Dr Ben Wild Conjunctivochalasis and dermatochalasis refer to the development of excess tissue. They describe conditions of excess conjunctiva, a clear layer of tissue above the sclera (white part of the eye) and excess eyelid skin, respectively. Frontal view of a healthy eye. Conjunctivochalasis, more specifically, is seen as 1 or more folds of extra conjunctiva poking out from underneath the lower eyelid. This condition interferes with the normal tear flow and if severe, can scratch the cornea. This is a major, often underdiagnosed, cause of dry eye. Frontal view of an eye with conjunctivochalasis above the bottom eyelid. Dermatochalasis, most commonly, is seen as the overhanging of excess eyelid skin of the upper eyelids. However, it can refer to baggy lower eyelids. When affecting the upper eyelids, the added weight of the extra skin can cause the eyelids to droop and limit someone’s vision. Frontal view of an eye with dermatochalasis of the upper lid. Signs Symptoms Causes Excess skin (either epidermal or conjunctival). Risk Factors Increased age, history of ocular allergies or other causes of eyelid swelling such as thyroid eye disease, infections, etc., and chronic ocular surface disease/dry eyes. Prevention Treat allergies, ocular swelling, and/or dry eyes. Treatments Conjunctivochalasis: · Artificial tears. · Topical non-steroidal anti-inflammatories. · Topical steroid drops. · Surgery (resection/dissection/cautery). Dermatochalasis: · Glasses crutch (an arm extending from glasses that hold the eyelids up). · Surgery (blepharoplasty). Conjunctivochalasis can rarely cause permanent corneal scarring but typically would not result in loss of any vision. It most often contributes to symptoms related to dry eye. Treatments listed above tend to work very well. Dermatochalasis is not a vision threatening condition, but if left long enough, can lead to temporary loss of superior vision (because the top of the pupil is covered by the eyelid). This restriction would be restored following surgery.

Dr Ben Wild The iris, the colored part of our eyes, contains 2 muscles. One, the sphincter, is controlled by the parasympathetic nervous system and the other, the dilator, is controlled by the sympathetic nervous system. The interplay between these muscles controls the size of the opening in the middle of the iris known as the pupil. Pupil size is therefore controlled by the sympathetic and parasympathetic nervous systems and any defects along any of those nerve pathways can cause abnormal pupils. Frontal view of an eye with a healthy pupil. Adie's pupil, or syndrome, refers to a condition where the pathways of the parasympathetic nervous system get disrupted. This results in an enlarged pupil that is unreactive to light and possibly the loss of near vision. This can occur in one or both eyes and is occasionally inherited. In most cases it affects one eye and often occurs after a viral illness. If it occurs in both eyes, it may be due to auto-immune inflammation or infection from syphilis. As time passes, the enlarged pupil shrinks but remains non-reactive to light. An enlarged irregularly shaped pupil even in bright light. Signs Large irregularly shaped pupil (may be both pupils), missing or very slow reaction to light, pupil still shrinks when crossing eyes, pupils become small with age. Symptoms Light sensitivity and blur at near. Causes Loss of parasympathetic nerve supply to the affect eye. Risk Factors Viral infection (still unknown which viruses can cause this), syphilis infection. Prevention There are no known preventative measures. Treatments revolve around eliminating the symptoms because there is no known cure for the condition itself. · 0.1% pilocarpine drops to shrink the pupil to reduce light sensitivity. · Colored contact lenses to “shrink” the pupil to reduce light sensitivity. · Reading glasses to help with near vision. An Adie pupil is not an indication of poor health and is not a cause for overall concern. It is, however, a condition without a known cure. Patients will deal with the light sensitivity and loss of near vision until the pupil naturally shrinks with age.

Dr Ben Wild The lacrimal system of the eye (tissues associated with producing your tears) includes the lacrimal gland and Meibomian glands along with many other components. The lacrimal glands create the watery portion of the tears and the Meibomian glands, about 40 tiny glands per eyelid, create a protective lipid/oil layer that sits above the watery layer. A chalazion is a Meibomian or Zeiss gland cyst filled with inflammatory cells and oily secretions. These cysts can turn into large nodules that produce discomfort and can lead to decreased vision. If left untreated these nodules can solidify. A hordeolum is a chalazion that is infected and tends to be much more painful. A frontal view of a normal eye (top) and another frontal view of a large chalazion on the upper lid (bottom) Signs Red to yellow nodule on the inside of the eyelid or on the eyelid margin. Symptoms Localized discomfort, discomfort when blinking, localized heat, if infected (hordeolum) it will be quite tender to the touch, decreased vision if large enough. Causes Inflammation of the eyelids (blepharitis) leading to thickened oil secretions, and finally, plugged meibomian glands. Risk Factors Seborrhea, acne rosacea, constantly rubbing eyes with dirty hands. Prevention Treat the blepharitis before a chalazion occurs with proper lid hygiene. If the blepharitis is chronic, a prophylactic oral tetracycline can help if linked to rosacea. Treatments Treatments aim at unblocking the meibomian gland and removing its solidified contents. · Small: tend to resolve on their own (1/3 cases) · Small to moderate: Lid hygiene with a good skin cleanser that does not burn the eyes (Blephaclean or Cetaphil) followed by 10 minutes of heat applied to the eyelid followed by massaging the eyelid from the base of the lid to the eyelid margin several times a day. · Moderate to large with possibility of infection: same as described in small to moderate but a topical or oral antibiotic may also be prescribed. · Chronic/long standing: steroid injection or incision and manual removal of contents About 1 in 3 cases resolve on their own. Others require about a month of lid hygiene, warm compresses and lid massage, and very few actually require steroid injections (which successfully treat 80% of stubborn cases) or incisions. They typically do not lead to permanent vision loss however, some causes of chalazions/hordeolum can cause vision loss.

Dr Ben Wild The cornea is the outermost layer of the eye in front of the iris. It is a clear tissue, void of any blood vessels, and is one of the main optical components responsible for focusing light on the retina (the light sensing layer at the back of the eye). Frontal view of a healthy eye. Corneal arcus refers to a condition where a white circular band contouring the periphery of the cornea starts to form. This circular band contains lipid/cholesterol deposits that have leaked from blood vessels around the cornea. In the mirror, it may appear as a white band or it may look as if the iris is a different color. It is usually a normal finding, seen in all seniors, but can represent a systemic health condition if seen in younger patients. Up to 30% of younger patients with arcus have high cholesterol. Front view of an eye with arcus. Signs White band of lipid/cholesterol around the edge of the cornea. Symptoms No symptoms. Causes Age, dyslipidemia (high cholesterol). Risk Factors Contact lens wear. Prevention Proper fitting contact lenses, use of silicone-hydrogel contact lenses that allow more oxygen, wearing glasses instead on contact lenses. Treatments No treatment is needed and none exist. Making sure blood work is done to rule out high cholesterol is the only step needed when this is diagnosed. Corneal arcus does not affect vision or cause any discomfort. As long as there are no underlying health conditions, it remains strictly a cosmetic issue.

Dr Ben Wild The eyes are connected in many different ways to themselves and different parts of the body. These connections can include the inner ear, brain, or many different parts of the eye sharing neural networks. If any of these fragile connections becomes disturbed, it can affect the eyes in many ways. Nystagmus is the involuntary oscillation of one or both eyes either left and right (most common), up and down, or rotationally. It involves a drift of the eyes away from their target and a fast snap back to their target. Nystagmus can be physiological (normal) or pathological (caused by disease). Physiological nystagmus can be noticed in some people when they look very far to the right or the left (extreme gaze). They can also be induced by looking at a moving repetitive target or through the vestibulo-ocular reflex (VOR). Briefly, a VOR can be stimulated by spinning in circles quickly thereby making the fluid in the semi-circular canals of the inner ear spin. When a person stops spinning the inner ear fluid continues to spin for a few seconds and the person experiences a nystagmus during that time because the movement of this fluid affects eye movement. Pathological nystagmus is most commonly congenital (born with nystagmus) and is associated with many conditions that cause decreased vision. These can include improper development of the eye, albinism, very high prescription, congenital cataracts, etc. Acquired nystagmus can be from a stroke, trauma, Multiple Sclerosis, brain tumors, inflammation of inner ear, certain anti-epileptic drugs, central nervous system diseases and more. Frontal view indicating different nystagmoid movements, either left-right, up-down, or rotating inwards-outwards. Signs Very fast eye movement either from left-right, up-down, or rotation inwards-outwards, possible torticollis (head tilt/turn) as some patients get some relief from their nystagmus when they look to the side. Symptoms Causes Risk Factors Prevention There are no known preventative measures. Treatments · Cataract surgery or fix refractive error (eye prescription). · Prism glasses to lower nystagmus in primary gaze (straight ahead gaze). · Surgery to lower nystagmus in primary gaze. · Contact lenses so the patient is always looking through the center of their lenses. · Low vision aids like magnifying glasses, telescopes, etc. · Baclofen or gabapentin to lower nystagmus. · Botox. People with congenital nystagmus will live their whole lives with this condition. It will likely affect their ability to get a driver’s permit, may restrict career path, but will not affect their ability to be an independent individual. Acquired nystagmus needs immediate attention as it could be a sign of a life-threatening condition. In some cases, once this condition is diagnosed and treated, the nystagmus will disappear, in other cases, it is permanent.

Dr Ben Wild Eye movements are controlled by 6 extra-ocular muscles. The superior rectus pulls the eye upwards, the inferior rectus pulls the eye downwards, the lateral rectus pulls the eye outwards and the medial rectus pulls the eye inwards. The superior oblique muscle connects to the eye after passing through a pulley called the trochlea and is mainly responsible for rotating the eye inwards and pushing the eye downwards. The inferior oblique follows a similar path as the superior oblique, except underneath the eye and does not travel through a pulley system. Frontal view of an eye with the extra-ocular muscles. The black square shows the trochlear tendon that holds the superior oblique muscle (shown behind the superior rectus muscle). Brown syndrome refers to a restriction of the superior oblique muscle usually due to tightness around the trochlea. It is almost always congenital (born this way) but can be acquired in cases of trauma or inflammation secondary to auto-immune diseases like rheumatoid arthritis. A person with Brown syndrome, while looking up and inwards with the affected eye, may experience double vision because that eye cannot look upwards while the other eye can. Other notables include tenderness/pain, and possibly a clicking noise when trying to look up and inwards. Signs Limited elevation of the eye in up and in gaze, clicking sound on up gaze, normal elevation when looking up and outwards. Rarely, you may notice one eye is pointed downwards in straight ahead gaze and is compensated for by raising of the chin. Symptoms Usually no symptoms, sometimes patients may notice double vision and pain/tenderness in up and inwards gaze. Causes Congenital malformation, trauma to the trochlea or inflammation of the trochlea. Risk Factors Scleritis, pansinusitis, autoimmune conditions such as rheumatoid arthritis. Prevention There are no known preventative measures. Treatments · No treatment required in most cases. · Surgery to lengthen the trochlea if it is causing double vision or affecting head posture. · Treat inflammation. Brown syndrome does not usually cause much discomfort or affect vision. It does not lead to further damage to vision or the eye. In certain cases where the patient has double vision or needs to hold their head a certain way to maintain single vision, surgery can restore proper function and is well tolerated.

Dr Ben Wild Our eye muscles are all interconnected in a complicated pathway with a common goal of delivering comfortable vision in any gaze and at any distance. To have comfortable near vision, the medial rectus muscles of each eye must pull the eyes inwards (converge the eyes) the appropriate amount, the pupils must shrink to help with depth of field, and the ciliary body, a muscle inside the eye, must constrict to change the shape of the lens inside the eye to focus the light from the near target on the retina. Sagittal view of an eye with the ciliary body highlighted. Accommodative insufficiency refers to the inability of the ciliary body to constrict, thereby allowing the lens inside the eye to change shape, leading to blurry vision at near. Sometimes, the ciliary body tries so hard to constrict at near, that it spasms and actually causes distance blur instead of near blur. This is not to be confused with presbyopia that occurs in everybody in early to mid 40s. Presbyopia refers to the natural ageing and stiffening of the lens with what is thought to be a fully functioning ciliary body. It also results in difficulty with near vision. Signs Inability to change focal distance (near to far or vice-versa), takes longer to change focus. Symptoms Blurred vision, holding reading materials further away, avoiding near work, eye fatigue, eye strain, headaches, decreased reading comprehension, words moving on a page, skipping words, inability to change focal distance (near to far or vice-versa), takes longer to change focus. Causes The causes are unknown. Risk Factors Concussion, traumatic brain injury, convergence insufficiency. Prevention Allow children to crawl and develop their near vision, avoid head trauma, apply the 20-20-20 rule (after 20 minutes of near work look at a target at least 20 feet away for 20 seconds). Treatments · Vision therapy including eye exercises that stimulate gradual accommodation (pencil push ups, Brock string, etc.), jump accommodation (Brock string, Hart Chart, etc.), lens training to simulate change in focal distance, computer-based training, in office-based training, and many more. · Seek out an optometrist who specializes in vision therapy. · Digital lenses with a small amount of reading power at the bottom of the lens. · Bifocals. Vision therapy can be effective in strengthening the ciliary body so that it can constrict and relax more efficiently and more timely. This can reduce some, if not all, symptoms of accommodative insufficiency. Vision therapy takes allot of dedication. For a more immediate remedy, try the 20-20-20 rule and/or the digital lens design or bifocals.

Dr Ben Wild Eye movements are controlled by 6 extra-ocular muscles. The superior rectus pulls the eye upwards, the inferior rectus pulls the eye downwards, the lateral rectus pulls the eye outwards and the medial rectus pulls the eye inwards. The superior oblique muscle connects to the eye after passing through a pulley called the trochlea and is mainly responsible for rotating the eye inwards and pushing the eye downwards. The inferior oblique follows a similar path as the superior oblique, except underneath the eye and does not travel through a pulley system. A frontal image of a right eye with the extra-ocular muscles. If any of these muscles are too tight, too loose, too strong or too weak, there is the potential for an eye turn (strabismus). Exotropia is a type of strabismus (eye turn) where one eye is seen wandering outwards compared to the other but all of the eye muscles still have full range of motion. There are a few different causes of exotropia that require different treatments. Early onset exotropia often occurs at birth or soon afterwards and often presents alongside other neurological anomalies. Intermittent exotropia is the most common, is not always present, and can be caused by fatigue, ill health, bright light, and inattentiveness. Types of intermittent exotropia include convergence insufficiency, where one eye wanders outwards when looking at a near object, divergence excess, where one eye wanders when looking at a distant object and basic. Consecutive exotropia may occur after already having strabismus surgery. A normal pair of eyes looking off into the distance. An image showing the right eye is turned outwards. This is an exotropia style of strabismus. Signs One eye is turned outwards compared to the other. It may be constant or intermittent (comes and goes), it my be dependent on where the patient is looking, it may just be one eye or it may alternate eyes. Symptoms Usually no symptoms, possibly eye strain, possible double vision, lack of depth perception. Causes Birth anomalies, vision impairment either in one or both eyes (cataract, retinal scarring, etc.), many still unknown factors. Risk Factors Family history of strabismus. Prevention 1st eye exam around 1 year old followed by another at 3-4 years old to ensure proper development of the eyes and eye muscles. Treatments · Glasses or contacts after a cycloplegic refraction (prescription done after dilating drops). · Treat any amblyopia (lazy eye) by patching the good eye 2hrs/day to full time. · Treat any issues causing decreased vision. · Vision therapy (eye exercises to regain proper eye muscle control). · Surgery by age of 1 or 2 if born with strabismus or upon 1st discovering a strabismus is constant (doesn’t come and go). If born with strabismus, surgery can align the eyes but the patient may need several re-alignment surgeries in their lifetime. There is also only a slim chance of gaining depth perception. If the strabismus develops after the age of 3-4, full glasses prescription and vision therapy can often correct the alignment issue, and if not, surgery can re-align the eyes. Regaining depth perception in this case is likely but not promised.