Dr. L and her newborn daughter. photo credit to Melissa DeLorme Photography

Try to picture what the world is like for a newborn entering the world.  Suddenly they go from the warm, cozy, darkness of mother's womb to a loud, cold world of bright lights and blurry shapes. And yet, research suggests that newborns are not paralyzed by sensory overload, but their visual skills that have been developing throughout their time in the womb immediately are ready to kick into gear! Full term and even some premature infants can fixate their eyes on a near object immediately in the delivery room.  This early visual alertness is used by doctors and nurses in the delivery room to assess the robustness and function of the central nervous system.

We can separate visual development in infancy into 5 main stages:

1. Awakening to the World 
Visual alertness occurs in the first hours/days/weeks of your newborn's life. What your baby can see, and what you as parents can do to support visual development in this stage is the subject of this article!

2. Learning to Look
In the first 1-2 months the eyes are learning to move and work together by following and tracking objects.

3. Eyes/Brain/Hands
Around 4 months old, your baby is integrating vision into motor control. Hand-eye coordination and balance are all being developed at this stage.

4. Adjusting Focus
At 6 months old it's time for the baby's first trip to the optometrist! At this visit, the doctor will use retinoscopy to assess how your child is focusing on objects near and far, check for any differences between the two eyes, and determine if a prescription is needed to prevent against lazy eye (amblyopia) or strabismus (eye turn).

5. See to Move
At ages 8 months to 1 year old, babies are actively moving and navigating their world using visual cues like depth perception.

One pair of shoes doesn't go with every outfit, so why should we be restricted to making one pair of glasses work every single day for our personal style? As a glasses-wearing adult, I have a total of 6 pair in my current prescription - from versatile clear plastic to a bold black and white tortoise with red details for when I want my eyewear to make a statement.  But for kids, whose prescriptions can often change dramatically from year to year, investing in multiple pairs of glasses for stylistic purposes often seems like a luxury that can be hard for parents to justify.

Founder and President Jessica Darcy shares her Funoogles collection at Vision Expo West

Ella-Jane clearly has a strong sense of fashion and self identity, and her eyewear style is always on point as evidenced by the @Funoogles Instagram account.

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For more great style inspiration on how to make your Funoogles pop, head to @funoogles on Instagram

For the roughly 11% of all contact lens wearers that wear hard or rigid gas permeable (RGP) contact lenses, finding the right cleaning and storage solution is a lot more complicated than just grabbing something off the shelf at the drug store. Most readily available contact lens cleaning solutions are meant to clean soft, disposable contact lenses and won't clean and disinfect RGP lenses thoroughly enough to be safe.  Because RGP and scleral contact lenses are replaced much less frequently than soft lenses (yearly to every few years, depending on the patient), keeping the contact lens surface clean of debris and protected against infections, chips and scratches is essential to both comfort and clear vision!



The biggest risk with contact lens wear, whether you wear soft or RGP lenses, is corneal infection. Unfortunately it's possible to be blinded by contact lens wear, so proper hygiene and care is essential. For patients wearing RGP or scleral lenses, the risk of infection is extremely low with only 2 cases per 10,000 patients reported. Compare that to soft contact lens wearers who have an incidence of 25.4 cases per 10,000 patients for those who wear monthly disposable overnight wear soft contact lenses!  Even though the risks of infection are much lower when you wear daytime wear RGP lenses than overnight wear soft contact lenses, because patients wear these lenses for much longer, up to a few years at a time, the repeat exposure to bacteria can cause significant risk.

So which solutions are the best to use? Here are the top options on the market:

Multipurpose Systems:  All-in-one solution systems (sometimes abbreviated MPS solutions) are super convenient because in just one bottle you can clean, disinfect, store, and condition your contact lens overnight. Many RGP contact lens solutions will mention "conditioning" -- that means improving the wettability of the contact lens so that it stays better hydrated on your eye to maintain great comfort and clear vision.

Boston Simplus: This cleaner and storage solution has protein deposit removal that is comparable to more abrasive cleaners on the market with the pro of being an all-in-one solution. For best results, the manufacturer recommends storing the contact lens in the solution overnight, then rubbing and rinsing the lens in the morning before putting on the eye.  No night time rub required.
Preservatives: clorhexidine gluconate and PAPB

Unique pH:  This solution is an all-in-one cleaner and storage solution that works to hydrate or condition the contact lens by adjusting to the natural pH of the tears on the surface of your eye. As your tear film pH decreases (becomes more acidic), the solution becomes thinner to help maintain comfort and visual performance.
Preservatives: polyquaternium-1 and EDTA



The Cons: These solutions are extremely popular due to convenience, but if you get a lot of deposits or build up on your contact lenses, these are typically not the best option. The cleaners in these contact lens solutions are necessarily very mild since they must be gently enough to come in contact directly with the eye.  If you have significant protein build-up, adding a daily cleaner (below) is likely necessary.


2. Hydrogen Peroxide Based Cleaners
These solutions use hydrogen peroxide as one or two-step cleansing options to both disinfect lenses, clean the surface of debris and build-up, and store overnight.  They both require 6 hours of cleaning time to fully disinfect the lenses.

ClearCare: This peroxide based cleaner is an all-in one option that cleans lenses overnight (6 hours). The hydrogen peroxide solution is converted to saline via an enzymatic reaction in the special case design. This solution can be used for both RGP and soft contact lenses.  To properly disinfect RGP lenses, the manufacturer recommends putting 2-4 drops of ClearCare directly on the contact lens and then rub the lens with your finger tips. Place the contact lens in the appropriate right and left sides of the case basket, and then rinse the lenses with ClearCare directly for 5 seconds. Only after this manual rub and rinse can you fill the case with solution, close the lid, and let the contact lenses clean overnight.
Preservative Free

Oxycept UltraCare: This 2-step peroxide based system uses an enzyme tablet to neutralize the hydrogen peroxide solution. The tablets contain cyanocobalamin (vitamin B12) to create a pink hue so you can visibly tell that neutralization is happening. The lenses must soak in solution 6 hours or overnight. Once weekly, an UltraZyme Enzymatic tablet can be added at the same time as the peroxide neutralizing tablet for an extra strength clean.

The Cons: These solutions must be allowed a full 6 hours or overnight to convert, otherwise they will cause significant discomfort and toxic corneal burn if hydrogen peroxide directly contacts the cornea. If you have had this happen to you, the pain can be severe but luckily the damage is superficial and won't cause any permanent harm to the cornea.

While these solutions have strong disinfecting properties, once the hydrogen peroxide has been converted, there is no preservative coverage to prevent contamination if you leave the lenses sitting in the storage container for days at a time. Manufacturers advise not to leave a lens stored for more than 7 days.  If you have back up lenses, it is always safest to store them dry and then clean them again before their next use.


3. Daily Lens Cleaners:
These are extra-strength cleaners that are either surfactant (soap) based to remove build up and debris or abrasive cleaners to remove more stubborn deposits.  This category of cleaner will come with a red cap to warn users not to get the solution directly in contact with the eye.  After using a daily cleaner, a separate solution will be necessary to rinse and then store the contact lenses.

Boston Advance Cleaner: This abrasive daily cleaner uses silica gel to physically scrub off proteins and deposits.  To use, place 2-4 drops of cleaner on the contact lens and then rub between your fingers for 20 seconds. Thoroughly rinse off the cleaner, and then store the contact lens overnight with Boston Advance Conditioning Solution. 
     

Lobob ESC: This surfactant based cleaner is self-preserved and contains no abrasive particles that could change the shape or design of the RGP lens over time. After a digital rub, it must be rinsed off thoroughly like Boston Advance Cleaner above.

MiraFlow Extra Strength Cleaner: This daily cleaner is compatible with both RGP and soft contact lenses, and is popular among eye doctors for its' ability to remove stubborn lipid-based deposits like makeup and lotions.  It's formula contains isopropyl alcohol so not only is it an excellent deposit-buster, but it has strong antimicrobial effects as well.

The Cons: Daily lens cleaners require that extra step of needing a second solution to rinse and store the lenses. Because of the chemical properties of salines or multi-purpose solutions, rinsing the lenses with these options requires a steady stream of solution and a thorough rinse to both sides of the lens. Historically, many RGP wearers were taught to rinse off daily cleaners with tap water, but studies have shown this could increase the risk of blinding microbial infections from Acanthamoeba. Many daily cleaners still mention rinsing with water on their instruction labels, however. As the FDA considers making changes to these instructions, it's safest to avoid using tap water with contact lenses all together, and if you do rinse daily cleaner off your RGP lenses with water, make sure you then immediately use a multipurpose disinfecting solution to clean your lenses and help reduce the risk of contamination and infection.

Also of note is that RGP lenses with Tangible Hydra-PEG coatings should NOT be cleaned with abrasive daily cleaners like Boston Advance due to the risk of damaging the surface coating.

4. Storage, Disinfecting, and Conditioning Solutions
These solutions are designed for overnight storage. They improve RGP lens wettability by hydrating the surface of the lens and improving it's ability to adhere to your tear film for best vision stability and on-eye comfort. They also have disinfectant abilities to prevent contamination of the lenses while being stored overnight or over several days.

Boston Original Conditioning Solution: For conditioning and disinfecting, soak lenses for at least 4 hours. This is a tried and true formula is getting harder to find and has been largely replaced in favor of the Boston Advance Conditioning Solution below.
Preservatives: chlorhexidine gluconate and EDTA

Boston Advance Conditioning Solution: This conditioning solution is made for disinfecting, storage, and improved wettability. It's designed to partner as the 2nd step after using the Boston Advance Daily Lens Cleaner.
Preservatives: chlorhexidine gluconate, polyaminopropyl biguanide, edetate disodium



Always check with your doctor about the most appropriate cleaning and storage solutions for your eyes. It's possible for patients to have allergic reactions to specific preservatives, and that's why I've listed them here for quick reference.  Taking the extra time to properly clean (with a rub!), rinse, and condition your lenses overnight can not only prevent potentially blinding infections, but can greatly improve your entire contact lens experience by keeping your RGP and scleral lenses comfortable and clear all day long.

This post contains affiliate links to the products listed 

In their 40s, the average American begins noticing some significant changes to their vision. When anything is held too close to the face, it's harder to focus on -causing eye strain and blurry vision. It might feel like you need bright lights to see fine print. It might take longer to adjust your focus from cell phones, screens or tablets to objects across the room or down a hallway.  All of these changes have one culprit: presbyopia.

The human lens seen here from above. The front curved structure (top) is the cornea.  The lens here is slightly yellowed, consistent with an early cataract.  Arrows labelled "4" point to the zonules, the fibrous connections that link the lens to the ciliary muscles which contract and release so that we can adjust the focus of the lens from distance to near and back again.  via

Presbyopia is a normal age-related change to vision that results from a stiffening and loss of flexibility of the eye's focusing system. The human lens sits behind the iris (the colored part of the eye) and is responsible for focusing light clearly onto the back of the eye.  Much like a camera lens, it moves in and out to focus. The lens inside our eye is attached to muscles by hundreds of fibers (called zonules), so our muscles squeeze in and out to move the lens in and out of focus.

Lens thickness increases as we age (thickness in micrometers on the Y axis).  via

But there's one major flaw to the system: as we accumulate birthdays from year to year, the lens is one of the only body parts that never stops growing. It lays down layers one on top of the other like the rings of a tree trunk.  That's why sometime in our 40s, we notice our eye muscles are having more trouble moving the lens in and out of focus and adjusting our vision to see clearly up close.  The lens has gotten so stiff, the muscles have to strain and work overtime to try to move it.  Eventually in a few more years there's no amount of squinting or muscle straining that will budge the lens at all. Things just stay blurry.

And that's when we pick up those over the counter reading glasses.

Everyday patients experience this discouraging visual change and wonder, what could I do to make this better?  Unfortunately no study has shown that eye muscle exercises can halt or reverse the effects of presbyopia.  Because the eye muscles are just as strong as they have ever been, and it's the thickening of the lens that's the problem, eye exercises aren't a possible solution since they don't treat the actual problem.

With modern technology, we have no way to thin the lens or restore it's flexibility, but a lot of research is looking at ways we could potentially delay onset of presbyopia until later in life.  The best way to slow down the eye's aging process?  Sunglasses!

Sunlight exposes the skin and eyes to ultraviolet radiation, causing cellular damage over time that cause what we consider "normal" aging changes. Studies estimate that 90 percent of skin aging (wrinkles, discoloration, and thinning) is caused by exposure to the sun. In the eye, we know that ultraviolet light also causes discoloration and thickening of the lens, resulting in cataracts as we age. 

Ultraviolet radiation in its' early stages of lens damage however may also have a connection to presbyopia. Studies show people living closer to the equator have earlier onset of presbyopia signs and symptoms.  In India (10-30 degrees latitude) the average age of presbyopia onset is 37.  Compare that with England (51-54 degrees latitude) where the average age of presbyopia onset is 43. The human lens absorbs both UV radiation and heat (infrared radiation), so scientists theorize that both the UV light exposure and the ambient temperature difference between these two countries is a cause.

Studies show about a 5 year difference in average age of onset of presbyopia between developed countries like North America, Japan, and Europe and less-developed countries like Latin America, Africa and Southeast Asia. Closeness to the equator and UV radiation exposure are leading theories as to why. via

While several companies are investigating ground-breaking treatment options to delay or even cure presbyopia, from eye drops to electric shock therapy, we are many years away from having treatable solutions.  In the meantime, if you want to delay having to pick up those reading glasses at the store, invest in a high quality pair of sunglasses now and encourage your children to wear them full time starting from a young age. It's a lifetime of chronic exposure that causes these aging issues of the eye, and like most conditions, prevention is the best protection!

A non-wetting scleral contact lens via

If you've ever tried driving through a foggy windshield, you know the vision quality is far from ideal (or safe!).  For many contact lens wearers, lens fogging is a daily struggle.  Typically this fog is created by debris from the surface of your own eyes - tear film lipids, proteins, and mucins sticking and smearing on the surface of the contact lens and creating an oily coating.  Blinking just spreads the film around, and typically only removing the lenses and cleaning the surface will improve your vision.  In soft contact lens wearers, the solution to fogging issues is most often changing to daily disposable contact lens materials which maintain clarity due to a fresh, clean surface every day and being made from thinner and more debris repellent materials.  For hard or rigid gas permeable lens wearers, hybrid contact lens wearers, or scleral contact lens wearers, no such solution exists.  Luckily there are several options for improving clarity and busting fog with these lens options too!

Enhancing Rigid Gas Permeable Lenses
When I first started fitting scleral contact lenses, the image above was all too frequent in my exam chair.  Patients would be putting on their first lenses directly from the lab, only to immediately find their vision foggy and distorted.  Non-wetting lenses cause immediate fog issues from the moment of dispense; they look completely normal off the eye, but once on the eye the patient's tear film beads up into non-spreading droplets of tear film on the lens' surface.  There is no way to clean or polish off this nonwetting issue.  The best bet is to reorder the lens with a few pro tips:

1. Call the lens manufacturer to report the issue. 
During the manufacturing process, rigid gas permeable contact lenses are cut on a lathe. For scleral contact lenses especially, this lathing process can expose the lens to excessive heat. Higher temperatures during manufacturing can prevent the lens from being able to properly wet on the eye. The lens manufacturer will make a note when remaking the lens to reduce lathing time in this case.

2. Ask for Plasma Treatment and Wet Shipment.
Plasma treatment is not a coating, but rather a hyper-cleaning technique that removes microscopic debris on the surface of the contact lens after the manufacturing process. Rigid gas permeable (RGP) contact lens plasma treatment involves the blasting of ionized oxygen particles against the surface of the lens in a vacuum chamber.  The oxygen interacts with organic debris on the surface of the contact lens, especially effective against organic lipids and oils.  Right after plasma treatment the lens is as clean as it will ever be!  It is immediately placed in a liquid storage solution (most labs use Boston Simplus) because if the lens is stored dry at this stage, the surface will immediately start collecting debris again. Studies show plasma treatment improves lens wettability and initial patient comfort, and reduces the risk of lens fogging.

How to Care for Plasma-Treated Contact Lenses

If you have plasma treated contact lenses, the best way to maintain this level of surface clarity at home is to use the right RGP lens cleaner. Boston Simplus, Optimum pH, and peroxide based cleaners like CLEAR CARE are all compatible. Do not use abrasive lens surface cleaners like Boston Advance.

3. Talk Materials
Silicone-based materials are very popular in today's contact lens marketplace due to their better breathability, but silicone can make contact lenses more hydrophobic - meaning they collect more debris. Changing to a lens material without silicone or with lower amounts of silicone can help reduce surface build-up issues.

Fluoroperm 60 or 30
For healthy eyes without any evidence of prior scar tissue or oxygen loss (hypoxia) traditional, Fluoroperm is an incredibly debris repellent material!  Fluoroperm 30 is considered an old-school work horse for heave depositing patients, but watch carefully for oxygen issues to the cornea like neovascularization or pannus.  For patients in such low oxygen permeable lenses, changing lenses regularly is important to maintaining corneal health. For most RGP wearers, recommended disposal is 1-2 years to prevent infection or corneal scarring or warpage.

The above patient has pannus (white areas seen temporal and nasal on the cornea) associated with Salzmann's nodular dystrophy. A low oxygen transmissible lens wouldn't be a good option in this patient because it could exacerbate corneal scarring.  via

Tyro 97
For scleral contact lenses that cover more of the eye, Fluoroperm does not offer enough oxygen transmission to be safe.  In this case, Tyro 97 is an excellent option for debris repellent lens material that still provides enough breathability to be safely used in a scleral contact lens fit.

For years this was a go-to lens material, but many patients still experienced surface fogging and debris despite doing all of the above.  Enter the newest lens material of choice for scleral lenses in my clinic: Optimum Extra with Hydra-Peg

via

What You Need to Know About Tangible Hydra-PEG
Tangible Hydra-PEG (Tangible Science) is an exciting new coating available across multiple lens materials.  Synergeyes hybrid lens materials and RGP Optimum lens materials are compatible currently, and by the end of 2018 it's expected that Boston materials will be available too. The PEG in Hydra-PEG stands for polyethylene glycol, a lubricant that's been used in artificial tears for decades. The Hydra-PEG coating is permanently bonded to the surface of the contact lens material, encapsulating the core lens material to improve wettability and help prevent surface lens debris.  Multiple studies have shown that the addition of Tangible Hydra-PEG to the lens surface improves both wettability of the lens and lubricity (reduced friction across the surface of the contact lens as you blink).

The addition of Hydra-PEG coating improved wettability and comfort across all lens types, gas permeable, soft silicone hydrogel based lenses, and hybrid contact lenses. via

On-eye studies performed at the University of Iowa also had compelling results.  Existing RGP contact lens wearing patients were refit into lenses with Hydra-PEG coating.  There was no change in visual acuity, but the patients classified before the study as moderate or heavy depositors in their habitual lenses reported clearer vision, better overall comfort, and less haze in their new Hyrda-PEG coated lenses.

via

Removing Lenses with Tangible Hydra-PEG
The addition of Tangible Hydra-PEG can cause changes to the handling of the contact lens as well.  Because of the increased lubricity (decreased friction) on the lens' surface, the contact lens becomes more "slippery" after the addition of Tangible Hydra-PEG.  For gas permeable lens wearers, this is not typically an issue because the lenses are removed most often with plungers. But for soft or hybrid contact lens wearers, it might be more difficult to grip the lens between your fingers to remove.

If you are having difficulty removing your Synergeyes hybrid contact lenses with Tangible Hydra-PEG coating, the company recommends using a tissue over your fingers to help get a better grip.


Cleaning Lenses with Tangible Hydra-PEG
Approved lens cleaners for use with Hydra-PEG include Boston Simplus, Unique pH, and CLEAR CARE cleaning and disinfection solution. Do not use alcohol based cleaners as they could damage and strip the coating with time. Alcohol based cleaners like MiraFlow are commonly recommended for patients with heavy depositing issues, but if you switch to a Tangible Hydra-PEG coated contact lens, this solution should be discontinued.

Treating the Root of the Problem
The most common reasons for fogging, debris, and lens wetting issues are because your own tear film's lipids and proteins are smearing up and collecting on the surface of the lens. Many doctors approach fogging as a two-prong attack: changing the lens surface to make it more resistant, and changing your tear film to make it more balanced.  Patients with dry eye and meibomian gland dysfunction (MGD) are at increased risk of lens fogging because their tear film components of mucin and lipids are out of balance.  Restoring the tear film to homeostasis can help decrease the amount of protein, lipid, and debris floating around in your tear film and thus decrease the risk of it causing fogging and debris on the lens surface.

Meibomian gland dysfunction is extremely prevalent! Over 80% of the estimated 20-30 million Americans with dry eye syndrome have meibomian gland disease.  The meibomian glands express the lipid or oily layer of the tear film.

To minimize lens surface issues in patients with MGD, doctors will often advise using a nightly warm massage or Bruder mask to improve gland expression, and cleaning the eyelid margins thoroughly each morning before inserting lenses.  Avenova eyelid cleansing spray or OCuSOFT lid wipes are commonly prescribed options for daily lid hygiene. 

Lotions and Makeup
The products you use around the eyes and face could also contribute to lens fogging!  Before inserting your lenses, make sure you thoroughly wash off any lotions or creams from your hands and finger tips and dry your hands completely on a clean cloth. Makeup and lotions are heavy on oils, which can immediately fog your contact lens if they come in contact.  Insert your lenses before applying any makeup or skin cream to avoid exposure of these oils to the lens surface. And when you do apply eye makeup, make sure you avoid the waterline area!  This is where the delicate meibomian gland openings are located, and any makeup products applied here will be smeared across the surface of your eye and contact lens all day long.

Makeup applied on the waterline (as above) is a major contributor to contact lens discomfort and fogging! via

What's Next
If you've been frustrated by foggy, cloudy contact lenses, there is plenty of hope in sight! Tangible Hydra-PEG coating is continuing to expand to multiple lens materials, and we may even see it commercially applied to standard soft contact lenses in the near future.  Fighting off fog is a constant battle for patients with underlying risk factors like chronic dry eye, so working closely with your doctor to explore all causes and solutions for your particular underlying issues is essential to maintaining clear vision.  The addition of coatings like Tangible Hydra-PEG is truly just the beginning! A recent Review of Optometry article previewed a future where contact lenses are coated with anti-microbial films to reduce the risk of contact lens related infections, of where contact lenses were treated with surface coatings that allow for electro-conduction, turning your contact lens into wearable lens technology that could monitor your health status directly from the surface of your eye.

For many Americans, grabbing a bottle of eye drops at the store is just something you do without much thought.  Whether your eyes are red, itchy, watery, or just feel like something is irritating them, grabbing a drop is the go-to solution.  But what are you really picking up when you grab an eye drop off the shelf?  And does what you select really matter?  We're breaking down the biggest myths and misconceptions about the $540 million a year over the counter eye drop industry!

As a dry eye sufferer myself (especially when flying or travelling), I like to keep artificial tears in my purse or carry-on bag at all times.  You never know when your eyes are going to feel uncomfortable!  If you are flying, I highly recommend putting in a drop before the flight takes off, and then if it's a long flight, reinserting each time you are fed a meal.  This can help prevent major red eye and sandy/gritty discomfort when you land!