Eyedolatry

Update on Discontinued Color Contact Lenses

I have had quite a few emails and posts wondering about the status of Ciba Vision's other color contact lens options since their launch of the new Air Optix Colors. As of July 2014, this is the memo that Ciba Vision has circulated to doctors and contact lens distributors for the future availability of their older color products:

Freshlook Toric Handling Tint Single Trials: Discontinued July 31st, 2014
Freshlook Colorblends Toric Boxes: Discontinued October 31st, 2014
Focus Softcolor Single Trials: Discontinued Immediately
Focus Softcolor Boxes: Discontinued March 31st, 2015 (or as supplies last)

There is no plan at this time for another color toric (or astigmatism) contact lens to be on the market from the Ciba Vision company. I am uncertain of the future option of an Air Optix for Astigmatism Color lens, but I imagine it would be several years away at the earliest.

The recommended replacement for Focus Softcolor lenses are Air Optix Colors or Freshlook Dimensions.

What to do if your lens has or is being discontinued?

Orion BioColor and BioColor Torics are a customizable soft
contact lens made by Alden Optical. These are
special order contact lenses requiring more sophisticated
contact lens evaluation and fitting process. At this time
BioColor is one of very few color contact lenses that are
available in astigmatism correction.

If you wear Freshlook Coloblends Toric, it appears that you should be able to continue to purchase boxes until October 31st. Certain distributors may no longer have the lens in stock, so you may need to call around if your vendor or doctor's office is unable to secure the lens for you. Your best bet is to order through a doctor if you are having trouble because they can order personally and directly from their Ciba company representative if there are any boxes left in your power or color to be had. After October 31st, if you would like to continue to wear color contact lenses with astigmatism, there will no longer be a readily available option. Ask your doctor if they offer custom contact lens fitting and the prices for this service. Custom contact lenses like Orion BioColor Toric come in a range of astigmatism and color options, but these lenses are specialized, made to order contact lenses. That means a more time consuming ordering and evaluation process, and typically a higher cost of goods and service. If you are interested in exploring custom astigmatism color contact lenses, your doctor will be able to tell you if it is a service they can provide, and the cost that this process and the lenses would require.

It is always frustrating when your favorite contact lens gets discontinued. Remember when they stopped making Durasoft colors? Remember when Acuvue discontinued all of their color contact lens options? In the future we may have more color options available again for people with high prescriptions or astigmatism, but it may take some time for new lenses that meet the FDA's safety protocols to get tested and approved to bring to market. Your doctor will work with you to find a lens that provides the health and comfort and vision that you need, but color options may be limited to the world of custom order for those in more specialized prescriptions for the time being.

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An Eye Obsession

charlotte olympia eye clutch 7:00 AM

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Investigating the Visual System with MEM Retinoscopy

Dr. S vision therapy 9:00 AM

We have discussed the symptoms that clue you in to an investigation for visual system inefficiencies, but what tests during your examination yield the most useful information? In the coming posts we will be diving in to Dr. S’s normal and preferred battery of testing for a visual system evaluation. Today’s topic: near retinoscopy and what it can reveal about the patient’s focusing system strength and ability.

MEM Retinoscopy

When: All patients under age 18, adults that are in school or are complaining of fatigue with near work (under age 40 when that would be atypical).

Why: MEM stands for Monocular Estimate Method and is a dynamic retinoscopy, meaning the patient is doing an active visual process while being observed. Unlike standard retinoscopy that we use to find a distance prescription, MEM retinoscopy reveals the focusing system’s work or effort (accommodation). Ideally the patient will under-accommodate for a target; +0.50D to +0.75 “lag” of accommodation at near is considered normal. A higher than normal lag of accommodation means that the focusing system is under-accommodating at an abnormal level, and a “lead” of accommodation means that the system is over focusing. The lead or the lag is not the real problem, but an adaptation of the visual system to deal with excessive visual strain. It is quite common for people with binocular visual issues to develop accommodative lag or lead to compensate for their focusing inefficiency. For example, a patient with esophoria (an over-convergence of the eyes when focusing together) may have a high lead of accommodation at first because their accommodative and vergence system are over-acting due to the stress on the system. When this finally takes a toll on the eyes, a high lag forms in an effort to reduce the action and reduce the stress. Dr. S sums it up nicely when she says “it's not the lag or lead that causes the stress - it's the lag or lead that occurs because of stress.” Don’t view a lag or a lead of accommodation as the problem, but evidence that a problem exists that the patient’s focusing system is fighting to overcome.

How: We are measuring the person’s near focusing system response, so we need to get as true a measurement as possible of what real life is like for them. That means the patient should wear their glasses prescription, and the near target should be held at the patient’s working distance (called the Harmon distance in the optometry world) . A great way to do this is to hand the patient a book or magazine, and not say anything leading about where to hold things. Just see where they hold things naturally, and take a measurement of this distance. This is where you will hold your retinoscope with you are ready to start the test. On average we would expect a 40 cm working distance for adults, but depending on the person's arm length or the age of the child, it might be closer or farther.

The ideal target stimulus is the age appropriate MEM retinoscopy cards that usually come with your scope set when you purchased them at school. They are arranged with varying degrees of difficulty that you can select based on the patient’s grade level. In very young children the picture card would be most appropriate. Remember, you want the patient actively engaged, so if they seem bored or reading too quickly it could mean that your target is too easy. Stop and go up to the next difficulty level. With the picture cards you can even make a matching game by telling the child to “find the bicycle” or “find the cake”. You need to measure your patient’s response during the “finding” part and not when they have found the target to get meaningful data, so you have to be on your toes with this method.

MEM Retinoscopy Cards via

With your retinoscope in one hand, held at your patient's working distance, your other hand is now going to be ready to “dip” trial lenses in place to neutralize the reflex. You only want to keep a lens in place for about a second at a time to not disrupt the patient’s response, so again this is an act-fast skill. Dr. S has developed a great way of quickly collecting data, just by using a single +1.00D trial lens:

STREAMLINED MEM METHOD WITH JUST 1 TRIAL LENS

1) Dip +1.00 in front of the patient while they are reading. Did you see with or against?

If you saw with, then you know they have a higher than normal lag (at least +1.25 or higher)

If you saw against, then do a quick retinopscopy sweep of the eye without any lens in place

If you saw with, then you know they are normal
If you saw no motion or against, you know they have a lead in accommodation

Exact quantification is not necessary on this test, bracketing is really your best friend to make MEM retinopscopy both efficient and informative. Remember, when assessing accommodation with this method you are just trying to assess if the accommodation to the target is normal, and if it is abnormal, is it a lag or a lead? This information tells you if the visual system is compensating for another problem that you need to uncover and explore, and is not an end point to your investigation.

Since your patient is actively reading or playing a “finding” game during the process, your results are tied to the patient’s behavior. If you find the lens required for neutralization fluctuates, this could be a hallmark of accommodative spasm. Fluctuation can also be a product of the patient’s lack of attention though. The target you use is very important due to this – make sure it is not too hard and not too easy because the effort involved to focus can be swayed by this difficulty level.

What Did You Learn?

Expected results for a normal accommodative response is +0.50 to +0.75 lag of accommodation at a 40 cm working distance. In presbyopes, you would expect the response to be whatever their near add is for that person (it doesn't make much sense to do this for presbyopes, honestly, unless you want to find an add in a more creative way haha). If your results do not reveal this normal lag range, then there are a number of possibilities that could be on your differential:

High Lag ( >+1.00):

-Accommodative dysfunction

-Presbyopia or pre-presbyopia (if around 40)

-Uncorrected or under corrected hyperopia

-Over minused patient

-Esophoria with insufficient vergence (patient under-accommodates to keep fusion)

-Patient wasn’t paying attention during the test or the stimulus was too easy

Lead of accommodation (<+0.25D or if you neutralized with no lens in place or a minus lens)

-Spasm of accommodation --the system is locked up creating “pseudo-myopia”

-Exophoria with insufficient compensating vergence (patient over-accommodates to keep fusion)

-Uncorrected or under corrected myopia

Unequal Results Between the Eyes

-Monocular Amblyopia – Dr. S sees this quite a bit in her vision therapy practice where the amblyopic eye shows a much higher than normal lag response

-Anisometropia (unequal prescription) resulting in unequal accommodative demand

-Incorrect binocular balance during the distance Rx

-Adie’s Tonic Pupil (1 eye has loss of accommodation due to pupil abnormality)

Fluctuation of Response

-Accommodative spasm

-Loss of attention

-Streff Syndrome – a condition where the patient has normal prescription but has difficulty seeing at all ranges and even tunnel vision due to stress

Dr. S is a residency trained
Vision Therapist and Pediatric
Optometrist.

Take Home: MEM retinoscopy is really a quick test to get set up once you have practiced a few times, and can tell you if there are focusing system problems in a short and efficient fashion. Fused Cross Cylinder (FCC) is another test in the phoropter that can yield the same accommodative lag or lead results, but especially in young children this test can be difficult to get accurate or meaningful data. With FCC there is no way for you to actively tell if the patient is paying attention to the stimulus, and being behind the phoropter can really mess with a patient’s “normal” behavior pattern. With MEM retinoscopy you can actively visualize the patient’s behavior, making it a more ideal method for gauging response. Even if the patient struggles to read the card and stay focused long enough for you to perform a quick MEM, it can be telling. If the child can’t stay focused long enough for MEM, then it could mean that they actively avoid near work because reading and near activities have been so difficult for them. The patient could even be asymptomatic when you are discussing visual issues with them and their parent in the room because they have been avoiding all difficult activities (like reading)!

Stay tuned for more in office testing methods to come, enhanced by the insights of Dr. S.

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Off the Runway: Previewing Fall's Glasses Trends

fall 2014 fashion eyewear 10:26 PM

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

Eyedolatry Sunglasses Initiative 8:00 AM

via

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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