When I first switched to a Daytona Optos imaging system for retinal photography, I'm not gonna lie -- I was a little hesitant.  I had gotten so comfortable with traditional imaging systems, and I felt like the posterior pole looked sort of warped in the Optos picture.  Within just a few weeks I was completely sold, though.  The images I was seeing were totally changing the way I talked about ocular health with my patients.  We could see tiny peripheral retinal hemorrhages.  We could see peripheral drusen that might increase their risk for macular degeneration later in life, or even the risk of Alzheimer's disease.  And the filter system allows for spectacular contrast views, even auto-fluorescent imaging.

A large rhegamatogenous retinal detachment

If you are considering upgrading to Optos imaging, or have a camera and want to share your fantastic photos, you need to check out What the Fundus?, a website dedicated to fascinating images taken with Optos cameras.  The founder Dr. M created "What the Fundus?" after a discussion with fellow eye doctors at a Optos training session. "We wanted a place where we could post interesting or just cool looking pictures that have been taken in our practices.  A place free from internet trolls and malcontents where we share what we are passionate about.  Hence, whatthefundus.com was born."

Asteroid Hyalosis

One (or a few) retinal tears going on in the periphery of an asymptomatic patient.

Have images of your own you want to share?  Email Dr. M at michael@whatthefundus.com to be featured on the site!  He adds new photographs regularly, so keep checking back to see what interesting cases walk through the door.

You know that feeling -- the ache behind your eyes, the heavy feeling of your eyelids, the redness and under eye circles you see looking in the mirror, and that intense sensitivity you get when you look at bright lights or step outside of your workplace and venture outdoors.  This feeling of light sensitivity and tired eyes has a name -- digital eye strain.  For 65% of Americans digital eye strain is wreaking serious havoc on work performance, and how your eyes feel when you're not logging those long hours at your computer and cell phone screen.  The average American spends nearly 6 hours a day using mobile digital devices and almost 11 hours daily when you include time on desktop computers, laptops, and watching TV!  Our eyes struggle adapting to light after logging long hours in a digital environment for two big reasons:

Lot's of announcements with the start of 2016 at CooperVision, including the impending nationwide launch of the lens we've been waiting (and waiting, and waiting) for -- Biofinity Toric XR.  For patients with high amounts of astigmatism, CooperVision has been the only company providing soft contact lens options that aren't custom order for this community for years. But Frequency 55 Toric XR is limited by its' low oxygen permeability (Dk/t is 15.7 in this lens -- other monthly disposable lenses on the market typically have numbers over 100), and the more updated extended power range option Proclear Toric XR isn't much better at 30.9 Dk/t.  Proclear Toric XR has also been notorious for easy ripping, a headache for patients and your doctors!  Biofinity Toric XR will be the first lens that isn't custom order that is made in a highly breathable silicone hydrogel material (Dk/t for Biofinity is 116).  This higher breathability is a needed improvement for patients that have suffered scarring or corneal health changes from the lower oxygen materials they've been stuck with due to their high prescriptions in the past.  The lens has been launched on a very limited initial roll-out already (about 400 offices nationwide), but is slated to be released nationwide between April and June/July.  Here are the details:

A flap of the cornea is removed during LASIK that is reapplied to act as a natural bandage via

With so many options, the best way to select the right surgery for you is to talk with a doctor you trust.  Refractive surgeons are well-versed in the options available today, and based on your personal and family medical history, your prescription, and your eye’s anatomy, they’ll be able to recommend the best option for you.  Just remember, any refractive surgery may not be able to achieve perfect, 20/20 vision in all lighting conditions.   Today’s refractive surgery may not mean no glasses ever again for every patient, but it will definitely significantly reduce your dependence on corrective eyewear and the freedom to see clearly without the constant hassle of bulky frames or contact lenses.  And what’s more, the technology just keeps getting better.  Even people with high prescriptions can now enjoy refractive surgery, even if you’ve been told you weren’t a candidate for LASIK in the past.  Better versions of LASIK and now the mainstream use of phakic IOLs means that there is a surgery option for nearly everyone.  


This post also  appears on the CIA Medical Insights Blog as free content donation by Dr. L to help promote discussion of ocular health on their website

A new white-colored, painless bump appears on your eyelid margin.  You've rubbed at it, and now there are more.  What could it be?

image via

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After a few years ruled by thick zyl frames in black and tortoise, eyewear is poised for a complete 180 -- lightweight metals and barely there plastics are dominating the marketplace.  And the color palate of choice? Think the soft pastels that received dual honors as Pantone's Color of the Year 2016: a blushy dust pink called Rose Quartz and an icy grey-blue called Serenity.

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MODO Eyewear's Paper Thin frame line is composed of ultra-lightweight titanium.

MODO Eyewear 4078

Celebrity favorite Oliver Peoples Annetta frame via

Olivia Palermo's latest collab with Westward Leaning is the Rose Gold Collection, featuring blush tinted lenses in a range of frame styles.  Our favorite is a combo made in Pantone heaven, the Flower 14 (below).

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There are a few things in life that are inevitable.  As a colleague of mine likes to phrase it, "If you live long enough, you will get a cataract."  But developing cataracts is not a diagnosis of doom and gloom.  Today's cataract surgery is as much a refractive procedure to bring you back to clear vision (maybe even without glasses!) as it is a medical one.  Some of my patients are actively hoping for that cataract diagnosis from year to year so we can correct their high nearsightedness or reduce their dependence on reading glasses.  And cataract surgery itself has changed so much, even in the last decade.  Now there are ways to reduce healing time, and achieve more precise vision refinement. There are implants that can correct even high amounts of astigmatism, and that can help you read again free from those OTC readers.  If you are about to undergo cataract surgery, here are the two questions you need to ask yourself to prepare for the best procedure for your needs:

In fall 2015 Alcon very quietly discontinued their preservative free saline solution for contact lens rinsing and filling, the well-regarded Unisol 4.  Most local pharmacies and box stores are now out of the product, and patients that have used the product loyally for years are scrambling for a replacement.  If you don't think the panic is real, just check out the price gauging on ebay -- $50 for a 3 pack that would have run you under $10 just a few months ago.  I've spoken with a rep from Alcon, and there was no official statement released as to why the product was discontinued, and there is no plan for reinstating the product in future.  If you are in need of preservative free saline, here are a few doctor recommended solutions that can take it's place.

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I was recently asked what was my favorite thing about eyewear.  Picture this: there was a moment somewhere in time that a great hero in the optical world decided he or she would make that little wire rimmed pair of glasses they had to wear look different.  They decided to change up the design of their glasses and make them more unique, more personal, more artistic.  In that moment, the idea that has blurred the line of glasses as a medical device versus a fashion accessory was born.  Braces, casts -- other medical devices never made it to true fashion status like eyewear, and our international obsession with glasses as wearable art is continuing to deliver fashion moments that make us perfectly content to be a little imperfect in eyesight and thus needing a new pair, of course.

The Optiprism sunglasses by Max Mara (Safilo) via

Celebrating this glorious marriage of function and fashion in ophthalmics, this year's collaboration between fashion house Max Mara and artist Maya Hayuk was a perfect melding of the minds.  The New York based artist was originally tasked with designing art to be featured on the Italian fashion brand's sunglass packaging, but the colorful patterns she created quickly became inspiration for the sunglasses themselves.  Her work is a reimagination how prisms reflect and bend light (the very concept behind how glasses work). The prismatic pops of color and shapes now appear on a 200 piece limited edition collection, signed by the artist herself!

"Optiprism" by Maya Hayuk via

Originally Hayuk's art was meant for the glasses packaging, but the print inspired Max Mara designers so much they have featured it in a limited edition run of sunglasses as well. via

The artist, Maya Hayuk standing in front of her artwork, "Optiprism" and wearing the Max Mara sunglasses she inspired.  via

As a primary care optometrist, the majority of my patients every day are scheduled for routine comprehensive exams.  It's time to update their glasses and contact lens prescriptions; no significant vision or pain complaints. I'm a strong believer that at every routine exam we should also do an ocular health assessment, even when the patient has no complaints about their eyes or vision. Unfortunately the eye is a body part that isn't very good at telling us when something is wrong.  Most blinding conditions of the eye, and most systemic conditions that steal sight have absolutely no symptoms -- no pain, no vision changes -- until you are permanently blind.  I know you and I wouldn't want to wait that long to find them.  I want to share this real case from my practice as a great example about why routine health care should always include dilation and/or retinal imaging.  This patient and his team of medical doctors are very happy that he didn't skip the dilation or imaging this year.

The Case:
47 year old white male presents for routine eye exam with no vision complaints.  Only known medical condition is hyperthyroidism, for which he takes levoxyl.  He had LASIK a few years ago and is 20/20 in both eyes without any glasses prescription required.  All ocular health is normal, even his eye pressure (11 and 10 mmHg in right and left eye respectively).  But then we look at his retinal imaging and we see this:

Right Eye:


Left Eye:


To the untrained eye, the multiple hemorrhages in these photographs might be hard to spot.  The photos below have been color and brightness enhanced to better visualize the bleeding going on in the retina:

Right Eye:


Left Eye:


Both eyes have multiple intraretinal hemorrhages scattered throughout.  The most obvious can be seen inferiorly on the right eye photograph -- they look like red blotches in the retina.  Whenever we find bleeding in the eye, the usual culprit is a systemic vascular condition.  High blood pressure and diabetes are two common systemic conditions that cause retinal hemorrhages.  But this patient had never been diagnosed with any vascular condition, and he saw his primary care doctor regularly. Blood work was ordered and the results came back with elevated white blood cell count.  Further testing confirmed the diagnosis: chronic myeloid leukemia.

Chronic myeloid leukemia (or CML) is a cancer of the bone marrow, disrupting the body's ability to make platelets, red blood cells, and white blood cells.  In the chronic stage of this cancer, most patients are completely asymptomatic.  They might feel fatigue or joint pain, but our patient had neither complaint.  Luckily with treatment the chance for survival with CML is very good.  A 2011 study of Gleevic found a survival rate of  95.2% of treated patients after 8 years.  With early intervention, the treatment has even better chances for success.  Interestingly, only 5-10% of patients with CML present with ophthalmic signs or symptoms at initial diagnosis, but those that do have retinal hemorrhaging or other associates retinal findings like optic nerve edema have a lower 5 year survival rate:  21.4% compared to 45.7% of those without.   That's why finding signs like retinal bleeds and getting the proper blood work is so essential  -- if the signs are there but aren't caught, the patient has a much lower chance of survival.  But if these signs are found during routine eye exams, the patient can get treatment much faster and earlier in the disease process, and improve their chance for survival!

This case is a great story about how routine health care is the best way to protect your health. Whenever you are tempted to blow off your annual exam, or skip that dilation because it's not convenient, think about that possibility that today's eye exam could save your life.

Many people remember the first time contact lenses hit the mainstream in 1971.  But the idea for contact lenses is much, much older.  That unparalleled visionary, Leonardo Di Vinci, drew a design for contact lenses back in 1508, which looked a lot more like a helmet than what we've come to know and love today.  The lenses from the 40s described in the video below involved a rather invasive on-eye mold, and the lenses themselves were not for the light of pocket, coming in at over $4000 when adjusted for inflation.  Looking back at images like this, less than a century old, just shows you the remarkable path of how far we've come in the world of ophthalmics!

We're rounding up our favorite internet finds for ODs or glasses wearers that just can't get enough!

For over a decade, researchers have been reporting great success in slowing down the rate of myopia (or nearsightedness) progression in children by using various concentrations of atropine.  It's popularity in countries like China where as many as 80% of children are near-sighted has been steadily growing as more research is published, and with continued positive study results, atropine drops for myopia control may be a treatment we see more and more commonly in the US in future. In the past, atropine has been controversial for use in children because it is a potent pupil dilator -- putting in just one drop a day of the full 1% atropine concentration available in the US causes significant dilation and all its' side effects -- namely severe light sensitivity and an inability to focus clearly up close.  That meant that any child taking atropine would have to wear tinted bifocal glasses in order to visually function during their school day.  The new release of the ATOM 2 study (ATOM stands for Atropine for the Treatment of Myopia) once again demonstrated great results for slowing down myopia progression with atropine usage, but the best part is that a much lower concentration of the drop may be even more effective, minimizing these unwelcome side effect issues.

In many Asian countries, myopia is a public health crisis -- the majority of children in these countries are developing myopia at a speed that leaves them dangerously near sighted as an adult.  Highly myopic patients are at significantly greater risks for glaucoma, retinal degenerative conditions, and retinal detachments that cause permanent blindness.  This advertisement was taken from the Singapore National Eye Centre -- showing just how quickly these countries are embracing new research as they fight to save their children's sight.  In the USA we can't get 0.01% atropine commercially at this time.

Let's Go Back to The Start: ATOM 1
To better understand the new study, let's review about the original ATOM study results that were published back in 2006.  This study followed 400 near sighted children split into a control group (given placebo drops to use once daily in one eye) and a treatment group (prescribed Atropine 1% drops to use once daily in one eye).  In the first 2 years, the treated group had a whopping 77% reduction in myopic progression as compared to the control group. However, when drops were stopped in year 3 a large rebound effect was seen in the treated group -- they progressed very quickly once they were off of the atropine drops.  Because of these results, plus the side effects of atropine, the treatment didn't really take off as a viable means of myopia control in the US.

The ATOM 2 Study
Dr. Donald Tan and the other researchers that participated in both trials knew that atropine worked, but they wanted to find a way to make it a more viable treatment option.  The ATOM 2 study looked at comparing lower doses of atropine to see if they could  get a similar treatment effect with much fewer side effects.  Again 400 myopic children aged 6 to 12 were followed for 5 years, but this time both of their eyes were treated with atropine.  The children were split randomly into 3 trial groups: 0.5% Atropine, 0.1% Atropine, and 0.01% Atropine.

Pupil sizes were measured before treatment (labelled as baseline in the above graphic) in both mesopic (low light) and photopic (bright light) conditions.  Children on 0.01% atropine had significantly smaller pupil dilation effect as compared to the larger concentration dosages.  Their pupil size increased by about 1 mm on the 0.01% dosage.  Only 1% of children taking 0.01% atropine reported glare symptoms, and none of the children had functional near vision loss side effects. via

At the end of 2 years, all children were stopped for a 1 year washout.  Just like was seen in ATOM 1, there was a rebound effect when the atropine was stopped, but the rebound was statistically significantly less in the 0.01% atopine group than in those children on higher doses.  68% of the 0.5% group had a progressive rebound of more than -0.50D during the washout year, compared to 59% of the 0.1% atropine group and only 24% of the 0.01% atropine group.  The younger the child, the more likely they were to have a rebound effect.

Graph showing percent rebound during the year 3 washout.  Rebound was defined as > 0.50D increase in myopia during that year.  0.01% atropine group had statistically significantly less rebound than the 0.1% and 0.5% groups (green bars = 0.01%, light blue = 0.1%, and dark blue = 0.5% graphically above).  Also note that the older children had much lower rebound risk than younger children, implying that rebound might not be a significant issue if drops are used through the early teenage years.  via

Researchers then restarted any child that progressed more than -0.50D during that washout year on 0.01% atropine for 2 more years.  At the end of the study, using the lowest concentration of atropine (0.01%) was shown to be as effective as higher doses in controlling myopia progression, but also had less patients to rebound with discontinuation of the drop, and less side effects of pupil dilation and near focusing issues.  The use of 0.01% atropine slowed myopia progression by 50%, and those patients that had a rebound during their washout year that were then retreated had equally effective control once they were placed back on 0.01% atropine.

The Problems
The results of the study look very favorable for low dose atropine, but some issues remain specifically in the US market.  As of today's publication, only 1% atropine is available commercially in the USA. It is possible to get a compounding pharmacy to dilute atropine to a lower concentration, but this can be difficult to find locally, and can result in high prices for the drops.  A quick google search shows that a 5 mL bottle (should last about 1 month) cost $38.00 to have compounded in 2014. Another issue is how long should a child be left on atropine?  Many researchers theorize for atropine to be an effective solution without rebound, a child would need to be on atropine until they are done growing (the highest risk time for myopia progression).  This could mean using it through the early twenties for best control.  For most children and parents, using a drop that creates more glare and light sensitivity becomes impractical when the child gets a driver's license, so using even low dose atropine after age 16 could be difficult to continue.  Luckily the ATOM 2 study showed that older teens are much less likely to have a rebound effect than younger children.  We also don't know exactly how atropine works to slow down myopia progression.  Does it somehow signal the eyeball to stop lengthening?  We can only theorize at the method of action for why atropine works at this time, but studies show very clearly that it does.  If you want to learn more about the current research and theories behind myopia control options, head to the Patient Guides tab and scroll down to the Myopia Control section for a full list of articles.