Red, itchy, watery, inflamed eyes with clogged meibomian glands.  Sound familiar?  Ocular rosacea is very similar to Meibomian Gland Dysfunction/Posterior Blepharitis from my most recent dry eye post, and in fact some would consider it a subset of the same disease.  To draw on a personal example, I recently had a patient that had been treated by several different OD's for dryness.  He told me that a doctor had been treating his eyelid gland disease without success, and then he went to a specialist who took one look at his eyes and said he had ocular rosacea.  He wondered why no one had told him that before?  I'm not sure how convincing it was when I told him his ocular rosacea and eyelid gland issues were one and the same thing, just different variations of the same ocular syndrome.  There isn't a set definition for when we call these symptoms ocular rosacea versus when we just call them MGD or bleph, but here are some guidelines:

Another Synergeyes post! Several visitors to this blog have started reading to find out more information regarding these new hybrid lenses, and because they are so new, information on the web is very limited.  I just got an email from my Synergeyes rep with important new information regarding what contact lens solution is best with this lens.  Note: results are based on a study performed by the Synergeyes company and independent of any company making contact lens solutions.

I know I'm not the only one out there with a major style crush on Zooey Deschanel.  To other girls, she has come to epitomize the dorky, quirky, cool fashion we all want to effortlessly achieve.  In her new Fox show, New Girl, her character Jess has really embraced the geek chic trend, complete with glasses of course.  This trend towards large, bold plastic or metal frames is still going strong for both men and women.  For more information and style advice, check out this post.


Wanting to copy her geek chic look?  Aim for thick plastics in dark colors or tortoise shell.  For the appropriate fit, the vertical depth of the glasses (distance from top to bottom of the frame, also called the B size) should be slightly deeper than traditional.  These glasses should look almost too big for your eyes, but fit correctly along the temples and still have your eye correctly centered along the horizontal axis. Any optician should be able to make sure the fit is appropriate for proper vision and comfort!

Robert Marc 261 in Jungle Tortoise is a great choice for this trend!

One of the most common types of dry eye I see is a direct result of clogging of the tear glands that line the upper and lower eyelids.  This type of dry eye is more common in younger patients and men than other etiologies.  If you are having dryness and also experiencing:

• itching, redness, or irritation along your lash line
• small white/yellow bumps along your lid
• recurrent styes
• thick, hazy tear film intermittently between blinks
• suffer from rosacea

Clogged Meibomian Glands: also called impacted or inspissated glands, or posterior blepharitis

As promised, the forthcoming posts are my opus to the overwhelming topic of dry eye.  The spectrum of Dry Eye Syndrome ranges from patients suffering from mild contact lens discomfort at the end of the day, to those at risk of needing a corneal graft due to the extreme damage done to their eye from dryness.  Most patients fall somewhere in the middle, with dryness being severe enough to cause marked discomfort at some point during the course of their day.

Do you have dry eye?  Here are some of the hallmark symptoms:

• dryness, itching, burning, sharp pains, and watering --- Though it seems counterintuitive, watering is a response to your eye being too dry!  The eye tries to protect its surface by producing emergency tears, but these tears do not have the proper components and run down the side of your face.  
• decreased visual quality or intermittent haziness, especially between blinks  (especially with Meibomian Gland Dysfunction specifically)
• discomfort at the computer --- Studies show we blink about half as often at the computer than we do in conversation!
• crusting or eyelid irritation 
• redness, both of the white of the eye and along the eyelids

At some point very soon, I know I need to dedicate a significant number of posts to Dry Eye Syndrome.  (It is in all caps, because this is a condition that significantly affects the quality of life of as many as 7 to 17% of the population depending on which studies you are looking at!).  People with Dry Eye experience redness, irritation, discomfort, blurred vision, sharp pain, watering, crusting, or dryness.  It is typically worsened with computer use, contact lens wear, and the use of ceiling fans and air conditioners.  Treatment ranges from over the counter drops to expensive prescriptions and ointments to lubricate the ocular surface.

This patient's meibomian glands are obviously clogged, causing a blockage of tear film secretion!

One of the leading causes of dryness is called Meibomian Gland Dysfunction, where the tear glands located along the top and bottom eyelid fail to properly release their oily tear film layer onto the eye, causing the tears to quickly evaporate and leave the surface dry.  To treat MGD, we often prescribe warm compresses with massage to open the gland orifice and force the tear secretion through the gland onto the eye.  Fish oil supplements and oral doxycycline can also help with the functioning of these sebaceous glands.  I will go into more detail concerning these treatments in the future, but this post is dedicated to the new treatment for MGD:  the LipiFlow device!

The LipiFlow device

A local company in Morrisville, NC called TearScience recently received FDA approval for this device to treat moderate to severe MGD.  As you can see from the image above, the major component of the device is a mechanical "cup" that is applied to your eyelids.  This machine heats the lids from the inside, then uses timed pulsations to express the clogged secretions from the meibomian glands.  The entire procedure lasts about 12 minutes, and there is very minimal discomfort reported by patients at this time.  The cup that sits over the eye is quite large, but it does not touch against the cornea (the clear dome of the eye), and as such, must be large enough to only touch the outer portions of the eye.  Yes, you read that right.  The suction cup-esque part of the device pictured above touches the inside of your eye.  Sounds uncomfortable, but you will be given a numbing drop before the device is inserted.

As you can see from this diagram, one part of the device is under the lids providing heat to the glands, and the other is external to provide pulsation to "milk" the glands

Things to know:
1) This procedure is very new, but results are showing that some patients are getting relief from their dry eye symptoms lasting anywhere from 3 months to more than a year!  For many patients life without artificial tear drops, or with significantly less drops, is well worse 12 minutes of pressure being applied to the lids.
2) Because this procedure is so new, only a very few clinics are offering it.  There is also no CPT code available, so this means in practical terms that no insurances will cover the procedure at this time.  Expect cost to be significant.  In my area, Duke Ophthalmology has access to the device, and the cost is around $1500.
3) The science isn't available yet as to how effective this machine is long term, or what the magnitude of objective improvements are in the level of dryness, such as tear film break up time and tear film osmolarity. The theories behind this device are the same that optometrists recommend to patients every day when they prescribe warm compresses with lid massage to improve meibomian gland secretion.  If you are interested in more information, please feel free to post here.  In the North Carolina area, there is a doctor at Duke who is accepting patients for this procedure for those that are interested!

The eyelid twitch: almost everyone has had this happen at least once in their life.  To the person with the twitch, it feels like their entire eyelid is spasming.  This twitch, called myokymia, is caused by a random firing of nerves in the lid tissue.  While it may seem like a very concerning phenomenon, luckily it has no permanent or lasting effect.  Myokymia is generally caused by one of three things:

• lack of sleep
• stress
• caffeine

I have had some interest in my experiences with the Synergeyes Duette lenses, so now that I have had more patients wearing the lenses and returning for follow-up I thought it was a good time to share.  If you are interested in my original post, please click here.

For those who may not recall from my previous post, Synergeyes Duette is the hybrid lens that combines a rigid gas permeable (or hard lens) center with a soft contact lens skirt that surrounds the lens.  The soft lens skirt provides added comfort and also helps deliver oxygen to the eye via the new silicone hydrogel material (in comparison to the original Synergeyes lens that had poorer oxygen transfer). It is a great choice for patients experiencing poor quality vision through soft contact lenses, especially in patients with astigmatism or those needing multifocal correction.

Synergeyes contact lens: notice the darker colored  hard lens (RGP) in the center to provide sharp, clear optics

If you are a patient interested in trying the Synergeyes lenses, here are some things to know:

1) The lenses are quite large and can be hard to get used to at first.  A lot of my patients request to try them, but when they see the size difference compared to their soft lenses they aren't as keen.  For best comfort you will fill the contact lens bowl up with solution before inserting it, to provide added moisturization.  To insert the lens patients often need to lean forward over a mirror placed flat on a table, and then insert the lens straight up towards the center of the eye. Due to this insertion method, it is not a great lens choice for a first time wearer due to the learning curve involved with inserting a lens of this size.  Most patients have no trouble after a short course of practice.

2) There may be some dryness and lid awareness, especially early on in the fitting experience.  Lid awareness should resolve with proper fit and adaptation time, but I have had patients with dry eye complaints prior to trying this lens notice their dryness seems worse.  This dryness issue is not affecting all of my patients, but I am still working on how to resolve the complaints. Right now my efforts are centered over adjusting the fit to ensure that adequate tear flow is present under the lens.  As far as solutions, I have been told by reps that the Revitalens solution is highly recommended with Synergeyes wear to improve comfort, though many other multi-purpose solutions can be effectively used.  Personally I have had great success with Aquify and Clearcare solutions with this lens.  Of course, I just love Clearcare in general, but that is another post, hah.

UPDATE:  The above information is now very outdated, and I recommend seeing this post for better information.  Suffice it to say that Revitalens is NOT what the current data supports even though the initial lens launch recommended this product.  BioTrue is the solution of choice for Synergeyes Duette, with regular cleaning with an additional build up remover like MiraFlow.

via

3) The multifocal lens (Synergeyes Duette Multifocal) isn't going to be perfect.  I have patients seeing 20/20 with this lens that aren't happy with the quality of their vision. Some of this is inherent in the lens design and I do try to tell patients exactly what their expectations should be. The design of this lens is called "simultaneous vision," and what that means to the wearer is that you are seeing both distance vision and near vision information "simultaneously."  That's a lot for the brain to process.  It can take 1-2 weeks of wearing time to know if this lens design will work for you.   If you are a doctor fitting this lens, to increase distance vision you need to switch to a larger add zone, or consider going to a steep base curve skirt.  To improve near vision, the add zone size needs to be small.  

4) There is a major price tag on these lenses.  Patients should expect to pay a higher contact lens fitting fee because your fit is going to include several visits to perfect your lens parameters.  The lenses themselves are also expensive, typically around $200-$300 for a set of lenses.  Keep in mind that each lens will last only 6 months, so you will need 4 lenses in total for a year's supply (that puts these around the $400-$600 range for your year!).  This is different from traditional RGP (hard) contact lens wearers that may sometimes be able to use their lenses for 1-2 years.

If anyone has stories to share about these lenses, I would love to hear them!

A question for the ages.  As an optometrist, I answer a lot of questions about vision and ocular health every day, but this particular question pops up more frequently than I would have suspected.  The simplest answer is this: if your glasses are the correct prescription, wearing them will in NO way hurt your vision. To be more thorough with this answer though, we actually need to break it down into several common scenarios:

1) My glasses prescription is correct, but it seems like my vision is worse than before when I take them off.  


I hear this often from patients that are new glasses or contact lens wearers.  If the glasses prescription truly hasn't changed, then vision without glasses looks worse than the patient remembered because they had never previously had crisp and clear 20/20 vision to compare to their own vision.  If your world looks blurry all the time, that becomes your normal.  Once you get used to 20/20 vision in your new glasses, that same amount of blur looks just terrible because now you know what you are missing!

2) I wear over the counter reading glasses, and I just keep having to get stronger and stronger powers.  Have I made my vision worse with the wrong reader?


For those individuals over age 40 that suffer from presbyopia (see this post for more details), reading glasses become a way of life.  Because over the counter readers are readily available, many patients will pick a pair in  the store based on what feels most comfortable, without seeing a doctor first to verify the necessary Rx.  The good news is that wearing readers will not hurt your vision even if you select the wrong power.  They can give you headaches if the prescription is too strong or too weak, but this is really the only side effect.  And rest assured, even though it feels like you are getting more and more dependent on your reading glasses, it is because your visual system is gradually declining at near due to normal aging changes (none of us are immune!) and not because of the readers.  My patients are also often concerned that they selected too strong a power in reading glasses (the powers typically span from +1.00 to +3.00), but a stronger pair will only give you greater magnification and force you to hold things closer if it is stronger than you really need.  No permanent harm done, but you will get used to a certain level of magnification if you use a particular power for a while.

Vera Bradley specializes in colorful OTC readers.  I also recommend Steinmart for a good selection.  Just remember, the quality of OTC readers is not the same as you will get with prescription glasses.  There's a reason many people call them "cheaters"-- in the correct power, they are just good enough to get you by!

3) Every year my child's glasses prescription is getting stronger. Is wearing glasses making his vision worse?


This question is the only one where we can get into a scientific debate.  Myopia can progress quite rapidly in children, and a number of factors influence this progression. Being near-sighted is a function of the curvature and length of your eye, which in turn is influenced by both genetics and environment. Numerous studies have shown a correlational relationship between amount of time doing near work (like reading) and the presence of myopia.  Whether myopic children tend to read more because it is easier for them than distance activities, or if they are myopic because of doing so much reading is under constant debate.  There is a school of thought however that near strain, or the strain on the eyes' focusing system when performing a task at near, can induce  myopia in an effort to relieve that strain.  An overview of these theories can be found in Myopia and Nearwork  by Rosenfield and Gilmartin.  As optometrists, we try to counteract this progression of myopia from near strain by:

• Prescribing the lowest possible prescription to attain 20/20 vision, and thus limiting the amount of near strain when reading with glasses.
• Prescribing bifocals or progressives for children when needed to ensure that their distance prescription does not adversely affect their reading facility.
• Studies have shown that certain contact lenses such as rigid gas permeable lenses or orthokeratology (where the patient sleeps in rigid contact lenses that act like a retainer to change their prescription overnight) can help slow the myopic progression in some cases. For more information (though it is quite technical), try this article:
• http://www.revoptom.com/continuing_education/tabviewtest/lessonid/106321/

This rigid gas permeable (or hard) contact lens has a special design that flattens the cornea overnight, leaving a myope with clear distance vision the next day.  This technique is best for myopes -4.00 in prescription or less.

It's that time of year again.  That's right, flexible spending account season, as it's known in the healthcare industry.  Most flex spending accounts expire on December 31st, so for many people who wear glasses this is the perfect time of year to make your purchase!  Due to the high demand of the season, expect your local doctor's office or frames retailer to be running discounts or sales, making this a great time to also get a good deal.

For the holiday season, bold designs and colors continue to dominate the eyewear industry.  Here are some of my best-sellers!

• ROBERT MARC: Branded as the eyewear line of choice for the stars, the quality of these frames is hard to beat.  This year's line features several styles in a colored tortoise pattern.  The red tortoise (below) and their olive green "jungle tortoise" are two of my favorites.  The only drawback on these frames is the pricetag, but the fit and design are truly impeccable.  

• TIFFANY'S: The company's newly launched eyewear line features their classic robin's egg blue color scheme, as well as familiar accents in silver such as the heart locket and key motifs.  This frame line has been very popular at my office because the brand is so distinctive. People can recognize that shade of blue from across the room.

• PRODESIGN: If you want bold color, no one does it better than Danish based Prodesign.  I find their frame shapes are very angular, but for those people with oval or round shaped faces they are a perfect fit.

How often do you throw away your contact lenses?  It is amazing the responses you can get on this simple question.  As an optometrist, I have had patients that have been wearing their same trial pair of contact lenses they were dispensed at an exam 2 years ago.  Most people aren't that daring, but it is not uncommon to have people wearing lenses for months longer than FDA guidelines recommend.  And most patients are very defensive  about just how often they are throwing their lenses away.  Why do I recommend following FDA guidelines for proper contact lens disposal?  Here are 5 very real complications that I treat on a regular basis that are a result of improper contact lens wear.

New blood vessel growth is not a good thing when it means opacification of what should be clear tissue!  Picture via optometric.com

A cornea with significant scarring and neovascularization

  Treatment = Change to more oxygen permeable contact lenses or daily wear. If severe enough, contact lens wear may have to be discontinued permanently.

Acute red eye, usually after sleeping in contact lenses is classic for CLARE

A Bacterial Ulcer: definitely something you do NOT want

Here's another post really geared to my OD (or future OD) readership. One of my largest learning curves since graduation from optometry school has been in the nuances of contact lens fitting.  There are no hard and fast rules that work every time, but here are some tips that I have picked up (sometimes the hard way) in contact lens fitting.

• BIOFINITY:  This is my go to lens for patients wearing monthlies.  I also like Air Optix Aqua, so if Biofinity doesn't work that is my next choice.  One tip about Biofinity lenses: the aspheric design allows for really superb vision.  Due to this you can often cut -0.25  from your Rx (so if you would usually pull a -3.00 for a patient consider a -2.75).

• AIR OPTIX FOR ASTIGMATISM: This is my go to toric contact lens.  Again, the Biofinity toric also works just as well, but if you have a higher prescription I really prefer the Air Optix for stabilization.  Both have the same base curve and the same diameter, but the Air Optix material tends to really hug the cornea creating better stabilization in those high power astigmats.  

For all of those times I hear mothers lament how video games are likely destroying their children's vision, new studies are finding that video games may actually improve visual acuity! These studies were specifically geared toward individuals with amblyopia, a condition where one eye has reduced vision despite the best possible pair of glasses.  Amblyopia (or a lazy eye as it is sometimes called) is the result of a high prescription that has been left uncorrected, or an eye turn causing a poor visual signal to reach the brain.  As a child is growing, a poor or blurry visual signal will cause the eye-brain connection to fail to develop properly, resulting in permanent visual decrease.  In the past it has been commonly accepted that ambylopes have no chance of regaining sharp vision to their "lazy" eye past the age of 8 (because by then the eye to brain connections have fully developed).  Children were typically treated by patching their good eye to force them to use their lazy eye in an attempt to develop these visual connections.  Newer studies, however, have shown that visual improvement may be possible past this critical period of 8 years of age!

Most children are happy playing video games, despite the face this one is making!

The other difficult part of treating amblyopia is that children (no surprise) don't exactly like having their good eye patched.  And you can't just put the patch on and let them go take a nap, or eat ice cream or something.  They traditionally had to perform at least 2 hours of near activities like reading or word searches or puzzles, etc.  These activities have high visual demand, and can be quite frustrating when you are looking through a blurry eye.  Two new studies are showing that playing video games for one to two hours with the good eye patched (an activity that won't exactly be hard to entice children or adults for that matter to perform) can also be effective, however!  One study showed a 30% improvement in visual acuity in patients with amblyopia between the ages of 15 to 61 (well past the critical 8 years of age that was traditionally set as the limit).  This improvement in vision was after just 40 hours of video game play.  It took 120 hours of traditional "near" activities to get the same 30% improvement in the control group.  A second study of 10-18 year olds showed similar notable improvement in vision versus a control group when video game therapy was employed for 1 hour a day.

What do these studies mean?  One, getting someone to participate in vision therapy activities is very taxing (and usually not that fun) when it involves forcing them to use an eye they can barely see out of.  When you temper that with an activity that is inherently enjoyable and doesn't seem like work, the compliance with treatment is going to be much better.  Do I believe that video games make the brain more plastic than traditional reading activities? Probably not.  But I'm quite sure that more therapy is getting done when the patient finds it enjoyable.

Traditional patching with near work.  He sure looks like he is having fun.  Photo courtesy National Eye Institute

Take home points: video games are not going to destroy your children's vision, but I would recommend they take breaks to play outside.  Video games can actually be useful as vision therapy because they have the advantage of improving hand-eye coordination and developing important visual skills like figure ground differentiation.  Will you create superhuman vision or stop needing glasses if you play enough video games?  Of course not.  But the good news is that people who are suffering from vision loss due to an amblyopic eye can see improvement through doing an activity that they enjoy!

Amblyopia is another reason why it is so important to have your child's vision checked, even if they are not complaining about blur.  If one eye is seeing clearly, no one will know the other eye is not working unless they develop a tell-tale eye turn (or strabismus).  Children as young as 6 months of age can be screened for signs of amblyopia, so please bring them to an eye doctor to make sure they have all the visual skills they need to learn to read and succeed at school!

I had the pleasure of speaking to a group of optometry students from my alma mater, the Southern College of Optometry earlier this week, and ever since then I have been thinking about the transition from student to practicing doctor.  It was not too long ago that I was in the classroom learning the techniques and skills that I utilize every day in diagnosing and treating my patients.  For all of those optometry school students out there, the rest of this blog post is for you!

My Graduating Class from SCO!

Best Advice for new (or soon to be new) grads:

• Take a deep breath; you are more than prepared to see your own patients!  By the time you get to the end of your fourth year of optometry school you have logged so many hours in patient care that you will have seen an example of almost every case that walks through your door.  And you have the advantage that all of this experience both from externships and classroom time being fresh in your memory.  If you are concerned about your diagnosis, you can always triage with a fellow optometrist (whether they are at your practice, mentors from school, or fellow peers from your optometry school days) or refer to a local ophthalmologist that specializes in that area of eye care. 
• Use your youth to your advantage.  Most new graduates are in their late twenties, and your patients are going to notice your relative young age.  Some more kindly than others.  For as many times that I have had patients ask me: "just how old are you?", I have had someone else (or sometimes even that same person by the end of the exam!) compliment me on how thorough I was.  Patients appreciate a new doctor's willingness to explain and patience with their questions of concern or during the refraction.  As one of my patients recently put it, "I can tell you aren't jaded yet, and I appreciate that!"
• Trying to build a reputation (and a good patient base)? Two ideas that can win you a lot of patient loyalty:
• 1) Always send a thorough referral letter or examination report to other doctors that you are triaging care.  The patient also appreciates it when you take time to send their primary care doctors a thorough report if you are following ocular manifestations of systemic conditions.
• 2) Call back your patients to follow up!  Have a red eye?  Call your patients in a day or two to make sure they are doing better.  You won't believe the positive response you get from this simple act!

You know you have thought about it. Compare the prices at different websites to what you see inside any optical, and the price difference is usually staggering.  And people order their contact lenses off the internet all of the time, right?  Ordering glasses from internet providers is a growing trend, but as its popularity rises so do the number of complaints.  Here is an honest look at some of the pros and cons of ordering glasses off the internet:

Pros:

• PRICE.  Some websites even offer designer frames for incredible discounts.  And the costs of lenses are much less expensive as well.  It is possible to save near a hundred dollars off typical optical costs.
• EASE.  Well nothing can be easier than shopping from your seat.  You just pick your frame and enter your prescription, and then swipe your card. No trip outside of your living room necessary (as long as you already have a copy of your Rx).
• SELECTION.  Let's face it, optical displays can be overwhelming.  And different offices offer differ frames and designer lines.  With the internet you can narrow your search immediately by brand or color or material, streamlining the selection process if you know your likes and dislikes. No more searching for frames on towering racks or drawers.  

This is how a progressive lens is worked up to get proper alignment in an optical lab, as you can see  a few millimeters of measurement in one direction or another can cause major disruptions because of all of the factors at play.

Remember those friends you had that never, ever had to wear glasses or contact lenses.  They were just blessed with perfect vision and never even entered the door of an optometrist's office growing up.  They went through life knowing how lucky they were and thinking how awful it was for those poor glasses wearing people. 

Presbyopia: the closer the reading material, the harder it is to see

The lens functions just like a lens on a camera, adjusting shape to focus images near and far.  Picture courtesy sciencedaily.com