When you're a parent, nothing breaks your heart more than seeing your child in distress. Between the normal range of infections and viruses that can cause conjunctivitis in infants (commonly termed "pink eye") and the fact that as many as 20% of children are born with congenital nasolacrimal duct obstruction (blocked tear ducts), the chance of having to battle red, goopy eyes in infancy is high.  Dr. Sarah Sweeney Dorhman is a new mother and optometrist, and experienced this common issue first hand when her daughter began suffering from chronic irritation and mattering discharge due to nasolacrimal duct obstruction.  She shares her experience, and what you can do at home to help your own child battle ocular irritation.

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.

Fashion it-girl Leandra Medine embraces her make-up free appearance, puffy under eye circles and all.  via

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.

• 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.

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

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

"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.

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."

"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!

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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.

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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.

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 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.

Vitor Pamplona with the NETRA auto-refractor device

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.

• 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!!)? 

As a doctor, we're educated that we should never, ever give a prescription for anything without assessing my patients' ocular health (or getting records proving they've had that done within the last year), and I'm wondering, what doctor would? Who are these doctors who would sign an Rx for any medical device without assessing ocular health themselves or verifying that health had been assessed by another doctor within a year's time?  We're all worried about refractive tech confusing our patients into thinking their eyes are healthy when they haven't even been checked, but it's doctors that would be to blame if a medical condition was missed. It's that doctor who compromised and offered refractive care without ocular healthcare who is at fault when a condition goes undiagnosed, maybe even blinds or kills someone -- no, I'm not being extremist.  So as doctors, I ask you to think about what you do and why you do it.  A prescription is more than just a print out from an autorefractor; it's your signature that you have evaluated this patient and given them your care. Stand for something bigger than your paycheck; stand up for those millions of Americans with undetected glaucoma, early retinopathy or retinal diseases, or even ocular tumors -- conditions that in early, treatable stages aren't going to present with any vision issues on a refraction.  You won't find these conditions if you don't look for them. And looking for them, that's our job. We have to claim this new autorefracting technology and all new tech innovations for what their true place is in the role of our exam.  The tech is not more than us; it isn't an exam but just a tool, and it can't operate to give anyone a prescription without us.  None of this new tech bypasses a doctor or bypasses an ocular health exam; only a doctor can chose to bypass an ocular health exam.  So I ask you, use this tech like it was designed.  It's a refractive tool to aid in your exam.  It's not an exam.  It doesn't even pretend to be an exam. The only person in the room that can make it replace an exam is you.

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?

Multifocal IOLs have rings of distance and near vision to achieve a range of vision near to far. via

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

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's hiding behind that cataract? A thorough retinal examination is needed to make sure each patient is a good candidate for premium IOLs.

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?

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:

• 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

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

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

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