam typically starts when the baby is born. The doctor shines light into her eyes and makes sure that it is reflected back appropriately. Thereafter in all well baby visits you will see this exam repeated. Sometimes pediatricians also perform computerized vision screening in preverbal kids. At around 2 years of age the kids are able to identify pictures on the eye chart. Each eye is covered well to test the other one. After this age, vision screening takes place in preschool and later on in elementary school. As a parent one should be vigilant about the occurrence of these tests and their results so that referrals, if any, are carried out in a timely fashion. In addition if you notice any abnormal behavior like holding books too close to face or squinting to see, you should take your pediatricians advice. You may also schedule a visit to an eye professional directly at any time.

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