Battling Under Eye Circles: The Science Behind Your Favorite Fixes
100% Pure Coffee Bean Caffeine Eye 10:50 PM
What's the number one complaint over 50% of women have about their appearance? Under eye circles and puffiness plague people of all skin tones and complexions. Why do the eyes show their age so much more prominently than other facial areas? Let's talk the science behind eyelid puffiness and what to look for in products to depuff and brighten your eyes for a more youthful appearance.
It's obvious when you look at friends and acquaintances of your own age that more than just time affects how old you look. The aging process of the skin is complex; in addition to simple passage of time, genetics, sun exposure, diet, hormones, pollution, and exposure to chemicals or toxins in your daily environment all play a big role. Sun exposure especially will cause thickening of the epidermis (the surface layer of skin), resulting in dark spots and deep wrinkles and lines.
Why does under eye skin sag? The skin around your eyes is some of the thinnest in the body, with some of the weakest moisture barriers and lowest natural elasticity of all skin areas. As we age, our skin has significantly lower counts of "plumping" molecules like collagen and elastin that help support the link between the surface and deeper dermis skin layers. On average, we lose 1% of skin collagen for every year of life. With less collagen and elastin, our skin tissue begins to sag from lack of support, causing wrinkles, drooping eyelids, and those pesky under eye bags to develop.
Dark circles are also a side effect of the eyelid's thin skin. Without a thick barrier, it's easier to see the matrix of blood vessels running underneath the skin, resulting in a dark purplish hue. Anything that dilates (or enlarges) the blood vessels under the eye will exacerbate the appearance of dark circles. The most common culprits are dehydration, fatigue, allergies, hormone changes (estrogen levels especially influence changes in dark circle appearance), and even warm environments. Sleep itself actually causes dilation of the blood vessels too, which is why many people feel their circles are worse when they wake up first thing in the morning. When we are asleep, our body's sympathetic nervous system is greatly turned down, causing blood vessels to dilate as our body enters "rest mode." Sleep and dark or dim rooms (like what we often have using a computer!) cause our body's sympathetic nervous system to deactivate, so a side effect will be a more obvious appearance of under eye dark circles.
What Can You Do?
Aging is inevitable, but there are some things you should start doing now that can protect against more dramatic aging changes and help your under eyelid skin look its best.
When an optometrist takes over the post-operative care for their patients after premium IOL implantation, are there any common patient issues with these types of lenses that ODs should be familiar with or know how to troubleshoot?
Fashion it-girl Leandra Medine embraces her make-up free appearance, puffy under eye circles and all. via |
Why does under eye skin sag? The skin around your eyes is some of the thinnest in the body, with some of the weakest moisture barriers and lowest natural elasticity of all skin areas. As we age, our skin has significantly lower counts of "plumping" molecules like collagen and elastin that help support the link between the surface and deeper dermis skin layers. On average, we lose 1% of skin collagen for every year of life. With less collagen and elastin, our skin tissue begins to sag from lack of support, causing wrinkles, drooping eyelids, and those pesky under eye bags to develop.
Dark circles are also a side effect of the eyelid's thin skin. Without a thick barrier, it's easier to see the matrix of blood vessels running underneath the skin, resulting in a dark purplish hue. Anything that dilates (or enlarges) the blood vessels under the eye will exacerbate the appearance of dark circles. The most common culprits are dehydration, fatigue, allergies, hormone changes (estrogen levels especially influence changes in dark circle appearance), and even warm environments. Sleep itself actually causes dilation of the blood vessels too, which is why many people feel their circles are worse when they wake up first thing in the morning. When we are asleep, our body's sympathetic nervous system is greatly turned down, causing blood vessels to dilate as our body enters "rest mode." Sleep and dark or dim rooms (like what we often have using a computer!) cause our body's sympathetic nervous system to deactivate, so a side effect will be a more obvious appearance of under eye dark circles.
What Can You Do?
Aging is inevitable, but there are some things you should start doing now that can protect against more dramatic aging changes and help your under eyelid skin look its best.
- Sun Protection: From early childhood we need UV protection, including sunscreen and sunglasses to protect the delicate skin around the eyes. Once the skin becomes sun damaged, it's very difficult to erase dark spots from activated skin melanin or the thick wrinkles that develop as a result of UV damage thickening the epidermis. Prevention is always the best protection.
- Stay Hydrated: The skin around the eyes has a very weak moisture barrier, so we need a good daily intake of water to help counteract bags and dark circles. Dehydration causes the blood vessels under the eyelid skin to dilate, making a more noticeable purplish, dark bag. Alcohol, tea, and sodas can all act as diuretics that increase dehydration. Medications commonly prescribed for high blood pressure, diabetes, mood stablizers/anti-depressants, and allergies (yes - Benadryl, Claritin, and other OTC antihistamines are your enemy when it comes to staying hydrated!) also commonly have dehydration as a side effect.
- Adjust Your Screens: Do you work on the computer all day? Your work environment can wreak havoc on your eyes and eyelid skin! Make sure you have good lighting in the room where you work, preferably a window or natural light source. Working in the dark or in a dim room makes your body enter "rest" mode, so you'll not only feel more tired, but your blood vessels will dilate and you dark under eye circles will be more noticeable. The blue light coming from your computer screen, cell phone, and other digital or LED light sources can also create problems by disrupting your body's natural sleep cycle hormones. Wearing glasses with blue light protection (Crizal Prevencia anti-glare coating or Transitions XtrActive both have great blue-blocking effects) and using a free download for reducing blue light from your screen like f.lux can help.
And we wonder why we have dark, puffy under eyes the next morning? via - A Little Morning Pick-Me-Up When you first wake up, under eye circles are more evident until your body gets going and active. The blood vessels will begin to constrict and fluid that may have pooled in your under eye area will get redistributed once the sympathetic nervous system kicks into gear. But you can speed that process along by holding a cool compress to your under eye area to constrict blood vessels before applying makeup, and doing a little morning exercise to get blood pumping. Caffeine like that in your morning coffee can also constrict the blood vessels to improve under eye appearance, which is why many skin creams for under eye circles contain a caffeine additive.
- Use the Right Products The skin absorbs moisture both from the blood stream (internally) and externally (from skin creams and lotions). Certain under eye products not only hydrate the eyelid tissue, but also boost under eye circulation and reduce the appearance of dark spots. But be careful of the chemicals found in many popular drugstore brands, because they may actually cause dryness, redness, and irritation - counteracting all your hard work!
Metallic applicators like that used in the LA MER Lifting Eye Serum begin to depuff eyes immediately with their cool temperature. via |
- 100% Pure Coffee Bean Caffeine Eye Cream: Caffeine reduces the appearance of dark under eye circles by increasing circulation, and this vegan eye cream delivers both coffee and green tea extracts to pack a punch. Rosehip oil hydrates and plumps the skin. Paraben free.
- JUARA Miracle Tea Complete Eye Cream: This nightly cream combines an anti-oxidant packed kombucha tea extract to fight wrinkles and UV damage with marigold extract that stimulates blood vessel circulation to reduce the appearance of dark circles. Plus as a vegan product its free of chemicals that might be toxic to the eye area.
- Yves Saint Laurent Forever Light Creator Eye Fluid: Want a concealer that also works on the root of the problem? This concealer also hydrates and contains caffeine and vitamin C to depuff eyes.
- The Estée Edit by Estée Lauder Late Night Eraser Brightening Eye Balm with Pink Peony: Applied with a metallic "cooling tip" that will begin depuffing under eye bags on contact, this balm also has hydrating cucumber oils and reflective powders that help bounce light back off the under eye area, deflecting the appearance of puffiness. While reflective powders don't actually reduce your eyelid circles, the trick of the light reflecting does make them look less evident to everyone else.
- LA MER Lifting Eye Serum: LA MER products use algae to help build and restore skin's elastin production. It also uses a cooling tip applicator with massaging instructions to depuff on contact.
What not to use? Retinol is a beloved anti-wrinkle product, but it is much too harsh to use on delicate eyelid skin. Retinol products are strong skin defoliants, causing peeling, flaking and redness. There are many people that will experience puffiness and redness around their eyelids with any contact around the lid margin -- retinol dehydrates the skin to encourage exfoliation, which is why the eyelid skin will get red and puffy! Make sure you avoid any retinol creams around the eye to prevent this unwanted side effect.
One thing that hasn't been associated with eyewear for a while: "Made in America." For decades eyewear design and manufacture has been split into 2 realms: luxury craftmanship in European markets like Italy or France, versus low cost, mass produced frames made in high production markets like China. American eyewear designers were plentiful, but actual frame production was always sent overseas. Through the early 2000s, many American industrial cities were plummeting into economic crisis as manufacturing jobs continued to rush off shore to drive down production costs. But there were many in the world of optical that wanted to move manufacturing back stateside. Enter the team behind STATE Optical Co. - the first luxury eyewear brand to be designed and manufactured in the USA.
How did STATE Optical turn the tide? In 1977 Alan and Cynthia Shapiro founded Europa, an industry leading eyewear company out of their garage. Fast forward to 2011 when their son, Scott Shapiro began working with Europa president Jerry Wolowicz on ways to bring producation of acetate eyewear to the US. They had the will, but they needed someone with the know how and craftmanship expertise to actually manufacture luxury eyewear - rare to find in the US since the industry had been international for so many years. They teamed up with the improbable pair of cousins Marc Franchi and Jason Staley -- men with a history of working primarily in the automotive field that had a passion for making things with their hands. When they learned so few eyeglasses were made in the US, they started learning the trade on their own. "Of course everyone told them they were crazy, and that the idea wasn't economically feasible," says Scott Shapiro.
Franchi and Staley learned eyewear manufacturing from the ground up, touring manufacturing facilities overseas and observing craftsmen at work. "They literally taught themselves how to produce acetate eyewear," marvels Shapiro. Shapiro and Wolowicz were first introduced to the cousins when they came across their original made in America eyewear, "Frieze Frames." They were wowed by the quality of the frames, unparalleled in the small American eyewear market. The partnership was born: the cousins and now 45 additional highly skilled eyewear craftsmen now produce frames out of the state-of-the-art Chicago home of State Optical Co.
The Process
Check out the entire collection on their website and get sneak peaks into the manufacturing process and the detailed hand-craftmanship behind each frame on their Instagram account.
How did STATE Optical turn the tide? In 1977 Alan and Cynthia Shapiro founded Europa, an industry leading eyewear company out of their garage. Fast forward to 2011 when their son, Scott Shapiro began working with Europa president Jerry Wolowicz on ways to bring producation of acetate eyewear to the US. They had the will, but they needed someone with the know how and craftmanship expertise to actually manufacture luxury eyewear - rare to find in the US since the industry had been international for so many years. They teamed up with the improbable pair of cousins Marc Franchi and Jason Staley -- men with a history of working primarily in the automotive field that had a passion for making things with their hands. When they learned so few eyeglasses were made in the US, they started learning the trade on their own. "Of course everyone told them they were crazy, and that the idea wasn't economically feasible," says Scott Shapiro.
Franchi and Staley learned eyewear manufacturing from the ground up, touring manufacturing facilities overseas and observing craftsmen at work. "They literally taught themselves how to produce acetate eyewear," marvels Shapiro. Shapiro and Wolowicz were first introduced to the cousins when they came across their original made in America eyewear, "Frieze Frames." They were wowed by the quality of the frames, unparalleled in the small American eyewear market. The partnership was born: the cousins and now 45 additional highly skilled eyewear craftsmen now produce frames out of the state-of-the-art Chicago home of State Optical Co.
The Process
It takes about 75 steps to manufacture one pair of acetate
eyeglasses; about 50% of these have to be done by hand. Each of those steps takes place
in the STATE Optical factory in Vernon Hills, Illinois. The designs are created in Northern
California by head designer, Blake Kuwahara.
Blake Kuwahara is the lauded American eyewear designer behind his popular eponymous frame line and a recent capsule collection with l.a. Eyeworks to name a few |
The only two elements that aren't currently produced in the States
are the hinges (made by German OBE) and the raw material (made mostly by Italian Mazzuchelli). "Our big dream is that if we are able to prove there’s a market for a luxury
brand of eyewear produced here in the US, and we can bring a brand new cache to
the phrase, “Made in America”, then we expect that other companies will also
want to produce their luxury eyeglasses here in the US. If that happens, and
there are 5, 6, 10 factories producing luxury eyewear here in the US, then it
will be reasonable to produce raw acetate and metal parts here as well."
"Part of our vision for building this factory was that optical professionals and eyewear lovers from around the country could come to our facility and see how frames are made. When you buy a pair of STATE frames and open the case, you’ll see the statement, “come see how your frames are made”. Our factory is open to the public. Anyone can make an appointment for a factory tour right from our website, STATEopticalco.com."
Each STATE Optical Co design features a pyramid of 21 drill dots reminiscent of the stars on the United States flag to represent Illinois, the 21st state of the union. |
Breaking Out
STATE Optical Co. is very new to the market, but already having a big impact. "We soft-launched the collection at Vision Expo West in 2015 and attracted a
lot of attention. That was literally the first time anyone outside our company
had seen any of the frames. We showed it again at Vision Expo East and were mostly booked
the entire weekend."
"We’ve tried to be very controlled about the roll-out by only
placing the collection in a select number of doors. That allows us not only to
make sure we can properly service all our accounts with reorders, but it allows
me the opportunity to personally meet with the staffs of each office and talk
to them about our backstory and some of the features that really make the
frames unique."
The Reception
"The reception has been overwhelmingly positive. We knew there
was a significant demand within our industry for American made eyewear, and we
knew professionals would be proud to have it in their offices – people had been
asking us for it for years – so we knew people would be interested. That said,
I think even our most excited customers never imagined it would meet the
quality standards that STATE Optical Co. has achieved. Furthermore, most of our accounts are
reporting very successful sell-through, which means consumers and patients are
loving the product too."
Their most popular frames? The Halstead (above) and the Burnham (below). All frame names take a strong Chicago influence as you can see.
What's Next
"At VEW (Booth G22005) we plan to launch another 6 styles, which
will grow the entire collection by 50%. These styles stay true to the brand and
very much work within the aesthetic of the first 12 styles, but they also
branch out a little and will appeal to an even wider segment of consumers."
"Our major focus right now is just on continuing to increase the capacity of our factory, and Marc and Jason are continuing to train our craftsmen to perfect these long-lost skills. As we achieve that, we will be able to take on some of the other wild endeavors we have on our white board. As for now, we’re preparing to make 2017 a very big year for STATE Optical Co."
Check out the entire collection on their website and get sneak peaks into the manufacturing process and the detailed hand-craftmanship behind each frame on their Instagram account.
Common misconception: a glasses prescription isn't a finite, objective number. We don't use a machine to measure your eye and spit a number that's immutable and definite -- if we did it wouldn't look that great to you, the wearer. The visual system is so complex, involving not just the eye itself but the muscles in and around the eye and the visual cortex of the brain, that a measurement of the eye is just one component to a successful glasses prescription. When prescribing for children, doctors are at a distinct disadvantage because the subjective responses of the patient can be unreliable or just plain unusable. Some kids are shy; some are scared; some really, really, really want glasses. The latter are one of the most challenging because as a concerned parent you might worry something must be horribly wrong; your child can't even see the big E! And then of course the doctor tells you "nope all fine, no glasses here" to the wail of your child's disappointment. Today we're talking the art of prescribing for kids -- when to prescribe, what to prescribe, and how to get kids that need glasses wearing them!
via |
Don't Under Minus
Parents often worry that their child's prescription is changing too fast, and some may even ask the doctor to cut back their child's Rx so it's not "too strong." But a prescription that is under minused in school aged children (made weaker on purpose) is much worse for the developing eye than one that corrects vision clearly. A 2002 study proved that undercorrecting near sighted children by +0.75D caused their eyes to worsen faster than if they were prescribed their full strength prescription. Scientists theorize that the presence of any blurred vision causes children's eyes to change at a faster speed. Prescribing the full amount to achieve 20/20 vision in near sighted (myopic) school-aged children is the best approach. Remind parents that if their child complains of changing vision in 6 months, go ahead and schedule a follow-up appointment to get things rechecked. It's better to adjust their glasses mid year to achieve clarity than to let them go another 6 months with blurry vision with that risk of accelerated rate of myopic progression. For more on myopia control check this post.
Don't Over Plus
It's normal for especially young children to be farsighted (hyperopic). Studies show the average newborn has just over 2.00D of hyperopia and the average 2 year old has just over 1.00D. The range of acceptable variability where a child would still be expected to have normal visual function is wide. When to prescribe?
For 1- 4 year old patients prescribe if Rx > +3.50 D; Cut Rx by 1.00D
For 4-5 year old patients prescribe if Rx > +2.50 D; Cut Rx for 1.00D
For 6 and up prescribe if Rx > +1.50 D or if pt is symptomatic; no cut in Rx necessary
It's important to cut back the prescription in young hyperopic patients to encourage the chance that the patient's eyes will normalize to zero as they continue to grow (called emmetropization). By age 6 research suggests emmetropization is pretty much over, which is why you no longer have to cut the Rx down. As a general rule, a school aged child with great visual acuity, normal binocular and accommodative function and no complaints is likely doing great without glasses, even if they have a low hyperopic prescription.
Correcting Astigmatism
There are few things in vision more normal than astigmatism. In fact, 69% of infants are born with over 1.00D of astigmatism. Most kids born with astigmatism undergo rapid improvement by the time they are four years of age, so prescribing for astigmatism in young children is not usually necessary. If astigmatism is still present by school age years, however, it can begin to have a big impact on classroom performance. A 2016 study showed that correcting the prescription of kids with high amounts of astigmatism (3.00D or more) immediately improved their reading fluency by an average of one grade level.
For patients under 2 prescribe if astigmatism > 2.50 D; Cut cylinder Rx by 50%
For 2-4 year old patients prescribe if astigmatism > 2.00 D; Cut cylinder Rx by 50%
For 5 and up prescribe if astigmatism > 1.50 D or if pt is symptomatic with lower astigmatism; no cut in Rx necessary
Astigmatism can make it difficult to distinguish letters or numbers, especially in higher grade levels where the font size gets smaller. via |
Exception to these rules: when the eyes have big differences in their prescription (called anisometropia) and amblyopia (lazy eye) or strabismus (eye turn) is developing, then prescribing the full amount of prescription even in very young children becomes important to achieving the best possible outcome.
Check for Accommodative Dysfunction
It's easy to think a child that has no prescription but won't read the chart is malingering (the polite doctor term for faking it). Glasses these days are the cool thing to have, and sometimes when a child's friend gets glasses it becomes mission number one for your child to have glasses too. But sometimes a child might have no real distance vision issue but won't be able to read the chart for a true medical reason. I always do a quick and easy accommodative test (NRA/PRA is a go to for responsive kids - MEM Retinoscopy on younger) to rule out accommodative dysfunction. If a child has accommodative dysfunction, they won't be able to see clearly in the distance because their focusing system is "locked up" at near. Their eyes won't be able to adjust back and forth between distance and up close, so distance looks blurry. Referral for vision therapy is a great solution for kids suffering from this issue, and sometimes progressive glasses can help the eyes adjust more easily from near to far.
When to prescribe progressives for myopes? For a few years it was a commonly discussed theory that prescribing progressive glasses for near sighted children could help reduce how quickly their vision worsened year to year. The COMET study proved that prescribing progressive or bifocal glasses for controlling nearsightedness had no benefit in children with normal focusing systems -- prescribing progressive glasses in a normal nearsighted child did NOT slow down the worsening of their myopia. But in myopic children that have accommodative dysfunction, progressive glasses do help. Prescribing for the right patient can make a difference.
Don't Forget Safety and Sun Protection
Did you know that kids are the most at risk for ocular sun damage? In fact 25% of the sun damage that occurs in a person's lifetime happens before age 18. Sun damage in the eye is responsible for potentially fatal conditions like ocular melanoma, but also diseases of the eye we associate with aging like cataracts and macular degeneration. Those conditions don't develop due to the sun damage we get when we're 80; they're a result of the sun damage we started getting as children. That's why prescribing sun protection in children's glasses is so important. Transitions lenses allow kid's glasses to be 100% UVA and UVB protective without kids having to keep track of multiple pairs -- a win for kids and parents both.
A huge trend in kids eyewear the last few years is wearing rec specs for full time glasses wear. The sporty appearance make kids feel more confident than the traditional round metal frames many kids get fit in with dread. photo via |
Another major risk for children's eyesight is injury, especially if they play sports. 90% of all blinding sports-related eye injuries in America could be prevented if the child had been wearing protective eyewear. Shatter resistant lens materials like polycarbonate and trivex are essential for kid's glasses both on and off the field to protect the eye from potential injury.
And don't underestimate the way that a child's self esteem can be tied to their perceived appearance. I always encourage parents to let their child lead the selection process for their glasses when they enter school age years. Their glasses need to be a part of their identity that they like; not only will the chance that they actually wear their glasses go way up, but higher self esteem is associated with higher academic performance as well!
A few weeks ago we got the not so surprising news that Opternative, the online refraction technology that's seen significant legal battles over the past few months, is now partnering with 1-800 Contacts to offer online contact lens prescription services. Not a surprise that a partnership would blossom between these two companies since they seemingly share a desire to avoid patients entering a doctor's office at all, but still, I have to admit when I read the news I took it with a morbid sense of pseudo-shock. Despite legislation making Opternative illegal in 3 states (Georgia, Indiana, and South Carolina), in today's world, tech business deals can move much quicker than our own legal system. And if you feel like you've been bombarded by new technologies attempting to replace traditional refractions, you're correct. This past year has seen not just Opternative, but portable refraction technology from Eyenetra, and SVONE PRO by Smart Vision Labs also enter the "subjective autorefraction" marketplace. Five years ago when I was wrapping up my optometric medical education at the Southern College of Optometry, if you would have told me that in just a few more years patients would be offered prescriptions right from their home computer, I wouldn't have believed you. It seems so reckless, so impractical, so insane. But that's just an eye doctor talking; to the general public, it's obviously not so dangerous sounding. And that's where the problem lies.
This week Dr. Darryl Glover and I got a chance to sit down with Vitor Pamplona, the designer and founder of Eyenetra for our new optometry podcast, Defocus. I was expecting to talk to someone who would be casually dismissal of ocular health exams, who didn't understand that refractions and vision correction often had nothing to do with the actual health of a patient's eye. What I found was a man who not only had an far-reaching command of the physics of our eye's optical system, but an impressive understanding of the healthcare issues facing the introduction of new tech like his. Vitor is clear he has designed software that is not a replacement for a doctor, and that the NETRA is marketed as nothing but a portable auto-refractor.
His tech doesn't write prescriptions; doctors write prescriptions. He paints a picture of a doctors using the Eyenetra smartphone-powered autorefractor just like any other work up test currently used in office, with the doctor choosing to additionally perform a phoropter based refraction to verify results. His pitch is if you can speed up refraction with his system, you can see more patients or spend more time on what really matters, the ocular health assessment and discussion. He talks about using this system remotely for mobile clinics, concierge care, or in areas or countries where the access to healthcare is limited. He talks about a future where patients with conditions like diabetes might even have an Eyenetra device at home; not to get their own prescriptions, but to check themselves regularly for Rx changes that could mean they need a trip to the doctor sooner for better blood sugar control than their yearly comprehensive. His vision is one that doctors would struggle to find fault with, but I had to remind myself during our interview that this is the same company that I saw illustrations circling on the internet for auto-refractor stations in a prominent online glasses retailer where patients could sit on couches sipping a latte during their refraction. No doctor; no exam room. It's a future that is easy to envision too; insanely lucrative for both the tech companies behind these inventions and the online and big box optical retailers that could offer in office Rxes without having to employ a doctor on site to do so.
Vitor understands that replacing ocular healthcare with only refractive care is not in the best interest of the patient, but he points out that it's optometry that has failed patients if there is a concern that patients would chose to skip a health exam. I'm sure not many ODs are going to take his idea of spinning off a new name for ocular healthcare providers, separate from the title of optometry, in order to rebrand our profession's image in the minds of patients, but the truth is, maybe we need a disruptive outside voice saying that optometry has a problem that we aren't successfully fixing. Our problem isn't new technology entering the marketplace; our problem is what patients think about what we do (glasses prescriptions, right?) and why they should care (they can see fine, so of course their eyes are healthy, right?). As a profession, we have been able to dilate our patients and assess and treat ocular health since the 1970s, but due to a complex history of propaganda from outside groups and in a not-so distant past even our MD colleagues, our public image has never expanded fully to that of comprehensive ocular healthcare providers, despite the fact that's what we've been doing since PCO first handed out the Doctorate of Optometry title in 1923.
I entered this interview thinking I was going to skewer Vitor for creating a product that is a public health risk (very nicely, politely, and enthusiastically based on the sound of my voice on playback apparently). Instead, I realized that the problem isn't his product; it's me, it's all doctors -- optometrists and ophthalmologists. We are the ones that write the prescriptions, and in the US, prescriptive medical devices like glasses and contact lenses require our signature.
I encourage all of us to think about our part in the future of our profession, and act now as a group to legislate ourselves about what is required of a doctor to give a prescription for glasses or contact lenses. We should all have personal ethics keeping the best interest of our patients in mind, and we should legislate and define those ethics in our own professions. Optometrists and ophthalmologists can legislate what's required for a prescription so no loopholes exist for a doctor that might be willing to compromise their personal ethics for a paycheck. The technology doesn't control our profession, our pens, or our patients. We are the caregivers, and the prescription is our care. What does your prescription stand for?
Head here to download or subscribe to our podcast and listen to this week's episode! |
This week Dr. Darryl Glover and I got a chance to sit down with Vitor Pamplona, the designer and founder of Eyenetra for our new optometry podcast, Defocus. I was expecting to talk to someone who would be casually dismissal of ocular health exams, who didn't understand that refractions and vision correction often had nothing to do with the actual health of a patient's eye. What I found was a man who not only had an far-reaching command of the physics of our eye's optical system, but an impressive understanding of the healthcare issues facing the introduction of new tech like his. Vitor is clear he has designed software that is not a replacement for a doctor, and that the NETRA is marketed as nothing but a portable auto-refractor.
"How many prescriptions has Eyenetra written in the United States and worldwide?" Dr. Glover asked him during our interview.
"None" Vitor replied.
His tech doesn't write prescriptions; doctors write prescriptions. He paints a picture of a doctors using the Eyenetra smartphone-powered autorefractor just like any other work up test currently used in office, with the doctor choosing to additionally perform a phoropter based refraction to verify results. His pitch is if you can speed up refraction with his system, you can see more patients or spend more time on what really matters, the ocular health assessment and discussion. He talks about using this system remotely for mobile clinics, concierge care, or in areas or countries where the access to healthcare is limited. He talks about a future where patients with conditions like diabetes might even have an Eyenetra device at home; not to get their own prescriptions, but to check themselves regularly for Rx changes that could mean they need a trip to the doctor sooner for better blood sugar control than their yearly comprehensive. His vision is one that doctors would struggle to find fault with, but I had to remind myself during our interview that this is the same company that I saw illustrations circling on the internet for auto-refractor stations in a prominent online glasses retailer where patients could sit on couches sipping a latte during their refraction. No doctor; no exam room. It's a future that is easy to envision too; insanely lucrative for both the tech companies behind these inventions and the online and big box optical retailers that could offer in office Rxes without having to employ a doctor on site to do so.
Could you refract yourself and order a drink at the bar at the same time? Oh wait, that bar is really an optical display. |
Vitor Pamplona with the NETRA auto-refractor device |
- Ethically, is it in our patient's best interest to perform a refraction (either in person or remotely) without assessing ocular health?
- Ethically, is it in our patient's best interest to give them a contact lens prescription without actually assessing if that contact lens fits properly on the eye or if the patient has corneal health issues putting them at risk for significant vision loss with the wrong type of contact lens (I'm looking at you Opternative!!)?
I encourage all of us to think about our part in the future of our profession, and act now as a group to legislate ourselves about what is required of a doctor to give a prescription for glasses or contact lenses. We should all have personal ethics keeping the best interest of our patients in mind, and we should legislate and define those ethics in our own professions. Optometrists and ophthalmologists can legislate what's required for a prescription so no loopholes exist for a doctor that might be willing to compromise their personal ethics for a paycheck. The technology doesn't control our profession, our pens, or our patients. We are the caregivers, and the prescription is our care. What does your prescription stand for?
In today's world, cataract surgery is typically met with excitement moreso than dread. Why? Many patients have been waiting for years to be more independent from glasses and contact lenses, and the intraocular lenses (IOLs) used after cataract removal can greatly reduce their need for glasses after surgery. If you or a loved one is undergoing cataract surgery, the choices for IOL designs can be overwhelming. Do you want multifocal implants, to help you see with a range of vision both near and far? Do you need toric implants to reduce your astigmatism and limit the chance you'll need glasses for clear driving vision? These options exist, but they are options you have to choose to pursue out of your own pocket. Insurance only covers standard implants--they won't correct your reading vision, and they won't correct moderate to high amounts of astigmatism; you will need glasses after cataract surgery for a majority of your visual needs with a standard implant. How do you know if pursuing premium IOLs is worth your investment? Your cataract surgeon and your personal optometrist that is comanaging your care can walk you through the best choices for your individual needs. Today we're bringing you the basics courtesy Dr. Dawn Williams, an optometrist at See Clearly Vision who routinely provides pre- and post-operative cataract care, and Irina Price, their surgery coordinator.
What can a patient expect with a successful multifocal IOL after surgery?
Success, from my perspective, is defined as increased functionality and decreased dependence on spectacles and/or contact lenses. I would suspect we are about 95% successful. Patients have to know that they will still need to use glasses sometimes; reading small print, reading in dim lighting, perhaps even for crystal clear driving vision. Success is highly dependent on setting realistic expectations prior to surgery. Preparing a patient for real expectations is a combined effort of every staff member who meets with the patient. From the surgeon, to optometrist to surgical counselors. This is where surgical counselors can play a big part in helping patients understand their expectations in comparison to their goal or surgical outcome. It is important for each patient to understand that the goal is to reduce dependency -- not eliminate the need for glasses. When a patient selects a multifocal they expect to be glasses free, however, when they’re sitting down at the sewing machine or trying to remove a splinter from a grandchild’s hand, they need to be educated that they may need assistance with reading glasses for these high visual demand situations.
Multifocal IOLs have rings of distance and near vision to achieve a range of vision near to far. via |
Are there any side effects with multifocal IOLs?
The possibility of halos at night are a negative side effect of multifocal IOLs due to their multiple ring design. Halos and glare aren't a big issue with the other type of near focusing implant, accommodating IOLs, but these implants tend to have more trouble with unclear near/reading vision. The implant has to move within the eye, and if the patient's ocular tissue doesn't adequately support this movement then reading vision will be limited. This is something that doctors can't really screen for, which is why there is such variability in the success rate of accommodating IOLs. This is where every doctor and eyecare provider who comes in contact with the patient needs to be educating the real expectations for what each implant can and can't do. Here's an example of our dialogue:
“Mrs. Smith, a multifocal is going to give you a range of vision, however, the goal is to reduce your dependency on glasses. That being said, you still may need reading glasses for doing fine hand work or to correct residual astigmatism at distance”.
Accommodating IOLs have to flex within the eye to focus your vision between near and far. The range of vision achieved post-operatively depends on the anatomy of the patient's eye and how much flexure is accomplished. via |
Can someone with high astigmatism or high prescription have multifocal IOLs? Or are there certain Rxes that are just not possible for this type of lens?
High amounts of cylinder (astigmatism) or highly ametropic (high prescription) patients are not excluded from having premium lenses unless they have corneal scarring, retinal pathology, or amblyopia. As long as the necessary IOL is within the range of available lenses, even in cases where the IOL would leave some residual refractive error, if it will reduce the patient's dependency and increase functionality it may be a good option. Patients with a high risk of residual prescription need to understand though that for their best vision they will still need glasses; these implants will reduce their need, but they won't give them crystal clear vision.
What conditions would prevent a patient from being a good candidate for multifocal IOLs?
Corneal scarring, retinal pathology like diabetic retinopathy or macular degeneration, and amblyopia (lazy eye) are a few things that would preclude a person from a premium IOL. Both eyes have to have a high level of function to be successful in these implants. The ring design of a multifocal IOL can greatly increase your risk for glare or halos at night or in dim lighting, so if the retina or cornea has a condition that causes visual distortion, the chance that the patient will be visually successful in this implant is very low. In the process of assisting patients in selecting their IOLs, physicians are able to guide patients towards certain lenses based on their overall ocular health. During the pre-op surgical evaluation, the doctor carefully examines the retina with dilated views and OCT imaging, and performs corneal topography for prospective multifocal patients; these results will help guide a patient towards, or away from, a premium IOL.
What's hiding behind that cataract? A thorough retinal examination is needed to make sure each patient is a good candidate for premium IOLs. |
When do you recommend monovision implants (one eye set for reading, one eye set for distance) versus multifocal (both eyes see a range of distance and reading) IOL implantation?
The most successful IOL recommendations are made based on the patient's prior visual correction and their goals. If a patient has had monovision before in their contact lenses with good success, it's generally very easy to achieve success with a monovision IOL surgery. But if a patient has never worn monovision before, it is not their best choice. It's very difficult to demonstrate monovision with the presence of a cataract in one or both eyes, so the patient won't be able to try it out in contact lenses prior to surgery in most cases to know if they like it or not. If a patient has not had monovision in the past, we would like recommend presbyopic (multifocal or accommodating) IOL
When do you recommend toric (or astigmatism) IOLs?
A good candidate for a toric IOL will have a cylinder power of -1.25 to around -5.00 diopters.
When do you recommend Laser Assisted cataract surgery?
Laser-assisted cataract surgery is FDA approved for the treatment of low amounts of astigmatism, with a maximum correction of up to -1.50 diopters. It can also be beneficial in patients with very dense cataracts or corneal endothelial disorders (Fuch's Dystrophy). It’s important to remember that the goal of laser-assisted cataract surgery is to help reduce patient dependence on glasses following surgery. Patients who have worn contact lenses all their lives may be more inclined to select laser-assisted cataract surgery to reduce their dependence on eyewear as that is the goal of contact lenses in the first place -- to reduce your dependence on glasses. As a surgical counselor, I find that many contact lens patients are excited at the thought of less dependence on contacts and glasses after surgery.
What should optometrists referring their patients for cataract surgery talk to their patients about before the referral?
Discuss the possible IOL options and realistic expectations for what premium IOLs can do; as an optometrist you've been caring for your patient for years and know their personality and needs better than anyone! Many patients that are referred to our offices have been utilizing the benefits of monovision for years. It is beneficial if the referring OD is able to discuss with the patient whether or not they would like to maintain monovision following surgery as well as provide the contact lens prescription the patient has worn in the past to achieve success.
When an optometrist takes over the post-operative care for their patients after premium IOL implantation, are there any common patient issues with these types of lenses that ODs should be familiar with or know how to troubleshoot?
Reassure the patient that vision after multifocal and accommodating IOLs keeps changing and improving after surgery. For most, the best vision will be achieved about 4 weeks after surgery, so don't panic if the vision is not quite perfect at the 1 week post-op. The brain needs time to learn to use it's new vision, and there is still healing going on from the surgery itself in the first few weeks, so we don't expect perfect clarity right away. Always remind pre and post-operative patients that healing takes time, patience and rest. Having worked as a technician and surgical counselor, I’ve often been known to remind patients that if they had knee surgery they wouldn’t be up running a marathon the next day so they need to give their eye the same amount of time to heal. It helps remind patients that they need to be realistic about healing and not consider their cataract surgery to be providing them with a bionic eye.
Check out Dr. Williams, Irina Price, and the whole See Clearly Vision team at their website and on their Instagram account to learn more.
Scleral Lens Fitting: Selecting and Evaluating Your Initial Lens
fitting guide scleral lens 11:31 AM
Since the mid 2000s, no other type of contact lens has seen more growth and excitement than scleral lenses. In last year's annual contact lens trend report from Contact Lens Spectrum, doctors reported fitting scleral contact lenses more than both rigid gas permeable toric and multifocal lenses, with sclerals making up 3% of all contact lenses being fit (including soft, hybrids, and RGPs) in 2015. Why sclerals? The larger contact lens size makes for more stable vision and improved comfort over traditional small diameter RGPs, ideal for irregular corneas, high astigmatism, and conditions like keratoconus. Breaking into the world of fitting scleral contact lenses can have a sharp learning curve, so I strongly recommend attending courses like those offered from the Scleral Lens Education Society, Blanchard, and Vision By Design. Once you feel ready to get started, the fitting set arrives and it's time to put lenses on your patient. What to do? We're talking initial lens selection and evaluation in today's post!
Choosing the Right Diameter
There are a ton of scleral contact lens options out there, with common diameters ranging from as small as 14.3 mm to over 18 mm. The truth is, lens diameter selection depends on your patient. Smaller lenses are typically easier to fit, especially on corneas with lower amounts of irregularity. Advantages of smaller diameter lenses include:
Choosing the Right Diameter
There are a ton of scleral contact lens options out there, with common diameters ranging from as small as 14.3 mm to over 18 mm. The truth is, lens diameter selection depends on your patient. Smaller lenses are typically easier to fit, especially on corneas with lower amounts of irregularity. Advantages of smaller diameter lenses include:
- better oxygen permeability (smaller lenses can be fit with less central vault, meaning better oxygen exchange through the tear film)
- easier patient handling
- easier removal (smaller lenses will fit flatter in general so will have less suction with removal)
- avoiding scleral toricity --- The white of the eye (sclera) tends to have more of it's own innate astigmatism as you venture more peripherally from the limbus. The larger the scleral lens you are fitting, the more likely you'll have to use toric peripheral curves to achieve a good fit.
- minimize fogging -- larger lenses tend to have more issues with lens fogging, theoretically because they are interacting more with the conjunctival goblet cells that produce mucin
Proper lens diameter should clear the limbus by 2-3mm on either side. The lens above shows inferior fenestration which isn't used by many doctors these days -- at one point fenestrations were popular to improve oxygen transmission. These days, doctors change their fit to improve oxygen transmission by minimizing their central and limbal vault (see below). via |
Select a lens that is about 5 mm larger than the patient's cornea. You want about 2-3 mm of lens clearance over the limbus in every direction. Almost 90% of the time I fit the 15.6 mm diameter Jupiter Scleral from Essilor, but there are options to size up or down as needed.
Choosing the Right Vault (Corneal Clearance)
When sclerals first began being popularized for irregular corneas in the early 2000s, we fit them a lot differently than we do now. Back then it was large diameter and deep vault (maybe 400 microns or more). But very quickly doctors learned that fitting with that much lens vault creates a potentially tight fit (meaning much more difficult for the patient to remove at night) and can drastically reduce the oxygen transmission through the lens. The more tear film between the lens and the cornea, the less oxygen trransmissibility you'll get. Ideally, you want between 150 and 200 microns of central corneal clearance 30 minutes after the lens is placed on the eye. So yes, we are at a disadvantage as clinicians because we often see patients right after they put lenses on their eyes. Studies show scleral lenses settle down by about 80 microns through the course of the day. Therefore if you are evaluating a lens right after insertion, you ideally want about 250-300 microns of central clearance to get that perfect fit after settling.
How do you assess central clearance? Fill the lens with nonpreserved saline and a swirl of NaFl dye. You can judge the central clearance of the lens by comparing the tear film thickness (green above due to the NaFl dye) to the corneal thickness on your slit beam. Knowing the average corneal thickness is about 550 microns, you have a predictable judge of tear clearance. In the picture above, the tear clearance is almost as thick as the corneal clearance, so I would grade this around 450- 500 microns of clearance. This is TOO MUCH!! Photo via |
Of course, if you have an OCT you can image the exact amount of corneal clearance with an anterior segment scan. via |
How do you get in the right ballpark for this perfect amount of clearance when starting with your fitting set? Select an initial lens based on your patient's flat K.
- For example: your patient has a flat K of 44 diopters. Your first lens to try on should be around a 7.67 mm base curve (select the closest thing in your fitting set). You can find a diopter to base curve conversion chart here.
- Need more or less central clearance? As a rule of thumb, changing base curve by 0.1 mm will give you about 35 microns of vault. Steepening the lens gives more vault; flattening the lens gives less.
Assessing Limbal Clearance
Once you are happy with the amount of central clearance you have, you still need to assess the periphery of the lens. At the limbus, you ideally want 30-40 microns of clearance to achieve good oxygen permeability. A great way to assess clearance is to insert NaFl dye in the lens before insertion, You should see a faint band of dye at the limbus -- just barely there. Bubbles here mean the lens has too much limbal clearance; touch means not enough.
Want the perfect limbal clearance? You should just see a faint hint of NaFL dye right at the limbus with the perfect fit of 30-40 microns. Of course, you could also use an OCT to assess this area if you have access! via |
- Need more limbal clearance? Increase the lens diameter will achieve more limbal clearance without changing your central vault
- Too much limbal clearance? You can decrease lens diameter, but likely if you have too much limbal clearance you have too much central clearance as well and you can solve the issue just by flattening your central base curve
Assessing Periphery
The edges of the lens are important for comfort and ease of removal. We've all seen pictures of a tight edge causing blanching of the conjunctiva. Assessing the lens after it's been on the eye for about 30 minutes will help you detect signs of blanching and reduce the risk of the lens binding down after the patient takes it home. Make sure you assess the peripheral edges, central vault, and limbal clearance with the patient looking in central gaze. When the patient looks up or extremely to the sides, you may see some changes to the clearance and especially the edges as the lens relationship with the sclera changes. Central fit is the important characteristic to evaluate!
If the edge of the lens is too tight, you'll see blanching of the conjunctival vessels in as little as half an hour. This will cause severe discomfort and binding of the lens when the patient attempts removal. Before sending the lens home with a patient, make sure you check the edge carefully to ensure that the conjunctival vessels are passing underneath the edge of the lens freely, without any pinching or thinning. via |
There are a few tips based on the patient's comfort that can help you troubleshoot improper edge fit:
- "My eyes are red after a few hours" Likely this is a tight edge lens. Tell the lab to flatten the edge
- "I can feel the edges" Likely this is a flat edge, causing some fluting of the lens as it lands on the conjunctiva. Tell the lab to steepen the edge.
Selecting Material
There are a ton of great materials that you can chose for scleral lenses, just like you have available in traditional RGPs. My personal go-to is Tyro 97 -- high oxygen transmission and low risk of surface filming or fogging with a proper fit.
Once you've found an initial lens you like, over refract and place your order! Need more scleral lens advice?
The last time a medication was approved for the treatment of dry eye syndrome? October 2003. That medication was the blockbuster Restasis, still commanding the dry eye marketplace 13 years later. Over those 13 years, we've learned a lot more about dry eye and the 16 million Americans that are diagnosed and treated for it every year. They suffer from symptoms like burning, watering, redness, blurry vision, and tired eyes. For many, even the best medical care available on the market is not enough to overcome their discomfort. That's why the world is so excited for a new medication on the market. Shire's Xiidra was FDA approved on July 12th for the treatment of the signs and symptoms of dry eye disease (Restasis is FDA approved to treat the signs of dry eye disease only). Slated to become commercially available this fall, there's still a lot about Xiidra that patients and eyecare providers don't know. We don't know the cost, we don't know exactly how patients will respond in our offices, we don't know how Xiidra will compete with Restasis, and we don't know how insurance coverage will look. Here's what we do know so far:
What It Is:
Xiidra (lifitegrast 5%) is a non-steroidal anti-inflammatory eye drop, treating dry eye by disrupting the inflammatory cascade responsible for much of the discomfort and ocular surface changes associated with dry eye disease. It specifically targets intracellular adhesion molecule 1 (ICAM-1); Xiidra binds to proteins on the surface of white blood cells (leukocytes) where ICAM-1 would typically bind, thus blocking ICAM-1 from being able to attach and signal the inflammatory cascade. When ICAM-1 molecules bind to leukocytes, they signal T-cells (the body's main inflammatory cell unit) to the area. Xiidra prevents this binding, and thus T-cells aren't signaled to migrat to the ocular tissue. What does blocking the inflammatory cascade mean to you? Inflammation is what makes dry eye so miserable - redness, burning, and surface cell damage (called superficial punctate keratitis -- basically dried out corneal cells sloughing off the cornea creating symptoms like sharp pain and blurry vision).
What It Does:
In the clinical trials that earned Xiidra FDA approval, over 1000 people with dry eye disease were treated with Xiidra over the course of 12 weeks and the results were compared to placebo treatment. Patients being treated with Xiidra showed statistically significant improvement at Week 6 and Week 12 as compared to those on placebo eye drops in both the signs and symptoms of dry eye, as measured by a subjective symptom scoring questionnaire called the Eye Dryness Score (EDS) and inferior corneal staining (see superficial punctate keratitis above).
How It's Used:
via |
What It Is:
Xiidra (lifitegrast 5%) is a non-steroidal anti-inflammatory eye drop, treating dry eye by disrupting the inflammatory cascade responsible for much of the discomfort and ocular surface changes associated with dry eye disease. It specifically targets intracellular adhesion molecule 1 (ICAM-1); Xiidra binds to proteins on the surface of white blood cells (leukocytes) where ICAM-1 would typically bind, thus blocking ICAM-1 from being able to attach and signal the inflammatory cascade. When ICAM-1 molecules bind to leukocytes, they signal T-cells (the body's main inflammatory cell unit) to the area. Xiidra prevents this binding, and thus T-cells aren't signaled to migrat to the ocular tissue. What does blocking the inflammatory cascade mean to you? Inflammation is what makes dry eye so miserable - redness, burning, and surface cell damage (called superficial punctate keratitis -- basically dried out corneal cells sloughing off the cornea creating symptoms like sharp pain and blurry vision).
Superficial punctate keratisis: when corneal surface epithelial cells dry out, the cell wall break and they begin to slough off. The process can cause you to feel sharp, shooting pain and chronic discomfort and visual fluctuations. via |
What It Does:
In the clinical trials that earned Xiidra FDA approval, over 1000 people with dry eye disease were treated with Xiidra over the course of 12 weeks and the results were compared to placebo treatment. Patients being treated with Xiidra showed statistically significant improvement at Week 6 and Week 12 as compared to those on placebo eye drops in both the signs and symptoms of dry eye, as measured by a subjective symptom scoring questionnaire called the Eye Dryness Score (EDS) and inferior corneal staining (see superficial punctate keratitis above).
How It's Used:
- Like Restasis, Xiidra is dosed 1 drop in both eyes 2 times a day.
- Clinical trials suggest that Xiidra will begin improving both the signs and symptoms of dry eye as early as 6 weeks into treatment, much faster than Restasis whose clinical trials showed improvement in signs of dry eye (judged by Shirmer score) at 6 months versus placebo.
- Xiidra and Restasis both target the inflammatory cascade, but they do not target the same molecules so there is no scientific data that suggests they could not be used in combination.
- Xiidra is pregnancy category C (meaning it was not tested for safety)
- Xiidra is approved for ages 17 and up
- Xiidra is not approved for use with contact lenses; you must remove contact lenses before insertion and wait 15 minutes before reinserting them.
- Side effects of Xiidra:
- 5-25% of users experienced burning with drop insertion, altered or bad taste (called dysguesia), and blurry vision after insertion
- 1-5% of users reported adverse reactions of ocular redness, headache, watering eyes, runny nose, and ocular discharge
What We Don't Know:
Now that Xiidra is FDA approved, Shire has the task of setting the price for the medication and working with government and insurance coverage. Cash price for competitor Restasis is currently over $400 for a 30 day supply when using 2 vials a day. Analysts expect Xiidra will be priced similarly. There is debate that Xiidra may try to come in slightly lower to directly compete with Restasis, but there are also analysts predicting Xiidra will come in slightly above Restasis in cost since they have a significantly faster method of action and Xiidra is also approved to treat the symptoms of dry eye while Restasis is not.
Stay tuned as more information become available we will continue to report on this exciting new treatment option!