As promised, the forthcoming posts are my opus to the overwhelming topic of dry eye.  The spectrum of Dry Eye Syndrome ranges from patients suffering from mild contact lens discomfort at the end of the day, to those at risk of needing a corneal graft due to the extreme damage done to their eye from dryness.  Most patients fall somewhere in the middle, with dryness being severe enough to cause marked discomfort at some point during the course of their day.

Do you have dry eye?  Here are some of the hallmark symptoms:

• dryness, itching, burning, sharp pains, and watering --- Though it seems counterintuitive, watering is a response to your eye being too dry!  The eye tries to protect its surface by producing emergency tears, but these tears do not have the proper components and run down the side of your face.  
• decreased visual quality or intermittent haziness, especially between blinks  (especially with Meibomian Gland Dysfunction specifically)
• discomfort at the computer --- Studies show we blink about half as often at the computer than we do in conversation!
• crusting or eyelid irritation 
• redness, both of the white of the eye and along the eyelids

At some point very soon, I know I need to dedicate a significant number of posts to Dry Eye Syndrome.  (It is in all caps, because this is a condition that significantly affects the quality of life of as many as 7 to 17% of the population depending on which studies you are looking at!).  People with Dry Eye experience redness, irritation, discomfort, blurred vision, sharp pain, watering, crusting, or dryness.  It is typically worsened with computer use, contact lens wear, and the use of ceiling fans and air conditioners.  Treatment ranges from over the counter drops to expensive prescriptions and ointments to lubricate the ocular surface.

This patient's meibomian glands are obviously clogged, causing a blockage of tear film secretion!

One of the leading causes of dryness is called Meibomian Gland Dysfunction, where the tear glands located along the top and bottom eyelid fail to properly release their oily tear film layer onto the eye, causing the tears to quickly evaporate and leave the surface dry.  To treat MGD, we often prescribe warm compresses with massage to open the gland orifice and force the tear secretion through the gland onto the eye.  Fish oil supplements and oral doxycycline can also help with the functioning of these sebaceous glands.  I will go into more detail concerning these treatments in the future, but this post is dedicated to the new treatment for MGD:  the LipiFlow device!

The LipiFlow device

A local company in Morrisville, NC called TearScience recently received FDA approval for this device to treat moderate to severe MGD.  As you can see from the image above, the major component of the device is a mechanical "cup" that is applied to your eyelids.  This machine heats the lids from the inside, then uses timed pulsations to express the clogged secretions from the meibomian glands.  The entire procedure lasts about 12 minutes, and there is very minimal discomfort reported by patients at this time.  The cup that sits over the eye is quite large, but it does not touch against the cornea (the clear dome of the eye), and as such, must be large enough to only touch the outer portions of the eye.  Yes, you read that right.  The suction cup-esque part of the device pictured above touches the inside of your eye.  Sounds uncomfortable, but you will be given a numbing drop before the device is inserted.

As you can see from this diagram, one part of the device is under the lids providing heat to the glands, and the other is external to provide pulsation to "milk" the glands

Things to know:
1) This procedure is very new, but results are showing that some patients are getting relief from their dry eye symptoms lasting anywhere from 3 months to more than a year!  For many patients life without artificial tear drops, or with significantly less drops, is well worse 12 minutes of pressure being applied to the lids.
2) Because this procedure is so new, only a very few clinics are offering it.  There is also no CPT code available, so this means in practical terms that no insurances will cover the procedure at this time.  Expect cost to be significant.  In my area, Duke Ophthalmology has access to the device, and the cost is around $1500.
3) The science isn't available yet as to how effective this machine is long term, or what the magnitude of objective improvements are in the level of dryness, such as tear film break up time and tear film osmolarity. The theories behind this device are the same that optometrists recommend to patients every day when they prescribe warm compresses with lid massage to improve meibomian gland secretion.  If you are interested in more information, please feel free to post here.  In the North Carolina area, there is a doctor at Duke who is accepting patients for this procedure for those that are interested!

The eyelid twitch: almost everyone has had this happen at least once in their life.  To the person with the twitch, it feels like their entire eyelid is spasming.  This twitch, called myokymia, is caused by a random firing of nerves in the lid tissue.  While it may seem like a very concerning phenomenon, luckily it has no permanent or lasting effect.  Myokymia is generally caused by one of three things:

• lack of sleep
• stress
• caffeine

I have had some interest in my experiences with the Synergeyes Duette lenses, so now that I have had more patients wearing the lenses and returning for follow-up I thought it was a good time to share.  If you are interested in my original post, please click here.

For those who may not recall from my previous post, Synergeyes Duette is the hybrid lens that combines a rigid gas permeable (or hard lens) center with a soft contact lens skirt that surrounds the lens.  The soft lens skirt provides added comfort and also helps deliver oxygen to the eye via the new silicone hydrogel material (in comparison to the original Synergeyes lens that had poorer oxygen transfer). It is a great choice for patients experiencing poor quality vision through soft contact lenses, especially in patients with astigmatism or those needing multifocal correction.

Synergeyes contact lens: notice the darker colored  hard lens (RGP) in the center to provide sharp, clear optics

If you are a patient interested in trying the Synergeyes lenses, here are some things to know:

1) The lenses are quite large and can be hard to get used to at first.  A lot of my patients request to try them, but when they see the size difference compared to their soft lenses they aren't as keen.  For best comfort you will fill the contact lens bowl up with solution before inserting it, to provide added moisturization.  To insert the lens patients often need to lean forward over a mirror placed flat on a table, and then insert the lens straight up towards the center of the eye. Due to this insertion method, it is not a great lens choice for a first time wearer due to the learning curve involved with inserting a lens of this size.  Most patients have no trouble after a short course of practice.

2) There may be some dryness and lid awareness, especially early on in the fitting experience.  Lid awareness should resolve with proper fit and adaptation time, but I have had patients with dry eye complaints prior to trying this lens notice their dryness seems worse.  This dryness issue is not affecting all of my patients, but I am still working on how to resolve the complaints. Right now my efforts are centered over adjusting the fit to ensure that adequate tear flow is present under the lens.  As far as solutions, I have been told by reps that the Revitalens solution is highly recommended with Synergeyes wear to improve comfort, though many other multi-purpose solutions can be effectively used.  Personally I have had great success with Aquify and Clearcare solutions with this lens.  Of course, I just love Clearcare in general, but that is another post, hah.

UPDATE:  The above information is now very outdated, and I recommend seeing this post for better information.  Suffice it to say that Revitalens is NOT what the current data supports even though the initial lens launch recommended this product.  BioTrue is the solution of choice for Synergeyes Duette, with regular cleaning with an additional build up remover like MiraFlow.

via

3) The multifocal lens (Synergeyes Duette Multifocal) isn't going to be perfect.  I have patients seeing 20/20 with this lens that aren't happy with the quality of their vision. Some of this is inherent in the lens design and I do try to tell patients exactly what their expectations should be. The design of this lens is called "simultaneous vision," and what that means to the wearer is that you are seeing both distance vision and near vision information "simultaneously."  That's a lot for the brain to process.  It can take 1-2 weeks of wearing time to know if this lens design will work for you.   If you are a doctor fitting this lens, to increase distance vision you need to switch to a larger add zone, or consider going to a steep base curve skirt.  To improve near vision, the add zone size needs to be small.  

4) There is a major price tag on these lenses.  Patients should expect to pay a higher contact lens fitting fee because your fit is going to include several visits to perfect your lens parameters.  The lenses themselves are also expensive, typically around $200-$300 for a set of lenses.  Keep in mind that each lens will last only 6 months, so you will need 4 lenses in total for a year's supply (that puts these around the $400-$600 range for your year!).  This is different from traditional RGP (hard) contact lens wearers that may sometimes be able to use their lenses for 1-2 years.

If anyone has stories to share about these lenses, I would love to hear them!

A question for the ages.  As an optometrist, I answer a lot of questions about vision and ocular health every day, but this particular question pops up more frequently than I would have suspected.  The simplest answer is this: if your glasses are the correct prescription, wearing them will in NO way hurt your vision. To be more thorough with this answer though, we actually need to break it down into several common scenarios:

1) My glasses prescription is correct, but it seems like my vision is worse than before when I take them off.  


I hear this often from patients that are new glasses or contact lens wearers.  If the glasses prescription truly hasn't changed, then vision without glasses looks worse than the patient remembered because they had never previously had crisp and clear 20/20 vision to compare to their own vision.  If your world looks blurry all the time, that becomes your normal.  Once you get used to 20/20 vision in your new glasses, that same amount of blur looks just terrible because now you know what you are missing!

2) I wear over the counter reading glasses, and I just keep having to get stronger and stronger powers.  Have I made my vision worse with the wrong reader?


For those individuals over age 40 that suffer from presbyopia (see this post for more details), reading glasses become a way of life.  Because over the counter readers are readily available, many patients will pick a pair in  the store based on what feels most comfortable, without seeing a doctor first to verify the necessary Rx.  The good news is that wearing readers will not hurt your vision even if you select the wrong power.  They can give you headaches if the prescription is too strong or too weak, but this is really the only side effect.  And rest assured, even though it feels like you are getting more and more dependent on your reading glasses, it is because your visual system is gradually declining at near due to normal aging changes (none of us are immune!) and not because of the readers.  My patients are also often concerned that they selected too strong a power in reading glasses (the powers typically span from +1.00 to +3.00), but a stronger pair will only give you greater magnification and force you to hold things closer if it is stronger than you really need.  No permanent harm done, but you will get used to a certain level of magnification if you use a particular power for a while.

Vera Bradley specializes in colorful OTC readers.  I also recommend Steinmart for a good selection.  Just remember, the quality of OTC readers is not the same as you will get with prescription glasses.  There's a reason many people call them "cheaters"-- in the correct power, they are just good enough to get you by!

3) Every year my child's glasses prescription is getting stronger. Is wearing glasses making his vision worse?


This question is the only one where we can get into a scientific debate.  Myopia can progress quite rapidly in children, and a number of factors influence this progression. Being near-sighted is a function of the curvature and length of your eye, which in turn is influenced by both genetics and environment. Numerous studies have shown a correlational relationship between amount of time doing near work (like reading) and the presence of myopia.  Whether myopic children tend to read more because it is easier for them than distance activities, or if they are myopic because of doing so much reading is under constant debate.  There is a school of thought however that near strain, or the strain on the eyes' focusing system when performing a task at near, can induce  myopia in an effort to relieve that strain.  An overview of these theories can be found in Myopia and Nearwork  by Rosenfield and Gilmartin.  As optometrists, we try to counteract this progression of myopia from near strain by:

• Prescribing the lowest possible prescription to attain 20/20 vision, and thus limiting the amount of near strain when reading with glasses.
• Prescribing bifocals or progressives for children when needed to ensure that their distance prescription does not adversely affect their reading facility.
• Studies have shown that certain contact lenses such as rigid gas permeable lenses or orthokeratology (where the patient sleeps in rigid contact lenses that act like a retainer to change their prescription overnight) can help slow the myopic progression in some cases. For more information (though it is quite technical), try this article:
• http://www.revoptom.com/continuing_education/tabviewtest/lessonid/106321/

This rigid gas permeable (or hard) contact lens has a special design that flattens the cornea overnight, leaving a myope with clear distance vision the next day.  This technique is best for myopes -4.00 in prescription or less.

It's that time of year again.  That's right, flexible spending account season, as it's known in the healthcare industry.  Most flex spending accounts expire on December 31st, so for many people who wear glasses this is the perfect time of year to make your purchase!  Due to the high demand of the season, expect your local doctor's office or frames retailer to be running discounts or sales, making this a great time to also get a good deal.

For the holiday season, bold designs and colors continue to dominate the eyewear industry.  Here are some of my best-sellers!

• ROBERT MARC: Branded as the eyewear line of choice for the stars, the quality of these frames is hard to beat.  This year's line features several styles in a colored tortoise pattern.  The red tortoise (below) and their olive green "jungle tortoise" are two of my favorites.  The only drawback on these frames is the pricetag, but the fit and design are truly impeccable.  

• TIFFANY'S: The company's newly launched eyewear line features their classic robin's egg blue color scheme, as well as familiar accents in silver such as the heart locket and key motifs.  This frame line has been very popular at my office because the brand is so distinctive. People can recognize that shade of blue from across the room.

• PRODESIGN: If you want bold color, no one does it better than Danish based Prodesign.  I find their frame shapes are very angular, but for those people with oval or round shaped faces they are a perfect fit.

How often do you throw away your contact lenses?  It is amazing the responses you can get on this simple question.  As an optometrist, I have had patients that have been wearing their same trial pair of contact lenses they were dispensed at an exam 2 years ago.  Most people aren't that daring, but it is not uncommon to have people wearing lenses for months longer than FDA guidelines recommend.  And most patients are very defensive  about just how often they are throwing their lenses away.  Why do I recommend following FDA guidelines for proper contact lens disposal?  Here are 5 very real complications that I treat on a regular basis that are a result of improper contact lens wear.

New blood vessel growth is not a good thing when it means opacification of what should be clear tissue!  Picture via optometric.com

A cornea with significant scarring and neovascularization

  Treatment = Change to more oxygen permeable contact lenses or daily wear. If severe enough, contact lens wear may have to be discontinued permanently.

Acute red eye, usually after sleeping in contact lenses is classic for CLARE

A Bacterial Ulcer: definitely something you do NOT want