One thing is certain in this life (besides death and taxes): eventually we will all get cataracts.  As one the most commonly performed surgeries in the USA, cataract removal is a highly specialized refractive procedure in today's world, restoring vision and also minimizing the reliance on glasses in some cases.  But while scientists have been perfecting artificial lenses (called IOLs), manufacturing a "holy grail" lens that focuses from distance to near like a young person's natural lens has proven extremely difficult. Imagine a world where you didn't have to implant an artificial lens that is limited by the physics of acrylic -- a world where you regrew your own lens that acted just like the 20 year old eye that you remember so fondly, adjusting freely to distance and up close ranges with reckless abandon.  Sound like a pipe dream? Not so fast.

An adult cataract via

Fresh off the presses in last month's Nature, scientists in China successfully regrew natural lenses in infants with congenital cataracts using their own lenticular stem cells. The idea to use stem cells to regrow a lens was a common nuisance following cataract surgery. Sometimes after removing the cataract and replacing it with an IOL, cells will grow across the implant and cause blur and distortion.  It's called posterior capsule opacification.  These cells are easily removed with a quick laser procedure, but where did they come from?  During cataract surgery, ophthalmologists leave the capsular bag of the natural lens behind to help hold and support the implant in its' proper place.  The capsule may have a few 'lens epithelial stem cells" or LECs as the study author refers to them left behind from the lens removal, which begin to divide and grow.  All this time doctors have treated these cells like annoying debris, but Dr. Lin and his team of researchers had a different opinion.  If these stem cells were growing, why wouldn't they keep growing a whole new lens?  They tested their theory in mice and rabbits, and when those studies proved effective they moved forward to the biggest challenge yet, human infants.

In 3 months, Dr. Lin's team reported the presence of a biconvex lens following cataract removal. A small 2 mm scar remained where the incision was made during cataract surgery that would have damaged the stem cells in that area.  Larger incisions would cause larger scars, making the surgery ineffective.  This is one of the reasons that many doctors question whether an adult procedure of this nature is possible; typical adult cataract surgery techniques require incisions 3 times larger than those used by Dr. Lin and his colleagues.

There are very few options for infants born with congenital cataracts; implanting IOLs to correct vision after removing the cataract causes significantly more issues in babies than in adults, and many doctors prefer leaving the child aphakic (without any internal lens) and relying on contact lenses for vision correction to avoid the risks.  Dr. Lin and colleagues conducted their research on a group of 12 infants with bilateral congenital cataracts. Half of the children were left aphakic (normal standard of care) using normal cataract extraction procedures, and the other half were left aphakic with "minimally invasive" cataract surgery that left layers of LECs behind. In 3 months a biconvex lens had regenerated in the eyes with stem cells left behind, and in 8 months that lens was the size and shape of the lens of a normal infant that had not undergone cataract surgery, and also showed accommodative (or focusing) ability. 

Game Changer?  Since we are dealing with infant eyes, we still know very little about how these regenerated lenses will perform visually in the coming years.  Will a cataract return much younger in life than expected? Will vision ever be truly normal? These are questions that only time will answer. The other pressing issue being raised is will this type of procedure potentially work in adults? Could we have a future where an 80 year old having cataract surgery will be able to regrow a brand new lens with all it's previous, youthful focusing ability? Doctors and scientists have raised several doubts:

• When Dr. Lin and his colleagues performed the "minimally invasive" technique required to leave behind enough stem cells to regrow a lens, they made only a small, 2 mm incision into the capsular bag.  In today's adult cataract surgery, a 6 mm incision into the bag is standard. Removing an adult cataract through such a small incision would be extremely challenging with today's technology, so we would need innovations to make this procedure possible in adults. 
• Could adult stem cells have the same capacity to regrow a lens as infant stem cells do?  Would you need to leave behind more of them to get the same result?  We just don't know what an elderly adult's stem cells would be able to accomplish yet.
• Will patients be willing to wait 3-8 months (or longer if adult stem cells work slower as some predict!) to be able to see again after cataract surgery? In today's world of IOL implantation, cataract patients see clearly the very next day.  Waiting for months at extremely high Rx ranges (without a natural lens, your Rx would hover in the +20.00  mark!) would probably be a dealbreaker for patients even considering this type of procedure.

You probably didn't see this one coming, but one of the biggest challenges new optometrists face is having an income for the first time. Living on loans for so many years of school, your first paycheck is an amazing luxury. And then every 2 weeks you get another one. But having an income can be a serious trap; we've all worked hard to get to this place where we finally can do things, buy things, travel, eat out, buy a new doctor appropriate wardrobe. With the luxury of having money for the first time comes a new problem -- you need to decide what to do with it. There is a strange paradox of having a great paycheck coming in (feeling you've made it!), but being deeply in debt from undergrad and professional school loans (nope, actually you are really, seriously broke still). Managing your money properly in those first few years after getting your first job can set the stage for your future financial success. Today's guest is Dr. Syed Hussain, the writer behind the informative and extremely readable financial strategies blog for professional students, The Broke Professional.  A 2009 graduate from the Pennsylvania College of Optometry at Salus University, Dr. Hussain has worked in nearly every type of modality of eyecare. He saw himself and fellow classmates struggle with financial decision making and planning after graduating, despite having good paychecks, and decided to do something about it!

Dr. Syed Hussain

Why did you decide on optometry? 
I come from a family of pharmacists which drove me to optometry since they warned me not to become a pharmacist.  All joking aside, I always wanted to work in the healthcare field and wanted a position that wasn't super stressful, has plenty of practice options and great income potential.  Optometry seemed like the best choice to me and still does.



You've worked in private and corporate settings.  What made you to decide corporate optometry was right for you?
I have been working full time in a corporate setting since 2010.  I enjoy corporate practice because I can still fully treat patients how I'd like and have free time outside of work to spend time with family and pursue my other passions (like blogging!).  

Now more than ever our patients are needing guidance for the right products for them -- what eye drops to use, what makeup can limit irritation, what cleanser can take it off without adding more chemicals to their irritated skin? We Love Eyes is a great product made by an OD who understands what patients truly need in skincare, and if you are an optometrist interested in carrying her product line in your office you can contact them to set up an account. For individual purchases you can buy We Love Eyes products directly from the website.

My Review



Both the We Love Eyes cleansing oil and the pump foam eyelid cleanser work incredibly well; with just a few swipes my makeup was entirely removed, and my skin felt hydrated and irritant free.  The cleansing oil especially left my eyelid area feeling extremely hyrdrated, and I could readily imagine my patients with chronic dry skin, rosacea, or eczema along their eyelids benefiting from regular use. And because this cleanser is so gentle, I had no irritation or discomfort cleaning right into my eyelash roots to remove mascara and eyeliner away from the waterline where our tear film glands (Meibomian glands) reside.




Let the picture do the talking.  I put 5 drops of the We Love Eyes Tea Tree Eyelid Makeup Remover Oil  on a cotton pad and gently swiped across my eyelid.  Makeup gone, no irritation, no burning, and the tea tree oil will fight inflammation and reduce skin bacteria counts the rest of the night!

Negotiation can be so intimidating for new doctors, so I was thrilled to get a chance to pick the brain of optometrist Mark Phebus, the expert behind 20/20 Consulting.  Wouldn't it be great if you had your own personal coach with years of negotiating experience to guide you through your contract and help find ways to maximize your offer? That's Mark.  He's a graduate of Indiana University School of Optometry with a residency in primary care and ocular disease and now practices in Charlotte, North Carolina.  Since he began practicing, he's worked in both private and corporate practice optometry, and learned firsthand the importance of negotiating his own contract in the trenches of these experiences.  He sat down with us to answer a few questions about how to make the most of your negotiation.

64.6% of all new graduates were female in 2014 which means now more than ever we need to make strides to close the gender pay gap in our profession.  photo is my 2011 graduating class from the Southern College of Optometry

• Experience:  Did you complete a residency? How long have you been working? Often times job postings are listed with new grads in mind so a doc bringing years of experience would be able to leverage that for a better initial offer.  If you are a new grad, there is still a chance you can advocate for yourself as bringing more experience that an average candidate despite your lack of prior work history or higher training.  Did you extern at a highly competitive or challenging environment?  Completing externships at VA hospitals or clinics offering specialization in pediatrics or brain trauma treatment can give you experiences that even older doctors can't match.  How many patients did you see during your externships?  Keep a log of the number of total patients you saw (I know it is tedious, but just keep a spreadsheet going that you update daily during your rotations).   You may surprise yourself (and your employer) by how many patients you have already cared for, despite your lack of traditional work experience as a new grad.
• Specialties: Does your employer have interest in bulding specialty contact lens services, pediatrics, vision therapy, or low vision? Even if you haven't actually had experience in these areas, just telling your employer that you are interested in developing that area of specialty to expand the scope of their practice can set you apart.  Of course, make sure you follow up by talking about what training you will do (educational events, online lectures, pursuing certification, etc) to make sure you can deliver on this promise for providing specialized care.
• Skills Outside of Patient Care: Think about work you did in optometry school or before that could be valuable to your employer in their office.  Did you perform research or publish journal articles? Did you work in an optical lab cutting lenses? You might not be logging optical hours grinding lenses for your new practice, but even if your employer doesn't have an in-house lab, your optical skill set gives your employer confidence that you will be a great resource working with the opticians in your workplace.  You can even offer to train new staff in their optical duties. 
• Languages: Being bilingual is a huge asset.  You can build up your employer's patient demographic in whatever language you speak.  
• Social Media: Maybe your employer doesn’t have a passable website, or isn't using social media to its fullest (or at all). You could employ your skill set towards creating a valuable digital footprint for the company.   These social media skills are increasingly recognized by employers because an ad for their office in the Yellow Pages just isn't going to cut it anymore. You'll be worth your weight in gold to many private practice ODs if you can come in and take over that side of the practice.
• Technology: Are you applying for a position where they have not yet changed over to electronic medical records?  The window is quickly closing on how long doctors have left to change over before penalties arise, and they need skilled, EMR ready doctors like yourself to get the system in place. As a new or recent grad. you have also just worked with the latest and greatest new technology in eyecare at your school. You were running all of your own OCTs and fundus autofluorescence cameras.  Not only are you now valuable to the doctors you work for because you can show them how to use new technology to its full capacity, but you can also help train their staff on the proper ways to run this equipment for quality scans.  

Want to add value to your employer's business?  Specialty contact lenses have a huge demand, and can quickly grow the practice you work at with referrals from other area doctors that don't provide such services. image via

1. They want to add monetary value to their practice by seeing more patients
2. They are looking to find a retirement  plan, and need to bring someone on to phase themselves out. 
3. They want both options 1 and 2 because retirement is at least five years away.

We've been fortunate in our industry to have several new multifocal contact lenses to launch in the past year that are offering significantly better optics for patients with higher reading needs.  Both the Clariti 1-Day Multifocal and the Acuvue 1 Day Moist Multifocal are fantastic lenses.  But we haven't had new innovations in a monthly multifocal contact lens material in quite some time.  Enter Bausch and Lomb's Ultra for Presbyopia. Built on the extremely comfortable Ultra monthly lens platform, the lens utilizes a 3-zone progressive multifocal design with a near center, gradually transitioning lens space to distance, reading, and intermediate zones.  The lens also has aspheric optics for enhanced distance vision and improved ability to compensate for low amounts of aberrations or astigmatism. On a personal note, many doctors note the steeper base curve of the Ultra lens as a potential issue for proper fit on patients with flatter corneas, but I have found that steeper base curve lenses can enhance visual acuity in multifocal lenses (the C-Vue Multifocal lens was almost always superior in the steeper base curve than in the flat). As long as the lens isn't fitting too tightly to be a health risk for the patient, the stepper base curve of Ultra may also be one of the advantages this lens has over it's competition for better visual performance.

Welcome to our first #WomenInFocus article!  I wanted to start things off at the very beginning -- starting salary is one of the very first numbers you have to evaluate when beginning your career, and one of the very first times that being female really comes into play in your optometric career as a disadvantage. Review of Optometry's 2015 income survey showed that the average full-time salary for male optometrists was 68% higher than the average full-time salary for women.  The average male OD made $171,603 and the average female OD made $117,020 last year.  Obviously we have an uphill climb in our industry to close this pay gap.  And Review of Optometry's numbers show the gap starts right from the beginning.  The average salary of a full-time female optometrist practicing for less than 10 years was 16% lower than that of male ODs with the same experience. 

via

So what's going on in our profession? I don't think that this salary difference ("more of a gulf than a gap") is a sign of overt gender bias in our profession.  For years optometrists have blamed age differences (more established docs are male and more new docs with less income are female) or a female OD's increased likelihood for working part-time hours to balance childcare as skewing the numbers to look worse than they really are.  But when you break down the categories to just new grads and just doctors working full time, that 16% pay gap in 2015 and 29% pay gap reported in 2014 still exist.

How can we close the gap?
First, we have to admit the gap is real across our profession and talk about it -- in schools, at meetings, and in publications.  I applaud Review of Optometry for reporting their data so carefully to prevent the gap in salary figures from being blown off as skewed data like so many articles I read when I first graduated.  And then as women, we have to admit to ourselves that we're doing something wrong.  Millennial women are often of the belief that the feminist battles have been won.  The very idea that we may be treated differently than our male counterparts seems absurd.  But then why don’t the numbers support our feelings of female equality being a forgone conclusion? The easiest explanation for what we can do to close the gap is to follow the lead of our male counterparts when it comes to income - bother to ask about your pay! Studies show that one of the biggest reasons women are paid less than men is because we don’t negotiate the initial offer of pay.  

Graduation day at SCO.  I feel like this photo symbolizes optometry today.  Male leaders in our profession are passing the baton to our generation of female ODs, but are we doing our part to grab hold?

Eyedolaty celebrates its 5th birthday next month, and it's been amazing how much has changed in the world of optometry in the short time since I began blogging.  We've grown from the days of a free blogspot domain posting pictures of conjunctival cysts and bad NBA glasses fashion, to a trusted optometric resource where thousands of readers around the world turn to find new technology and solutions to their unique visual challenges. There are more resources than ever for young ODs to find their way online -- from the educational articles at Review of Optometry, to the quick and fun guides at New Grad Optometry, and the inspirational success stories at Women in Optometry.  

Way back  in the archives to first year and the White Coat Ceremony at SCO

If you've ever looked in the mirror and seen this:

via

Thankfully subconjunctival hemorrhages look at lot worse than they truly are in most cases.  Blood is trapped on the surface of the eye due to a broken blood vessel in the conjunctiva (the vascular tissue that overlies the white of the eye). Because the conjunctival tissue is a vascular membrane, blood that leaks gets trapped underneath and can take 1-2 weeks to fully reabsorb.

What Caused This? 
The most common causes for subconjunctival hemorrhage are:

• coughing, sneezing, straining, heavy lifting, or vomiting These activities acutely raise blood pressure in the veins, causing a small rupture in the capillary bed where arteries and veins connect; it's called a valsalva maneuver.  
• injury 
• rubbing the eye
• trauma
• ocular surgery or ocular injections
• contact lens related injuries (inadvertantly pinching the conjunctiva for example when removing your contact lens -- about 5% of subconjunctival hemorrhages are related to contact lens wear) 
• uncontrolled vascular disorders like diabetes and high blood pressure, anemia, or blood clotting disorders
• blood thinning medications

via

• Aspirin
• Warfarin  
• Coumadin
• Heparin
• Plavix
• nutritional supplements (these also have blood thinning or anti-coagulation properties which can increase the risk of subconjunctival hemorrhage, especially when the patient is already taking other blood thinners, or when they have uncontrolled high blood pressure)
• Tienchi (Panax notoginseng)
• Garlic Supplement (Allium sativum)
• Ginkgo biloba
• Fish Oil/Omega 3 
• Bilberry (Vaccinium myrtillus)
• Less common but possible:
• abrupt changes in acceleration like sudden braking during a car accident
• abrupt changes in barometric pressure like scuba diving
• viral conjunctivitis (acute hemorrhagic conjunctivitis)
• vascular tumors (cavernous hemangioma, lymphangioma)

What Can I Do To Look Normal Again?
Unfortunately subcojunctival hemorrhages will reabsorb in their own good time.  There is no eye drop or medication that can make them heal faster.  Typically resolution occurs within 1-2 weeks, depending on the size of the hemorrhage.  If the hemorrhage happened at the top of the eye, it may actually look worse before it gets better as gravity brings the trapped blood downwards toward the lower eyelid area.

To potentially speed things up you should:

• Avoid blood thinners like aspirin or the supplements listed above if possible (it's best to consult with your primary care doctor before changing medication)
• Avoid intense weight-lifting workouts (heavy lifting can cause another break)
• Some people report success alternating a cool and warm compress (just held over the closed eye --no rubbing).  Heat can improve circulation to the area and potentially help breakdown clotted blood so it absorbs faster.  Cool compresses can reduce the swelling often associated with an acute hemorrhage by constricting the conjunctiva.

Need a painkiller but have a subconjunctival hemorrhage?  Tylenol and Ibuprofen have reduced risk of blood thinning as a side effect than aspirin.  via

An estimated 11 million Americans have macular degeneration, and with an aging population the number of new diagnoses are expected to sky rocket by as much as 50% by 2050.  As the leading cause of blindness in Americans age 60 and older, we are still without any cures for this blinding eye disease.  The mainstay of treatment in the early (dry) stages of macular degeneration is all about preventive care -- sun protection, stopping smoking, and nutritional supplements have all been shown to reduce the risk of progression.  A 2014 study published in the Journal of Neuoscience suggests eye doctors should be adding at least one more recommendation to that list -- regular exercise.

Macular Degeneration causes permanent disruption to the retinal tissue and central vision loss, and unfortunately in many people it continues to worsen despite the best treatment options available today.

The premise behind the study is one that eye doctors hold very near and dear in concept -- the eye is a part of the neurological system, made of the same tissue that comprises our brain and central nervous system.  Aerobic exercise has already been proven to be both protective and rehabilitative in neurological diseases, improving memory in those with Alzheimer's and nonmotor function in Parkinson's.  Could exercise also be neuroprotective or rehabilitative in eye disease?

The Set-Up
48 mice were divided into different treatment groups and macular degeneration was simulated by using Light Induced Retinal Degeneration.  24 mice were placed in the "exercise" treatment group: they used a treadmill 5 days a week for 60 minutes each day at a set speed.  These mice were "pretreated" with a 2 week regimen of exercise, then were exposed either to toxic bright light (10,000 lux)  for 4 hours to cause Light Induced Retinal Degeneration or dim light (25 lux).  Another 1-2 weeks of exercise followed. The other 24 mice were placed on a non-moving treadmill for the same 60 minutes a day, so no active exercise occurred. They were then exposed to to either the toxic or dim light stimulus and maintained without exercise for 1-2 more weeks.  Retinal function was measured using ERG responses at the end of the four week period.

The Results
As predicted, toxic bright light exposure (10,000 lux) resulted in significantly worsened retinal function. But even in those mice undergoing toxic light exposure, the mice who had received pre and post-exposure exercise had much better retinal function than the stationary mice.  Interestingly, the mice that were exposed to dim (non-toxic) light had better retinal function if they were exercised than if they were not.  Could exercise also improve retinal function in normal eyes? Possibly, according to this data.

A) Toxic Light Exposure mice had greatly reduced ERG amplitudes compared to those exposed to dim light, but in both groups, the exercise mice had better retinal performance than their non-exercised cohorts. C) In the toxic light exposure group, treadmill mice had much greater retinal function than stationary mice.  The a-wave amplitude measures cone and rod function in an ERG via

Structural changes to the photoreceptors were also found.  In the mice exposed to dim light, there was no difference in the number of photoreceptor cell nuclei in the the exercise or non-exercised groups. But in mice exposed to toxic bright light, the exercised group had preserved photoreceptor nuclei, while the stationary mice lost approximately two rows of photoreceptor nuclei and suffered tissue disorganization.

Compare the number of photoreceptor nuclei in C (non-exercised mice before toxic light exposure) to D (non-exercised mice after toxic light exposure).  Both exercised and non-exercised mice suffered photoreceptor changes after toxic light exposure, but these changes were significantly more severe in the stationary mice group. via

Conclusion
The data very clearly implies that aerobic exercise can help our retina better withstand degenerative events.  Researchers theorized that brain derived neurotrophic factor (BDNF) was the essential protein activated with exercise that had neuroprotective benefits. Could BDNF be isolated outside of exercise to help in the treatment of conditions like macular degeneration?  Previous studies have shown unwanted side effects with the injection of neurotrophic factors, so at this time exercise is the best and safest way to activate the protein. We don't yet know how much or how long a person should exercise in order to produce enough BDNF to be effective. The results are convincing enough that I now add exercise to my list of recommendations for how patients can help prevent macular degeneration progression, along with wearing sunglasses, not smoking, and nutrition/AREDS 2 vitamins.  It's also a great recommendation for people with genetic risk factors for macular degeneration -- this study implies exercise can protect against retinal damage, so starting regular exercise while the eyes are healthy could be essential to protecting life long vision.

CooperVision continues to streamline their portfolio of available contact lens products by dropping older low oxygen permeable hydrogel lenses in favor of newer technology.  Beginning in April, here are the changes in product availability:

Discontinued Trials, Boxes still Available
No trials means that doctors cannot start new fits for this lens, and they cannot order replacements for lost or torn lenses.  Usually discontinuing trials is a precursor to discontinuing the lens itself as a way to pull it off the market less abruptly.

• Biomedics XC (also called UltraFlex XC)  

• Frequency 55 Toric 

Note the slightly whitish hue of the drop inside?  That's because this product isn't water or saline but an oil-based emulsion that's made to act like a restorative version of your own tear film.