Sunday, January 12, 2020

Welcome to the new decade! 2020 is here! Artificial Intelligence - better than humans?

Happy New Year! Welcome to the 3rd decade of the 21st Century!

2020 has arrived on our doorstep and we had welcomed a new decade. We have left behind 2010s with many contributions to the development of eye care and eye health. As anticipated our world is continuously digitized so is the field of ophthalmology. Telemedicine is here so are doctors on call coming to the rescue with Uber/Lyft like on demand care.

The other day a friend of mine was bedridden with a severe cold and she later confessed that it was easy enough to pay $99 fee for an online doctor on call local to Orange County service that sends a board certified primary care physician to patient's house to examine and treat her. No leaving the house, waiting in the waiting room of urgent care or emergency room department, or lengthy insurance paperwork was necessary. With a click of a button a doctor appeared at her door step.  I believe the field of ophthalmology is going in a similar direction.  More and more services are available for online contact lens dispensaries.   However, these services still rely on a prescription by a real doctor who patient needs to see, however, a shift is on the way to automated refraction available online. It is not accurate at this point, but this decade may change that.

A significant challenge of he world wide web is a deluge of available information and one's ability to sift through it in a meaningful way. One can google the symptoms and "self diagnose" his or her problem.  Over and over again I have seen patients in my chair ridden with anxiety after reading about diagnosis that is not remotely relevant to his or her condition.  I have to take the time to disspell "Dr. Google"'s diagnostic techniques and reassure the patient.

There is a caveat to the technology in its early adaptation period in health care. At this point, in my opinion there is no single Google search or Healthgrades reference that can diagnose or treat any particular disease.  A board certified physician is still the gold standard of care. There is no substitute to a face to face human to human interaction where subtleties of clinical presentation, physical exam, mental state, socioeconomic situation as well as ability to process comprehensive medical information in the year 2020.

As a practicing physician, I like thousands of my colleagues, had to embrace Electronic Health Records (EHR), that have digitized a medical chart.  Now, the new task is to let not technology mislead the patient and their well being.  A fine line of balancing the use of technology will be walked by all who are involved in direct care, and that is what I will personally watch evolve this decade with great anticipation.

Friday, January 18, 2019


Recently I was invited to a private tour of our local Orange County, CA medical ophthalmic device  company Glaukos located in San Clemente, CA.  Here are the pearls of my visit that I would like to share with you.

As of 2012 Glaukos broke out into glaucoma research and clinical care field with a new and pioneering device Istent that changed the treatment of glaucoma forever.  For patients diagnosed with glaucoma, it is a life long struggle to keep the intraocular pressure as low as possible.  That commitment requires constant discipline to take pressure lowering drops, sometimes up to three times a day.  Imagine your elderly relative or busy colleague that runs at the pace of our modern life who has to stop three times a day for 5 minutes at a time to put one drop into each eye and wait 5 minutes for absorption of these drops.  What if that patient is driving on a freeway and stuck in traffic, will he or she miss the drops? What if he or she forgot the drops at home?  Every time a patient misses the drops, glaucoma chips away at the optic nerve and leads to slow but permanent peripheral vision loss.

The breakthrough idea about the original Istent device back in 2012 was that the it lowered intraocular pressure in patients who have undergone cataract surgery and Istent implantation at the same time.  Istent was and is the smallest medical device that has been successfully implanted in human body to date.  The initial studies showed that patient had additional decline in intraocular pressure  by 15-20% in large populations in clinical trials compare to cataract surgery alone.  The original Istent required a bit of a steep learning curve for an ophthalmic surgeon.  Encouraged by the first five years of wide clinical implementation and receptive to surgeon user feedback, Glaukos developed a user friendly Istent Inject when two Istent devices with modified shape are implanted by a surgeon at the time of cataract surgery.

I have been implanting Istent since 2017 since have done over a 100 implantations at this point.  I was the first surgeon that implanted Istent Inject at out Newport Bay Surgery Center since it was introduced late in 2017.  I have seen excellent results where intraocular pressure decline in patients who have undergone combined cataract surgery and Istent implantation.  There are no side effect that we see with traditional glaucoma surgery that requires large implants in the eye.  There are no additional risks to the cataract surgery when Istent inject is added to the planned cataract removal.

If a patient can reduce dependence on glaucoma drops, not only is it a relief in time consumed placing the drops, it also leads to reduced risks of side effects associated with use of pharmaceutical agents, and the relief of financial burden placed by the costs of drops to the patient.

I am looking forward to offering that latest Minimally Invasive Glaucoma Surgery (MIGS) which includes Istent Inject implantation for all of my patients with glaucoma at Clarity Eye.  I feel strongly that Istent Inject is the safest medical device that I have placed in the eye since the advent of the intraocular implant.  Soon, we will have a decade of data from the pivotal studies on the original Istent implantation. With every new generation of Istent, just like every new generation of Iphone, the safety profile, and efficiency of the Istent device has increased manifold and now should be an attractive option to any patient who is looking to reduce or eliminate dependence on intraocular pressure lowering medication.  If you or your family member have glaucoma, ask your surgeon about Istent Inject!

Wednesday, February 21, 2018


As a Board Certified Ophthalmologist, I like to share news about eye health with my patients that will enhance their life.  I strongly believe that lifestyle choices affect your eye health.  Now we have several studies to confirm that we can prevent glaucoma  Dr. Pasquale of Cornell University emphasized that there is not any particular proven strategy to prevent glaucoma, but he shared six suggestions that show promise:
  1. Eat many green, leafy vegetables. “These are a great source of nitrates that can be converted into nitric oxide,” Dr. Pasquale said. “In primary open-angle glaucoma, there is impaired nitric oxide signaling.” There are drugs in development that will target this highly druggable pathway, he added.
  1. Protect the eyes from the sun starting at an early age. “There is considerable evidence that sunlight reflected off water and snow may be associated with an increased risk of exfoliation syndrome,” Dr. Pasquale said. “A good strategy to start in your younger years is to protect your eyes from the sun.”
  1. Maintain good dental health. This strategy may sound odd initially, but there is a theory that periodontal disease could trigger neuroinflammatory markers that reside in the base of the tooth and travel via the blood to the optic nerve. “At least two studies show that those with poor dental health had a greater open-angle glaucoma risk,” he said.
  1. Exercise in moderation. Moderate exercise is associated with a lower intraocular pressure (IOP), but vigorous exercise appears to be associated with primary open-angle glaucoma.
  1. People should see an ophthalmologist regularly, especially if there is a family history of glaucoma.Dr. Pasquale is involved with a NEIGHBORHOOD consortium focused on finding common gene variants for glaucoma. “We hope this effort will translate into people finding out earlier if they are at an increased risk for glaucoma,” Dr. Pasquale said.
  1. Maintain a healthy body weight. A higher body weight and body mass index are associated with metabolic syndrome and diabetes risk. They could also lead to an elevated IOP. However, someone who is thin, has a low body mass index, low blood pressure, and cold hands and feet could have a disturbed autoregulation, leading to an increased risk of normal tension glaucoma.

Friday, January 19, 2018

Shingrix Vaccine is a MUST for patients 50 and older to prevent painful shingles outbreaks

A controversy existed because the American Academy of Ophthalmology and the American Dermatologic Society recommended that patients over 50 years be vaccinated for shingles but the CDC recommendation was 60 years and above, Pepose said.
Now all recommendations are in line.
In October, the U.S. FDA indicated all healthy adults over 50 years be vaccinated and Shingrix (GSK) was selected as the preferred vaccine.
There are 1 million new cases of zoster annually in the U.S. versus 35,000 new cases of herpes simplex keratitis (HSK), he said. Along with 100,000 new cases of zoster ophthalmicus.
One in two people over 70 years will get shingles in their lifetime, he said.
The risk of stroke increases by 30% within 1 year of zoster and 4.5 times following herpes zoster ophthalmicus, Pepose said.
“This is thought to be related to varicella zoster virus (VZV) travelling down the afferent sensory fibers of the trigeminal nerve to internal carotid and its intracranial branches,” he said.
There are common misconceptions about shingles, he added.
It was thought that the vaccine could perhaps curb immunity in older patients.
“It turns out the incidence of zoster was increasing with age even before the production of the vaccine,” Pepose said.
The vast majority of zoster patients are healthy, he said. The mean age of onset for shingles is 52 years.
The ocular disease usually occurs weeks after.
“Although zoster is more severe in immunocompromised individuals, 92% of zoster patients are healthy,” he said.
The risk of PHN increases with age. PHN is associated with depression and is the leading cause of suicide in chronic pain patients over 70 years.
“Both varicella and varicella vaccine establish an immune response and lifelong neuronal latency, but changes in cell-mediated immunity lead to reactivation,” Pepose said.
He added that only 24% of eligible patients aged 60 years or older have been vaccinated.
“All patients over age 50 years should be vaccinated. I think you’ll have to be cautious with this in first quarter as the reimbursement is going through for the insurance company,” he said.
Zoster trials are ongoing.
“In those who currently have zoster, I wouldn’t vaccinate after it clears but wait a year and then vaccinate. I don’t think there is any evidence that proves the vaccine causes reactivation,” he concluded. – bAbigail Sutton

Pepose JS. The shingles vaccine and zoster ophthalmicus. Presented at: Hawaiian Eye; Jan. 13-19, 2018; Wailea, Hawaii.

Wednesday, June 21, 2017

I have exciting news! My office started carrying a leading  ANTI AGING skin care line, Rodan & Fields. Dr. Rodan & Dr. Fields are two dermatologists, who created acne fighting product Proactive in late 90s. In early 2000s they have extended their expertise into the anti aging skin care line for men and women interested in looking their best every day. The new line has a sun protection and age defying regimen REVERSE, as well as a skin maintenance and rejuvenation kits REDEFINE.  There is an improved acne fighting line UNBLEMISH as well for younger patients, and people suffering from adult acne.  The most revolutionary product to me as an ophthalmologist is LASH BOOST which GROWS your lashes over 2 months of use. NO MORE EXTENSIONS!
I am so excited to be part of R & F team, and to be able to extend the years of research from the leading dermatologists to benefit my patients.
Summer is the perfect time to protect your face from sun damaging rays as well as rejuvenate and repair skin, boost eyelashes and eliminate fine lines.
Starting June 22, 2017 purchase skin care kit+LASH BOOST to receive 20% off.
*First three patients in the month of June to come to our office for an eye exam and mention this ad, will get a FREE sample of GLOW packet for skin rejuvenation and 10% towards LASH BOOST purchase!* 

See more at: and shop the skin care line of your choice.

Thursday, June 1, 2017

Have you noticed your "sunkissed" eyes looking yellow lately?

Southern California boasts 281 sunny days a year. Sunny days means tremendous amount of direct ultraviolet radiation exposure to our skin and eye surface. Without the physical protection of sunglasses and a wide brim hat, continuous UV radiation results in chronic and permanent changes on the white part of the eye called conjunctiva. 

Conjunctiva when healthy is smooth, moist, and white; it has a glistening reflection from an abundant tear film covering it. Sun leads to mutations in the way elastin and collagen, the soft tissue building blocks, are synthesized on the eye surface and dermis of the skin. These mutations lead to permanent deposition of yellow, fatty, elevated tissue on the white of the conjunctiva. These striking deposits grow over time to unsightly and commonly irritating lesions called pingueculi. These areas are frequently easily irritated by wind or allergies and turn the whole eye red.  When the fatty deposits cross over the cornea, the clear window of the eye, the clarity of vision is affected by the pulling of the scar affecting the optics of the eye.

Most people are not aware that removal of the pterygium is a short outpatient procedure with minimal down time. It is done at an outpatient facility and most patients return to desk jobs within two days. With the use of doctor prescribed eye drops the healing process continues for a month after surgery until the eye looks “pristine” and white as it did before sun damage ravaged the ocular surface.

Surfers and farm workers are people that are most affected by pterygia. People who spend significant hours outdoors golfing, sailing, fishing or playing tennis maybe at risk as well if sunglasses are not worn. Some people have a genetic predisposition to develop sun damage
as early as teens. For those patients the cosmetic effect of the pterygium or even pingueculum is quite significant.

Our office speciliazes in identifying and treating sun damage of the ocular surface with medical options as well as a more definitive surgical removal.

Saturday, February 25, 2017

Grapes may support ocular health

Compounds found in grapes may help protect against eye disease, according to new research led by researchers at the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine. The study showed that a diet supplemented with grapes was able to counter damage from oxidative stress and preserve retinal structure and function in a laboratory model of retinal degeneration, the university said. The study was funded by the California Table Grape Commission; researchers investigated whether a diet supplemented with grapes, in the form of whole grape freeze-dried powder, would protect the photoreceptors of the retina from degeneration induced by acute oxidative stress. Mice were fed the grape-supplemented diet (corresponding to about 3 servings per day for humans), a sugar-matched control diet, or a normal chow control diet. Both retinal structure and function were preserved in the mice consuming the grape-enriched diet, where they maintained their retinal thickness, the quantity of photoreceptors, and the amount of photoreceptor activity, despite the elevated oxidative stress conditions. Conversely, in the non-grape consuming group, retinas were damaged, displaying holes and lesions, and with a significant decrease in thickness.