Having eye problems? Why not ask an Ophthalmologist – the MD of the eye world.
The latest innovations in ophthalmology.
Dr. Plemel is an oculoplastic surgeon in a hospital practice. His patients are primarily adults requiring surgical care for various conditions, including skin cancers, age-related changes to the eye area, and trauma. Dr. Plemel takes pride in being able to offer comfort and compassion to help patients through an otherwise stressful time in their lives.
What are some of the most common non-cancerous conditions that present as lumps/bumps around the eye?
When we think about the different lumps and bumps that can occur around the eye, there are many types that aren’t cancerous. They fall into a few broad categories:
Skin tags are small, non-cancerous growths that tend to develop where the skin rubs together. When they occur in or around the eye, people might seek treatment because they’re bothered by the appearance or by irritation.
Freckles or moles can occur on the eyelids.
Blood vessel growths called hemangiomas can occur around the eyes, especially in kids. Sometimes they grow so big that they close the eye and need to be treated.
Growths can also occur on the surface of the eye itself. A pterygium is a triangle-shaped growth of fleshy tissue from the eye’s conjunctiva, often occurring near the inside corner of the eye. It can grow to cover the cornea. Pterygiums are commonly seen in people who spend a lot of time in the sun. Sometimes they are referred to as “surfer’s eye”, but I’ve only had one professional surfer come to me for a pterygium!
What are the types of cancer that can occur in and around the eye?
About 1 in 6 of the patients on whom I operate have skin cancers. The most common forms around the eyes are:
Basal cell carcinomas
About 90% of skin cancers around the eyes
Squamous cell carcinomas
5-10% of skin cancers around the eyes
Less common types include sebaceous cell carcinomas, malignant melanomas, and other rare forms.
It’s also possible to get skin cancers on the surface of the eye (such as ocular surface squamous neoplasias). Malignant melanomas, as well as some other cancers, can also occur on the surface of the eye or even inside the eye.
Who’s most at risk for developing cancers in and around the eye?
Skin cancer is the most common form of cancer. While it can happen at any point in life, skin cancer is more common with age – about 1 in 5 North Americans will have skin cancer by the time they are 70, with 5-10% of cases occurring in the zone around the eyes. UV exposure is the biggest environmental risk. About 90% of all skin cancers can be attributed to UV radiation. In fact, having a single blistering sunburn in childhood or adolescence doubles your lifetime risk of developing skin cancer. Other risk factors include a history of other skin cancers, having fair skin, smoking, and having a weakened immune system (such as people on immunosuppressants). But remember, even individuals with dark skin are at risk of skin cancer. Everyone should take precautions and have unusual spots examined by a health care provider.
There’s a small spot on my upper eyelid that has been bleeding/scabbing over for a couple of months. Is this something I should have checked out?
My healthcare provider has referred me to an oculoplastic specialist to look at a lump on my eyelid. What can I expect from my appointment?
Understanding what might happen at your upcoming appointment can help reduce anxiety and make you feel better prepared. In my own practice, a typical appointment of this nature would involve:
Assessing your risk factors for periocular cancers
(previous history of skin cancer, skin complexion, sun exposure, smoking, etc.)
Examining the appearance of the area under the room lights and
with a slit lamp
Features suggestive of skin cancer?
NO
Remove the spot surgically for aesthetic reasons, if desired (typically not covered by your provincial health insurance)
UNCLEAR
Offer to take a biopsy to confirm
About 1 in 5 biopsies of indeterminate spots end up being cancer
Some patients prefer to watch the spot to see if it worsens; photographs can be helpful to track changes over time
YES
Remove the cancer surgically
When caught early, many common forms of eyelid cancer can be successfully treated
Your ophthalmologist will help determine what next steps to take. We are fortunate in Canada to have excellent standards in training and care as reflected by the membership of the Canadian Ophthalmological Society. Many oculoplastic surgeons are also members of the Canadian Society of Oculoplastic Surgery (CSOPS), which represents a qualified group of Ophthalmic Surgeons who have additional training and experience.
I had a biopsy done for a lesion on my eyelid that came back as cancerous. What are the different treatment options?
Your doctor will determine the best treatment options for you based on the type of cancer found and its extent. For example, there are some small pre-cancerous and cancerous lesions that can be treated with liquid nitrogen. There are also some topical creams that are very effective at killing cancerous cells. However, these methods do come with some risks when used near the eyes. In most cases, lesions around the eyes are removed surgically. Other forms of therapy, like chemotherapy or radiation, may be considered in patients who are medically complex or can’t undergo surgery.
What happens during a surgery to remove eyelid cancer?
There are three main goals, in order of priority, of a surgery to remove skin cancer:
Completely remove the cancer
Maintain the
function of the eyelid
Achieve a cosmetic
outcome with the eyelid
Thankfully, oculoplastic surgeons are often able to achieve all of these goals. Surgery is typically done with the patient awake, without sedation. To help ensure we get all the cancerous cells, we most often use wide local excision to cut out the cancer and a few millimetres on either side of the lesion. The pathologist will examine the removed tissue to confirm the cancer has been completely removed. If there is still some cancer left, we operate again to take a little bit more until all the cancer is gone. Other specialized techniques, called intraoperative frozen sections and Mohs micrographic surgery, are used in extra sensitive or large areas to ensure complete cancer removal before any reconstruction work is done. These specialized techniques are not available everywhere in Canada.
Depending on the amount of the eyelid we’ve had to remove, we may need to use skin flaps (where local skin is moved to help fill the defect) or grafts (where skin is taken from another location) to help reconstruct the eyelid for the best possible functional and cosmetic outcomes.
What are the best things I can be doing to lower my risk of skin cancer?
90% of skin cancers are caused by UV light, so the best way to prevent them is to avoid unnecessary UV exposure. All the usual sun protection measures apply:
Early detection and treatment of skin cancers is crucial, so it’s a good idea to make a regular skin check part of your routine and report any changes to your doctor.
Virtual health care has rapidly expanded across Canada in recent years. Dr. Vivian Yin explains its role in ophthalmology and how it’s being used to increase access to eye care.
Dr. Vivian Yin
Ophthalmologist and oculoplastic surgeon
University of British Columbia, Vancouver, BC
Tele-ophthalmology is a way of delivering eye care remotely, using any form of telecommunications technology or digital medical equipment. It offers the opportunity for ophthalmologists to attend to patients who may have limited access to eye care, like patients living in remote or rural areas.
While tele-ophthalmology isn’t new, the COVID-19 pandemic led to a rapid uptake of virtual eye care visits out of necessity.
Due to public health restrictions, virtual visits were encouraged/legalized in many jurisdictions
Patient acceptance of virtual health care grew
Physician billing codes for virtual visits were introduced by health authorities
While many in-clinic visits have resumed, tele-ophthalmology has proved valuable in addressing barriers related to accessing in-person care. The infrastructure is now in place to support its use in ophthalmic practice moving forward.
See how tele-ophthalmology was used to help Tara, 61, receive the eye care she needed.
Patient of Dr. Yin from Fort St. John, BC
Tara is a 61-year-old from Fort St. John, BC. She felt a lump on her eye and had some intermittent double vision for over a year. She is seen by a visiting ophthalmologist as recommended by her GP.
The visiting ophthalmologist arranges for a CT scan of her orbits and determines that Tara has a tumour behind her left eye in the lacrimal gland. She is referred to Dr. Yin, an oculoplastic surgeon in Vancouver, to discuss surgical treatment options.
Tara has a virtual consult with Dr. Yin via Zoom. During this appointment, Dr. Yin reviews Tara’s CT images (taken locally in Fort St. John). Dr. Yin explains to Tara the most likely diagnosis is a lacrimal gland tumour and suggests that Tara proceeds with a biopsy for diagnosis.
Tara travels to Vancouver for surgery. She meets with Dr. Yin right before the surgery for any additional questions.
Tara’s surgery is performed by Dr. Yin. She returns home to Fort St. John.
Tara’s follow-up appointment with Dr. Yin is conducted virtually.
Once Tara’s condition is considered stabilized, her care is managed by her local ophthalmologist.
“I don’t think a virtual exam can replace an in-person appointment. Rather, virtual exams are an adjunct to help coordinate patient care in certain specific scenarios so that everything that needs to be done can be arranged in one trip.”
– Dr. Vivian Yin
Tele-ophthalmology has a long history in Canada. Several provinces have established successful tele-ophthalmology programs for disease screening and management in remote and underserved populations.
In a program that ran successfully for many years, collaboration between the local community and ophthalmologists was key to a successful diabetes care program. The First Nation community took ownership of a diabetes screening clinic, with ophthalmologists acting as consultants and providing imaging cameras, training, and data collection. In addition to providing retinal screening, the program provided comprehensive diabetes care that was valuable to the community, with nurses and point-of-care labs doing additional assessments and education about diabetes management.
Retinoblastoma is the most common form of childhood eye cancer. Since specialists are available in only a few centres of excellence, access to care remains an issue for many affected families. The retinoblastoma team at SickKids hospital in Toronto provides service to 100% of children with retinoblastoma in Ontario, as well as Alberta and Manitoba.
To help reach a highly vulnerable recent immigrant population in Ottawa, standing imaging cameras at drop-in community health centres can allow patients to get an eye exam at times and in ways that are more convenient to them, when there may not be an eye care professional available.
Artificial intelligence (AI) technology is being used to screen rural, remote, and Indigenous populations in Northern and Eastern Ontario for DR. The AI-based system can take and interpret retinal images without the need for an eye care specialist. Patients who fail the screening are referred to an ophthalmologist for further evaluation and care.
Tele-ophthalmology programs have been successfully implemented to serve patients across various regions, including remote areas like Nunavik and Cree territories. These initiatives aim to address the unique healthcare needs of these populations, considering their geographical isolation and limited access to specialized eye care services. By connecting patients to ophthalmologists, optometrists, and family doctors, these underserved communities receive critical eye care services and screening for DR.
New technology is allowing for certain diseases, like glaucoma, to be monitored at home
Linking a centre in a rural community to a major centre via tele-ophthalmology could help increase access to eye care for many Canadians
With all the recent buzz about artificial intelligence (AI) in medicine, you might be wondering how it might be used to support eye care. Dr. Fares Antaki shares his perspectives on the potential role of AI technology in the field of ophthalmology.
Dr. Fares Antaki
Ophthalmologist
Centre hospitalier de l’Université de Montréal,
Montréal, Québec
An aging population means more patients who require eye care
The number of ophthalmologists in Canada isn’t expected to keep up with the growing patient load
Patients in remote or rural areas face barriers to accessing eye care
“I believe we need to build AI systems that are useful for the clinician, for the patient, and for the healthcare system. It’s important for us to determine what the bottlenecks are for providing efficient and high-quality care for our patients and using AI to address those issues.”
– Dr. Fares Antaki
Provide large-scale, low-cost screening for some Big 5 eye diseases, like diabetic retinopathy (DR) and in the future, AMD and glaucoma
AI-assisted screening may help:
Eventually, there’s a potential to reinvent eye exams using AI-based tools at every step to:
This could transform the clinic waiting room into a pre-testing space or give ophthalmologists the ability to take care of patients in remote areas
Assist eye care professionals in making a diagnosis or predicting risk of disease progression with better accuracy
AI models are in development that can help:
Optometry clinics
could employ AI models that help detect signs of eye disease and triage patients for referral to their nearest ophthalmologist based on the urgency
Ophthalmology clinics
could have more advanced clinical decision-making tools (for example, an AI system that considers patient demographics, optic nerve appearance, and visual fields to inform risk of glaucoma or risk of progression)
Advance precision medicine – choosing the best treatment for each unique patient
Cataract surgery
AI algorithms already allow ophthalmologists to select the best power of intraocular lens for each patient based on their eye dimensions
AMD/DR
A smart AI agent is in development that informs the specialist performing anti-VEGF injections whether they need to switch medications or adjust the treatment interval, based on the appearance on imaging and patient’s visual acuity
Retinal surgery
In the future, AI systems could allow ophthalmologists to determine the ideal surgical technique and post-operative instructions for each patient for the best possible outcome
“There are many ways to fix a retinal detachment – which technique is right for this patient?”
Visual assessment devices equipped with a virtual assistant that can coach patients through a visual field assessment without a technician
RETFound – the first ophthalmic foundation model
Foundation models are a novel paradigm for building AI systems. They can be multimodal – so they can understand different types of data, including text and images. Since ophthalmology is a speciality that is multimodal (relying on imaging from different machines to make a diagnosis), foundation models have a benefit over traditional deep learning models that can only take one modality at a time.
While AI has the potential to transform many areas of eye care, there are several barriers to widespread adoption in Canada. Rolling out an effective AI system requires:
Electronic health records
(many provinces don’t have them, or they aren’t shared across healthcare settings)
IT infrastructure to support sophisticated AI technology & tools
Clinical guidance and strong frameworks to support ophthalmologists so they understand how to use AI tools effectively and responsibly
Even once these hurdles are addressed, AI won’t be adopted overnight. There are important questions to answer and steps to take before AI technology can be put into practice.
Find an AI model with
good performance
metrics
Validate the model in
the local patient
population
Integrate the model
into the current care
pathway
Ensure the new
pathway is in line
with the cost of the
current standard of
care, while staying
safe and effective
for patients
Put the right
mechanisms in place
to maintain patient
data confidentiality,
perform audits to
maintain
performance of the
system, etc.
There’s certainly a place for AI in the future of eye care. AI offers opportunities to complement and support the expertise of ophthalmologists, ultimately leading to delivery of better care.
“As AI will continue to get better; we have to invest in two things: surgery and compassion. I don’t see any automated tool replacing ophthalmologists performing any type of surgery anytime soon. And I don’t think AI is here to make medicine inhumane, on the contrary. It will give us time to spend with patients that really need us, but for us to be good at that we need to invest in compassion and in our ability to care for patients as a whole.”
– Dr. Fares Antaki
Dr. David Maberley is a retina specialist at The Ottawa Hospital. He provides medical and surgical care to patients referred to him for a range of retinal conditions, including AMD. For Dr. Maberley, the most rewarding part of treating patients with AMD is being able to offer them reassurance that, with therapy, vision can often be stabilized and, in some cases, improved.
What is AMD?
AMD is a condition that affects the retina and, specifically, the macula. The retina is a structure at the back of the eye made of light-sensitive tissue. It acts like the film in a camera; it converts light into a signal that the brain interprets as an image. At the centre of the retina is a small area called the macula that allows us to see fine details clearly. A layer of cells underneath the retina provides it with nutrition and allows it to function healthily. This layer of cells is called the retinal pigment epithelium.
AMD happens when cells of the macula begin to break down or deteriorate, causing loss of central vision. With AMD, one loses the sharp, detailed vision necessary for activities like driving, reading, and recognizing faces.
What’s the difference between wet and dry AMD?
To understand the two types of AMD, you can think of the retina and underlying cells as a sidewalk. It starts off as a smooth, paved sidewalk, but over the course of many decades, the sidewalk starts to crack and crumble. This is like what happens with dry AMD. The cells of the retina start to deteriorate. Symptoms of vision loss occur gradually and slowly worsen over time.
Sometimes, small trees start to grow through the cracks in a sidewalk. These can push apart the edges of the sidewalk and cause a lot of damage in a short amount of time. This is what happens to the eye with wet AMD. Blood vessels can start to grow up through weakened areas under the outer retina. These vessels bleed and leak fluid, causing swelling and scarring, which lead to vision loss. Because damage happens relatively quickly, wet AMD has a more sudden onset of vision loss compared to dry AMD.
I’m a woman in my late 50s. How can I lower my risk of developing AMD?
It’s great that you’re being proactive about your eye health. When it comes to AMD, however, the strongest risk factors are largely out of our control. The biggest risk factor is age; we typically see AMD starting to develop in those over 70 years of age. We also now know that about 80% of AMD is driven by genetic predisposition.
You may also be at a higher risk of developing AMD if you:
Quitting smoking, eating a healthy diet (including foods rich in antioxidants and omega-3 fatty acids), getting regular exercise, and keeping other health conditions in check may help lower your risk of AMD.
While you can’t control all risk factors, the best way to protect your vision from AMD is to get regular, comprehensive eye exams so that AMD can be detected and treated early.
Ophthalmologist Dr. Setareh Ziai shares more lifestyle tips for keeping our eyes healthy
My optometrist noticed some changes in my retina. I’ve been referred to an ophthalmologist to confirm if I have AMD. What can I expect from my upcoming appointment?
Your referral to an ophthalmologist will allow you to get a definitive diagnosis of AMD (or rule out other conditions that may be affecting your retina). Typical assessments for AMD include a vision test and a full eye exam, including a retinal exam. You’ll likely also have an imaging test done called optical coherence tomography (OCT). This is a non-invasive laser scan of the back of the eye. It allows your ophthalmologist to see areas of the retina that may be damaged or dying and whether there are any abnormal blood vessels. Based on what your ophthalmologist finds with these tests, further imaging might be needed.
Once a diagnosis is made, your ophthalmologist will be able to provide treatment recommendations and, if appropriate, start therapy. Depending on where you live and the complexity of your condition, you may also be referred to a retina specialist to manage your care.
How do AMD treatments work to prevent vision loss?
In wet AMD, a protein called vascular endothelial growth factor (VEGF) encourages abnormal blood vessels to grow under the macula. These blood vessels can leak and bleed, forming scar tissue under the retina, which causes permanent vision loss. The good news is that we have medications known as anti-VEGFs that target these abnormal blood vessels. Anti-VEGFs turn off blood vessel growth and leakage and cause the abnormal blood vessels to shrink and fade away, preventing further vision loss. As the fluid around these vessels dries up, symptoms of vision loss can even improve.
Unfortunately, there are no medical treatments available yet for dry AMD. A specific high-dose vitamin regimen known as AREDS 2 has traditionally been used for people with dry AMD. Evidence suggests it may slow disease progression. It has also been shown to reduce the risk of dry AMD progressing to wet AMD. If you have dry AMD, ask your ophthalmologist if you might benefit from the AREDS 2 supplement. Health Canada is currently reviewing an injection treatment that might slow the progression of geographic atrophy (advanced dry AMD). This is likely to be available in mid to late 2024.
Anti-VEGF drugs are administered by intravitreal injection, which is a procedure used to place the medication directly into the space in the back of the eye called the vitreous cavity. The procedure will be performed by your ophthalmologist or retina specialist in their office, and the entire process only takes about 5-10 minutes.
Your ophthalmologist will numb your eye and eyelid with anesthetic eye drops or gel to reduce pain. Then the eye is cleaned to minimize the risk of infection. The anti-VEGF medication will be injected through the white part of the eye with a very small needle. You might feel some pressure or discomfort with the injection, and you might also feel a short sharp pain.
While there are few side effects from anti-VEGFs and complications are rare, there is always a small risk of infection. If you notice any worsening pain or redness that develops a couple of days after your injection, call your ophthalmologist’s office.
My mother mentioned that she has noticed some blurry vision. Is this just a normal part of aging?
I think it’s critical for everyone to understand that vision loss as we get older is not normal. If you have a sudden change or deterioration in your vision, there’s very likely an eye condition at play that may be treatable.
Since AMD is the leading cause of blindness in Canada, it’s important to be aware of the risk as you get older. All adults over the age of 65 should have a comprehensive eye exam at least every year so that any signs of AMD (or other serious eye diseases) can be detected early and treatment can be started before vision loss occurs. If you develop any visual symptoms, like blurred or distorted vision or patches of vision loss, don’t ignore them – seek attention immediately.
“Aging does not mean you have to lose vision. There’s so much out there we can offer to keep most people seeing throughout their lives.”
I’ve just been diagnosed with wet AMD. How long will I need treatments for?
Treatment for wet AMD requires a long-term commitment. In my discussions with my own patients with AMD, I always focus on the importance of consistent follow-up. Typically, after the first few monthly injections, anti-VEGF drugs are given less frequently and are often only needed every 2-3 months. We may shorten or extend the time between injections depending on how the patient is doing, but you’ll likely be in relatively intensive therapy with your ophthalmologist for a few years. Even when we’re able to get control over the macular degeneration and your injections are reduced or possibly even stopped, there’s always a risk of recurrence and a need for ongoing monitoring.
We don’t yet have treatments available that can reverse the damage caused by advanced wet or dry AMD. But for people who end up with permanent vision loss, it’s important for them to understand that we have tools we can offer them even if there’s nothing more that can be done therapeutically. Vision rehabilitation therapy is a rapidly evolving area of specialty care in ophthalmology that helps people function better with their remaining vision. Treatments might include magnification or training patients to use parts of their retina that are still functional. It provides patients with strategies and devices to maximize their remaining vision and improve their ability to manage in their daily lives. There’s a lot that can be done with technology like speech-to-text, text-to-speech, magnifiers, telescope glasses, and closed-circuit televisions to help individuals with vision loss lead more independent, active lives. If you have low vision due to AMD or another serious eye disease, talk to your ophthalmologist about getting a referral to a vision rehabilitation clinic.
It’s certainly an exciting time for AMD, with innovations on the horizon that will improve AMD care in Canada. For wet AMD, next-generation anti-VEGF drugs are in development that may be more durable than currently available options. These would mean patients wouldn’t need to receive injections as often. We’re also anticipating new treatments coming to market soon for geographic atrophy (GA) – a currently untreatable late-stage form of dry AMD. In GA, photoreceptors are completely lost, first in patches and then progressing throughout the macula. Clinical trials have shown promising results in slowing the progression of this form of dry AMD.
Other types of therapies are in early investigational stages. Gene therapy is being studied to help the eye produce its own anti-VEGF that would prevent the disease from worsening. You might also have heard some buzz about stem cell therapy as an opportunity to replace the damaged retinal cells. These cell transplants would potentially ‘repave the sidewalk’, if you will. The studies are still very early, so this treatment option isn’t on the near horizon just yet.
Other areas of advancement are in diagnostics and monitoring. Fundus autofluorescence (FAF) is an imaging technique that’s useful for more clearly defining the areas of damaged cells in dry AMD. The images can be coupled with AI algorithms to help track disease progression and monitor lesion growth. Once this machine learning technology is widely available at the clinic level, it will give us another tool to monitor advanced forms of AMD.
Inexpensive monitoring technologies that detect distorted vision are also being studied in clinical trials. These devices have the potential to be used in patients’ homes, with data relayed directly to their ophthalmologists so that follow-up plans can be adjusted accordingly.
With these and other promising advancements, the future of AMD management is looking bright.
Dr. Setareh Ziai
University of Ottawa Eye Institute, Ottawa, ON
Dr. Setareh Ziai is an academic ophthalmologist at The Ottawa Hospital, specializing in cornea, anterior segment, external disease, and refractive surgery. As a clinician at a teaching hospital, she provides patient care while training the next generation of ophthalmologists. Dr. Ziai is a cofounder of Canadian Women in Medicine, an organization advocating for women doctors.
Anything you do to improve your overall health will also contribute to better ocular health. Things like exercise, not smoking, and eating a balanced diet can all help. Dark leafy greens, in particular, are really good for eye health, and studies have shown that certain vitamins can help with macular health in some patients.
Protecting the eyes from the sun is another big one. We’ve become so good at putting on sunscreen every time we go outside, but we often forget about our eyes. I find we’re still living in a society where sunglasses are more of a fashion statement than a necessity. We can’t forget the importance of UV protection, not just for our eyes, but also the structures around the eyes, including the eyelids.
Our eyes are truly a “window into the soul” – we can get a lot of insight into a patient’s health simply by looking into their eyes. Some eye diseases are associated with systemic diseases, which are diseases that can affect the entire body. Sometimes when ocular signs are detected, it will prompt us to look for associated medical conditions elsewhere in the body.
One of the most common systemic conditions that we sometimes first find in the eyes, before a patient is even aware they have it, is high blood pressure. Long- or short-term high blood pressure can lead to changes in the structure of the blood vessels in the back of the eye. Diabetes is another condition that is sometimes first diagnosed by an ophthalmologist based on the appearance of the retina. Ophthalmologists can also help diagnose and monitor multiple sclerosis and other neurological diseases based on what’s happening with the patient’s eyes.
The opposite scenario is also true – oftentimes, a patient is diagnosed with a systemic condition, and then sent to an ophthalmologist to see if there are any associated changes in the eye.
The first step in looking after your eyes is understanding the difference between an optician, an optometrist, and an ophthalmologist, or what we refer to as the 3 Os of the eye care team. While each of the 3 Os has a specific role in eye care, we work together to monitor and manage your eye health.
An optician is trained to help you see better; they will fit and dispense eyeglasses, contacts, and low vision aids and devices. As a primary eye care provider, an optometrist is who you’ll most likely routinely encounter. An optometrist has completed optometry school and is well qualified to provide screening exams and identify ocular conditions. If an eye disease is diagnosed, an optometrist can monitor you until you need further treatment. They can also prescribe certain eye drops.
If you and your optometrist feel that additional consult is needed (for example, to confirm a diagnosis), or if your eye condition requires management beyond prescription drops, then you would be referred to an ophthalmologist like me. Ophthalmologists have gone through a minimum of 4 years of medical school and 5 years of surgical training, so we have the unique, specialized expertise to diagnose and treat all eye diseases, including with surgical or laser procedures if needed.
It’s important to be aware that a lot of eye diseases are silent and can progress without causing many, or any, symptoms. Take glaucoma for example. You wouldn’t necessarily know you had it unless an eye care professional detected it during an eye exam, or until it became very advanced. For many eye diseases, early detection and treatment can lead to better outcomes and can prevent vision loss. So just like you have your teeth checked regularly by a dentist, you should have your eyes checked every couple of years by an optometrist or ophthalmologist to make sure you don’t have a condition that might need treatment or monitoring.
It’s great that you’re already thinking about your child’s eye health. Most babies will have a quick eye exam performed by their primary care provider within the first week or two of life, during the routine well-baby exam. It’s recommended that all kids have at least one comprehensive eye exam before they’re 5 years old.
There are some conditions in children, like amblyopia or “lazy eye”, that can affect vision into adulthood if not caught early enough. There’s this magic window of time in which we can help both eyes see at their best potential, but only if we treat the condition early enough. After the age of about 10-12, if you discover that one eye is weaker than the other and try to strengthen it, the success rate of improving visual potential in that eye drops dramatically. What breaks my heart is when children aren’t seen until they are teenagers, and only then discover that they have a condition like amblyopia. If we had caught it when they were younger, both eyes could have been “normal-seeing eyes”. Some of these problems are so preventable – they can often be fixed if treated in a timely fashion.
If you don’t remember the last time you had your eyes checked, go get a comprehensive eye exam. If the optometrist or ophthalmologist says your eyes look healthy and doesn’t have any concerns, try to stick to the recommended schedule of an eye exam every 2 years (or yearly, if you’re over 65).
Your eye care professional might recommend more frequent follow-ups and will advise on the appropriate interval if:
For kids, make sure they’ve had at least one comprehensive eye exam by age 5. If everything is normal, periodic eye exams are recommended thereafter. Young children will often not complain of vision changes, especially if only one eye is affected, so it’s a good idea for them to get an eye exam every year to make sure they’re seeing clearly.
Dry eye is extremely common, especially given our harsh Canadian climate, and dry eye can be debilitating. There are steps you can take on your own to help relieve the symptoms.
Screen time is one of the main culprits for dry eye. In fact, any focused work, including screen time or even reading a book, causes you to blink less often than you normally would, so it’s important to take a break every 20-30 minutes. Just look away, focus on something in the distance, and blink your eyes. You can increase the humidity in your home or office space using a humidifier. Artificial tears or lubricating drops can help improve the quality of the tear film. An oilier tear film stays on the surface of the eye longer. Some studies have shown that omega-3 supplements, like fish or flax oils, can help produce oilier tears. Hot compresses can help too. For many people with mild dry eye, these tips can help. If you’ve tried all of these and still haven’t found sufficient relief, speak to your eye doctor because other treatment options are available.
Blue light–blocking glasses have recently become trendy and are advertised to reduce digital eyestrain. While they won’t cause harm, there’s no evidence to support their use. The best way to find relief from digital eye-strain is to take regular breaks, position the screen at about arm’s length, and reduce glare by adjusting the ambient light in the room.
So instead of splurging on blue light–blocking glasses, you’re better off putting the money towards a pair of sunglasses to protect your eyes from UV – which is known to cause eye damage.
Dr. Phil Hooper
Ivey Eye Institute, London, ON
Dr. Phil Hooper is a leading Canadian ophthalmologist with a clinical focus on uveitis and retinal diseases. He is the immediate past president of the Canadian Ophthalmological Society (COS).
A lot of the eye injuries I see in my practice are sports related; they’re usually the result of a blow to the eye from a ball, elbows, or hands. Contact sports like basketball and boxing pose a particularly high risk of injury. Workplace eye injuries are also quite common. People who work with chemicals or in construction, carpentry, or other industrial settings are at the greatest risk. Weekend chores like yard work and home repair projects are another major cause of eye injuries – hammers and power tools like drills and saws can send sharp objects or debris flying up toward the eyes.
The good news is that the vast majority of these injuries can be prevented by wearing the right protective eyewear. Look for CSA-certified glasses or goggles and wear them in any potentially risky situations.
Sports-related eye injuries can range from corneal scratches and eyelid lacerations to more severe blunt-force trauma that can cause orbital fractures or even retinal detachment, which can result in complete vision loss. Most sports-related eye injuries occur in basketball, baseball, and racquet sports – but any activity with a high-velocity projectile (like paintball) can be dangerous. Combat sports like boxing and martial arts are more likely to cause a serious or even blinding eye injury.
To protect your eyes, ensure both you and your kids wear the right kind of eye protection for the sport you’re playing. Often, that means glasses or goggles with impact-resistant, shatterproof polycarbonate lenses. Sports like hockey or lacrosse require helmets with polycarbonate face masks or wire shields. And if you’re on snow or water, wear protective glasses or goggles with UV protection to shield your eyes from harmful UV rays and reduce glare.
Eye injuries can sometimes be more serious than they appear, and serious injuries can lead to vision loss or even blindness. In general, any eye injury other than small scratches or grit in the eye may be potentially serious.
If you’ve damaged some of the structures inside your eye, you might be more likely to experience severe consequences such as glaucoma, retinal detachment, or development of cataracts. Even if you think an injury is minor or you aren’t sure you’ve injured your eye, it’s a good idea to get checked out by an eye care professional or other medical doctor. They can assess the severity of the injury and provide the appropriate treatment to help reduce the risk of long-term vision loss.
Fireworks are a fun way to celebrate with family and friends but it’s important to be aware of the risks and take recommended safety precautions. When not handled properly, fireworks can cause burns and injuries, including serious eye injuries. Firework-related eye injuries tend to be especially severe because fireworks combine force, heat, and chemical exposure – they can cause anything from burns to ruptured eyeball and retinal detachment. Even sparklers, which many people assume to be safe for kids to play with, burn hot enough to cause serious burns.
The best way to avoid a potentially serious injury is by attending a professional, public fireworks show rather than buying fireworks for home use. If you decide to use fireworks at home, there are some safety precautions you can follow to help ensure your fireworks displays are fun and memorable (for the right reasons!):
If you do experience an eye injury from fireworks or a sparkler, get medical attention right away.
It’s great that you’re considering eye safety when shopping for gifts for kids. Eye injuries among children are one of the major causes of visual impairment. Many kids end up in the ER with toy-related eye trauma each year, so it’s important to take precautions.
Here are a few tips to help prevent eye injuries when it comes to toys:
Be sure to confirm toys are age appropriate – look for minimum age requirements on the toy’s packaging
Avoid toys that pose a high risk of injuries – lasers, sharp toys, aerosols like silly string, and flying or projectile toys come to mind
Show kids how to properly play with the toys in a safe manner
Keep toys that pose a potential eye injury risk away from children unless supervised by an adult
If you’re giving sports equipment as a gift, make sure to include the appropriate protective eyewear
The feeling you describe, of something rubbing against your eye when you blink, is called foreign body sensation. While it can be caused by a number of eye conditions, it’s also possible you’ve scratched your eye. If you have, you might also be noticing redness, irritation, and excessive tearing. Eye scratches and corneal abrasions are common and can be caused by anything from sand or sawdust in your eye to your pet’s claws. The good news is that most are minor and will heal on their own within a few days. It’s a good idea to get your eye examined if the sensation is severe or doesn’t settle in a few hours. It is possible that the foreign body is embedded in the cornea or stuck to the lid and causing continued irritation. Using the slit lamp and high magnification, the eye can be examined and any remaining material removed. If severe scratches are present, your eye care professional can then advise you on the best approach to speed up healing. They might prescribe an antibiotic eye drop to help prevent infection and steroid eye drops to reduce inflammation and lower the chance of scarring. You might also be given lubricating eye drops to help reduce discomfort.
There are things you can do to help provide some relief while the injury is healing. Blink often and rinse your eye with saline solution or clean water. You might notice that your eye is sensitive to light, so wear sunglasses when heading outdoors. Try not to rub or touch your eye and avoid wearing contact lenses until your eye is fully healed. If you notice persistent or worsening pain, vision changes, or are worried about your eye, head to the emergency room.
Eye injuries are common and while accidents happen, the reality is that most of these injuries are preventable. The easiest step you can take to reduce your risk of eye injury is to wear proper protective eyewear. It can prevent up to 90% of all eye injuries! Look for CSA-certified safety glasses and use them whenever you’re doing anything risky around your home – yard work, home repairs, or even using chemical cleaning products. Not only will you help keep your eyes safe, but you’ll also be acting as a good role model for your kids and instilling safety habits in them.
Ensure both you and your kids wear sports eye protection – especially for high-risk sports and recreation like baseball, basketball, racquet sports, hockey, and paintball. Keep eye safety top of mind when choosing toys for your kids. Remember that the sun can cause injury to your eyes, too. Shade your family’s eyes from harmful UV rays with sunglasses that offer 100% UVA/UVB protection – that goes for kids and babies, too. Protecting your eyes from injury is one of the simplest things you can do to maintain lifelong healthy vision.
Dr. Hady Saheb
McGill University Health Centre, Montreal, QC
Dr. Hady Saheb is a glaucoma surgeon whose ophthalmology practice is focused on medical and surgical glaucoma care, as well as cataract and complex anterior segment surgery. He’s the President of the Canadian Glaucoma Society and the Director of the Glaucoma Fellowship at McGill University. For Dr. Saheb, the most rewarding part about treating glaucoma is helping patients understand their disease and engaging them in their treatment to help preserve their vision.
Glaucoma refers to a group of eye diseases that affect the optic nerve, which connects your eye to your brain. Glaucoma is often related to the pressure inside the eye, known as intraocular pressure. When the eye fluid doesn’t drain properly, pressure builds up in the eye. This increased pressure can damage the optic nerve fibers, leading to a loss of peripheral vision and sometimes even complete vision loss.
I think it’s really important for everyone to know that glaucoma can lead to blindness if not treated early. In fact, it’s one of the most common causes of blindness both in Canada and worldwide. It’s equally important to remember that vision loss from glaucoma is preventable with early diagnosis and treatment. The best thing that you can do to protect yourself from glaucoma-related vision loss is to be screened regularly for glaucoma. Every adult should have a comprehensive eye exam with an eyecare provider every 1-2 years.
I’d urge Canadians to be aware of the risk factors for developing glaucoma. People over 50 years of age, who have a family history of glaucoma, or from certain ethnic groups (e.g., those of African descent) are at higher risk of developing glaucoma. Those individuals should be screened earlier and more often, at a minimum of once a year.
Recognizing how highly most people value their sense of sight, the thought of going blind is scary, so your question is common and an important one to ask. Glaucoma is a serious eye disease and remains one of the most common causes of blindness. What’s helpful to keep in mind is that in looking at studies of glaucoma around the world, most patients who go blind either started treatment when their glaucoma was already at a severe stage, or they struggle with adhering to treatment and follow-up. In many cases, if patients are engaged in their treatment and follow-up, the chances are very good that we’ll be able to maintain their vision throughout their lifetime.
Glaucoma care is complex and may involve an optometrist, ophthalmologist, or sometimes both working together. As medical doctors with extensive training, ophthalmologists have a unique and specialized expertise in managing patients with glaucoma. We also have the training required to perform laser and surgical procedures as well as manage any potential complications safely and quickly. In general, if they are not already seeing an ophthalmologist, patients with glaucoma should be referred for evaluation or treatment in the following cases:
The short answer is yes – something else can almost always be done so it’s really important to share this feedback with your eye care provider. Prescription drops can be extremely effective for managing glaucoma, but some have side effects, such as increased dryness or irritation of the eyes. We know that patients who are bothered by their drops are less likely to take them regularly, so we want to work with you to help you find a treatment option you’re comfortable with. That could mean switching to a different kind of eye drop or considering other treatment options like laser or surgery. The key is to keep those lines of communication open with your eye care provider so they can find an option you’re likely to stick with.
Ophthalmology is a medical discipline that’s constantly evolving and within glaucoma care specifically, there is a lot to look forward to in the next few years. The surgical space in glaucoma is continuing to evolve and there are new procedures expected to become available to patients that will improve surgical outcomes and safety. We’re also seeing laser treatment playing an increasing role as patients are looking for alternatives to eye drops to lower eye pressure. There’s also some exciting innovation still in the research phase looking at reversing glaucoma, rather than the current approach of preventing or stabilizing damage from the disease. Lastly, the COVID-19 pandemic has really accelerated the uptake of virtual glaucoma care and moving forward we’re likely to see more telehealth options available to make glaucoma care more accessible and convenient to patients.
Dr. Vivian Hill
Assistant Professor, University of Calgary, Alberta
Ophthalmologist at Ashenhurst Eye, Calgary
Dr. Vivian Hill is a pediatric ophthalmologist with particular interest in strabismus management in both children and adults. Her clinical practice in Calgary comprises patients of all ages. Dr. Hill is active in training residents and medical students, and she has been a longstanding examiner for the Royal College of Physicians and Surgeons of Canada.
For Dr. Hill, the most rewarding aspect of being a pediatric ophthalmologist is the opportunity to make an impact on a patient’s vision not only in childhood but in a way that gives them the best possible chance of lifelong healthy vision.
I’m a first-time mom to a 10-day-old baby. Is it true that newborns can’t see very well?
Babies do have vision at birth, but their visual system is immature and continues to develop over the first few years of life. A newborn baby can see motion but can’t really focus on an object in front of them because they don’t yet have central or foveal vision. At around 3 months of age, babies develop the ability to focus on things. Improving visual coordination at this age allows the eyes to work together to track moving objects. Over the next few years, children experience increasing maturity of their central vision, with most acquiring 20/20 vision by age 4-5 years.
My two-year-old seems to be able to see clearly. What is her eye doctor looking for during an eye exam?
During an eye exam or vision screening, we check for common childhood vision problems like refractive errors, which can cause blurry vision at either near or far distances. Another important thing we look for in young children is eye alignment. In the first few years of life, children are developing vision in both their left and right eye. They are also developing binocular vision, which is a merging of vision between the eyes. To work together, each eye needs to have good vision and be functioning well, but the eyes also need to be aligned and pointing at the same object. And that’s the big one that can get missed in early childhood. If the eyes aren’t aligned, even by just a few degrees, a child can learn to ignore vision in one eye, which impacts vision not only in that eye, but also reduces the potential for optimal binocular vision. If your child’s eye doctor thinks they may have strabismus (or misalignment of the eyes), they will refer your child to an ophthalmologist for further evaluation.
My 4-year-old has been referred to an ophthalmologist for possible amblyopia. What exactly is it, and why is it so important to treat it right away?
Amblyopia (commonly known as “lazy eye”) is one of the most common causes of vision loss in children. It refers to reduced vision in one eye (or rarely, both) caused by abnormal visual development early in life.
While the visual system is developing (from birth to about 8 years of age), both eyes need to receive normal, appropriate visual stimulation. Amblyopia can occur if problems like uncorrected refractive errors, strabismus, drooping eyelids, or cataracts prevent this stimulation from occurring. Over time, the brain favours the eye with stronger vision and ignores images from the weaker eye. So amblyopia is a brain-based form of vision loss, resulting in a weakness in the pathways that connect the eyes to the brain’s vision centres.
Treatment of amblyopia is somewhat a race against the clock because by about 8-10 years of age, the vision pathways mature and become more resistant to change. Amblyopia can be treated by forcing the amblyopic eye to work harder than the stronger eye. This is often done by wearing a patch over the stronger eye, or using atropine eye drops to blur vision in the stronger eye. Generally, the earlier this treatment starts, the more successful it is, and long-term problems with your child’s vision can be prevented.
How often should children be getting an eye exam?
Regular vision screenings can help protect your child’s vision by detecting any problems early on. While screening programs currently vary among provinces, the following are general recommendations for vision screening in children:
Babies
Children
What are the signs that my child may be having a problem with their vision?
Children, especially younger ones, might not always be able to tell you there is a problem with their vision. It’s helpful to watch for signs of vision problems so that they can be addressed early and appropriately, while vision is still developing. If you notice your child doing any of the following, it’s worth discussing with your eye care provider:
Remember, sometimes eye conditions can be asymptomatic, or the signs may be too subtle for you to notice, so it’s important that kids get screened regularly for eye issues.
Is too much screen time really bad for my kids’ eyes?
You’re not alone in wondering this, and there are many reasons why parents might want to be mindful of the amount of time their children spend in front of a screen. From an eye health perspective, the development of myopia, or nearsightedness, in children is a growing issue worldwide. Myopia is the need for glasses to see at a distance. There is evidence that the more time children spend reading up close (whether that is on smart phones, tablets, books, or doing homework) and the less time they spend outside, the higher the risk of myopia.
The root cause of myopia is the eye growing too quickly during childhood and becoming abnormally long. As the eye gets too long, the tissues inside the eye stretch and become thin, making them more vulnerable to damage during adulthood (retinal detachment, growth of abnormal blood vessels, even glaucoma). While genetics play a role in the development of myopia, environmental factors like increased near-screen time and reduced time outdoors also seem to contribute.
Parents who have myopia (and whose children are therefore at a higher risk) need to make a real effort to counteract some of these environmental factors to help prevent myopia, or at least delay its onset:
There are new treatment options, like eye drops and certain specialized optical corrections, that can intervene during the rapid growth phase to help slow the progression of myopia.
How can I help set my child up for lifelong healthy vision?
Good vision is very important to a child’s physical development, success in school, and overall well-being. It’s great that you’re thinking about protecting your child’s eye health. There are several things you can do to support healthy vision now and for the future:
1) Take eye safety seriously
2) Practice good screen hygiene
1) Spend time outdoors
4) Ensure kids wear glasses if prescribed
5) Make sure kids are getting vision screenings in early childhood
My child’s ophthalmologist has suggested for him to see an orthoptist. What’s their role on the eye care team?
You’re probably most familiar with the “3 O’s” of the eye care team: the optician, the optometrist, and the ophthalmologist. An orthoptist is another important member of the team who specializes in ocular mobility and visual development. Orthoptists often work in close collaboration with pediatric ophthalmologists to assess, diagnose, and monitor problems related to eye movement and alignment, such as strabismus, amblyopia, and double vision. They also provide support in formulating and carrying out non-surgical treatment plans for these conditions. Orthoptists can also work with comprehensive ophthalmologists to assist them in delivering optimal care for their pediatric patients. If your child has been referred to an orthoptist, rest assured that they are in good hands.
Brought to you by the Canadian Ophthalmological Society
Copyright © Canadian Ophthalmological Society / 309-1505 Laperriere Avenue, Ottawa ON K1Z 7TI
