Walking to my office on East 25^th Street in Manhattan on the morning of September 11, 2001 I was struck by the beautiful clear sunny sky.  Like everyone else enjoying the fall weather I did not know how terrible this day would be for my city and my country. Office hours started at 9:00am.  The first patient of the morning called us at 9:20am and told us that she saw a plane crashing into the World Trade Center and was afraid to leave home.  We put on the radio and listened in horror to what was happening downtown.

I felt the ceiling rumble at some point and wondered what the upstairs occupants could be doing that was so loud. When I heard the news that the Towers had come down I realized that I had felt the Twin Towers crumbling.

I decided to close the office early so everyone could get home. Normally there are several lanes of traffic going North and South on Park Avenue South. When I walked to the corner all I saw were throngs of people walking north. There was no car or bus traffic on Park Avenue South at 25^th Street. Looking downtown smoke was visible over the horizon.

After getting to my apartment near the office I called the New York Eye & Ear Infirmary to see if they needed medical staff for emergency care.  I was told that very few patients were there. I packed a knapsack with medical supplies and walked to the Beth Israel Hospital ER to volunteer. Doctors and nurses were waiting outside but no ambulances or emergency patients arrived.

The streets and avenues had very little motorized traffic. I walked the blocks and saw people walking quietly, dazed, covered in white soot. A soldier with an M-16 was directing traffic on 23^rd Street and Park Avenue. I could not believe this was really happening. It was surreal.

But this was not a dream. In the following days and weeks as life in the neighborhood started to take on some semblance of normality the attacks of 9/11 were impossible to escape. The pervasive smell of burning rubber was a constant reminder as was the black column of smoke that rose from the horizon downtown.

Walking to work was an ordeal for months because the Armory on Lexington Avenue between 25^th and 26^th Streets was a center for those searching for loved ones they were never to find. The light posts, bus shelters and the storefront windows of the Staples store on 26^th Street and Park Avenue were plastered with pictures of missing people.  The streets around the Medical Examiners at 1^st Avenue and 30^th Street were surrounded by refrigerator trailers for holding body parts.

The New York Times had a two-page spread of pictures of the 343 brave firefighters who died that day. My office manager Susan mounted the pages on a poster board and hung them on the wall of my waiting room. The homemade poster stayed on the wall until a few weeks ago when I was given a wonderful gift from a patient who on 9/11 was an FDNYEMS. He volunteered for service after 9/11, served in the Iraq war and was awarded a Purple Heart.

He and his wife gave me a framed poster of these brave FDNY heroes. Their memory will be forever honored in my office.  I also want to thank and remember the service of the American men and woman in our armed forces whose sacrifice is keeping us safe and free.

Here are photos of the original tag board poster and the new framed one:

New York Times 2001

New Poster

G-d Bless America

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External Causes of Eye Pain

Material such as dust particles, metal fragments, cat hairs, and eyelashes feel like there is a particle in the eye. These are easy to find and remove. They can cause a scratchy feeling in the eye. Sometimes a foreign body is lodged under the inside surface of the upper lid and can only be removed by everting the upper lid. If the foreign body is embedded in the cornea it can cause a corneal abrasion.  A corneal abrasion feels like there is something in the eye. Dry eye can also cause external irritation and dry eye patients often complain of burning and feeling something in their eyes. Dry eye, superficial corneal or conjunctival foreign bodies rarely cause blurred vision or photophobia (light sensitivity). External irritation associated with photophobia and/or blurred vision suggest a more serious condition such as a corneal ulcer. A sty can also cause a foreign body sensation.

Internal Causes of Eye Pain

Episcleritis is an inflammation of the outer layer of the sclera, the white of the eye. This often presents with localized redness and tenderness to touch. Uveitis, an inflammation of the inner eye is associated with eye pain. The pain is usually felt inside the eye and does not feel like there is something in the eye. Inflammation of the front portion of the inner eye is called iritis and causes photophobia. Optic neuritis, an inflammation of the optic nerve, is associated with pain on eye movement.

Other Causes of Eye Pain

Migraine, sinus disease, and glaucoma can also cause eye pain. Even eye strain from wearing the wrong eyeglass or contact lens prescription can cause eye pain. Pain following eye surgery can be a sign of infection and requires immediate attention. Pain following trauma to the eye can also indicate a serious condition.

causes light sensitvity

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Modern antibiotic drops can treat bacterial corneal ulcers successfully if the diagnoses is made early and the drops started promptly. Corneal infections caused by a fungus or an organism such as an amoeba can be devastating and may require a corneal transplant.

REMEMBER

• Avoid sleeping in contact lenses,
• always wash hands prior to handling contact lenses,
• wash and replace contact lens cases, and sterilize the lenses in a good sterilizing solution.
• Replace the lenses on schedule.
• Do not try to “stretch” the wearing interval beyond the lens specifications.

The risk of getting a corneal ulcer is not worth it.

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Glaucoma is a disease of the optic nerve often associated with increased intraocular pressure (IOP).

Elevated IOP alone is not enough to make the diagnoses of glaucoma. Some patients may have glaucoma when their IOP is within normal limits. This is called Normal Tension Glaucoma (NTG). Conversely many patients have IOP elevation and never develop glaucoma. This is called Ocular Hypertension (OHT).

If you are confused by this, don’t worry, you are not alone. Most patients and many physicians have difficulty understanding glaucoma. We are used to concentrating on numbers. Hypertension is defined as blood pressure above 140/90. Diabetes is followed by measuring the blood sugar and the hemoglobin A1C (HgbA1C). So it is natural for the IOP measurement to be the focus of glaucoma diagnoses and treatment.

But glaucoma is different from hypertension and diabetes.  Aside from intraocular pressure measurements the function and structure of the optic nerve must be evaluated when evaluating glaucoma. Calling IOP measurements a “glaucoma test” and the use of IOP measurements in “glaucoma screenings” is inadequate and misleading.

The best way to evaluate a patient for glaucoma is:

1. - Obtain a complete medical history including a review of systems and family history concentrating on a family history of glaucoma and a history of migraine.
2. - Visual acuity, slit lamp exam, IOP measurement and careful examination of the optic disc are the minimum examination techniques required in glaucoma evaluation.

If the medical history is negative and the physical eye exam normal then this is an adequate “glaucoma screening.” IOP measurement alone is not good enough.

If the medical history is positive or the eye exam suspicious then further testing is necessary, such as ultrasonic pachymetry – measurement of corneal thickness, computerized visual field testing and photographic imaging of the optic disc. The optic disc is the portion of the optic nerve that is visible when looking at the ocular fundus, the inside of the eye.

I have only touched on the surface of glaucoma evaluation. More information is available here, here, here and here.

Noah Klein, MD

Noah Klein, MD, PC

August 13, 2009

January 3, 2010

This is another good link about glaucoma:

http://www.travatanz.com/High-Eye-Pressure.aspx

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August 4, 2009

Red eyes with itching, tearing, clear discharge and a foreign body sensation (feeling of something in the eye) can be caused by a virus. This is called viral conjunctivitis or “pink eye” and can be quite uncomfortable.It may be difficult to differentiate between a viral conjunctivitis and an allergic conjunctivitis. Here are some tips.

Viral conjunctivitis is likely if:

1. The patient recently had an upper respiratory infection (URI), a cold. If so then most likely the same virus has caused the conjunctivitis.
2. There is a tender pre-auricular lymph node on the same side as the conjunctivitis.  If yes then a virus is the likely cause. This lymph node is just in front of the tragus of the ear. The tragus is the bump before the external auditory canal (the ear opening).
3. The pink eye started in one eye and then went to the other eye, but in a milder form. This is characteristic of viral conjunctivitis.
4. The patient had contact at work or home with someone who has a pink eye. If so then the viral infection which is very contagious has spread from that other person.

<!–noadsense–>

Allergic conjunctivitis is likely if:

<!–noadsense–>

• The patient has a history of allergy and it is now allergy season.
• Symptoms are relieved by anti-histamine drops or pills.
• Aside from itching and red eye none of the above criteria exist.

<!–noadsense–>

Treatment

Unfortunately, aside from relieving symptoms, there is no treatment for viral conjunctivitis. It should resolve in 7-10 days just like the common cold. Antibiotic drops do not cure a viral conjunctivitis and nothing but good hygiene can prevent it from spreading to others. Lubricating eye drops and cool compresses help the symptoms.

<!–noadsense–>

Most of the time the condition resolves with no permanent effects. Rarely, a few weeks after the infection is gone the patient experiences photophobia (light sensitivity), foreign body sensation and possible blurred vision. Corneal infiltrates cause this and the patient must be evaluated by an ophthalmologist right away. These may require treatment.

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Conjunctival Hemorrhage

Conjunctival Hemorrhage

Conjunctival Hemorrhage

Although this looks dramatic and scary it is quite harmless most of the time especially if not accompanied by any discomfort and without a history of trauma to the eye.

Some possible associations are anti-coagulant therapy such as warfarin, Plavix or even aspirin. Vomiting and coughing can cause this too.     Why does it happen? The causal event is blood leaking out of a small blood vessel under the conjunctiva. You can think of it as a bruise.

<!–noadsense–>

If you got a bruise anywhere in your body you probably would not pay much attention to it.    However, because the red blood is outlined by the white of the eye it is very noticeable.    Often it is not the patient but a friend or relative that first notices it. Another reason it is so dramatic is that the space between the conjunctiva and the white of the eye, the sclera, is so small that a tiny drop of blood is spread over a large area and appears larger than it truly is.    It usually takes about a week for this to resolve. While resolving it can actually spread and appear as if it it getting larger. It can look yellow as it is being resorbed.<!–adsensestart–>

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computer vision syndrome

Do your eyes hurt or burn when looking at a computer screen? Do they tear, or feel tired after hours of computer use? Do you get headaches after staring at a CRT or LCD computer screen? Do you have neck or shoulder pain? If so then you are probably suffering from computer vision syndrome (CVS).  I see many patients who suffer from this condition and have never been offered a comprehensive solution to their problem.

The best way to deal with this is to first have a comprehensive ophthalmological exam to rule out eye diseases. Once this is done then the more basic issues can be addressed.

Think about the extent and type of your computer use by reviewing the following issues:

• If your computer vision use is mostly work related do you feel better on weekends than during the work week? If you feel better on days that you do not work then CVS may be an issue.
• Do you primarily use a laptop or desktop computer? Where is the computer display relative to your eyes?  Is it directly in front of you or do you look down as when using a laptop? Your doctor should know where the display is in order to customize your computer glasses. Measure the distance between your eyes and the computer screen before coming in for customized computer eyeglasses.
• Is your display an old fashioned CRT or an LCD screen? LCD screens are easier on the eyes and usually have an anti-reflective surface. Old-fashioned CRT screens can cause a noticeable “flicker” of images on the screen, a major source of computer eye strain. Even if this flicker is imperceptible, it can still contribute to eye strain and fatigue during computer work. Complications due to flicker are even more likely if the refresh rate of the monitor is less than 75 hertz (Hz). If you must use a CRT at work, adjust the display settings to the highest possible refresh rate.

·        How is the lighting in your computer workspace? Glare is a factor for computer eye strain. It is important to understand that glare can come from various sources, such as reflections off of walls, and not just your computer screen. Several tools can be employed to reduce glare, such as placing an anti-glare screen or a computer hood on your monitor.

• Do you wear bifocals or reading glasses? These are usually not appropriate for computer use. Dedicated specially prescribed computer glasses are necessary if you wear bifocals or progressive lenses, because these lenses are generally not optimal for the distance to your computer screen. Putting the head back to see the screen through bottom of bifocals or progressives is what causes neck and shoulder pain.
• Are your eyes dry? Even if they aren’t dry under normal conditions people tend to blink less frequently when they stare at a computer monitor, so additional lubrication with artificial tear drops is very helpful. The tears coating the eye evaporate more rapidly during long non-blinking phases, which can be especially problematic for contact lens users. Blinking is very important when working at a computer; it rewets your eyes to avoid dryness and irritation.
• A component of computer eye strain is focusing fatigue. To reduce your risk of tiring your eyes by constantly focusing on your screen, look away from your computer every 20 minutes and gaze at a distant object outside or down the hallway. Looking far away relaxes the focusing muscles inside the eye to reduce fatigue. This is especially true for patients under forty (40) years of age.

Please go to this link to see how I solved Dr. Simon Rosenberg’s computer related problems http://www.youtube.com/watch?v=goWoYXEEKo8

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• Conjunctival Hemorrhage - Blood in the Eye One of the most frequent "emergency" visits in my office is due to a conjunctival hemorrhage. This is what it looks like: /caption] Although this looks dramatic and scary it is quite harmless most of the time especially if not accompanied by any discomfort and without a history of trauma......
• VIRAL CONJUNCTIVITIS - PINK EYE Dr. Noah Klein Noah Klein, MD, PC August 4, 2009 Red eyes with itching, tearing, clear discharge and a foreign body sensation (feeling of something in the eye) can be caused by a virus. This is called viral conjunctivitis or “pink eye” and can be quite uncomfortable.It may be difficult......

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Noah Klein, MD

Noah Klein, MD, PC

Ocular Melanoma and Routine Ophthalmoscopy

I examined a 50 year old healthy woman today who came in for stronger reading glasses.  Because she had not had a dilated eye exam (ophthalmoscopy) for years I dilated her pupils and found a melanoma in her left eye. I referred her immediately to an ocular tumor specialist.  With prompt modern treatment she stands an excellent chance of retaining her eyesight and surviving this cancer.

If I had not performed this “routine ophthalmoscopy” today she would not have been referred promptly to an ocular tumor specialist.  Instead the cancer in her eye would grow and perhaps lead to blindness in one eye, removal of the eye, or even death from metastatic disease.

I have seen many diseases of the back of the eye such as retinal detachments, macular degeneration and cancerous tumors. Many were detected with routine ophthalmoscopy.

Insurance companies refuse to pay ophthalmologists to perform “routine ophthalmoscopy.”  I suggest that when you see your ophthalmologist (Eye MD) you ask for this test and agree to pay for it out-of pocket. It could save your sight and maybe even your life.

There are 1400 new cases of ocular melanoma in the United States every year.

I hope you found this post helpful.

Dr. Noah Klein

• WHAT IS GLAUCOMA? WHAT IS GLAUCOMA? Glaucoma is a disease of the optic nerve often associated with increased intraocular pressure (IOP). Elevated IOP alone is not enough to make the diagnoses of glaucoma. Some patients may have glaucoma when their IOP is within normal limits. This is called Normal Tension Glaucoma (NTG). Conversely......
• EYE PAIN When a patient complains of eye pain asking the right questions often helps determine the cause of the pain. This makes the diagnosis and treatment easier. It is helpful to distinguish between eye pain caused by external factors such as a foreign body on the surface of the eye and......
• BLEPHARITIS Blepharitis is an inflammation of the eyelids. Patients often complain of red eyes, eye irritation, itching, foreign body sensation (feeling of something in the eye), ocular discharge, crusting and flaking of the eyelashes. Some get red pimples on the eyelid and refer to them as styes. Get more information here. Most......
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Noah Klein, MD

Noah Klein, MD, PC

Senator Barak Obama Has a Right Head Tilt 

Watching the Saddleback Church Forum with Pastor Rick Warren interviewing Senator Barack Obama on Saturday August 16, I was struck by the marked and obvious tilting of the Senator’s head Forum. The tilt is to the right side. This phenomenon has not been widely written about from a medical perspective.

A head tilt can be a sign that a patient has double vision also known as diplopia.  Diplopia can be benign if it is caused by a congenital (from birth) eye muscle weakness or it can be associated with autoimmune medical disorders such as thyroid disease or Myasthenia gravis.  Serious medical conditions such as a brain tumor or stroke can also cause it.

The value of looking and observing the entire patient not just their eyes is an invaluable tool for me as an ophthalmologist and doctor.

How does diplopia occur?

Both eyes must work together to create a single image in the brain called binocular vision. In order to avoid double vision both eyes must be focused on the same object and the eyes must perceive the object on the same vertical and horizontal plane. If this alignment is not perfect then the images sent to the brain are` dissimilar and the brain registers two different pictures simultaneously causing double vision.  Double vision is when the brain sees two copies of the same object at the same time. The two objects can be next to each other horizontally causing horizontal diplopia, one on top of the other causing vertical diplopia, or at an oblique angle.

Each eye has six muscles, called extraocular muscles, that control its movements, and those muscles are innervated by four different cranial nerves, the third, fourth, sixth and seventh nerves. Four of the muscles control simple movements such as up, down, right and left, and the other two the inferior and superior oblique muscles are responsible for tilting and rotating the eye. 

A muscle or a cranial nerve disorder can cause an extraocular muscle to be weak or not function at all. As a result the two eyes send dissimilar images to the brain causing the patient to complain of double vision.

A head tilt is frequently seen in patients who are trying to overcome diplopia by turning their head in such a way as to avoid using a certain extraocular muscle. 

Why SENATOR OBAMA’S HEAD tilt is  important

Senator Obama should have a medical evaluation, perhaps even an MRI to determine the cause of his head tilt.  Hopefully the cause is not serious, but early detection is always best.

Dr. Noah Klein

Noah Klein, MD, PC

• VIRAL CONJUNCTIVITIS - PINK EYE Dr. Noah Klein Noah Klein, MD, PC August 4, 2009 Red eyes with itching, tearing, clear discharge and a foreign body sensation (feeling of something in the eye) can be caused by a virus. This is called viral conjunctivitis or “pink eye” and can be quite uncomfortable.It may be difficult......
• BLEPHARITIS Blepharitis is an inflammation of the eyelids. Patients often complain of red eyes, eye irritation, itching, foreign body sensation (feeling of something in the eye), ocular discharge, crusting and flaking of the eyelashes. Some get red pimples on the eyelid and refer to them as styes. Get more information here. Most......
• Contact Lens Irritation Part 1: Contact Lens Solution Dr. Noah Klein Noah Klein MD, PC Many patients present to my office complaining of eye redness, eye irritation,  and a foreign body sensation (feeling of grit or sand in the eye) when wearing their soft contact lenses. They feel this way even when they try on a brand new pair......
• 9/11 9/11 Walking to my office on East 25th Street in Manhattan on the morning of September 11, 2001 I was struck by the beautiful clear sunny sky.  Like everyone else enjoying the fall weather I did not know how terrible this day would be for my city and my country.......
• Conjunctival Hemorrhage - Blood in the Eye One of the most frequent "emergency" visits in my office is due to a conjunctival hemorrhage. This is what it looks like: /caption] Although this looks dramatic and scary it is quite harmless most of the time especially if not accompanied by any discomfort and without a history of trauma......
• Contact Lens Irritation Part 2: Dry Eye Dry eye is a very common cause of contact lens problems and contact lens intolerance. It causes wearers to feel as if there is something in their eyes, a foreign body sensation in their eyes, as if there is grit or dirt in the eye, and eye pain when......
• WHAT IS GLAUCOMA? WHAT IS GLAUCOMA? Glaucoma is a disease of the optic nerve often associated with increased intraocular pressure (IOP). Elevated IOP alone is not enough to make the diagnoses of glaucoma. Some patients may have glaucoma when their IOP is within normal limits. This is called Normal Tension Glaucoma (NTG). Conversely......

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