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

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

The first time I heard about InfantSEE I was still a student at the Southern College of Optometry.  One of my staff doctors, the lauded Dr. "Bubba" Steele, is a co-founder of the program.  Training with Dr. Steele was a huge asset to my career, and I can't express enough what a huge benefit it was that I was able to work under both him and Dr. W.C. Maples, two of the most well-known names in Pediatric Optometry.  But to get back on track, the InfantSEE program is a great initiative dedicated towards promoting ocular health for infants between 6 months and a year old.  Providers in the InfantSEE program offer FREE eye exams for infants, so every new parent should consider finding a provider in their area!

Infants will readily follow lights, so checking eye muscle movement and alignment is relatively easy for your doctor.  To get a complete look at the back of the eye, dilation will be needed.  Rest assured, there will be no damage to your child's eyes from these drops.  Photo from The Eye Care Center in Royal Falls, Virginia.

Why is an infant exam important?
Most children don't get visual screenings until they enter kindergarten, but the eyes are developing from the time your child opens them for the first time.  Remember, the eyes have to transfer information to the brain in order for you to see, so there are a multitude of important connections developing in newborns. The retinal photoreceptors respond to light, the optic nerve delivers this information to the brain, and the brain processes and interprets the information.  Not to mention the eye muscles that have to work together for eye movements and binocular vision (using both eyes together, creating depth perception).   If there is any breakdown in the flow of information, permanent vision loss results.  Detecting problems early (WAY before your child is being asked to learn to read) is obviously essential!

Retinoblastoma is a dangerous cancer that quickly passes from the eye to the brain.  It can best be detected with a dilated eye exam.

What conditions will be screened for?

• Retinoblastoma or other ocular tumors
• Congenital cataracts.  Yes, you can be born with cataracts!  If you notice a white reflection in photos of your child's eyes, take them to a doctor immediately.  A red reflex is normal, but a white reflex could be evidence of cataracts or even more dangerous cancerous growths.
• Strabismus (Eye Turns)  Sometimes a child's eyes can look like they are turning, but are actually normally aligned due to the poorly developed nasal bridge of an infant.  Your eye doctor will be able to differentiate a real eye turn from a "pseudo" strabismus.
• Amblyopia (Lazy Eye) In order to see depth, both eyes have to work together equally.  If prescriptions are greatly different between the eyes or an eye turn exists, the child will ignore that eye's blurry image.  The risk is that the brain connections to that eye will NEVER develop.  That means even with the best pair of glasses or contact lenses, if this condition is not caught early the child will NEVER have good vision out of the "lazy" eye.  The earlier amblyopia is caught, the better chance of getting the vision of the lazy eye back to normal.

Leukocoria is an ominous white reflex indicating a vision threatening (and sometimes life threatening) ocular condition.