Who would have known watching the NBA All-Star game I would have been surrounded by glasses fashion?  The "geek chic" look (reference this post) has reached new heights, and is being fully embraced by two of Miami's Big Three.  You have to wonder with so much exposure how much longer this trend can last, but it is definitely still going strong right now!

Dwayne Wade and LeBron James love eating hot dogs together while wearing nerd  chic glasses

Close up of James' Dita frames.  They do fit his face quite well so congrats to the optician for getting this look right!  Remember, the glasses are supposed to be big, but you still want your eyes well centered in the frame.

If you have dry eye, at some point your doctor has probably mentioned Restasis.  I was recently told that Restasis is the most commonly prescribed pharmaceutical eye drop, and that statement doesn't surprise me in the least.  For patients suffering from dry eye, over the counter artificial tears are not always enough to relieve the signs and symptoms of dryness.  If you are having to use over the counter artificial tears routinely more than four to six times a day, then you are in need of more advanced intervention to treat your dry eye.  Restasis is the next step for many doctors, but there is a lot to understand about this drop.

1) When to use Restasis
Depending on who you ask, you are going to get different answers to this question.  Personally, I always treat meibomian gland issues (see this post) first with a combination of warm compresses, lid hygeine, and artificial tears as needed. If the glands start responding to treatment and the patient still is having complaints (dryness, watering, grittiness, sharp pain, etc), I offer punctal plugs or Restasis as the next therapy line.  You will have some doctors tell you that Restasis is best used on post-menapausal women, but I have seen it be effective in men as well, and there is no scientific evidence as of yet to limit the use to a certain population base.  In short, if tears and MGD treatment isn't resolving things, it is time to consider Restasis.



2) How Restasis Works

Vials come in trays, with 1 tray equal to 2 weeks technically, but really this amount will last 1 month if you recap.

I asked this question to my Allergan rep just last week, and he just gave me the simplest answer: "we don't know yet."   What we do know is that Restasis is cylcosporine (a potent anti-inflammatory that has been used in organ transplants in a different concentration).  The goal of this anti-inflammatory is to stop the production of T cells which are inflammatory mediators that are naturally in your tear film.  Chronically dry eyes have these T cells in higher concentration than normal eyes.  Point of interest: the T cell has a lifespan of 180 days, so Restasis should take 3 months to begin to effectively work.  Restasis also helps increase the production of tears, but how this happens is not effectively understood.

3) How to Write the Rx
Allergan provides an Advantage Pack with a card that can be activated for savings on the patient's copay.  This card doesn't work with Medicaid plans unfortunately.  In order to use this savings card, you have to write the Rx for 6 trays/90 day supply.  This is the most cost effective way to write this Rx for your patient!

4) What to Tell Your Patients

• Restasis is to be used twice a day.  Every day. 
•  It burns when it goes in and this is normal for this drop.
• It may take 3 to 6 months for this drop to reach full effectivity.  Some patients may notice relief as early as 3 weeks.
• Because it takes so long for Restasis to become effective, some doctors will start treatment with a more potent anti-inflammatory such as Lotemax dosed once or twice daily for a month.
• Your pharmacist's directions will tell you to throw the vial away after 1 use.  Do not do this.  Recap your vial after your morning dose and store in a clean environment, then use it again for your night time dose.  This will make the 3 month supply your doctor wrote your Rx for really last 6 months.

Recap your vials to get a full day's use (two drops per eye)

Synergeyes Duette is a RGP in the center for great optics, surrounded by a silicone hydrogel skirt for comfort

You can probably tell from my previous posts (here, here, and here) that I have really been incorporating the new Synergeyes Duette lenses into my practice.  Unfortunately, they haven't always been the easiest lenses to fit.  I was seeing patients back 3 or 4 times (or more!) over a period of 2 months to get the vision and fit comfortable for some patients.  The lens would look great, I was following the fitting guide, but my patients were getting variable results.

Then came the break through.

If you are going to fit Synergeyes Duette lenses, don't follow the fitting guide.  At least, not the one they gave you initially.  I was told earlier this week that the fitting guides are being changed and redistributed, so if you have a trial set in your office this new information will be available soon.  The original fitting guide had you fitting lenses based on flat K, over refracting, and then maybe going to a steeper skirt curve if the distance vision still didn't seem sharp enough.  Sometimes it worked; sometimes it bombed.The new fitting technique is straight forward and makes a lot of sense.

Step 1:  Get the Patient's K readings and find the average K value.




You can use a topographer (left), your autorefractor, or a (gasp) keratometer for your K readings.  If you are fitting this lens, the cornea should be pretty regular, so using the autorefractor K's should be good enough in most cases.









Step 3: Round your Base Curve to the nearest available Synergeyes Base Curve (they only offer 7.90, 7.70, 7.30, and 7.10)

Step 4: Insert the trial lens in the Median Skirt curve and Over Refract -- make sure you are within +/-1.00D of the spherical glasses correction!  Remember, you need less than 0.75D of residual astigmatism (just like any other RGP) to make this lens work.  I have been told it can handle up to 4.00D of cyl, but I haven't tried that high.  If your over refraction isn't within that 1.00D target, your base curve probably needs to be adjusted.  Just SAMFAP to tell you which direction to go.

Step 5: Order.  You can still adjust skirt curve for comfort (steep and flat options are available).   And in the multifocal lens you can use a large (better for distance vision) or small (better for near vision) add zone to improve vision.  I will say that basically every lens that I put on a patient looks like a good fit, so using fluorescein hasn't been that helpful.  Judge going steeper or flatter based on patient complaints.  Also, there is very little movement of the lens if the fit is too steep, so make sure to check that out. Little tweaks from your original fit should be all that is needed!


I am just now incorporating this method into my office, but so far it seems to make a lot of sense!  Please post if you are having any problems or any advice for other ODs out there fitting this lens.  Overall my patients do really like the vision and comfort in this lens once we get the fit correct.  Hopefully with this new method, finding the right fit will be a lot less time consuming.

Ernest Hemingway sporting the "old reliable"  metal rim frame Undeniably unstylish

Now that I am practicing at my own office, I get all sorts of surprise optometry mail.  It's one of those new OD perks that is still exciting to me. "Oh you want me to read this?  You are trying to inform me about this product? " Wonders never cease. Friday I received a flier advertising the new Ernest Hemingway Collection eyewear line. Let me tell you, I love some Hemingway.  A Farewell to Arms is my favorite book.  But Mr. Hemingway wasn't exactly a glasses style icon (check out the photo left as proof).

Popular black and white combo that fashion forward men are daring to try these days

Round frames are difficult for men to wear, but there is also a women's line with the collection offering more delicate options in the same dark/tortoise color family

And you can get them in sunglasses!

The Sun Also Rises was originally published as Fiesta.  Who knew?

Back in July, I wrote about the potential use of retinal photography in the early detection of Alzheimer's Disease in this post.  At that time, research had just been published showing a correlation between narrowed arteriole lumens (which can only be seen by a doctor during a retinal exam without cutting into the body!) and individuals with Alzheimer's.  Utilizing retinal photography in this way is still in its infancy, but new studies are emerging all the time supporting comprehensive eye exams as a potential source of early detection.

Brain tissue imaging depicting anomalous amyloid proteins

In a study by Susan Stark at the University of Washington, 125 individuals of "normal cognition" with an average age of 75 were asked to record the number of falls they suffered over a period of 6 months.  Brain scans were performed on all study participants looking for amyloid beta plaques (a calling card of Alzheimer's brain damage), and it was found that the risk of falling was 3 times greater for every unit of amyloid plaques found!  What does this have to do with eye exams? While we aren't the only doctors that treat people after a fall, we do see patients on a regular basis with injuries around their eyes from falls.  Additionally, patients discuss with their eye doctors at their annual exams if they are having dizziness or falling because they often attribute this imbalance to a problem with their glasses.  People suffering or complaining of frequent falls traditionally are referred to their primary care doctor to be screened for blood pressure issues, but these new study results support screening for signs of dementia as well!

As I mentioned earlier in this post, one of the most important aspects of your eye exam is screening the health of the retina.  It is so important because it is the only place we can look at blood vessels and nervous tissue without invasive procedures!  Ongoing research by Dr. Lee Goldstein at Boston University and the company Neuroptix is trying to utilize our easy access to the eye by developing a laser scanner to detect amyloid proteins in the eyes.  According to Dr. Goldstein, the presence of amyloid proteins (which form the brain plaques) can be measured in the lens of the eye (the structure where cataracts form, which is also entirely comprised of proteins).

Retinal Photography gives a high-definition view of the optic nerve (center) as well as the retinal arterioles and venules which aids in detection of hypertension, diabetes, and potentially even Alzheimer's!

Early detection of amyloid plaques and misfolded tau proteins has captured the medical community, and new research is being published almost daily.  Most recently, we are learning that these anomalous tau proteins are found even in young people that are suffering traumatic brain injuries, such as football players.  Most recently investigators found the proteins in the brain of an 18 year old football athlete who had suffered multiple concussions.

Anomalous proteins in the brain of an 18 year old football player; image courtesy link above

We are only beginning to understand this disease, and there is a lot of research yet to come before detection of Alzheimer's in its earliest stages is possible.  What we do know is that routine health care, including eye exams, is our best option for catching health issues in their earliest stages.  So even if you don't need glasses, remember it is really worth your time to have a comprehensive examination!