Who would have known watching the NBA All-Star game I would have been surrounded by glasses fashion?  The "geek chic" look (reference this post) has reached new heights, and is being fully embraced by two of Miami's Big Three.  You have to wonder with so much exposure how much longer this trend can last, but it is definitely still going strong right now!

Dwayne Wade and LeBron James love eating hot dogs together while wearing nerd  chic glasses

Close up of James' Dita frames.  They do fit his face quite well so congrats to the optician for getting this look right!  Remember, the glasses are supposed to be big, but you still want your eyes well centered in the frame.

If you have dry eye, at some point your doctor has probably mentioned Restasis.  I was recently told that Restasis is the most commonly prescribed pharmaceutical eye drop, and that statement doesn't surprise me in the least.  For patients suffering from dry eye, over the counter artificial tears are not always enough to relieve the signs and symptoms of dryness.  If you are having to use over the counter artificial tears routinely more than four to six times a day, then you are in need of more advanced intervention to treat your dry eye.  Restasis is the next step for many doctors, but there is a lot to understand about this drop.

1) When to use Restasis
Depending on who you ask, you are going to get different answers to this question.  Personally, I always treat meibomian gland issues (see this post) first with a combination of warm compresses, lid hygeine, and artificial tears as needed. If the glands start responding to treatment and the patient still is having complaints (dryness, watering, grittiness, sharp pain, etc), I offer punctal plugs or Restasis as the next therapy line.  You will have some doctors tell you that Restasis is best used on post-menapausal women, but I have seen it be effective in men as well, and there is no scientific evidence as of yet to limit the use to a certain population base.  In short, if tears and MGD treatment isn't resolving things, it is time to consider Restasis.



2) How Restasis Works

Vials come in trays, with 1 tray equal to 2 weeks technically, but really this amount will last 1 month if you recap.

I asked this question to my Allergan rep just last week, and he just gave me the simplest answer: "we don't know yet."   What we do know is that Restasis is cylcosporine (a potent anti-inflammatory that has been used in organ transplants in a different concentration).  The goal of this anti-inflammatory is to stop the production of T cells which are inflammatory mediators that are naturally in your tear film.  Chronically dry eyes have these T cells in higher concentration than normal eyes.  Point of interest: the T cell has a lifespan of 180 days, so Restasis should take 3 months to begin to effectively work.  Restasis also helps increase the production of tears, but how this happens is not effectively understood.

3) How to Write the Rx
Allergan provides an Advantage Pack with a card that can be activated for savings on the patient's copay.  This card doesn't work with Medicaid plans unfortunately.  In order to use this savings card, you have to write the Rx for 6 trays/90 day supply.  This is the most cost effective way to write this Rx for your patient!

4) What to Tell Your Patients

• Restasis is to be used twice a day.  Every day. 
•  It burns when it goes in and this is normal for this drop.
• It may take 3 to 6 months for this drop to reach full effectivity.  Some patients may notice relief as early as 3 weeks.
• Because it takes so long for Restasis to become effective, some doctors will start treatment with a more potent anti-inflammatory such as Lotemax dosed once or twice daily for a month.
• Your pharmacist's directions will tell you to throw the vial away after 1 use.  Do not do this.  Recap your vial after your morning dose and store in a clean environment, then use it again for your night time dose.  This will make the 3 month supply your doctor wrote your Rx for really last 6 months.

Recap your vials to get a full day's use (two drops per eye)

Synergeyes Duette is a RGP in the center for great optics, surrounded by a silicone hydrogel skirt for comfort

You can probably tell from my previous posts (here, here, and here) that I have really been incorporating the new Synergeyes Duette lenses into my practice.  Unfortunately, they haven't always been the easiest lenses to fit.  I was seeing patients back 3 or 4 times (or more!) over a period of 2 months to get the vision and fit comfortable for some patients.  The lens would look great, I was following the fitting guide, but my patients were getting variable results.

Then came the break through.

If you are going to fit Synergeyes Duette lenses, don't follow the fitting guide.  At least, not the one they gave you initially.  I was told earlier this week that the fitting guides are being changed and redistributed, so if you have a trial set in your office this new information will be available soon.  The original fitting guide had you fitting lenses based on flat K, over refracting, and then maybe going to a steeper skirt curve if the distance vision still didn't seem sharp enough.  Sometimes it worked; sometimes it bombed.The new fitting technique is straight forward and makes a lot of sense.

Step 1:  Get the Patient's K readings and find the average K value.




You can use a topographer (left), your autorefractor, or a (gasp) keratometer for your K readings.  If you are fitting this lens, the cornea should be pretty regular, so using the autorefractor K's should be good enough in most cases.









Step 3: Round your Base Curve to the nearest available Synergeyes Base Curve (they only offer 7.90, 7.70, 7.30, and 7.10)

Step 4: Insert the trial lens in the Median Skirt curve and Over Refract -- make sure you are within +/-1.00D of the spherical glasses correction!  Remember, you need less than 0.75D of residual astigmatism (just like any other RGP) to make this lens work.  I have been told it can handle up to 4.00D of cyl, but I haven't tried that high.  If your over refraction isn't within that 1.00D target, your base curve probably needs to be adjusted.  Just SAMFAP to tell you which direction to go.

Step 5: Order.  You can still adjust skirt curve for comfort (steep and flat options are available).   And in the multifocal lens you can use a large (better for distance vision) or small (better for near vision) add zone to improve vision.  I will say that basically every lens that I put on a patient looks like a good fit, so using fluorescein hasn't been that helpful.  Judge going steeper or flatter based on patient complaints.  Also, there is very little movement of the lens if the fit is too steep, so make sure to check that out. Little tweaks from your original fit should be all that is needed!


I am just now incorporating this method into my office, but so far it seems to make a lot of sense!  Please post if you are having any problems or any advice for other ODs out there fitting this lens.  Overall my patients do really like the vision and comfort in this lens once we get the fit correct.  Hopefully with this new method, finding the right fit will be a lot less time consuming.

Ernest Hemingway sporting the "old reliable"  metal rim frame Undeniably unstylish

Now that I am practicing at my own office, I get all sorts of surprise optometry mail.  It's one of those new OD perks that is still exciting to me. "Oh you want me to read this?  You are trying to inform me about this product? " Wonders never cease. Friday I received a flier advertising the new Ernest Hemingway Collection eyewear line. Let me tell you, I love some Hemingway.  A Farewell to Arms is my favorite book.  But Mr. Hemingway wasn't exactly a glasses style icon (check out the photo left as proof).

Popular black and white combo that fashion forward men are daring to try these days

Round frames are difficult for men to wear, but there is also a women's line with the collection offering more delicate options in the same dark/tortoise color family

And you can get them in sunglasses!

The Sun Also Rises was originally published as Fiesta.  Who knew?

Back in July, I wrote about the potential use of retinal photography in the early detection of Alzheimer's Disease in this post.  At that time, research had just been published showing a correlation between narrowed arteriole lumens (which can only be seen by a doctor during a retinal exam without cutting into the body!) and individuals with Alzheimer's.  Utilizing retinal photography in this way is still in its infancy, but new studies are emerging all the time supporting comprehensive eye exams as a potential source of early detection.

Brain tissue imaging depicting anomalous amyloid proteins

In a study by Susan Stark at the University of Washington, 125 individuals of "normal cognition" with an average age of 75 were asked to record the number of falls they suffered over a period of 6 months.  Brain scans were performed on all study participants looking for amyloid beta plaques (a calling card of Alzheimer's brain damage), and it was found that the risk of falling was 3 times greater for every unit of amyloid plaques found!  What does this have to do with eye exams? While we aren't the only doctors that treat people after a fall, we do see patients on a regular basis with injuries around their eyes from falls.  Additionally, patients discuss with their eye doctors at their annual exams if they are having dizziness or falling because they often attribute this imbalance to a problem with their glasses.  People suffering or complaining of frequent falls traditionally are referred to their primary care doctor to be screened for blood pressure issues, but these new study results support screening for signs of dementia as well!

As I mentioned earlier in this post, one of the most important aspects of your eye exam is screening the health of the retina.  It is so important because it is the only place we can look at blood vessels and nervous tissue without invasive procedures!  Ongoing research by Dr. Lee Goldstein at Boston University and the company Neuroptix is trying to utilize our easy access to the eye by developing a laser scanner to detect amyloid proteins in the eyes.  According to Dr. Goldstein, the presence of amyloid proteins (which form the brain plaques) can be measured in the lens of the eye (the structure where cataracts form, which is also entirely comprised of proteins).

Retinal Photography gives a high-definition view of the optic nerve (center) as well as the retinal arterioles and venules which aids in detection of hypertension, diabetes, and potentially even Alzheimer's!

Early detection of amyloid plaques and misfolded tau proteins has captured the medical community, and new research is being published almost daily.  Most recently, we are learning that these anomalous tau proteins are found even in young people that are suffering traumatic brain injuries, such as football players.  Most recently investigators found the proteins in the brain of an 18 year old football athlete who had suffered multiple concussions.

Anomalous proteins in the brain of an 18 year old football player; image courtesy link above

We are only beginning to understand this disease, and there is a lot of research yet to come before detection of Alzheimer's in its earliest stages is possible.  What we do know is that routine health care, including eye exams, is our best option for catching health issues in their earliest stages.  So even if you don't need glasses, remember it is really worth your time to have a comprehensive examination!

Punctal plugs are a concept that sounds quite scary when presented to a patient for the first time, but could have a number of benefits for multiple ocular conditions.  A new article by Review of Optometry features all of the unsung potential uses for plugs.  For a treatment once thought out of date due to the advent of Restasis, more and more doctors are returning to plugs for helping their patients achieve relief from dry eye.  Now we are finding new applications for this quick and painless procedure!

Properly inserted permanent plug

DRY EYE 
We recently discussed punctal plugs and their benefits for patients with dry eye, and Dry Eye Syndrome is still the most popular use for these devices.  Punctal plugs prevent rapid drainage of your own tears through your nasolacrimal tear duct, keeping a healthy layer of tear film on the eye for a longer time.  I especially prefer plugs on patients where there is minimal to no meibomian gland dysfunction and:

• Contact Lens Wearers with poor comfort due to dryness
• filamentary keratitis from advanced dry eye
• pre or post-op LASIK --- a healthy tear film will improve comfort and post-LASIK visual outcome!

Nothing beats flipping through some mindless magazines when your brain needs a little time to relax.  I just used some frequent flier miles that were about to expire on a few magazine subscriptions since I didn't have enough for an actual flight.  The choices were limited, so I got a year's worth of Elle magazine.  I have to say, I was pretty disappointed with the contents inside, but I did love their Spring Pastels photoshoot.  Still in the thick of winter here, but the days are warm enough for me to hate those red and green sweaters in my closet and want to pull out anything I have in the new spring pallete.  The trend for sunglasses this spring is definitely all about pastels, so look for pinks, light teals, and pale yellows to compliment your softer, lighter wardrobe.

Cutler and Gross: embracing the Cat Eye shape from last summer/fall with a  fresh yellow for spring

Stella McCartney in Pink and White

Apparently  a recent episode of 90210 was sponsored by RayBan, complete with their new pastel Wayfarers

Pink Wayfarers.  This looks a little too Malibu Barbie for me, but to each their own

Let's face the facts; women report dry eye symptoms more frequently than males in the same age group.  In a study by the American Journal of Ophthalmology, 7.8% of women over 50 report dry eye, versus only 4% of polled men.  The theoretical culprit?
As women go through menopause, androgen levels appear to drop, causing a range of side effects.  In the ocular world, the result is a significant reduction in the production and secretion of tears. We need tears constantly to keep the eye lubricated; these baseline tears are necessary for clear vision and comfort.  Reflex and emotional tearing are a different etiology, and are not the type of tearing we are discussing. Menopause isn't the only time imbalanced hormones wreck havoc on the eye in women; we can also see significant dryness and vision changes during pregnancy!

Treatment Options
If artificial tears and gel drops aren't offering enough relief, there are some more aggressive options to try.  When I prescribe tears for this population, sometimes an artificial tear with supplemental natural tear components like growth factors can be more beneficial than the standard OTC brands.  Viva drops are my favorite tear drop when I am trying to supplement missing components of natural tears.

In this patient population I also really like Restasis.  It tends to perform well in post-menopausal women, and I know some doctors that prescribe it strictly for this population.  Restasis increases tear production by reducing inflammatory mediators that cause poor tear film performance.  Remember, Restasis is a twice a day; every day drop, and sometimes it can take as long as 3-6 months to get relief.  Sometimes when initiating Restasis it is a good idea to pulse with a stronger anti-inflammatory like Lotemax until Restasis has time to get into the system.  Patients are less likely to give up if they see some relief!

A less common treatment involves direct hormone supplementation.  In this 2003 study, Dr. Connor of SCO fame offers testosterone cream as an effective option.  He recommends applying 3% Testosterone Cream twice daily to the eyelids.  No insertion into the eye itself is necessary.  Interestingly, estrogen supplementation is not found to be effective. The extra testosterone helps to counteract the androgen deficit found post-menopause.  After just two weeks of treatment, he reported 50% of patients had improved signs and symptoms.  I haven't prescribed this myself, but in the future if a patient is willing to try, I might have some case studies to report of my own.

At the beginning of January I was lucky enough to get my own office, and these past few weeks have been a flutter of activity.   My life has been awash in excitement and decision making and new responsibilities.  And every few days I have the great little milestones that invariably result in a little "geek out" moment.  Like the first time my diploma and license went on the wall (luckily someone else hung them for me).  The first time my name went on the door (even though it was in removable sticky letters -- I think that must be standard but stickers do seem so fleeting).  The first time the office letterhead got my name as a standard feature.  The first time I got the stamp that had my signature emblazoned so I don't even have to pick up a pen most days what with electronic medical records and my new tablet!

All my diplomas framed and hung!  It is incredible how big the state license (top right) is when you compare it to an undergrad degree (top left).  I guess the size directly correlates to the amount of stress and tears required.

With all these firsts, I decided it was about time to start making my small office into a nice homey atmosphere to write letters/finish my charts/call RGP companies and reorder lenses...again.  So I embarked upon a little project inspired by Pinterest.

My Inspirations:

Simple bulletin boards are dressed up with picture frame borders.  It's amazing how much better this looks than just slapping a cork board from Wal-Mart on the wall.

Even better, you can cover your corkboard with fabric for a  hanging surface  almost too pretty to use.

My Office Project: Unfortunately I am a notorious spend-thrift (that's the nice word for it), so instead of splurging on expensive frames, I decided to tackle my own "do-it-yourself" project that was fast, easy, and of course cheap.

So this is the wall of my office where I decided to remove the old standard bulletin board and replace it with cork tiles for posting important notes and info.  The hanging files underneath are nailed into the wall and a remnant of the previous OD, so I had to work my design around their positioning.

What I used: 

• Mirror from Target, just $19.99!  This is great for after lunch when you need to check your teeth before going in with a patient.  Or to help your hair after one to many rounds with the BIO.

• Cork Board Tiles from Michael's; set of 4 that are 12 x 12 for $13.  They are about 4 inches thick and made of a dark, rich looking cork but I did have several issues.  They come with sticky adhesives for easy attachment, but within a few days they were falling off the walls.  The issue has since been resolved with my handy glue gun since I don't get along well with nails.  My other complaint is that they leave a brown residue all over the walls, so every time they fell I had to do wall clean-up too.  

I would love to get more ideas about making my small, windowless office more appealing so please post advice!

I don't know about you, but one of my favorite pastimes of winter is looking forward to spring.  The runways are promising bright and bold colors, and of course top designers are incorporating these trends into their glasses lines too.  Here are two trends all over the runway that have made their way into the world of eyewear.

Cutler and Gross Pink Sunglasses

NEON   You can find neon yellows, greens, and pinks in numerous spring lines, and if you really want ophthalmic frames that stand out from the crowd try a bright yellow!  This is a difficult trend to wear, so most people will find they prefer trying it in sunglasses.  Pink sunglasses are popping up with several designers and look to be quite popular for the spring!

Peter Som collection via Marieclaire.com

Lacoste in vibrant yellow

We've been talking a lot about Dry Eye Syndrome and its causes and treatments, so I thought it was about time to address punctal plugs!  When my patients can't get relief from their dryness symptoms with artificial tear drops, I always suggest we try either Restasis or punctal plugs as our next option.  Restasis is a prescription drop that improves production of the patient's own tears.  There are some drawbacks however.
Restasis is:

• expensive; most insurances have high copays 
• time consuming; it is dosed twice a day every single day, potentially forever
• takes time to work; in some cases it can be as long as 3 to 6 months before the drop reaches optimum performance

Collagen plugs insert fully into the puncta and are not visible to the patient.  I use Eaglevision Durasert plugs most frequently of this type.

Permanent plugs: I find that the Parasol plugs are very easy to insert and remove.    Oasis is also a very nice brand.

We have covered the Meibomian glands of the eyelid quite in depth now, and how clogged glands are often the culprit for dry eyes.  Remember, those Meibomian glands secrete the oily surface layer of the tear film, that locks the tears onto the eye and prevents evaporation.  There is another gland located higher up in your eye lid area, tucked just under the brow bone, that is responsible for the actual "watery" component of tear production.  The lacrimal gland is responsible for the "aqueous" middle layer of the tears.  This gland is responsible for emotional and reflex tearing, as well as producing the aqueous layer of regular tear film.  So just because you cry easily, doesn't mean you don't have dry eyes.

Let me set the stage with a classic patient presentation.