Dr. Pradhan’s Blog


May 11, 2018 S Pblog0

Quick post:

This is the year of change for me as I’m turning 40. Trying to get life, weight, skin under control! I’m grateful to have found Arbonne and my gluten-free diet along the way.

If you want to try any product whether it is the weight loss or skin care or phytosport product, just let me know at drpradhan@eyedoctormd.org or text me at 804-277-9458 or shop online at shilpipradhan.arbonne.com

Sharing an inspiring video about human potential and grit:



March 24, 2018 S Pblog

Painful or neuropathic dry eye disease

If you have pain in your eyes, you need to come in for an examination.  After a complete evaluation to check for other serious eye conditions like glaucoma, I (Dr. Pradhan) might tell you that you have dry eye disease.   If you may have pain that is relieved with topical numbing medication in clinic or if you have severe light sensitivity, you could have abnormal corneal nerves.  One of the additions to the definition of dry eye disease in the DEWS II report was to add neuropathy or pain to the definition.

Chronic dry eye disease can lead to damage of your corneal nerves.  Chronic dry eye changes the feedback loop of the surface of your eye.  If you have had any eye surgery, it can also cause painful dry eye disease.  Certain eye surgery actually cuts the corneal nerves (like LASIK) and depending on the location of the surgery and your body’s healing response, the corneal nerves may not grow back or they may grow back abnormally, leading to painful dry eye disease or painful light sensitivity. The treatment not only involves treating the surface dry eye disease but helping treat the source of the pain and light sensitivity.  Thankfully, a few treatment options have been shown to help regrow corneal nerves over time (via in-vivo confocal microscopy) and help treat the pain from dry eye disease.

One of these effective treatment is autologous serum drops.  These are tears made out of your own blood.  This treatment and the regrowth of your corneal nerves also helps reset the feedback loop for your body to produce more tears and decrease pain and light sensitivity over the course of treatment, which can range from 6 months to 2 years depending on the severity of your symptoms.  Autologous serum drops have even been used in other causes of dry eye disease including graft-vs-host (GVHD) or chemical burns to the eyes.  I (Dr. Pradhan) offer my painful dry eye patients the options which help regrow corneal nerves effectively.  These include autologous serum tears, amniotic membrane graft (like Prokera) and sometimes topical medications like cyclosporine 0.05% (Restasis).  Depending on the severity of your condition, you may need a combination of these treatment options.

Here’s a recent case published in the Ophthalmology Times newsletter which highlights a patient with painful dry eye disease and his treatment.

Neuropathic dry eye: When serum defeats tears by By Melina I. Morkin MD, Pedram Hamrah MD FACS

I searched the medical literature website (Pubmed.gov) for autologous serum eye drops this morning and got 198 responses/articles so there is plenty of research supporting the use of autologous serum drops on the surface of the eye.

Autologous serum drops:

Autologous serum drops can be formulated at any concentration but typically start at 20% concentration and can be increased if needed over time.

Once you instill them, you will want to keep your eyes closed for 3 minutes.  They are thick and can blur your vision for upto 5 minutes after instillation.

Since they are a blood product, they need to refrigerated or frozen at all times.

No one else can use them except the patient from whose blood they are made.

They have growth factors, immunoglobulins and vitamins which are not present in normal tears which can help heal your dry eye disease.

We are fortunate in Richmond to have a local compounding pharmacy which can make autologous serum drops for you.  I (Dr. Pradhan) or my staff will draw your blood and the compounding pharmacy takes it from there to make your autologous serum drops and deliver them to your house usually within 2-3 days.

There is hope for painful dry eye disease.  Thanks for reading.



February 24, 2018 S Pblog

Have you been screened for glaucoma?

The recommendation is to be screened every 2-3 years starting at the age 40 for glaucoma if you have no risk factors.  If you have risk factors, you need to be screened starting at a younger age (in your 20s and 30s).  Risk factors include a family history of glaucoma, race (higher risk in black, Latino and Asian patients), trauma to the eye and steroid use.  You should be screened annually after the age of 55 even with no risk factors.  As we learn more, genetic risk factors will also determine our risk analysis for all medical conditions including glaucoma.  How long do you plan on living? Do you want to keep your vision for the rest of your life?  Come in and see Dr. Pradhan for your glaucoma screening exam.

What is the treatment for glaucoma?

Depending on your type and level of glaucoma, the treatment will be different.  Read more about the types of glaucoma on our glaucoma page. We can divide the treatments into medical, laser or surgical.

MEDICAL treatment

With medical treatments, there are different classes of drugs and combination drugs to consider.  Patient adherence to the treatment regimen is a factor in choosing the right treatment as well.  A medication will only work as long as you are taking it.  Therefore, generally treatment is initiated with once daily dose medications which are easy to remember to take daily.

There are classes of drugs with different side effects and different efficiency in each patient as well as dosing regimens required (once daily, twice daily, or three times daily).  Depending on the rest of you (whether you have asthma or sulfa allergy or other factors), your eye doctor can help choose the best treatment for you.  The treatment also needs monitoring however because your body can become resistant to the medication over time (tachyphylaxis).

LASER treatment

For narrow angles and narrow angle glaucoma, the only treatment is with a laser to create a hole in the iris and open your angles.  If that does not work, it may become necessary to do another type of laser (iridoplasty) or remove the lens in the eye to open up your angles.

For open angle glaucoma, there is a laser called the trabeculoplasty which helps open the drain of the eye.  It can be performed with different types of lasers and is named accordingly (SLT or ALT).  Generally, the SLT (selective laser trabeculoplasty) is less traumatizing to the eye tissue and is titrated to a level with no visible damage on examination and equally effective as the ALT (Argon Laser Trabeculoplasty – older style laser treatment).  Some patients are more likely to respond to the laser treatment than others (such as patients with more pigmentation inside their eye, pigmentary glaucoma or pseudoexofoliation glaucoma).

SURGICAL treatment

If your glaucoma is at a level where medical or laser treatments are not effective and your eye disease is progressing, it may be time to consult with a comprehensive ophthalmologist who routinely does glaucoma procedures or a “glaucoma specialist” (a physician who did fellowship training in glaucoma surgery).  There are many surgical options for glaucoma treatment including the newer MIGS procedures (minimally invasive glaucoma surgery) like the “istent” or “cypass” and the traditional and effective procedures like trabeculectomy (sometimes called filtration surgery or a “bleb”) or Ahmad or Baerveldt implant (sometimes called a “tube” or “tube shunt” surgery).

Monitoring your glaucoma and treatment with your ophthalmologist is important to help you keep your vision for the rest of your life.  Come in and see Dr. Pradhan for your glaucoma screening exam.



February 17, 2018 S Pblog

What’s the deal with turmeric?

Turmeric is a spice and you hear about it in cooking especially Indian cooking.  It is an ingredient sold as a capsule in most grocery stores now and even Costco.  Doing a search for “turmeric” on the medical literature search engine, www.pubmed.gov, you get 4350 hits.  That’s pretty amazing.  So, turmeric has been studied and published in that many peer-reviewed medical publications!  Turmeric has curcuminoids and curcumin is the major one in turmeric.  You may have heard of polyphenols and how they are good for you.  Curcumin is a yellow-colored polyphenol from the plant Curcuma-Longa.

Turmeric and the EYE

A great review article published in frontiers in Pharmacology by Liu et al in Feb of 2017 reviews it effects on various parts of the eye.  Curcumin has amazing properties including anti-oxidant, anti-inflammatory, anti-angiogenic and wound-healing as well as anti-tumor (breast, prostate, lung, pancreas, ovary, bladder, cervix, head and neck, brain, kidney and skin).  “Curcumin can also induce cell death in human uveal melanoma cells through the mitochondrial pathway.” Wow!

Turmeric and the CORNEA

The cornea is the clear window on the front part of the eye.  Inflammation can cause blood vessels to grow and cover the surface of the eye. The article goes on to say curcumin can help corneal neovascularization (KNV) (blood vessel growth on the cornea/front part of the eye) and different formulations which may help.  Curcumin blocks various growth factors and cytokines which can lead to KNV either locally or in your diet.  It can help wound healing on the cornea as well.

Turmeric and DRY EYE DISEASE

Dry eye disease is caused low tear production and increased evaporation, both induced by ocular surface inflammation.  That’s why we try to address both tear production and prevent evaporation.  But if we can attack the inflammation, we can stop dry eye at it’s source.  The main treatments for dry eye are anti-inflammatory as well including omega-3s, topical cyclosporine (Restasis), topical lifitegrast (Xiidra).  Treatment with the Intense Pulse Light (IPL) and Lipiflow can also decrease the chronic inflammation on the surface of the eye by helping photocoagulate the inflammatory blood vessels and decrease the chronic inflammation released from clogged oil glands in your eyelids.

Curcumin can inhibit inflammatory cytokines which can then decrease the feedback loop which causes dry eye disease.  More research needs to be done in this area. However, I have patients who I prescribe omega-3 and turmeric and their dry eye is 60-75% better in 3-4 months.  It may be the omega-3 effect or a combination.  But there is no denying that a change in their diet (not topical medications or more drops), made the difference in their symptoms.

The article also highlights a product named “Ophthacare” made by the Himalaya Drug Company which has 8 different herbs including curcuma-long 1.30% which can help dry eye and conjunctivitis, as well as pterygium.  I was able to find it on Amazon.  The product includes: Carum copticum, Terminalia belirica, Emblica officinalis, Curcuma longa, Ocimum sanctum, Cinnamomum camphora, Rosa damascena and meldespumapum”.  The article also mentions “Haridra Eye Drops” which may help in conjunctivitis.  I couldn’t find those online.  To be clear, I am NOT recommending use of these drops at this time until further research has been done to ensure they are safe. The oral Doctor’s Advantage Dry Eye Relief supplements include a small amount of oral turmeric.

Turmeric and UVEITIS

Uveitis is an inflammation inside the eye of the uvea.  The uvea includes the iris, the ciliary body and the choroid.  Uveitis can be in the front, back or both parts of the eye.  They report a study from 1999 that showed oral curcumin 375 mg 3x per day helped uveitis.

Turmeric and CATARACT

Cataract is a clouding or opacification of the lens inside the eye.  “It is believed that oxidative damage to the eye lens contributes to the development of different kinds of cataracts.  The primary mechanism for the anti-cataract effect of curcumin is through its antioxidant properties.” “…vitamin C may have a preventative role in cataract progression.”  Curcumin helps increase vitamin C levels as well. Vitamin E also has been shown to prevent certain types of cataracts.  Turmeric and curcumin especially help the progression of diabetic cataracts by modifying the protein aggregation which may lead to lens opacification as well as reducing oxidative stress from excess calcium and nitric oxide.  The authors go over 10 articles which break down the ways in which turmeric can help delay cataract progression.

Turmeric and GLAUCOMA

Glaucoma is irreversible chronic progressive vision loss due to optic nerve damage from eye pressure that’s too high for you.  Sometimes glaucoma progresses even when the eye pressure is low.  The thought is the nerves are getting damaged at the exit from eye and we need neuro-protection to help prevent progression.  This means we need to help the nerve cells suffer stress and not suffer damage.  Curcumin has been shown to have neuroprotective properties by inhibiting oxidative damage as well as helping prevent mitochondrial dysfunction.

What dose of Turmeric is effective?

Turmeric has low solubility and bioavailability.  Bioperine (found in black pepper) has been shown to help the absorption of turmeric.  The recommend dose on WebMD is Turmeric extract 500 mg 2-4x per day depending on your condition.  If you read the NIH website from the National Center for Complementary and Integrative Health, it states it is generally safe to take however the studies are still ongoing about its full benefits.

What are others saying about Turmeric?

If you read about Turmeric on Wikipedia, you will find the author states there is no strong studies to support the use of Turmeric to reduce inflammation.  It does importantly warn about lead and another dye to monitor for which may make a product look orange but does not actually have turmeric in it.

If you read the WebMD article about turmeric, you will find that turmeric has been used for various inflammatory conditions with some effectiveness including reducing high cholesterol, helping osteoarthritis and itching/allergies.  It also lists insufficient evidence for using turmeric for other conditions including Alzheimer’s, colorectal cancer, gout, diabetes and many others. What this tells me is more research is needed.

________________________________________________________________________

Figure 2 from article by Liu et al in Front Pharmacol. 2017; 8: 66.  Published online 2017 Feb 14. doi:  10.3389/fphar.2017.00066



January 27, 2018 S Pblog

This is an article I’ve shared before but it is so powerful in demonstrating the role of proper diagnosis and treatment that I’m highlighting it again.

Brown M, Hernández-Martín A, Clement A, Colmenero I, Torrelo A. Severe Demodexfolliculorum–Associated Oculocutaneous Rosacea in a Girl Successfully Treated With Ivermectin. JAMA Dermatol. 2014;150(1):61–63. doi:10.1001/jamadermatol.2013.7688

Brown et al discuss a 12 year old girl with both facial and ocular manifestations of rosacea.  She had blepharitis, conjunctivitis and even corneal scarring.  She had been treated for over a year with traditional therapies including doxycycline pills, isotretinoin pills (Accutane), steroid eye drops, tacrolimus ointment, cyclosporine 0.05% eye drops (Restasis) without resolution.  She had numerous skin biopsies and the fourth one revealed some demodex mites. A single dose of oral ivermectin (anti-parasite or anti-mite) medications achieved full resolution without recurrence for two years of both her skin and her eye symptoms!

What is rosacea?

Rosacea is a skin condition typically known for redness and dilated blood vessels (telangectasias) on the face (nose, cheeks, chin, forehead).  It is most commonly seen in fair-skinned individuals but can occur in any race.  The cause of rosacea is not well known. The National Rosacea Society developed a classification system in 2002 and updated it in 2017.  The primary features include flushing or redness which is transient or nontransient, papules and pustules and telangectasias.  The secondary features including burning/stinging, elevated plaques, dry skin appearance, swelling of the skin, ocular changes (see below), and growth or thickening of the skin especially of the nose (rhinophyma).

What is ocular rosacea?

Ocular rosacea includes dilated blood vessels (telangectasias) on the eyelids which can lead to eyelid and eye redness (conjunctivitis), crusting (blepharitis), increased risk of infection of the meibomian glands (styes), scarring of the meibomian glands (chalazions), and chronic dry eye disease.  Persistent untreated disease can lead to blurry vision and even corneal scarring. Eye manifestations can occur even without facial signs of rosacea.

What is demodex?

Demodex are tiny mites that live in hair follicles.  The two species which live on humans live in the eyelashes (!) but can also live on the face, eyebrows and other places on your body.  They can be transferred from person to person with contact with the face especially hair and sebaceous glands and likely from shared makeup as well.

What can demodex do to your skin and eyes?

At times, having demodex does not bother the patient at all or cause problems. In other patients, it can cause significant eyelid itching, redness/conjunctivitis, crusting/blepharitis, can worsen rosacea, cause cystic acne (as highlighted in the case above).  Chronic inflammation from demodex can lead to dry eye disease with blurry vision which can lead to corneal changes (punctate keratitis, Salzmann’s nodules, corneal ulceration).  Demodex can also lead to loss of hair (alopecia) on the head or the eyelashes (madarosis).  On the eyelashes, the classic appearance of demodex reveals a cylindrical cuff of dandruff at the base of the lashes known as collarettes.  Gently removing one lash can also reveal numerous demodex mites living buried in the lash follicle.

How is demodex treated?

The first step is to eliminate possible reinfection so please wash your sheets and pillow cases on high heat and in the dryer and get new pillows or wash your pillows as well as no makeup for 2-4 weeks and when you resume, it should be a new supply of makeup. Do not ever share makeup.

The second step is eliminating the crusting on the lashes which is protecting the mites.  You can do this with gentle scrub of the base of your eyelashes at home 2x per day with tea tree oil eyelid cleansers (like Eye Eco – available in our office), or in the office with a BlephEx treatment (available in our office) to jump start your treatment. Don’t forget to also scrub your eyebrows.

The third step is killing the mites which can be achieved with either Tea Tree Oil (20-50% concentration diluted in walnut or olive oil), tea tree oil wipes (like Cliradex – available in our office) and if needed, prescription topical ivermectin cream (Soolantra) or ivermectin pills (anti-mite medication like in the highlighted case above).  If you have lesions on other parts of your body, consider using Tea Tree Oil soap and shampoo as well.  Intense Pulse Light (IPL) treatment (available in our office) also has been shown to help rosacea, ocular rosacea, eyelash crusting (blepharitis) and may help kill the demodex mites as well.

Topical treatment typically takes approximately 6 weeks to kill demodex and their larvae.

If you have any symptoms or signs consistent with rosacea, ocular rosacea or demodex, come in for an evaluation with Dr. Pradhan and find the right treatment for your eyes and skin.

 



January 22, 2018 S Pblog

Amazing long-term study looking at data for 121,050 adults over 26 years was just published showing that dietary inflammation increases risk of colorectal cancer.

Bottom Line:

An anti-inflammatory diet lowers your risk of colorectal cancer.  This includes taking your multivitamins, vitamin D, Calcium, fiber, maintaining a healthy weight, drinking some alcohol (if you want – in moderation), avoiding smoking and taking a baby aspirin (if indicated by your PCP).

If you need help getting started, also read my gluten-free page and think about the Arbonne-30-clean eating program to help you reset your diet habits to include daily probiotics, daily fiber, delicious protein shakes with vitamins already mixed in as well as remove gluten from your diet and eat organic to increase your nutrients and decrease your pesticides with recipes and support via a FB group.

Now let’s read about the research….

Article citation:

Fred K. Tabung, MSPH, PhD1,2; Li Liu, MD, PhD1,2,3,4,5; Weike Wang, PhD1,2; et alTeresa T. Fung, PhD1,6; Kana Wu, MD, PhD1; Stephanie A. Smith-Warner, MS, PhD1,2; Yin Cao, MPH, ScD1,7; Frank B. Hu, MD, PhD1,2,8; Shuji Ogino, MD, PhD2,4,9; Charles S. Fuchs, MD, MPH4,8,10; Edward L. Giovannucci, MD, ScD1,2,8  Association of Dietary Inflammatory Potential With Colorectal Cancer Risk in Men and Women.  JAMA Oncol. Published online January 18, 2018. doi:10.1001/jamaoncol.2017.4844

Patient Population

The adults in the study were from cohort study (46,804 men from the Health Professionals Follow-up Study 1986-2012 and 74,246 women from the Nurses’ Health Study 1984-2012).  Out of this patient population, 2699 incident cases of colorectal cancer were documented out of 2,571,831 person-years of follow-up.  The study was done on well-educated people who know what to eat.

Background

“Colorectal cancer is the third most commonly diagnosed cancer in both men and women in the United States.  Inflammation plays an important role in cancer development, including colorectal cancer.”  Other background information presented states obesity leads to low-grade chronic inflammation in the body.  Chronic inflammation can lead to insulin resistance and hyperinsulinemia, also associated with an increased risk.  It’s a feedback loop we have to break!

The food they studied

They looked at 18 food groups and circulating biomarkers of inflammation and food questionnaires.  The food groups were processed meat, red meat, organ meat, fish (other than dark-meat fish), other vegetables (other than green leafy veg and dark yellow veg), refined grains, high-energy beverages (cola, fruit drinks), low-energy beverages (low-energy cola), tomatoes were all positively correlated with inflammatory markers and beer, wine, tea, coffee, dark yellow vegetables (carrots, squash, sweet potatoes), green leafy vegetables, snacks, fruit juice and pizza were inversely related to inflammatory markers.

How they scored the results

EDIP (empirical dietary inflammatory pattern) was developed to score the inflammatory potential of whole diets.  The more negative the score, the more the anti-inflammatory diet and the more positive, the more pro-inflammatory the diet. Three blood markers of inflammation were found and studied (IL-6, CRP, TNFRSF1B -TNF-α receptor 2).

Results

They divided the patients into quintiles (5 groups) for comparison based on their EDIP scores.

Patient with proinflammatory diets reported lower physical activity, higher BMI (body mass index) and were more likely to have diabetes, less likely to use multivitamins, reported lower intakes of dietary fiber, calcium and whole grains.

For men – colorectal cancer in the lowest risk group (anti-inflammatory diet) was 113 per 100,000 person years versus 151 per 100,000 person years in the highest risk group (pro-inflammatory diets).  Diet seems to be much more of a significant risk especially in obese men.

For women – colorectal cancer in the lowest risk group (anti-inflammatory diet) was 80 per 100,000 person years versus 92 per 100,000 person years in the highest risk group (pro-inflammatory diets).  The risk seems to be higher in lean women but not in overweight women.

So, a poor diet contributed to 44% higher risk of colorectal cancer in men and 22% higher risk in women!

There was also a higher risk in men and women NOT consuming any alcohol, however high intake of alcohol is associated with a higher risk of all cancers, including colorectal cancer. Everything in moderation!

Check out Table 1 with the details.

 

 



January 5, 2018 S Pblog

Still not sure about taking more omega-3? Still think medications are more important than your diet/food?

Look at one of the most important publications from 2017:

Renata Micha, RD, PhD; Jose L. Peñalvo, PhD; Frederick Cudhea, PhD; Fumiaki Imamura, PhD; Colin D. Rehm, PhD; Dariush Mozaffarian, MD, DrPH.  Association Between Dietary Factors and Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United States. JAMA. 2017;317(9):912-924. doi:10.1001/jama.2017.0947

Key Points:

“Question  What is the estimated mortality due to heart disease, stroke, or type 2 diabetes (cardiometabolic deaths) associated with suboptimal intakes of 10 dietary factors in the United States?

Findings  In 2012, suboptimal intake of dietary factors was associated with an estimated 318 656 cardiometabolic deaths, representing 45.4% of cardiometabolic deaths. The highest proportions of cardiometabolic deaths were estimated to be related to excess sodium intake, insufficient intake of nuts/seeds, high intake of processed meats, and low intake of seafood omega-3 fats.

Meaning  Suboptimal intake of specific foods and nutrients was associated with a substantial proportion of deaths due to heart disease, stroke, or type 2 diabetes.”

Bottom line: In just one  year (2012), 702,308 cardiometabolic deaths occurred in the USA and of those 318,656 were due to dietary factors.

What are the 10 dietary factors?

The 10 dietary factors assessed by this study included: “fruits, vegetables, nuts/seeds, whole grains, unprocessed red meats, processed meats, sugar-sweetened beverages (SSBs), polyunsaturated fats, seafood omega-3 fats, and sodium.”

The high risk dietary factors associated with cardiometabolic death:

        • High sodium intake (>2000 mg/day) – 9.5% of all cardiometabolic death
          • Highest for ≥ 65 yrs old
        • Low nuts/seeds intake (<20.2 g/day) – 8.5% of all cardiometabolic death
          • Highest for ages 45-54 yrs
        • High processed meats (>0 g/day) – 8.2% of all cardiometabolic death
        • Low seafood omega-3 fats (<250 mg/day) – 7.8% of all cardiometabolic death
        • Low vegetables (<400 g/day) – 7.6% of all cardiometabolic death
        • Low fruits (<300 g/day) – 7.5% of all cardiometabolic death
        • High sugar-sweetened beverages (SSBs) (>0 g/day) – 7.4% of all cardiometabolic death
          • Highest for ages 25-34 yrs (26.8%) and 35-44 yrs (28.9%) of all cardiometabolic death
        • Whole grains (<125 g/day) – 5.9 %
        • Polyunsaturated fats (<11% energy/day) – 2.3% of all cardiometabolic death
        • Unprocessed red meats (>14.3 g/day) – 0.4% of all cardiometabolic death

       

    It was reassuring to read that some of the numbers are improving with time. Comparing from 2002 to 2012, the number of cardiometabolic deaths decreased by 26.5% especially in the SSB category.  However, there was an increase with unprocessed red meats by 14.4%.

    However, these numbers are astonishing. You have control of your health.  Every meal, every bite helps make you either healthier or at higher risk for medical conditions.  You are given one body.  You can buy different clothes, shoes, houses, cars and phones.  You cannot buy a different body.  Take care of the one body you have with proper nutrition.  

    Learn more about omega-3’s

    Get a PRN representative to call you and educate you more on a good quality omega-3 – complete this form.

    Think about joining Arbonne’s 30-day clean eating program – email me if you’re interested at drpradhan@eyedoctormd.org