Many people remember the first time contact lenses hit the mainstream in 1971. But the idea for contact lenses is much, much older. That unparalleled visionary, Leonardo Di Vinci, drew a design for contact lenses back in 1508, which looked a lot more like a helmet than what we've come to know and love today. The lenses from the 40s described in the video below involved a rather invasive on-eye mold, and the lenses themselves were not for the light of pocket, coming in at over $4000 when adjusted for inflation. Looking back at images like this, less than a century old, just shows you the remarkable path of how far we've come in the world of ophthalmics!
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Storage Solutions for your Glasses Collection
For over a decade, researchers have been reporting great success in slowing down the rate of myopia (or nearsightedness) progression in children by using various concentrations of atropine. It's popularity in countries like China where as many as 80% of children are near-sighted has been steadily growing as more research is published, and with continued positive study results, atropine drops for myopia control may be a treatment we see more and more commonly in the US in future. In the past, atropine has been controversial for use in children because it is a potent pupil dilator -- putting in just one drop a day of the full 1% atropine concentration available in the US causes significant dilation and all its' side effects -- namely severe light sensitivity and an inability to focus clearly up close. That meant that any child taking atropine would have to wear tinted bifocal glasses in order to visually function during their school day. The new release of the ATOM 2 study (ATOM stands for Atropine for the Treatment of Myopia) once again demonstrated great results for slowing down myopia progression with atropine usage, but the best part is that a much lower concentration of the drop may be even more effective, minimizing these unwelcome side effect issues.
Let's Go Back to The Start: ATOM 1
To better understand the new study, let's review about the original ATOM study results that were published back in 2006. This study followed 400 near sighted children split into a control group (given placebo drops to use once daily in one eye) and a treatment group (prescribed Atropine 1% drops to use once daily in one eye). In the first 2 years, the treated group had a whopping 77% reduction in myopic progression as compared to the control group. However, when drops were stopped in year 3 a large rebound effect was seen in the treated group -- they progressed very quickly once they were off of the atropine drops. Because of these results, plus the side effects of atropine, the treatment didn't really take off as a viable means of myopia control in the US.
The ATOM 2 Study
Dr. Donald Tan and the other researchers that participated in both trials knew that atropine worked, but they wanted to find a way to make it a more viable treatment option. The ATOM 2 study looked at comparing lower doses of atropine to see if they could get a similar treatment effect with much fewer side effects. Again 400 myopic children aged 6 to 12 were followed for 5 years, but this time both of their eyes were treated with atropine. The children were split randomly into 3 trial groups: 0.5% Atropine, 0.1% Atropine, and 0.01% Atropine.
At the end of 2 years, all children were stopped for a 1 year washout. Just like was seen in ATOM 1, there was a rebound effect when the atropine was stopped, but the rebound was statistically significantly less in the 0.01% atopine group than in those children on higher doses. 68% of the 0.5% group had a progressive rebound of more than -0.50D during the washout year, compared to 59% of the 0.1% atropine group and only 24% of the 0.01% atropine group. The younger the child, the more likely they were to have a rebound effect.
Researchers then restarted any child that progressed more than -0.50D during that washout year on 0.01% atropine for 2 more years. At the end of the study, using the lowest concentration of atropine (0.01%) was shown to be as effective as higher doses in controlling myopia progression, but also had less patients to rebound with discontinuation of the drop, and less side effects of pupil dilation and near focusing issues. The use of 0.01% atropine slowed myopia progression by 50%, and those patients that had a rebound during their washout year that were then retreated had equally effective control once they were placed back on 0.01% atropine.
The Problems
The results of the study look very favorable for low dose atropine, but some issues remain specifically in the US market. As of today's publication, only 1% atropine is available commercially in the USA. It is possible to get a compounding pharmacy to dilute atropine to a lower concentration, but this can be difficult to find locally, and can result in high prices for the drops. A quick google search shows that a 5 mL bottle (should last about 1 month) cost $38.00 to have compounded in 2014. Another issue is how long should a child be left on atropine? Many researchers theorize for atropine to be an effective solution without rebound, a child would need to be on atropine until they are done growing (the highest risk time for myopia progression). This could mean using it through the early twenties for best control. For most children and parents, using a drop that creates more glare and light sensitivity becomes impractical when the child gets a driver's license, so using even low dose atropine after age 16 could be difficult to continue. Luckily the ATOM 2 study showed that older teens are much less likely to have a rebound effect than younger children. We also don't know exactly how atropine works to slow down myopia progression. Does it somehow signal the eyeball to stop lengthening? We can only theorize at the method of action for why atropine works at this time, but studies show very clearly that it does. If you want to learn more about the current research and theories behind myopia control options, head to the Patient Guides tab and scroll down to the Myopia Control section for a full list of articles.
In many Asian countries, myopia is a public health crisis -- the majority of children in these countries are developing myopia at a speed that leaves them dangerously near sighted as an adult. Highly myopic patients are at significantly greater risks for glaucoma, retinal degenerative conditions, and retinal detachments that cause permanent blindness. This advertisement was taken from the Singapore National Eye Centre -- showing just how quickly these countries are embracing new research as they fight to save their children's sight. In the USA we can't get 0.01% atropine commercially at this time. |
Let's Go Back to The Start: ATOM 1
To better understand the new study, let's review about the original ATOM study results that were published back in 2006. This study followed 400 near sighted children split into a control group (given placebo drops to use once daily in one eye) and a treatment group (prescribed Atropine 1% drops to use once daily in one eye). In the first 2 years, the treated group had a whopping 77% reduction in myopic progression as compared to the control group. However, when drops were stopped in year 3 a large rebound effect was seen in the treated group -- they progressed very quickly once they were off of the atropine drops. Because of these results, plus the side effects of atropine, the treatment didn't really take off as a viable means of myopia control in the US.
The ATOM 2 Study
Dr. Donald Tan and the other researchers that participated in both trials knew that atropine worked, but they wanted to find a way to make it a more viable treatment option. The ATOM 2 study looked at comparing lower doses of atropine to see if they could get a similar treatment effect with much fewer side effects. Again 400 myopic children aged 6 to 12 were followed for 5 years, but this time both of their eyes were treated with atropine. The children were split randomly into 3 trial groups: 0.5% Atropine, 0.1% Atropine, and 0.01% Atropine.
Pupil sizes were measured before treatment (labelled as baseline in the above graphic) in both mesopic (low light) and photopic (bright light) conditions. Children on 0.01% atropine had significantly smaller pupil dilation effect as compared to the larger concentration dosages. Their pupil size increased by about 1 mm on the 0.01% dosage. Only 1% of children taking 0.01% atropine reported glare symptoms, and none of the children had functional near vision loss side effects. via |
At the end of 2 years, all children were stopped for a 1 year washout. Just like was seen in ATOM 1, there was a rebound effect when the atropine was stopped, but the rebound was statistically significantly less in the 0.01% atopine group than in those children on higher doses. 68% of the 0.5% group had a progressive rebound of more than -0.50D during the washout year, compared to 59% of the 0.1% atropine group and only 24% of the 0.01% atropine group. The younger the child, the more likely they were to have a rebound effect.
Graph showing percent rebound during the year 3 washout. Rebound was defined as > 0.50D increase in myopia during that year. 0.01% atropine group had statistically significantly less rebound than the 0.1% and 0.5% groups (green bars = 0.01%, light blue = 0.1%, and dark blue = 0.5% graphically above). Also note that the older children had much lower rebound risk than younger children, implying that rebound might not be a significant issue if drops are used through the early teenage years. via |
Researchers then restarted any child that progressed more than -0.50D during that washout year on 0.01% atropine for 2 more years. At the end of the study, using the lowest concentration of atropine (0.01%) was shown to be as effective as higher doses in controlling myopia progression, but also had less patients to rebound with discontinuation of the drop, and less side effects of pupil dilation and near focusing issues. The use of 0.01% atropine slowed myopia progression by 50%, and those patients that had a rebound during their washout year that were then retreated had equally effective control once they were placed back on 0.01% atropine.
The Problems
The results of the study look very favorable for low dose atropine, but some issues remain specifically in the US market. As of today's publication, only 1% atropine is available commercially in the USA. It is possible to get a compounding pharmacy to dilute atropine to a lower concentration, but this can be difficult to find locally, and can result in high prices for the drops. A quick google search shows that a 5 mL bottle (should last about 1 month) cost $38.00 to have compounded in 2014. Another issue is how long should a child be left on atropine? Many researchers theorize for atropine to be an effective solution without rebound, a child would need to be on atropine until they are done growing (the highest risk time for myopia progression). This could mean using it through the early twenties for best control. For most children and parents, using a drop that creates more glare and light sensitivity becomes impractical when the child gets a driver's license, so using even low dose atropine after age 16 could be difficult to continue. Luckily the ATOM 2 study showed that older teens are much less likely to have a rebound effect than younger children. We also don't know exactly how atropine works to slow down myopia progression. Does it somehow signal the eyeball to stop lengthening? We can only theorize at the method of action for why atropine works at this time, but studies show very clearly that it does. If you want to learn more about the current research and theories behind myopia control options, head to the Patient Guides tab and scroll down to the Myopia Control section for a full list of articles.
I have to admit, when I heard about the launch of Acuvue Oasys 1-Day this fall, I was a bit confused about what was missing in the premium contact lens market place that another spherical daily contact could fill. Acuvue already had a silicone hydrogel lens in Acuvue TruEye, which never really took off as a premium product because it was too stiff in lens texture to keep pace with Dailies Total 1 in patients with sensitive or dry eyes. But Acuvue's latest launch is a truly successful contact lens that not only will compete with the two other premium lenses on the market, Dailies Total 1 and MyDay, but also offers the widest fitting range for a premium product to date.
The Details:
Power Range: +8.00 to -12.00
Base Curve: 8.5 and 9.0 in all power options!!
Diameter: 14.3
Material: Silicone Hydrogel/ senofilcon A with 121 Dk/t (oxygen transmissibility)
What's Different:
Acuvue Oasys 1-Day changes up the moisturization polymers within the popular Oasys senofilcon A material to create a lens that's made to lock in hydration and achieve that "no lens" feel. You'll notice "HydraLuxe" on the packaging which is a new innovation in their "Hydraclear" moisture network for keeping the Acuvue lens comfortable all day long -- this time the moisture particles (polyvinylpyrrolidone or PVP) are bound within the lens in a matrix that's made to mimic the mucin layer of your natural tear film, simulating your own eye to prevent lens drying. The lens is also packaged in a saline solution set to mimic the salinity of actual tear film, meaning less irritation or discomfort when you put the lens on your eye straight out of the package. Another difference is the increased diameter of the lens. At 14.3 mm it is one of the larger contact lenses on the market, which allows it to drape over a larger range of corneal shapes and sizes. They also expanded out the optical zones of the lens to help increase visual performance for patients with larger pupils. Like all Acuvue products the lens comes with a light blue visibility tint, and Class 1 UV protection against UV-A and UV-B rays.
My Take:
This is a truly comfortable contact lens, and where I never found Acuvue TruEye very comfortable (I'm pretty intolerant to most silicone hydrogel lenses, even dailies), this lens performed on par with Dailies Total 1 and MyDay in my experience. The truth is that all three of these premium contact lenses are fantastic in my book, and as a consumer and patient I would have a hard time deciding which one worked best for me. We are in a true renaissance for contact lens comfort and performance, but the biggest limiting factor on these premium contact lens products has been their limited parameters. This month Dailies Total 1 is now expanded to include plus powers, so now all three lenses are available to hyperopes as well as myopes. There are still no premium lens products for astigmatism or multifocal needs at this time. One place where Acuvue may have a leg up on it's competition is that it offers two base curves, letting patients with significantly flatter corneas enjoy the comfort of a premium lens product as well. It also handles extremely well compared to Dailies Total 1 which is known to be especially slippery when trying to remove from the eye. If you are having a hard time getting Dailies Total 1 out at the end of the day, Oasys 1-Day may be the product that you prefer.
While for me there is no clear winner against these three lenses for best performance, I'd love to hear your opinions! Please post your thoughts on this new product so we can learn more about what works for you and what doesn't.
Thursday our office got a phone call for an emergency work-in appointment. A 13 year old boy got hit in the eye playing flag football at school, and now 2 hours later his vision was getting blurry. A history like this definitely warranted him being seen as soon as possible, so thirty minutes later he was in my chair. My technician gave me a quick over view before I went into the room, but I heard only one sentence before my mind immediately grasped out situation. "And I can see blood in his eye!" A red eye is one thing, but when you see blood actually trapped inside the front of the eye, we're onto something much more serious.
In addition to paralyzing iris constriction and dilation with a cycloplegic drop, the patient needs to decrease their own movement as much as possible too. Bed rest with the head elevated until the blood has fully reabsorbed is the general rule of thumb. At 13 years old, our patient was told to stay home from school (we supplied a note) and he was to stay in bed and rest as much as possible, getting up when necessary to only to eat, use the bathroom, and come to our office for follow-ups. In cases of smaller hyphemas, the patient is typically monitored every 48 hours until the blood has reabsorbed to ensure improvement without rebleeds.
I wish I had taken a picture of my patient, but the presentation was almost identical to this photo via |
Hyphema is the medical term for a collection of blood cells in the anterior chamber of the eye (between the cornea and the iris). Typically we see hyphema after blunt trauma to the eye, like being hit in the eye with a ball or an elbow. The blood is typically due to a damage to the tiny blood vessels that run through the iris and the muscles around the iris (the ciliary body). Because your eye is bleeding internally, it can't escape and is suspended within in the anterior chamber and begins to collect at the bottom of the cornea. Vision is going to be cloudy because there are blood cells circulating inside the eye, but as a response to injury your body immediately mounts an inflammatory attack sending white blood cells to the area too. Now you're looking through blood, and your body's own repair mechanism of proteins and inflammatory cells (called cells and flare). Vision is going to be noticeably blurry as a result, and you well likely notice a significant increase in light sensitivity and a feeling of deep aching in and around the eye.
As a result of inflammation and red blood cells being trapped in the eye, your intraocular pressure is going to shoot up. My patient's IOP was 39 at presentation (and his other, uninjured eye was only 19). The biggest risks for permanent vision loss due to hyphema is from untreated inflammation leaving IOP elevated for too long and causing glaucoma, or that the eye continues to rebleed, resulting in permanent clarity loss as red blood cells stain the cornea. As many as 38% of people with hyphema will have a rebleed, which makes bed rest an essential part of your management plan.
We typically see hyphema in the office due to injuries during sports, but they can also occur spontaneously in patients using strong blood thinners or with hemolytic conditions. The patient above had hyphema secondary to warfarin use. via |
How To Treat
Depending on the amount of blood filling the anterior chamber and the age of the patient, you may be referred to a hospital setting to better monitor improvement around the clock and ensure absolute bed rest. My patient only had about 10% of the anterior chamber filled with blood, which is quite commonly managed by your local optometrist or ophthalmologist in an out-patient setting. The main goals of treatment are to reduce inflammation and stabilize the iris to reduce the risk of rebleeding.
1. Assess The Risk
The eye just suffered a blunt trauma, so you need to make sure there is no retinal break or detachment going on inside the eye. With smaller hyphemas it's easy to get a view inside the eye after dilation; large amounts of blood in the anterior chamber may restrict the view too much. This is where a referral for possible ultrasound may be necessary to make sure the patient doesn't need concurrent retinal detachment repair.
2. Stabilize The Iris
In office I went ahead and put in a drop of Atropine 1% to dilate the iris, giving me a great view of the retina to assess for a detachment, but just as importantly stabilizing the iris so it can't move around in response to different levels of light. Prescribing a dilating agent until the blood has fully reabsorbed is a mainstay of hyphema treatment. Atropine 2 x a day or Cyclopentolate 2-3 x a day are great options. Homatropine used to be a favorite choice of doctors but it's not commercially available anymore.
In addition to paralyzing iris constriction and dilation with a cycloplegic drop, the patient needs to decrease their own movement as much as possible too. Bed rest with the head elevated until the blood has fully reabsorbed is the general rule of thumb. At 13 years old, our patient was told to stay home from school (we supplied a note) and he was to stay in bed and rest as much as possible, getting up when necessary to only to eat, use the bathroom, and come to our office for follow-ups. In cases of smaller hyphemas, the patient is typically monitored every 48 hours until the blood has reabsorbed to ensure improvement without rebleeds.
3. Reduce the Inflammation (and the IOP)
There is a ton of internal swelling going on, and a steroid eye drop is essential here. Prednisolone acetate every 2 hours for the first day or two and then tapered in accordance to improvement is a good option. Remember to shake a lot when using generic prednisolone. Studies show that some generic versions of prednisolone need to be shaken as much as 50 times to get into proper suspension. For a time I tried to write branded Pred Forte only so my patients wouldn't have to deal with this crazy amount of shaking, but most pharmacies won't have branded prednisolone in stock, and your patient doesn't need to be waiting 24 hours to start treatment. Go with generic for expediency, but shake and shake and shake.
Because the blood in the eye is such a huge irritant (and a major trigger for inflammation!), starting the patient on prednisolone is usually all you need to bring down the IOP as well. You can additionally add an IOP lowering agent like timolol (twice daily) or brimonidine (two to three times a day) if greater control is needed. Prostaglandin analogue glaucoma drops aren't a good choice here because they increase ocular inflammation. On prednisolone and cyclopentolate alone our patient's IOP dropped from 39 at presentation to 21 at the next visit. We will continue to monitor IOP, presence and amount of red blood cells, and check for retinal breaks or tears every 48 hours until all blood has reabsorbed. Typically we'd expect resolution of hyphema in a healthy patient with only a small bleed to occur within 2 week's time. Avoiding another injury soon after hyphema is essential for minimizing risks of rebleed. Taking time away from contact sports for a few months is a good way to lower the chance of another injury so soon after the first.
This time of year there are usually a lot contact lens problems popping up -- patients coming in with red eyes, infections, or just trouble wearing their lenses all day. One of the best ways to keep your contact lenses problem-free and keep you out of your doctor's chair (and potentially out of contact lenses for a few weeks as your eye heals!) is to rethink your cleaning regimen. Prone to infections? Overwearing your lenses, sleeping in your lenses, or not cleaning them properly are the three biggest reasons most people get contact-lens related infections. Contact lenses drying out or causing irritation? Again, overwearing your lenses, sleeping in your lenses, or not cleaning them properly are the three biggest reasons most people have trouble with contact lenses during some parts of the year and not others. The first two are no-brainers: throw your lenses away on time and take them out every single night. But wouldn't it be great if there was one solution that both killed bacteria and removed surface debris to leave a fresh, clean lens for the next morning? Luckily someone has already invented the answer and it's hydrogen peroxide based contact lens solutions, but only about 11% of contact lens wearers are using this technology. With new improvements in this technology coming out this year, there's more reasons than ever to make the switch to the product that can change how you view your contact lenses.
CLEAR CARE Gets An Upgrade
Out this fall is the latest version of CLEAR CARE, the hydrogen peroxide solution that really set the standard for safety and performance for the last few decades of lens wearers. The solution still requires 6 hours (overnight) to neutralize, and there is no change to it's anti-microbial properties. But the solution now includes an extra hydration polymer called "Hyrdaglyde" that helps prevent drying out of the contact lens as it goes through it's life span (be that 2 week or monthly). This polymer is also in the new OPTI-FREE PureMoist solution.
Sometimes my patients will ask me if using CLEAR CARE is too harsh for their eyes. On the contrary, hydrogen peroxide solutions are the only preservative free lens cleaners on the market so compared to multi-purpose solutions these are way less harsh and great for sensitive patients or those with hypoallergenic needs. One thing traditional hydrogen peroxide solutions could do though was potentially dry the lens. Yes this solution removes debris, but that extra cleaning may wear on the moisture layers on the front and back surface of your contact lens too. That's the concept behind the new addition of moisture "boosters" like Hydraglyde in CLEAR CARE. Now the solution is deep cleaning, and adding back moisture to the lens at the same time.
New Smart Contact Lens Case Tells You When Your Lenses Are Clean
One of the potential knocks against hydrogen peroxide contact lens solutions is how do you know when your lenses are ready to wear again? If you don't neutralize the peroxide long enough (for CLEAR CARE, that's 6 hours and for PeroxiClear it's 4 hours), then your lenses will sting your eyes really terribly when you try to put them back in. The FDA has recently approved NovaBay's Intelli-Case, a contact lens case to be used with peroxide solutions that tells you where you are in the cleaning process. When your lenses are ready, the light turns green on the top of the case, telling you it's safe to insert them in your eyes.
The company plans to have the case widely available for purchase in 2016. Currently, the packaging of Intelli-Case will be included in a bundle with 2 bottles of NovaBay's own hydrogen peroxide solution, NovaClear, with recommendations that each case would last for 60 days (through 2 bottles worth of solution) before needing to be changed.
CLEAR CARE Gets An Upgrade
Out this fall is the latest version of CLEAR CARE, the hydrogen peroxide solution that really set the standard for safety and performance for the last few decades of lens wearers. The solution still requires 6 hours (overnight) to neutralize, and there is no change to it's anti-microbial properties. But the solution now includes an extra hydration polymer called "Hyrdaglyde" that helps prevent drying out of the contact lens as it goes through it's life span (be that 2 week or monthly). This polymer is also in the new OPTI-FREE PureMoist solution.
Click over to get your $5 Coupon off a bottle of CLEAR CARE Plus |
Sometimes my patients will ask me if using CLEAR CARE is too harsh for their eyes. On the contrary, hydrogen peroxide solutions are the only preservative free lens cleaners on the market so compared to multi-purpose solutions these are way less harsh and great for sensitive patients or those with hypoallergenic needs. One thing traditional hydrogen peroxide solutions could do though was potentially dry the lens. Yes this solution removes debris, but that extra cleaning may wear on the moisture layers on the front and back surface of your contact lens too. That's the concept behind the new addition of moisture "boosters" like Hydraglyde in CLEAR CARE. Now the solution is deep cleaning, and adding back moisture to the lens at the same time.
New Smart Contact Lens Case Tells You When Your Lenses Are Clean
One of the potential knocks against hydrogen peroxide contact lens solutions is how do you know when your lenses are ready to wear again? If you don't neutralize the peroxide long enough (for CLEAR CARE, that's 6 hours and for PeroxiClear it's 4 hours), then your lenses will sting your eyes really terribly when you try to put them back in. The FDA has recently approved NovaBay's Intelli-Case, a contact lens case to be used with peroxide solutions that tells you where you are in the cleaning process. When your lenses are ready, the light turns green on the top of the case, telling you it's safe to insert them in your eyes.
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Did you see this interview with last year's NBA MVP, point guard Stephen Curry? Curry is not only one of the NBA's best shooters, but his ball handling skills make him an elite passer and give him the ability to create his own shot (which is probably going in, let's face it). One of the key aspects to Curry's off-court training is his sports vision/vision therapy program. Check out his flashing light drill where Curry has to respond to different colored lights on a screen while dribbling a ball.
via |
Interested in the drills Steph Curry uses? The FitLight Trainer system can be used in endless new combinations to train peripheral awareness and hand/eye or even foot/eye coordination. Check it out here:
If you have a sports vision success story please share your link with us! I'd love to feature more vision therapy information on the blog!