Macular Degeneration is the leading cause of blindness in the United States.  It can be found during routine eye exams, but don't wait to get your eye health checked until you have vision issues!  There is no cure of macular degeneration, and treatments that exist work best when started early in the disease process!

With Medicare announcing its 2012 payments last month, ophthalmology had a microscope upon them as questions about why $20 million was paid out to a single ophthalmologist in Florida that year.  While there is an investigation about whether these charges were fraudulent, the entire world of ophthalmology has been getting lambasted in the press over the expensive use of Lucentis to treat wet macular degeneration.



You see, Lucentis costs Medicare about $2000/injection.   But Avastin, a drug made by the same company (Genentech) that is biologically similar, cost only $50/injection.  

Lucentis is a "snip"  off the larger Avastin molecular, designed to be specifically used in the eye via

Why aren't ophthalmologists saving Medicare (and taxpayers) an estimated $1 billion by using Avastin? These recent news articles would lead you to believe they are the exact same drug, with the exact same efficacy.  And it is true that studies have shown Avastin and Lucentis do have a very similar efficacy when used to treat macular degeneration.  But Lucentis has been FDA tested and approved for intravitreal injection to treat macular degeneration, and Avastin has not.  Avastin usage in the eye is still considered "off-label" since Genentech has never sought FDA approval for this use of Avastin.

Doctor's use off-label applications of medications very frequently, and using Avastin for macular degeneration does have science to support the doctor's decision to do so.  But are we forgetting why so many doctors that were often using Avastin made the switch over to Lucentis in 2012 any way?

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Unlike Lucentis that comes ready from the parent company Genentech for doctors to inject in their offices, Avastin has to be compounded into formulation for ocular injection.  This is the job of a compounding pharmacist, someone that the ophthalmologist or surgery center would contract with to ready their injections.  Unfortunately Florida, Tennessee, Texas, and a VA hospital in Los Angeles all had separate instances of contamination during this compounding procedure in 2011.  At least 21 people across those instances were infected by the Avastin injection, and in some cases the infection resulted in blindness.  One of the patients that lost vision sued for a reported $4 million, with litigation against the ophthalmologist, the pharmacy, and Genentech who manufactured Avastin.

Under this heavy fire, here was Genentech's statement to the New York Times:

“Avastin is not manufactured or approved and to date has not been proven safe for use in the eye,” a spokesman for the company said Tuesday.

So why would any ophthalmologist be willing to risk infection of a patient by using Avastin, if they would not have the support of the company who made that drug?  It would be a huge financial and ethical risk if doctors did not disclose to patients this risk of infection (no matter how small), and if both treatments are covered by the patient's insurance, why would the patient choose the off-label treatment with infection risk, versus the FDA-approved treatment?

It has been hard reading the news the last few days as the media has continued to spin against ophthalmology's practices.  But the truth is, ophthalmologists were using the FDA-approved treatment they had on the market to treat a condition that is the leading cause of blindness in the United States. Would you want your parent or grandparent to be blinded by macular degeneration, when there is a safe, FDA-approved treatment?  Absolutely not.  And until ophthalmologists get industry and FDA support for using Avastin safely, why would they make the switch?  Doctors have to think about their patients, and not about tax payer dollars, unfortunately.  And when you are the patient looking at 2 treatment options: one FDA approved, and one not, which would you pick?  You probably aren't thinking about taxpayer dollars at that moment either; just about your vision which is in imminent risk of permanent loss.

Optometrists, ophthalmologists, healthcare practitioners of all branches, and mostly the patients who are getting these treatments need to band together right now for what makes sense.  This is not the time for finger pointing, even though the financial burden on our health care system seems so overwhelming, blaming someone is the easiest option to "fix" things.  We want the best treatments for ourselves and our families, and doctors want to offer their patients the best standard of care.  When we want so much, sometimes it starts to get expensive.  And unfortunately, there is just no one that can be blamed for that simple fact.

You don't need me to tell you that health care is changing.  In optometry, it sometimes feels like health care is changing every single day.  As insurers try to cut their own costs, many new policies are being explored in how insurances reimburse practices for services and goods.  Here's an example of a recently proposed plan by Superior Vision that was supposed to go into effect May 1st:

Let me start with a picture:

Remember, this (above) is what a normal retina looks like.  The red dot in the center of the photograph is the macula, and the yellow circle to the right is the optic nerve. Think of the nerve as a chord that hooks your eye to the brain, a high-speed information highway.  The above picture shows a textbook average optic nerve.  via

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Meet Dr. S -- a new member in the Eyedolatry team!

Introducing a new segment for the site -- please meet Dr. S, who has so nicely agreed to be our resident fashion columnist!  There are so many great looks for glasses out there, and who better to have the inside knowledge on the best new trends than an optometrist who spends all day with glasses?  We have a ton of great looks in store for you over the coming weeks, so stay tuned for regular posts featuring new glasses trends!

Today's feature: Two-Tones

The two-tone trend that has really taken the ophthalmic world by storm.  Two-toned glasses are popular for both men and women, and they are a great way to put a pop of color into your look without being over the top.  You can chose a subtle combo of tortoise and clear plastic, or for a bigger statement chose a pairing of brown or black with a bright color like radiant orchid (this year's pantone color of the year) or turquoise!


I love this pairing of two-tone with that bright pop of purple.  From a distance, the color is so subtle, but up close the statement is bold!

Frame: Kenneth Cole, Style 198, Color 005

For a more traditional take on two-tone, you can never go wrong with a pairing of tortoise and clear plastic.  The color combo draws your focus to your eye and not your glasses, a perfect way to wear plastic frames but get that light-weight look.

Frame: Marchon, Style Mulberry, Color: 601 (rose pink sheer fade)

All photos are via the talented Melissa DeLorme!  please check out her site for more info if you are in need of a photographer or want to learn more.

Fitting contact lenses can be such a routine after awhile, it's easy to forget about that little fitting guide the reps give you the first time a lens launches.  We all know how to do it any way, right?  Pick the right lens, the right add, and over refract.  But with the new launch of Ciba's Dailies Aqua Comfort Plus Multifocal which is utilizing the exact same multifocal design as their original monthly Air Optix Multifocal lens, let's take another look at the fitting guide because what's inside may surprise you.

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How good is good enough?  This is a question that many athletes find themselves wondering when it comes to eyesight.  Today's optometrists and ophthalmologists are investigating the challenges and demands of sports vision -- what advantages does perfect eyesight give to the world's best athletes, and how much of eyesight or visual performance is trainable?  With a ton of new research being produced, we may be able to maximize athlete's innate ocular abilities to give them the best chance to succeed in their field.

Correcting Vision to it's Maximum Potential

Pelli Robson Low Contrast chart--another measurement of vision performance.  Sometimes your eye's ability to detect contrast is poor, but your eyesight with the normal Snellen chart (that 20/20 measurement we all get with routine eye exams) is quite good.  Sports Vision specialists look at all areas of visual peformance, not just letters on one type of chart!  via

We all know that perfect vision is 20/20, but what if you could see better than that?  Many professional athletes see 20/15, 20/10 and even a shocking 20/8 (the best vision ever recorded by a human).  If you naturally are so genetically blessed to have 20/20 vision without needing glasses or contact lenses, but could get help to see 20/10, would it matter  in making you into a professional athlete?  Dr. Mike Peter's excellent book, See to Play discusses the disproportionately better vision that professional sports athletes have to the rest of the population.  So if you want to have your best chance of athletic success, correcting your eyes to their maximum potential may help get you there.

Depending on your sport, contact lenses, tinted sports goggles (especially great in baseball where a tint can help enhance the appearance of a white ball against blue sky or green field), or even LASIK or refractive surgery correction can help your eyes overcome any uncorrected prescription.  Contact lenses have often given athletes issues -- poor comfort, falling out during games.  Today's new generation of daily lenses are so thin that comfort is less of a problem than ever, and lenses like Ciba's Dailies Total 1 are a great option for someone needing high moisture content, but a lens that likes to stay on the eye (sometimes it is even hard for people to remove on purpose).  Maybe with a bit of help you can see that 20/10 or even 20/8 line.  What does that mean to you?  You are seeing a ball, a player, or any other target that much sooner than someone with 'perfect' 20/20 vision standing beside you.  This level of clarity is going to enable you to react faster, because you are seeing things much sooner than anyone else on the field!

Dr. Terry Kim of Duke (I am so lucky to have mutual patients with him in the Raleigh/Durham area!) was the doctor who brought Parker back to perfect vision by convincing him, yes contact lenses can help on and off the court!

A great recent example of how much vision matters on the basketball court is Duke's Jabari Parker.  Parker is nearsighted, but refused to wear his glasses or contact lenses growing up.  When he got to Duke, his vision was an atrocious 20/50 in the right eye, and 20/150 in the left.  In case you are wondering, no that is not legal driving vision.  But he had been successful enough to get recruited by Duke to play basketball with blurry vision, so how much of a difference did wearing his contact lenses make to his game?  Interviews with Duke coaches and staff suggest that Parker is now seeing cues from the sidelines without having to walk over to the bench during the game, able to read his teammates facial expressions for better on court interactions, and of course, able to perform better in the classroom where there has been a significant improvement in the ease with which he is able to study and perform classwork without headaches.  Did I mention he could now legally get a driver's license and operate a motor vehicle again?

But are there some advantages to blurry vision too?

That's an argument that might seem counter intuitive, but blurry may have some unrealized perks.  Take for example Olympic ice skater Jason Brown who ditches his glasses on the ice so that his blurry vision can let him focus on his own skating, instead of the crowd or judges.  A surprising result was also found in a study of basketball players with poor vision performed by optometrist Dr. Raymond Applegate.  He found a slight improvement in free throw percentage in players with 20/20 vision versus 20/40 (but statistically too small to be significant), but really no difference in made free throw success with vision of 20/40 to 20/250.  At a certain point, blurry was blurry and the amount of blur no longer mattered.

Imagine trying to focus on the rim with this circus in the background. Blurring that peripheral mess out is a skill that sports vision optometrists can help train!  via

Why did blurry vision have so little apparent affect on free throw shooting?  Perhaps it harkens to a sports vision training skill known as "the quiet eye".  Imagine shooting a free throw in game -- all those yelling fans, floating heads, balloons, and other shenanigans.  The "quiet eye" technique has players focus on just 1 point of the rim, and purposefully "blur out" the rest of their visual field.  In free throw shots, focus on just the one target is what matters, and the ability to ignore all else is actually helpful. Players with uncorrected vision didn't have to practice this technique; they could only focus on one point clearly anyway!  But if Dr. Applegate's study had had other measurables, wouldn't clear vision have been helpful on spotting that perfect entry pass, or reading someone's eyes for that steal?  Of course.  The best line of action is to make your vision perfect, and then train your eyes to focus on what you need.  That's the beauty of sports vision therapy!  Maximize the eyesight you have, and then train you on how to get your eyes to process the world depending on that particular moment's needs.

In future posts I hope to feature more sports vision topics and how optometrists and eye care specialists are helping future athletes achieve their dreams.  If you are interested in learning more, please head over to Dr. Mike Peter's blog about sports vision, and pick up his book See to Play for a more in depth understanding of how today's science can maximize the vision of tomorrow's sports stars.

While they are battling on the court, did you know these star basketball players are also battling poor eyesight?  Here's a look at college basketball's most prominent stars and their personal ocular challenges.

Rec specs or sports goggles protect the good eye and are made from shatter-resistant material like polycarbonate or Trivex via

Isaiah Austin's right eye prosthetic is almost indistinguishable from his normal left eye.  That's the power of a great prosthetic -- they can be hand painted to perfectly match your other eye!  via

Otule volunteers with visually disabled children often due his own inspirational story of achieving success despite blindness in one eye via

Hard to believe, but it has been since around 2007 since we actually got a new monthly contact lens.  (The Purevision2 lens that launched a few years ago was a recycling of an older material).  In these past seven years, the market has shifted drastically towards daily use lenses, but monthlies continue to dominate the marketplace due to their excellent price points for every day lens wearers.  The big knock against monthlies?  Comfort.  Wouldn't it be nice if they made a monthly lens that felt a lot more like a 2 week or a daily lens?  Well, maybe Bausch and Lomb has finally accomplished just that.

My personal pair of Ultra lenses. Note they dropped "Purevision" from their packaging all together.  B+L is going in a different direction this time

Cosmetic injections and fillers are old news at this point -- we all know that they are commonplace among Hollywood's aging stars, and they have become routine enough in the general population that no one bats an eye at a little Botox or the idea of a lunch-hour cosmetic filler.  But just because dermal injections are increasingly popular (a reported 2.2 million cosmetic injections were performed last year alone in the US!), doesn't mean they are without risk.  A new report published in this month's JAMA (Journal of the America Medical Association) links 3 cases of dermal filler injections with central retinal artery occlusion, an ocular condition that results in permanent vision loss.

Most dermal fillers are tested and approved for use around the nose and mouth.  In all three reported cases of central retinal artery occlusion with injection, the site of injection was the forehead--an "off-label" site that is commonly preformed at this time, but may be more tightly regulated against in future.  via

Lack of oxygen causes a whitening of the retinal tissue, causing the macula  to appear darker red due to contrast (called "cherry red spot" macula).  Note also the attentuation (narrowing) of the arteries and veins and the whitening of the optic nerve where it has also suffered cell death via

Let me tell you just one more thing that I love about being an OD -- optometry is such a small community, your classmates and colleagues are going to be constantly sharing their work (and life) experiences with you!  When you get done seeing your day's patients, you may have 1 or 2 of your friends patients to discuss too via texted images.  As a huge optometry nerd, yes, I enjoy this very much.

There was a ton of great eyewear on stage Sunday night at the 2014 Academy Awards, and here's a recap of some of the night's best looks.  Meryl Streep was really the only female holding strong wearing her glasses with her red carpet look, but for the men, glasses were a very common accessory!  Black frames were the overwhelming favorite, likely since more colorful glasses might have looked too casual for black tie affair.

Giving an eye exam to a screaming 2 year old with zero attention span may be the least exciting part of your optometric day.  But I am here to offer you my quick and easy guide to making the most of the 5-10 minutes of information retrieving you may be at the luxury of obtaining.  Here's my quick and easy guide to making the most of your toddler or challenging pediatric exams.

Yes, if you Google a diagram of corneal layers this image is the first to come up.  No, it is no longer correct.  Not even Google can keep up!  via

Remember when we all thought the cornea was just five layers thick?  These were simpler times, when diagrams were neatly organized and mnemonic devices were memorized -- the ancient history of pre-June 2013.  That was when Professor Harminder Dua of the University of Nottingham first published his discovery of a layer just 15 microns thick between the corneal stroma and Descemet's Membrane which he named Dua's layer.  The thin corneal layer is surprisingly tough, able to withstand up to 2 bars of pressure.  Due to it's properties, it has been used as a guidepost for surgeons in corneal transplants, banking on the toughness of Dua's layer to determine the depth of their incisions.

Chicks have long been used to help investigate refractive error development since their ocular model closely resembles the development of our own  via

So little is really understood about the progression of myopia (near-sightedness).  Many of my patient's parents are quick to blame computer games and the large amounts of homework required by schools as to why their children's vision is getting worse from year to year, but these culprits are too simplistic.  Genetics, environmental influence--it seems to all be connected.  But new research points to a surprising new potential culprit -- light.

Around 2011 several reports came out linking myopia to reduced sunlight exposure in studies performed with baby chicks.  Sunlight, it appears, increases the rate of release of retinal dopamine, which inhibits growth rate of the eye.  Myopia is a result of light falling in front of the retinal photoreceptors, most often due to a longer than normal eyeball.   The more the eye grows, the more near sighted a person will be.  Researchers suggest 10-14 hours per week of outdoor light exposure may help slow myopia progression, but more studies need to be performed for this effect to be truly demonstrated.

A new study published in December takes our understanding of light's effects on myopia to a new level.  In their experiment, Foulds et al separated baby chicks into red light and blue light exposure groups with a 12 hour on/off cycle for a period of 2-6 weeks.  The results were amazing -- the red light group showed marked progressive myopia and the blue light group showed progressive hyperopia (far sightedness).  And then they did something even more impressive -- by putting the red-light raised chicks with now high-induced levels of myopia in blue light for 3 weeks, they reversed the myopia.  The same held true for reversing the hyperopia.

So what does this mean for us?  We are a long way from putting your child under blue light for 12 hours a day, but we are beginning to understand what is happening on the neurologic level of the eye when refractive error is created.  So many of our methods of reducing myopia have shown limited response, but maybe the future looks brighter.  If you are worried about your child developing high levels of near sightedness, my best recommendation to you is get them involved in outdoor sports.  Wear proper sun protection of course, but the more time spent outdoors with ambient light levels, the better your child's chances look for a lower prescription!