Monday, August 19, 2019

Styes and Chalazia — the Blink Link and Other Remedies

A Single Stye

It started with a single stye. On a sunny summer day four years ago, I rubbed my right eye and it hurt. I looked in the mirror and saw a red spot on my lower eyelid. A quick Internet search suggested that I had a stye. I'd never had one before. More fascinated than alarmed, I assumed that the stye would heal in a few days and I'd never be bothered again. I couldn't have been more wrong.

I went to see an ophthalmologist about four days after noticing the stye, when it seemed to be worsening. The doctor diagnosed meibomian gland dysfunction, a blockage of the meibomian glands, which supply the oil that makes up part of our tears. This blockage prevents the glands from releasing enough oil onto the surface of the eye. Without sufficient oil content, tears evaporate too quickly, causing a condition known as evaporative dry eye. Eventually, the blocked glands can become inflamed, leading to blepharitis, a condition of the eyelid margins, which makes them red and crusty and often causes styes and a related affliction, chalazia.

Now I knew why my eyes were always so crusty! To add another complication, I suffer from mild rosacea, a skin disorder that can sometimes spread to the eyes. Known as ocular rosacea, it can cause meibomian gland dysfunction and blepharitis and all their accompanying woes. My eye doctor believed that ocular rosacea was likely the root cause of my stye. He prescribed hot compresses and 100 mgs of doxycycline twice daily for ten days to keep the infection in the stye from spreading to other parts of my eye.

Under Assault

Now I had a diagnosis, but that didn't solve my problem. What had at first seemed like a minor inconvenience quickly turned into a nightmare. One stye followed another. My eyes felt under constant assault. Sometimes I had to deal with more than one stye at once. They looked horrible, they hurt, and they required constant soaking with very hot compresses if I wanted even a chance of preventing permanent scarring and lumps on my eyelids.

What is a stye, exactly? Also known as a hordeolum, it's a localized infection that starts either at the base of an eyelash (an external hordeolum) or within one of the meibomian glands (an internal hordeolum). An external hordeolum is usually caused by an infected hair follicle and is much like a pimple that needs to come to a head and drain. An internal hordeolum, the kind I suffered from, starts within the eyelid, near the margin, when one of the meibomian glands becomes blocked and then infected. Internal styes are generally more painful and harder to treat than external styes.

I also began to suffer from chalazia. These are similar to internal hordeola — they are usually caused by a blocked meibomian gland, in either the upper or lower eyelid. They tend to come on gradually and initially appear red, though they're generally not painful. Sometimes they begin as an internal stye, but more often the blockage is away from the edge of the eyelid, with the chalazion appearing as a swelling or lump on the eyelid.

I was getting these eye afflictions so frequently that I felt I would soon be spending my entire life in the bathroom with a hot wet rag pressed over my eyes. This was no way to live! To make matters worse, whenever a stye or chalazion started, I had to go back on doxycycline for another ten days. Before my eye issues began, I hadn't taken an antibiotic for decades. Now I was taking them frequently. I didn't feel good about it, but I didn't know what else to do.

Low-Dose Doxycycline

Finally, I consulted another ophthalmologist, who suggested I take a prophylactic dose of doxycycline in order to decrease inflammation. He said this would cause the meibomian oil to thin out and thus prevent the formation of styes and chalazia. The doctor assured me that a low dose of 20 mg twice per day was considered sub-antimicrobial. That is, the small amount of doxycycline would not act as an anti-bacterial drug, only as an anti-inflammatory medication, which meant I wouldn't develop antibiotic resistance.

At last, I had another way to combat my eye afflictions. But, though the doxycycline did help reduce the number of styes and chalazia that formed, it wasn't the cure-all I'd hoped for. I still needed a better solution.

I had read that some patients with meibomian gland dysfunction resort to a treatment called Lipiflow. This thermal pulsation device uses heat and pressure to unblock the meibomian glands. Some ophthalmologists express the glands manually, but Lipiflow claims to do it more effectively. The treatment is expensive, though, and not covered by insurance. Plus, it has to be repeated at least every two years, with many doctors recommending annual treatment. The cost put me off, plus I felt anxious about subjecting my corneas to excessive heat in order to unclog the glands in my eyelids. The company's website claimed that special eye cups would protect the corneas, but I still worried.

Hypochlorous Acid

Then I got a particularly ugly stye just in time for my niece's wedding. It took weeks to heal. I decided to find a doctor who offered Lipiflow and give it a try. There weren't many practices in my area that had a Lipiflow machine, but I found a dry-eye specialist who offered the treatment. I made an appointment, fully expecting him to recommend Lipiflow for me.

Instead, after examining me and listening to my litany of eye complaints, he had his nurse bring him a small glass bottle with a spray attachment and said, "I have something that I think will really help you — hypochlorous acid."

Acid? That sounded like the last thing I'd want to put in my eyes. But the doctor explained that hypochlorous acid is an eyelid wash that reduces the bacterial load and thereby the symptoms of meibomian gland dysfunction and blepharitis. He demonstrated by spraying his own finger with the hypochlorous acid and rubbing it back and forth along his closed eyelid. He predicted the treatment would be so effective that I'd be able to stop taking the low-dose doxycycline before long.

The product he recommended, pure hypochlorous acid, was called Avenova. Once opened, he said, each bottle lasts a month, after which it must be discarded, since no preservatives are used in the formulation. I purchased one bottle and went home to give it a try, twice a day, as the doctor had recommended.

The results were immediate and dramatic. My red and inflamed eyelid margins began looking better within a day or two. The hypochlorous acid actually felt nice when I rubbed it gently along my closed eyelids. I later learned that at least two other companies make similar products, Heyedrate Lid and Lash Cleanser and OCuSOFT Hypochlor. Both those brands contain preservatives, which allow the solutions to last longer but have the potential to cause sensitivity, particularly the preservative in Hypochlor. I've since tried all three eye sprays and have had no issues with any of them.

Finally, I'd found something that really helped but, alas, even hypochlorous acid didn't completely eradicate my problem. My eyelids were still sightly red and from time to time I noticed tiny white spots on my eyelid margins, which indicated that my meibomian glands were still blocked. I needed to keep applying hot compresses once a day (to liquify the meibomian oil and reduce the chance of blockage), and I was afraid to stop taking the low-dose doxycycline.

One day, several months after I'd started using the hypochlorous acid, I noticed a somewhat larger white spot on my eyelid margin, like a small whitehead. When I gently pulled back my eyelid, the area behind the whitehead looked very red. I feared a stye was forming. What to do?

A Lasting Solution

I suddenly recalled a series of blink exercises that I had come across during one of my prior research forays. At the time, I hadn't taken seriously the idea that something so simple as better blinking could improve meibomian gland dysfunction. But now I decided to take a closer look.

Developed by Donald Korb, OD, blinking exercises are intended to compensate for a reduced blink rate or incomplete blinking. According to dry-eye specialist Paul Karpecki, OD, the lower eyelid meibomian glands are responsible for 78% of the oils in our tear film. As he explains it, the theory behind blink exercises is that failure to fully blink results in less pumping of the oil in the lower eyelid meibomian glands. A reduced blink rate also negatively affects the amount of oil that can be pumped by the eyelids. Without sufficient pumping the oil remains in the glands, where it accumulates, eventually resulting in clogging and inflammation.

Dr. Karpecki notes that partial blinking can have many causes, among them cosmetic surgery, lagophthalmos (the inability to close the eyelids completely), and the use of digital devices. He says digital devices affect blink rate, as well. "The average person using a computer blinks 4.4 times per minute as opposed to someone who is gazing (21 blinks per minute) or in conversation (over 30 blinks per minute)."

I spend hours every day using my desktop computer, my iPad, or my iPhone. And when I'm not online, I'm often reading. It turns out that blink rate decreases while reading, too, whether from a book or a tablet. It seemed I was a prime candidate for blink exercises. I resolved to try them. The basic sequence of the exercises is this:

CLOSE YOUR EYES - PAUSE - PAUSE 

SQUEEZE YOUR EYELIDS TOGETHER - PAUSE - PAUSE

OPEN YOUR EYES - PAUSE - PAUSE

Dr. Korb has created an app, which I downloaded, that guides users through six repetitions of this sequence. Initially, I performed the entire sequence of six repetitions several times per hour. It only takes a minute to do the sequence six times and it certainly seemed worth a try.

The results were astonishing. After one day, the whitehead on my eyelid had disappeared. When I did the exercises, I could literally feel the stickiness of the oil extruded onto my eyelids. My eyelid margins soon lost the slight redness that had persisted even after I'd started using hypochlorous acid. My eyes stopped looking bloodshot, and they felt less tired. After a while, I found that I didn't need to do the exercises as frequently, though I still make sure to do them several times per day. And I was able to stop taking low-dose doxycycline. It's now been over eighteen months since I started doing the exercises. I've had no styes or chalazia during that time. I recently had my eyes examined by an optometrist, who confirmed that my eyelids are now healthy. 

Despite my original diagnosis of ocular rosacea, I've come to believe that the primary cause of my problems was a failure to blink properly. A simple mechanical fix, the blink exercises, has made all the difference. I don't take my eyelid health for granted, though. In addition to doing the eye exercises several times a day, I continue to use hot compresses once daily for five minutes and I apply hypochlorous acid to my eyes morning and evening. I believe this combination gives me the best chance of keeping those nasty styes and chalazia at bay.

Saturday, June 15, 2019

Cardiac Arrest and the Ketogenic Diet

At age 37, Jessica (a pseudonym) experienced a terrifying event. Her heart stopped. She was at a performance of Hamilton when it happened. Someone in the audience cried out that there was an active shooter. There wasn't, but in the ensuing panic, while running to escape, Jessica collapsed.

Fortunately, a woman among those fleeing the theater knew CPR and immediately started chest compressions. Within two minutes a defibrillator was brought, which restarted Jessica's heart. Miraculously, she suffered no permanent damage. She was told by the cardiologist at the hospital where she was taken that this was likely a one-time event. However, that optimistic diagnosis was contradicted by the second cardiologist she consulted, several weeks later, after she'd obtained the results from the electrocardiogram (EKG) performed at the time of the defibrillation.

The EKG showed that Jessica had suffered a torsade de pointes, a type of ventricular tachycardia which caused her heart's two lower chambers (the ventricles) to beat faster than the two upper chambers (the atria). The doctor concluded that this was a result of a long QT interval, a condition in which the heart muscle takes longer than normal to recharge between beats. He surmised that the long QT interval was likely due to a congenital defect and warned that Jessica could go into cardiac arrest again at any moment.

Courtesy of Blausen.com staff (2014)
Fortunately, there's a very effective preventive treatment — an implantable cardioverter-defibrillator (ICD), which helps to regularize rapid heartbeats and arrhythmias. The ICD sends information directly to the hospital on a daily basis, so that any potential problems with either Jessica's heart or the device itself would be addressed quickly. Jessica was advised to remain in the hospital under observation until the device could be implanted. That happened within a couple of days.

A few months have now passed and Jessica is doing fine. The ICD, which is implanted below her left collarbone, makes it uncomfortable for her to sleep on that side, but that's a minor inconvenience compared to the benefit it provides.

In the midst of her adjustment to life after such a major trauma, Jessica made another change — she went off the ketogenic diet, which she had been on for more than a year. When I heard about this, something clicked — I wondered whether the diet had a connection to Jessica's heart problem.

What is the ketogenic diet? Basically, it's a high fat, very low carbohydrate, moderate protein diet. The standard keto diet consists of 75% fat, 5% carbohydrates, and 20% protein. The diet encourages ketosis, a state in which the body, deprived of sufficient amounts of its normal fuel, glucose, burns fat instead — a desirable result for people who want to lose weight. It's also been found to reduce seizures in epileptic children, when followed rigorously. In an article by the Epilepsy Foundation, it's noted that the diet doesn't provide several essential minerals and vitamins, among them selenium, so supplementation is necessary.

Why is this relevant to Jessica's situation? After I postulated that there might be a connection between her heart event and the keto diet, I did a simple Google search for "torsade de pointes and ketogenic diet." One hit was an abstract of a 2008 article in Pediatric Neurology, describing the cases of two epileptic children who had been on the keto diet and died. One was found to have "complications related to torsade de pointes, with documented QT prolongation." The second child "experienced QT prolongation while on the ketogenic diet and later died suddenly at home." I was struck by the fact that both children "exhibited selenium deficiency."

In the abstract, the authors state that "two complications related to the ketogenic diet are selenium deficiency, which has been associated with impaired myocardial function, and QT prolongation as documented on electrocardiography." They don't speculate about causality, however. That is, they don't address whether the QT prolongation might be caused by the selenium deficiency.

However, another abstract found during my Google search suggests a connection. The abstract of a 2012 article in the Journal of Clinical Neuroscience describes the authors' attempt to evaluate the effect of the keto diet on the QT interval by performing electrocardiograms on 27 children with refractory epilepsy after they'd been on the diet for one, three, six, and twelve months. No changes in the QT interval were found, and no heart problems. Interestingly, all the patients had been supplemented with oral calcium and selenium, which makes me wonder whether the selenium supplementation might have prevented QT interval problems from developing.

At the time of her cardiac arrest, Jessica was following the ketogenic diet, but now that she's been off it for a number of months, any selenium deficiency she might have had will probably have been corrected. So, it may be impossible to know for sure whether the diet led to Jessica's near-fatal arrhythmia. If there was a direct connection, though, I wonder whether the QT prolongation will persist now that Jessica has discontinued the diet, or whether it will revert to normal, making a recurrence unlikely.

I am sure of one thing — Jessica should never go on that diet again, even with selenium supplementation. That's one recommendation I can confidently make without a medical license.

Note: Click on image to enlarge it.