Thursday our office got a phone call for an emergency work-in appointment.  A 13 year old boy got hit in the eye playing flag football at school, and now 2 hours later his vision was getting blurry.  A history like this definitely warranted him being seen as soon as possible, so thirty minutes later he was in my chair.  My technician gave me a quick over view before I went into the room, but I heard only one sentence before my mind immediately grasped out situation.  "And I can see blood in his eye!" A red eye is one thing, but when you see blood actually trapped inside the front of the eye, we're onto something much more serious.

I wish I had taken a picture of my patient, but the presentation was almost identical to this photo via

We typically see hyphema in the office due to injuries during sports, but they can also occur spontaneously in patients using strong blood thinners or with hemolytic conditions.  The patient above had hyphema secondary to warfarin use. via

This time of year there are usually a lot contact lens problems popping up -- patients coming in with red eyes, infections, or just trouble wearing their lenses all day.  One of the best ways to keep your contact lenses problem-free and keep you out of your doctor's chair (and potentially out of contact lenses for a few weeks as your eye heals!) is to rethink your cleaning regimen.  Prone to infections? Overwearing your lenses, sleeping in your lenses, or not cleaning them properly are the three biggest reasons most people get contact-lens related infections.  Contact lenses drying out or causing irritation?  Again, overwearing your lenses, sleeping in your lenses, or not cleaning them properly are the three biggest reasons most people have trouble with contact lenses during some parts of the year and not others. The first two are no-brainers: throw your lenses away on time and take them out every single night.  But wouldn't it be great if there was one solution that both killed bacteria and removed surface debris to leave a fresh, clean lens for the next morning? Luckily someone has already invented the answer and it's hydrogen peroxide based contact lens solutions, but only about 11% of contact lens wearers are using this technology.  With new improvements in this technology coming out this year, there's more reasons than ever to make the switch to the product that can change how you view your contact lenses.

CLEAR CARE Gets An Upgrade

Out this fall is the latest version of CLEAR CARE, the hydrogen peroxide solution that really set the standard for safety and performance for the last few decades of lens wearers.  The solution still requires 6 hours (overnight) to neutralize, and there is no change to it's anti-microbial properties.  But the solution now includes an extra hydration polymer called "Hyrdaglyde" that helps prevent drying out of the contact lens as it goes through it's life span (be that 2 week or monthly).  This polymer is also in the new OPTI-FREE PureMoist solution.

Click over to get your $5 Coupon off a bottle of CLEAR CARE Plus

Sometimes my patients will ask me if using CLEAR CARE is too harsh for their eyes.  On the contrary, hydrogen peroxide solutions are the only preservative free lens cleaners on the market so compared to multi-purpose solutions these are way less harsh and great for sensitive patients or those with hypoallergenic needs.  One thing traditional hydrogen peroxide solutions could do though was potentially dry the lens.  Yes this solution removes debris, but that extra cleaning may wear on the moisture layers on the front and back surface of your contact lens too.  That's the concept behind the new addition of moisture "boosters" like Hydraglyde in CLEAR CARE.  Now the solution is deep cleaning, and adding back moisture to the lens at the same time.

New Smart Contact Lens Case Tells You When Your Lenses Are Clean

One of the potential knocks against hydrogen peroxide contact lens solutions is how do you know when your lenses are ready to wear again?  If you don't neutralize the peroxide long enough (for CLEAR CARE, that's 6 hours and for PeroxiClear it's 4 hours), then your lenses will sting your eyes really terribly when you try to put them back in.  The FDA has recently approved NovaBay's Intelli-Case, a contact lens case to be used with peroxide solutions that tells you where you are in the cleaning process.  When your lenses are ready, the light turns green on the top of the case, telling you it's safe to insert them in your eyes.

via

The company plans to have the case widely available for purchase in 2016.  Currently, the packaging of Intelli-Case will be included in a bundle with 2 bottles of NovaBay's own hydrogen peroxide solution, NovaClear, with recommendations that each case would last for 60 days (through 2 bottles worth of solution) before needing to be changed.

via

Did you see this interview with last year's NBA MVP, point guard Stephen Curry?  Curry is not only one of the NBA's best shooters, but his ball handling skills make him an elite passer and give him the ability to create his own shot (which is probably going in, let's face it).  One of the key aspects to Curry's off-court training is his sports vision/vision therapy program.  Check out his flashing light drill where Curry has to respond to different colored lights on a screen while dribbling a ball.

via

The degree of difficulty of Curry's sports vision training is astonishing.  While dribbling he responds to different cues from colored lights.  One color of light tells him to switch his handle and he has to reach out and touch the trigger with his opposite hand, all while maintaining his dribble of course.  A different color might signal a crossover dribble, or a pass to someone standing to his side.  Sometimes this same person standing off to the side in Curry's peripheral vision is holding up different numbers of fingers that Curry must call out correctly, yes, all while dribbling and still responding to the flashlights.  These peripheral players may even toss him back a pass from time to time that he needs to catch between his flashlight responses.  Sound overwhelming?  Many vision therapy specialists support the idea that these skills are difficult but trainable -- visual awareness, reaction time, hand/eye coordination, peripheral visual processing, etc.  Some of us might be innately better than others, but all of us can improve if we practice and "build" these skills.  And the great thing about sports vision training is that it can be completely customized to your sport, your position, and your personal strengths and weaknesses.  Just search vision therapy or sports vision specialist optometrists in your area and you can find a doctor who can help you develop your skills too -- be it for better classroom performance, on-the-field performance, or both.

Need a little last-minute inspiration for your costume this weekend?  Your glasses don't have to be in the way for your costume; you can make them a vital part of your look!  Here are some of my favorite ideas for the season that are all about your eyewear.

Clark Kent/Superman can be cute at any age -- but he needs his glasses to complete his disguise via

Have some round frames on hand?  It's Harry Potter's signature style via

Cousin It: layer lots of Dollar Store hula skirts for the "hair" and top off with your favorite pair of sunglasses.  Just make sure you can see through those skirt straws.  via

You could also use a large alarm clock or a toy clock at your house to make this White Rabbit costume via

Instagram-famous Trotter the French Bulldog seems to have an endless collection of doggie costumes (glasses included of course). via

Hipster cat probably doesn't really love wearing glasses though, let's be honest. via

I love how these oversized sunglasses really add to your classic bumblebee costume.  via

Sure if you have safety glasses you could be a scientist.  But why not be a Jurassic Park scientist while you're at it with a quick trip to the toy section (or your kid's toy box). via

Ok, I'm not going to even pretend this is last minute.  But aviator sunglasses are essential if you are going as a pilot this year. via

via

Less than 10% of contact lens wearers use RGP lenses, and this niche market hasn't seen much change in technology or price in many years in traditional lens options.  Next week prices are slated to take a sudden spike however as Valeant Pharmaceuticals institutes a price hike to their multiple RGP materials-- reports saying prices are increasing on various products from 28 to as much as 127%.  Valeant owns about 75% of the U.S. RGP market between their 2014 purchase of Bausch and Lomb (who owns the popular Boston material line) and their recent acquisition of Paragon Vision Sciences who manufacturers common lens materials Paragon HDS and Fluoroperm.  Price increases are set to take effect after October 30th. All this comes in the shadow of much larger legal issues brewing within Valeant's corporation.

For decades, parents of children born with congenital cataracts (a cloudiness of the lens that reduces vision from birth) were faced with a difficult choice.  If they did not have the cataract removed early on, the result was permanently reduced vision in the eye even if cataract surgery was performed at an older age because the eye was functionally occluded during it's prime years of visual development. However if they did remove the cataract, there was significant risk of complications with using intraocular lens implants (IOLs) at such a young age, and parents were often left with having to use high powered glasses in the affected eye until the child was older and could have a less risky IOL surgery implantation.  Both choices had major drawbacks -- a risky surgery or a child needing to wear bulky glasses with a high prescription in the affected eye that is left without a lens for several years.  Luckily research has provided us with new options, and the current recommendations from a 2014 study by the American Medical Association point towards contact lens use as being a great alternative in the pediatric aphakic patient until an IOL can be safely implanted.

Congenital cataract via

The research published in the Journal of American Medical Association Ophthalmology compared the visual outcome of infants with unilateral congenital cataracts treated with implantation of an intraocular lens immediately after removal of the cataract, or treatment with contact lenses until a child could more safely have an intraocular lens implanted.  The Infant Aphakia Treatment Study followed 114 infants with congenital cataracts in one eye removed surgically between age 1 and 6 months.  Study participants were enrolled randomly between 2 groups: 57 having immediate IOL implantation, and 57 using contact lenses for vision correction while aphakic (without a lens).

The Results:

At 12 months old, infants in both treatment groups had no statistically significant difference in visual acuity (measured with grating acuity).  The IOL group had more intra- and post-operative complications, higher cost of treatment (by 38%), and higher stress reported by parents or caregivers 3 months after surgery.

At 4.5-5 years old, children were again assessed.

Vision: The average visual acuity between both treatment groups had no statistically significant difference.  50% of children in both groups had "poor visual acuity" out of the treated eye (vision was equal to worse than 20/200 in that eye).  Twice as many children had "good visual acuity" (greater than or equal to 20/32) in the contact lens group compared to the IOL group; 23% of the contact lens group had good acuity versus only 11% of the IOL group.

Ocular Alignment: A high number of patients in both treatment groups had issues with strabismus (an eye turn) in the treated eye.  37% of children in the contact lens group and 43% in the IOL group had strabismus surgery by age 5.

Adverse Effects:  There was a significantly higher complication rate in the IOL group compared to the contact lens wearing group.  56% of contact lens wearing group had had at least 1 adverse event as compared to 81% of children in the IOL group with adverse events.  Glaucoma developed in statistically similar rates between each group.  Contact lens adverse events included corneal abrasion, ulceration, and infections, but none of these events resulted in corneal scars that were considered to impact visual acuity.  Three patients in the contact lens group had IOL implantation before age 5 due to issues with "the day to day contact lens changing and maintenance."

via

Additional Surgeries:  At age 5 only 21% of the contact lens wearing group had to have additional intraocular surgery compared with 72% of the IOL group.  The most common surgical procedures were clearing the visual axis of opacity (lens reproliferation, hemorrhage), followed by glaucoma surgery.

Conclusions:
This study did not demonstrate any visual benefit of recommending IOL implantation at the time of infant cataract extraction as compared to leaving the child aphakic and correcting vision with a contact lens.  Due to the significantly higher risk involved with IOL implantation at such a young age, it should only be considered if there is a reason that parents or the child will have extreme difficulty with contact lens insertion, removal, or wear.

This quote from study author Dr. Scott R Lambert, MD sums it up nicely:
"We think that for most infants with unilateral cataract, contact lenses are a better option than an IOL," Dr. Lambert said. "However, in some cases, the parents and their physician may decide that contact lens wear proves to be too challenging, and ultimately not in the child's best interests."

via

On a personal, today's post was inspired by a friend of the blog's recent battle with congenital cataracts in her newborn son.  Christina was featured back in 2013 as part of our local blogger sunglasses initiative, and her son, Thomas, has recently had successful bilateral congenital cataract removal.  Just like this study suggests, her doctor has recommended leaving Thomas aphakic and they are about to start with contact lens wear in the coming weeks.  If you want to follow along with Christina and Thomas, just check their blog for regular updates at Carolina Charm. We are wishing them the best in the next step of their journey!

The first hard (rigid gas permeable) contact lens was introduced mainstream in the 1970s.  If you or your parent recounts their lens wearing experience from this decade, it usually is not with fond memories.  The lenses weren't comfortable, you had to clean them with much greater care, and they were a lot more expensive.  So when disposable hydrogel (low oxygen permeable) soft lenses hit the market in 1987, and then later high oxygen permeable (silicone hydrogel) soft lenses became available in 2002, many thought RGP contact lenses would go the way of the dinosaur.  Who would want hard contact lenses they kept for a year or two at a time when they could have a new, fresh, inexpensive, comfortable lens exchanged out monthly (or even more often!)?

Debris (in this case microscopic balls of mucin) trapped underneath your contact lens can result in increased risk for inflammation and infection of your eye with contact lens wear.  It's much more common to get debris like mucin balls under soft contact lenses as compared to under RGP lenses. via

The truth however, defies that expectation.  RGPs continue to make up around 7-10% of the contact lens wearing market, and the number of wearers has not been steadily declining, but instead remaining stable over the last decade.  The two biggest reasons for the resilience of RGP lenses in the marketplace are visual quality and excellent ocular health benefits.  Soft contact lens wearers suffer from microbial infections at an average rate of 4/10.000 wears per year; RGP wearers only have infections at a rate of 1.2/10,000 wears per year.  So if we are throwing away soft lenses more regularly, why do we have more infections with these lenses than the older generation RGP materials?  The answer lies to a large extent with how your tear film moves underneath the contact lens.  Tear film movement is responsible for washing away debris, bacteria, and cycling nutrients in a regular flow out from underneath the contact lens with every blink of your eye.

Understanding Tear Film Exchange

Imagine the front surface of your eye.  Your cornea is continuously coated in tear film.  That tear film expresses with every blink, moving across your eye and then drained down your nasolacrimal duct through the puncta openings in your eyelid.  The tear film helps keep your eye hydrated; it's essential for comfort, oxygen transmission, and clear vision, and also is responsible for flushing away debris and contaminants that your eye gets exposed to regularly in the atmosphere.

There are multiple layers to your tear film, and when you place a contact lens on the eye, the tear film must split to both coat the lens surface and the space between your cornea and your contact lens. via

Now imagine putting your contact lens on your eye.  When the lens sits on the cornea, it splits your tear film in half; some of the tear film now goes over top of your contact lens, but some of it remains underneath the lens, sandwiched between your lens and the cornea.  In order to properly flush "dirty" tear film off the eye with your blink, you must move not just the tear film from over top of the contact lens, but also the tear film from the behind the lens. This is the limiting step with soft contact lenses.  Tear exchange is measured in units of tear turnover time; T95 represents the time in minutes for 95% of the tear volume to be eliminated from under the lens.  The lower the T95, the faster (healthier) the movement of tear film from under the lens. Studies show the average T95 for soft contact lenses is around 30 minutes; the  average T95 for RGP contact lenses is around 5 minutes.

Why do RGPs exchange tear fluid so efficiently?  

1. Smaller Diameter:  The average RGP is about 5 mm smaller than the average soft contact lens, and because it is smaller, it is easier for tear film to move freely underneath.

   RGP lenses are typically between 9-10 mm in size via

   A well-fit soft contact lens is around 14 mm in size and covers the entire cornea via

2. More Movement on the Eye:  RGPs are properly fit to have more up and down movement on the eye than soft lenses are traditionally fit.  The properly fit RGP lens will move 1-2 mm vertically with blink.  A soft contact lens typically moves around 0.5 mm.  The lesser movement of soft lenses is one of the reasons that they are considered to be significantly more comfortable on the eye than RGPs.  Mobile RGP lenses bump against your eyelids as you blink, creating lens awareness (let's face it-- that's a euphemism for discomfort) that's a hallmark of RGP wear. But the con of soft contact lenses eliminating this comfort problem caused by greater movement is a tighter fit that traps tear film and the debris caught inside it longer underneath the lens.  This is one of the reasons that doctors must carefully assess the fit of soft contact lenses every year for proper on-eye movement.  A decrease in lens movement with blink of just 0.2 mm can increase the wearer's risk for an inflammatory or infectious event 4.5 times higher.  Just a little too tight can mean the difference between you getting an infection this year!