Glaucoma is a spectrum of ocular diseases that cause optic nerve destruction

There are so many different types of glaucoma, and all of them work in different ways.  One thing unites them all: the optic nerve that delivers the message from the eye to the brain is destroyed.  The destruction is most commonly slow and painless, but in some types of glaucoma can be very quick with acute headaches and halos around lights.  Damage to the optic nerve causes PERMANENT vision loss, and that is why glaucoma is such a devastating ocular disease.

To simplify this discussion, let's talk about the most common form of glaucoma: primary open angle glaucoma.

Glaucoma typically is caused by high pressure building up inside the eye.  There is a fluid called the aqueous humor that is made to deliver nutrients to the internal components of the eye.  If too much fluid gets made, or if too much is retained inside the eye instead of draining out into surrounding tissue, then the fluid builds up in the eye.  This creates increasing pressure pushing against the back of the eye and the delicate optic nerve.

Eye Pressure or Intraocular Pressure

Goldmann Tonometry, the "gold standard" pressure reading Photo via http://www.sco.edu/

Every time you visit your eye doctor, a pressure reading is taken.  Most commonly an "air puff" is used, but there are also sophisticated hand-held and microscope attached instruments called tonometers that can be used.  Pressure is measured in mm of mercury (mmHg).  Average pressure is 10-21 mmHg.  Typically numbers over 21 are considered elevated, and thus suspect for glaucoma, but there are varying factors that may affect these eye pressure readings.  Your doctor will investigate further if your pressure is reading high.


What Glaucoma Looks Like

Most offices use retinal photographs to show patients what an eye disease looks like, but glaucoma is a disease that is not easy to "see."  What your doctor looks for to detect glaucoma is atypical appearance of the optic nerve.

Photo via http://www.glaucoma-eye-info.com/

Everyone has a hole in their optic nerve where blood vessels pass through.  The average person has a hole that is smaller than half the diameter of the nerve (is that complicated enough??).  The photo above shows a normal, small hole. The larger the hole, the generally more suspicious it is for glaucoma.  Here's the thing, everyone has a different size optic nerve and a different size hole that can be entirely normal.  In the average eye, the size of that hole is constant through life.  In glaucoma, the size of the hole in the nerve will get LARGER with time, because the nerve tissue is getting destroyed.  This is why taking routine retinal photography is such a great option, and why everyone should be routinely examined by their eye care professional even if they don't have vision trouble or had no eye diseases several years prior.  Glaucoma is PROGRESSIVE, which means you might not have it today, but you may have it in a few years.  The only true way to detect it is by monitoring for changes.

2003

2011: Note hole or cup is getting BIGGER near the bottom edge. If you look close, you can see a hemorrhage near the area of inferior damage (a tell-tale Drance heme)

2012:  Even thinner at the inferior edge of the nerve!!

We've all read the debates on whether or not we should wear a white coat, and I completely agree that it is a personal decision.  You can look entirely professional and gain the respect of your patients wearing blue jeans, but it's a little more of an uphill battle.

When I first started practicing, I didn't wear a white coat. Mostly because the coat I owned made me look like a little girl playing dress up.  It was at least three sizes too big, fell to my knees, and I had to roll the sleeves to keep them from looking like arm tents.  Patients were constantly asking my age, or how many years optometry school was.   I needed a new look that brought some sophistication to my staple doctor's coat.

I suppose I could have sport this white coat, but I don't think having student doctor emblems on the sleeve would have helped my cause!

Melelita Ellody:  a great fit and durable feel

That's when I sought advice from a fellow optometrist, who encouraged me to try out Medelita.  (NOTE I am in no way being paid for this post, and I paid full price for the coat that I purchased from them).  If you an optometrist or medical professional looking for the ultimate white coat, I cannot recommend this product more.  They have a "Teflon" infused material that resists stains and spots.  It can be machine washed and dried, so no expensive dry cleaning trips.  For women, the sizing is superb.  You can get anywhere from size 00 to 16, and the fit is nice and tapered.  Many of the options come with free embroidery, so your coat can be personalized with your name.  There are even multiple color options to match your office's color scheme.  For an extra charge, you can submit your own logo to be incorporated.

Tons of personalization options, at no extra charge!

I'll be the first to admit, this coat is not cheap.  My coat was $118, but honestly, the quality is worth it.  When you feel the fabric for the first time, you will understand what I mean.  This is a coat that will last for years, doesn't look wrinkled all the time, repels stains, and actually fits!  Try it out if you are in the market for a great white coat!

How many times have you looked at the side effect lists on your medications, and read that "blurry vision" may result from taking that medication?  As an optometrist, I get asked about visual changes from medications on a daily basis.  While most commonly prescribed medications are more likely to cause dryness than a real prescription change, there are a few out there that could have you not only seeing poorly, but at risk for permanent vision loss!

Topamax

Qysmia

Topamax (topiramate) is a medication commonly prescribed for seizures, migraines, and depression.  One of its side effects is also a decrease in appetite, so it has been increasingly used "off label" as a weight loss supplement.  Just this past July, the FDA cleared Qysmia, a combination of topiramate and phenterine as a weight loss medication.  Like all adrenergic agents (that act on the nervous system) this medication causes dry mouth, dry eyes, and an increased heart rate.  Just like Topamax, Qysmia will have the added possible side effect of sudden onset blurry vision.


Serious Side Effects

Topiramate causes a narrowing of the anterior chamber in some patients that results in sudden onset blur from myopia (or night sightedness) as well as headache and possible acute angle closure.  That's a lot to take in, so let's break this down a bit:

The Anterior Chamber Angle

We all have an angle where the cornea (front, clear surface of the eye) and the iris (colored part of the eye) meet.  This area is where the aqueous humor (a liquid nutritional secretion) drains out of the eye.  If the angle becomes more narrow, the aqueous humor has a harder time draining out, which can result in increased eye pressure.  That's a lot of confusing anatomy, but what it really means to you is:
topiramate can change your eye's anatomy, putting you at risk for high eye pressure and vision changes.

IRIS = colored part of eye CORNEA = clear layer over top

Acute Angle Closure Attack

If the angle is too small, the pressure inside of the eye can sky rocket.  Normal eye pressure is generally under 21 mmHg, but in acute angle closure it can be higher than the 40s or 50s.  Your optic nerve can only take so much pressure before the nerve fibers start to  die off, resulting in permanent visual damage.  Acute angle closure is a medical emergency and requires immediate treatment.  If you are experiencing an angle closure attack, the symptoms are:

•  headaches
• haloes around lights
•  pain

 Report to your doctor immediately with these symptoms!

Photo via Medrounds.org RIGHT:  Aqueous humor has plenty of room to drain between the iris and the cornea LEFT: narrow angle anatomy causes the fluid to have great difficulty in draining out, resulting in a big spike in ocular pressure

Myopia

Even if the angle is not closed, and your eye pressure is normal, topiramate can cause the angle to narrow enough that your prescription changes to be more near sighted.  Myopia is a refractive condition where distance vision becomes blurry.  These changes are not permanent, and your prescription should return to normal after the medication has been stopped.


In Summary

All medications have side effects, and weight loss medications are definitely no exception.  If you notice a vision change, headache, or pain around the eyes after starting a new medication, it is definitely worth consulting your eye doctor.  If there is a real ocular change going on, getting you off the medication and finding an alternative with your primary care provider could be essential to protecting your eye from permanent visual damage!

It's official: I have entirely fallen for fall's two-tone glasses. My Juicy Couture ophthalmics arrived the  other day, and I have been sporting them as frequently as someone who owns five pairs of glasses (and counting) can wear a pair of glasses.  Two-tone specs are an updated version of the past few year's resurgence of thicker plastic frames, known lovingly as "geek chic" in the industry.  Where darker glasses were popular last fall, this fall the same styles are being infused with bright colors or an ombre effect.  Here's a pictorial overview of fall's best fashion trend:

Juicy Couture 115.  My new fall favorite pair of glasses.

Armani Exchange: two-tone for men.  The ombre effect is entirely on point with other fashion trends being sported this fall.

Dylan Sunglasses by Urban Outfitters

Who can resist Coach's new line of colorful sunglasses Style name is Casey

In the next few years your optometrist may be fitting contact lenses for more than just your eyesight!

Contact lenses are more than just a way to restore vision without glasses, they are a highly advanced medical device that scientists are still learning how to utilize!  Contact lenses can be used as clear bandages to heal large abrasions.  Biomedical companies are developing ways to use them for delivering doses of antibiotics or other medications to the surface of the eye over a long period of time.  New research is now being reported that we may be able to use contact lenses in people with diabetes to monitor their blood sugar without painful finger stick tests.

At the University of Akron, professor Jun Hu has applied a chemical coating to contact lenses that react to glucose levels in tear film.  The coating is comprised of a molecule that binds to sugar in the tear film, and at a certain concentration, will cause a color change reaction.  Imagine a pH test with its color  scale, and you get a similar picture.  When the level of glucose returns to normal in the tear film, the color of the contact lens would again normalize.

In his initial proposal, Hu suggests the patient will wear the lens in 1 eye, and then take a picture of their own eyes with a free smartphone app to monitor for changes. The app will compare the color difference between the normal eye and the eye with the contact lens to calculate the blood glucose levels.  The color change will be subtle, without affecting vision or comfort of the contact lens.

Microsoft is researching an electronic sensor implanted inside the contact lens

A timeline for the product reaching the market is still at least three years away.  At the same time, other companies are researching using electronic sensors inside contact lenses to detect glucose level in the tear film.

Sources:  High-tech contact lenses: Glucose Monitoring by Dr. Goodfellow and Dr. Maino published in AOA News

We've already addressed the best solutions for your soft contact lenses, but for those patients wearing  specialty contact lens options, finding good information about how to care for your lenses can be quite difficult.  Synergeyes contact lenses are a unique "hybrid" option; one part soft lens and one part hard (or rigid gas permeable) lens.  The hard lens center allows for improved vision in patients with high astigmatism or irregular corneas (like those found in keratoconus).  The soft lens skirt of the lens allows for superior comfort.  These lenses last for 6 months of wear, but can easily tear or build up deposits if not cared for properly.  You can always find more information on the best way to care for your lenses at the Synergeyes website, but here is a breakdown of what I recommend.

SYNERGEYES DUETTE

The Duette lens is the company's latest design which has superior optics for "regular" corneas and up to 4 or 5 diopters of astigmatism. A multifocal design is also an option.  The company has performed studies to see which solutions operate best to keep the lens moisturized but still clean.  Click here to see a more thorough post on their findings.

1) CLEANING

The best options to clean your lens are Biotrue multipurpose solution and Aquify multipurpose solution. These two solutions provide the moisturization that the soft contact lens portion of your lens needs to prevent dryness, especially as the lens ages.  Previously Clearcare was the top recommendation, but in a large percentage of patients, the Clearcare solution will cause white deposits on the soft portion of the lens, preventing proper moisturization.  Clearcare can be used for intense cleaning, but I no longer recommend it on a nightly basis unless my patients have severe depositing issues.

2) FILLING THE LENS

Before you insert the lens into your eye, you should fill the lens with the correct saline solution to provide better fit and comfort.  I usually recommend Unisol 4 sterile saline for this purpose.  You want the solution that you fill your contact lens with to be preservative free, since preservatives can be toxic to the cornea with prolonged contact.  Preservative free artificial tears are sometimes also recommended.



SYNERGEYES CLEARKONE, SYNERGEYES KC, SYNERGEYES A

1) CLEANING
For this lens, I solely recommend Clearcare.  Synergeyes Clearkone is made for correcting the vision of patients with keratoconus.  The company also offers products like Synergeyes A that are made to correct for higher astigmatism.  These products are made with a hydrogel soft lens skirt (versus Duette which is a higher oxygen permeable silicone hydrogel), and this material responds better to the intense cleansing ability of Clearcare.


2) FILLING THE LENS
Unisol 4 saline is still a great option for filling the bowl of the lens.  Again, you really want to avoid preservatives if you are using this solution against your cornea all day.  In some cases, a thick preservative free tear like Celluvisc has even been used to help with comfort in patients that are just learning to use the lenses.  Long term the  thicker Celluvisc is usually replaced with a thinner solution to improve visual quality.

Wouldn't it be incredible if you could see your own blood vessels inside your body?  What if you could see your own brain tissue?

Wait.  You can with retinal photography.  Every day I take photos of the back (and front) of my patient's eyes and it is amazing how much information can be gleaned.  Your eye doctor can detect high blood pressure, high cholesterol, and diabetes just from looking for changes in your eyes.  Sometimes detecting these changes can save a person's vision from permanent damage; sometimes they can even save them from the repercussions of serious systemic diseases.

I can't recommend having a comprehensive eye examination more, even if you have no vision issues.  We all should want to see the inner workings of our bodies, and the eye is the perfect window inside!

Here are some of the photographs I have taken of common ocular conditions and diseases just this year.  I apologize about the persistent artifacts from my camera -- they look like 2 white circular glare areas in every photo.

MYELINATED NERVE FIBER LAYER (looks bad, but this is actually a harmless finding ) Myelination typically only exists behind the eye, but sometimes passes into the eye without harming vision

SCATTERED DRUSEN Enlarge this photo and you will see tiny yellow areas that are known as drusen near the dark central vision spot (the macula) Drusen are harmless by themselves, but can put you at a heightened risk for Macular Degeneration

CENTRAL RETINAL VEIN OCCLUSION This prompts an immediate referral and investigation for systemic health issues

CENTRAL SEROUS RETINOPATHY The area of edema is visible as subtle color changes around the macula This condition causes central vision changes, and is often due to stress Usually no treatment is necessary, just time for the swelling to resolve

ADULT VITELLIFORM DYSTROPHY See the yellow area at the macula?  It shouldn't be there.  This condition can cause central vision disruption, and no real treatment exists