You've done it!  You've made the decision to devote the rest of your life to eye balls and their care and keeping.  I know that may seem like an exaggeration, but when you become an optometrist, you really do think about eyes all day long.  When you aren't at work seeing patients, you are talking to your optometrist friends about eyes, talking to your family about their eye problems, talking to your outside of optometry friends about their eyes, talking to total strangers that ask what you do for a living about their eyes.  Just as a word of advice, when you are on vacation and don't want to talk about eyes for a few days, pretend that you have a different career.  White lies can't hurt in this case. There is nothing like hiking Yosemite and having to talk to a stranger about their uncle's cousin's cataract surgery complication all the way up the mountain.

States with current optometry schools -- more coming soon!  via

My Graduating Class

With the recent launch of Ciba's Daily Aqua Comfort Plus Multifocal, the world of daily multifocal lens options just got a second look.  Remember about a year ago when CooperVision first pioneered the option with their Proclear 1 Day Multifocal lens?  Within a few tries, I think most ODs sighed a long, low sigh of exasperation at the peculiar performance of the lens, and went back to fitting Biofinity Multifocal.   Well, I know I did at least.

But as with most products, what we really needed was a good fitting guide to cut down all the time spent trying and failing in the room.  CooperVision has recently published their recommended guide, and it is time to take a second look at fitting this lens!

Things to Know:

No, this lens is NOT designed like Proclear Multifocal (the monthly version) or the newer Biofinity Multifocal.  Unlike Ciba's daily product that uses their exact same Air Optix multifocal fitting strategy, you need a whole new method to fit the Proclear 1 Day multifocal.

Center Near design via

Even though this is a multifocal, you will definitely need to be maximizing vision by using the dominant eye.  Make sure you determine this before you get started.

This is a center-near optical design, and there are no add powers to select. CooperVision states the lens can accommodate up to +2.50 add despite this.  If you have detail oriented patients that like to question the power of their contact lenses compared to their glasses Rx, please tell them up front that this lens power will look NOTHING like their glasses Rx.  Set the stage that this is a whole different way of seeing, and the power of this lens on the box label does not mean the power they are getting out of the lens due to the center-near aspheric optics!

Fitting Guide:

1) Refract and determine eye dominance.  I like to use the +2.00 blur out method (the eye that cannot take the plus is your dominant eye).
2) Select your initial lens:  

Dominant Eye:  Select +0.50 over top of vertexed distance power
Non-Dominant Eye:  Selection depends on add
             +1.00                          Select +0.50 over top of vertexed distance power
             +1.25 to +1.75            Select +0.75 over top of vertexed distance power
             +2.00 to +2.50            Select +0.75 to +1.00 over top of vertexed distance power

3) Over-refract with +0.25/-0.25 in binocular conditions
For distance refinement refract over dominant eye
For near refinement add more plus to non-dominant eye

In Summary:

Since changing to this fitting guide method, I have saved a ton of chair time.  The lens takes A LOT of plus, so don't waste time by grabbing their distance Rx as a starting place.  Vision has all the complaints of normal multifocal lens wearers -- ghosting at near, poor performance in low lighting, etc.  Typically I can get 20/25 distance vision and around 20/30 near vision on most every patient.  These are my target goals for optimal performance (I set the expectation before we ever start the fitting process so the patient knows what to expect, and that for better vision than this they will likely need glasses).  If you were frustrated before by the large over refraction needed over their distance Rx, take a second look at the Proclear 1 Day Multifocal. In my experience the vision performance out of the Biofinity Multifocal tends to be better for most people, but for the comfort of a daily, you are still achieving usable vision with this lens approach!

One thing is always true about fashion: we love to recycle the past.  Glasses styles are definitely no exception, and this spring no vintage look is having a bigger moment than horn-rimmed specs.  It is popping up everywhere from Ray Ban's classic Clubmaster shades being relaunched in every spectrum of the rainbow, to ophthalmics embracing a new take on the geek-chic look that has become played out in the oversized trends of years past.

With the patent set to expire for Restasis this month, the dry eye world is poised to have a new option on the block with Shire's lifitegrast molecule that is just reporting Phase 3 clinical trial data.  When Restasis first hit the market in 2002, it was the first prescription available for dry eye, showing increased tear production for patients and an anti-inflammatory effect.  For over a decade Restasis has been your doctor's only prescription choice for a drop to help produce more tear film, but due to the varied issues that cause dry eye, it has not been a cure-all for every type of dry eye sufferer.  Here is what we know about the potential new kid on the block:

Lifitegrast is an anti-inflammatory molecule, working to reduce T-cell activation and cytokine release.  Anti-inflammatories like Restasis and lifitegrast theoretically combat dry eye by breaking the inflammatory cycle.  When your eye gets dry, redness and irritation result from increased inflammation on the eye's surface.  This inflammation appears to reduce normal tear film function, causing more dryness and more inflammation.  It is a never-ending circle of dryness, redness, and discomfort.  Both Restasis and lifitegrast are T-cell modulators, but it is theorized that lifitegrast will be faster-acting than the Restasis molecule. Restasis typically requires around 3 months (the lifespan of a T-cell) to begin effectively breaking the dry eye cycle, whereas early data suggests lifitegrast will begin having effects in as early as 2 weeks.  There are at this time no head-to-head studies that compare the two drugs.  Potentially they could even be used in combination for a greater effect!

Lifitegrast is completing Phase 3 FDA trials, and so far results have been mixed.  All trials so far compare lifitegrast to placebo (the vehicle in the drug).

SPK or corneal staining is a clinical sign of moderate to severe dryness. Unfortunately lifitegrast performed no better than its placebo at improving SPK on the surface of the eye in the OPUS-2 study.  Patients did however report improvement of their dry eye symptoms in the blind study.  via

In the OPUS-2 study, paitients reported a  statistically significant relief from dryness symptoms with lifitegrast versus placebo.  Unfortunately the clinical signs of dryness measured in the study (inferior corneal staining) was not statistically significantly improved with the use of the drug.  Thus continues the infuriating issue with dry eye -- symptoms and signs of dryness tend not to coincide.  So while patients felt better, the clinical findings of dryness and damage on the surface of the eye (corneal staining in this study) had not improved.

In the SONATA safety study, there were no reported dangerous side effects with lifitegrast use. The most common side effect was bad after-taste (16.2% of users) and irritation after installation (7.8%).  Burning with installation is also a common complaint with Restasis use.

While there is no way to accurately predict when or if lifitegrast will come to market as a true alternative or additive therapy to Restasis treatment, it can be several years before a drug with successful phase 3 trials actually makes it to market.  I will continue to keep you updated as we learn more!

Why is it so important to have an eye exam at 6 months of age?  There are so few people taking advantage of the great InfantSEE program that offers free eye exams for children age 6 months to 12 months, but the conditions that can be found during this exam can influence a lifetime.  During the exam your optometrist will be able to find life and vision threatening tumors, large prescriptions or eye muscle anomalies that could result in severe eye turns or vision loss, and congenital conditions that can result in permanent blindness and be associated with serious systemic health issues.  Yes, all that is what is taking place at your eye examination. It is so much more than "which is better, 1 or 2."

For many people, having a stye is just a one time issue -- maybe you slept in your eye makeup one night, or just didn't wash around your eyes well after being exposed to a dirty environment.  But for some people, the chemistry of their skin and eyelid oil glands (Meibomian glands, glands of Zeiss, or glands of Moll) make styes a regular occurrence.  Here is how to fight back if you fall into the latter category.

Warm Massage
One of the best things you can do to combat styes is apply heat.  Every night take a hot wash cloth and gently massage the eyelash root area, both top and bottom eyelid.  The heat will open the oil glands, and help encourage release of any hardened glad secretion that would otherwise clog.  You are also removing the day's bacteria and dry skin from the area, decreasing your chance of infection. Try to do this every night: just a hot washcloth massage for 30 seconds at the eyelash base of both top and bottom eyelids.

Eyelid Cleansers
If you need more intensive help than just a warm cloth, you can't go wrong with Ocusoft's eyelid cleansing products.  The pad or pump bottle foam options are both great at cutting down bacteria and dry skin.  In many cases this product alone can solve issues ranging from recurrent styes to itchy and inflamed eyelids and dry eye syndrome.  If you get flaky skin or crusting build up along your eyelid and lash roots, the pad version is your better option.  For a more gentle daily cleanser, the pump bottle version is much more economic because you can control the amount you need.  It is perfectly safe to use every day, and doubles as a gentle but effective eye makeup remover. Some people swear by diluted baby shampoo, but I often find it to be  too drying and irritating to the lid surface if needed for daily use.


When you are seen by your eye doctor, they will be checking the eyelash line and lids for signs of an inflammatory infection of Demodex.  Demodex is a parasitic mite that lives on our skin's hair follicles.  The amount of people with demodex infestations is jawdropping -- as high as 100% of people over age 70 are affected!  If your doctor sees a a Demodex infection, normal treatments may not be as effective for your inflamed, red eyelids.  Tea tree oil treatments are great at getting rid of Demodex; you can use a diluted tea tree oil shampoo to clean the eyelids nightly.

Demodex mites can be seen attached to the bash of your eyelashes during a regular eye examination. The only thing that really fights a demodex parasite is tea tree oil; other products (even steroid ointments)  are often of little success via

Oral Medications
During more acute flare-ups, oral medications may be needed to knock styes out of commission.  The go-to treatment for this purpose is oral doxycycline (or minocycline when there is a nation-wide shortage of doxy!)  For chronic use, a low dosage of doxycycline can be mild enough to keep styes at bay without causing side effects like upset stomach or sun burns.  A 50 mg dosage is generic, and can be enough to effectively decrease eyelid inflammation.  Dermatologists also frequently use the 20 mg dosage year round to fight acne and skin issues, and this low dosage works wonderfully on the eye as well for many patients. If you have rosacea or other skin issues with concurrent styes, oral doxycycline used more chronically (usually 1 month on, and 1 month off, or even all year round) can treat both issues at the same time.

Thinking of buying dietary supplements?  This is one time that you need to buy the name brand.  Fishy burps are not pleasant, but quite common in poorer concentrated fish oil products. via

Nutritional Supplements
Look for nutraceuticals with anti-inflammatory effects for best results.  Omega 3/fish oil is your best bet -- with 1500 mg a day being shown to effectively keep oil glands like the meibomian glands flowing with better gland secretion.  In the case of oral supplements, name brands can really be digested much better.  Nordic Naturals or Physician's Recommended get the best reviews.  Other options for improving tear gland function include flax seed oil and bilberry.

If you keep getting a stye in the same place?
See your doctor!  Recurrent styes are an unfortunately common problem if there is a skin chemistry issue, but the styes shouldn't keep coming back in the same place over and over.  This is more suspicious of a sebaceous gland carcinoma.  To rule out a cancerous lesion, your doctor is going to be looking for pigmentary changes, lash loss, defects to the shape of the eyelid margins.

In a world dominated by trendy, oversized plastics, the spring 2014 runways brought a fresh look from designers -- metals.  Gone are the boring, unisex-looking metal frames that made many Americans hate wearing glasses in the past.  This new take on metals has all the power and punch of color of any plastic, but some added perks too.