I never suspected my most popular post on Eyedolatry all time would be a short segment on NBA players wearing glasses.  (Click here to access the post that sparked my realization of the original eyewear obsession).  Fortunately (or unfortunately in some player's cases) the trend for the NBA's top players to sport the latest eyewear fashions is rolling full steam ahead.  Here's the latest look at some of the top eyewear sported in this year's playoffs so far:

Paul Pierce


The Celtics star gave a post-game interview in these large rimmed zyl frames.  My verdict: these frames are much too large.  Look at all of the excess space between the side of Pierce's head and the outer rim of the frame.  If you see more air than face, this is a big indicator that your frames are too large.  Even when purchasing oversized frames for the "geek" eyewear trend, it is still best to get a deep frame (which will give you that oversize look) that actually fits your face for a tailored appearance. For more information on properly fitting  oversize "geek chic" frames to your face, please visit this post.

LeBron James
James has been photographed in glasses so many times, but honestly, there's a reason he is the poster-child of this trend.  He knows how to wear these glasses.  His frames fit his face; his eyes are perfectly centered in the lenses both horizontally and vertically, and there is no excessive air visible between the line of his face and the edge of the rim.  Somehow he gets it right every time!

Kevin Durant
Durant (pictured here on the right) actually does a great job with his glasses as well.  Let's ignore his less fortunately styled teammate to the left for a moment, and focus on the fit of Durant's frames.  They are sized appropriately, and  they appear to be well-centered even when we are viewing him from this angle.  The color of the frame is a little washed out, but clear and caramel colored plastics are having a major moment right now, despite being very difficult to wear.  Overall a good job.

Russell Westbrook
Let me start with this photo from Westbrook's own facebook page.  I admire his willingness to take fashion risks (and what is fashion but one risk after another anyway?) but these frames are really not helping anything.  Again, they are WAY too large, his eyes are positioned very high in the frames giving too much excess lens inferiorly, and with his round face shape, a round rimmed frame is never going to be the best choice.  (See this post for more information on better options for round faces)

Does Westbrook (or any of these NBA players) actually need glasses?  Definitely not in Westbrook's case at least.  Here is an excerpt from a "Daily Thunder" interview (courtesy http://blogs.thescore.com/tbj/2012/05/15/russell-westbrook-talks-fashion-ive-been-knowing-how-to-dress-for-a-while/)

Reporter: Your wardrobe last night drew national attention. I loved the glasses. Where’d you come up with that style? 

Westbrook: I’ve been wearing glasses all season. I think last night was probably just the night they finally seen it.

Reporter: Now why no lenses in the frames? 

Westbrook: I see better without ‘em.

Reporter: So why wear ‘em at all then? Just a fashion statement? 

Westbrook: There you go. 

Reporter: Where’d you get the idea? 

Westbrook: I’ve been knowing how to dress for a while.

Well, I think that last comment has sparked quite a bit of internet debate, but I am definitely not qualified to judge overall fashion statements.  Let me stick to glasses.


Compare Westbrook's (right) to Durant's frames here.  These frames aren't terrible, but again, too round for his face.  A frame like Durant's that is slightly more rectangular in shape would be much more flattering.  Conversely, Durant's face shape is much longer and he could wear a round frame like Westbrook's more easily.  Just some nuances of the glasses world.


And to the right we have Westbrook's now infamous "Gone Fishing" ensemble.  I'm not going to give any serious critiques here because that would be positively ridiculous.  I am still a big fan of red frames in case anyone is wondering.  The point that I respect about Westbrook's glasses choices is that he is obviously just trying to have fun.  And I think any celebrity encouraging the world that glasses are fun and stylish is a great thing to do!

So in my first year of practicing, insurance billing has been the biggest learning curve I have faced.  They try to prepare you in school.  They try to prepare you at your externships.  But the problem is that billing and coding seem to be changing every couple months.  Here is a review of the latest coding conundrum I have faced:

Insurances for Medically Necessary Contact Lenses
First off, not all insurances are going to offer any coverage for contact lenses.  With time and experience, you will learn which insurances reimburse anything.  So far I have successfully filed to VSP, Eyemed, and Superior Vision for visual conditions that require contact lens correction.  Medical insurances like Blue Cross are not going to cover anything for vision correction.   Medicaid (at least in NC) will offer some base level of reimbursement if filed correctly.  On the contrary, if you have a corneal abrasion or another condition where a bandage contact lens is appropriate, medical insurances like Blue Cross WILL offer coverage and vision insurances will not.

Medically necessary contact lenses for post-RK

Not all vision insurances cover medical contact lenses for vision correction to the same amount of reimbursement. Some insurances will reimburse cost of lenses and evaluation fee.  Some will only give a certain amount of dollars to be applied toward eval or lenses.  Just remember, if you are going to try to bill for contact lenses, do NOT use the patient's insurance benefits towards glasses.  Once the insurance has been used, they won't provide for anything else.

What Conditions Typically are Covered
Again, different insurances have different guidelines, but here are the most commonly accepted reasons for medically necessary lenses:

• Keratoconus, pellucid marginal degeneration, or a corneal degenerative condition where vision improves in contact lenses versus glasses
• High anisometropia (usually there are guidelines about how much, typically between 3D and 5D minimum)
• Condition where best corrected vision improves by at least 2 lines with use of contact lenses versus glasses (this includes high refractive error conditions)
• Bandage contact lenses for treatment of ocular surface conditions (this is typically with a medical office visit code and is billable to medical insurances, unlike the previous items)

Synergeyes ClearKone lens is a great option for medically necessary keratoconus correction

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.