I know I don't need to convince anyone why daily soft contact lenses are often the best option for comfort and convenience for the average patient.  No solutions, no cleaning, no storage.  Sure you have a lot of packaging, but dailies are ideal for people who want to spend basically no time worrying about their contact lenses.  Here's a breakdown on how I have made dailies a large part of my practice:

A new study out of Tokyo published in this month's American Journal of Ophthalmology (link here) reports that caffeine may improve tear film secretion.  The true implication for dry eye treatment gleaned from this study's results are obviously in their infancy, but here is a breakdown of what researchers have found:

Pictured in blue is the layer of tear film that coats the surface of the eye,  The tear film meniscus is the  thickness of tears measured at the lower lid margin.  In a patient without dry eye, the tear film meniscus would be greater than 2 mm.  Picture courtesy University of Oxford

There's nothing like the promise of color to brighten up an overcast day of April showers.  Summer will be in full swing before we know it, so it's definitely not too soon to be accessorizing your summer wardrobe.  If you prefer to shop local for your sunglasses (prescription or non-Rx!) you might be surprised that the best deals are sometimes found at a local optometrist's office. I know in my area sunglasses are being heavily promoted this month, so take advantage of your local deals.  $100 off promotions or free lenses with the purchase of frames deals are all over right now.  If you have vision insurance and aren't wanting to get new ophthalmic frames or contact lenses this year, remember that you can use your insurance benefits (on most plans) towards Rx suns as well.

Perfect Vintage inspired shades in a rose fade with Velvet "Joie".  Retail listed $159

Ray Ban's are beyond bold this season in multi-hue and print options.  They are even coming in florals!

Preppy in Pink with Lacoste

Anne Hathaway in red--can't find the designer of these shades though!

Last week I had the benefit of attending a presentation on the most up to date recommendations for fitting the Synergeyes lenses.  For new ODs out there just getting familiar with this lens, I have been promised that this new method can simplify your fitting time to around 15 minutes on the initial day and 1 to 2 follow-up appointments.  Believe me, this is considerably less chair time than what it has been taking me to perfect the lenses since I began fitting larger numbers of patients in December.

Here's the idea:  Mid-K fitting.  To summarize the words of Dr. Beatty (who gave the presentation), "fit the RGP like a hard lens, and the soft skirt like a soft lens."  Makes so much sense...

1) Determine K's, then find the average K value (mid-K value).
I usually just use my autorefractor and average the K's from flat and steep.  Remember, in order for this lens to work you can't have more than 1 diopter of residual astigmatism, so K values and corneal cyl are really important to evaluate before even opening your trial set.  I was told that if the patient has less than 1 diopter of corneal cyl, you should add 0.50 D to your mid K value.

2) Use the Synergeyes conversion table to select the appropriate base curve for your Mid-K value.
Find your mid-K, go across the table to find the base curve in radians.  Remember, the Synergeyes lenses only come in a few base curves (7.9, 7.7, 7.5, 7.3).  Round your conversion value to the nearest available base curve.  Example: if your K value gave you 7.46, select the 7.5 base curve.

3) Insert the appropriate lenses on each eye, using the medium skirt curve.

NaFl staining should look like this, but it pretty much always does unless you are really off on base curve.

For first time wearers, it works best for you to insert the lens yourself.  I have found that fluorescein really doesn't tell you much on these lenses unless you are super flat or steep, so I would skip that step if you feel comfortable looking at RGPs with a slit lamp.  To save on time, have your tech insert the lenses for you.  You need to let the lenses settle at least 10 minutes before evaluating to truly judge the fit.

4) Over-refraction
All the fitting set lenses are a -3.00, so you have to over-refract to find the correct power to order.  Patient will tend to want to overminus you in this lens, so make sure you fog well, or do retinoscopy.  Your final lens should be within -0.50 to -1.50 more minus than the spherical spec Rx.  This is different from the original fitting recommendation, allowing more minus!  It has been recommended that you let your patient wear the trial frame of their Rx around the office before they leave so they can see what their distance and near vision will look like.

5) Slit Lamp Evaluation
Waiting that 10 minutes is going to help you evaluate the soft lens skirt to make sure it is not fitting too tightly.  Originally, the Synergeyes lenses were recommended to be fit with a steep skirt when comfort or vision problems arose, but we now know that movement of the lens between blinks is essential to fit and comfort.  If you have a medium skirt on the patient and you don't see movement with blink, then you need to order a flat skirt.  Changing the skirt should not influence the over-refraction.  I have seen patients come back a week after their initial lens was dispensed with a ring around the cornea from the skirt fitting too tight, so make sure the lens is moving!  It will only get tighter as it dries out during the day.

6) Duette Multifocal Add selection

Ghosting creates almost a "3D" view for near This is normal with this lens

For presbyopes, there are 2 add powers available: small and large.  The new method recommends starting with small adds in both eyes.  This is especially true for early presbyopes. If near or computer vision becomes an issue, try going to a large add on the non-dominant eye. I was told that a large add in both eyes is really reserved for late presbyopes.  I think this is different from original recommendations as well. Educate your patients to expect to have that "shadowing" or "3D ghosting" effect that so many multifocal wearers describe.  If you prepare them for it, they won't think of it as a problem inherent to a bad fit.

7) Insertion and removal
Check out the company's videos here
Always fill the bowl of the lens before inserting.
Best to insert the lens with your face parallel to the floor.
Remove the lens by pinching the soft skirt between your fingers below the center of the lens, and then lifting up and out to break suction
Use Biotrue or Aquify solutions.  Clearcare for heavy depositors.  See this post for more info.

Over the counter drops not relieving your itching, watering, redness, and swelling? A prescription strength drop is much more effective at knocking out moderate to severe allergies.  For contact lens wearers, OTC drops and their frequent dosing schedules are just not practical.  A once daily prescription strength drop will be much more effective for these patients, and less disruptive of their daily routines.  Here's a breakdown of the available ophthalmic drops; how often to dose them, and what, if any, side effects to expect.


TOP OF THE LINE ANTI-HISTAMINES
PATADAY: Fast relief, good medical coverage so the copay tends to be reasonable
Dosage: 1 x Day
Side Effects: None commonly reported.  Do not use on top of contact lenses.
Also available is the weaker concentration Patanol, that is dosed 2 x daily instead of once daily.


LASTACAFT: Fast relief, studies show that patient's get relief within 5-10 minutes of dosing
Dosage: 1 x Day
Side Effects: None commonly reported.  Do not use on top of contact lenses.


BEPREVE: Fast relief, can also give some minor nasal symptom relief as it drains down the back of your throat from the eye.
Dosage: 2 x Day
Side Effects: Can have a metallic after taste in some patients.
This drop comes in a much larger bottle than the prior 2, so it offers some financial advantage.  For milder symptoms, it can be used just once daily.



GENERIC ANTI-HISTAMINES: Prescription strength, but budget friendly.  These are older drops that are still effective, but need more frequent dosing than above.

EPINASTINE HCL: Also known as ELESTAT
Dosage: 2 x Day

AZELASTINE: Also known as OPTIVAR
Dosage: 2 x Day


SOFT STEROIDS: For patients suffering from severe allergic reactions with marked chemosis (swelling), you can't beat a steroid.  This is really effective for patients with a contact lens induced allergy like Giant Papillary Conjunctivitis.

If the eyelids look like this, you might want to use a steroid for faster resolution of this follicular reaction

ALREX: Loteprednol 0.2%
Dosage: Anywhere from four to once daily.  I typically dose twice daily unless the allergy reaction is very severe and I think four times a day is necessary.
Instructions:  SHAKE WELL.  This is a suspension, so you need to shake several times to adequately mix the medication into solution.
I typically keep patients on this drop for 2 weeks to 1 month, but in lower doses it is safe for longer term use.

FML or LOTEMAX OINTMENT: 
Dosage: 1 to 2 times daily
Lotemax has a higher safety profile, but FML ointment is still a low strength steroid.  Neither are generic, and an FML ointment Rx can have a copay as high as $60.  For really chronic follicular reactions, the contact time of an ointment can truly make a difference.  Obviously, like all the drops listed in this post, do not insert when wearing contact lenses.

Ready for another fashion post?  I've already posted about my disappointing airline miles turned magazine subscription experience, but a current issue of Glamour did have a great picture of Revenge's Emily VanCamp sporting a great pair of geek chic glasses.  Need a refresher on geek chic?  Check out this post:  Geek Chic Glasses.  The photo made me stop and admire just how much glasses are a part of fashion right now.  And for the first time, it's not just sunglasses that are fashionable, but actually everyday wear ophthalmic frames.  Heck, I have patients getting plano (zero power) glasses just to have frames for style.  That scenario is not very often, but any time this happens is more than historically.  Ophthalmic frames are a legitimate fashion accessory, so let's all stop and bask in the glasses glory.

Librarian inspired styling Via Glamour.com

Robert Marc 251 (above) and 252 (below).  I own 252 in  "jungle" green, and the fit is great!  My face is a difficult shape for glasses, so I was really pleased with  the versatility of this frame.

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