Category: Blog

Chronic Dry Eye

Dry eye is a condition caused by lack of oil or tears in the outer layer of the eye. The causes, signs, and symptoms of Chronic Dry Eye (also called Dry Eye Syndrome or Dry Eye Disease) vary from person to person, but here are some of the most common indicators you should know about:

• • Stinging
  • Irritation
  • Grittiness
  • Occasional blurry vision
  • Feeling like you have something in your eyes
  • Burning eyes
  • Itchy eyes
  • Redness
  • Watery eyes—which can seem confusing, given the name “Dry Eye”

That’s why, if you think your eyes are feeling dry, itchy, gritty, or blurry at times, it’s important to speak to your doctor. We have several methods to test for various types of dry eye, including tear film testing, inflammation testing, and gland imaging. If you do suffer from dry eye, early intervention is critical to managing your condition.

Dry eye treatments can include:

• • Omega 3 Supplements – available through our office
  • Lid Hygiene Products
  • Artificial Tears
  • Warm Compresses
  • Blinking Excersizes
  • Medication
  • LipfiFlow Treatment

Dry Eye or MGD? It’s time to change your outlook on dry eye. There are roughly 30 million people in the United States and over 300 million worldwide who have been diagnosed with dry eye. Most have learned to live with eye discomfort and have become dependent on drops or other treatment methods that only offer temporary relief. This has been due to a lack of understanding that the root cause of most dry eye (86%) is now known to be a chronic and progressive condition, Meibomian Gland Dysfunction or MGD. MGD occurs when there is a compromise to the function and/or structure of the meibomian glands in the eyelids that produce the protective oily layer of the tear film. These glands can become blocked over time and can no longer produce oils needed for healthy tears. This blockage results in rapid evaporation of your tears and can lead to irritation, discomfort and if not treated, gland dropout. MGD Identification A series of evaluations will be performed to determine if you have MGD. This can include a LipiView^® tear film and gland imaging and a meibomian gland evaluation. Knowing what is causing your Dry Eye will help your doctor determine the best treatment option. Now, with the breakthrough LipiFlow^® technology, it’s possible to directly treat the root cause of MGD.   Treating MGD with LipiFlow While there are multiple choices available for treating MGD, LipiFlow is the only FDA-cleared device for removing gland blockages and restoring gland function. Through advances in the application of Vectored Thermal Pulsation (VTPTM) technology, the LipiFlow treatment utilizes a patented algorithm of heat applied to the inner eyelids and massage to remove the obstructions in your meibomian glands. For more information, download our Patient Booklet Brochure.

Dry Eye and MGD? (with subtitles) from TearScience on Vimeo.

Fish Oil Triglycerides vs. Ethyl Esters

Omega-3s from fish oil, eicosapantaonic acid (EPA) and docosahexaenoic acid (DHA) come to consumers in one of two forms: triglycerides or ethyl esters. One of the most controversial and debated quality issues surrounding fish oil is which form of fish oil is best – Triglyceride (TG) or Ethyl Ester (EE) ?

What form  are the long-chain omega 3 fatty acids (EPA and DHA) in when we absorb them from eating fish ? The answer is triglyceride. Over 98% of all fats ingested are in triglyceride form.

Cost vs. Absorption

Ethyl ester forms of omega-3 fatty acid supplements are becoming more prevalent in the market because of the cost: they are cheaper to produce than triglyceride forms. The industry created ethyl ester because they are more malleable form than triglycerides. They have a much higher boiling point, and are easier to work with when processing for supplement distribution.

The main purpose of molecular distillation is to remove the industrial contaminants (e.g., heavy metals, dioxins, and PCBs) present ine the commodity fish oils most supplement makers use, and concentrate the omega-3 molecules, EPA and DHA. In this model sterility overshadows efficacy.

Studies have shown that ethyl esters are the least bio-available forms of omega-3’s compared to TG forms and/or whole fish. One purification is complete through the micro distillation process why would the manufacturer leave them in an EE form – COST.

The process to convert fish oil EEs back to TGs is costly. Bulk oil costs for TG concentrates are typically 30-40% higher than EE concentrates.

Mico Distillation

Ethyl esters are produced by reacting crude fish oil in a free fatty acid form with ethanol (and industrial alcohol) to form a synthetic substrate. Under a vacuum, the mix is then heat distilled and the resulting condensate is a concentrated omega-3 ethyl ester solution. The concentration of the omega-3 fatty acid depends on the variables of the distillation process but normally results in a 50-70% omega-3 solution.

The process of converting TGs to EEs is necessary from a technical standpoint in the production of fish oil concentrates to purify the oil. However, once this molecular distillation process is completed, there is an option to leave the fatty acids in free form, attached to an ethyl alcohol backbone, or to reattach them to a glycerol backbone (triglyceride).

Metabolism

While in the EE form, the glycerol backbone is missing. Therefore, the fatty acids will find an available triglyceride backbone or take one from an existing molecule. If the latter occurs, the molecule missing the backbone will look for another backbone, and so on, creating a domino effect. The free fatty acids are taken up by the enterocytes (gut epithelium) and must be reconverted to TGs to be transported in the blood.  Fats are stored and transported in the body in triglyceride form.

Research shows that after ingestion of an omega-3 fatty acid molecule in triglyceride form, the fatty acids are cut from the glycerol backbone, the the backbone and fatty acids are absorbed via the gut epithelial cells and immediately reattached to form the natural triglyceride.

This is supported by our own understanding of human physiology: when ethyl esters are consumed, they are processed in the liver, where the ethanol is drawn off, and the body must then rebuild the resulting free fatty acids back into a triglyceride. The EEs that get digested produce free fatty acids plus ethanol. This is certainly a less efficient absorption process compared with the direct intake of a natural form trigycleride because  the EE form must be reconverted in the body back to a TG form. The delay in TG re-synthesis suggests that transport to the blood is more efficient in natural TG fish oils in comparison to EE. Furthermore, this delay of TG re-synthesis in EE fish oils causes a release of ethyl alcohol and may subsequently produce oxidative stress by releasing free radicals in addition to releasing the ethanol.

Just the Science

A bioavailability of different omega-3 formulations was reported by Dyerberg (the father of the fish oil), 95 et al. 72 healthy subjects were allocated to be given a reesterified TG, EE free fatty acid, fish oil or cod liver oil preparation for two weeks. The concentration of EPA and DHA was highest in the re-esterified TG group and lowest in the cod liver oil group.

A similar study also concluded that only 20 percent of the omega-3s in the standard ethyl ester from were absorbed, unless they were taken with a high-fat meal, which raised the absorption level three-fold, to 60%. In contrast, the absorption of other fish derived omega-3s (EPA and DHA) in their natural triglyceride form was substantially greater in either context (high fat or low fat): absorption of DHA was equally superior with either low-fat meals or high-fat meals, while participants absorption of EPA increased from an already-high 69% to 90% when taken with a high-fat meal.

Evidence suggests that triglyceride (TG) fish oils are better absorbed in comparison to EEs. Natural TG fish oil results in 50% more plasma EPA and DHA after absorption in comparison to EE oils, TG forms of EPA and DHA were shown to be 48% and 36% better absorbed than EE forms, EPA incorporation into plasma lipids was found to be considerably smaller and took longer when administrated as an EE.

Omega-3 fish oils in the form of EEs are much less stable than those in the natural TG form and readily oxidize. The oxidation kinetics of DHA as an EE or as a TG was assessed by measuring the concentration of oxygen found in the head space of a reaction vessel with both TG and EE forms. The EE form of DHA was more reactive, and quickly oxidized, demonstrating that EE fish oils are far less stable and more readily product harmful oxidation products. Furthermore, the stability of oil containing DHA in phospholipid triglyceride, and EE form has been assessed. After a 10 week oxidation period, the EE DHA oil decayed 33% more rapidly.

Side Effects: Ethyl Ester vs. Triglyceride

Ethyl Ester form:

The ethanol in EE form MUST be filtered through the liver. As we have just discussed, when ethyl esters are consumed, they are processed in the liver, where the ethanol is drawn off, and the body must then rebuild the resulting free fatty acids back into a triglyceride. Any form of alcohol filtering through the liver runs the risk of side effects.

The most common side effects: burping (thus the need for enteric coating), infection, flu symptoms, upset stomach, a change in your sense of taste, back pain, and skin rash. Indeed, the impact of ethanol release from ethyl ester forms of fish oil can be documented under the adverse events section in the prescribing information for Lovaza, the EE prescription form of fish oil. Some of these adverse events include body odor, vomiting, gastrointestinal disorder, pancreatitis, cardiac impact and hypertriglyceridemia (which is paradoxically the clinical issue for which this drug is prescribed). All of these side effects are a result of the toxicity of the ethanol released from this highly concentrated EE form.

Triglyceride form:

Almost all Clinical Evidence showing Omega-3 benefits relate to fish consumption. Fish are in a TG form. There are no ethyl ester fish in nature. Humans must consume fish oil in the same form as the fish to receive the maximum benefits.

Ethyl esters have been in the human food chain approximately 20 years.

Triglyceride fatty acids have been eaten safely, and for great benefit, for an estimated 600 million years.

Source: PRN- Physician Recommended Nutriceutical pamphlets

Dry eye can result in discomfort or visual changes.   Common symptoms can include stinging, burning, a gritty feeling, redness, or mucous in the eye.  Some people experience excessive watering as the eye tries to compensate.  Other people notice visual fatigue or blurring, or other changes to visual acuity.  Advanced dry eye can lead to susceptibility to infection, as well as changes to the corneal surface that can impair vision. Dry eye symptoms can vary significantly from person to person. Recurring blurred vision sometimes may be the only symptom, while counter-intuitively, excessive tearing can actually be a symptom of dry eye in other patients. Symptoms alone are NOT a true indication of how severe dry eye is. Only dry eye testing done during an eye exam can truly show how progressed dry eye is in a sufferer.

Dr. Farbowitz strives to stay up-to-date on the latest technology breakthroughs. In an effort to create a comprehensive treatment program for dry-eye, our practice has added several new diagnostic and treatment options to better serve our patients.  We have added testing for inflammation, tear film osmolarity,  and blocked or insufficient meibomian glands.  Common causes, such as screen time, medical conditions, medications, lid hygiene, environmental factors, nutrition are evaluated as well.  These tests and evaluations help Dr. Farbowitz determine the type of dry eye that a patient is experiencing and form an appropriate plan of treatment.  Preventative measures might include eye protection, using a humidifier, eye breaks, and use of  artificial tears.  Treatments can include artificial tears, lid hygiene products, vitamin supplements, prescription drops, punctal plugs, and LipiFlow treatment to improve oil flow in the tear film.  LipiFlow technology helps unblock oil glands to protect the tear film and corneas.  This 12-minute procedure is done in-office.  It uses special heat and massage techniques to promote oil flow in the eyes.  Patients liken the experience to a spa treatment, and the results can last for years with proper maintenance care observed afterward.

Proper moisture levels in the eye are vital to overall eye health.  Our practice is proud to offer solutions and preventative measures to our patients to combat this growing problem.

If you experience any symptoms of dry eye, call to schedule an evaluation at 973-379-2544.

Read Dr. Farbowitz’s published article on Dry Eye for more information!

Eye Health Tips for High School and College Students

Students face special challenges to the eyes when they are under academic performance pressure. Lack of sleep, prolonged computer use and long hours studying make for tired eyes that are dry, scratchy and achy.

Prolonged computer use contributes to eye fatigue because you blink less frequently. Less blinking significantly reduces lubrication in the eye making it feel tired, scratchy and “dry” as a result. Also eyes are not designed for prolonged focus on a single object, such as the computer. Remedy: place a note on the computer screen as a reminder to blink and to look away from the screen and focus on objects in the distance.  Looking out a window (20 – 20 – 20 rule:  for every 20 minutes of computer work, look away for 20 seconds, and focus on a scene or object at least 20 feet away) is a good break for the eyes. The key is to give your eyes a rest.

“Dry eye” is a common feeling from not giving your eyes enough rest while some people just naturally do not produce enough tears to keep their eyes healthy and comfortable. Some common symptoms of dry eye are stinging and burning to the eyes, scratchiness, excessive eye irritation from smoke or wind and excessive tearing. Remedy: If you have occasional symptoms of dry eye, you should try eye drops called artificial tears. These are similar to your own tears and help lubricate the eyes and maintain moisture. For persistent “dry eye,” see your Eye MD.

Contact Lenses and Sleep Deprivation

When a contact-lens wearer stays awake studying for 18-20 hours or more with their contacts in, it’s almost the equivalent of sleeping with contacts in, something that Eye M.D.s warn against. Prolonged wearing of your contact lenses is a problem for people who wear regular hydrogen lenses, since traditional hydrogels are relatively less permeable to oxygen than newer alternatives like silicone hydrogels. The eye needs oxygen to keep it healthy. Without regular exposure to oxygen, the eye’s cornea can become inflamed and the vision blurry.  Prolonged contact lens use can even lead to infections or corneal ulcers that in the worst case can permanently damage vision.

Sometimes students fall asleep without knowing it (with their contacts in), while studying. Remedy: Alternate wearing contact lenses with use of eyeglasses during long study periods.  Also, students with irregular sleep patterns can wear contact lenses made of silicon hydrogen, a new material with improved oxygen permeability, which may reduce risk of infection and discomfort.

For more information about contact lenses and proper contact care guidelines please visit http://www.geteyesmart.org/eyesmart/glasses-contacts-lasik/contact-lens.cfm.

This article reprinted with permission from the American Academy of Ophthalmology’s EyeSmart® program (www.geteyesmart.org).

Short Hills Ophthalmology has been growing our practice over the past few months.  We have proudly welcomed Dr. Antonelli and Dr. Ryan-Brophy to our staff.  Dr. Antonelli is available on Monday afternoons and evenings in the Short Hills office.  Dr. Ryan-Brophy is available in Short Hills on Tuesdays and alternate Thursdays, and in Clifton on alternate Thursdays and every Friday.  Dr. Mund will be in Clifton Mondays and Tuesdays.

In addition, we are pleased to offer an alternative to traditional dilation.  Ask our staff if our digital imaging option is right for you!  In addition to saving time, this technology  can allow our patients to return to normal activity immediately after the appointment.  We are pleased to offer this option for the convenience and care of our patients. Digital imaging allows your eye doctor to evaluate the health of the back of your eye, the retina.  Our office stores these images in your record, allowing your doctor to detect and measure any changes to your retina each time you get your eyes examined, as many eye conditions, such as Glaucoma are diagnosed by detecting changes over time.

As always, our team is always researching and evaluating the best options for contact lenses and glasses.   Talk to our contact lens specialist or our optical shop about new options for your vision care!

In my 20 years as an ophthalmologist, nothing has given me more gratification than the ability to remove a cataract and restore someone’s vision.  A cataract is a clouding of the natural lens that occurs with advancing age.  Trauma, certain medications, and diseases can also cause cataracts, but like wrinkles, anyone who lives long enough will eventually develop cataracts.  Cataracts are so common that surgery to remove them is the most common surgical procedure performed in the United States. Symptoms of cataracts include blurry vision at distance and/or near, difficulty seeing or driving at night, and glare from sunlight or oncoming headlights.

The good news is that cataract surgery has evolved from a very complicated and risky procedure with a prolonged and difficult recovery period to a marvel of modern medicine.  Modern cataract surgery is performed in an outpatient setting, with most patients returning to normal activity within a few days.

In the early days, cataracts were removed by “couching”, which involved striking the eye with a blunt object to dislocate the clouded lens into another area inside the eyeball.  Through the 1960s and 1970s, the lens was removed in one large piece through an incision in the eye, which meant stitches, long recovery periods, and often, hospitalization.  After surgery, since patients could not see without a lens inside their eye, they required thick “coke bottle” type glasses.

Artificial lens implants at the time of surgery became commonplace in the 1980s. They were invented when Sir Harold Ridley, a pioneering British ophthalmologist, discovered that World War II fighter pilots who sustained eye injuries and had pieces of their plastic windshield inside their eyes tolerated the material without infection or inflammation.

These days, cataracts are removed by breaking up the clouded lens with tiny ultrasound equipment and vacuuming out the debris through a tiny 3mm opening.  These incisions are so small they rarely require stitches and seal themselves.  Instead of “coke bottle” glasses, a foldable lens implant made of acrylic or silicone is inserted through the same tiny 3mm incision and positioned inside the space left by the cataract.  This modern procedure results in very rapid recovery and little to no down time from regular daily activities.

In the past few years, the explosion in technology has taken a very safe and successful surgery and made it even better.  New vision correcting lens implants have allowed me to correct my patients vision and eliminate the need for distance and reading glasses after surgery.  It is very exciting to hear patients describe their experiences with independence from their old glasses after surgery, especially when they were so dependent on glasses beforehand.  With the use of astigmatism-correcting and multifocal lens implants, I can correct the vision of almost any cataract patient at the time of surgery.  Post-operative day one, when I remove the eye patch in my office, is often the most satisfying day for everyone.

The advances don’t stop with lens implants.  Our surgery center was among the first in New Jersey to offer laser-assisted cataract surgery.  This new technology automates certain delicate parts of the procedure, softens the cataract making it easier to remove with ultrasound, and makes the incisions with increasing precision.  We also have a device that attaches to the operating room microscope called an aberrometer that measures the eye during surgery, improving the selection of the lens power and improving my patients resulting vision.

All in all, it’s an exciting time to be a cataract surgeon.  I set the bar very high for my patients and myself.  I not only aim to remove the cataract safely and successfully, but to eliminate the need for glasses to the best of my ability.

Despite all the new technology, I still use my skills in the old fashioned technique, when I travel to third world countries.  There we don’t have access to modern ultrasounds and microscopes, so I still remove cataracts in one piece.  Even with the old-fashioned surgery, I get immense gratification in restoring sight.