False diagnosis #1: RSI

In mid-October 2010 I (Sanjeev Sabhlok) came down with pretty severe eye strain. Working at a frentic pace for around 12 hours (not including breaks) on the computer each day, plus reading and writing on the bus to and fro from work, and reading books at the bedside (apart from newspapers and magazines), I precipitated a most severe form of eye strain.

I didn't realise I had eye-strain till a few days after initial symptoms had started. For days there was extensive soreness and heaviness in the eye – in my frontal lobe area, almost as if my brain was hurting. It hurt to look at the computer screen (or even a book) for more than a few minutes without experiencing severe aggravation of the symptoms. The eyes hurt with a burning and painful sensation, and were swollen and puffy.

I immediately tried to determine (localise) the source of the pain. It was hard, but there was one crucial symptom: when I widened the eyes and then tried to relax them, terrible fatigue and soreness set in. And there was no getting away from this pain, whether in the morning or night. Incessant. One day it became so bad that I almost felt nauseated and could not stand. The onset and severity was rather quick and abrupt. 

It was clearly a form of RSI – RSI of the eye. 

I had no choice but to cut out 80% of my discretionary work. All reading/writing stopped except some work on the blog. I spent quite a bit of time on research on this issue, knowing (based on my experience with RSI) that it was going to be impossible to find any doctor in the world who fully understood this problem.

An extensive search of the internet proved this point. 99% of the material on 'eye strain' on the internet is irrelevant: quite useless. I therefore not only studied the internet but many academic journal articles. Finally, I arrive at a diagnosis and then a "cure". Like all RSI issues, I know this is a temporary cure. Once the problem starts it doesn't go away entirely. Below is an initial description of the logic underpinning the solution I've arrived at. I'll update it in due course as I learn to manage it better. 

STEP 1: What muscles could possibly be affected?

The first step in my analysis was asking: which eye muscles can get affected? I learnt that there are three main areas where eyes have muscles:

i) External (eyelids)

ii) Internal (ciliary)

iii) Muscles to move the eye (outside the eyeball) [Click image to make it a bit larger – for best results, see a good book on anatomy]

The eye has over a dozen important muscles. In each of these case static load is the key problem. If a particular position is held for a long time, the muscle will become tired. Lactic acid will build up. This acid must be moved out quickly thorugh the bloodstream, else it will eat away/damage the muscle cells. The rubbery "goo" created by the acid makes the muscle fibres sticky and further clogs their movement – causing severe burning/pain. This is what happened to my upper body and arms with RSI. This is what happened to one or more of my muscles of the eye. The question was which.

STEP 2: Which muscles have the greatest likelihood of being affected?

a) RULING OUT THE CILIARY BODY:

The ciliary body or ciliary muscle is alleged on some internet websites to be the key muscle affected by computer work. I'm not sure if that is the case. Damage to the cililary body would mean that eye accommodation (ability to focus) would be lost. Blurring or images or double vision would result [indeed it does – see this]. This did not happen in my case, and I wonder if such would be the first consequence of computer work, for it would require CONSTANT focus on a single place, but even while working on the computer the eye moves from one part of the screen to the other and often re-focuses. In any event, I had an eye test scheduled a week after this problem struck me and the optometrist found that my eyes are fine from the inside. The focal acuity is fine. I can see well better than 20/20 with corrective glasses. This muscle, if affected by RSI can virtually never be cured. It is very important therefore to undertake relevant preventative exercises (more on that later).http://gamrconnect.vgchartz.com/thread.php?id=100744

b) POSSIBLE EFFECT ON EYEBALL MUSCLES:

I'm not sure whether my eyeball muscles have got affected yet. Perhaps a bit. Eye movement slow down while looking at the computer and hence I'd expect some harm to have been caused to these muscles. However, the probability of this harm is, in my view, but I'm not sure how good is blood circulation of these eyeball muscles. Best to be very safe and exercise the eyes (more later). Just like the ciliary body, if these muscles get affected there is NO WAY to masage them. I have wrked out the following "cure" for these internal muscles, but I'm not sure if it is going to be effective if these muscles get seriously affected ;

– head stand (sirsasana) to increase blood flow (I now do this every day for the past few days – and would need to continue further. Note that those with high blood pressure should NOT do this exercise.

– careful eye movements to stretch and make these eyeball muscles more mobile (more later).

c) DEFINITE EFFECT ON UPPER EYELID:

A careful examination of the eyelid anatomy shows that it is the upper eyelid that moves, the lower generally moving very mildly. While staring at a computer, one is liable to move the upper eyelid up for long periods of time, and reduce blinking significantly, which causes further static strain. There are two muscles that hold the upper lid up  the biggest the levator and a smaller superior tarsal muscle (Mueller's muscle). Muellers muscle is very susceptIble to sleep, fatigue, illness.  In addition, the lachrymal gland (tear gland) gets affected, being located just to one corner of the upper eyelid. The constant pressure imposed by the static upper eyelid means that the lachrymal gland can't secrete tears as smoothly as it was earlier able to. That leads to dry eyes. 

My optometrist noticed dryness in the eyes and gave me a artificial tears (Optive which I now use upto 5 times a day – and receive a bit of a relief). But that did NOT solve the problem. Headaches were still very bad.

Having understood the eye anatomy carefully I decided to visit my doctor, Sam Assad. Turned out to be a good decision. He is familiar with my herculean battle against RSI and has (I think) learnt that most computer injuries are like sports injuries – over-use and strain based. On hearing that everything else is fine, he suggested that the upper eyelid must be the cause of the problem.

And he had a solution! Called Metsal. It is used in sports injuries. He asked me to try it over my eyelids. Very small quantity, and away from the eye. I tried it immediately, and over the first day itself, started feeling some relief. By the third day, the severe headache has gone. I've used it over 10 times by now. It works. It is the most horrendous experience to have this BURNING HOT cream go into one's eyelid, but that's the best way to release the "goo" from the muscles. The muscles will take many days to heal, but the process has started.

Things aren't normal yet. Soreness remains, although on a scale of 10 it is down to 3 out of 10 (compared with 8 or 9 out of 10 earlier). It also gets better with sleep now. Earlier, sleep would not make any difference.

I'll talk about the many other steps I've undertaken and the other precautions that are necessary in order to revert to some normalcy. This includes replacing the computer monitor, changing the tilt and height of the monitor, blinking a lot, etc. etc. But that will be later. Let me finish for now.

REPORT ON FURTHER PROGRESS

Artificial tears did not give much relief, just a slightly soothing effect. The hot rub (metsal) (using since 6 November) has led to a significant reduction in the headache. The burning of the eyes has reduced.

I applied Metsal extensively for the first few days. Then decided not to exceed three times a day given the risks of an side-effects (see notes, below). There were a few moments within the next few days when it almost seemed that I was normal. I noticed that a couple of glasses of wine would temporarily  dampen the sensation soreness. But eyestrain came back with the slightest computer work. The severe tiredness (and burning of the eye) gave way to soreness. That basically continued for another week.  

Other things like homeopathic creams and pills, and anti-inflammatory tablets might have helped to some extent but after a few days I've basically stopped taking them. 

What really worked:

Massage worked, along with hot towel placed on the eyes – many times a day. Massage is particularly important. I was pretty brutal for the first time in pulling and squeezing the eyelid muscles and all others around the eyes. I rubbed the eyes, I squeezed them hard and released them. Techniques learnt from yoga to tighten all facial muscles and relax them, were useful. All that many times a day. I stretched the outer eyes muscles as much as I could, and pressed down hard on the connecting tendons. As a result the eyes became sore, but that was "good soreness" – the one that comes as muscles are healing.

Within two days of the massage (and wet heat) the results started showing. As I write this (21 November), I've now experienced virtually no headache for 2 weeks and virtually no heaviness or soreness for 3-4 days. Instead, there is a slight sense of stickiness/pressure/tiredness in the eyes, and I know that I must keep up this regimen:

a) Metsal

b) Massage

c) Hot towel

I've not put eye drops for 2-3 days now, without any adverse effects. I've also been very sporadic in taking the homeopathic medicines/anti-inflammatory medicine. There's no harm in doing all these things if time permits. I've also been sporadically doing the head stand to increase blood flow. But these are NOT the main solution. The package of solutions is the one outlined directly above.

And now for the preventative stuff. It is crucial that I learn to blink more, rest the eyes more frequently, and keep the computer screen at a good distance. At work, I've pushed back the screen nearly three feet away, and use very large fonts to read. At home, I've switched to a 20" LED screen (Viewsonic VA2038wm-LED) and blow up the images each time rather than focus on small objects. The key is to keep the eyes TOTALLY RELAXED. I am very mindful of the stress or strain on the eyes, and use techniques learnt through yoga meditation to relax both eyes periodically. 

SIDE-EFFECTS OF METHYL SALICYLATE

Don't overdo Metsal or other 'hot rubs' that contain methyl salicylate.  Do NOT use Methyl Salicylate/Menthol Cream if you are allergic to any ingredient in Methyl Salicylate/Menthol Cream, including oil of wintergreen. 

Some medical conditions may interact with Methyl Salicylate/Menthol Cream. Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you:

• if you are pregnant, planning to become pregnant, or are breast-feeding
• if you are taking any prescription or nonprescription medicine, herbal preparation, or dietary supplement
• if you have allergies to medicines, foods, or other substances
• if you have had an allergic reaction to aspirin or other salicylates
• if you have a wound at the affected area or your skin is broken or damaged in any way
• Some MEDICINES MAY INTERACT with Methyl Salicylate/Menthol Cream. Tell your health care provider if you are taking any other medicines, especially any of the following:
• Anticoagulants (eg, warfarin) because the risk of their side effects may be increased by Methyl Salicylate/Menthol Cream
• Ask your health care provider if Methyl Salicylate/Menthol Cream may interact with other medicines that you take. Check with your health care provider before you start, stop, or change the dose of any medicine.