Keeping an eye on dry eye syndrome

Keeping an eye on dry eye syndrome

Eye complaints are becoming more common especially when the weather is hot, dry and hazy

A Patient of mine who suffered from dry and allergic eyes and eyelids told me recently that she deemed me a role model because of my “sparkly eyes”. As an eye doctor of 20 years and counting, it was the first compliment of its kind, amidst the usual polite comments on my youthful appearance or “nice eyes” I received.

As I pondered it, it drove home to me how precious having healthy eyes is. Aside form seeing well, with good quality of vision, eye health also encompasses healthy appearance and eye comfort, which together contribute to a good quality of life.

It is probably no coincidence that some of the common eye complaints I manage are eye irritation and discomfort. In times of hot, dry spells and haze, eye clinics including ours see even more such cases.

Majority of these are in working adults, but they do come in all ages, including children. They are caused by a combination of eye dryness and allergic conjunctivitis, a condition that plagues the conjunctiva, the superficial lining of the visible part of the white of eye. Accompanying symptoms are blurring of vision, tired eyes and even headaches.

Often relegated to primary eye care, in my experience, these conditions are becoming commoner in recent years, due to the increasing and prolonged use of personal digital devices, computerization of workplace, possibly an increase in airborne particles in our environment and insufficient eye hygiene. The latter is likely contributed to by a multi-billion dollar eye cosmetics industry, several times that of dry eye treatment.

As we gear up against global warming and climate change, it is apt to consider how it relates to our health, including the eyes.

The World Health Organization regularly studies and responds to climate change and human health. For ocular health related to climate change, experts in recent years predicted an exacerbation of symptoms of dry eye disease.

Dry eye specialists classify the sub-types of dry eyes into tear production deficiency versus evaporative eye dryness, in a nutshell.

On the ground, the picture is often mixed. It is suffices to note that dry eye disease is usually chronic and multi-factorial. Apart from the garden variety of dry eyes, arising from a combination of ageing, hence slowing of tear gland production, and increased evaporation, more severe forms may result from diseases such as the autoimmune Sjogren’s syndrome that may cause dry mouth too. Thyroid disease, rheumatoid arthritis, lupus and diabetes are also associated with dry eyes, as are certain medications like anti-histamines, antidepressants and isotretinoin for acne.

Relief for sufferes

The average dry eye sufferers can improve their conditions through several simple measures. These include keeping themselves well hydrated, limiting their onscreen duration, taking more frequent visual breaks, positioning their computers at the lowest height possible to reduce exposed eye surface area, and avoiding direct drafts of air such as fan or air-conditioning from desiccating their ocular surface.

In addition, over-the-counter medications such as tear supplement eye drops and mild versions of anti-allergy eye drops can provide sufficient relief for milder cases.

If these failed to work, specialist care from an eye doctor is recommended, especially for detailed diagnosis to rule out any underlying eye, connective tissue or general health disease, which may contribute to persistent and severe eye dryness.

Sometimes diagnosis merits a variety of examinations including blood tests for related diseases. Treatment will then be targeted again the pertinent issues, such as managing eyelid inflammation or concurrent allergic eye diseases.

Supplements such as oral Vitamin D and omega-three fatty acids are sometimes also advocated, the details of which warrant in-clinic discussions.

More severe dry eyes will required further management, potentially with novel treatment options and even eye surgery. It is important to note that dry eyes can lead to complications such as cornea infections in severe cases, which in turn ricks scarring and spreading in the eye, particularly in ill patients.

In general, the cost of treatment of dry eye disease other than those of higher severity is shared by both the sufferers as well as healthcare sponsors. The global economic and quality of life burden of dry eye diseases had been studied by Dr Marguerite McDonald, published in The Ocular Surface, April 2016, and results suggested that is is a substantial economic burden.

Dry eye disease was found to contribute to loss of work productivity as well as substantial negative impact on physical and also psychological function. An American study by Schiffman et al in 2003 found that in severe cases, its impact on quality of life was comparable to that from having severe angina or chest pain.

Seeing that the global market for treatment of dry eyes is reported to be in the billions currently and expected to increase steadily, health promotion strategies, in my personal opinion, will be well-served to include prevention and management of dry eye syndrome.

In my clinic, in association with the laser refractive and cataract surgery I performed, I highly recommend routinely keeping an eye on dry eye management for improved results.

Long-term care

Screening, pre-treatment, appropriate selection of microsurgical techniques to reduce post-operative dry eyes, compliance to dry eye treatment, patient education and lots of patience from the doctor as well as patients are factors that can lead to success in long-term care of dry eye disease and improved surgical satisfaction.

As for sparkly eyes, my thoughts are that it has to do with my having enough sleep the previous night. Any other factors observed (apparently wisdom also show in sparkly eyes) would be a bonus!

Straits Times Life
24-25 August 2019

Set your sights on eating right

Set your sights on eating right

Have you ever eaten “with your eyes”? The chances are yes.  Apart from odor and taste, the sight of food contributes significantly to our assessment and enjoyment of food.  In fact, the glamourised appearance of a particular food item often becomes the single most powerful advertisement, especially on social media, to the extent that it becomes commonly called food pornography.  As such, eating with our eyes is certainly a true fact, underlining the importance of our sense of sight in the quality of life.

But have you ever thought of eating “for your eyes”?

Eating to see well follows universal dietary principles, which are to have a varied, broad-based diet and preferably fresh food from uncontaminated sources.  In addition to this, several unique food apply to visual health.  I would divide them into two categories, broadly-speaking: eating for the health of the front of eye and the back of eye.

Firstly, the front of eye.  The ocular surface comprising the cornea and conjunctiva is what meets the environment.  The cornea, a transparent tissue, permits light through, and provides structural integrity to the front of our eyes, while the conjunctiva is the lining of the white of our eyes.  These are usually protected by a thin layer of fluid called the tear film, which can dry out when blinking rate drops due to prolonged visual attention.

Modern, desk-bound lifestyle sees many of us glued to computer screens and for way toolong. The consequence of that is an increase in what is termed “digital eye strain”, which causes tired eyes and sometimes, blurring of vision due to dryness and exposure.  Coping mechanisms are none other than reducing the duration of near work and taking frequent visual breaks.  Dietary supplements in the form of omega-three fatty acids, either fish oil or plant-based in origin, are commonly prescribed for dry eyes syndrome.  Simplified, they work in a two-pronged way: strengthening the external oily layer of the tear film to prevent early evaporation of the tear, and also to improve the health of the oil glands at the lid margin, a vital part of our eye surface.  These supplements are, in my experience, truly helpful for low to moderate grades of dry eyes, and are generally very safe to be consumed long term.  They are available over the counter in most pharmacies, with several formulae produced specifically for dry eyes, even though generic formulae are often just as effective.  .

From my understanding, the amount of these fatty acids acquired from modern day regular meals are usually insufficient, and there are no issues in taking supplements in the form of capsules for these.  I occasionally suggest oil forms of these supplements, added to salads or soups.  I routinely recommend these supplements to my cataract and LASIK patients, who usually will encounter a short duration of dry eyes post-operation.  However, severe grades of dry eyes should also be treated medically with prescription eyedrops.

Eye problems arising from nutritional deficiency such as night blindness and xerophthalmia (very severe dry eyes) from severe lack of Vitamin A are very rarely encountered nowadays due to the improved diet in our society.  There is some evidence that adequate Vitamin C from natural food sources has protective effects against cataract formation.

For the back of eye, the central area of the retina called the macula is where photoreceptors are the most concentrated and hence the most sensitive area of our retina.  The macula is the site of insult of two common eye diseases: diabetic retinopathy and age-related macula degeneration.  This area, when affected by these diseases, may swell up, bleed internally and collect deposits of waste substances.  The damage caused to sight can be grave, as central vision and reading are affected.  Other than the macula, the rest of the retina may also be affected by diabetes.

Dietary guidelines for diabetic eye disease sufferers are identical to other diabetes sufferers.  Studies have, however, shown that a tight control of blood glucose level helps to maintain vision, as the tiny blood vessels of the retina succumb easily to poor diabetes control, resulting in sprouting of new and fragile blood vessels that bleed and scar, causing retina detachment and blindness in the advanced stages.

Often, a visit to a dietitian helps to plan a diabetic diet.  A diet composed of regular meals to prevent extreme blood sugar swings is the aim, while keeping intake of calories and body weight in check is definitely a plus.  Further attention to types of carbohydrate consumed may also result in maintaining an even keel.

As for age-related macular degeneration, a disease affecting the elderly in which the macula area is affected by deposits of waste material which result in abnormal blood vessels, the link between diet and vision is much studied.  These studies showed that a regular intake of lutein and zeaxanthin (carotenoids, or pigments found in naturally colourful food), zinc and vitamin A, C and E can reduce the incidence of disease and reduce the risk of disease progression by up to 25 percent.  The dietary recommendations resulting from the oft-quoted large-scale Age-Related Eye Disease Study 2 (AREDS2) form the basis of several oral supplements for macula health, available fairly readily over the counter and in most specialist eye clinics.  For natural sources of lutein and zeaxanthin, look no further than the usual colourful fruits and vegetables, including kale, spinach, papaya, blueberries, goji berries and peppers.  These colourful foods help to maintain colourful vision.

Care in avoiding the wrong food can also bode well for our sight.  Infrequent reports of severe blindness from toxicity to the optic nerves, due to accidental ingestion of methanol are still encountered in the region, even in Singapore.  Possible ocular side effects of medications such as steroids and some oral drugs for cardiac and rheumatoid diseases should also be monitored by the eye specialist, to prevent vision impairment.

Healthy eyes and vision are some of the best gifts in life.  Why not repay our eyes the enjoyment we derive from it, by eating right for our sight?

Have a date with our Specialists at 360 Health Management Seminar on 30 Mar 2019, Saturday 10am to 2pm at SPH News Centre Auditorium. Our Specialists will be sharing various health issues that you might be facing. Register online at

Dr. Daphne Han
Senior Consultant, Ophthalmologist
Singapore Medical Specialists Centre

The Business Times, Sunday, 2 March 2019

More needs to be done to manage myopia in children

More needs to be done to manage myopia in children

More needs to be done to manage myopia in children

Recently my clinic was running very low on unit vials of low dose (0.01%) atropine eyedrops, a nightly medication that is currently commonly prescribed to moderate myopia progression in children.  I was informed by the pharmacist that there is a regional shortage as the demand seemed to be outstripping the supply of this eyedrops treatment for myopia in kids.  The popularity of this medication is hardly surprising as it has been proven effective by multiple researches in Singapore and elsewhere, with almost no known undesirable side effects.  It seems to me that the production and business side of it could see improvement, and if I were an investor I would certainly explore this.

Myopia, or short-sightedness, is a rising epidemic around the world.  Recent studies showed that a trend towards increased incidence of myopia is seen everywhere, particularly in East Asian and urban areas.  Many communities are anxious that more children are getting myopic and starting at a younger age, leading to more years of seeing myopia progressing, before the short-sightedness finally stabilizes at the end of adolescence.

One of 4 types of refractive errors, myopia is particularly cumbersome as it renders one to see blur for distance, with clear sight only for near.  The higher the degree of myopia, the shorter the range of view becomes, thus affecting activities requiring clear vision outside this range, unless it is treated.  Treatment is two-pronged: optically, to provide temporary relief by glasses or contact lenses, or if a more permanent solution is required, surgeries such as laser vision correction or lens implantation can be sought, when the degree is deemed stable.  In addition, increasing focus is placed on strategies to curtail the progression of myopia in childhood, in order to keep myopia within manageable levels. Some of these include encouraging healthy visual habits such as having regular breaks during near visual tasks and spending more time outdoors.

In Singapore, huge efforts had been made both in terms of public health and education measures and in research, aiming to manage this scourge.  The efforts seem to have paid off somewhat.  Last year, we gave ourselves a pat on the back for seeing some signs of stabilization of myopia rates.  Even so, no time should be lost in rejoicing.  For many families with school-going children, regular trips to the optician’s and eye doctors’ continue in a bid to dethrone ourselves as the most myopic country in the world.  To persevere with low dose atropine eyedrops therapy for children with myopia is the least we can do to control the situation, as inevitably, more and more time is spent on near work, no thanks to the increasingly wider applications on hand-held personal digital devices.  Eyedrops treatment is as non-invasive as it gets, and higher concentrations sometimes being trialled for more resistant progressions, with increasing side effects as the medication becomes more powerful.  Next up in the regime is contact lenses, including rigid nightwear lenses (orthokeratology), which require much more handling and strict care in hygiene, without which blinding complications may arise.

Historically, myopia is not a “new disease”.  In fact, it had long existed in the Chinese, Singapore’s predominant ethnic group.  As far back as during the ancient dynasties in China, scholars spent countless hours in tiny, dimly-lit study booths preparing for the imperial exams and were well known to be myopic.  The soft focus rendered by their myopia apparently inspired many a funny and witty Tang poem, mirthfully enjoyed and passed down the generations, along with some myopia genes.  This was the topic of a tongue-in-cheek poster I had put up for the 11th International Myopia Conference (IMC) in Singapore in 2006.  The biennial IMC, currently almost in its 17th iteration, usually never disappoints me with its interesting research from the ground-up and lack of dogma.

Indeed, all the refractive errors, myopia is the only one that has been shown in studies to be associated with psychometric intelligence, particularly of the verbal kind. Interestingly, a previous study apparently found that of a group of subjects with high IQ, a large proportion had very early onset myopia compared with a control group with normal IQ.  To strengthen theories or prove alternative hypotheses, the scientific community often likes to retest similar subjects.  Of course, the devil is in the details. In January this year, a scientific study (which made for an entertaining read to me) was published in the highly respectable journal Nature, titled “Refractive Error is Associated with Intracranial Volume”.  The Japanese researchers went to great length studying the various volumes of the brain in more than a thousand young adults and concluded that myopia is associated with the total intracranial volume, but not the actual grey or white matter volume.  As an analogy, rather like how if you are an L-size for shirts you are most probably L-size for pants too.  Hence if your whole brain size is large your eyeballs would probably be large (and myopic) too, regardless of why and how the brain got to its size. Conventional wisdom would have it that both nature and nurture likely contributed to these facts and findings.

Before we rejoice in the above seemingly positive connotations of myopia, let it be known that definition of an error, in this case in refraction, still equals a state of imperfection to be improved on.  Indeed myopia should be carefully minded.  Not only does it make life inconvenient and certain activities difficult, if not downright dangerous without optical aids such as spectacles and contact lenses, it can be associated with and lead to a higher prevalence of other eye diseases.  Some of these may be blinding, such as glaucoma and retinal detachment.

While the other errors of refraction like astigmatism, hyperopia (or long-sightedness) and presbyopia (or “old-sightedness”) are equally inconvenient, none of them is as common and impactful in the formative years of a person’s life.  For instance, it may be unwieldy in certain sporting pursuits, predispose to higher incidence of injuries or mishaps, and may generally affect self-esteem or self-perception.  In fact, scientific research had shown associations between myopia and personality traits of lower extroversion and behavioural patterns such as having a narrow focus of visual attention.  In the more severe cases, hallucinations and paranoid tendencies had been reported to be linked to myopia.

Therein should be the impetus to reduce the incidence and severity of the plague of myopia, one of the most common causes of visual impairment in the world.  In my humble opinion, simply prescribing glasses for school children is not sufficient in today’s scenario, when multiple researches have shown proven benefit of medical therapy such as using low dose atropine eyedrops in retarding myopia progression. Regular monitoring with a view to such safe and effective treatment should be highly recommended in young children and teenagers.  Encouragement for more time spent outdoors in natural outdoor lighting, with the natural fluctuations in intensity that come with it, is also highly recommended, as this is what the results of several comparative studies seem to point to.

Dr. Daphne Han
Senior Consultant, Ophthalmologist
Singapore Medical Specialists Centre

The Business Times, Sunday, 11 November 2018