As an optometrist, I get a lot of questions.  People ask me about their eyes during their exam (of course), but also when I meet strangers on vacation, at the grocery store, or am just hanging out with friends.  Talking about eyes this much, some of the same questions inevitably get asked over and over. So here is one I know you all want answered:  what are those spots you see in your vision sometimes?

First, we need to break down the kind of spots you are seeing.  Remember, this is just a general guideline, so if you are seeing strange visual changes, you should see your doctor to be sure what you are seeing is normal and not a serious medical problem.

• Floaters: Small dark or outlined shapes
•  move when your eyes move
•  most easily seen in bright or white backgrounds
•  can be normal as the vitreous jelly that fills the eye breaks down during our teenage years
• If you see a swarm of new ones at all once, see your doctor immediately as this could be a retinal tear!
• Click here for more info

• Phosphenes: Balls of light that can be seen even when the eyes are closed
• Ever rub your eyes and seen spots afterwards?  These are phosphones.  Mechanical pressure can also cause the retinal photoreceptors inside the eye to trigger.  Since the retina cells only know how to communicate "light" they will respond the same to mechanical pressure as they do to incoming light!
• Stand up to fast and see spots?  This is a type of phosphene resulting from orthostatic hypotension.  Basically with your quick change in positioning, blood flow to the eye was momentarily minimized, causing the eye to see these spots.  Remember, the retina can only say "light" so when the cells are getting less oxygen and nutrients than they need, they only can communicate that issue with a light signal. When blood flow returns to normal levels, the spots go away.  This can also occur if you are about to faint!

  Want to see some interesting art?  Check out this site for work depicting the artist's ocular migraine symptoms!

• Visual Auras: Changing visual phenomenon
•  Commonly described as waterfall motion, kaleidoscope changes, tunneling of vision, or a light that starts in the center and then expands out.  Medically this is termed scintillating scotomas or ocular migraine
• Visual auras typically last around 15 minutes, but can last as long as 2 hours
• Often followed by a migraine headache, but they don't have to be.  It is possible to just get an ocular migraine where only the visual symptoms occur
• Vision will return 100% to normal within 2 hours.  If it does not, see your doctor immediately!
• What's the cause?  Scientists believe a vascular spasm is the cause of these ocular migraines, and remember, when the eye gets blood flow disruption, it can only communicate by processing light.

Hehehe I could't resist myself.  Optometry jokes are always the best.

Ray Ban RB4171 comes in so many colors!  I love this bright yellow/orange, but they also have a great teal.  If you are interested in more subtle options, of course you can also get black or brown, but where's the fun in that?

Maui Jim just does sunglasses right.  If you are looking for the tops in quality and performance, I can't recommend them more.  Their Hawaiian Time frame is my personal favorite this year -- great for someone who likes the look of aviators but has a small face shape that can be easily dwarfed by common aviator shapes on the market!

Prodesign has really stepped their game up this year, and I am so impressed by their men and women's lines for the season.  For the special man in your life, these wood-inspired frames (Zense 7622) are made from biodegradable materials, so not only is the aesthetic so visually appealing, but you are supporting a company who is putting environmental concerns first too.  A win-win.

Doesn't it seem like everyone in blogland has these Karen Walker Super Duper sunglasses?  Maybe I stalk Atlantic-Pacific too much.  Or maybe they are just that universally good.  They literally go with everything, and would like to personally thank Blair Eadie for being such a great advocate for wearing sun protection because she incorporates it into almost all of her looks!

Is there anything more overwhelming than the artificial tear aisle at your drug store or pharmacy?  Take 10 minutes and stake it out if you are curious.  You will see poor lost souls wander up and down in frustration, comparing bottle labels that could be written in a foreign language for all they tell you, and then landing on the familiar: Visine.  Oh no!  Everyone, please let me help you break this terrible cycle of doom.

This time of year, allergies are typically subsiding so the most likely reason that your eyes are red, irritated, itchy, burning, or watery is that they are DRY.  Dryness is prevalent in winter due to the lower humidity in the air, and the drying action of heaters in homes, offices, and cars.  In mild cases of dryness, usually a good rewetting drop is all you need to get your eyes performing back to their normal standards.  But for more persistent and chronic dryness, your doctor's intervention with more aggressive treatment is often required.

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If you are in the mild category, you need to pick the right drop in order to get successful relief.  To aid in your selection, please ask yourself these simple questions to see which drop works best for you:

1) Are your eyes infrequently dry, red, watery, itchy, burning or irritated?  Usually after certain environment exposures (like going for a run in the cold air) or at the end of your day?

• Best Choice:  Moisturizing or Lubricating Artificial Tears
• Examples:  Systane Ultra, Refresh Optive, Blink Tears, Soothe XP, Theratears
• Dosage:  1 drop in both eyes as needed, up to 4 x a day

You can also use all of these over top of contact lenses.

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2) Do you have the above issues, but eye drops usually sting when they hit your eye, or cause any other discomfort after using them?   Do you need to use drops more than 4 times a day for relief of your symptoms? Have you recently had a surgical eye procedure (like LASIK) causing you to have more frequent dryness issues?

• Best Choice:  Preservative Free Artificial Tears 
• Why? Prevents irritation from unwanted preservatives that are toxic to the eye but found in all bottle-stored eye drops
• Examples: Systane Ultra in Vials, Refresh Optive Sensitive, Retaine MGD in individual vials
• Dosage:  1 drop in both eyes as needed, can use as often as you want

3) Do you have crusting of your eyelid, or see white dome-like growths on your eyelid margins near the lash roots? Do your eyes sometimes feel filmy between or after blinking?

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• Best Choice: Lipid Based Artificial Tears 
• Why?  The questions above are aimed at diagnosing Meibomian Gland Dysfunction, the most common cause of dry eye.  Click the link to learn more.
• Examples: Refresh Advanced, Systane Balance, Retaine MGD
• Dosage:  1 drop in both eyes as needed, up to 4 x a day (or more with Retaine MGD since it is preservative free)

• Best Choice: Gel Artificial Tears or Ointments
• Why?  Gel tear drops are thicker, and will last through the night to rehydrate the eye or protect the eye if your eyelids do not close fully.
• Examples: GenTeal, Systane Gel, Refresh Gel or Celluvisc, Blink Gel, Nighttime ointments
• Dosage:  1 drop in both eyes at bedtime

I always love reviewing retinal photos with patients, because so much can be going on inside the eye without ever causing any vision issues!  Here is one such example: that circular deformity at the optic nerve in this photo is a congenital condition called an optic nerve pit.  When the eye is developing in the womb, a structure called the optic vesicle (the precursor to the optic nerve) turns in upon itself to create a channel through the center of the nerve fiber where all of the blood vessels to the eye will eventually pass through.  This grove or hole is the "cup" we often speak of when determining glaucoma risk.  If the optic vesicle doesn't close completely after this fissure or groove is created, an optic pit is formed.  Basically this is a little hole or excavation in the nerve where the tissue didn't close up properly during development. In and of itself, it is typically asymptomatic and will only be found by a doctor examining the child after birth.

Most of the time, an optic pit is harmless -- you may have an enlarged natural blind spot in your field of vision, but most people are not bothered by this (optic pits are usually only in 1 eye).  There is an association with serous retinal detachment, however.  Since the optic pit it is usually located near the macula (central vision area), a detachment in that area can be devastating to vision. Therefore, a person with an optic pit is watched closely for signs of swelling or fluid leakage inside the eye.  If this occurs, laser treatment can minimize the damage if caught early enough and prevent permanent severe vision loss.

Without someone looking, you would never know if you have an optic nerve pit, so make sure you are seen by an eye doctor for routine health care even if you have no vision complaints!

If you wear multifocal contact lenses, you know the pitfalls: vision is often a compromise between clear distance and clear reading, lighting has huge affects on vision quality, and finding a balance between good computer vision versus clear reading vision is often a struggle in higher prescriptions.  Multifocal contact lenses on the market today are leaps and bounds better than their predecessors, but I always counsel my patients on what to expect, because vision won't be as clear as it is through glasses, no matter what power multifocal contact lens we chose.  This is all the function of the lens design, since in a contact lens you are only looking  through the center of the lens, the multiple powers for distance and near must be layered in rings one on top of the other.  That means your brain is processing a distance and a near image at the same time, and having to select the clear image to process.  But luckily, multifocal designs are continuing to improve, and Bausch and Lomb's new design has been a true upgrade to the market!

Via Parameters available +6.00 to -10.00, approved for 30 days extended wear!

The PureVision2 Multifocal uses the company's new thinner silicone hydrogel material, that has also received approval for overnight monthly wear due to its high oxygen transmission (130 dk/t in a -3.00 lens).  It is a monthly disposable contact lens, just like the best soft lens designs on the market.  The design is tailored from the the innovative C-Vue multifocal designs that have found a regular place in my arsenal.  Previous multifocals have a 2 power design: 1 for distance and 1 for near.  The PureVision2 offers a "3-Zone Progressive" design that offers blended distance, computer and reading vision.   The result?  A much stronger reading vision effect without compromising distance clarity to the extent other lenses on the market do!

How to Fit the Lens

I've had this lens in my office for less than a month, so fitting is still a work in progress.  I have had good results with the company's recommendations for fit, so here's a quick break down:

Glasses add up to +1.50D  = Fit both eyes in LOW Add
Glasses add +1.75 or up = Fit both eyes in HIGH Add

My rep recommended letting the lens settle for 10 minutes for best vision results, and I have found that near tends to focus quickly, but it does take a few minutes for best distance vision to come into view for the patient.  You need to give it that focusing time, just like you would an astigmatism contact lens. Trouble shooting? B and L recommends splitting adds if the patient is suffering from blur before over-refracting:

• Low add lenses with near blur?  Bump the non-dominant eye to a high add lens
• High add lenses with distance blur?  Bump the dominant eye down to a low add

Like most multifocals on the market, the PV2 MF doesn't mask astigmatism well.  Apparently up to -1.00D cyl you may be able to get acceptable vision, but past that the results are mediocre.  Still waiting on a good soft contact lens with astigmatism and multifocal correction (keep dreaming right now...).

Liking this lens?  Have any trouble shooting advice or want questions answered?  Please post in the comment section and I will try to help out!

Time to bring out the boots and scarves, everyone.  But one thing not to put away for the winter? Sunglasses are important to protect your eyes year-round.  The UV damage that can occur from direct sun exposure to the eye and sensitive eyelid skin is not season dependent, and if there is snow or ice in your area, don't forget that the reflections off snow can also be harmful for the eyes.  And there is no shortage of great sunglass fashion inspiration out there to take a page from.  Here's some of my winter-highlights so far:

Celine sunglasses with a wool coat via

Olivia Palermo via

Want a little more color in your winter wardrobe?  The new ZEAL line of sunwear is offering great color options with an earth conscious approach to manufacturing.

Zeal Sunglasses offer 100% UV protection, polarization for the sharpest vision, and are also 100% biodegradable

I probably don't need to wax poetic anymore about my love affair with scleral lenses, but click the link if you are interested in why I think they are such a great alternative for irregular cornea patients.  Since I first started fitting sclerals, there has been a major learning curve and the excellent reps at Essilor have really helped me triage difficulties.  My first few fits were a bit like walking in the dark -- no one seemed to be publishing information about sclerals!  Now you have Contact Lens Spectrum devoting almost entire issues to sclerals, and excellent resources at the Scleral Lens Education Society page.  But if anyone wants a cliff notes version of how I fit scleral lenses, here it is:

1) Flatter is Better

The concept of sclerals is that they don't interact at all with the cornea, so there should never be touch.  But a lens that is too steep causes a lot of vision, comfort, and fit problems. There is some debate about just how much vault you want centrally in your lens, but I have been ascribing to the around 250 micron rule with excellent results.  Apparently there may be some settling to the lens after a few hours or days of wear, so it is not a bad idea to check a patient back after dispensing lenses in a few days to see how they are doing (have them wear the contact lens in, and tell them to have had the lens on for at least 3-4 hours before coming).  Not sure what 250 microns looks like?  Don't worry, I don't have microscopic eyes either (or an anterior segment OCT).  The average cornea is around 540 microns, so just aim for a vault that is about half the thickness of the cornea in an optic section beam on your slit lamp.  Works like a charm!

2) Size Matters

When I first started reading about fitting sclerals the theory was that a larger lens is easier to fit.  Well that is true if you have a large cornea, but so many people out there have small/tight eyelids.  A large lens is going to be really difficult to fit in this case!  I like to measure corneal diameter (I never did this at first and it caused me a lot of headaches) with my slit lamp --just turn the beam horizontally and measure width.  If you have a small diameter cornea (anything around 10 mm) then a smaller diameter scleral is a better bet.  Maybe start between 14 to 16 mm in diameter on your lens.  In some cases, the cornea is too small and the lids are too tight to ever make a scleral fit appropriately, so if you are having no luck getting rid of bubbles in this type of fit, I have been advised to abort.  The new toric peripheral curve lenses may help in future.

3) You Do Need a Perfect Fit (or at least really close to perfect if you want optimal lens performance; this means no bubbles, no conjunctival entrapment, and no scleral blanching)

Blanching is Bad via

To me a perfect fit means a nice even tear film under the lens.  Scleral blanching is a huge no-no; check for this by letting the lens sit for 20 minutes in office.  If the lens is too tight, the sclera will be blanched white underneath and result is a ton of discomfort and suction when the person tries to remove their lens.  Small bubbles tend to not worry people much; they may be insertion related.  But I have found bubbles do matter - - even small ones cause poor comfort after a few hours of wear, and can really wreck havoc on vision, even if you think that it is just a little peripheral bubble.  Believe me, you want it gone.  A central bubble means the lens is too steep of course. A reverse geometry design is sometimes necessary to get rid of those pesky mid-peripheral bubbles. Conjunctival entrapment, where the conjunctiva folds over the limbal cornea under the lens, used to be no big deal in the literature.  Now there is evidence that this can cause neovascularization to form in the limbal tissue underneath, where the corneal tissue is being deprived of oxygen under the conj.  Flattening the lens tends to help solve this issue (read here for more details).

4) Poor Comfort?  Check the Edge
The peripheral edge is a major source of lens awareness in this lens.  We spend a lot of time with sclerals looking at the central and mid-peripheral fit, but you need the edge of the lens as flush as possible against the conjunctiva.  If the patient can feel the edge with blink, it is going to be exceedingly uncomfortable.  A great tool in knowing if you have achieved a good fit is by checking the suction when the patient removes their lens with a plunger.  Too steep centrally = a lot of suction.  Too much peripheral edge lift = a lot of suction.  Believe it or not, a properly fit lens will actually have very little suction when the patient removes it properly.  It is a really nice feed back tool for your fit if you don't have the luxury of having an anterior segment OCT.

Oh No!! Another non-wetting lens!  There goes another 2 weeks to order a new lens to check if vision is acceptable or we need another over refraction!  Via

5) Choose the Right Material
Nothing is more annoying than having that perfect fit lens, but the patient can't see out of it because the surface is non-wetting.  In my experience, Tyro 97 is your best material to prevent that non-wetting surface issue.  With that being said, Optimum Comfort is the material my Essilor rep tends to recommend for better comfort, but I have had too many wetting issues with Optimum Comfort to go that route anymore.  Especially if the patient has MGD issues.  Tyro 97 every time for me now.

If you are a regular here, you know I was very excited to speak as a panelist for Allergan this weekend at the North Carolina Optometry Fall Congress in Asheville, NC.  It was such an honor to sit beside some of the most recognized female optometry leaders in our state:  Dr. Ann Hoscheit and Dr. Sally Miller.  Both are published, private practice owners that have held numerous leadership positions both in state and national optometric organizations, and I was a bit out of my league as the "new doc perspective" on our panel.  It was an incredible experience, and I came away with a few new concepts that I thought more female and prospective ODs might benefit from:

• Create your own personal statement:  This is a common tool used in business management, but as a person, it is so important to know what you stand for too.  Just thinking about what you want to accomplish, what you want to prioritize, and what you want as your personal identity can help guide your decision making through the entire year.  Ask yourself who you want to be as a doctor, a wife, a mother, or any other responsibility you have in your life.  If you know your own identity, and what you want to be, it really helps you stay focused on what truly matters in the stresses of daily life.
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• Don't be afraid to negotiate--and learn how to speak the language of negotiation:  For me, this is a very challenging task.  As a new grad, I felt like I was just one more face in a sea of graduating optometrists looking for an opportunity to see patients.  The first time I spoke to students in optometry school, they asked me how I negotiated my contract and employment.  My helpful response?  It didn't really work like that.  For me, I was not in the position to buy in to partnership with an established OD, and I had just two job offers to choose between.  Not much negotiation.  Looking back, maybe if I had had more of a business background I would have understood that I had more room to negotiate my situation than I thought at the time.  Since my first signed contract, however, I have done a lot more negotiating than many would think.  As an OD you are constantly negotiating your hours, your number of patient exams in a given day, your exam time slots.  The helpful advice given at this Allergan panel meeting was that as women, we need to negotiate for ourselves like we are negotiating for a business.  Dr. Rachel Wruble advised to negotiate for the business of you -- less personal desire, and more how what you are requesting is an asset to the company or situation. For example, it feels natural to say, "I want a lunch break because I will get hungry if I work for that many hours without lunch."  I know I said something similar the first time I negotiated my hours.  But if you want to have a bigger impact in the business world, negotiating is less about you, and more about how you function within the business.  You need a lunch break because without a chance to refuel, you will be working less efficiently, and risking providing a lower level of care.  That turns the exact same concept less personal; creating a greater level of importance and impact for your request. 
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• The Future Is Bright:  I capitalized this because there was an overwhelming positive message to this meeting of the female minds.  We discussed the importance of public outreach in educating Americans about the importance of the eye exam, with programs like the AOA's Think About Your Eyes campaign and even the impact on a smaller level that school screenings or career days to educate young people about what we do.  Our profession is such a legislated career, and political action campaigns are the arena where optometry gains its rights for practice and to see patients on insurance plans that may try to cut us out.   We have to fight for new healthcare changes that will provide patients access to us with equal pay as our MD counterparts.  And there are so many new fights on the horizon, like the proposal for universal licensure that would make optometrists licensed nationally instead of filing for individual state licensure.  The important take away is that we need leaders in this industry with a voice, that are willing to fight for our profession.  I hope to become more and more involved in getting the word out about optometry (the driving force between the creation of this blog back in 2011!)

If you have been diagnosed with dry eye, which 48% of Americans experience according to this study, your doctor has probably tried to describe the underlying cause of your dryness.  You knew your eyes were feeling badly:  itching, watering, redness, burning, pain, dryness, or blurriness between blinks are all common symptoms of dry eye syndrome.  Now it is your doctor's job to find a way to make your eyes feel better and perform more optimally.  In order to do that, they have to know what is causing your dryness.  Current literature often breaks down dry eye syndrome as one of 2 categories:

• Aqueous Deficient Dry Eye:  Basically this means you aren't making enough tear film.  In many cases this is associated with conditions like Sjogrens Syndrome where inflammatory mediators are reducing both tear and saliva production
• Evaporative Dry Eye:  Basically the tears that you make just dry right up off the ocular surface.  This type of dry eye means you are producing tear film, but the tear film is missing the proper components to stay long enough on the eye. 

Inspissated Meibomian Gland

Posterior Blepharitis

Chronic Infammation -- classic for Ocular Rosacea

Long-standing Dry Eye

In just 10 days I have the pleasure of speaking as a panelist for Allergan's VIEW (Visionary Insights for Eye Care Women) luncheon at my state's optometric society meeting.  It was such a great honor to be chosen as a speaker, representing the changing face of the new generation of optometrists--a profession dominated by females. More students than ever are graduating with their doctorate in optometry (when I first enrolled there were 16 schools in the USA, now there are 21 with more scheduled to open in the coming years).  And more students than ever are females (there is a reported 60-65% female enrollment in optometry schools across there country).

Why are so many women pursuing optometry, especially when faced with the negativity of many optometrists in today's healthcare marketplace?  There are many reasons that would appeal to stereotypic gender norms:

•  optometry is a flexible career, with part-time work available for family-minded doctors
•  shorter lenght of time in school (a 4 year program instead of 4 plus 4 or more years of residency in an MD program)
•  no surgeries, so no blood / lower stress, no life or death discussions

But we all know that for many women, these perceived "female-friendly" points may not have had any influence on their career decision at all.  My personal opinion is that optometry is appealing as a career in general, not just to women.  More than ever, women are driven to pursue higher education, and as such they are finding careers in medicine, law, and other professional degrees.  But where optometry really separates itself from other professions is the ability to focus on one topic, and become an expert at that.  Optometry is a career that appeals to the detail-oriented (maybe there are more of females with this talent/curse than males??).  You spend the entire day looking at one body part, talking about one body part, measuring and calculating minuscule changes in that body parts length and curvature.  You talk about eyes all day long.   To me, as a woman, I love having that focus, the ability to pour my entire body of knowledge and study into the smallest of details about the human eye.  Thinking of being an expert on the entire body sounds just ludicrous to me -- I don't know how primary care doctors can manage so much at once.  As an optometrist, I am the doctor you see for all eye-related questions and concerns-- the eye specialist.  You can't get much more rewarding than that for someone that loves details.

With that being said, I am not immune to the pinch of negativity in my industry. I feel my eyes are more open than ever to the uncertainties of healthcare in today's world.  I have seen the profession of optometry struggle under the weight of reduced insurance reimbursements and general perception of the value of an eye exam.  Eye exams reimburse very little through most vision insurances (between $40-50 for a comprehensive exam on average).  In the past, doctors have offset those terrible margins by relying on product sales, but glasses and contact lens marketplaces have expanded (like all products) into the realm of the internet, and doctors are feeling the heat to see more and more patients every day.  In many cases this means compromised ability to focus on the details that made our profession so unique and rewarding -- the time to discuss all of the health benefits of the exam, to investigate dry eye, ocular allergies, and UV exposure changes that affect the eye and vision.  The eye is the only part of the body to assess the blood vessels with a live view, and most of my patients are surprised to learn that I am screening them for hypertension, cholesterol issues, and diabetes during their eye exam.

So why do so few people in the general population not know that your eye exam is an important health screening?  Most people are under the misconception that if you can see, your eyes are healthy.  If you read this website routinely, you know how many times I have debunked this myth.  In most cases, if your vision is affected by an ocular disease, it is too late to improve vision, even with glasses or contact lenses.  

My charge to all optometrists, new and old, female and male, is to embrace this profession for the specialist career that it is.  We need to educate at every chance we get what we are seeing when we look at our patient's eyes.  We need to take medical responsibility for the eye -- we are the primary EYE care provider after all.  We are who you need to see for a red eye, dry eye, burning eye, blurry eye, watery eye.  You name it; we are eyes.  Embrace the medical training we have and promote it!  This is the way to bring optometry into 2014, and the new wave of female optometrists are going to be the industry leaders to usher this change in patient perception.

If you are a female optometrist or optometry student, please comment and let me know what struggles you have faced or concerns that you have about our career and our role as female doctors in shaping its future.  I want to hear from you, so that I can bring these topics to my VIEW panel discussion, and the greater audience of online readers and industry leaders!

I may have been the only person on Friday to open my work email and do a little dance of excitement when I saw the good news -- Biofinity XR is launching on November 4th!  To most of us, wearing contact lenses seems like a normal part of our day.  We don't ever worry about what would happen if there were no contact lenses being made in our prescription.  But for some people, having a soft, disposable contact lens that is available in their power at their doctor's office is a luxury they have never experienced.  With Cooper's new launch, we will finally have a contact lens that offers the thin material and high oxygen benefits that lower prescription wearers have been enjoying for a decade!

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A typical RGP (gas permeable lens above, compared to the larger scleral lens below via

The first time most people see a scleral contact lens, the immediate response, is "wow, that's big."  The size of a scleral contact lens can be intimidating, but there are so many reasons for patients (and their doctors) to learn to love these larger contact lenses.  They offer unparalleled vision and comfort for many patients with irregular corneas, dry eye, or high astigmatism.  If your doctor has recommended scleral contact lenses for you, here's what you need to know:

A scleral contact lens fully covers the cornea and sits on the white of the eye (the sclera) via

• Scleral Contact Lenses typically range from 14 to over 18 mm in diameter, fitting completely over the cornea so that no part of the edge of the lens touches the cornea.  As such, the lens is much more initially comfortable than a smaller rigid gas permeable lens that moves around on the cornea with blink.   A scleral lens basically creates a shell covering the cornea, masking any corneal irregularities like keratoconus, scarring from refractive surgeries like RK and LASIK that have resulted in vision issues, and high amounts of astigmatism.
• Scleral lenses create a little pool of moisture under the lens that stays between the contact lens and the cornea all day.  Due to this property, scleral lenses have even been used for dry eye treatment.  Before you put your lenses in, you must fill the contact lens with the proper saline (or bath water if you will) to keep your cornea from getting irritated under the contact lens.  Most commonly recommended filling solutions are:

• Preservative Free Saline (like Unisol)
• Preservative Free Artificial Tears
• 0.9% NaCl inhalation vials (off label use but these are preservative and buffer free, making them ideal for the sensitive cornea)

• These lenses are difficult for some to learn how to insert and remove.  Since you are filling your contact lens up with a pool of solution, you have to put the lens in without dumping all of your solution out.  Your doctor will train you on the proper technique, but the Scleral Lens Education Society has a great instruction video if you need more help at home: 


• Why do I fit scleral contact lenses?  They definitely aren't a quick-fit type of contact lens, but once you have the proper lens, your patient should see better and with better comfort than they have in years.  With that being said, I typically plan for between 3-5 visits for first time scleral wearers to get the proper lens fit.  If you are a patient in the process of the fit and are feeling frustrated, keep in mind that these lenses are all made to order, and the parameters to change are very involved.  Most companies have a remake period of 2-3 months since it takes 1-2 weeks to make a new lens, and then more time to ship out and schedule a time that works for the patient's schedule.
• Wouldn't it be nice if scleral contact lenses are the end all-be all lens that works for everyone?  Unfortunately, that is not the case.  I have found that people with small diameter corneas and small eyes/tight eyelids are very difficult to fit with this lens.  I use Essilor Jupiter lenses, and their company representative discouraged fitting lenses on people with smaller than 12 mm corneas (especially with limbus to limbus astigmatism) due to the problematic issues they have encountered.  These lenses are gaining more and more popularity, but doctors are still debating the best fitting techniques and trouble shooting skills, so we may not be able to get the perfect lens for every patient yet.  With more doctors fitting sclerals, and more companies offering better parameter options, the industry may grow to accommodate more and more patient types. If you are an optometrist or student, I plan on posting tips on scleral lens fitting in a future post, so stay tuned for what I have learned so far!

I was blown away when I stumbled across these sunglasses by Midas and Moros!  If you are looking for glasses to make a bold statement, look no further.  These sunglasses take accessorizing to a whole new level.  Let's take a look, shall we:

Duchess and Heidi

Gatsby

Autumn

Crete

Their glasses are non-prescription, 100% UV Blocking and Polycarbonate (shatter-proof material), which means that you are not sporting a strong fashion statement, but protecting your eyes when you wear these sunglasses too.  All photos via

Oregon cheerleaders sported custom school-themed contact lenses for their game on Saturday via

Did anyone watch the Oregon/Washington football game last weekend and notice something a little odd with the cheerleaders?  In addition to the usually inspiring uniforms sported by the football team (I for one am a HUGE fan of the feathered shoulders that change colors from different angles), Oregon's cheerleaders went outside of the box to show school spirit by incorporating custom contact lenses into their game day attire.  The result?  A gimmick look that as an eye doctor I can only hope doesn't catch on.

Why do eye doctors hate color and halloween-theme contact lenses so much?  We aren't against having fun, but contact lenses are actually a really dangerous device in the wrong (or poorly trained) hands.  When you break down what a contact lens really is, you can see why-- a contact lens is a piece of plastic that lays over your cornea (which by the way only gets its oxygen straight from the atmosphere since if has no blood vessels of its own).  No surprise, that little plastic piece obstructs oxygen from getting to the eye, and can result in infection or severe scarring (and permanent vision loss) if the cornea suffocates too long.  But when you have decorative contact lenses, it is easy to think of them as a fashion accessory instead of medical device, and not take the care required to safely wear lenses seriously.  Let's be frank, Oregon athletics seems to have no shortage of money, so the cost of custom contact lenses, the doctor's fee to have them prescribed (you can't buy any contact lenses legally without a prescription from a doctor even if they have no correction and are just zero-powered!), and the training for the cheerleaders to properly care for them was probably an easy expense.   I am sure that Oregon took all the necessary precautions, and that there were no harmed eyes in the entire incident.  All in good fun.  What "scares" me is the example this sets. For most people, buying custom contact lenses is excessively expensive, and the temptation is to keep the lenses much longer than they are safe to wear.  Most color contact lenses on the market have a shelf-life of 2 weeks (Acuvue and Freshlook), and never more than 1 month (Focus Monthly Softcolor).  That means total lifespan, not number of wears.  I do worry that high schools may want to copy this trend, but without the financial backing, would be tempted to put students at unwarranted risks.  And even if other schools don't want to take on the legal ramifications and responsibility of fitting students with contact lenses, it does encourage Americans as a whole to treat contact lenses with a lowered level of concern.

I'll go ahead and spare anyone wanting to comment about me taking things too seriously-- no need to "call the contact lens police", just wishing that we would all treat our eyes carefully.  When I stop having to treat patients for bacterial ulcers and corneal abrasions from their contact lens wear, and I don't have to worry about that middle of the night phone call from someone at risk from blinding themselves permanently because they didn't treat their contact lenses seriously, then maybe cheerleaders wearing crazy contact lenses for "fun" will seem like a better idea.  Until then, let's all be careful. With Halloween around the corner, the temptation to wear contact lenses unsafely is at its highest, so let's review some simple rules of advice.

Don't eat unwrapped candy.  Don't poke something into your eye unless you know everything about it.

See, easy enough.

This one isn't exactly a "bump" but I thought it would be good to include in my series (see these posts on eye and eyelid bumps).  Every once in a while,  I will have a concerned child or parent ask me about a small purple-ish circular appearance on the white of the eye.  Typically these areas are seen under the eyelids, but can appear anywhere on the white of the eye.  In many cases, they do appear to have a slight elevation over the area that is purple-hued (commonly 1-2 mm in size).  The good news-- if your eye looks like this, it is all very normal:

Via

A zoomed-in look via

A nerve loop of Axenfeld is a normal, often pigmented loop found in the sclera (white ocular tissue) where the posterior ciliary nerve comes very close to the scleral surface before it loops back through the sclera and then into the ciliary body.  In many cases there is a slight elevation to the area as the nerve loops back into the scleral tissue.  The pigmentation of the area may increase with time, and is commonly faint, giving a "purple" appearance instead of brown or black.  These areas can never result in melanoma, or any other cancerous or infective condition, and do not need treatment.

Unfortunately, many of my patients fear that these areas are signs of damage from pencils being poked at the eye by a classmate (usually a colored pencil of course).  Apparently pencil poking is still quite common in today's younger generation.  And apparently my office is not the only eye care specialist that gets these questionable pencil foreign body questions.  There are multiple reported cases of these normal nerve loops being mistaken for entrapped graphite pencil tips.  

Sigh of relief, if you have this, you are just a normal person after all.   But if you get poked by a classmate's pencil, probably best to still get it checked out by your eye doctor!

Most of you have probably seen the Novant Health commercial promising a doctor's visit via the web from the ease of your desk chair (or lake house deck as the commercial depicts), but have you ever wondered what the real feasibility of telemedicine is?  How likely is it that your medical condition can be accurately treated via a web chat?  How can telemedicine be practically applied?

If a patient's photograph looked like this in their retinal screening, it would prompt a call for a live office visit for the doctor to assess the patient's diabetic retinopathy in person!

The truth is, I do think there is some room for telemedicine in our future, and I am not the only eyecare provider that sees its merits.  Wills Eye Hospital (the optometrist medical bible is named for it, by the way) has a retinal photography telemedicine department, and they aren't the only one.  Similar strategies were being used in the VA Hospital system when I was rotating through several years ago.  What's so great about retinal telemedicine?  Photographs of the retina can be used to track changes for various conditions, like diabetic retinopathy and macular degeneration.  While you can't replace a one on one visit with the doctor altogether, when monitoring a condition for changes, telemedicine can be a great resource.  The patient would be able to come to the clinic with more flexibility since they wouldn't have to be scheduled into the doctor's patient care hours, a technician would be trained to take the photograph, and then the doctor would have a dedicated period of time to review the collected data and images, and then inform patients of their results.  The photography is utilized as screening tool (typically some manner of vision check and compliant questioning would also be recorded by the technician to help detect any other issues). If changes are seen in the photograph (or the patient has specific complaints to be addressed), then a live visit with the doctor would be necessitated.  If the retinal image and vision are stable, the doctor may decide to push back a live follow-up visit.  This method of treatment has proven to be effective in recent studies: at the European Retina Congress, there was a 90% agreement between treatment plans of in-office ophthalmologist visits and telemedicine reviews for a group of patients being followed with macular degeneration.  A photograph can tell the doctor so much about the ocular condition, and a trained doctor can catch the signs of even the smallest of changes.

There is a large gap between photo-monitoring retinal conditions, and ridding the need for any in person office visits with your eye care provider, so I am not purporting that a photograph will replace all patient care.  The retinal evaluation is just one small aspect of the comprehensive ocular exam, and you can't evaluate the entire retina without dilation and a live, in-office view of the retina by the doctor.  But conditions like macular degeneration and diabetic retinopathy do result in the need for more frequent monitoring than just yearly examinations, and telemedicine may help reduce the burden on the healthcare industry by offering patients convenient times without double or even triple-booking doctors.  I don't expect the type of clinical care that the commercials depict where a doctor seems to be on duty full-time with web access is the way of the future--the type of care that can be provided without direct evaluation is very limited.  But the industry around us will continue to change, and telemedicine in eyecare  may become more and more utilized as our population ages and more people are diagnosed with macular degeneration and diabetes.  The health care industy is an exciting landscape, and it is fascinating to see how new technology can entirely change the face of our standard of care!

The Leader C2 frame comes in 6 colors and multiple accent colors for the temple.  Via

Glasses fashion has always been about individuality, but Hilco is taking sports goggles to a whole new level.  Their new Leader C2 frames are Rx-able sports goggles that meet federal ASTM standards for safety eyewear.  But what makes this frame so unique is the customization potential!  You can select from a wide variety of colors to match your team uniform, and even have your personal jersey number displayed on the temple.  For kids, these customization options could make wearing their protective eyewear more appealing, as it is now a part of their team uniform.  And anything that makes wearing ocular protection fun and exciting for kids, I stand firmly behind!

I can't imagine the crickets that Huffington Post writer Amanda Chan must have faced when she pitched her recent article idea concerning contact lens safety to her editors.  Contact lens wearers are a notoriously tough crowd -- most people have a hard time listening to their doctor for advice on their contact lens wear, much less an article in a newspaper.  That's why I applaud the efforts of her article, What Every Contact Lens Wearer Needs to Know (But is Afraid to Ask), for asking contact lens wearers to question the safety of their daily practices.

Large Corneal Scar from contact lens complications.  This person will never see clearly again! Via

If you are a blog regular, you know that I can get on a major soap box about contact lens compliance.  But that is only because as an optometrist, I am constantly seeing the side effects that contact lens wear can cause.  Contact lens wear can cause permanent scar tissue, and in some cases permanent blindness!  Yet, most of us admit to treating contact lenses carelessly.

How many times in this past year have you stretched the wear time of your contact lens by a few days or weeks (if you say months, really be still my heart!).

How many times did you put the contact lens in your mouth to rehydrate it or run it under tap water?

How many times did you sleep in your lens when you know that you don't wear a lens approved for overnight wear?

And how many times did you toss your lenses into a case of multi-purpose contact lens solution without emptying the case from the night before, or even put them in fresh solution but without rubbing the lens or cleaning it in any way before tossing it in?

And we wonder why there is a 12.5 x greater risk of infection when you wear multiple-wear contact lenses when compared to the industry safety leader, daily disposable options?

I love daily disposable contact lenses because all of those major risk activities we just mentioned are negated when you wear the super-hydrated daily wear options.  No nightly wear needed--you just toss the lens in the trash (or on your nightstand for the next morning's trash) and pop in a fresh pair in the morning.  No cleaning; no risk of overwear.  It is just so easy.  But dailies only make up about 17 percent of American contact lens sales (compared to nearly 40% globally).  So if you don't wear daily lenses, make sure you are taking the steps necessary to keep your eyes healthy for years to come.  One infection can mean you can never wear contact lenses, or have quality vision!, ever again if the infection occurs in the wrong place on your cornea.  Is it really worth the risk of blindness?

Key take homes from my experience (and perfectly outlined by aforementioned article):

• Know your contact lenses.  Know how often you need to throw them away and if they are approved for overnight wear; and then follow the guidelines.  The FDA tests these lenses to get these guidelines; your doctor doesn't make them up!  But in some cases, your doctor may tell you that with your particular eyes, a certain lens is not safe for you and you may have even stricter contact lens wear guidelines.
• Know your solutions.  If you are using a "no-rub" solution, it doesn't mean that you just toss your lens in a case.  You have to read the fine-print!  A no-rub solution means you have to "power wash" your contact lens with a stream of fresh solution for 30 seconds before putting in the case with fresh solution.  If you properly are using a no-rub solution, you should use up an entire bottle within 2-3 weeks.  Best just to rub, right?
• Know how old your case is.  My oh my, have I seen some terrible looking cases.  Cases are petri dishes of bacteria-broth, and if you can actually see dirt on your case, don't put your contact lens in there.  It's a no-brainer.  I strongly recommend the every 3 month disposal of your case rule that Dr. Thau and Dr. Taylor describe in the article.

I'm a little late with my fashion week post, but better late than never.  Here's a glimpse of the eyewear top designers sent down the runway:

Just Cavalli goes futuristic in Milan.  Mirrored sunglasses continued to be a popular trend for designers.

Louis Vuitton frames with widened bridge evoke a sports goggle aesthetic.  It's hard to imagine these being popular mainstream, but definitely breaks the norm!

Burberry Prorsum in London.  While this frame shape can be challenging to wear, the graphic juxtaposition of white frame and dark lens is a definite bold statement.

Charlotte Ronson rehashes the geek chic look - oversize frames re-envisioned in clear plastics.  To me, this takes the trend way over the top, but that's what fashion week is all about.

Marc Jacobs sunglasses in dark plum, giving a harder to edge to the familiar round shape from last season that was seen more frequently in pastels.  I can imagine these darker jewel tones faring well on the market after we were bombarded with pastels and neons for the past few seasons.