Eyedolatry

Not Just For Summer Whites

2014 fall glasses fashion 7:00 AM

White glasses and sunglasses were all over multiple designer's collections for the spring and summer, but I don't see white leaving us when Memorial Day hits our calendars. White glasses are so bold and graphic in a world where colorful plastics have dominated eye wear for the past several years. We traditionally associate whites with spring and summer, but making a bold statement is in style every month of the year. Here are a few good reasons to bring white into your wardrobe, even if you are looking ahead into fall fashion.

Mixing white with gold is always a winning choice. Gold metal accents always transition well into fall and winter because of the warm color palate that we typically associate with these seasons. If you break down the color theory, by pairing white (a cool color) with gold (a warm color) you are achieving a look that should be great with any outfit, any skin tone, and any season. via

I know they are rather avant garde, but I have been a huge fan of Prada's collection this year featuring oversized plastics with large gemstones. Where the loud color combos used in other sunglasses in this collection can look almost juvenile (bright yellow sunglasses and cobalt blue bedazzles anyone?), the white on white look is much more sophisticated. It could look great even with a white wool coat, scarf and hat in the middle of winter. via

I would wear these glasses every day if I owned them. Literally every day. When I saw them on Eye See Euphoria, it was just love at first sight. The art deco-inspired detailing over the browline is a nod to another major trend in eyewear, making this pair of glasses really fashion forward for the moment. via

Round is not leaving us any time soon, and as the trend sticks around more and more people are beginning to dare to try it. If you want a younger and more fun look, then you need to go big with this trend. Oversized plastics in round shapes are almost cartoon-like, but there is no denying that you are making a statement.Wildfox Round White Sunglasses via

If you like the idea of white round sunglasses, but want a more mature and sophisticated route, look for a frame that is more delicate in size. Round glasses are always going to look very graphic because you are creating a new shape on your face, so keeping the size smaller and the color more subdued can make round glasses actually wearable for the average person. These Rochas frames are a really understated take on the trend, and therefore much more wearable than your average round pair of glasses via

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Differentiating True Optic Nerve Edema

differenting true papilledema optic nerve edema 7:00 AM

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Need a Better Artificial Tear? Try Retaine MGD

best artificial tear recommendation 8:00 AM

I don't know that there is a medical marketplace so oversaturated and underperforming as artificial tears. Just ask 10 people who complain that their eyes are red or burning or dry what eye drops they are using and the variety of answers is astounding. Depending on the OTC drops you purchase, you may be experiencing really poor relief of your dry eye symptoms, and could even be making your symptoms worse! (Please, please, don't buy those red eye drops. They are full of preservatives that are making your eyes much worse!)

Your tear film is made of 3 layers. The lipid layer (surface
coating) is usually the one that is compromised in dry eye,
so the best artificial tear drops will help replace or stabilize
this lipid layer. via

With so much variability in drop quality and performance, I never recommend to my patients to buy just artificial tears, but always encourage the use of high performing products. My brands of choice include Systane, Refresh, Soothe, Blink, Genteal, and Theratears. But even though these companies make very good, high performing artificial tear supplements, for some patients their eyes are still irritated and uncomfortable within even just a few minutes after dosage. This is because artificial tears just aren't made to last on the eye's surface -- in fact water-soluble molecules common in over the counter artificial tears are usually gone from the ocular surface after just 2 minutes of being on the eye. Researchers have been working for years to find a molecular make-up to keep moisturizing eye drops on the eye longer, but without blurring up your vision or creating stinging or discomfort. In 2002, Allergan's Restasis was one of the first eye drops on the market to present a good solution -- an ophthalmic emulsion drop that combines oil in water to increase the adhesion of the drop to the ocular surface.

Ocusoft (Novagali Pharma) has been a leading innovator in the field of dry eye; their lid scrub products are my go-to for improving meibomian gland dry eye issues. Researchers at the company have taken the success of the Restasis emulsion platform for keeping moisture on the eye longer and integrated it into their new artificial tear: Retaine MGD. The drop has been available for a few years, but was difficult to come by since it was made in France and only available for purchase through your doctor or the Ocusoft website. With a nationwide roll-out earlier this summer, you can now find this great artificial tear at your local pharmacy and on Amazon.

via

So what makes Retaine MGD so special?

Cationic Ophthalmic Emulsion -- Not to get too heavy into the science, but if you want to get something to last longer on the cornea, you need to find away to get the moisture molecules in the artificial tear to stay attracted to the corneal surface for a long time, instead of just blinking right off like most artificial tears do. The key is in electrostatic molecular attraction -- the corneal surface has an overall negative ionic charge, so the Retaine MGD emulsion is formulated with a positive molecular charge to "stick" to the surface. Opposites attract- it is a law of the universe.
Lipid-Stabilizing Molecular Make Up -- This drop is called Retaine MGD for a reason. MGD stands for meibomian gland dysfunction, the most common cause of dry eye. The meibomian glands are oil glands that secrete the top-coat of the tear film, slowing evaporation of your mostly water-based tear film off of your eye. In meibomian gland dysfunction, the meibomian oil glands are faulty, meaning that the tear surface is unstable and can quickly evaporate. Retaine MGD is formulated to help support and reinforce your natural lipid top coat, helping keep your own tear film on your eye longer!
Preservative Free -- Preservatives are great to kill bacteria and pathogens, but what is toxic to bacteria is also toxic to your eye. Preservatives are the main source of burning and stinging for most people when they use OTC eye drops, and the more you use a drop, the more toxic preservative you are exposing yourself to. Preservative free drops reduce this irritation, and make it safe to use the drops as often during the day as you need without causing dryness as a side effect of your eye drop use!
Long-Lasting but Not Blurring -- When you insert this drop, you will notice it is quite thick. But amazingly this thickness does not result in persistent blurry vision. This is because the ionic charge of the molecular makeup causes Retaine MGD to spread evenly over the ocular surface as you blink, and then stay evenly spread in between your blinks. The effect is a noticeable feeling of comfort, without the blurry vision induced by similar thicker drops like gel artificial tears currently on the market.

Some of the Cons

Like all products, Retaine MGD isn't without its drawbacks. With the benefit of being preservative free comes the downside that the drop must be packaged in single use vials to prevent contamination. Single use vials can be difficult to handle for people that struggle to put in eye drops or have a hard time squeezing the small bottle to get a drop to come out. The drop is also quite thick, so when I use it I find that I have a good deal of eye drop left in the vial after I have put a drop in both eyes, but there is no way to recap the vial or store it for later use.

Take Home

I would definitely recommend Retaine MGD for patients that experience dry eye regularly. It works great for high demand environments like people that are all day computer users or that have to fly often for their jobs. If you have tried artificial tears and feel like they don't work for you, then you need to try Retaine MGD before you throw in the towel. This drop feels amazingly comfortable on the eye, and it can provide much longer relief time than similar over the counter products that aren't gel-based. Remember, even though Retaine MGD has a great contact time and moisturizing effect, it does not in any way change your personal body chemistry or your tear film production. Restasis is the only prescription dry eye treatment on the market that can increase your natural tear film production; Retaine MGD is an over the counter moisturizing agent. If you are looking for a good over the counter product that could help solve your issues, put down the Visine and try a high quality, long lasting product like Retaine MGD. But if your symptoms of dryness and discomfort persist, then it is time to seek you eye doctor's help in what the available treatments are for more aggressively addressing your dry eye issues.

Disclaimer: I am in no way affiliated with Ocusoft or receiving any benefit for posting about their products here.

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Update on Discontinued Color Contact Lenses

acuvue colors discontinued 7:00 AM

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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