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The medical landscape is constantly changing, and eye care providers have a new medication in their arsenal to fight glaucoma with the introduction of Simbrinza (Alcon).  Want a refresher on glaucoma? Simbrinza is a combination drop containing the carbonic anhydrase inhibitor brinzolamide with the alpha 2 adrenergic agonist brimonidine.  These medications individually have been used in glaucoma treatment for years, and with a combination of the two, the hope is that a patient will get the combined method-of-action effects of these two drugs with a lower frequency of daily dosing.

What You Need to Know:

Early FDA studies show Simbrinza to have a high efficacy in the lowering of IOP (intraocular pressure) with a reported 21-35% reduction.  The recommended dosage is 3 x a day for maximum effect.  Not surprisingly, side effects and contraindications are indicative of what we would find with each individual drug:

Most common side effects: blurred vision, eye irritation, unpleasant taste, dry mouth, and eye allergy

Price:  Around $100/ bottle for cash pay patients; coupon cards available through Alcon
      -- At this time I do not know the average copay with medical insurance to expect, but I will try to update this when I receive the information!

When Not to Use:

Like all CAIs, Simbrinza is not recommended for patients with known sulfa allergies, significant corneal endothelial loss (it can result in corneal edema in patients with conditions like Fuch's Dystrophy), or in conjunction with oral CAIs.

Like all alpha 2 adrenergic agonists, there is a risk of hypotension when combined with anti-hypertensives, an increased risk of side-effects when taken concurrently with MAO Inhibitors, and lethargy in children under 6 years of age (in as high as 50-83% of pediatric glaucoma patients! -- most specialists highly advise against pediatric dosing of this drug as a result).

The drug is Pregnancy Class C, meaning it is not advisable unless the benefits outweigh the potential risks.

Why This is Exciting News for our Industry

Any time we get new glaucoma medication, it is a step in the right direction.  Even though this particular drug only combines two existing therapies, combination drugs already on the market are so effective because they require less dosage for patients.  Imagine you were taking brimonidine and a CAI individually.  You have 2 different bottles to buy every month and as many as 6 drops to instill a day (up to 3 x a day each).  Then imagine getting just 1 bottle to keep track of for the month, and dosing half as often.  It may not seem like much of a difference, but studies routinely show that poor drop compliance is a huge reason glaucoma patients suffer progressive damage.  Glaucoma is a painless and symptomless disease, and remembering to put 6 drops in a day is probably not going to happen unless you are the most vigilant of patients.  By making your patient's drops easier to remember to take, and less of a drain on their day, you can make it easier for them to keep their pressure controlled every day of the year!

As an optometrist, I test children for color blindness on a routine basis, but many adults come in asking me if they might have a color vision problem too.   Have you ever wondered if your color vision is up to snuff?  No surprise, but there is an app for that.  

This well-done image tries to depict what a color blind person would see on a Ishihara Color Blindness test Protanope = no red receptors, Deuteranope - no green, and Tritanope = no blue via

Optometry jokes are the best

"There's a freckle in my eye!?"

A small choroidal nevus can be seen inferiorly in this photograph (it looks like a grey-green circle)

That's usually the response to seeing a retinal photograph that contains a freckle or choroidal nevus (as it is formally called).  With today's excellent imaging software, small freckles inside the ocular tissue are easier and easier to detect.  So if you have a nevus, what does this freckle mean to you?

Normal, benign choroidal nevi occur in as much as 7.9% of the population (though with new technology we may find this incidence is a little higher since it is easier than ever to spot faint, small nevi).  Melanoma inside the eye, conversely, are exceedingly rare, with only 6 in 1 million incidence rate. In neither a melanoma or a normal nevus will there be any visual effect (unless the melanoma is significantly advanced), so your doctor will only detect these lesions through dilation or retinal photography.  Just like any freckle, the most important thing you can do is protect it from UV exposure.   A normal freckle can turn into a malignant melanoma under certain conditions, and this malignant change has an incidence rate of 1 in over 8,000 freckles.  While exceedingly rare based on these numbers, it is best to protect yourself.  I always recommend sunglasses with 100% UV protection, but it is an absolute must for my patients with ocular nevi!

Can you find all the nevi in this person's retinal photo?  Hint (there are a total of 3).

What do I look for in detecting suspicious freckles?  Growth from year to year is a big risk factor, so I use retinal photographs to find any small changes in size or shape from year to year.  A freckle that is 3 x larger than the optic nerve is highly suspicious.  I also look for changes in thickness (if the blood vessels run over top of the freckle without changing their path, the freckle is flat!), coloration, and position inside the eye.  Freckles that are closer to the optic nerve are in a higher suspicion category.  Your nerve is the eye's highway to the brain, so we don't want any malignant changes occurring so close to this pathway.

Always remember, most of the internal ocular findings that your doctor evaluates at your annual eye examination have no real consequence to vision, so you wouldn't know anything was changing inside your eye just by judging vision alone.  Always best to get your eye evaluated regularly even if you don't need glasses or contact lenses!

Imagine a world where your vision limited you to the point that you could no longer pass your driver's test.  So many of my patients ask me if they are legally blind, but the truth of legally blind is that you CAN'T get better vision with glasses or contact lenses.  No matter what prescription is in your glasses or contact lenses, your vision is severely limited.  In these cases, your visual abilities can keep you from performing routine tasks like driving a car or crossing the street.

Bioptic telescope via

If you have "special eyes," you know how difficult it can be to wear contact lenses.  You know that your doctor will never have a lens in the office that works for you.  You know that if you need to change brands for some reason it may take multiple visits and special orders to find something that works.  And you also know that you probably won't see as clearly in contact lenses as you do in glasses.  These are the hard truths for patients that don't fit in the "average" power-options that most soft contact lens companies provide.

I'm not sure that cat-eye sunglasses ever really go out of trend, but they are back with a vengeance on runways this fall.  Designers featured both wearable and over-the-top looks that are sure to inspire sunglasses envy.  Here's a preview from the latest top design houses:

ARMANI:  Navy gives this classic cat-eye a new twist.

TEMPERLEY LONDON:  Color updates again prevail.  These cat-eyes incorporated two-tone frames and lenses with gradient color changes to spice up the classic silhouette.




























CAROLINA HERRERA : Play up the vintage cat-eye appeal with browns and amber tinted lenses.



TORY BURCH: Go statement with over-the-top sunglasses as vivid as the statement necklaces that were trending all last year.

I was reviewing retinal photography with a patient today, and everything looked healthy.

A retinal hemorrhage tells us that blood flow has been compromised, a huge red flag for blood pressure issues!

With this type of bump, a picture is worth a thousand words in describing appearance.  If your eye looks like this, you have a pterygium.

A pterugium this size likely is affecting vision and may require surgery for this patient to see clearly.  via

And if you have a pterygium, likely you have noticed it and already asked for advice on what it is--a pterygium is hard to miss, even in its early stages!  It looks like a mass of blood vessels growing onto the surface of the eye, almost like the white of your eye is overtaking the clear corneal tissue.  They can be large or they can be small and non-progressive, but they are very challenging to remove once they begin to form.

Imagine navigating your daily world without being able to see.  How could you get dressed in the morning?  How could you safely cross the street?  How could you even recognize the loved ones around you?

OrCam sits on the temple of your glasses, providing minimal bulk and disruption.  In the past low vision aids have often been large and unwieldy, creating issues with comfort and even with patients being able to adjust to their use.

OrCam is activated by finger pointing, making the design user friendly.  Most older devices have required head pointing and spotting through a magnified lens, while the OrCam utilizes image recognition software that has been utilized in security systems for years.

People with significant vision loss have to deal with these issues every single day, and luckily companies around the world are innovating ways to improve their lives.  One such company is OrCam, a start-up company that has launched a highly advanced camera system with image recognition software that is so non-intrusive that it can easily sit on the temples of your glasses (much like the design of Google Glass).  The software is programmed to "read" any text, recognize colors, common objects, and can even be programmed to recognize faces.  The camera's image recognition software connects to a small earpiece that the patient wears inside his ear (similar in design to an ear bud) that will translate the image into its English description.  You can point your camera at the closed caption TV screen and "watch" your favorite show as OrCam reads the words from the screen.  It can tell you how much money you are holding in your hand.  It can tell you if you are holding your credit card or your driver's license.  It can tell you if that light is green or red.  Or is that kid playing in the yard your grandson or a neighbor's kid?

Believe it or not, this isn't a technology that we are dreaming up, years away from the market.  You can purchase it now for just $2500 off their website.  Due to high demand, they are working to fill currently placed orders by the end of 2013.  If you or someone you love is vision impaired, consider scheduling them to see a Low Vision specialist to discuss all the products on the market that can make life easier.  OrCam appears to be easy to use and easy to fit, and your optometrist is a trained vision provider than can help you learn how to use these low vision aids and write the proper glasses prescription to maximize the use of the technology.

It wouldn't be fitting to wrap up the Eyedolatry Sunglasses Initiative of 2013 without featuring Dr. G over at Eye See Euphoria. The man knows how to style a pair of glasses, be it with ophthalmics in his daily wear or when he is sporting suns on the beaches of the Dominican Republic.  Cue the photo gallery:

Versace Sunglasses

Maybe a new campaign in the works?

As an optometrist, Dr. G always speaks about the protective health benefits of sunglasses on his blog, but he also writes about styling men's and women's frames for you fashion readers out there.  If you are interested in learning more about current designer frames on the market, his website is a great launching point!


I hope that our feature of local bloggers has inspired you to reach for your sunglasses this month. Whether you are buying designer labels or sunglasses over the counter, just remember that those lenses are medical devices and you are protecting yourself and being fashionable with the summer's latest trends at the same time. Never compromise on your own safety standards with sunglasses -- make sure your lenses are at least 98% UV blocking; in today's market there is never an excuse to sacrifice protection for style!

I had a great email question in my inbox this month so I decided to devote an entire post to it (keep those questions coming!).

Why does my doctor turn the lights low when checking my distance vision when I want to see sharply in daylight?  And then when they check my reading vision they use a bright light, while my problem is that I have trouble seeing to read in dark places, like in restaurants to look at menus?  

This is a question that a lot of my own patients ask, so I know there are a ton of people out there that have been wondering the same thing.  Here's your chance to have this mystery explained!

Checking Distance Vision in Low Lighting Creates the Most Challenging Environment

Is it easier to drive in daylight or during the night?  What about on a bright day or when it is raining?  Most everyone will agree that low lighting is very difficult on their eyes' distance vision.  That's one simple reason why your doctor typically uses a dimly lit room.  They want to challenge your visual system to find a prescription that works for all of life's difficult visual environments.  There are some technical reasons that make low lighting important too, however:

Phoropter via

In dim lighting your pupil dilates, and your eye muscles that control focusing relax.  When you are behind the phoropter, your doctor needs to keep you from squinting and over focusing to get a true reading, and lowering the lights is one way to achieve that.  Now your doctor is going to use several other tactics to prevent your eyes from over focusing too.  When I perform a refraction (getting your prescription) I always make sure I  go through a series of blurring and then clearing steps to make sure the eyes aren't over focusing.  There is a reason your doctor spends four years in optometry school -- they are being educated on how to make sure they always give you the best prescription without overworking your eyes, even if you don't answer 1 or 2  "correctly" if you will.

Checking Reading Vision in Good Lighting Gives the Truest Prescription

In bright light, or in near focusing conditions, the pupil constricts (letting less light into the eye) Pupil constriction is tied with the eye's ability to focus at near.  That's why we read better with light than in the dark, no matter the prescription of glasses or contact lenses.

Have you ever tried to read in dim lighting?  It's hard, right.  The simple answer is that we check reading vision with light because it is next to impossible to achieve good vision to read in the dark, even if you are a kid.  The results just won't be very good, no matter what prescription we give you in glasses.

There is a technical reason to explain this, of course.  Everyone sees more poorly at night; that's because in dim lighting your pupil is larger. The pupil opening is a muscle, and when it is smaller that means it is contracting; and this contraction is inherently tied with your eye muscles focusing.  When we focus on something up close, we naturally have a constriction reaction to the pupil too.  If I want to determine your true near focusing ability, I need to create pupil constriction, and that's why lighting on the reading chart is important.  I want to create an environment where I can test your eye's natural focusing ability, and then see what prescription you need to aid that ability.  If I have your focusing system relaxed (as in dim or no light), everyone is going to have difficulty seeing to read and prefer stronger reading glasses. Remember, we use low lighting to test distance vision because we don't want to initiate your eye muscles to work.   When I check reading vision, I DO want your eyes muscles to work, so I can tell how strong they are.  That is why I need light!  As we age, our eyes are naturally losing their focusing ability (called presbyopia) so it is ALWAYS better to read with light if you want to be able to see what you are reading.  There is no way with any pair of glasses to get you to read as well in the dark as you do in light, because your pupil is not going to constrict as much, and your focusing system is not going to kick in as much!  We check reading vision with a light on because for most people, that is the only way they are going to see the 20/20 line (or anything close to it).

In a dim restaurant and need to read something, but having more trouble than reading glasses can alleviate in full?   Try using the flashlight app on your smart phone for a quick fix!

Feel free to post more questions regarding this here, and I will do my best to provide more technical answers if desired!

Time for another local blogger that is truly embracing the message here with the Eyedolatry Sunglasses Initiative.  Christina at Carolina Charm  is a huge supporter of sun protection.  She even blogged about her daily routine to here.  What I love about featuring a lifestyle blogger like Christina is that she is showing us that sunglasses aren't just about fashion.  They are a product that she wears for function and protection, and fashion is the frosting on top.

When you are buying over-the-counter sunglasses, it can be hard to know how much protection you are really going to get from wearing them.  The truth is, not all sunglasses available for purchase really meet the standards required to protect you from diseases like macular degeneration or cancers, or painful conditions like photokeratitis (a sunburn of the eye).  Here's what you need to know before swiping your credit card:

• Know Your UV Coverage

  A sticker  like this verifies 100% UV Blocking, so make sure your OTC sunglasses have this sticker too! Via

If you haven't seen the styling of Megan from For All Things Lovely, you have probably never been on Pinterest before.  This South Carolina blogger dishes out fashion hits on a daily basis, and her sunglasses wardrobe makes even me envious.  I had such a hard time narrowing down her best sunglasses styles; this post is going to be very picture heavy.

What does she look for in sunglasses?

"I always go for sunnies that have a cat eye shape or a classic aviator.  I've tried to branch out so many times, but those shapes just seem to glam up any outfit.  And always, always have at least a little bit of gold or silver on them.  You can never go wrong with metallic's."

She is an expert at remixing her sunglasses to create casual and more sophisticated looks.  And she really knows how to fit the shape of her face with a designer's frame shape.  If you need sunglass inspiration, look no further.

Karen Walker Sunglasses

Ray Ban Sunglasses

Prada Sunglasses

Even her husband knows how to rock a good pair of sunglasses.

Scarring from Macular Degeneration

Megan from For All Things Lovely--our next Carolina Style Blogger to Be Featured this week!

Today's technology driven world is an incredible place.  Not too many years ago, your doctor dilated your eyes to look inside to check for bleeding, holes, tears, and growths.  He or she may have been able to describe to you what they were seeing, but you were left to using your imagination for the most part, even with the use of the best diagrams and artistic renditions.  With retinal photography available at most eyecare providers now, the world inside the eye is a place both your doctor and you as the patient are able to explore.

July is being dedicated to sunglasses here at Eyedolatry, so prepare yourself for a lot of fashion-inspired posts this month.  From now until late August, millions of Americans will be trekking to the coast or the community pool to enjoy the fantastic weather.  A must-have for your summer adventures? Sunglasses.  Even if you are just walking around at the Farmer's Market, or bustling around town in and out of doors, sunglasses are protecting your eyes not just from annoying glare, but the harmful UV light that leads to conditions like Macular Degneration and advanced or early onset cataracts (see this post).  I am going to be featuring local Carolina fashion and lifestyle bloggers this month on what they look for in sunglasses, and their favorite way to style their glasses for Summer 2013.

Up first is Caitlin, a blogger out of Charlotte, North Carolina.  Her blog Southern Curls and Pearls is an homage to her personal style and Carolina roots. Her featured glasses for the summer are a classic tortoise shell look that are 100% UV blocking that she was able to snag on sale at her local Anthropologie.





What does she look for in sunglasses?

"I want sunglasses that protect my eyes but are chic at the same time, and these are definitely it. The tortoise look is really "in" at the moment, so I knew I couldn't pass these up. They are also similar to a Karen Walker pair I've had my eyes on, but without the expensive price tag! "

Karen Walker Super Duper Strength Suns

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The Karen Walkers she refers to have been sported by celebrities like Gwen Stefani, but come with a $348 price tag.  Looking for designer shades but a chance to try them on and get great local service?  Remember, you can also find designer sunglasses at your local high end optical providers that are 100% UVA and UVB blocking with the quality of frames that will last for years and years, and often this time of year they will be running sunglass promotions to help you save by protecting your eyes.  And if you have vision insurance or a flexible spending account, you can use your benefits towards prescription sunglasses too (even if you have a very small prescription) because sunglasses are really medical devices that are protecting your eyes and eyelid skin from cancer and degenerative conditions for years to come.

I truly believe my patients try to keep their eyes healthy.  We talk every year about the cornea getting enough oxygen under their contact lenses, and I know that my patients want to wear their contact lenses correctly so that their eyes stay healthy enough for another year of contact lens wear.  Imagine how hard it is for the patient (and for the doctor for that matter) when you have to have a conversation about not being able to wear contact lenses anymore -- for a few months, or perhaps even for a lifetime depending on the amount of damage.

This eye may look okay at first glance, but there is a huge scar in the central cornea!  This person will never be able to see clearly again!  Via

The biggest reason my patients tell me that they don't change their contact lenses on time is simply because they forget.  Their lenses are so comfortable, they just don't remember to change them after 14 or 30 days.  Some people even tell me that they will use comfort as a judge to know when to You cannot trust how a lens feels, because you cannot feel your cornea getting oxygen from the atmosphere.  If you fall into this category of lens wearers that has trouble remembering to change on time, here are some helpful aids to let you keep your eyes healthy enough for contact lens wear!
change the lenses.  If you wait until your lenses feel bad to change them, you have waited to the point that your eyes have suffered damage!  And all that lack of oxygen in an old contact lens smothers your corneal nerves, so next month, you will feel even less as your eye is starving more and more for oxygen.

1) Email Based
Acuvue as a brand makes some of the hardest lenses to remember to change on time (every 2 weeks!) so I appreciate their effort to help remind patients to keep healthy since they know they have a problem with their lenses being abused.  Their website Acuminder tool is free; can be used with any product (not just Acuvue lenses), and is very non-invasive.  You just sign up for a monthly or 2 week email (depending on your lens) that will remind you to throw your lenses away.  They also offer a text message based system.

2) SmartPhone Apps
There are number of apps out there that act as reminder alarms, but here is a breakdown of my opinion:

Contact Lenses Timer app: free and simple interface

• Lens Tracker LE: Free; Simple and clean.  It also tells you how many lenses you have left so you don't surprise yourself when you are on your last box.
• Contact Lens Tracker:  $0.99; To me the app has a little too much data -- it can track the number of times you wear a lens as well as how old the lens is, which is information that may confuse the issue.  If you have a monthly lens, you need to replace it monthly whether you wear it 28 times or 31 times.  The lens deteriorates every day it is opened from the package, not just every day you wear it.
• My Contact Lens:  $0.99; To me this one looks to be aimed for younger patients. It has linked data pages to tell you proper cleaning and care, removal strategies, etc.  
• Contact Lenses Timer: Free;  It also has a place for you to record you doctor's name and number, your brand and prescription, in case you ever need that information.  
• Contact Lenses: Free; Again, too complicated with the ability to "skip a day" of wear affecting the tracker.  And you have to record each eye separately.

There are certain ocular diseases that we all know can cause blindness, and we know that we should be checked for those at every eye examination.  But during my tenure as an optometrist, I have discovered that while most people have heard of conditions like glaucoma, cataracts, and macular degeneration, we haven't done a very good job of telling people what those ocular conditions actually are. Glaucoma is a disease of the eye where the optic nerve is destroyed, causing permanent visual loss.  For more details, please read this post.  What most people don't realize is that diagnosing glaucoma is a very complicated process.  Your doctor can't just look at your eyes and say "You have it!" (unless it is very advanced that is).  Here is a breakdown of all the information your doctor is collecting to screen your eyes for glaucoma at every eye examination:

1) Checking the pressure inside the eye

Goldmann's Tonometry is a more accurate pressure reading that is often used to verify NCT (or air puff) data

The dreaded air puff test has an important goal-- it tells your doctor the pressure inside of your eye.  A range of pressure between 10 and 21 mmHg is considered normal, but some people are going to have higher pressure and it still be normal for them.  The air puff (or non-contact tonometer) is a preliminary screening tool.  If your pressure is high, it does not mean you have glaucoma.  If your pressure is normal, it does not mean that you don't have glaucoma.  Your eye pressure is going to be different depending on the time of day, the medications you take, whether you are sitting or lying down... Lots of things can vary.  But over the course of several years of pressure data, your doctor is compiling a trend for your "normal" pressure, which can help them find suspicious changes with time.  For example let's say you have a pressure of 10 for several years, and the next year we check your pressure and it is 18 mmHg.  That is still a normal pressure reading according to our "average range", but it is not normal for you!

2) Inspecting the Anatomy of the Eye
I don't want to make this too complicated, but when the doctor looks at the surface of your eye in the microscope, they are checking for numerous medical conditions, including suspicious structural changes that could cause acute spikes in your eye pressure.  If the anatomy of your eye where the cornea meets the iris (colored part of the eye) is very narrow, you are in a higher risk category for having this acute spike.  This is something your doctor measures at every examination, and will record in your chart whether this structural meeting place is "wide open" or grade the amount of narrowing on a scale of 1 to 4.  If you are in the 1-2 range on this grading scale (very narrow), your doctor will be discussing the signs and symptoms of an acute angle closure attack.  If you have acute onset redness, pain, blurry vision, and halos around lights, you need to be seen immediately!

3) Inspecting the Anatomy of the Optic Nerve

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The optic nerve is a like a chord that hooks the back of the eye to the brain.  In the retinal photographs that many doctors take, it looks like a yellow circle.  Inside of this chord, blood vessels run through delivering oxygen and nutrients to the eye.  That means that there is a hole inside of the nerve to let the vessels pass through.  In doctor-speak, this hole is called "the cup".  To make things as simple as possible, the bigger your hole, the more at risk you are for glaucoma, because in glaucoma the nerve tissue is dying, which would cause the hole to get bigger and bigger, or more hollowed out if you will.  Here's the catch -- not everyone with a large hole or "cup" has glaucoma.  Some people just genetically will have a large hole.  And not everyone with a small cup does not have glaucoma.  I have seen several patients with a small cup that had diffuse visual field loss from glaucoma.  There are some trends that help your doctor determine if your nerve "cup" size is normal:

• Is the size of the cup the same in both eyes?  If you have one large hole and one small hole, there is a greater chance that the eye with the large hole has a disease process.  Usually in nature we are symmetric in anatomy, so we would expect the right and the left eye optic nerve to look the same if it was healthy and normal.
• Is the size of the cup the same as last year?  As 10 years ago?  This is where photodocumentation is pivotal.  In a normal eye, the size of the hole in the nerve will not be changing from year to year.  If you have photos of your eye over a lifetime, it can be very beneficial to have your doctor compare to check for gradual changes.  If you started out with a smaller hole and now have a larger hole a few years later, that is very suspicious for glaucoma.
• Is there bleeding around the nerve?  A hemorrhage near the nerve is often a sign of glaucoma (called a Drance hemorrhage).
• The bigger the nerve, the bigger the cup.  This is a just a rule of thumb -- not everyone has the same size optic nerve.  If you have a larger optic nerve, your doctor expects you to have a larger hole inside the nerve.  What is a normal size hole in one person with a large nerve, could be a major glaucomatous process in another person with a smaller nerve size.  It is all relative!

This picture is from the right and left eye of the same patient.  Look at the asymmetry of the cup or hole inside the optic nerve!  The large hole inside the nerve on the right side of the photos is a major giveaway that this person probably has advanced glaucoma.