Eyedolatry

Tips and Tricks for Fitting Scleral Contact Lenses

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Allergan's VIEW Program Explores Females in Optometry

If you are a regular here, you know I was very excited to speak as a panelist for Allergan this weekend at the North Carolina Optometry Fall Congress in Asheville, NC. It was such an honor to sit beside some of the most recognized female optometry leaders in our state: Dr. Ann Hoscheit and Dr. Sally Miller. Both are published, private practice owners that have held numerous leadership positions both in state and national optometric organizations, and I was a bit out of my league as the "new doc perspective" on our panel. It was an incredible experience, and I came away with a few new concepts that I thought more female and prospective ODs might benefit from:

Create your own personal statement: This is a common tool used in business management, but as a person, it is so important to know what you stand for too. Just thinking about what you want to accomplish, what you want to prioritize, and what you want as your personal identity can help guide your decision making through the entire year. Ask yourself who you want to be as a doctor, a wife, a mother, or any other responsibility you have in your life. If you know your own identity, and what you want to be, it really helps you stay focused on what truly matters in the stresses of daily life.
Don't be afraid to negotiate--and learn how to speak the language of negotiation: For me, this is a very challenging task. As a new grad, I felt like I was just one more face in a sea of graduating optometrists looking for an opportunity to see patients. The first time I spoke to students in optometry school, they asked me how I negotiated my contract and employment. My helpful response? It didn't really work like that. For me, I was not in the position to buy in to partnership with an established OD, and I had just two job offers to choose between. Not much negotiation. Looking back, maybe if I had had more of a business background I would have understood that I had more room to negotiate my situation than I thought at the time. Since my first signed contract, however, I have done a lot more negotiating than many would think. As an OD you are constantly negotiating your hours, your number of patient exams in a given day, your exam time slots. The helpful advice given at this Allergan panel meeting was that as women, we need to negotiate for ourselves like we are negotiating for a business. Dr. Rachel Wruble advised to negotiate for the business of you -- less personal desire, and more how what you are requesting is an asset to the company or situation. For example, it feels natural to say, "I want a lunch break because I will get hungry if I work for that many hours without lunch." I know I said something similar the first time I negotiated my hours. But if you want to have a bigger impact in the business world, negotiating is less about you, and more about how you function within the business. You need a lunch break because without a chance to refuel, you will be working less efficiently, and risking providing a lower level of care. That turns the exact same concept less personal; creating a greater level of importance and impact for your request.
The Future Is Bright: I capitalized this because there was an overwhelming positive message to this meeting of the female minds. We discussed the importance of public outreach in educating Americans about the importance of the eye exam, with programs like the AOA's Think About Your Eyes campaign and even the impact on a smaller level that school screenings or career days to educate young people about what we do. Our profession is such a legislated career, and political action campaigns are the arena where optometry gains its rights for practice and to see patients on insurance plans that may try to cut us out. We have to fight for new healthcare changes that will provide patients access to us with equal pay as our MD counterparts. And there are so many new fights on the horizon, like the proposal for universal licensure that would make optometrists licensed nationally instead of filing for individual state licensure. The important take away is that we need leaders in this industry with a voice, that are willing to fight for our profession. I hope to become more and more involved in getting the word out about optometry (the driving force between the creation of this blog back in 2011!)

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Dry Eye Syndrome: A Photographic Review

blepharitis photo 10:59 AM

If you have been diagnosed with dry eye, which 48% of Americans experience according to this study, your doctor has probably tried to describe the underlying cause of your dryness. You knew your eyes were feeling badly: itching, watering, redness, burning, pain, dryness, or blurriness between blinks are all common symptoms of dry eye syndrome. Now it is your doctor's job to find a way to make your eyes feel better and perform more optimally. In order to do that, they have to know what is causing your dryness. Current literature often breaks down dry eye syndrome as one of 2 categories:

Aqueous Deficient Dry Eye: Basically this means you aren't making enough tear film. In many cases this is associated with conditions like Sjogrens Syndrome where inflammatory mediators are reducing both tear and saliva production
Evaporative Dry Eye: Basically the tears that you make just dry right up off the ocular surface. This type of dry eye means you are producing tear film, but the tear film is missing the proper components to stay long enough on the eye.

If you are an eye doctor, you know these generalized break downs are way too simplistic, and usually a person has multiple causative dry eye factors. Evaporative dry eye is typically associated with issues with the oil glands of the eye, called Meibomian Gland Dysfunction. Every time you blink, these meibomian glands that lie in the eyelid secrete the oily top coat of the tear film that keeps tears on the eye. Studies suggest that as much as 60% of dry eye sufferers have Meibomian Gland Dysfunction as a major cause of their symptoms. This means that when I am checking your eyes for dryness, I look even more closely at your eyelid, where these meibomian tear glands are. What exactly am I looking for? Well, luckily I have a few patient pictures to illustrate:

Inspissated Meibomian Gland

A clogged, or inspissated, meibomian gland is a very common finding. In many cases, I will find one or two on the eyelids, but the patient will only have mild complaints associated with dryness. They will describe some itching along their lid margin, maybe some end of day dryness or intermittent blurry vision between blinks. They may have a history of styes (clogged meibomian glands that get infected with bacteria). I have even had some patient tell me that they see these in the mirror (great eyesight) and try to pop them! The best way to fight clogged meibomian glands is to use a warm cloth massage or eyelid cleansing product like Ocusoft eyelid pads or foam nightly before bed. This will open up the gland and let all of that nice tear film flow freely onto the eye again!

Posterior Blepharitis

This is obviously a bit more advanced. Not only is there significant blockage of every meibomian gland on this person's eyelid, but there is a ton of inflammation! Blepharitis is a common word in eyecare that translates in layman's terms to eyelid inflammation. All that redness? That's inflammation. This person is going to complain about sore or even puffy and swollen eyelids, and typically has some significant complaints with dryness, burning, and redness. Warm massages and lid cleansers are still used in this patient, but typically an anti-inflammatory treatment like steroid drops or ointments, or oral doxycycline would also be used at this point.

Chronic Infammation -- classic for Ocular Rosacea

Compared to the preceding photo, this person also has redness, but there is a pretty big difference here. This is a patient with ocular rosacea, a condition associated with chronic dryness and inflammation. Typically there are other facial areas of rosacea as well. The big give away? Those squiggly blood vessels on the eyelid margin are called telangiectasia, a hallmark of rosacea. This patient will typically have chronic, persistent dry eye complaints but get little relief from lid massages and warm compreses in my experience. Anti-inflammatory treatments like steroids or Restasis are typically the preferred treatment route, and oral treatments like doxycylcine are especially popular because they also improve facial patches of rosacea.

Long-standing Dry Eye

This is a great example of how a patient with chronic inflammation and meibomian gland issues looks. This eye has hallmarks of old inflammation (notice the faint telangiectasia by the lash roots), but no acute inflammation at the moment. The inflammation has subsided, but the meibomian glands still fail to function ideally. How can I tell? The glands towards the middle of the picture have a hardened, white center. If the patient blinks, or I put pressure on the lid at that area, there will likely be NO tear film coming out. This patient will still have dryness, because the glands aren't functioning like they should! At this point in the patient's treatment plan, we are turning to more chronic therapies. The inflammatory cycle has been broken so steroids and doxycycline will give less results, but the glands still aren't normalized. Sometimes treatment like Restasis that helps the body make more tear film, or new treatments like Lipiflow that pumps the meibomian glands open may be effective, but there is no permanent cure. This person will have a lifetime of battling their dry eye due to their poorly active meibomian glands. Once the glands have been damaged, their function may never be restored. That's why treating dry eye early and aggressively is so important!

There is no cure for dry eye or meibomian gland dysfunction, but new treatments to combat these signs and symptoms are being developed every day. Talk to your doctor if you have any of the symptoms of dry eye. Ask if they have external photography that can show you what factors are causing your dryness (or if they can describe what they see if they don't have a camera)! Your doctor is an eye specialist, trained to treat these conditions and educate you on your personal cause factors. External photographs like the ones featured here are a great way of tracking progress with treatments, and to educate patients about their personal culprit causing their dry eye symptoms. Keep in mind that not all insurances cover these photographs, unfortunately-- only medical insurances and NOT vision insurances will cover medical treatment or diagnosis of dry eye. By working with your doctor and trying different treatment plans geared toward your dry eye root cause(s), there is a way to manage these symptoms and achieve relief.

Look closely at your eyelids; if they are red or you notice clogged glands, you need to see your doctor to combat these issues early. The earlier we treat the causes of dry eye syndrome, the less likely you are to have permanently damaged meibomian glands (and permanent dry eye symptoms!).

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Women in Optometry -- How Can We Make This Profession Great?

optometry career 9:26 PM

In just 10 days I have the pleasure of speaking as a panelist for Allergan's VIEW (Visionary Insights for Eye Care Women) luncheon at my state's optometric society meeting. It was such a great honor to be chosen as a speaker, representing the changing face of the new generation of optometrists--a profession dominated by females. More students than ever are graduating with their doctorate in optometry (when I first enrolled there were 16 schools in the USA, now there are 21 with more scheduled to open in the coming years). And more students than ever are females (there is a reported 60-65% female enrollment in optometry schools across there country).

Why are so many women pursuing optometry, especially when faced with the negativity of many optometrists in today's healthcare marketplace? There are many reasons that would appeal to stereotypic gender norms:

optometry is a flexible career, with part-time work available for family-minded doctors
shorter lenght of time in school (a 4 year program instead of 4 plus 4 or more years of residency in an MD program)
no surgeries, so no blood / lower stress, no life or death discussions

But we all know that for many women, these perceived "female-friendly" points may not have had any influence on their career decision at all. My personal opinion is that optometry is appealing as a career in general, not just to women. More than ever, women are driven to pursue higher education, and as such they are finding careers in medicine, law, and other professional degrees. But where optometry really separates itself from other professions is the ability to focus on one topic, and become an expert at that. Optometry is a career that appeals to the detail-oriented (maybe there are more of females with this talent/curse than males??). You spend the entire day looking at one body part, talking about one body part, measuring and calculating minuscule changes in that body parts length and curvature. You talk about eyes all day long. To me, as a woman, I love having that focus, the ability to pour my entire body of knowledge and study into the smallest of details about the human eye. Thinking of being an expert on the entire body sounds just ludicrous to me -- I don't know how primary care doctors can manage so much at once. As an optometrist, I am the doctor you see for all eye-related questions and concerns-- the eye specialist. You can't get much more rewarding than that for someone that loves details.

With that being said, I am not immune to the pinch of negativity in my industry. I feel my eyes are more open than ever to the uncertainties of healthcare in today's world. I have seen the profession of optometry struggle under the weight of reduced insurance reimbursements and general perception of the value of an eye exam. Eye exams reimburse very little through most vision insurances (between $40-50 for a comprehensive exam on average). In the past, doctors have offset those terrible margins by relying on product sales, but glasses and contact lens marketplaces have expanded (like all products) into the realm of the internet, and doctors are feeling the heat to see more and more patients every day. In many cases this means compromised ability to focus on the details that made our profession so unique and rewarding -- the time to discuss all of the health benefits of the exam, to investigate dry eye, ocular allergies, and UV exposure changes that affect the eye and vision. The eye is the only part of the body to assess the blood vessels with a live view, and most of my patients are surprised to learn that I am screening them for hypertension, cholesterol issues, and diabetes during their eye exam.

So why do so few people in the general population not know that your eye exam is an important health screening? Most people are under the misconception that if you can see, your eyes are healthy. If you read this website routinely, you know how many times I have debunked this myth. In most cases, if your vision is affected by an ocular disease, it is too late to improve vision, even with glasses or contact lenses.

My charge to all optometrists, new and old, female and male, is to embrace this profession for the specialist career that it is. We need to educate at every chance we get what we are seeing when we look at our patient's eyes. We need to take medical responsibility for the eye -- we are the primary EYE care provider after all. We are who you need to see for a red eye, dry eye, burning eye, blurry eye, watery eye. You name it; we are eyes. Embrace the medical training we have and promote it! This is the way to bring optometry into 2014, and the new wave of female optometrists are going to be the industry leaders to usher this change in patient perception.

If you are a female optometrist or optometry student, please comment and let me know what struggles you have faced or concerns that you have about our career and our role as female doctors in shaping its future. I want to hear from you, so that I can bring these topics to my VIEW panel discussion, and the greater audience of online readers and industry leaders!

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High Prescription? Biofinity Contact Lenses Offer a Solution

Biofinity XR 9:27 AM

I may have been the only person on Friday to open my work email and do a little dance of excitement when I saw the good news -- Biofinity XR is launching on November 4th! To most of us, wearing contact lenses seems like a normal part of our day. We don't ever worry about what would happen if there were no contact lenses being made in our prescription. But for some people, having a soft, disposable contact lens that is available in their power at their doctor's office is a luxury they have never experienced. With Cooper's new launch, we will finally have a contact lens that offers the thin material and high oxygen benefits that lower prescription wearers have been enjoying for a decade!

via

Most soft disposable contact lenses are available in limited power options. On average, +8.00D to -12.00D is the span of options. If your prescription needs more correction than this, our only options become specialty contact lenses: either hard RGP contact lenses that provide less comfort, or custom soft contact lenses that are usually very expensive or lower in oxygen to the eye, creating risks for scarring, blood vessel growth into the cornea, and infection even when worn appropriately. The new Biofinity XR lens will be available up to +15.00 D and -20.00 D, a very generous span of power options.

Biofinity XR lenses will be monthly disposable soft contact lenses and have a measured Dk/t of 160 (amount of oxygen to the eye). The breathability of this lens will be unparalleled on the market as the first available high Rx lens made in silicone hydrogel material. Most lenses in these power ranges having Dk/t of no higher than 55 (some as low as 8 still on the market today!!). With that being said, keep in mind that the thickness of the prescription does influence Dk/t, so a -10.00D lens will have more oxygen to the eye than a -20.00D lens.

Price is another point where Biofinity XR should offer great performance. For a custom contact lens in these power ranges, a year supply with monthly disposable lenses may be as high as $800-$1000 dollars. Expect Biofinity XR to be available for around $260-$300 for a year supply. A huge improvement for the wallet!

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An Introduction to Scleral Contact Lenses

fitting advice scleral contact lenses 3:47 PM

A typical RGP (gas permeable lens above, compared to the larger scleral
lens below via

The first time most people see a scleral contact lens, the immediate response, is "wow, that's big." The size of a scleral contact lens can be intimidating, but there are so many reasons for patients (and their doctors) to learn to love these larger contact lenses. They offer unparalleled vision and comfort for many patients with irregular corneas, dry eye, or high astigmatism. If your doctor has recommended scleral contact lenses for you, here's what you need to know:

A scleral contact lens fully covers the cornea and sits on the white of the eye (the sclera) via

Scleral Contact Lenses typically range from 14 to over 18 mm in diameter, fitting completely over the cornea so that no part of the edge of the lens touches the cornea. As such, the lens is much more initially comfortable than a smaller rigid gas permeable lens that moves around on the cornea with blink. A scleral lens basically creates a shell covering the cornea, masking any corneal irregularities like keratoconus, scarring from refractive surgeries like RK and LASIK that have resulted in vision issues, and high amounts of astigmatism.
Scleral lenses create a little pool of moisture under the lens that stays between the contact lens and the cornea all day. Due to this property, scleral lenses have even been used for dry eye treatment. Before you put your lenses in, you must fill the contact lens with the proper saline (or bath water if you will) to keep your cornea from getting irritated under the contact lens. Most commonly recommended filling solutions are:

Preservative Free Saline (like Unisol)
Preservative Free Artificial Tears
0.9% NaCl inhalation vials (off label use but these are preservative and buffer free, making them ideal for the sensitive cornea)

These lenses are difficult for some to learn how to insert and remove. Since you are filling your contact lens up with a pool of solution, you have to put the lens in without dumping all of your solution out. Your doctor will train you on the proper technique, but the Scleral Lens Education Society has a great instruction video if you need more help at home:

Why do I fit scleral contact lenses? They definitely aren't a quick-fit type of contact lens, but once you have the proper lens, your patient should see better and with better comfort than they have in years. With that being said, I typically plan for between 3-5 visits for first time scleral wearers to get the proper lens fit. If you are a patient in the process of the fit and are feeling frustrated, keep in mind that these lenses are all made to order, and the parameters to change are very involved. Most companies have a remake period of 2-3 months since it takes 1-2 weeks to make a new lens, and then more time to ship out and schedule a time that works for the patient's schedule.
Wouldn't it be nice if scleral contact lenses are the end all-be all lens that works for everyone? Unfortunately, that is not the case. I have found that people with small diameter corneas and small eyes/tight eyelids are very difficult to fit with this lens. I use Essilor Jupiter lenses, and their company representative discouraged fitting lenses on people with smaller than 12 mm corneas (especially with limbus to limbus astigmatism) due to the problematic issues they have encountered. These lenses are gaining more and more popularity, but doctors are still debating the best fitting techniques and trouble shooting skills, so we may not be able to get the perfect lens for every patient yet. With more doctors fitting sclerals, and more companies offering better parameter options, the industry may grow to accommodate more and more patient types. If you are an optometrist or student, I plan on posting tips on scleral lens fitting in a future post, so stay tuned for what I have learned so far!