Eyedolatry

Why Aren't You Wearing Sunglasses? Surprising Data from The Vision Council

Eyedolatry Sunglasses Initiative 8:00 AM

Raleigh, North Carolina -- I am officially calling you out. We all know that we should be wearing sunglasses every time we step outdoors, right? According to recent data published by the Vision Council, it may be time to rethink this assumption. Surprisingly large amounts of surveyed Americans not only are not wearing their sunglasses, they don't even associate sunglasses wear with health benefits. Here are some of the survey findings that may shock you (all results are from the 2012 Vision Council report):

27% of Americans don't wear sunglasses, at all
20.2% believe that they "are not at risk from sun exposure"
10.8% responded that wearing sunglasses "is not important to them"

As an optometrist practicing in Raleigh, it was really disheartening to learn that so many of my fellow Raleighites don't wear sunglasses. In fact, only 26% of those surveyed in my community wear sunglasses on a regular basis. Unfortunately, the Raleigh area has a large amount of risk for UV damage during the year -- 29.86% of days out of the year have a UV exposure classified as extreme or very high risk for damage. So by not wearing sunglasses, my fellow citizens are exposing themselves to high risks for damage. We are getting UV exposure even on cloudy or overcast days -- but why aren't we protecting ourselves?

Top 25 American Cities with the highest number of days of extreme or very high risk UV damage. Unfortunately, some of these cities are also some of the worst at wearing sunglasses or believing in their importance via

Sunglasses are an item so ubiquitous in today's society, they sometimes seem like more of a fashion statement than a medical device. The great thing about sunglasses is that they are truly both. Just like dermatologists are checking your skin for possible cancerous growths from UV damage, your optometrist is checking your eyes for UV damage at every yearly visit. By looking for cataracts, eyelid cancers, and growths on the white of the eye like pinguecula and pterygium, your eye doctor can find early sun damage and intervene before it is too late. If you are one of those people who think sunglasses are inconvenient, or not important for you, please take a step back to reconsider. The UV damage you are exposing yourself to today will not affect you for years, but by the time you have vision loss from cataracts or macular degeneration, it is too late to change your habits. We live in a world where information is right at our finger tips, so let's start with something easy that can make a difference in your health for the rest of your life. It all starts with just putting on your sunglasses. Follow our lead, or any of the other trendsetters or bloggers or celebrities that are so much more stylish than we claim to be, but are setting a great example!

Dr. L wearing Maui Jim

Dr. S wearing her favorite cat eye shaped shades

For more articles about why sun protection matters and what your doctor is looking for during an examination that is evidence of sun damage occurring in your eyes, please follow these links:
one, two, three

Images of Dr. S and Dr. L are courtesy Melissa DeLorme Photography

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Plaquenil Retinopathy: The Risks and What Your Doctor is Looking For

fundus autofluorescence plaquenil bulls eye 7:00 AM

via

Have you ever been prescribed a medication where vision loss was a potential side effect? For many people suffering from chronic inflammatory conditions, they are faced with a decision to take a medication that can help, but needs careful observation to prevent possible permanent vision loss. Plaquenil (hydroxychloroquine) is an anti-malaria oral medication that is more commonly prescribed in the US for inflammatory conditions like systemic lupus erythematosus, rheumatoid arthritis, and Sjogren's Syndrome. This medication can help combat the crippling side effects of chronic inflammation, but it is not without its own potential risks. If you have been prescribed Plaquenil, your rheumatologist likely referred you for a routine eye examination. One of the uncommon side effects of this medication is vision loss, but since the damage can be permanent, this is a toxic effect that you and your doctor will be closely monitoring for.

Luckily Plaquenil maculopathy (damage to the central vision area or macula) is quite rare. Much less than 1% of users develop this side effect, but there are several factors that can increase your chance of having vision damage due to the medication:

Increased Risks for Plaquenil Toxicity

> 5 years on medication

>1,000g total dosage (the average recommended dosage is 400 mg daily)

Elderly age

Systemic Health issues: high BMI, liver or kidney function issues

Previous Ocular Disease

What does Plaquenil Toxicity Look Like?

During your yearly eye examination your eye doctor is looking for changes called "Bulls Eye Maculopathy". These are pigmentary changes typically in a target or ring pattern occurring right at the central vision area. Rarely enough, I have had a patient with confirmed plaquenil maculopathy. She presented with 20/20 vision in both eyes, but her macula looked like this:

Unfortunately the pigmentary "bulls eye" changes that occur in plaquenil toxicity are a late stage finding, meaning that typically there has been structural damage and vision loss by the time these changes are observed on your eye exam. As such, your doctor will be performing routine screenings with more advanced technology, separate from your comprehensive examination to ensure that there is no early damage developing. These tests can include color vision screenings, central visual field tests, and periodically are required to include macular thickness scans (called OCT imaging), multifocal ERG, or fundus autofluorescence. If you want to learn more about the required testing, and how often federal medical standards require that they be performed, follow the link to this post.

FUNDUS AUTOFLUORESCENCE showing photoreceptor damage in Plaquenil induced "Bulls Eye" Maculopathy via

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Plaquenil Retinopathy Screening Requirements: Are You Up to Date on the New Standards?

OCT bulls eye 7:00 AM

Macular OCT is one of the three ways that you can meet the
standards for current Plaquenil care. Most optometrists have easy
access to OCT imaging, and may even have autofluorescence cameras.
MultifocalERG is the least likely test that will be found at your local
eye doctor's office, but some surgery centers or larger teaching
hospitals may have an ERG on site. via

In 2011 the American Academy of Ophthalmology published new clinical guidelines for appropriate annual screenings for those patients taking Plaquenil. These guidelines are much different from the previous 2002 recommendations, and many practicing doctors were trained with the 2002 guidelines in mind. Here are the new recommendations for how frequent and what tests should be performed with today's standard of care for Plaquenil patients:

1) Initial Baseline Screening upon first prescription:

Full comprehensive examination with dilation and/ or fundus photography to assess baseline macular health
Other possible screening tests: color vision testing, visual field 10-2 central field testing
One of the Required Standard Testing Items:

Required Standard Testing Items (this is the most important thing you can read on this post because this is the big area where guidelines have changed).

ONE of the following items MUST be performed: macular OCT, multifocal ERG, or Fundus Autofluorescence

2) Determine Risk (Low or High)

Risk is based on patient's health, dosage (400 mg or less is the recommended daily dosage, so if the patient takes more than this they are at higher risk), and the initial baseline testing of macular health. If the patient is low risk (low dosage, good systemic health, no ocular health issues found on initial screening), then regular annual examinations-- without needing one of the above required standard testing items--should continue yearly for the next five years.

3) 5 Years Of Dosage and Thereafter

Begin yearly performance of 1 of the required standard testing items (either OCT of macula, multifocal ERG, or fundus autofluorescence) in addition to the yearly comprehensive examination. The risk for toxicity increases after 5 years on the medication, and this why more intensive testing begins at this point.

OCT of Macula with Plaquenil induced Bulls Eye Maculopathy c/o Dr. Nathan Goldberg

Visual Field 10-2 with Plaquenil induced Bulls Eye Maculopathy c/o Dr. Nathan Goldberg

Take Home:

Remember, visual field 10-2 alone is a no longer standard of care. It is a good supplemental item, just like macular photography and color vision testing. But at the baseline exam and beginning at 5 years and thereafter of the patient taking the medication at least one of the required sstandard testing items has to be performed every year to meet these new guidelines. Amsler grid testing is no longer recommended at all.

Special thanks to Dr. Nathan Goldberg for allowing me to share his images

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Finding Multiple Sclerosis During Your Eye Exam

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Multiple Sclerosis is a medical condition that has become very personal to my heart. My husband works for a company that specializes in making MS medications, and as an optometrist, I see patients regularly that have been diagnosed or are starting new treatments that could even have ocular side effects (Gilenya). Interestingly, many cases of MS are originally found during a routine eye exam. My patients often ask me what I would see in a patient with MS to prompt an investigation for the disease. Here's a break down of the most common ocular signs that your doctor is looking for that are suspicious for MS:

1) Unilateral Vision Loss

The most commonly associated ocular finding with MS is sudden onset vision loss due to optic neuritis (an inflammation of the optic nerve). The amount of vision loss can vary, but typically ranges from 20/60 to 20/200 in the involved eye. The typical patient population are females age 20-30, but males can be affected as well. A hallmark is associated pain with eye movement in the eye with vision loss due to the swelling of the nerve behind the eye. In the majority of presentations, there will be no visible swelling or edema at the optic nerve during the eye exam -- most cases are retrobulbar optic neuritis meaning the swelling is happening behind the eye. The presenting symptoms will guide your optometrist to make the correct referral for MRI to find this swelling behind the eye, and perhaps other white matter lesions in the brain that can indicate a diagnosis of MS.

Optic Nerve Edema (swelling at the optic nerve) is a hallmark of optic neuritis. Unfortunately, MS is
more commonly associated with retrobulbar optic neuritis, meaning that the eye will look perfectly normal
during your eye exam.

2) Decreased Light Sensitivity or Color Vision in 1 Eye

Optic neuritis can cause more than just vision loss. The optic nerve delivers all visual information from the eye to the brain, so swelling along the nerve can disrupt all visual transmission. Colors out of the affected eye may look washed out or less saturated. Lights may look dimmer. Your optometrist may perform some comparison tests to try to categorize this difference by looking for differences in color and brightness perception between the two eyes. The "Red Cap" test where your doctor has you grade the degree of redness that you see between the two eyes is a common in-office measurement.

This is a great artistic rendition of an abnormal red cap test result. The normal eye on the right has better
color saturation of the red eye drop cap than the eye on the left in this case. Via

3) Visual Field Defects

Running a visual field test on the eye with optic neuritis can show areas of significant change. Most commonly the affected eye will show central visual field loss -- either a central scotoma (area of field loss) or a generalized depressed response of the central 30 degrees of vision.

4) Decreased Eye Muscle Movement Ability or Double Vision

Sudden onset double vision is another symptom that needs immediate investigation. The most commonly associated defect with MS is called INO or internuclear ophthalmoplegia. To put in layman's terms: the affected eye can't turn in towards the nose. This means when one eye moves to turn out, the other eye is pointing straight ahead because it can't move to turn in. As a result of this misalignment, you will see double vision (would cause horizontal diplopia, or two images side by side). Other common eye muscle anomalies during MS include nystagmus, where the eye makes jerky back and forth movements.

Recovery:

The good news is that most patients will recover from vision loss when optic neuritis is the culprit over a period of 6-12 months. 85% of patients return to 20/40 vision or better. Despite visual recovery over time, light and color sensitivity may remain abnormal out of the affected eye indefinitely. There is a very strong association between an optic neuritis event and later onset of MS: 75% of women with optic neuritis will go on to develop MS over the next 15 years, and 40% of males.

If you have sudden vision loss, it is always best to call your eye doctor immediately to schedule an examination. Unfortunately, vision loss in one eye (especially if it is subtle) can often go unnoticed because we keep both eyes open most of the time, and hardly ever compare the two. This is one reason why regular eye exams are so important; even if you feel your vision is great. Finding your glasses prescription is one of the least important components of an eye exam -- the health of your eyes is really a window that your doctor uses to assess the health of the entire rest of your body!

via

Have you or a loved one been diagnosed with MS? I am partnering with Healthline to promote their video campaign: "You've Got This" where people living with MS can post inspirational video messages that can inspire and encourage others who are recently diagnosed. Visit the link here to check out the videos or post your own! Healthline is donating $10 for every video submitted so please take some time to post your story or words of hope for this great cause!

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Celebrate July 4th!

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Can Genetics Impact the Right Vitamin Recommendations in Macular Degeneration?

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Ocular vitamins have long been a mainstay for macular degeneration management, since the first AREDs study was reported back in 1999. Subsequent investigations have adjusted what vitamins to include in our recommended formulas: removing beta carotene, adding lutein and zeaxanthin, not adding Omega 3s... It has been an active and ongoing investigation to determine which supplements truly seem to help. But a recent article published by Dr. Awh in Ophthalmology has raised a new question: does your genetic make-up influence what supplements work for you? The results were surprising, and have the ocular medical world taking a second look at just how important genetic testing with macular degeneration might be.

Dr. Awh's study is a review of AREDS study results, dividing the study into 3 different genetic groups and running a "sub" analysis of the data. He parsed the study participants into different categories based on the presence of known genetic polymorphisms linked to macular degeneration: complement factor H (CFH) and the aptly named gene age related maculopathy sensitivity (ARMS). The results were surprising: the presence of certain genetic markers appeared to correlate with very different levels of effectiveness with vitamin supplementation. These patient groups not only did not appear to benefit from certain supplements, they seemed to get worse!

The Break Down:

Published data from Dr. Awh's review showing different breakdown of genes performed better with different
nutritional supplementation routines via

The AREDS study participants when separated by their genetic profiles appeared to perform better with specific components of the standard recommended AREDS vitamin supplementation plan. 2 ARMs genes? Prescribing antioxidants looked to make these people worse; zinc alone worked better! 2 CFH genes? Adding zinc seemed to make things much worse, and anti-oxidants only was the better path. The sub analysis appears to demonstrate that the supplements that may help some people with macular degeneration, may actually hurt other people with the disease, all based on their genetic make up.

What does all of this mean?

Genetic testing is officially not recommended by the American Academy of Ophthalmology for macular degeneration at this time, and these study results alone will not be enough to turn the tide. While the results are initially compelling, there have been numerous holes punched in the design of Dr. Awh's review. The biggest flaw is that Dr. Awh's report was a subanalysis of an existing study -- a study not designed to separate treatment for macular degeneration based on genetic make up. While 1000 people were included in the study, there was not an even distribution of different allele types. We also have to keep in mind that the AREDS study itself shows only modest benefit for nutritional supplementation, but since we have no effective treatment for dry macular degeneration at this time, it is one of the few recommendations that can be made. AREDS reports that there is only a 25% reduction of risk that macular degeneration will progress with the addition of AREDS 2 formula vitamin supplementation. That means 75% of time macular degeneration will still progress, even if you take the supplements. Not exactly the ideal treatment plan.

With the new data published, despite its shortcomings, we have to consider that genetic testing and so called "personalized" medicine might be the future for health care (but likely a very distant future). Macular degeneration is not the only condition where multiple genes and polymorphisms are involved, meaning that in each person there might be an individual profile for how the disease will behave and respond to treatment. The cost to the health care system not only to perform these genetic tests and assessments, but to bring to market medications specialized for individual genetic make-ups would be huge, and is one of the biggest deterrents at this time for getting genetic testing approved for medical coverage. We don't have any answers, so at this point in time the AAO is recommending that we continue to follow AREDS 2 guidelines for recommending nutritional supplementation in macular degeneration. Here is a review of the current guidelines:

When to Treat? Intermediate or Advanced Macular Degeneration

Intermediate AMD: extensive intermediate sized drusen (64-124 microns), more than one large (>125 microns) drusen, or non-central geographic atrophy.
Advanced AMD: Central geographic atrophy or neovascularization causing vision loss (visual acuity worse than 20/32) in one eye.

via

Note for OD readers: the average optic nerve is 1500 microns, and the average vein width at the nerve is 120-150 microns, so if the drusen is about the width of the vein as it exits the nerve, then it is a large drusen.

AREDS 2 Recommended Formula

500 mg vitamin C
400 iu vitamin E
10 mg lutein
2 mg zeaxanthin
80 mg zinc
2 mg copper

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Pages

Why Aren't You Wearing Sunglasses? Surprising Data from The Vision Council

Plaquenil Retinopathy: The Risks and What Your Doctor is Looking For

Plaquenil Retinopathy Screening Requirements: Are You Up to Date on the New Standards?

Neon Glasses Love

Finding Multiple Sclerosis During Your Eye Exam

Celebrate July 4th!

Can Genetics Impact the Right Vitamin Recommendations in Macular Degeneration?

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