This year's Small Business Saturday had me thinking: optometry is full of independent practitioners but for many years we've been providing eyewear designed by large corporations.  Don't get me wrong, I am a fashion world junkie as much as the rest.  But while we can be wowed by designer names on the side of our glasses, we often aren't getting much in the way of true design.  Many large fashion house designers outsource their optical divisions to larger corporations, and that's where you see entities like Luxottica retailing everything from Oakley to Tory Burch and Michael Kors.  Where can you find truly crafted eyewear?  Until recently there was very little going on in America, and the top independent eyewear craftsmen were designing in France, Italy, and Japan.  But in the past few years we've seen a Renaissance in American eyewear design, and in honor of Small Business Saturday, we're featuring 6 reasons that you should shop small for your eyewear this year too!

Were your glasses made by hand? I challenge you to try on a custom crafted pair of eyewear and feel the difference true design and quality can make.  Wonder why your glasses always push dents on your nose or pinch behind your ears?  You don't have to hate your glasses; you just need to invest in quality, thoughtful eyewear design. Photo above via State Optical

Article One Eyewear: Based in Flint, Michigan, Article One originated as an idea to give back. Designer Wes Stoody was inspired to create an eyewear line that combined luxury craftsmanship with a cause. Every frame purchased donates money to Helen Keller International, a non-profit fighting blindness from vitamin A deficiency in impoverished nations.  To date over 15,000 lives have been touched by their mission.  Right now Article One frames are handcrafted in Northern Italy, but Stoody dreams of bringing production to craftsmen in his hometown of Flint in the future.  You can hear more of his story here.

A bonus for you  Sign up for the Article One newsletter and you'll have a chance to earn a free pair of Article One eyewear and 50% off future orders. This promotion is only open to eyecare providers.

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Bevel This Kansas City based eyewear company is the brainchild of opticians Richard Mewha and Rick Nelson, and their mission statement is a bit unusual.  "Neither wants the brand to be the coolest or hottest or most recognizable" states their website, but the focus is on the simple perfection of minimalist ideals: great fit, clean lines, quality materials. Their titanium and acetate frames are designed in America and hand crafted in Japan with a focus on bold colors like the chartreuse used in their graphic brand logo and marketing campaigns. 

• Start your own practice! The best way to have flexibility over your own schedule is to be the boss. As an employed optometrist your schedule is dictated by the doctor or corporation you work for, but when you are working for yourself, you can arrange your hours in the office to best suit your needs.
• Treat your practice like your first child.  Right out of school, Dr. Shen Lee put all of her time, energy, and disposable income back into her practice. The first few years are the hardest and the leanest, but that dedication to the practice in the start lays the foundation for future success.
• Focus on creating patient loyalty by giving patients a reason to come back every year. One of the biggest mistakes Dr. Shen Lee sees practitioners making around the country is letting a patient that isn't complaining or demanding solutions go without getting education for what she can offer.  Even when a patient is successful in a contact lens, she encourages them to try out the newest technology on the market.  Her practice had grown to around 70% daily disposable lens wear because of her dedication to encouraging her patients try out the best lenses on the market, and she's found this technique is a great practice builder.  Her patients come in asking "what's new?" every year because she has focused on building loyalty and value in her exams. 
• How does she balance home and work life? “Instead of telling you what I do, let me tell you what I don’t do.  I don’t do dishes; I don’t do laundry.” She spends her precious time at home being present and active in the lives of her family and loved ones, helping with homework, trekking to fencing lessons and tournaments with her daughters,and  just being a mom and mentor to her children.   Getting help for the day to day chores that can steal away precious time is essential for her to have the time to explore her passions in optometry and as a mom and wife.

Can I rewind myself in time and start over as a member of Gamma Omicron at my alma mater, the Southern College of Optometry? I'm not saying I want to go back to school, or that I haven't enjoyed the last 5 years seeing patients and you know, getting paid to do so. But today's generation of future female ODs isn't messing around.  They've seen the statistics on the 16% gender starting salary gap for new graduates in our profession and while most of their classmates are women (67% of all enrolled optometry students were female in the 2015-2016 calendar school year), they noticed some overt discrepancies.  When asked, Sandy Trybus (SCO '17) says she cofounded Gamma Omicron on campus when she began realizing none of the successful doctors brought back to speak on campus were women.  Where were her female optometric role models and mentors? Women that could help her and her classmates navigate the issues that they would disproportionately face as they graduated and began searching for job opportunities and navigating establishing leadership and authority in their relationships with employers, staff, and patients? Where were the people like her that were success stories and leaders in our profession? She and cofounder Michelle Moscow set out to bring more female voices on campus by giving them a place all their own.

Head over to the Defocus Podcast for the full interview!!

Gamma Omicron was once a club on campus at SCO back in the 70s, when just a small subset of the student body was female.  At that time, female students at SCO felt they needed a place where they could establish their own leadership and autonomy in a historically male dominated profession.  As female enrollment continued to grow, the club eventually fell out of existence as class sizes became more equally split and equality in the classroom and workplace became less of an exception than a rule in the general public. 40 years later, Trybus and Moscow were looking for a place to focus on women leaders in the profession to help mentor themselves and fellow classmates and came upon Gamma Omicron in old yearbooks.  It was a perfect fit to re-establish the club that had lovingly drawn it's greek letters from "Girls Only."

Gamma Omicron members speak with Dr. Brigitte Keener (SCO '11) at their annual speed-learning event

Over the past month I've had the privilege of speaking with Trybus, and new club leaders Julia Hamm and Maddie Coughlin via the latest Defocus Media podcast, and then to the entire Gamma Omicron club as a speaker at their first 2016-17 school year meeting to talk salary and contract negotiations, and navigating difficulties young women often face in staff, employer, and patient interactions. Our discussions have yielded so many great talking points I wanted to share some pearls with you ladies that might not yet have a Gamma Omicron chapter established at your school:

• When applying for a job, how can you negotiate if you haven't really had any experience?  My recommendation is to think outside the box; you may not be an expert in patient care by the numbers, but I bet you're an expert in something your hiring doctor is not.  Look at their practice: are they offering specialty contact lenses, vision therapy or sports vision, infant and pediatric care, or dry eye specialties?  These are all buzzword specialties in optometry that older doctors may not be personally interested in training on, but would love to bring into their practice through you.  Look at their social media: is their website a mess? Facebook underutilized? Are they even online at all? Taking over social media marketing is a great way to bring instant value, and your hiring doctor will not question your generational expertise in this area. For more negotiating tips head here.
• But hold your horses, because bringing value to a practice is great, but you need to make sure you and the hiring doctor are on the same page about your future.  When we first spoke on the podcast, I was surprised to hear that putting a date on when to begin buying in to a practice at the initial contract signing wasn't a top priority for students.  It's true that you want to try out the practice first before you commit, but many friends and good doctors before and after me have fallen into this trap.  If you don't set a date to begin buy-in negotiations, then the day will somehow never magically come.  Five years later you're still waiting to have that conversation and the doctor you work for still thinks you might not be ready to take on the leadership and commitment of being a full partner because you're about to start a family or you're still growing into the position.  That's 5 years of blood, sweat, and tears you've put into that practice that you will eventually have to buy back from yourself, because every day you've worked there you've grown the business patient encounter by patient encounter.  I highly recommend setting a 1 year from hire date to get the practice evaluated by an outside party and to begin buy-in discussions.  Doctors love their practices and those in the baby boomer generation have universally seemed reluctant to walk away or retire, so they often put off handing over the reigns to their practice even after bringing you on board with the mindset to do just that.  Help keep the ball moving in that direction by getting firm plans set in stone for buy-in discussions right from the start.
• "You look like you just graduated high school" or "when's the doctor coming in?" are questions these ladies will likely be asked as new docs (and 5 years later, yes I'm still getting them).  The best medicine is laughter in these situations - I always laugh a little and say something to the effect of "Oh thank you so much! My wrinkle cream must be working!" with a genuine smile like I truly appreciate the compliment.  Yes, I know patients who criticize our appearance as too youthful aren't complimenting my wrinkle-free skin, but they are telling me with those comments that they feel anxious or concerned that my level of care might not be up to par. Th best way to alleviate fear is to help get the patient smiling or laughing with you on the other side.  If I smile and laugh, they will smile and laugh, and it's hard to feel anxious when you're smiling so much!

While new scientific advancements have revolutionized treatment and even cured some systemic diseases in recent years, blinding eye conditions have remained stubbornly difficult to treat.  For many, a diagnosis of severe vision loss or blindness is a forever diagnosis, with no cure or treatment possible. Full thickness macular hole was once a medical condition that held little to no hope; the macula is the central vision area critical for fine detail sight and while a complete hole in the tissue is rare (studies show around 0.09% of the population will develop a macular hole in their lifetime), the visual prognosis is very poor.  Only about 5% of patients with full thickness macular hole will have vision of 20/50 or better, and 40% of patients will be worse then 20/200 in the affected eye (the criteria for legal blindness if both eyes are affected).  But new innovations in macular hole repair may be making these numbers a thing of the past.

A large full thickness macular hole as seen on retinal fundus imaging (above) and OCT imaging (below) via

What is a Macular Hole
Macular holes can be caused by a number of different factors, both genetic, trauma related, and purely aging related. The inside of the eye is filled with a gel-like substance called the vitreous, and one of the places that this gel attaches most strongly is at the very middle of our central vision area called the macula.  Whether from high prescriptions stretching the eye too thin, trauma causing sudden disruption, or just the normal aging process, the vitreous gel naturally begins to separate from the back of the eye with the passage of time (called posterior vitreous detachment).  As this separation of the vitreous from the retina happens, sometimes the vitreous stays attached right at the central macula (or fovea), pulling the retinal cells of the macular region up and off with it. There are various stages of macular holes as the tissue is lifted up and away, but in full thickness macular holes an entire area of retinal cells are missing at the macula, causing a bling spot in that vital area of central vision.

Macular holes often begin with simple traction; the vitreous gel that fills the eye attaches more strongly at the central macular area, so when it begins to pull away from the eye due to trauma or age, it may stay attached at the macula and beginning lifting the retinal tissue up and away with it.  This is termed vitreomacular traction.  via

In some, the traction on the macula does not release, and the separating vitreous pulls the macular tissue off with it, leaving a hole in the retina underneath.  This hole will not self-repair, and since the macula is the central vision area, a missing plug of retina tissue at this vital spot is usually devastating to vision. via

New Techniques
Traditional treatment for macular holes was limited; studies showed holes older than 6 months in age or larger than 400 microns were unlikely to benefit from macular hole repair.  The technique was difficult for both doctor and patient. The doctor would remove all of the vitreous from inside the eye (called vitrectomy), then painstakingly peel away the layer of cells right on top of the retina (called the ILM or internal limiting membrane) with fine tipped forceps. Then the patient's eye was filled with a gas bubble and the patient would lie face down in a specific position to hold the gas bubble properly in place over the macular hole for a period of days to weeks. Unfortunately, larger or older holes didn't respond well even to these aggressive approaches, with only 47% of holes that were 1 year or older closing after surgery.

New treatments have been showing promise in repairing larger and older macular holes, however. In 2010 researchers reported a new technique for repairing large macular holes (400 microns or more). Instead of fully peeling away the ILM, researchers folded the tissue back and made a little flap of ILM right over the are of the macular hole. Gas bubble positioning was performed followed by 3-4 days of head down positioning, and the results were impressive: 98% of large macular holes were repaired with the ILM flap approach (compared to only 88% repaired in traditional methods).  It is unknown why the ILM helps support macular hole closure, but doctors theorize that the basement membrane properties of the ILM supports abundant glial cells growth, and photoreceptors in surrounding areas of reitna are drawn towards the glial cells and begin filling in the macular hole.

A. A 68 year old with large macular hole and 20/80 vision;  B. 3 months post-ILM flap technique, the macular hole is repaired and vision improved to 20/30 via

The most difficult macular holes to repair, with low success rates even with ILM flap procedures, are those associated with high myopia and posterior staphyloma. With significantly high prescriptions (typically -8.00 or higher), the retina is so elongated that the retinal tissue is stretched dangerously thin across the back of the eye.  These patients are at a much higher risk of retinal detachments and even splitting of the retina right at the central area, an event called foveoschisis. There is so much tractional force on the retina from these severely elongated eyes that the macular holes associated are often massively large and resistant to closure by even the most advanced techniques. In a brand new surgical technique described by Dr. Dilraj Grewal and Dr. Tamer Mahmoud in June 2016, there is hope of a breakthrough.  Doctors Grewal and Mahmoud treated a -15.00D myopic woman with 1100 micron macular hole that had previously failed repair from traditional technique with ILM peel and vitrectomy.  Because the ILM was already removed (and with the size of the macular hole involved an ILM flap would have had very little chance of closure), the doctors instead removed an appropriately sized wedge of peripheral retinal tissue and laser barricaded around this area to prevent retinal detachment, then placed this wedge of retina to "plug" the macular hole. This procedure has been termed autologous retinal transplant, using the patient's own retina to patch the area of the macular hole, and this was the first of its kind in human case study. OCT imaging 3 months after surgery showed closure of the macular hole and improvement in vision from 20/200 prior to surgery to 20/80 at the last reported follow-up.

Drs. Grewal and Mahmoud operated on a longstanding 1100 micron macular hole (seen in preop above) by transplanting a flap of retina from the periphery.  At 3 months post-op OCT imaging shows complete closure of the macular hole, and at 7 months post-op there is continued improvement as the retinal layers continue to thicken and the flap integrates into the surrounding macular tissue. via

With these exciting new innovations, there is hope for macular hole closure and at least some improvement to vision even in large and longstanding macular holes that have failed previous treatment.  If you have a patient that has resigned themselves to untreatable vision loss, there is reason to hope that these new innovations in macular hole repair can help!

When you're a parent, nothing breaks your heart more than seeing your child in distress. Between the normal range of infections and viruses that can cause conjunctivitis in infants (commonly termed "pink eye") and the fact that as many as 20% of children are born with congenital nasolacrimal duct obstruction (blocked tear ducts), the chance of having to battle red, goopy eyes in infancy is high.  Dr. Sarah Sweeney Dorhman is a new mother and optometrist, and experienced this common issue first hand when her daughter began suffering from chronic irritation and mattering discharge due to nasolacrimal duct obstruction.  She shares her experience, and what you can do at home to help your own child battle ocular irritation.

What's the number one complaint over 50% of women have about their appearance? Under eye circles and puffiness plague people of all skin tones and complexions.  Why do the eyes show their age so much more prominently than other facial areas? Let's talk the science behind eyelid puffiness and what to look for in products to depuff and brighten your eyes for a more youthful appearance.

Fashion it-girl Leandra Medine embraces her make-up free appearance, puffy under eye circles and all.  via

It's obvious when you look at friends and acquaintances of your own age that more than just time affects how old you look.  The aging process of the skin is complex; in addition to simple passage of time, genetics, sun exposure, diet, hormones, pollution, and exposure to chemicals or toxins in your daily environment all play a big role.  Sun exposure especially will cause thickening of the epidermis (the surface layer of skin), resulting in dark spots and deep wrinkles and lines.

Why does under eye skin sag? The skin around your eyes is some of the thinnest in the body, with some of the weakest moisture barriers and lowest natural elasticity of all skin areas. As we age, our skin has significantly lower counts of "plumping" molecules like collagen and elastin that help support the link between the surface and deeper dermis skin layers.  On average, we lose 1% of skin collagen for every year of life.  With less collagen and elastin, our skin tissue begins to sag from lack of support, causing wrinkles, drooping eyelids, and those pesky under eye bags to develop.

Dark circles are also a side effect of the eyelid's thin skin.  Without a thick barrier, it's easier to see the matrix of blood vessels running underneath the skin, resulting in a dark purplish hue. Anything that dilates (or enlarges) the blood vessels under the eye will exacerbate the appearance of dark circles. The most common culprits are dehydration, fatigue, allergies, hormone changes (estrogen levels especially influence changes in dark circle appearance), and even warm environments.  Sleep itself actually causes dilation of the blood vessels too, which is why many people feel their circles are worse when they wake up first thing in the morning.  When we are asleep, our body's sympathetic nervous system is greatly turned down, causing blood vessels to dilate as our body enters "rest mode." Sleep and dark or dim rooms (like what we often have using a computer!) cause our body's sympathetic nervous system to deactivate, so a side effect will be a more obvious appearance of under eye dark circles.

What Can You Do?
Aging is inevitable, but there are some things you should start doing now that can protect against more dramatic aging changes and help your under eyelid skin look its best.

• Sun Protection: From early childhood we need UV protection, including sunscreen and sunglasses to protect the delicate skin around the eyes. Once the skin becomes sun damaged, it's very difficult to erase dark spots from activated skin melanin or the thick wrinkles that develop as a result of  UV damage thickening the epidermis.  Prevention is always the best protection.
• Stay Hydrated: The skin around the eyes has a very weak moisture barrier, so we need a good daily intake of water to help counteract bags and dark circles.  Dehydration causes the blood vessels under the eyelid skin to dilate, making a more noticeable purplish, dark bag. Alcohol, tea, and sodas can all act as diuretics that increase dehydration.  Medications commonly prescribed for high blood pressure, diabetes, mood stablizers/anti-depressants, and allergies (yes - Benadryl, Claritin, and other OTC antihistamines are your enemy when it comes to staying hydrated!) also commonly have dehydration as a side effect.
• Adjust Your Screens: Do you work on the computer all day? Your work environment can wreak havoc on your eyes and eyelid skin!  Make sure you have good lighting in the room where you work, preferably a window or natural light source. Working in the dark or in a dim room makes your body enter "rest" mode, so you'll not only feel more tired, but your blood vessels will dilate and you dark under eye circles will be more noticeable.  The blue light coming from your computer screen, cell phone, and other digital or LED light sources can also create problems by disrupting your body's natural sleep cycle hormones. Wearing glasses with blue light protection (Crizal Prevencia anti-glare coating or Transitions XtrActive both have great blue-blocking effects) and using a free download for reducing blue light from your screen like f.lux can help. 

  And we wonder why we have dark, puffy under eyes the next morning? via

• A Little Morning Pick-Me-Up When you first wake up, under eye circles are more evident until your body gets going and active.  The blood vessels will begin to constrict and fluid that may have pooled in your under eye area will get redistributed once the sympathetic nervous system kicks into gear.  But you can speed that process along by holding a cool compress to your under eye area to constrict blood vessels before applying makeup, and doing a little morning exercise to get blood pumping. Caffeine like that in your morning coffee can also constrict the blood vessels to improve under eye appearance, which is why many skin creams for under eye circles contain a caffeine additive.
• Use the Right Products The skin absorbs moisture both from the blood stream (internally) and externally (from skin creams and lotions).  Certain under eye products not only hydrate the eyelid tissue, but also boost under eye circulation and reduce the appearance of dark spots.  But be careful of the chemicals found in many popular drugstore brands, because they may actually cause dryness, redness, and irritation - counteracting all your hard work!

Metallic applicators like that used in the LA MER Lifting Eye Serum begin to depuff eyes immediately with their cool temperature. via

• 100% Pure Coffee Bean Caffeine Eye Cream: Caffeine reduces the appearance of dark under eye circles by increasing circulation, and this vegan eye cream delivers both coffee and green tea extracts to pack a punch. Rosehip oil hydrates and plumps the skin. Paraben free.
• JUARA Miracle Tea Complete Eye Cream: This nightly cream combines an anti-oxidant packed kombucha tea extract to fight wrinkles and UV damage with marigold extract that stimulates blood vessel circulation to reduce the appearance of dark circles.  Plus as a vegan product its free of chemicals that might be toxic to the eye area.
• Yves Saint Laurent Forever Light Creator Eye Fluid: Want a concealer that also works on the root of the problem? This concealer also hydrates and contains caffeine and vitamin C to depuff eyes.
• The Estée Edit by Estée Lauder Late Night Eraser Brightening Eye Balm with Pink Peony: Applied with a metallic "cooling tip" that will begin depuffing under eye bags on contact, this balm also has hydrating cucumber oils and reflective powders that help bounce light back off the under eye area, deflecting the appearance of puffiness. While reflective powders don't actually reduce your eyelid circles, the trick of the light reflecting does make them look less evident to everyone else.
• LA MER Lifting Eye Serum: LA MER products use algae to help build and restore skin's elastin production. It also uses a cooling tip applicator with massaging instructions to depuff on contact.

One thing that hasn't been associated with eyewear for a while: "Made in America."  For decades eyewear design and manufacture has been split into 2 realms: luxury craftmanship in European markets like Italy or France, versus low cost, mass produced frames made in high production markets like China. American eyewear designers were plentiful, but actual frame production was always sent overseas.  Through the early 2000s, many American industrial cities were plummeting into economic crisis as manufacturing jobs continued to rush off shore to drive down production costs.  But there were many in the world of optical that wanted to move manufacturing back stateside. Enter the team behind  STATE Optical Co. - the first luxury eyewear brand to be designed and manufactured in the USA.


How did STATE Optical turn the tide?  In 1977 Alan and Cynthia Shapiro founded Europa, an industry leading eyewear company out of their garage.  Fast forward to 2011 when their son, Scott Shapiro began working with Europa president Jerry Wolowicz on ways to bring producation of acetate eyewear to the US.  They had the will, but they needed someone with the know how and craftmanship expertise to actually manufacture luxury eyewear - rare to find in the US since the industry had been international for so many years. They teamed up with the improbable pair of cousins Marc Franchi and Jason Staley -- men with a history of working primarily in the automotive field that had a passion for making things with their hands. When they learned so few eyeglasses were made in the US, they started learning the trade on their own.  "Of course everyone told them they were crazy, and that the idea wasn't economically feasible," says Scott Shapiro.  

Franchi and Staley learned eyewear manufacturing from the ground up, touring manufacturing facilities overseas and observing craftsmen at work.  "They literally taught themselves how to produce acetate eyewear," marvels Shapiro.  Shapiro and Wolowicz were first introduced to the cousins when they came across their original made in America eyewear, "Frieze Frames."  They were wowed by the quality of the frames, unparalleled in the small American eyewear market. The partnership was born: the cousins and now 45 additional highly skilled eyewear craftsmen now produce frames out of the state-of-the-art Chicago home of State Optical Co. 

The Process

Blake Kuwahara is the lauded American eyewear designer behind his popular eponymous frame line and a recent capsule collection with l.a. Eyeworks to name a few

"Part of our vision for building this factory was that optical professionals and eyewear lovers from around the country could come to our facility and see how frames are made. When you buy a pair of STATE frames and open the case, you’ll see the statement, “come see how your frames are made”. Our factory is open to the public. Anyone can make an appointment for a factory tour right from our website, STATEopticalco.com."

Each STATE Optical Co design features a pyramid of 21 drill dots reminiscent of the stars on the United States flag to represent Illinois, the 21st state of the union.

STATE Optical Co. is very new to the market, but already having a big impact. "We soft-launched the collection at Vision Expo West in 2015 and attracted a lot of attention. That was literally the first time anyone outside our company had seen any of the frames. We showed it again at Vision Expo East and were mostly booked the entire weekend."

"Our major focus right now is just on continuing to increase the capacity of our factory, and Marc and Jason are continuing to train our craftsmen to perfect these long-lost skills. As we achieve that, we will be able to take on some of the other wild endeavors we have on our white board. As for now, we’re preparing to make 2017 a very big year for STATE Optical Co."

Check out the entire collection on their website and get sneak peaks into the manufacturing process and the detailed hand-craftmanship behind each frame on their Instagram account.  

A few weeks ago we got the not so surprising news that Opternative, the online refraction technology that's seen significant legal battles over the past few months, is now partnering with 1-800 Contacts to offer online contact lens prescription services.  Not a surprise that a partnership would blossom between these two companies since they seemingly share a desire to avoid patients entering a doctor's office at all, but still, I have to admit when I read the news I took it with a morbid sense of pseudo-shock.  Despite legislation making Opternative illegal in 3 states (Georgia, Indiana, and South Carolina), in today's world, tech business deals can move much quicker than our own legal system. And if you feel like you've been bombarded by new technologies attempting to replace traditional refractions, you're correct.  This past year has seen not just Opternative, but portable refraction technology from Eyenetra, and  SVONE PRO by Smart Vision Labs also enter the "subjective autorefraction" marketplace.  Five years ago when I was wrapping up my optometric medical education at the Southern College of Optometry, if you would have told me that in just a few more years patients would be offered prescriptions right from their home computer, I wouldn't have believed you.  It seems so reckless, so impractical, so insane.  But that's just an eye doctor talking; to the general public, it's obviously not so dangerous sounding.  And that's where the problem lies.

Head here to download or subscribe to our podcast and listen to this week's episode!

This week Dr. Darryl Glover and I got a chance to sit down with Vitor Pamplona, the designer and founder of Eyenetra for our new optometry podcast, Defocus. I was expecting to talk to someone who would be casually dismissal of ocular health exams, who didn't understand that refractions and vision correction often had nothing to do with the actual health of a patient's eye.  What I found was a man who not only had an far-reaching command of the physics of our eye's optical system, but an impressive understanding of the healthcare issues facing the introduction of new tech like his.  Vitor is clear he has designed software that is not a replacement for a doctor, and that the NETRA is marketed as nothing but a portable auto-refractor.


His tech doesn't write prescriptions; doctors write prescriptions.  He paints a picture of a doctors using the Eyenetra smartphone-powered autorefractor just like any other work up test currently used in office, with the doctor choosing to additionally perform a phoropter based refraction to verify results.  His pitch is if you can speed up refraction with his system, you can see more patients or spend more time on what really matters, the ocular health assessment and discussion.  He talks about using this system remotely for mobile clinics, concierge care, or in areas or countries where the access to healthcare is limited.  He talks about a future where patients with conditions like diabetes might even have an Eyenetra device at home; not to get their own prescriptions, but to check themselves regularly for Rx changes that could mean they need a trip to the doctor sooner for better blood sugar control than their yearly comprehensive.  His vision is one that doctors would struggle to find fault with, but I had to remind myself during our interview that this is the same company that I saw illustrations circling on the internet for auto-refractor stations in a prominent online glasses retailer where patients could sit on couches sipping a latte during their refraction.  No doctor; no exam room.  It's a future that is easy to envision too; insanely lucrative for both the tech companies behind these inventions and the online and big box optical retailers that could offer in office Rxes without having to employ a doctor on site to do so.

Could you refract yourself and order a drink at the bar at the same time? Oh wait, that bar is really an optical display.

Vitor understands that replacing ocular healthcare with only refractive care is not in the best interest of the patient, but he points out that it's optometry that has failed patients if there is a concern that patients would chose to skip a health exam. I'm sure not many ODs are going to take his idea of spinning off a new name for ocular healthcare providers, separate from the title of optometry, in order to rebrand our profession's image in the minds of patients, but the truth is, maybe we need a disruptive outside voice saying that optometry has a problem that we aren't successfully fixing.  Our problem isn't new technology entering the marketplace; our problem is what patients think about what we do (glasses prescriptions, right?) and why they should care (they can see fine, so of course their eyes are healthy, right?).  As a profession, we have been able to dilate our patients and assess and treat ocular health since the 1970s, but due to a complex history of propaganda from outside groups and in a not-so distant past even our MD colleagues, our public image has never expanded fully to that of comprehensive ocular healthcare providers, despite the fact that's what we've been doing since PCO first handed out the Doctorate of Optometry title in 1923.

Vitor Pamplona with the NETRA auto-refractor device

I entered this interview thinking I was going to skewer Vitor for creating a product that is a public health risk (very nicely, politely, and enthusiastically based on the sound of my voice on playback apparently). Instead, I realized that the problem isn't his product; it's me, it's all doctors -- optometrists and ophthalmologists.  We are the ones that write the prescriptions, and in the US, prescriptive medical devices like glasses and contact lenses require our signature.

• Ethically, is it in our patient's best interest to perform a refraction (either in person or remotely) without assessing ocular health?  

• Ethically, is it in our patient's best interest to give them a contact lens prescription without actually assessing if that contact lens fits properly on the eye or if the patient has corneal health issues putting them at risk for significant vision loss with the wrong type of contact lens (I'm looking at you Opternative!!)? 

As a doctor, we're educated that we should never, ever give a prescription for anything without assessing my patients' ocular health (or getting records proving they've had that done within the last year), and I'm wondering, what doctor would? Who are these doctors who would sign an Rx for any medical device without assessing ocular health themselves or verifying that health had been assessed by another doctor within a year's time?  We're all worried about refractive tech confusing our patients into thinking their eyes are healthy when they haven't even been checked, but it's doctors that would be to blame if a medical condition was missed. It's that doctor who compromised and offered refractive care without ocular healthcare who is at fault when a condition goes undiagnosed, maybe even blinds or kills someone -- no, I'm not being extremist.  So as doctors, I ask you to think about what you do and why you do it.  A prescription is more than just a print out from an autorefractor; it's your signature that you have evaluated this patient and given them your care. Stand for something bigger than your paycheck; stand up for those millions of Americans with undetected glaucoma, early retinopathy or retinal diseases, or even ocular tumors -- conditions that in early, treatable stages aren't going to present with any vision issues on a refraction.  You won't find these conditions if you don't look for them. And looking for them, that's our job. We have to claim this new autorefracting technology and all new tech innovations for what their true place is in the role of our exam.  The tech is not more than us; it isn't an exam but just a tool, and it can't operate to give anyone a prescription without us.  None of this new tech bypasses a doctor or bypasses an ocular health exam; only a doctor can chose to bypass an ocular health exam.  So I ask you, use this tech like it was designed.  It's a refractive tool to aid in your exam.  It's not an exam.  It doesn't even pretend to be an exam. The only person in the room that can make it replace an exam is you.

I encourage all of us to think about our part in the future of our profession, and act now as a group to legislate ourselves about what is required of a doctor to give a prescription for glasses or contact lenses.  We should all have personal ethics keeping the best interest of our patients in mind, and we should legislate and define those ethics in our own professions. Optometrists and ophthalmologists can legislate what's required for a prescription so no loopholes exist for a doctor that might be willing to compromise their personal ethics for a paycheck.  The technology doesn't control our profession, our pens, or our patients.  We are the caregivers, and the prescription is our care.  What does your prescription stand for?

Since the mid 2000s, no other type of contact lens has seen more growth and excitement than scleral lenses.  In last year's annual contact lens trend report from Contact Lens Spectrum, doctors reported fitting scleral contact lenses more than both rigid gas permeable toric and multifocal lenses, with sclerals making up 3% of all contact lenses being fit (including soft, hybrids, and RGPs) in 2015. Why sclerals?  The larger contact lens size makes for more stable vision and improved comfort over traditional small diameter RGPs, ideal for irregular corneas, high astigmatism, and conditions like keratoconus.  Breaking into the world of fitting scleral contact lenses can have a sharp learning curve, so I strongly recommend attending courses like those offered from the Scleral Lens Education Society, Blanchard, and Vision By Design.  Once you feel ready to get started, the fitting set arrives and it's time to put lenses on your patient.  What to do? We're talking initial lens selection and evaluation in today's post!

Choosing the Right Diameter
There are a ton of scleral contact lens options out there, with common diameters ranging from as small as 14.3 mm to over 18 mm.  The truth is, lens diameter selection depends on your patient. Smaller lenses are typically easier to fit, especially on corneas with lower amounts of irregularity. Advantages of smaller diameter lenses include:

• better oxygen permeability (smaller lenses can be fit with less central vault, meaning better oxygen exchange through the tear film)
• easier patient handling
• easier removal (smaller lenses will fit flatter in general so will have less suction with removal)
• avoiding scleral toricity  --- The white of the eye (sclera) tends to have more of it's own innate astigmatism as you venture more peripherally from the limbus.  The larger the scleral lens you are fitting, the more likely you'll have to use  toric peripheral curves to achieve a good fit.
• minimize fogging -- larger lenses tend to have more issues with lens fogging, theoretically because they are interacting more with the conjunctival goblet cells that produce mucin

Proper lens diameter should clear the limbus by 2-3mm on either side.  The lens above shows inferior fenestration which isn't used by many doctors these days -- at one point fenestrations were popular to improve oxygen transmission.  These days, doctors change their fit to improve oxygen transmission by minimizing their central and limbal vault (see below).  via

How do you assess central clearance?  Fill the lens with nonpreserved saline and a swirl of NaFl dye.  You can judge the central clearance of the lens by comparing the tear film thickness (green above due to the NaFl dye) to the corneal thickness on your slit beam.  Knowing the average corneal thickness is about 550 microns, you have a predictable judge of  tear clearance.  In the picture above, the tear clearance is almost as thick as the corneal clearance, so I would grade this around 450- 500 microns of clearance.  This is TOO MUCH!! Photo via

Of course, if you have an OCT you can image the exact amount of corneal clearance with an anterior segment scan. via

Want the perfect limbal clearance? You should just see a faint hint of NaFL dye right at the limbus with the perfect fit of 30-40 microns.  Of course, you could also use an OCT to assess this area if you have access! via

If the edge of the lens is too tight, you'll see blanching of the conjunctival vessels in as little as half an hour.  This will cause severe discomfort and binding of the lens when the patient attempts removal.  Before sending the lens home with a patient, make sure you check the edge carefully to ensure that the conjunctival vessels are passing underneath the edge of the lens freely, without any pinching or thinning. via