Each year the statistics on which forms of plastic and reconstructive surgery, along with less invasive cosmetic procedures, are collected by several groups.  This infographic below from RealSelf.com, a great website to peruse if you are considering a surgical procedure, breaks the stats down with some simple charts.  Eyelid surgery is in the top 5 most common procedures, and enjoys are very high “worth it” rating by patients. Check it out:

RealSelf.com plastic surgery infographic

 

 

Often when people come to our office complaining that their eyelids are sagging, they actually have a drooping forehead and brows.  This downward sliding skin causes the upper eyelid to look especially redundant and fold over the eye.  Many times, especially in men, the brow hairs are down at the level of the eyelashes and the brows block out their entire upper visual field. Simply raising the forehead without even touching the eyelids corrects most of the problem and dramatically improves their visual angle. Recently, a couple of patients told me they just couldn’t believe how much of their world they were missing out on seeing because of their heavy brows.  So in this article, we’ll talk briefly about what causes this problem and what are the main ways of treating it, including their pros and cons.

What causes brow and forehead descent?

  • The main cause is aging.  With age the skin of the forehead becomes less elastic and gravity causes it to descend. It is fairly firmly attached at the top of the head, but more mobile over the forehead where the frontalis muscle allows the skin to move up and down with facial expression.  In time this skin gets stretched and has no place to go but down.
  • Weight loss can also cause drooping of the brows.  Heavier individuals develop a layer of fat under the forehead and brow skin, which when lost can lead to forehead droop.
  • Certain illness can cause loss of tissue elasticity and drooping brows.  Others cause damage to the nerves that innervate the forehead and brow muscles, such as Bell’s palsy or facial nerve injury. The brow and forehead droop

What are the main ways it is treated?  With my patients I like to divide the treatments into good, better and best.

  • Good: Direct brow lift will raise the brows very well.  It involves an incision above the brow hairs full thickness and removal of a strip of skin.  The brow is then raised with heavy sutures stitched from the deep skin below the hairs into the muscle and covering of the bone up higher.  Its biggest drawback is the scarring it can produce.  A man with very bushy eyebrows may be able to hide the long linear scars, but in most they are very apparent, even after months of healing.  The shape of the brow often tends to be more rounded, which looks fine in a woman, but unusual in men.
  • Better: Newer techniques are being used to raise the brows, either through small incisions above the brow hairs, or through the upper eyelid incision used in blepharoplasty.  These techniques, call browpexy, essentially just raise the brow height with sutures without removing skin or shifting underlying tissue planes.  They produce relatively smaller scars, but generally aren’t as powerful and tend to regress quickly.  I do think they are better than direct brow lift, however, due to their less noticeable scarring.
  • Best: Moving the entire forehead, or a large portion of it, will give the longest lasting, best looking brow lift.  This can be done in several different ways, some which involve raising the hairline and others that are remove a portion of skin, leaving the hairline intact.
    Brow lift and upper eyelid blepharoplasty

    Patient who wanted a conservative brow lift and eyelid lift due to skin blocking his vision

    How do the methods of forehead elevation differ and which is best?

    • The median forehead lift involves making an incision across the entire forehead through a deep crease (if you’ve got one), removing a strip of skin, and suturing up the forehead and brows in similar fashion to the direct brow lift.  The scar can be noticeable, but in the right person is a good choice.
    • Endoscopic brow lift is my method of choice for forehead elevation. It involves making 3-5 incisions behind the hairline through which instruments are introduced to elevate the skin off of the forehead down to the brow area.  A camera is used to directly visualize the dissection around the brows to avoid damaging the nerves and blood vessels in this area, and to partially remove the muscles of the brow which cause the furrow above your nose (think of it as permanent Botox).  A portion of skin can be removed above and behind the ear to create lift in an outward/upward direction as well.  The forehead tissues are then fixated in a higher position using either a suture and screw or a resorbable fixation device called an endotine.  I was recently introduced to absorbable screws (Lactosorb) combined with sutures and find this to be  a very stable method of fixation that can’t be easily undone by a patient not properly caring for the tissue flap after surgery.
    • A pretrichial (meaning in front of the hairline) lift involves an irregular incision along the hairline with a portion of the forehead skin removed.  This gives a great forehead lift without raising the hairline.  It can cause noticeable scarring and works best for someone who has thicker hair and wears it forward.
    • The supposed “gold standard” forehead lift is the coronal lift.  This involves an incision from ear to ear over the top of the head, with dissection down over the forehead and brows and  removal of a portion of the scalp and hair.  Many plastic surgeons swear by this procedure, and in actuality it is the most long lasting along with the pretrichial lift, but it requires a large amount of skin removal, a large scar which is often noticeable even in thick haired people, it causes numbness of the scalp behind the incision, and it can dramatically raise the hairline.

    Forehead and brow lifting can make a dramatic improvement to a tired appearing face.  Of all the procedures I perform, this procedure leaves patients the most satisfied as it so dramatically improves their visual field and appearance.  If you have further questions or think you might be a candidate, give our office a call or email me directly at [email protected].

     

When someone finds out I’m an ophthalmologist, 99% of the time their first question is, “Do you do that laser eye surgery?”…or something to that effect.  Some marketing geniuses did a great job of associating eye surgery of any kind with precision lasers.  Most people seem disappointed when I tell them I don’t do LASIK (I guess because they won’t be scoring a sweet discount).  Lasers are frequently used in the eyelid surgery I perform and are regularly advertised as better than the standard surgical techniques (just drive down I-15 and you’ll see a half dozen billboards promoting laser surgery, usually depicting people who have never had or won’t soon need any surgery).  So do lasers live up to the hype?  Is surgery performed with a laser superior?  The answer is a resounding maybe.

Laser eyelid surgery

Lower eyelid blepharoplasty with laser

Where lasers excel:  CO2 laser has been used for eyelid surgery since 1980, and was greatly improved in the 1990’s.  It is extremely precise.  When properly focused, the laser cuts, coagulates severed blood vessels, and can be used as a blunt dissecting instrument.  This can greatly speed up the procedure. One study showed that a 4 eyelid surgery took 58 minutes on average with laser compared to 94 minutes with a blade.  A separate study showed that patients returned to their normal activities after about 6 days following laser surgery compared to 9 days after scalpel surgery.  In most cases, bleeding is very well controlled, which speeds up surgery and may result in less bruising post-operatively, even in patients on blood-thinners.

Where lasers suffer:  When you cut with a blade, only the tissue directly incised is damaged. The adjacent skin and muscle is left intact and ready to aid in healing once the wound is closed.  With a laser, a zone of coagulative necrosis (fancy for burned dead tissue) is created on either side of the cut.  In order to heal, the body must first clear these dead cells and debris out of way before forming a healed scar.  This will require a more intense inflammatory response with the possibility of a larger scar.  The incision may also heal slower, leaving it at greater risk of opening back up inadvertently (wound dehiscence).  The other big problem is cost.  The most popular CO2 laser unit in use costs about $100,000 up front and can be expensive to maintain, a portion of which you’ll pay for in higher surgical costs.  A #15 scalpel blade costs 18¢. Lasers also require more personnel to operate and add extra setup time before surgery, also adding to costs.  Electrocautery causes similar short-term damage to tissues, but only costs around $50-$100 per case and heals equally well.

Long-term results:  Most people really want to know what the longterm differences are, and the short answer is: there really aren’t any.  Several comparison studies have shown that eyelid surgery done with laser, electrocautery, or a blade have similar outcomes once completely healed.  In my experience, patients operated on with laser have less bruising and swelling initially, but this is not noticeable at 2 weeks post-op.  Surgery with electrocautery falls in the middle, with less bruising than when using a scalpel, but slightly more swelling.

Bottom-line:  Laser eyelid surgery does work well and may get you back to your usual activities a few days sooner.  It is very safe and has been used in thousands of cases over 3 decades.  It may, however, cost you more in a cosmetic setting (where you’ll be paying out of pocket), and probably won’t make a difference in the final outcome.  As always, surgeon skill is the most important thing to consider as expensive instruments are only as good as the hands driving them.

Call our office at 801-264-4420 for an eyelid surgery consultation where we can discuss which laser or traditional surgery is best for you.  We offer laser blepharoplasty at Intermountain Medical Center, or other traditional techniques at our other surgical centers.

 

 

We have been running a contest for a free eyelid lift and are down to our 10 finalists. Unfortunately, the contest app only shows the contestants pictures, but not the stories they sent along with them. We felt they were so compelling that we wanted to share them for anyone interested in voting. After reading, you can go to our Facebook fan page, “like” us and vote.  Here they are in random order.  Voting ends January 19th.

Marian Jones
Marian Jones

The eyelift is for my mom Marian who lives in Utah. She’s wanted an eyelift for about 10 years now as it’s been hindering her sight. She couldn’t afford it due to costs from breast cancer and other health concerns. After two mastectomies, she is now cancer free and has lost 50 lbs this past year! This would be the perfect Christmas gift for her to boost her self-esteem, restore her vision, and celebrate her and her accomplishments these past 5 years.
Sherry Weston

I need an eyelid lift because I am only 41 and my eyelids are way too droopy! (along with some other things). I am a newly divorced mother of 3 beautiful little girls all under the age of 10, I came out of a abusive 10 year marriage. I have overcame many obstacles in my life. And I have been through allot in my life and it really shows…All over my face.

 

Pat Rusk
Pat Rusk

I was an elementary school teacher for 33 years and it was a job that kept me young at heart – if not in face. Now I work as an advocate for teachers. As a working professional, it would be nice to be able to wear eye makeup that others could actually see. It would be nice to have visible eyelashes. I would love to stop hiding behind glasses, wear contacts, and maybe even hear comments about my big brown eyes again.

 

Jeff Wells
Jeff Wells

My family genetically has had fat eyelids. I have not mined it until recently when, on most days I can actually see the eyelid when I look normally at my surroundings in the distance. I feel self conscience about it. My regards, Jeff

 

Emilee Fike
Emilee Fike

When I was in fourth grade I injured my left eyelid by being bullied. I was pushed by a boy while on the monkey bars:( The result was me falling and anding face first on a rail road tie. I have a large scar and the eye socket was broken. The eye socket is not noticeable except by touch and photos show a uneven look. My parents never were able to repair this injury. We were the typical large Mormon family, and my dad was the sole provider. My oldest brother battles with schizophrenia and and younger sister with a paralized arm was the focus of any medical treatments for my parents. I now am happily married mother of three and own and run a small pet grooming business. I love my life! I would love to be able to be proud of my eyes. I have always swept my bangs to the left to cover this scar. The last 4 years
my eye lid has started to sag and droop because of
aging. The left eyelid is sagging a lot more, making
this scar alot more noticeable. I would love to see if it is possible to have my brow have a implant on the left side to match the right brow bone. Scar removal on the left eyelid and a lift so both eyes match. Thanks
Peggy Cummings
Peggy Cummings

I am a middle aged woman with sagging eye lids and circles under my eyes. I also have a scar on my left upper lid that was repaired by an ER physician and not a plastic surgeon. I have always had beautiful eyes and received comments daily when I was younger. Now that I am overweight and middle aged; I no longer receive comments. I want to be pretty again and feel good about myself. I know many people who have had their eyes done by your facility and they look fabulous. In fact, I worked for a local plastic surgeon and we used to refer our patients to your office because we knew you would do a much better job. I am a very friendly vocal person and I will not be embarrassed to share my experience with others. Hopefully, this would bring your office many referrals. It would be a true honor and a dream come true if I was selected for this procedure. Thank you for being in the business of helping people feel good about themselves. PS: I tried taking new photos but I am too embarassed to post what I look like now. The photo I am posting is several years old.
Greg Davis
Greg Davis

I am nominating my dad for eyelid surgery. We used to be able to see his eyes, now his eyelids have taken over, they are droopy, and he can hardly see. He has talked about having eyelid surgery, but it has been just all talk until now!! Now it is time to have something done about it, but we need Utah Oculoplastic Consultants help.
He as never won anything in his life, I believe winning this would be a life changing, eye opening experience and opportunity for him. My concern with him not getting this done now is, it will only progress and get worse. He has tags growing on his eyelids that he takes his clippers and clips them off himself…ouch! He wouldn’t like that I told you this, but……that’s a problem. Please help or else in a couple of years we will have to invest in toothpicks to hold his eyelids open. Respectfully yours,
Jen Schuster
Peter Denis
Peter Denis

The skin around my eyes is so protruding and sagging that it actually gets sunburned before anything else on my face does. My eyes are so droopy that I get pollen and dust in them very easily. My eyes have become so sensitive to light I can’t bear it.Please Dr., help me with these troublesome eyes!

Jeri Nielsen
Jeri Nielsen

My name is Jeri Nielsen, I am 52 years old and think that overall I look and feel younger than I am, Except for one thing.
I look in the mirror and notice the bags that someone has packed for a long trip and stored them in the overhead compartment above my eyes.
I would not say that I am a vain person; however I do notice that my eyelids tend to get in the way sometimes. When I am very tired they tend to droop a bit more, could be my imagination, but it bothers me.
I have looked into having them corrected and have been told that unless you are of a certain age this is considered cosmetic and insurance will not cover it. Cosmetic or not, I would challenge whomever made that rule to take a trip through town with my eyelids. I am sure they would have a whole new outlook, assuming they could actually see.
I realize that there are bigger problems in the world. And I do not wish to convey that I think by being able to correct my droops that world hunger will be solved by any means but I do wish to impress the importance of how much this procedure would mean to me. Not a day goes by, not a hour, not a minute, that I don’t at some point think it would be so nice to be worried about something more important why this is such a deep issue for me cannot really be explained… it just is!
I heard about this contest through a friend and thought I may as well give it a try. What have I got to lose other than droopy eyes and a bit of insecurity?
Rusty Carroll
Rusty Carroll

Would like my eyes to look younger, I am unemployed and I feel looking a little younger might help me

The doctor-patient relationship is an interesting subject.  You go to a doctor trusting they’ll give you good advice, provide expert care, and always have you best interests at heart.  The doctor, on the other hand, needs you to give them all the information and cooperation necessary to make good decisions and give great treatment. Both of you must work together properly for this to all work out well.  Oh, and it helps if you actually like the doctor and she or he treats you with equal respect as a partner in your healthcare decisions. We’ve all had doctors that do and don’t fit this bill. So how do we know who will be good without investing time with several visits, or even enduring poor care? There is no perfect way, but here are a few suggestions from someone who hangs out with lots of doctors.

First, do your homework.  Asking your friends and family for a recommendation is a start, but after that you need to go a few steps further. Check them out online next. There are numerous websites that grade doctors (i.e. HealthGrades).  I find most of these are only good if the doctor has wronged a lot of people and they have gone online to voice their concerns. Multiple bad reviews may be a sign you should look elsewhere. If half the reviews are copious exalting praise and the other half say he is Satan’s intern, you are back at square one. You can also check the state medical board for any sanctions against the doctor.

Next, when calling for an appointment, ask the secretary about the doctor’s credentials.  Is he board certified or fellowship trained in the particular specialty you are looking for? If you are interested in a particular procedure, how many have they done, or better yet, how often are they currently doing the procedure? If an older surgeon, who previously did “procedure X” five times a week, now only does it once a month, he may be rusty.  Can they get you in quickly, or will you have to wait a long time? A long wait may indicate you’ll have trouble getting back in to see the doctor if there is a problem.  As a young doctor, I know all too well that people want someone experienced (my hair can’t go gray fast enough). What younger doctors may lack in sheer numbers of procedures performed, they may make up in knowing the most up-to-date techniques and state-of-the-art treatments (this is where talking with others who’ve had the procedure performed by your prospective doctor is helpful).

Finally, make sure the physician can communicate well with you, both listening and explaining. Discuss with your doctor exactly what they plan to do in your treatment or surgery. They must clearly explain it to you in language you understand.  A recent article in the Chicago Tribune about doctor-patient communication listed the following things to look for when searching out a physician:

The Tribune stated that a good doctor:

1.  asks why you’ve come and what you would like to get from the appointment.

2.  shows respect to you and your family members.

3.  is respectful of your time (apologizes for being late and explains why he held you up).

4.  listens as much as he talks, give answers in understandable, non-jargon language, and helps you make informed decisions.

5. is scientifically up to date and willing to share his reasoning behind his advice.

6. is encouraging if you desire a second opinion.

7. makes you feel good about asking questions.

8. makes you a partner in your care, rather than just a recipient.

9. promptly returns phone calls or emails.

10. makes appointments easy to make, with minimal waiting times.

11. creates a warm environment where you can have an open and honest discussion.

On the flip side, you may have found a not-so-good doctor if he/she:

1. is dismissive of your questions and concerns.

2. leaves you feeling unsatisfied and unsure of your treatment and other issues.

3. doesn’t welcome second opinions (leave immediately).

4. is disrespectful of you, family members, office staff (a good indication that he is the reason he goes to work, not you).

5. makes you feel too uncomfortable to have an open, honest discussion.

6. has State Board disciplinary violations.

7. makes it difficult to book appointments (it can take weeks or months).

8. isn’t available to you during off hours (weekends/nights) and neither are his colleagues.

To make the doctor-patient relationship work, you as a patient can do a few things to make your appointments successful.  First, be prepared. Have a list of questions you want answered.  Also, keep a brief medical history with you containing a list of all your medications with dosages and schedules, any previous surgeries or major medical events, drug allergies or intolerances, and any pertinent family medical history. Printing out a copy of this to take with you and give to the doctor will give them a complete picture of your past and keep all your doctors on the same page. For an eye appointment, be sure and bring your current glasses and contact lens boxes.  This can make that annoying refraction a lot quicker and more accurate.

Next, when relating your problems to the doctor be succinct and tell a clear story.  We are human and can get lost just a easy as the next person when listening to a long disjointed narrative. Answer the questions asked, but don’t be afraid to give other information you may think is important.  And don’t worry about asking stupid questions.  I’ve had patients sheepishly ask me if some symptom is worth mentioning, only to determine it was the primary problem.

Finally, don’t be afraid to challenge your doctor on their opinion, but also be willing to take their advice and adhere to the treatment they’ve prescribed.  Nothing is more disheartening than to see someone suffer unnecessarily because they are unwilling to follow the advice they’ve sought out and received. You’ve gone to them because you believed they knew something you didn’t, so give their ideas a chance.

A little homework and effort on your part can lead to finding a doctor that will take great care of you and your family, and make you feel you’re are an integral part in the process.

Facial Dog Bites in Children

I have not been shy about my feelings for dogs with my friend’s and family over the years. I love all animals, I just don’t want them butt-sliding on my carpet, shedding on my couch, or biting my childrens’ faces off. Harsh, maybe, but it is worth considering a doctor’s perspective on this last point before calling PETA to picket my office. Over the past few years, without fail, week in and week out, I see and treat kiddos whose little cheeks, noses, eyelids and foreheads have been permanently scarred or worse because mom and dad thought Fido was completely harmless. I’m here to tell you that he is not, no matter how well trained, how much you overpaid for him, or what the local dog whisperer tells you.

Dad got me a pitbull for Christmas, next year I’m asking for LEGOs.

Over 4 million dog bites are thought to occur annually in the US and over 500,000 require medical care in the ER.  Small children are particularly at risk for facial dog bites as they are down at the dogs level, and dogs seem programmed to go for the face when provoked.  I’m willing to wager that most of you know 1 or more people with a scar on their face from a dog bite as a child. I am usually called when these bites involve the eyelids and often cut through the tear drain system, or rarely, completely tear off the eyelid. Most can be fixed satisfactorily, but nearly all still result in a scar.  And dog bites are at high risk of becoming infected, so using antibiotics for 3-7 days is recommended (no, your dog’s mouth is not sterile as some think, stop letting them lick your face or your ice cream cone *shudder*). Clearly, dogs pose a risk to their owners and to children, no matter who causes them to lash out. There are, however, many things you can do to prevent these unfortunate injuries from taking place.

A dog’s propensity to bite is affected by many factors, including heredity, sex, early nuturing, interactions and training, overall health and reproductive status. Males are over 6 times more likely to bite than females. Neutered dogs are 2-1/2 times less likely to bite and unchained dogs are almost 3 times less likely. Sexually intact males and females are generally more aggressive, especially when tending to their young. Large breed dogs will obviously inflict more damage when biting, which accounts for their disproportionate number of reported dog bites. Below are the most common breeds causing serious or fatal bites according to a popular law website:

Common Dog Bites causing injury or fatality:

  • Labrador Retriever
  • Bulldogs
  • Akita
  • Bullmastiff
  • Mastiff
  • Boxer
  • Collie
  • Cocker Spaniel
  • Sheepdog
  • Ridgeback
  • Australian Shepherd
  • Chesapeake Bay Retriever
  • Coonhound

    “I love kids, they’re delicious”

 

Notice that the Labrador Retriever, considered a great family/kids dog is top of the list.  This is mostly due to its being so common, but also because people underestimate its temperament.  Certain breeds, such as bulldogs, are bred for aggression and will bite with little or no provocation and often without showing any behavioral warning signs. In a 2001 study, children aged 0-14 comprised 42% of all people presenting at the ER for dog bite treatment.  In a separate study where greater than 90% of dog bites were from animals owned by the family, 63% of those dogs bit again when kept by the family.  I have personally stitched up the face of a child twice in one year after dog bites from the same dog. The following are ways to prevent dog bites from ever happening:

1. Properly train and socialize your own dog: Never tolerate aggressive behavior by saying, “that’s just how he/she is” or blame it on the breed.

2. Control the number of aggressive dogs: Neuter male dogs to reduce aggressive tendencies, limit reproduction where dogs have little chance of proper socialization, confront aggressive behavior, and limit the breeding of pit bulls. (Personal opinion: these dogs are a menace and bringing one into your home or allowing your kids near one is a form of child endangerment).

3. Obey leash laws: It doesn’t matter how docile you think your dog is, you don’t know how he/she will behave when confronted by a stranger.  As someone who has been bitten or just jumped all over by strange dogs while their owners stand by, I can attest that this isn’t pleasant. If you truly love your pet, don’t put them in a situation where they could hurt someone else, especially children, or you’ll be giving them a one-way ticket to the gas chamber.  Don’t let your children approach strange dogs or hug or tease any dog that is in the least bit aggressive.  An unknown dog older than four months should not be placed in a household with young children unless it has been evaluated by an animal behaviorist or by a veterinarian.

4. Know when dogs are more likely to be aggressive: dogs that have recently delivered puppies or are eating or sleeping tend to be in a foul mood when messed with.  Teach your kids to treat dogs kindly and never tease them or take away food or bones.

5. Use proper barriers: Enclosures, fences and sometimes muzzles should be used to keep dogs away from potential problems.

I’ll admit, dogs can be loveable, like when they are biting criminals, carrying whiskey to lost alpine skiers, or playing poker and smoking cigars.  Let’s just use some common sense around them so our kids will also find them loveable and avoid ever having to meet me in the ER..

 

 

 

Every service related industry has their “bread and butter” clients. These are the clients that occupy most of their time with the most common needs. Medicine is no different. Although I like to share stories with my family and friends about bizarre and interesting cases, most of my day is spent seeing lots of people with just a few common problems. I thought I’d share some of those problems and what you can do to begin treating them at home and maybe avoid a doctor visit.

#5 – Styes: So you feel a funny sensation in your eyelid, perhaps even pain. You touch it and the eyelid is swollen. It appears red in the mirror with a bump that has quickly gotten huge. You most likely have one of two things: a stye or a chalazion. A stye is an infection at the base of an eyelash follicle. It presents as a rounded, painful bump at the eyelash margin. It comes on fast and often spontaneously drains. Styes are actually not as common as their ugly stepbrother, the chalazion. A chalazion forms when the oil glands along your eyelid margin get plugged up and the oil has nowhere to go. It ends up getting backed up into the skin of the eyelid and forming a red, non-painful nodule. This nodule will be deeper within the eyelid away from the lash follicles. It is not an infection and won’t get better on antibiotics. Both of these are treated first with warm compresses and eyelid scrubs with baby shampoo or mild soap a few times a day. They have to be treated for a few weeks before they’ll go away. If they don’t drain and resolve on their own, you may have to have them lanced in an ophthalmologists office. Most adults who develop chalazions have blepharitis, which is a mild inflammation of the eyelids. It is often associated with rosacea. It leads to crusting of the eyelid margins and overgrowth of bacteria along the eyelashes. Warm compresses and lid scrubs are the main treatment.

Chalazion


Stye (external hordeolum)

#4 – Dry eyes: I’ve posted about this before here. To summarize, dry eyes are very common, cause eye irritation, tearing, “tired eyes”, and blurry vision. See my previous article for the best treatments, most of which you can do on your own once you are diagnosed.

#3 – Floaters: These are probably the most common complaint I hear about, but not usually the reason people come in. They are usually mentioned as an “Oh yeah, and I have these annoying spots floating around in my vision.” Floaters are most often totally harmless and just annoying, but there are a few instances when you can’t ignore them and should see a doctor immediately. Suddenly developing a bunch of new floaters, especially if they are accompanied by flashes of light and/or a curtain-like loss of a part of your vision, could signal a retinal tear or detachment. The gel that fills the bulk of the eye is called vitreous. It is firm like jello when we are young and slowly liquifies and clumps together as we age. It is made up of 98% water and some thin collagen fibers and other molecules that hold the water together. The collagen strands are attached to the retina along blood vessels, at the optic nerve, around the center of the retina (the macula) and just behind the lens. When the vitreous liquefies it pulls away from these attachments and can occasionally make a tear in the retina in the process. Through these tears, the water can get under the retina and peel it off like wet wallpaper (retinal detachment). This can cause permanent loss of vision if not promptly fixed. Retinal tears can often be fixed with a laser or by freezing the eye (cryotherapy). Once a detachment occurs, an emergency surgery to correct the problem is often necessary. Bottom line: if new flashes of light and floaters are occurring, get to an ophthalmologist right away for a dilated eye exam. For those of you with long-standing, but annoying floaters, you’ll just have to get used to them. Surgery would be required to remove them, which is very risky and could cause a retinal detachment by itself. (Rarely, floaters are caused by an infection or inflammation inside the eye, but this would generally be accompanied by other symptoms such as decreased vision or eye pain).

#2 – Eyelid twitching: This occurs in just about everyone at some point in their lives and is called myokymia. Usually one eyelid starts quivering and may not stop for days or weeks. It is usually just strong enough to be annoying, but doesn’t affect vision or keep you up at night. The most common causes are fatigue, stress and caffeine, but it can also happen spontaneously for no apparent reason at all. If this starts, get a little introspective and see if you’ve brought it on yourself. I remember having eyelid myokymia in medical school for a month, only to have it resolve once I went on vacation. In rare cases, the twitching may continue and involve a larger area, such as the eyelids on both sides, or the upper half of one side of the face. If twitching lasts more than a few weeks, affects vision or eyelid opening, or involves the muscles of the cheek or corner of the mouth, you should have it checked out by a doctor. Ophthalmologists often treat this chronic twitching with Botox or other medications.

#1 – Pink eye: Conjunctivitis is what we call any infection or chemical irritation of the conjunctiva, the clear thin skin of the eyeball. The most common cause for infectious pink eye is adenovirus, the same virus that causes the common cold. This usually causes both eyes to become bloodshot within a day or two of each other or at the same time. They will be itchy and watery and produce a little mucus. They can be sensitive to light and occasionally painful if the cornea is involved. Being a virus, you can’t take an antibiotic pill or use a drop to make it go away. You have to wait it out and treat the symptoms. Chilled artificial tears are good to soothe the irritation, and diligent hand washing is a must to prevent spreading the disease. Bacteria can also cause conjunctivitis, but this generally leads to abundant production of mucus or pus. The eyes will be even more red and the cornea can be involved, at times severe enough to cause permanent damage. Bacterial conjunctivitis will respond to antibiotics, so seeing your ophthalmologist is recommended. If you are unsure which type you have, an ophthalmologist can help you here as well, just don’t be upset when he or she tells you your problem is viral and recommends an over the counter treatment.

Humans are visual animals and we are programmed to make judgments based on what we see, even before we can consider any other information.  This is never more apparent than when we look at the faces of others and make judgments. These may be about their attractiveness, their social status, or even their intelligence. We may judge them to be safe appearing or threatening, perky and happy or cold and reserved.  All of these thoughts can come to us just based on what we see in their faces (I’m sure we’ve all been surprised at some point when we have judged someone’s character based solely on appearance, only to find out later we were totally wrong). It is no wonder then that we are also innately vain, meaning we care deeply about our appearance and what it projects to others.

I dare say that most of us, when we look in the mirror, ponder whether or not our appearance is attractive to others, regardless of our relationship status.  People want to look good.  Everyone enjoys knowing others have a positive view of their appearance.  On the flip side, knowing others have a negative view of your appearance can be psychologically troubling. We could debate all day whether any of this matters in the grand scheme of life, but it is a fact of life that our appearance has an effect on what others think of us and in turn how they treat or act around us.  Recently, there have been many reports of an increase in baby-boomers, who are still in the work-force, getting facial plastic procedures to make themselves appear fresh and young (see here).  They were finding that they were missing out on jobs due to their more aged appearance and bias among hiring companies for younger or more attractive workers.  Men in particular were seeking out facial and eyelid surgeries.  Many felt this was an investment in their careers.

So how do you figure out what makes up an attractive face?  You do lots of research.  There are many universities around the world looking into these types of questions and most are coming up with the same answers.  First of all, they have found that people like average looking faces.  Researchers have used morphing software to combine the faces of scores of people, making an average face, and then placed it in a line up of the faces it was made from.  Almost invariably, the average face is favored as most attractive. The average face ends up being very symmetric with smooth skin.

Average women's faces from countries around the world

Where the average face loses is when it is compared with a “truly” attractive face, one which tends to have more exaggerated features that are considered attractive and but judged to set a face apart.  For women, one study found the following characteristics associated with a more attractive look (Click here for the study website and comparison photos):

  • Suntanned skin
  • Narrower facial shape
  • Less fat
  • Fuller lips
  • Slightly bigger distance of eyes
  • Darker, narrower eye brows
  • Thicker, longer and darker lashes
  • Higher cheek bones
  • Narrower nose
  • No eye rings
  • Thinner lids

For men, the list goes like this:

  • Browner skin
  • Narrower facial shape
  • Less fat
  • Fuller and more symmetrical lips
  • Darker eye brows
  • Thicker and darker lashes
  • Upper half of the face broader in relation to the lower
  • Higher cheek bones
  • Prominent lower jaw
  • More prominent chin
  • No receding brows
  • Thinner lids
  • No wrinkles between nose and corner of the mouth

The researchers also looked into how attractiveness affects peoples perception of mood, intelligence and so on.  They found a striking difference in how subjects perceived attractive people.  They consistently ranked the attractive people as being more sociable, content, hard working, creative, friendly, successful, exciting, accessible and honest.  Mind you, this is just based on a first impression…looking only at a picture!  It is clearly unfair to make these judgments based on looks alone, but we humans do it everyday and knowing about it gives us an edge when it may matter (i.e. a job interview). Sadly, looking your best may be your biggest help when competing against hordes of other similarly qualified applicants.  Hopefully, this information also gives us insight into our own prejudices and we can hold off on snap judgments based on appearance until we have more information on which to form our opinions of someone.

(Another group of researchers looking into similar questions is here: http://www.faceresearch.org/

To see the face of humanity, see this website: http://www.trood.dk/blog/the-face-of-humanity/)

One of the most common complaints I hear in my office is, “My eyes feel dry.”  Many people get that scratchy, irritated feeling to their eyes and know what the problem is.  Even more people, however, come in complaining of a whole host of eye symptoms, not knowing that many of them are caused by dry eyes.  These include blurred vision that improves with blinking, “tired eyes” or “eye strain”, eye pain, light sensitivity and frequent tearing (a reflex due to dry eye sensation). Yes, even eyes that feel wet a lot can be dry.  Let’s first talk about why we tear, then why our eyes are dry, and lastly, what we can do about it.

First, it is important to know that our tears are crucial for good vision.  The first thing light hits when it reaches your eye is the tear film on the surface of your cornea.  The cornea is like the front window to the eye and the tears are like a polish on that window.  With each blink, the eyelid spread a smooth layer of tears across the cornea.  This light is then focused by the cornea and lens onto the retina, forming an image. When the tears dry out on the cornea, they leave a bumpy, irregular surface that distorts the light coming into the eye and makes the image blurry. If the tears are continually drying out between blinks, the surface of the cornea becomes constantly irregular due to dead and dying corneal surface cells.  This often triggers a reflex to produce lots of tears, so many that our tear drain system is overwhelmed and the tears drain down our face. When we see this in the clinic, we diagnose dry eyes.

The tear film is made up of oil, water and mucus

Our tears are made up of 3 components: oil, water and mucus.  The watery part is made mainly in the lacrimal gland which is in the upper outer part of our eye socket under the upper eyelid. There are also many smaller glands on the insides of our eyelids. The skin on the inside of our eyelids makes mucus and rows of glands on our eyelid margins, just behind the eyelashes, make the oil.  All three of these components have to be present in the right amounts to make tears work.  Without water, the tears gum up and you get eye matter.  Without oil, the tears dry out very rapidly between blinks.  Without mucus, the tears are too thin and don’t cover the eye well.

This brings us to the causes of dry eyes:

  • Lack of tear production. This happens due to age, inflammation of the tear glands (such as in Sjögren syndrome), hormonal changes causing less production and loss of reflex tearing.
  • Excessive tear evaporation. Excessive evaporation can occur due to tears having not enough oil (usually due to blockage of the oil ducts) and not blinking enough (common when using the computer or reading).
  • Eyelid problems that prevent the tears from being where they need to be. Eyelid problems also lead to dry eye.  These include poor blink due to a facial nerve problem (i.e. Bell’s palsy, facial or head injury), eyelid deformities, eyes not closing after over-aggressive eyelid lifting, and in cases where the eyes protrude, such as thyroid eye disease.

So what can be done about it?

  • Get properly diagnosed by an ophthalmologist who knows dry eyes.  They will do this by looking at your eyes with a microscope, analyzing your tears with special drops and other tests, and looking at the health of your corneal surface. They will also examine the eyelids to ensure you blink and close the eye appropriately.
  • Use artificial tears. Nearly all types of dry eyes benefit from extra tears.  They need to be used often, at least 4 times daily and up to every 10-30 minutes in severe cases.  There are many different viscosities of tears.  The thicker they are, the longer they’ll last, but thicker tears tend to blur the vision for a while after they are given. Tear ointments are also helpful, especially at night as they can significantly blur the vision when used during the day.
  • Keep your natural tears around longer.  Plugs that block off the tear drains in your eyelids will keep you from swallowing away all those tears as they drain into your nose.  In more severe cases, we often permanently close off the tear drains, which can greatly improve the eye surface. Your natural tears can be enhanced by taking omega-3 supplements.
  • Practice good eyelid hygiene.  Warm compresses on the eyelids to helps oils to flow out more easily into the tears.  Lid scrubs with mild baby shampoo and warm water along the eyelash margin will also keep the oil flowing and keep matter from accumulating in the eyelashes.
  • Prevent excess evaporation.  Blocking out moving air can reduce evaporative tear loss. This is done by wearing close fitting sunglasses during the day and even special moisture goggles to bed at night. Avoid sleeping under a ceiling fan or blowing the air conditioning at your eyes while driving.
  • Reduce or eliminate contact lens wear. Contact lens wearers can use tears or “re-wetting solution” to keep the eyes more moist and improve lens wear comfort. Never wear them overnight and clean them often, no matter what the lens manufacturers say.
  • In special cases, treat inflammation. In a small number of people with inflammation of the tear producing glands, eye drops like Restasis can help produce more tears.  In my view, this medicine is over-prescribed in this country and few patients truly get a benefit from it, so caveat emptor.

Dry eye is common and annoying, but can be readily treated and may improve your vision and overall eye comfort. If you have questions or would like a consultation, call our office at 801-264-4420 or email me at [email protected]

One of the best parts of being a doctor is talking to patients and putting their minds at ease about concerns they have.  It is always nice to turn their worry into a sigh of relief (I wish that was always the case).  Many of the concerns brought up by patients are based on common myths about the eyes that have been propagated and repeated over the years.  Here are the top 10 myths I hear about and hope to debunk once and for all.  I wish everyone’s eye problems were this simple.

#10: “Reading in low light or with very small print will damage your eyes.” The eye is more like a camera than you think. Just as shooting a photograph in low light doesn’t damage your camera, the same holds true for your eye. The picture may be dim and you have to mentally focus more to figure out what you are seeing, but the eye doesn’t know or care if there is a lot of light or a little, it just adapts to give you the best possible picture. People read by candlelight for thousands of years and did just fine.

#9: “Wearing sunglasses indoors/at night will harm your eyes.” No, you’ll just look like you want to be cool and you may bump into the furniture.

#8: “If I wear my glasses all the time I’ll get dependent on them and my vision will be worse.”  Once again, your eyes are very similar to a camera.  They have a series of lenses in the front (the cornea and lens) and a sensor in the back with little pixels (the retina). Putting a different lens on your camera or adjusting the focus doesn’t hurt the camera, it just generates differently focused pictures.  The same is true with glasses.  Their only function is to better focus the light entering your eye on the retina.  You want the best lens system you can get all the time so your pictures are always sharp and clear.  Your body doesn’t know if the picture is sharp or not, only your brain can interpret this and it has no real capacity to permanently change the physical characteristics of your eyes.  You paid a fortune for those fancy frames and lenses.  Use them.

#7: “All eye surgery should somehow involve lasers, or it isn’t state of the art.”  Marketing mavens love to extol the virtues of lasers because they sound so much more technologically advanced.  I have had countless patients express disappointment that I won’t be using a laser to fix their eyelids, because laser surgery is always better.  While a few eye surgeries depend on lasers (i.e. LASIK), most are done with the familiar scalpel, scissors and sutures most people associate with surgery.  With respect to plastic surgery around the eye, lasers can be used to cut the skin, but so can a scalpel or electrocautery.  There is no evidence that any of these devices has any better outcome. One thing lasers do have going for them is that they are much more expensive to operate and maintain than a scalpel, so you can feel good knowing that you paid more for something that is usually no better than the old standby.

#6: “They removed my eye from the socket, fixed it, and put it back in.”  Don’t laugh, every eye doctor hears this at least monthly.  I once tried to argue with the patient, but I was told he had also seen it in a movie (two witnesses).  The eye is directly connected to the brain via the optic nerve.  Removing the eye from the socket involves cutting the optic nerve and several muscle attachments.  Once the optic nerve is severed it cannot regenerate and the eye is blinded. During surgery we use an eyelid speculum to hold the eyelids open, or a different approach is made through the eyelids or occasionally even through the skull.  Every effort is made to keep the optic nerve safe and intact.

#5: “Kids will outgrow crossed eyes.” When a child develops crossing of the eyes (strabismus), an eye exam should be performed as soon as possible. Children have a very small window of time when they can develop binocular vision.  This is where their eyes learn to work together to help produce a 3-dimensional image and allow for normal depth perception. Crossed eyes cannot work together and must be corrected. Often, all that is needed is corrective lenses.  Sometimes patching or eye surgery is necessary.  However, ignoring the problem will most likely lead to one eye losing its ability to achieve sharp vision and making 3-D vision impossible.

#4: “Sitting too close to the TV or computer will damage your eyes.”  This myth is dying out, but you still hear it from time to time. Based on what you already know, you can see why this myth doesn’t hold water. Many people do notice that spending a lot of time watching television, reading or looking at the computer makes their eyes feel tired.  When we use our eyes intently, we tend to blink less, allowing more time for our tears to evaporate.  This leads to dry eye, which will make the eyes become blurred, burn and tear.  Closing your eyes or blinking them more will feel good and this is interpreted as “tired eyes.”  If this is a problem, try putting in some artificial tears a few minutes before starting to work at the computer and take occasional breaks. Focusing up close also requires muscular effort to bring your eyes inward. The eye muscles get tired after a while and may even ache.  Taking break to look off in the distance for a few minutes will usually solve this problem.

#3: “Eating carrots (or some other random food) will make your eyesight better.”  While many vitamins are important to the eyes, anyone with a normal diet gets plenty of them.  A deficiency of vitamin A, which is plentiful in carrots, can affect your vision, but this is rare nowadays and it isn’t necessary to eat extra vitamin A to keep good vision. A balanced diet is good for you, worrying about one particular vitamin isn’t. (People diagnosed with macular degeneration in its early form can benefit from a select group of vitamins called the AREDS formula, named after the study that proved it, otherwise don’t waste your money).

#2: “Wearing contact lenses overnight is okay, my contact lenses are made to be worn that way.” This is a dangerous marketing ploy that contact lens manufacturers use to lure people into buying their lenses. I have seen plenty of nasty corneal infections, and nearly all involved contact lenses. When pressed, most patients will admit to wearing them while sleeping from time to time. While you might get away with wearing your lenses overnight for awhile, this habit will catch up with you and one day you’ll be in serious pain and in danger of a permanent corneal scar, loss of vision, or even loss of your eye.  It can be that serious.  Just take them out and sleep easier knowing you aren’t putting your sight in danger.

#1: “My kid isn’t smart because he can’t see,” or “bad vision can cause dyslexia.” Kids can adapt to almost anything, including very poor vision. This myth gets propagated by people selling all manner of eye exercises and vision enhancing devices for kids who are having trouble learning.  In reality, most kids have some refractive error, usually far-sightedness, which they gradually outgrow as they mature.  Most eyes go from far-sightedness to emmetropia (normal vision not needing glasses).  Some kids go past emmetropia and become near-sighted, eventually needing glasses. Regardless of where you kid’s vision is at, he or she is very adept and compensating for any difficulty in seeing.  Kids squint, hold text closer, or cheat off their friends when they can’t see the blackboard.  They don’t start mixing up their numbers and letters and fail in school.  Save yourself some money and hire a tutor or see a guidance counselor.  That eye doctor that promises to cure dyslexia with eye exercises is only going to separate you from your money.

Honorable Mention: “‘Sexual activity’ or ‘masturbation’ will make you go blind.” If my kids ever ask, this is completely true.  You don’t want to end up blind, do you?