Allergy season is in full swing, so many of my patients are relying on over the counter medications for short term relief of their symptoms.  If symptoms are mild, over the counter drops can offer complete relief without large copay costs.  Here is a breakdown of the best drops you can pick up without a prescription.

THE BEST: A straight anti-histamine will relieve itching, without any major side effects.  Both of these drops have BAK as the preservative, so if you are known to have major preservative sensitivity, these could cause some irritation.  If you are going to buy an allergy eye drop, I recommend purchasing one of these 2:

ALAWAY:  My most recommended OTC drop

Mad Men returned to TV last Sunday, and while the world is still abuzz about "Zou Bisou Bisou," I was once again inspired by all of the great throwback styles!  Here are some options for copying some of your favorite retro looks.

It's finally spring!  I know this fact is a blessing to me since I hate being cold, but for many Americans the transition into spring means untold suffering.  In my area, allergies are a way of life.  By the second week in March my car was permanently covered in a disgusting yellow dusting and my chair was filled with patient after patient with the first flare up of their seasonal ocular allergies.  How do you know if your irritation and discomfort is an allergic reaction? Let's discuss--

Redness, watering, and swelling of the conjunctiva are classic

SYMPTOMS
Itching. Itching.  And itching.  Your eyes may look red, water or feel dry, or you may experience a foreign body sensation, but itching is universal with allergies.  Contact lenses will feel uncomfortable and my patients complain that their lenses feel "dirty."  Mucus debris will deposit on the lenses and you may get some mucus discharge as well. Children often have a hard time telling you what they are feeling, so watch out for eye rubbing.  

SIGNS
The most classic sign I look for are called papillae: red elevations that form from inflammation of the conjunctiva (the tissue that lines the inner eyelid).  Papillae can be different shape and sizes, but they always mean allergy.  Other major signs of allergy are redness (called hyperemia) and swelling (called chemosis).

Fine papillae have red vascular cores.  Even though they are small, the number of papillae in this photo indicates a severe allergic reaction.  Photo from andrewgasson.co.uk

Large cobblestone papillae are found more often in children who suffer from a severe type of allergy called "vernal conjunctivitis".  Frequent eye rubbing is the first tip off!

TREATMENTS

• For mild cases, artificial tears may be enough.  Best for temporary relief for mild itching.

• For moderate cases where papillae are are lot less severe than the two photos above, I like to use anti-histamine/mast cell stabilizer combinations.  There are numerous over the counter drops, but my favorites are Zaditor and Alaway.  Prescription drops are much more effective, with common once daily drops including Pataday and Lastacaft.  They provide relief from itching within 5 minutes of instilling the drop

• Severe cases where there is substantial swelling, large papillary reaction, and marked discomfort, I like to also use a low strength steroid.  My favorite is Alrex, which can be used safely without risk of an intraocular pressure spike.  On really resistant cases, I have used FML or Lotemax ointment (steroid ointments) that can be applied under the eyelid to reduce swelling.

HOW TO PREVENT YOUR ALLERGIC REACTION FROM GETTING SEVERE
If you have undergone allergy testing or know certain irritants that really set off your symptoms, you can track their arrival in your area at pollen.com .  Plan ahead and start using drops as soon as you know symptoms should be forthcoming.  The drops work best when they have a few days to get into your system.  Mast cells in your body release histamine, which is the culprit behind your allergy reaction.  Any drop with a mast cell stabilizer will prevent this release of histamine, but if you start taking the drop after the histamine is released, the mast cell stabilizer isn't effective!

Echenique wearing protective glasses.  The yellow tint also increase contrast sensitivity!

Like so many Americans, I spent the past weekend on the couch, watching every basketball game I could devour.  Imagine my surprise when I the words "retinal detachment" crossed the airways while I was indulging in an optometry-free weekend.  Creighton has since been eliminated from the tournament, but for those of you who don't know, their star big man Gregory Echenique suffered a retinal detachment back in 2009.   He was playing a pick-up game and was accidentally poked in the eye by a teammate.  Immediately after the injury he experienced blurry vision, but he felt his vision improved over the following days.  Several weeks later, the blurry vision returned and that is when the detachment was found.  Since his surgical repair, Echenique has returned to the court wearing protective sports glasses to prevent further damage to his eyes.


I can't say enough how important it is to wear eye protection during sports.  I know most athletes don't wear protective glasses, but especially for young children a stray finger or ball could result in reduced vision for the rest of their lives.  It is so important to have a dilated eye exam if you do suffer an ocular injury.  Every athlete should be told the signs and symptoms of a retinal detachment.  They are

• flashes of light
• sudden onset floaters
• dark or blurry vision, like a veil or curtain obstructing your sight

Ok, I love this picture of Richard Howell.  He hardly ever smiles!

For those that don't know, I have a wonderful sister who I stole the idea of going to optometry school from.  She is fixing to take National Boards Part 1 next week.  By the way, I know it is extremely southern to say "fixing to" but I am doing it anyway.  It seems like decades since I sat down for the grueling Part 1 marathon, but it was really only 2 years ago.  I'm not going to remember it any better in the future, so here is my top advice for student doctors.

1) Study.                                                    

KMK has great online features to aid studying as well!

No, really.  It is kind of "common" knowledge in the optometry world that you need to study for Part 1 for about 3 months.  This test is going to challenge you with questions over EVERY subject you have had in school thus far, and on some things you probably have never heard of.   I didn't get the KMK study guide, but I had a lot of friends that did and I ended up being very jealous.  If you are super motivated, you can just use all the notes from all the classes you have ever taken as a study guide.  Or you can drop a couple of hundred dollars for a KMK guide to have it all streamlined with memorization tips and practice questions in one place.  It is worth your money, as much as a spendthrift like me hates to admit it.


2) Focus on high percentage topics
That means don't spend a ton of time on topics like contact lenses and binocular vision that are less represented on the test.  If you have had these classes recently, and you see that the topics aren't covered with a lot of test questions in the topic breakdown, you can spend the least amount of time studying for these.  Prioritize and study smarter, not harder.  The contact lens cases I had were very straightforward, so don't worry about having to perform crazy calculations.

3) There will be questions that you have NO idea what the answer is.
You may find yourself saying, "I never learned anything about that in class!"  This is normal, and I guarantee that everyone in the room with you is thinking the same thing!  Don't let it worry you; you aren't going to know the answer to every question.  That is why it is multiple choice.  Regardless of what the NBEO thought my year, I didn't have a class that told me the appropriate decade of life to recommend a flu shot.  So I just made a guess, and moved on.

4) 1 Week Before the Test

Truth: I have ray traced exactly 0 times since NBEO Part 1.

Work math problems.  Optics and contact lens calculations will be on the test, so don't miss easy problems like converting to plus cylinder because you aren't fresh on your formulas or math facts.  If you haven't thought about math in a while, it is good to run through some sample problems to brush up your skills.  The test is timed, so thinking fast is important.  If it takes you 10 minutes to work a math problem, things might get hairy on test day.  On optics problems, some people would rather do a quick ray trace than rely on straight memorization, so if you feel confident in your ray tracing skills it can save a lot of brain space for other formulas and lists.

5) The Night Before the Test
Don't try to flip through your entire KMK book again!  My best advice is to go through lists, formulas, and mnemonic devices.  Hit the big, high volume material.  Optics formulas were the thing I drilled most the night before.  I recommend writing the most common ones on a sheet of paper, and looking at that paper repeatedly until you can picture it with your eyes closed.  When you are allowed to start the test, some people prefer to jot down quickly all the formulas floating in their brain before they even read question one.  Hey, if it helps, go right ahead.

6) Time is not your friend
Don't mull over a question; skip the one you are struggling with, star it, and move on.  If you have time at the end of the session, go back and ponder your starred questions again.  If they are calling time and you don't have an opportunity to reread your marked questions, you can at least bubble in a random answer on your skipped ones.  Getting through the test is very important!  Don't get stuck and miss answering questions you could easily have gotten right if you had had enough time to answer them.

7) Don't try to compare your answers afterwards
It will drive you mad!  People love to discuss, but if you are one of those people that gets worried easily, skip the student circles that invariably form after tests.  If you don't answer the questions the same as your friends, it doesn't mean you failed.  You will NEVER know who got what questions right, so don't worry about it.


GOOD LUCK!

First off, I don't want anyone to think that I am picking on Acuvue as a company.  I wore Acuvue 2's very happily until I got to optometry school.  And I thought I was supposed to wear them for a month at a time.  I was just like so many of my patients, overwearing my lenses due to poor information.  This post is for all of those misinformed people like my younger self, who may be permanently harming their eyes by incorrectly wearing their contact lenses.

IS ACUVUE 2 A HEALTHY LENS?

Yes, when worn properly.  If you dispose your lenses every 2 weeks, and do not sleep in them, then Acuvue 2 can be a perfectly healthy lens.  Remember, the cornea gets all of its oxygen from the atmosphere, so contact lenses must allow oxygen to pass through.  The amount of oxygen passing through to the cornea in an Acuvue 2 lens is 33 Dk/t (this is a unit describing the rate of oxygen passing through the lens).  Newer lenses (like Biofinity, Acuvue Oasys, and Air Optix Aqua) have Dk/t values over 100!  So as you can see, Acuvue 2 lenses have significantly less oxygen to the eye than newer products.  To be safe for overnight wear, studies have shown that lenses have to have at a minimum of 80 Dk/t (and even this shows some signs of corneal swelling the next morning).  This means Acuvue 2 lenses are absolutely not healthy to be slept in!

WHY DID MY DOCTOR MAKE ME CHANGE BRANDS FROM ACUVUE 2?
There are 2 reasons that I switch a person from a brand they like:
1) They are overwearing their lenses past the FDA approved wear time.  If you are sleeping in your lenses or want to wear your lenses longer than 2 weeks, we have to change to a different contact lens brand and material that is approved and healthy for that amount of wear.
2) They are suffering from damage to their cornea.  Some people can wear their lenses correctly, and still have consequences from poor oxygen flow to the eye.  Any time I see corneal neovascularization (the growth of blood vessels into the cornea, which is supposed to be a clear tissue) I know that the cornea needs more oxygen than it is getting.  Contact lens acute red eye, giant papillary conjunctivitis, and corneal scars are other indicators.  See this post for more information.

Corneal Neovascularization: it looks like chronic redness in the mirror, but under the microscope your doctor can see individual anomalous blood vessels that have entered the clear tissue of your cornea

I HAVE TRIED OTHER LENSES, BUT NOTHING FEELS AS GOOD AS ACUVUE 2
I hear this all the time from my patients.  Acuvue lenses are VERY comfortable, and it can sometimes be hard to find a lens that feels as good.  Lenses that have more oxygen to the eye are generally made of a different material called Silicone Hydrogel.  In some patients, this material can cause more depositing, making vision more blurry through the day than when they wore their old hydrogel lenses.  This only happens to a small percentage of patients, but it is a definite possibility. Almost every patient will experience some "tingling" sensation within the first month or two after changing lenses, but this is actually a good side effect.  This tingling means that the cornea is being stimulated by the extra oxygen, and the damaged corneal nerves are regenerating.  If you can make it through this transition period, the new lenses are going to be comfortable and more healthy.

TAKE HOME POINTS:
Acuvue 2's can be healthy lenses when worn properly.  This means NO sleeping in the contact lenses, and throwing them away every 2 weeks.  If your doctor sees signs of corneal damage, a change in lenses might still be necessary.  As an optometrist, I want to reassure everyone that we don't have a grudge against your lenses, we just have seen the complications from unhealthy contact lens wear and don't want to see that happen to you!

UPDATE: 
Many of you may have noticed that back in the early 1990s when Acuvue 2 was FDA approved, it did get overnight wear approval as long as the lens was thrown away every week.  That means if you slept in the lens, you had to throw it away after 1 week of wear, not two. Since that time, multiple studies have shown that a lens like Acuvue 2 has too low oxygen transmission (Dk/t) to be safely worn overnight without causing corneal edema (swelling). Doctors no longer recommend any overnight wear of this lens, and instead recommend Acuvue Oasys with weekly disposal if you prefer sleeping in an Acuvue lens.

Dry Eye Syndrome is a nagging, disruptive condition that a large percentage of patients suffer from.  I know I have been dedicating a lot of posts to this topic, but there is still so much to cover!  For example, most of my patients are very aware of how their work environment or their contact lens routine contributes to their dry eye complaints, but medications that you are taking on a regular basis can have an equal, if not more pronounced, affect on dryness!  That's one of the many reasons that when you go to an eye doctor they inundate you with questions about your overall medical history.  I can look at a patient's medication list and quickly pick out offending meds that are making their dryness more unbearable.  Here are the most commonly used culprits:

This patient's meibomian glands are not even visible due to scarring from chronic dry eye.  Photo courtesy Optometric Mangagment