If it's not obvious by the fact my "down-time" is spent here, blogging about my profession, I really love being an optometrist.  I would make that decision again even if I time-traveled back to my undergrad days (and please, don't let that recurring nightmare of facing tests and papers all over again ever become reality). But there are plenty of times in this career where I've had experiences I'd rather forget.  Uncomfortable encounters with male and female patients, angry belligerence, threats, casual and blatant sexism.  All in a day's work when your profession is part of the customer service industry known as healthcare.

The face I make when I think about this issue - captured perfectly by artist Karen Goins

Recently I was asked to reflect upon some of the difficult situations I've been placed in as a young female optometrist by fellow OD from across the globe in Australia, Jane of BrightEyed Blog. She interviewed both me and my friend Dr. Jaclyn Garlich of 20/20 Glance fame about some uncomfortable scenarios we've been faced with, and how we best recommend other new grads tackle the challenge if they are ever put in the same situation.  

In optometry school, you learn a lot about how to be a great doctor. Ocular disease, surgical procedures, prescribing medications. And the curriculum typically includes business management courses too - basics of understanding net versus gross profit, balancing the books, budgeting for staff and paying yourself (hopefully).  Building your own practice from scratch though reveals a lot of the things we didn't learn: we know how to be a great doctor, but how do we figure out how to be a great brand?

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Dr. Lyerly spends a lot of time talking about meibomian gland disease in her practice.

The yellowish circles here are the meibomian glands of the superior eyelid. Inflammation is clearly evident in my patient; the lid margin is very injected (red) - a hallmark of chronic dry eye.

Evaluating the meibomian glands with the Korb Meibomian Gland Evaluator via

A doctor uses a transilluminator to see the meibomian glands.  To do this, turn the slit lamp and room lights off, place the transillumintor on the bottom eyelid and gently evert the lower lid.  via

Imaging systems offer a great tool for both the doctor and the patient to be able to see damaged meibomian glands. The LipiView imaging system uses infrared light to highlight the glands (below). Also available is the Oculus Keratograph with its Meibo-Scan software.

The LipiView system by TearScience is the method used where Dr. Lyerly practices, Triangle Visions Optometry.  The patient pictured here is in her 20s and unable to wear contact lenses anymore due to dry eye and fluctuating vision with lenses.

Back in 2014 when Bausch and Lomb Ultra hit the market, it was the first new material for a monthly disposable contact lens in over a decade. With material designed to maintain 95% of lens moisture for a full 16 hours of wear, the end of day comfort for this lens has made it a fast growing entry in the monthly contact lens marketplace.  This spring, the Ultra lens launches nationwide in astigmatism parameters, and it's actually lens movement even more than the lauded lens material that is making this contact lens a fast success.


All About the Blink
One thing noted by many practitioners with the original Ultra lens was that compared to other lenses on the market, Ultra exhibited much less vertical movement with blink. As recently as the early 2000s, doctors were touting the traditional mindset that a soft contact lens should exhibit 1 mm of movement with every blink.  But pivotal contact lens studies in 2009 and 2014  have greatly changed our understanding of comfort and lens dynamics. On a normal eye, blink motion mechanics predict 0.3 mm of movement would be ideal for limiting eyelid interaction and corneal nerve sensitivty at the delicate limbal region (the area where the white of the eye and the cornea meet), and that's backed up by patient comfort surveys where anywhere between 0.1 mm and 0.4 mm movement was graded as most comfortable in patient wear. We do need some movement to promote tear film exchange under the contact lens, for both comfort and ocular surface health, but much less movement than we once thought is necessary to get this dynamic!

Besides comfort, vision is greatly affected by lens movement and no population of lens wearers sees a larger impact from this than those with astigmatism.  All soft contact lenses for astigmatism are weighted in design, so that the 2 different powers in the contact lens will align properly with the 2 different meridians on the patient's eye for best vision. If the contact lens moves excessively, the power meridians also move from their ideal alignment with the cornea, resulting in blur.  Imagine every time you blink, move your eyes quickly, or rub your eyes that your vision goes out of focus. For many astigmatism contact lens wearers, that's a normal part of their day. Combating movement became a key focus of the design time at Bausch and Lomb on this lens, and to maximize their chance for success, they really started to look at just how complicated a simple blink can be.


Every time we blink, the contact lens is not just moved vertically by the eyelids, but rotationally as well. The lower eyelid rotates up and in towards the nose as it moves to meet the upper eyelid during a blink. That rotational force can easily shift contact lens alignment, and minimizing the amount the lens moves with the force of the eyelids and maximizing how quickly the lens returns to its ideal location is essential to success. The initial reports show amazing results for stability in Bausch and Lomb's Ultra for Astigmatism; 94% of patients experienced 5 degrees or less of rotation at their initial contact lens dispensing appointment.  In my own experience as a clinician, it's quickly become a problem-solver contact lens for me in meeting the needs of my patients reporting inconsistent vision or having difficulty with lens rotation in their current contact lenses.

The Ultra for Astigmatism lens has an alignment marking at 6 o'clock, and a smaller indicator marking that displays what axis the astigmatism correction is being delivered to.

The Lens Details
Base Curve: 8.6 mm
Diameter: 14.5 mm
Power range: plano to -6.00 in -0.25D steps with astigmatism -0.75 through -2.25 in -0.50 steps
plus powers are slated to be available in the near future
Cylinder Axis: 0 to 180 in 10 degree steps
Oxygen Transmission: 163 Dk/t for a -3.00 lens

Have you tried Ultra for Astigmatism? Please share your experience as a wearer or as a prescribing clinician!

I am not a spokesperson for Bausch and Lomb and there was no payment or incentive for this post; all opinions are my own. I did attend an educational event to learn about the lens firsthand in April 2017 as a clinician and member of the optomettic press.

If you're a long time reader, you'll know I've dedicated a lot of articles to writing about specialty contact lenses for keratoconus because its the specialty I've chosen to pursue in my own eyecare practice. In the five years that I have been out of optometry school, I've fit hundreds of patients with specialty contact lenses for irregular corneas, and over and over I found myself wondering, how could I be seeing so many? A new study out of the Netherlands in 2016 has revolutionized how common we believe keratoconus to be, reporting a prevalence of 1 in 375 people.  Compare that to the previous estimated prevalence of 1 in 2000 reported in a 1986 study out of Minnesota, and you can see why the news has rocked the eyecare world. 

An eye with keratoconus and corneal scarring via

What is Keratoconus?
Eyecare specialists define keratoconus as "bilateral, asymmetrical, noninflammatory pathology characterized by progressive, localized thinning and protrusion of corneal tissue." In layman's terms, you'll often hear it described as a steepening of the cornea, causing the cornea to bulge forward and disrupt vision. One reason why we've struggled so much to both treat and properly define how prevalent keratoconus is in society is because we still have a poor understanding of what is happening in this disease. We know that the process of corneal thinning and protrusion usually starts around puberty, and progresses on average 10-20 years from there. Most people by age 40 have no further progression of the disease because of aging changes that stiffen and thus strengthen the cornea and prevent further prolapse. Keratoconus can be detected in its earliest stages with corneal topography, where the tell-tale surface steepening is visible creating a pattern of asymmetric and irregular astigmatism on the corneal surface. 

Corneal topography showing normal (regular) astigmsim on the left and irregular astigmatism caused by keratoconus on the right. Note the lack of symmetry vertically in this map - a giveaway of corneal dystrophy. via

Access to corneal topography is the big reason researchers think keratoconus was so greatly under reported in earlier population studies. In the 1986 study that reported a prevalence of 1 in 2000, doctors had to detect keratoconus based on irregularities seen on keratometry and during retinoscopy. These days, you'll be hard pressed to find an office with old-school manual keratometers, replaced with high tech corneal topography that can detect even subtle changes. With this newer technology, earlier and much milder forms of corneal irregularity can be detected. 

What We Know and What We Don't
For years doctors have theorized that keratoconus had a genetic component, but there has never been a gene found that definitively proved this. And population studies looking at genetic prevalence show mixed results. Environmental factors like allergies and chronic eye rubbing also appear to contribute. So if you are looking for a definitive answer to why you have keratoconus, the answer is not so simple. It's probably a mixture of environmental and genetic risk factors.

Here's what we do know:

• Keratoconus is more common in India, the Middle East, and China than other countries around the world. It is unknown if this is due to environmental difference in temperature, oxidative UV damage from being closer to the equator, or diet and nutritional differences.
• The genetic prevalence of keratoconus differs based on ethnicity.
• In the US, the genetic prevalence of keratoconus is between 6 and 13.5% depending on the study you look at. 
• When prevalence in a 2015 study was separated by ethnicity, Caucasians were found to have a genetic prevalence of 5% and Asians had 25% prevalence.
• Eye rubbing is an associated risk factor; chronic ocular allergies may be a risk factor (or is it just the rubbing?)
• People with keratoconus tend to rub their eyes longer and "more vigorously" than those with normal corneas. An average cornea patient tends to rub their eyes on average for 5 seconds and no longer than 15 seconds even when bothered by allergies; surveyed keratoconus patient rubbed their eyes between 10 and 180 seconds. Additionally, keratoconus is associated with:
• rotational knuckling motion with rubbing
• more forceful rubbing
• rubbing frequency greater than once a day
• rubbing year round (not just seasonal with allergies)
• Study results are mixed as to whether the risk of keratoconus is higher with a history of chronic allergies or atopic hypersensitivity like asthma and eczema. About 1/3 of patients with keratoconus self-report a history of allergies. 

An eye with keratoconus via