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The medical landscape is constantly changing, and eye care providers have a new medication in their arsenal to fight glaucoma with the introduction of Simbrinza (Alcon).  Want a refresher on glaucoma? Simbrinza is a combination drop containing the carbonic anhydrase inhibitor brinzolamide with the alpha 2 adrenergic agonist brimonidine.  These medications individually have been used in glaucoma treatment for years, and with a combination of the two, the hope is that a patient will get the combined method-of-action effects of these two drugs with a lower frequency of daily dosing.

What You Need to Know:

Early FDA studies show Simbrinza to have a high efficacy in the lowering of IOP (intraocular pressure) with a reported 21-35% reduction.  The recommended dosage is 3 x a day for maximum effect.  Not surprisingly, side effects and contraindications are indicative of what we would find with each individual drug:

Most common side effects: blurred vision, eye irritation, unpleasant taste, dry mouth, and eye allergy

Price:  Around $100/ bottle for cash pay patients; coupon cards available through Alcon
      -- At this time I do not know the average copay with medical insurance to expect, but I will try to update this when I receive the information!

When Not to Use:

Like all CAIs, Simbrinza is not recommended for patients with known sulfa allergies, significant corneal endothelial loss (it can result in corneal edema in patients with conditions like Fuch's Dystrophy), or in conjunction with oral CAIs.

Like all alpha 2 adrenergic agonists, there is a risk of hypotension when combined with anti-hypertensives, an increased risk of side-effects when taken concurrently with MAO Inhibitors, and lethargy in children under 6 years of age (in as high as 50-83% of pediatric glaucoma patients! -- most specialists highly advise against pediatric dosing of this drug as a result).

The drug is Pregnancy Class C, meaning it is not advisable unless the benefits outweigh the potential risks.

Why This is Exciting News for our Industry

Any time we get new glaucoma medication, it is a step in the right direction.  Even though this particular drug only combines two existing therapies, combination drugs already on the market are so effective because they require less dosage for patients.  Imagine you were taking brimonidine and a CAI individually.  You have 2 different bottles to buy every month and as many as 6 drops to instill a day (up to 3 x a day each).  Then imagine getting just 1 bottle to keep track of for the month, and dosing half as often.  It may not seem like much of a difference, but studies routinely show that poor drop compliance is a huge reason glaucoma patients suffer progressive damage.  Glaucoma is a painless and symptomless disease, and remembering to put 6 drops in a day is probably not going to happen unless you are the most vigilant of patients.  By making your patient's drops easier to remember to take, and less of a drain on their day, you can make it easier for them to keep their pressure controlled every day of the year!

As an optometrist, I test children for color blindness on a routine basis, but many adults come in asking me if they might have a color vision problem too.   Have you ever wondered if your color vision is up to snuff?  No surprise, but there is an app for that.  

This well-done image tries to depict what a color blind person would see on a Ishihara Color Blindness test Protanope = no red receptors, Deuteranope - no green, and Tritanope = no blue via

Optometry jokes are the best

"There's a freckle in my eye!?"

A small choroidal nevus can be seen inferiorly in this photograph (it looks like a grey-green circle)

That's usually the response to seeing a retinal photograph that contains a freckle or choroidal nevus (as it is formally called).  With today's excellent imaging software, small freckles inside the ocular tissue are easier and easier to detect.  So if you have a nevus, what does this freckle mean to you?

Normal, benign choroidal nevi occur in as much as 7.9% of the population (though with new technology we may find this incidence is a little higher since it is easier than ever to spot faint, small nevi).  Melanoma inside the eye, conversely, are exceedingly rare, with only 6 in 1 million incidence rate. In neither a melanoma or a normal nevus will there be any visual effect (unless the melanoma is significantly advanced), so your doctor will only detect these lesions through dilation or retinal photography.  Just like any freckle, the most important thing you can do is protect it from UV exposure.   A normal freckle can turn into a malignant melanoma under certain conditions, and this malignant change has an incidence rate of 1 in over 8,000 freckles.  While exceedingly rare based on these numbers, it is best to protect yourself.  I always recommend sunglasses with 100% UV protection, but it is an absolute must for my patients with ocular nevi!

Can you find all the nevi in this person's retinal photo?  Hint (there are a total of 3).

What do I look for in detecting suspicious freckles?  Growth from year to year is a big risk factor, so I use retinal photographs to find any small changes in size or shape from year to year.  A freckle that is 3 x larger than the optic nerve is highly suspicious.  I also look for changes in thickness (if the blood vessels run over top of the freckle without changing their path, the freckle is flat!), coloration, and position inside the eye.  Freckles that are closer to the optic nerve are in a higher suspicion category.  Your nerve is the eye's highway to the brain, so we don't want any malignant changes occurring so close to this pathway.

Always remember, most of the internal ocular findings that your doctor evaluates at your annual eye examination have no real consequence to vision, so you wouldn't know anything was changing inside your eye just by judging vision alone.  Always best to get your eye evaluated regularly even if you don't need glasses or contact lenses!

Imagine a world where your vision limited you to the point that you could no longer pass your driver's test.  So many of my patients ask me if they are legally blind, but the truth of legally blind is that you CAN'T get better vision with glasses or contact lenses.  No matter what prescription is in your glasses or contact lenses, your vision is severely limited.  In these cases, your visual abilities can keep you from performing routine tasks like driving a car or crossing the street.

Bioptic telescope via

If you have "special eyes," you know how difficult it can be to wear contact lenses.  You know that your doctor will never have a lens in the office that works for you.  You know that if you need to change brands for some reason it may take multiple visits and special orders to find something that works.  And you also know that you probably won't see as clearly in contact lenses as you do in glasses.  These are the hard truths for patients that don't fit in the "average" power-options that most soft contact lens companies provide.

I'm not sure that cat-eye sunglasses ever really go out of trend, but they are back with a vengeance on runways this fall.  Designers featured both wearable and over-the-top looks that are sure to inspire sunglasses envy.  Here's a preview from the latest top design houses:

ARMANI:  Navy gives this classic cat-eye a new twist.

TEMPERLEY LONDON:  Color updates again prevail.  These cat-eyes incorporated two-tone frames and lenses with gradient color changes to spice up the classic silhouette.




























CAROLINA HERRERA : Play up the vintage cat-eye appeal with browns and amber tinted lenses.



TORY BURCH: Go statement with over-the-top sunglasses as vivid as the statement necklaces that were trending all last year.

I was reviewing retinal photography with a patient today, and everything looked healthy.

A retinal hemorrhage tells us that blood flow has been compromised, a huge red flag for blood pressure issues!