210: How Steroid Creams Impact Your Eyes w/ Dr. Brian Boxer Wachler

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Many people don't think twice about applying steroid creams near their eyes to get rid of rashes. But did you know that steroid creams can actually affect your eyes and your vision?

 

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My guest today is Dr. Brian Boxer Wachler. He is known as America's TV Eye Doctor, as he's been featured on Good Morning America, The Today Show, CNN, Dr. Phil's The Doctors and many more.

He has over 1.6 million followers on TikTok and is known as the go-to doctor for calling out what's real or cap (which is Gen-Z term for ‘fake').

Join us as we discuss how steroid creams can affect your eye health.

Have steroid creams impacted your eyes? Tell me about it in the comments!

In this episode:

• Guidelines that Dr. Brian tends to give patients when using topical steroids in the orbital area
• How does skin around the eyes differ from skin on the rest of the face and body?
• What is a healthy eye pressure?
• The dangers of pressure in the eyes increasing
• What are cataracts?
• Are there any alternatives to steroids for rashes around the eyes?
• Why you have to be careful about what you put around the eye area

Quotes

“Steroids in a small percentage (but not an insignificant percentage) can increase the pressure in the eye. If that was undetected and went on for a long time, it actually could cause glaucoma. Another risk of steroids long term is developing cataracts as well.” [2:04]

“Please wear sunglasses, everybody. It's like sunscreen for your eyes.” [11:54]

Links

Find Dr. Brian online

Follow Dr. Brian on TikTok | Instagram

210: How Steroid Creams Impact Your Eyes w/ Dr. Brian Boxer Wachler FULL TRANSCRIPT

Jennifer: Thank you so much, Dr. Boxer Wachler for being here. I really appreciate it.

Dr. Brian: I'm excited to be here.

Jennifer: I know. Especially because we found out, for everyone listening, we were talking before this interview, and I discovered that Dr. Boxer-Wachler actually knew my dad and he knew of his work. So it's just a very small world. Who knew my last name was the clue.

Dr. Brian: Yeah, when you said your dad was an ophthalmologist, an eye surgeon, I was like, “Fugo, oh my gosh. He invented the Fugo blade.”

Jennifer: Yup.

Dr. Brian: He's well known in the field. Yeah, he's famous.

Jennifer: So it's a real honor to be here with you today, especially because I would've normally have asked my dad to do this. So it's nice that I'm getting to interview someone who actually knew of my dad and his work on this topic, which is really near and dear to my listeners' hearts or shall I say eyes so to speak because the reality is that many of the people who I'm talking to on my podcast, they're listening because they're dealing with skin rashes of some sort. Actually, I might ask you some other questions just on steroid drops and some things, but we're going to talk about steroid creams predominantly and the use of them on your face, especially around the eye area.

Jennifer: So as an ophthalmologist, if someone comes to you and they very apparently have swelling or some sort of rash in the orbital area, obviously a steroid cream could help, but are there some guidelines that you tend to give patients to be careful about usage of a topical steroid in that area?

Dr. Brian: Applying the steroids to the skin can have huge benefits, especially short term. If I have a patient who comes in, has been on a cream for a long time, one of the things we're always going to do, we would do this anyway but I'd be wanting to pay particular attention to see what the results are is to see what the pressure in the eye is. Because steroids in a small percentage but not an insignificant percentage can increase the pressure in the eye. If that was undetected and went on for a long time, it actually could cause glaucoma. Another risk of steroids long term is developing cataracts as well. Then there's a rare risk of steroids which could cause a droopy eyelid or ptosis as we call it. It's spells like the pterodactyl, like P-T, ptosis.

Dr. Brian: They just forgot the P, and we're just going to go with the T for ptosis.

Jennifer: Ptosis. So let's back up a bit because we got three things to unpack here. So thinning of the skin is… That's actually separate issue that you didn't even mention.

Dr. Brian: Right.

Jennifer: But this area around the eye, is that skin thinner than other areas say on the face or the body?

Dr. Brian: It is. It's one of the thinnest skin areas in the body. I'm going to venture to say it's the thinnest.

Jennifer: Oh, okay.

Dr. Brian: Let somebody out there in the PhD community come back and say, “No, actually, there's this one area right here.” But let's just say it's the thinnest skin in the body.

Jennifer: Because thin skin, so could that also contribute to premature aging around the eyes and whatnot if you're using steroid long term to deal with rashes in the orbital area?

Dr. Brian: Well, by thinning the skin, then it does increase the risk, and I was going to close my eyes just to demonstrate, is there's blood vessels there and veins for example. One sign of aging is when people have more of a veiny look. So if when people are blinking or closing their eyes, if there's more of those blue veins showing, then that's going to make people appear older than what they are, which is not usually a desirable look.

Jennifer: No. I didn't even think of that, the intraocular pressure. So for everybody who doesn't know, you have basically fluid inside your eye, and you have these different chambers. You have the posterior and the anterior. So front and back. You need for that pressure to be… What do you consider to be a healthy eye pressure? I know that varies from person to person. But generally speaking, what would a normal, healthy eye pressure range be?

Dr. Brian: Between 10 and 21 is considered your general “normal” range. There's exceptions of people walking around a little bit higher, but they are passing all the glaucoma screening tests. That's probably okay. Of course based on what their eye doctor says. But generally that's the case.

Jennifer: So if you're going to prescribe this medication or say if somebody's just going to their family doctor and getting this med, and it's not to say maybe using it for a week might not be a problem. But if there's an ongoing use of it, in your opinion, do you believe that someone should go to an ophthalmologist or an eye doctor of some sort and make sure to get the pressure in their eyes checked?

Dr. Brian: That would be my recommendation because if somebody's on a steroid cream or lotion of months, then a small percentage can get this response where the pressure starts going up in the eyes. The thing about that is it's not painful. Nobody would feel that pressure go up usually. So the only way it's going to be detected is by the eye doctor checking in.

Jennifer: I know the answer to this, but I'm going to ask. So is there anything wrong with the pressure going up? If it just goes up and stays there for a while, is there damage that can be done? Is it something that it's not that big of a deal? If you're on it for two years and then come off, you're probably fine.

Dr. Brian: You can never make that assumption. No patient using a steroid long term should make that assumption because there is a real risk of causing glaucoma. Basically think of the eye as fluid filled, like a balloon, and if you over inflate that balloon with water, it puts more pressure on it, and that pressure can cause damage to the really key nerve called the optic nerve that connects the brain to the eye. If that pressure is causing nerve damage, that can start to affect the vision, the peripheral vision. That's how glaucoma manifests is loss initially at least of the peripheral vision. So left unchecked, the vision keeps closing in and closing in and really if it was high pressure for a long time, can cause complete blindness if untreated.

Jennifer: So this is something that's kind of a big deal I would say. You don't want to be using a topical steroid around the eye area and not having that checked. Then you said too about the issue with I guess essentially premature cataracts. So you could end up developing cataracts early. For those who do not know, what is a cataract, and what does that mean essentially for your vision?

Dr. Brian: So a cataract is where the natural lens on the inside of the eye, which is typically clear, starts to develop an opacity or a cloudiness. That can cause vision to decline or even before that just increase glare and halos at night, make driving at night a little bit challenging.

Jennifer: So can you naturally get rid of a cataract?

Dr. Brian: There's really no natural treatments that have been proven to reduce or get rid of a cataract. Eventually if it's a significant enough cataract, obviously as an ophthalmologist, I do cataract surgeon. That means we remove the natural lens and we put a lens implant in its place. So if somebody had that develop after using steroids of a while and I've had patients who've come in with blurry vision, and I start asking about their history and looking at their medication list. I've seen it. I've seen this happen and people are just so surprised that a steroid caused their cataract.

Jennifer: I mean, there's so many risks too on being on steroids for long term. Does the same apply to steroid eye drops? Because I know that there was some instances where my dad would say, “Oh, well you're using a steroid… I think a steroid type medication for your eyes themselves.” Is there the same risk?

Dr. Brian: Absolutely because if anything it's probably more easily absorbed directly on the eye. So yeah, steroid eye drops long term have that same risk, if anything probably a little bit of an increased risk over topical steroid creams on the skin.

Jennifer: Is there anything that you recommend, if someone's really struggling with rashes around the eye area and maybe even too chronic blepharitis or some sort of issue where the eye is really red and irritated in addition. I mean, I've seen photos of folks who have really inflamed red eyelids and their eyes also look really scratchy and uncomfortable. They just cannot seem to get rid of this. Are there any other potential options that they could use other than steroids?

Dr. Brian: I think you bringing up blepharitis is a great, great point because any inflammation, inflammation of the eyelid glands, that's what blepharitis is. That can cause a lot of pain and irritation and dry eye symptoms and red eyes. Steroids can help knock it down, but it's a bandaid treatment. So what we know is that the most common type of blepharitis, dry eye is inflamed oil glands that are called meibomian glands. Research out of Harvard Medical School over many years has found that these glands have receptors of this hormone testosterone.

Dr. Brian: So what we've developed over the last probably 15-17 years is using a cream that has some testosterone in it and it sounds a little bit crazy but this works in about 95% of people so well that they just continue with this cream. Because if they stop, they're like, “Oh my gosh, my eyes are starting to feel like they're back in the toilet again basically.” So they use the cream just on the skin right here at the edges, and it absorbs and gets into the glands. Like I said, for a huge percentage of people have worked wonders when blepharitis is usually a chronic, life long condition.

Dr. Brian: I even have it myself. I'm also a patient, and I use this testosterone cream myself on my own eyelids. I've been doing this for probably 14-15 years now. It's kept it totally in check. I don't even have dry eye or feel my eyes at all because of it.

Dr. Brian: So that's really addressing the root cause of blepharitis. Where steroids can help maybe break that vicious cycle but shouldn't be used long term.

Jennifer: What about someone who has really inflamed, a lot of redness in the conjunctivitis? The conjunctiva is the white part of your eye that should be I guess a whiter-ish tone. So for somebody who's really struggling because I do also have clients that really struggle with histamines. So they're very sensitive to histamines in their diet. Their eyes just get really, really red almost from exposure to histamine. They may even have a lot of allergies, really sensitive to environmental issues. Is there anything that you have found that's helpful in terms of someone goes to their ophthalmologist, what they could possibly ask for? Is there any type of help there to help calm the eyeball itself down?

Dr. Brian: I think that's a good point. I think it's important to distinguish allergy or histamine related red eyes from sun damage red eyes because very different mechanisms. I just want to make a public service announcement that it's really important for everybody to wear sunglasses outside, especially on cloudy days because the ultra violet light from the sun causes damage to the conjunctiva, like you were talking about, the membrane over the white of the eye. That can make it permanently blood shot or have yellow spots develop, and people with darker complexion get brown spots on that white area.

Dr. Brian: We treat it with a procedure called the whiter eyes procedure. So that's treatable, but the point is it's different than the redness from allergies. But please wear sunglasses, everybody. It's like sunscreen for your eyes.

Dr. Brian: So when you're talking about help now for allergic related red eyes. So there's over the counter drops like Patanol, which can help. Those are anti-histamine type drops and can stabilize. Then for some short term allergic relief, there's Naphcon A. That's a good one. You have to be a little careful using some of those drops that are also the vasoconstrictors that make the eyes look white temporarily because it can cause a rebound redness that can be permanent over time. They almost trick the eye into thinking that it doesn't have enough blood flow. Then the blood flow is created by the eye in reaction to that. Then people can end up with permanently blood shot eyes.

Jennifer: That does not sound fun at all.

Dr. Brian: Yeah, I've seen it. That's why I know it exists because people are coming also for that whiter eyes procedure that I've unfortunately been unknowingly victimizing themselves with the chronic-

Jennifer: Get the red out.

Dr. Brian: Get the red out.

Jennifer: So can I ask another question because you've mentioned this a few times. Drops can be readily absorbed through the tissue. The creams can be absorbed through the tissue. Here's the thing, I get asked a lot, my eyelids, my eye area is really bothering me. Can I use this cream? Can I put this moisturizer, this product around this area? I always tell people, I'm like, “I'm not a doctor. You need to speak with your doctor, but my experience had been in working with my dad that people had used all sorts of things around their eyes and then ended up like in a lot of pain.” So for somebody who is struggling with this because I don't want to be like, “Don't, don't, don't, don't, don't do all these things.” Because that sort of feels like, what can I do? But as an ophthalmologist, do you have another little PSA maybe you could share with people about why you have to be careful what you actually put around the eye area?

Dr. Brian: I think it ranges not just from creams but even when people are getting lashes applied and the glue in the lashes could have formaldehyde, and that can be extremely irritating to the skin. If the glue, for example, even got in the eye, it could actually cause potentially corneal ulcer. So I think look for things that are low alert, low allergy profiles, that's probably the best way to think about it and more natural. So even for people who have dryness of the skin around the eyes or dry eyes, we've had amazing results having people just taking oral flax oil capsules because it internally lubricates the membrane. So that's been huge as a natural thing.

Dr. Brian: But in terms of the creams, look for things that have less of the chemicals and just more natural because those chemicals [crosstalk 00:16:37] can be very irritating.

Jennifer: … an eczema cream for your body, right? Does that necessarily mean because it's an eczema cream it's safe to put literally around the skin of the eyeball itself?

Dr. Brian: You'd have to look and see how it's labeled, and if you have any concerns, talk to a doctor about that. Because like we talked about, the skin around the eye is very thin. So it's more sensitive [crosstalk 00:17:07], it's more susceptible.

Jennifer: Go ahead.

Dr. Brian: By the way, there's one other thing I think is good to mention. We talked a lot about the steroids, but in rare cases, people using steroids, especially steroid creams, it can cause [crosstalk 00:17:21]-

Jennifer: What would cause the eyelid to droop? That's right. Thank you for circling back on that. Do you know what the reason is that it would cause the ptosis?

Dr. Brian: Yeah, the presumed reason is that it's affecting the muscle. Because as we're looking at each other right now, we have eyelid muscles that are holding our eyes up. Not our eyes, our eyelids up technically. But if those muscles get weakened, guess what happens.

Jennifer: The eyelid… Yeah.

Dr. Brian: Right. The eye droops. Now people will interpret it usually as my eye got smaller, which of course didn't happen. But the eyelids drooping makes it appear smaller. So steroids in rare cases can cause what's called a myopathy, which is just a really fancy way of saying it's messing with the muscle, and it's not as strong. It's weakening the muscle. So the muscles here droop. So that's a rare risk. People taking systemic steroids can get a systemic myopathy or muscle weakening in their body too. Like higher dose systemic steroids, like prednisone and things like that. But that's important to be aware of if you're using an eyelid steroid and you're getting a droopy eyelid. You should definitely [crosstalk 00:18:40] talk to your doctor.

Jennifer: I knew some of this from my dad and some of it I didn't know. It's really helpful to hear this because I don't know where else to… I was like, “I got to ask somebody,” because I don't know where else this information is being shared. You're the first ophthalmologist who I've had on the show. I've had a lot of dermatologists. I've had some gastroenterologists. I've had dieticians and all. But you're the first ophthalmologist I've had on the show, and this is really helpful for people to hear because your eyes… The one thing that I took from all the years of just having a dad as an ophthalmologist was that while we've made so many advancements, we can't replace the eyes. The eyeball itself. We can't. So if there is damage, sometimes it's not fixable. We're not there yet. There's no bionic eye. If the retinas damaged, sometimes that is what it is.

Jennifer: So he always impressed upon me the eyeballs are essentially an extension of your brain. You want to take care of them. So we want to do our best. This has just been so cool and enlightening. I really appreciate you spending the time sharing this with us, especially too because you have… For those who don't realize, Dr. Boxer-Wachler actually has a really great TikTok. If any of you are on TikTok, he has a really great TikTok account, and actually I've watched your account, and I was like, “What is that?” Then you told me that the eye surgery didn't go over so well on TikTok, which is not honestly surprising. I'm desensitized to eyeball surgery because my dad made me watch it as a child. But most people, eyes are a funny thing.

Dr. Brian: It's funny because on TikTok my main role is to help answer questions and in Gen Z's language, something that's fake or not true is called cap. So I have this whole game where I hold up my blue hat and put my blue cap on in response to a video if it's not true. So mostly it's been dispelling a lot of myths or confirming things that are true that could be really surprising, natural remedies for things, which I've learned a lot doing this. But when I was doing eye surgery one day, people are asking me, “Oh, I want to see a LASIK. I want to see a LASIK.”

Jennifer: You don't. You don't want to see a LASIK.

Dr. Brian: [crosstalk 00:21:17]. Yeah. So you're desensitized of course. I'm desensitized because I do LASIK. So I thought because people were asking, so we were showing a live LASIK. People just get so wigged out when they see an eyeball and instruments going in an eyeball that they've never associate the two going together. So after that, we're like, “No, we're not going to show any live surgery, and we're not going to post any surgery videos on my account. That doesn't go over well to the general…”

Jennifer: I think eyes are like teeth. Most people those two areas don't want to… No way.

Dr. Brian: I'm going to venture to say eyes are like sausage. I know you're wondering how is that. It's like you like the sausage, but you don't want to-

Jennifer: No, you don't. No, you don't. You don't want to know how the surgery's done and everything. I mean, I saw a lot of interesting things that my dad would do over the years, but I will say having that direct… Just getting to see firsthand the damage that can happen, and actually I've even had corneal abrasions, which are extremely painful. So even just that, I can't imagine what a corneal ulcer must feel like. So obviously some of these things you do want to take seriously and make sure that we're reaching out to an ophthalmologist. I think a lot of times too people get confused. If you wouldn't mind, I think this would be a great question. Very simplistic. But why would someone reach out to or when is the right time to reach out to an ophthalmologist versus an optometrist because they're not the same thing? I think people get confused and think eye doctors are all the same, but they're really not.

Dr. Brian: That's a great question. So an ophthalmologist is somebody who went through medical school, is a medical doctor, and then they specialized in eye care and eye surgery. An optometrist is also an eye doctor but they went through optometry school. So they're really specialists in optical care, IE glasses, contact lens, but also medical care for eye conditions too. Some of them can be very well trained with specialty training to treat other types of eye conditions. But they also treat regular eye conditions as well.

Dr. Brian: So one's a bit more specialized, but both are eye doctors and provide really good eye care.

Jennifer: Yes. Obviously if it gets too serious-

Dr. Brian: Depending on what their needs are.

Jennifer: … for an optometrist, they're going to refer you to an ophthalmologist or you might even get referred to some sort of sub-specialty, depending on what issue. I knew there was neuro ophthalmology and there's all these different specialties. So okay.

Dr. Brian: Yeah, like my specialty is cornea. So most of my world is in the front part of the eye, the windshield to the eye basically. That's one of my specialties is keratoconus where the cornea bulges out, and I developed and pioneered a number of procedures, like cross linking to help stabilize it from bulging and other procedures to-

Jennifer: That's awesome.

Dr. Brian: … restore the vision, improve the vision.

Jennifer: Yeah.

Dr. Brian: So we can get really specialized in one area.

Jennifer: All the surgeries very tiny.

Dr. Brian: Very micro.

Jennifer: Yes. It's very tiny.

Dr. Brian: My world is about a half a centimeter.

Jennifer: I just want to thank you so much for being here Dr. Boxer-Wachler. This has been so informative, so helpful for my listeners. I know that they will really appreciate it. We'll make sure to link up to all of your social media accounts and your website and everything in the show notes so they'll be able to find you. I just thank you so much for being here. It's been an honor to talk to you.

Dr. Brian: Well, it's been a lot of fun as well, Jennifer.