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November 2, 2018
InnovativEyes
The visual field test is designed to see how well you see outside of the center part of your vision (peripheral vision). When we test your vision on the basic eye chart it is only testing how well yo...

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The visual field test is designed to see how well you see outside of the center part of your vision (peripheral vision).

When we test your vision on the basic eye chart it is only testing how well you see right in the center and gives us no idea if you can see out away from the center. Your peripheral vision is very important because it gives you the ability to move around your environment without running into things.

There are several diseases that can severely impact your peripheral vision while leaving central vision unaffected. Some people can have perfectly normal 20/20 central visual acuity and have almost complete loss of their peripheral vision.

The main culprits that can have a big impact on your peripheral vision long before your central vision are glaucoma, some retinal diseases such as retinal detachments or retinitis pigmentosa, and some neurological problems like brain tumors, strokes, pseudotumor cerebri and multiple sclerosis.  

Most visual field tests are now done on an automated machine that flashes lights in your peripheral vision while you stare straight ahead. The lights continue to get dimmer until you can no longer detect that they are there. The machine is trying to find the dimmest light you can see at each point in your peripheral vision that it is testing for.

Many patients get anxious when they take this test because everyone wants to do well on it. That sometimes results in people not staring straight ahead but trying to look around to find the lights in an effort to do better.

That just makes the test come out worse. The machine also makes some noise as it changes location of the test light. Some people start pressing the buzzer whenever they hear a noise. They think there must be a light they missed but the machine, several times during the test, makes noise and then doesn’t put a light on to specifically see if you are trying to cheat by hitting the buzzer on the noise rather that seeing the light. Don’t do those things - you are only cheating yourself and making it more difficult to figure out your problem.

Ocular Coherence Tomography (OCT)

The OCT really took hold in Ophthalmology at the beginning of this century. It was the first time we were able to see anatomy and pathology inside the eye on a microscopic level without the use of any radiation.

It has been a great addition to our examination techniques and allowed us to see many causes of vision loss at a level of detail we could never do before.

The two biggest uses for OCT in ophthalmology are diagnosing diseases of the retina, particularly the area of central vision called the macula, and for diseases of the optic nerve, the most common of which is glaucoma.

For retinal disease it has been extremely helpful in macular problems such as macular degeneration, the leading cause of blindness in the U.S., diabetic retinopathy, retinal vascular occlusions and retinal swelling from inflammation.

The OCT allows us to see the individual cellular levels of the retina and helps in diagnosing the exact level where the pathology is occurring. If you look into the eye at the retina and see some bleeding in the macula it is difficult to judge where that blood exists. Is it superficial in the retina and coming from the retinal circulation or is it deep in and coming from the choroidal circulation under the retina?

The difference between those two locations can have a significant impact on what disease is causing the problem and what the proper treatment is. The OCT is also very helpful in following the effect of treatment. If you are treating a bleeding or swelling problem in the retina, the OCT can track the degree of improvement with a level of detail that could never be matched by the human eye.

For glaucoma and other problems with the optic nerve, the OCT can very precisely measure the thickness of the nerve tissue as it passes through the optic nerve. The hallmark of glaucoma is progressive loss of nerve fibers in the optic nerve.  Being able to measure the nerve thickness down to the micron level is very helpful in both diagnosing and watching for progression of any optic nerve disease.

Fundus Photography

A picture is worth 1,000 words (said just about everyone at some point or other in their lives).

Fundus photography is just that, a regular picture of the inside of your eye. The pictures highlight the appearance of the macula and the optic nerve and record it for prosperity.

As eye doctors we make notes in the medical record of what we see when we look in the eye. The wording of anything that looks abnormal with the retina or optic nerve does vary somewhat from doctor to doctor. One of things we record is something called the cup to disk ratio (C:D) of the optic nerve. We express that ratio as a percentage. Normal is about 30% or .3. The range of normal is very wide and some “normal” eyes have a .1 cup and others can have a .7.

In glaucoma those percentages get larger over time as the person loses nerve tissue. So, if you were born with a .3 cup but in your 60’s you were found to have a .5 cup that would be a strong indicator that you might have glaucoma.  However, if you were born with a .5 cup and at 60 you still have a .5 cup then you don’t have glaucoma.  When you look at someone at 60 with a .5 cup it’s hard to be sure if this is normal for that person or did they progress from a .3 cup to a .5 cup.  If only I had a picture …  

Pictures of the back of the eye really do tell the story better than words. I can describe what the C:D looks like to me but a different doctor may describe it differently. Doctors are usually fairly consistent in their estimate of the C:D when it is the same doctor watching that C:D over time. When a different doctor estimates the C:D that consistency is just not there. My .4 C:D may be my partner’s .5. But you can’t argue with the picture.  

The same thing occurs with retinal bleeding. Rating the amount of bleeding as mild, moderate or severe is somewhat helpful but there is a broad range of “mild” or “moderate”. When comparing two pictures taken at two different points of time it is much easier to decide if something is really getting better or worse.

We also use fundus photography to keep an eye on small tumors that can develop in the eye called choroidal nevi. These are increased areas of pigmentation under the retina in an area called the choroid. Most eye doctors explain these pigmented spots a “freckles in the eye”.  Most choroidal nevi are small and fairly flat. They can, however, sometimes grow larger and rarely turn into a melanoma in the eye. Serial photographs are very helpful in watching the lesions for growth.

These three tests - visual field, OCT and fundus photography - make up the core of our testing. There are many other tests that can be performed along with your eye exam but these three we described here probably make up about 80% of the tests you may encounter, depending on your individual problem.

Article contributed by Dr. Brian Wnorowski, M.D.

Drug Allergy or Side Effect? Knowing the difference could save your life

There is a common misconception that any adverse reaction to a drug is an allergy. That is definitely not the case.

Reporting to your doctors that you have an allergy to a medication when what you really had was a side effect could potentially create a substantial alteration to your medical care in the future. And this could mean a physician may avoid using a drug that could possibly save your life because of the fear of an allergic reaction.

An anaphylactic allergic reaction generally produces a very specific set of symptoms, including difficulty breathing due to constriction of windpipe, swelling of your tongue and/or a rash and hives that break out over your entire body. While an allergic reaction can present in other ways, these are the most frequent reactions that occur when you have a true allergy to something.

If that is not the type of reaction you had then it probably isn’t an allergy. If you are uncertain if your reaction to a medication is an allergy or not, testing by an allergist may be able to tell you for sure if your reaction was a true allergy or a side effect.

It is not always just the patient who misconstrues a side effect for an allergy. Sometimes it is the doctor or the dentist who tells the patient, “You must be allergic.” This is a quick and easy explanation but not always the correct one.

In Ophthalmology there are not a lot of “lifesaving” incidences but there are several drugs that are the preferred treatment for certain conditions and if you report an allergy to these drugs it may make your doctor use a much less effective drug.

Here are some of the specific examples of when a false report of an allergy may lead to less effective treatment or even failure to offer life-saving treatment.

Epinephrine

The most common potential “lifesaving” drug to which patients sometimes report an allergy to is Epinephrine.

The story usually goes something like this: “I was having a dental procedure and soon after the dentist injected my mouth with a local anesthetic of lidocaine with epinephrine my heart started racing and pounding out of my chest and I almost passed out.” This hypothetical patient may come to the conclusion or the dentist may mention that the patient is allergic to epinephrine. That reaction is almost never an allergy but a side effect that occurs when a substantial dose of the lidocaine and the epinephrine gets into the blood stream and stimulates the heart.

The mouth and gums are very vascular, and it is easy to have some of that injection end up in the bloodstream, but that reaction is not an allergy and should not be reported as such.

Epinephrine is used to treat severe (anaphylactic) allergic reactions and not using it if you were to ever have a severe allergic reaction could lead to some very bad outcomes. This is not to say you can’t be allergic to epinephrine. You can, but it is extremely rare. If there is any doubt you should be tested by an allergist before you ever record yourself in a medical setting as being “allergic” to epinephrine.

Cortisone/Steroids

Cortisone is a highly effective drug to treat many conditions. Again, it is unlikely but not impossible to be allergic to it.

We all have naturally occurring cortisol circulating in our bodies and cortisone is a very similar molecule but not exactly the same. Cortisone also can have a wide range of side effects depending on where and how it is administered

Some of the common side effects of cortisone, which have been mislabeled as an allergy, are: Making your blood sugar rise, insomnia, mood swings, nausea, and weight gain. These are all known side effects of the drug and not allergies. Cortisone side effects are associated with only certain routes of administration and are often dose dependent.

Why is this important in terms of your eye care? We often use cortisone derivatives, like Prednisolone, to fight inflammation that may occur in your eye, particularly after any ocular surgery. If you report that you are allergic to cortisone when you really only experienced a side effect we are going to have to use a less-effective medication to deal with your eye inflammation.

As I mentioned above, most side effects are dose dependent and the dose you got in a pill may have caused a side effect you’d rather not have again but the dose in an eye drop is significantly less and highly unlikely to give you the side effect you got with a pill taken orally.

Antibiotics

People often report they are allergic to antibiotics when they really experienced a side effect.

The most common side effect with oral antibiotics is some type of gastrointestinal disturbance, like nausea, or diarrhea. If that was what you had and just prefer not to get that again you still shouldn’t report it as an allergy. If you do, then the drug can’t be used as an eye drop or ointment that might be the best treatment for your condition.

An antibiotic eye drop/ointment is very unlikely to produce the same gastrointestinal trouble that the same antibiotic gave you when given as a pill. You don’t want to take away the most effective treatment for your problem because you mislabeled a side effect as an allergy.

Sedatives/Anesthesia

Most of the time with these drugs the issue is how you felt either during or after a procedure.

Common comments are “it took me too long to wake up” (side effect not an allergy); “the sedative I got in my IV burned when it went in” (side effect not an allergy); “I was sleepy all day” (side effect not an allergy); “I was nauseous after the procedure” (could be an allergy but much more likely to be a side effect).

Why are these important? We can make you much more comfortable for a local anesthesia procedure if we can use some sedation. Using sedation may be better for you and the doctor performing the surgery because you are much less likely to move during the surgery if you are resting comfortably.

If you ever have an untoward reaction to a medication it is worth your time and effort to really probe into the issue to figure out if what you had was really an allergy or just a side effect because sometimes your life may depend on it.

Article contributed by Dr. Brian Wnorowski, M.D.

Eye doctors typically pride themselves on being able to improve someone’s vision through either glasses or contact lens prescriptions. Whether it’s a first-time glasses wearer, or someone having either a small or large change in their prescription, we like to aim for that goal of 20/20 vision.

Despite our best efforts, however, correcting vision to 20/20 is not always a positive outcome for the patient. Whether someone will be able to tolerate their new prescription is based on something called neuroplasticity, which is what allows our brains to adapt to changes in our vision.

You or someone you know may have had this happen: Your vision is blurry, so you go to the eye doctor. The doctor improves the vision, but when you get your new glasses, things seem “off.”

Common complaints include that the prescription feels too strong (or even too clear!) or that they make the wearer feel dizzy or faint. This is especially true with older patients who have had large changes in prescription, since neuroplasticity decreases with age. It is also more likely to happen when the new prescription has a change in the strength or the angle of astigmatism correction. Conversely, this happens less often in children, since their brains have a high amount of plasticity.

Quite often, giving the brain enough time to adapt to the new vision will decrease these symptoms.

Whenever a patient has a large change in prescription, I tell them that they should wear the glasses full time for at least one week. This is true for both large changes in prescription strength, as well as changing lens modality, i.e. single vision to progressives.

Despite the patient’s best efforts, though, sometimes allowing enough time to adapt to the new vision isn’t enough, and the prescription needs to be adjusted. Even when someone sees 20/20 on the eye chart with their new glasses, if they are uncomfortable in them even after trying to adjust for a week then we sometimes have to make a compromise and move the script back closer to their previous script so that there is less of a change and they can more easily adapt.

In conclusion, adapting to a new prescription can sometimes be frustrating. It does not mean there is anything wrong with you if you have difficulty adjusting to large changes in a glasses prescription. With a little patience and understanding about how your brain adapts to these kinds of changes, your likelihood of success will be that much higher.

Article contributed by Dr. Jonathan Gerard

Dry Eye Disease affects more than 5 million people in the United States, with 3.3 million being women and most of those being age 50 or over. And as people live longer, dry eye will continue to be a growing problem.

Although treatment options for dry eyes have improved recently, one of the most effective treatments is avoidance of dry eye triggers.

For some that might mean protecting your eyes from environmental triggers. To do that experts recommend using a humidifier in your home, especially if you have forced hot-air heat; wearing sunglasses when outside to help protect your eyes from the sun and wind that may make your tears evaporate faster; or being sure to direct any fans  - such as the air vents in your car - from blowing directly on your face. For others, it may mean avoiding medications that can cause dry eyes.

There is one other trigger that may need to be avoided that doesn’t get as much notice: The potentially harmful ingredients in cosmetics.

Cosmetics do not need to prove that they are “safe and effective” like drugs do. The FDA states that cosmetics are supposed to be tested for safety but there is no requirement that companies share their safety data with the FDA. There are also no specific definition requirements for labeling cosmetics as “hypoallergenic,” “dermatologist tested,” “ophthalmologist tested,” “sensitive formula” or the like, making most of those labels more marketing than science.

Things to watch out for in your cosmetics if you have dry eye include:

Preservatives

Preservatives are important to prevent the cosmetics from becoming contaminated but many are known to exacerbate dry eye. Common preservatives in cosmetics that could be adding to your dry eye problems (Periman and O’Dell, Ophthalmology Management August 2016) are: BAK (Benzalkonium chloride); Formaldehyde-donating (yes, Formaldehyde!) preservatives (often listed as DMDM-hydantoin, quaternium-15, imidazolidinyl urea, diazolidinyl urea and 2-bromo-2-nitropropane-1,3-diol); parabens; and Phenoxyethanol.  All of these preservatives in sufficient quantities can cause ocular irritation or inhibit the function of the Meibomian Glands that produce mucous that coats your tear film and keeps it from evaporating too quickly.

Alcohol

Alcohol is used in cosmetics mostly to speed the drying time but the alcohol can also dry the surface of the eye.

Waxes

Waxes can block the opening of the Meibomian Glands along the eyelid margin. If these glands are blocked they will not be able to supply the mucous and lipids necessary to the tear film to prevent it from drying too quickly. If you have trouble with dry eye it would be advisable not to apply eye liner behind the eyelashes along the lid edge where the Meibomian gland openings are.

Anti-aging products

While these may be safe and effective for the skin of the face they should not be used around the eyes. Most of these products contain some form of Retin A. These products have been shown to be toxic to the Meibomian glands and could be contributing to your dry eyes.

These components of cosmetics do not adversely affect everyone. However, if you suffer from dry eye and are not effectively able to keep your eye comfortable and your vision clear, you should investigate your cosmetics as a potential contributor to your problem.

Article contributed by Dr. Brian Wnorowski, M.D.

There are certain eye conditions where an injection into your eye might be recommended.

Injections into the eye, specifically into the vitreous or gel-filled cavity of the eye, are called intravitreal injections.

In Part 1 of ‘Why Do I Need an Injection in my Eye?’ we talked mostly about anti-vascular endothelial growth factor (anti-VEGF) injections. Anti-VEGF injections are probably the most commonly injected agents and they are used to treat wet age-related macular degeneration (ARMD), diabetic retinopathy, and retinal vein occlusion.  

But there are other injections that may be used as treatment.

Another injected medication used in combination with Anti-VEGF agents to treat wet macular degeneration, diabetic retinopathy and retinal vein occlusion are steroids. Additionally, steroids can be used to treat inflammation, or uveitis, in the eye. There is a steroid implant called Ozurdex, that looks like a white pellet and can last up to 3 months in the eye. The downside of steroids is that they can increase eye pressure and cause progression of cataracts.  

Antibiotics are another type of medication that is injected into the eye. Sometimes an infection called endophthalmitis can develop inside the eye. This can occur after eye surgery or a penetrating injury to the eye. The presenting signs and symptoms of endophthalmitis are loss of vision, eye pain and redness of the eye. Bacteria is usually the cause of the infection, and antibiotics are the treatment. The best way to deliver the antibiotics is to inject them directly into the eye.  

Another relatively new injection is Jetrea, an enzyme that breaks down the vitreous adhesions that may develop on the surface of the retina. As we age, the vitreous contracts away from the retinal surface.  When this occurs over the macula, the region responsible for fine vision, the result is visual distortion. Jetrea is an injection that will dissolve the vitreous adhesions and relieve the traction on the retina.  Prior to the advent of Jetrea, the only treatment would have been surgery to physically remove the vitreous jelly and traction on the retina.   

The next time you visit your eye doctor and are told you need an injection of medication, it will likely be one of the above agents.

Article contributed by Dr. Jane Pan

There are some eye conditions where your doctor might recommend an eye injection as a treatment option.

Injections into the eye, specifically into the vitreous or gel-filled cavity of the eye, are called intravitreal injections.

Anti-vascular endothelial growth factors (anti-VEGF) are probably the most commonly injected agents. They are used to treat wet age-related macular degeneration (ARMD), diabetic retinopathy, and retinal vein occlusion.

In these conditions, there are abnormal leaky blood vessels that cause fluid and blood to accumulate in and under the retina. This accumulation of fluid results in loss of central vision. The role of anti-VEGF agents is to shrink these abnormal vessels and restore the normal architecture of the retina.

There are three anti-VEGF agents widely administered: Lucentis, Avastin, and Eylea.

Lucentis (Ranibizumab) is FDA approved for treatment of wet ARMD, diabetic retinopathy, and vein occlusion. It is specially designed for injection into the eye and is a smaller molecule than Avastin so it may have better penetration into the retina.

Avastin (Bevacizumab) was originally approved by FDA for treating colorectal cancer. It is used “off-label” for the same treatment indications as Lucentis. Off-label usage of medication is legal, but pharmaceutical companies can't promote a medication for off-label use. The amount of Avastin needed for eye injections is a fraction of the amount used to treat colorectal cancer, therefore, the cost of ophthalmic Avastin is only a fraction of the cost of Lucentis. This means that Avastin needs to be prepared sterilely into smaller doses by an outside pharmacy prior to injection into the eye.  

Eylea (Aflibercept) is the third anti-VEGF agent. It was designed to have more binding sites than Avastin and Lucentis so it may last longer in the eye than the former two.  Eylea is FDA approved for treatment of wet ARMD, diabetic disease, and vein occlusion, and therefore, the cost of Eylea is similar to the cost of Lucentis.

Various studies have been performed to compare these agents. The most anticipated study was the CATT trial (N Engl J Med 2011; 364:1897-1908), which compared Avastin and Lucentis for the treatment of wet ARMD.

The study found that both had equivalent treatment effects on vision over the course of a year. In general, most ophthalmologists would consider all three agents to be very similar.

There is a thought that after prolonged injections, some patients may develop resistance to one particular agent but still respond to the other 2 agents. Therefore, your ophthalmologist will individualize your treatment.

Article contributed by Dr. Jane Pan

What are conditions that can affect a child’s vision and the potential for learning? What is Amblyopia? What is Strabismus? What about Convergence Insufficiency? These are serious conditions of a child’s eye that need addressed. Did you know that 80% of learning comes through vision? The proverb that states, ”A picture is worth a thousand words” is true! But what if a child cannot visually see or process those words?

Let’s explore Amblyopia , or “lazy eye”. It affects 3-5% of the population, enough that the federal government funded children’s yearly eye exams into the Accountable Care Act or ObamaCare health initiative. Amblyopia occurs when the anatomical structure of the eye is normal, but the “brain -eye connection” is malfunctioning. In other words, it is like plugging in your computer to the outlet and the power never gets to the computer all the way.

Amblyopia need to be caught early in life, in fact if it is not caught and treated early (before age 8) it can lead to permanent vision impairment. Correction with glasses or contacts and patching the good eye daily are ways it is treated. Most eye doctors agree that the first exam should take place in the first year of life. Early detection is a key.

Strabismus is a condition that causes an eye to turn in (esotropia), out (exotropia), or vertically. It can be treated with glasses or contacts, and if needed surgery. Vision therapy or strategic eye exercises prescribed by a doctor can also improve this condition. In fact, vision therapy is the treatment of choice for Convergence Insufficiency.

When we read, our brain tells our eyes to turn in to a comfortable reading posture. In Convergence Insufficiency, the brain tells the eyes to turn in, but they instead turn out, causing tremendous strain on that child’s eye for reading. Another tell tale sign of this condition is the inability to cross your eyes when a target approaches. The practitioner will see instead, that one of the eyes kicks out as the near target approaches. This condition can be treated with reading glasses or contacts, and eye exercises that teach the muscles of the eye to align properly during reading.

It is important to understand the pediatric eye and all the treatments that can be implemented to augment the learning process. Preventative care in the form of early eye examinations can mean the difference between reading properly or struggling badly in a child’s learning. Remember, a young child can’t tell you if they have a vision impairment or not. For the success of the child: be proactive in encouraging exams in the first year of life and beyond.

 

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The American Academy of Ophthalmology has recommendations for how often adults need to get their eyes examined and those recommendations vary according to the level of risk you have for eye disease.

For people who are not at elevated risk the recommendations are:

  • Baseline eye exam at age 40.
  • Ages 40-54 every 2-4 years.
  • Ages 55-64 every 1-3 years.
  • Ages 65 and older every 1-2 years.

Those recommendations are just for people who have NO added risk factors. If you are diabetic or have a family history of certain eye diseases then you need exams more frequently.  

As you can see, the guidelines recommend more frequent exams as you get older. Here are the Top 4 reasons why you need your eyes examined more frequently as you get older:

1. Glaucoma

Glaucoma is the second leading cause of blindness in the United States. It has no symptoms when it begins and the only way to detect glaucoma is through a thorough eye exam. Glaucoma gets more and more common as you get older. Your risk of glaucoma is less then 1% if you are under 50 and over 10% if you are 80 or over. The rates are higher for African Americans. Glaucoma can be treated but not cured.  The earlier it is detected and treated, the better your chances are of keeping your vision.

2. Macular Degeneration

Macular degeneration is the leading cause of blindness in the U.S. Like glaucoma, it gets more common as you age. It affects less than 2% of people under 70, rises to 10% in your 80s and can get as high as 50% in people in their 90s. The rates are highest in Caucasians. Macular degeneration can also be treated but not cured. Early intervention leads to better outcomes.

3. Cataracts

As in the cases above, cataracts get more common as you get older.  If you live long enough, almost everyone will develop some degree of cataracts. In most people cataracts develop slowly over many years and people may not recognize that their vision has changed. If your vision is slowly declining from cataracts and you are not aware of that change it can lead to you having more difficulty in performing life’s tasks. We get especially concerned about driving since statistics show that you are much more likely to get in a serious car accident if your vision is reduced. There is also evidence that people with reduced vision from cataracts have a higher rate of hip fractures from falls.

4. Dry Eyes

Dry eyes can affect anyone at any age but the incidence tends to be at its highest in post-menopausal women. Dry eyes can present with some fairly annoying symptoms (foreign body sensation in the eye, burning, intermittent blurriness). Sometimes there aren’t any symptoms but on exam we can see the surface of the cornea drying out.  Dry eye can lead to significant corneal problems and visual loss if it gets severe and is left untreated.

One of the most heart-breaking things we see in the office is the 75-year-old new patient who hasn’t had an eye exam in 10 years and comes in because his vision “just isn’t right” and his family has noticed he sometimes bumps into things. On exam his eye pressures are through the roof and he is nearly blind from undetected glaucoma. And at that point there is no getting back the vision he has lost. If he had only come in several years earlier and just followed the guidelines, all this could have been prevented. Now he is going to have to live out the rest of his years struggling with severe vision loss.

DON’T LET THAT BE YOU!!!!!!

Article contributed by Dr. Brian Wnorowski, M.D.

Is There Anything I Can do to Stop Getting More Nearsighted?

I recently received a text from an out-of-state relative, asking if he should have his college-age daughter put in progressive lenses to help delay progression of her nearsightedness.

I told them that there wasn’t good evidence that doing that would help, and since progressive lenses generally cost about three times as much as single-vision lenses that he shouldn’t do it.

The optometrist they were seeing at the time insisted I was wrong and strongly encouraged them to do it. Included in that exchange was a comment by their optometrist that I should stick to surgery and let her handle refractions!!

Based on that exchange I decided to do some homework and make sure I wasn’t missing something. There have been multiple interventions tested over the years to help slow the progression of nearsightedness (myopia).  Some have worked, some have not. Some that have worked have side effects that limit their usefulness. We will try and delve into several of these here.

Progressive Lenses

Let’s start with the intervention that got me into this review.

There have been multiple studies attempting to demonstrate a usefulness for progressive lenses in retarding the progression of myopia over time. Some have demonstrated statistically significant lessening of progression of myopia, but none demonstrated clinically significant differences.

What is the difference? In a large study, with hundreds of participants, you can often measure a statistically significant difference in outcomes without that difference having any clinical relevance.  

That is what happens in this case. The most commonly cited study for the use of progressive lenses in retarding myopia is the COMET Study by Gwiazda et al. In this study there were 469 children ages 6-11 with myopia, to whom half were given standard single-vision lenses to correct their myopia and half were given +2.00 addition progressive lenses. The two groups were studied for three years.  After three years the progressive glasses group was -1.28 diopters more near sighted and the single vision lens group was -1.48 diopters more nearsighted.  

That was statistically significant but clinically irrelevant. Why clinically irrelevant?  Because what we are trying to accomplish in retarding myopia is attempting to not have people progress to high myopia (greater than -5.00) because high myopia increases your risk for several significant eye diseases. An improvement of .2 diopters over 3 years is like the proverbial “spitting in the ocean,” it just doesn’t matter for the long-term health of your eyes. In fact, when we prescribe glasses or contacts we do it in .25 diopter steps, so after three years of buying much more expensive glasses and having to get used those glasses, which sometimes isn’t easy, the treated group was less nearsighted by an amount that is smaller than the smallest measurement we make in glasses. That is not clinically relevant.  

Even the authors of the study state as their conclusion “The small magnitude of the effect does not warrant a change in clinical practice.” Therefore, if you or your children are offered this as a solution, your answer should be no thanks!

Atropine

Atropine is an eye drop that basically does two things - dilates your pupil and impairs your eyes’ ability to focus up close. It has been shown in various doses to slow myopia progression in multiple studies. The issue with atropine has been the side effects. It dilates your pupils, which leads to some light sensitivity and may increase the eyes’ exposure to UV light and that could increase the risk of cataracts or macular degeneration much later in life.

It also causes some difficulty in focusing on near objects, especially with the distance corrective glasses on. Some children in the studies had enough near-task trouble that they needed to have reading glasses in addition to their distance glasses in order to function properly.

More recent studies on lower doses of atropine 0.01% (ATOM2) did produce clinically significant reduction in myopia progression with much lower side effects.  Progression in myopia over two years on this dose was -0.49D, compared with the control group of intervention in ATOM1, which was -1.20D. That difference of .71 diopters in 2 years is clinically significant compared to the .2 diopters over 3 years in the Comet study.  With this low of a dose of atropine there were very mild effects in pupil diameter and almost no effect on near visual acuity.

The use of low-dose atropine has been slow to catch on in the United States.  There are several reasons for that, including that the ATOM studies were done in an Asian population, which may not generalize to the diverse U.S. population since Asians overall have a higher rate of high myopia.

Other issues are: no long-term data yet and it is an “off-label use” (not an approved indication by the U.S. Food and Drug Administration). It’s unclear how early to start the treatment, how long to keep it going, and if it is worth using in low myopia or should it be preserved for children who get into the higher degrees of myopia, such as -4.0 or greater.

A clear recommendation on low-dose atropine is harder to give. With the currently available information I would consider utilizing low-dose atropine if I thought a child had a high risk of ending up with high myopia. The risk factors I would consider using it in would be Asian descent, parents with high myopia (it does run in families) and significant myopia (-4.0 or greater) at a young age.  

Ortho-K or Soft Bifocal Contacts

These are hard or gas permeable contact lenses worn overnight to flatten the central cornea to reduce the amount of myopia. Studies about slowing of myopia progression with Ortho-K generally demonstrate a decrease of myopic progression on average of about .3 diopters over two years compared to glasses – a slightly greater effect than progressive lenses but not as good low-dose atropine. Sleeping in contacts significantly increases the corneas’ susceptibility to bacterial infection, including corneal ulceration and, in my mind, the reduction in myopia is not worth the complications compared to the better effect and less severe side effects of low-dose atropine.

Soft bifocal contacts are worn during the day, not while sleeping, so their infection risk is lower. They have similar reduction of myopia progression rates as Ortho-K so they may be a slightly better option then Ortho-K in terms of complications. However, I have consistently found when using soft bifocal lenses in adults over 40 (for which the lenses were intended) that people often complain that the clarity of their vision for both distance and reading is just not as good as the vision with their glasses. This limits their usefulness, in my view.

More Time Spent Outdoors

There have been several studies that have shown decreases in myopia with more time spent outdoors. The effect has been somewhat small, and it has more of an effect on decreasing the incidence of myopia and less of an effect on decreasing progression once myopia is already there. This intervention is free and getting outside and increasing physical activity instead of sitting inside attached to a screen all the time carries many other health benefits. Even though for this effect is small for myopia progression it makes sense to try and encourage it.

Conclusion

Given the variety of potential intervention and their mild effects, which options should a parent take in regard to their children?

Recommending more time playing outside seems to be an easy one to suggest. It’s free with no significant side effects and although its prevention capabilities are mild there is no reason not to do this. So get off the screen and get outside!

Personally, the Ortho-K would not be something I would choose. I’ve seen enough corneal ulcers in patients who slept in their contact lenses for that to be a nonstarter for me. I don’t like the soft bifocal lenses because they do not produce the same level of clarity at either distance or near as their single-vision counterparts, so I would not want to subject my child to them for what seems like a very small benefit.

Progressive glasses do not have a clinically significant effect, are expensive, and are sometimes difficult to get used to wearing so I find no place for them even being in the discussion.

The one intervention, besides more time outdoors, mentioned in this blog that I personally would consider using on my children is the low-dose atropine. I would only recommend this if several criteria/risk factors were meet. The first would be a higher-than-average risk for myopia. The elevated risks for high myopia are Asian decent and family history, especially if one or both parents have high myopia. The second risk factor would be already being myopic at a young age.  For me personally, it would have to be a child in the age groups these studies were done (generally from 5-13) and the degree of myopia would have to be  -4.00 or more.

As I mentioned, almost every study in regards to prevention of progression in myopia are conducted on the age groups of 5-13 so there is no evidence that any of these interventions will work for children older than 13 or young adults so I would be very hesitant to utilize them on a child whose age is outside the study subject.

Article contributed by Dr. Brian Wnorowski, M.D.

1. Vision is so important to humans that almost half of your brain’s capacity is dedicated to visual perception.

2. The most active muscles in your body are the muscles that move your eyes.

3. The surface tissue of your cornea (the epithelium) is one of the quickest-healing tissues in your body. The entire corneal surface can turn over every 7 days.

4. Your eyes can get sunburned. It is called photokeratitis and it can make the corneal epithelium slough off just like your skin peels after a sunburn.

5. Ommatophobia is the fear of eyes.

6. You blink on average about 15 to 20 times per minute. That blink rate may decrease by 50% when you are doing a visually demanding task like reading or working on a computer – and that’s one reason those tasks can lead to more dry-eye symptoms.

7. Your retinas see the world upside down, but your brain flips the image around for you.

8. If you are farsighted (hyperopia) your eye is short, and if you are shortsighted (myopia) your eye is long.

9. An eyelash has a lifespan of about 5 months. If an eyelash falls out it takes about 6 weeks to fully grow back.

10. All blue-eyed people are related. The first person with blue eyes was thought to have lived 6,000 to 10,000 years ago. All people before that had brown eyes.

11. One in every 12 males has some degree of “color blindness.”

 

 

Article contributed by Dr. Brian Wnorowski, M.D.

This blog provides general information and discussion about eye health and related subjects. The words and other content provided on this blog, and in any linked materials, are not intended and should not be construed as medical advice. If the reader or any other person has a medical concern, he or she should consult with an appropriately licensed physician. The content of this blog cannot be reproduced or duplicated without the express written consent of Eye IQ.

Just like adults, children need to have their eyes examined. This begins at birth and continues into adulthood.

Following are my recommendations for when a child needs to be screened, and what is looked for at each stage.

A child’s first eye exam should be done either right at or shortly after birth. This is especially true for children who were born premature and a have very low birth weight and may need to be given oxygen. This is mainly done to screen for a disease of the retina called retinopathy of prematurity (ROP), in which the retina does not develop properly as a result of the child receiving high levels of oxygen. Although rarer today due to the levels being monitored more closely, it is still a concern for premature babies.

The next level of an eye exam that I would recommend would be at 6 months. At this stage, your pediatric eye doctor will check your child’s basic visual abilities by making them look at lights, respond to colors, and be able to follow a moving object.

Your child’s ocular alignment will also be measured to ensure that he or she does not have strabismus, a constant inward or outward turning of one or both eyes. Parents are encouraged to look for these symptoms at home because swift intervention with surgery to align the eyes at this stage is crucial for their ocular and visual development.

It is also imperative for parents and medical professionals to be on the lookout for retinoblastoma, a rare cancer of the eye that more commonly affects young children than adults. At home, this might show up in a photo taken with a flash, where the reflection in the pupil is white rather than red. Other symptoms can include eye pain, eyes not moving in the same direction, pupils always being wide open, and irises of different colors. While these symptoms can be caused by other things, having a doctor check them immediately is important because early treatment can save your child’s sight, but advanced cases can lead to vision loss and possibly death if the cancer spreads.

After the 6-month exam, I usually recommend another exam around age 5, then yearly afterward. There are several reasons for this gap. First, any parent with a 2- to 4-year-old knows that it’s difficult for them to sit still for anything, let alone an eye exam. Trying to examine this young of a patient can be frustrating for the doctor, the parent, and the child. Nobody wins. By age 5, children are typically able to respond to questions and can (usually) concentrate on the task at hand. If necessary at this stage, their eyes will be measured for a prescription for glasses and checked for amblyopia, commonly known as a “lazy eye”. Detected early enough, amblyopia can be treated properly under close observation by the eye doctor.

The recommendations listed above are solely one doctor’s opinion of when children should have eye exams. The various medical bodies in pediatrics, ophthalmology, and optometry have different guidelines regarding exam frequency, but agree that while it is not essential that a healthy child’s eyes be examined every year, those with a personal or family history of inheritable eye disease be followed more closely.

 

Article contributed by Dr. Jonathan Gerard

This blog provides general information and discussion about eye health and related subjects. The words and other content provided on this blog, and in any linked materials, are not intended and should not be construed as medical advice. If the reader or any other person has a medical concern, he or she should consult with an appropriately licensed physician. The content of this blog cannot be reproduced or duplicated without the express written consent of Eye IQ.

Sunglasses are more than just a fashion statement - they’re important protection from the hazards of UV light.

If you wear are sunglasses mostly for fashion that’s great, just make sure the lenses block UVA and UVB rays.

And if you don’t wear sunglasses, it’s time to start.

Here are your top 6 reasons for wearing sunglasses:

Preventing Skin Cancer

The strongest evidence that sunglasses provide a medical benefit is in preventing skin cancer on your eyelids. UV light exposure from the sun is one of the strongest risk factors for the development of skin cancers.  

Each year there are more new cases of skin cancer than the combined incidence of cancers of the breast, prostate, lung and colon.

About 90 percent of non-melanoma skin cancers are associated with exposure to ultraviolet (UV) radiation from the sun.

Your eyelids, especially the lower eyelids, are also susceptible to UV light and they do develop skin cancers somewhat frequently.

Many people who now regularly apply sunscreen to help protect them from UV light often don’t get that sunscreen up to the edge of their eyelids because they know the sunscreen is going to make their eyes sting and burn. Unfortunately, that leaves the eyelids unprotected. You can fix that by wearing sunglasses that block both UVA and UVB rays.

Decreasing Risk For Eye Disease

There is mounting evidence that lifetime exposure to UV light without protection can increase your risk of cataracts and macular degeneration. It also increases your risk of getting growths on the surface of your eye called Pinguecula and Pterygiums.  Besides looking unsightly they can interfere with your vision and require surgery to remove them. All of those problems are better off with prevention than treatment.

Preventing Snow Blindness

The snow reflects UV light and the exposure can be intense enough on a sunny day to cause a burn on your cornea like what happens when people are exposed to a bright welding arc.

Protection From Wind, Dust, Sand

Many times, when you are spending time outdoors and it is windy, you risk particles blowing in the wind getting into your eyes. Sunglasses help protect you from that exposure. The wind itself can also make your tears evaporate more quickly and cause the surface of your eye to dry and become irritated and then cause the eye to tear again.

Decreasing Headaches

People can get headaches if they are very light sensitive and don’t protect their eyes from bright sunlight. You can also bring on a muscle tension headache if you are constantly squinting because the sunlight is too bright.

Clearer Vision When Driving

We have all experienced an episode of driving, coming around a turn and going directly into the direction of the setting or rising sun that causes our vision to be significantly impaired. Having sunglasses on whenever you are driving in sunlight helps prevent those instances. Just a general reduction in the glare and reflections that sunlight causes will make you a better and more comfortable driver.

So it’s time to go out there and find yourself a good pair of sunglasses that you look great in, and that protect your health too.

Your eye-care professional can help recommend sunglasses that are right for your needs.

Article contributed by Dr. Brian Wnorowski, M.D.

This blog provides general information and discussion about eye health and related subjects. The words and other content provided in this blog, and in any linked materials, are not intended and should not be construed as medical advice. If the reader or any other person has a medical concern, he or she should consult with an appropriately licensed physician. The content of this blog cannot be reproduced or duplicated without the express written consent of Eye IQ.

A recent study published in JAMA Ophthalmology has demonstrated in older women a correlation between having cataract surgery and a decrease in death rate from all causes.

The data comes from a prospective longitudinal study called the Women’s Health Initiative. This study involved women 65 years or older and collected data from Jan. 1, 1993, until Dec. 31, 2015.

In the study, there were 74,044 women who had been identified with a cataract and within that group 41,735 had undergone cataract surgery during the study time period.

The results showed that of those in the group who had cataract surgery, the mortality - or death - rate was 1.52 deaths per 100 person years. That means that in any given year if you took 100 women who had cataract surgery about 1.52 died in that year. The mortality rate in the women who did not have cataract surgery was 2.56 deaths per 100 person years. Those numbers mean that women who had cataract surgery were 40% LESS LIKELY to die in any given year than women who did not have surgery.

An important aspect of this study is that the authors accounted for several reasons that might have increased the death rate in the non-cataract surgery group. They adjusted for issues such as smoking, alcohol use, Body Mass Index (a measure of a degree of excess weight), and physical activity. Controlling for those factors means that the higher death rate in the women who did not have cataract surgery cannot be explained or blamed on them having a higher rate of smoking, alcohol use, being overweight or being less physically active.

Although the authors excluded any of those above factors for the mortality difference they did not have any specific reasons as to why this difference exists. There just may be some inherent reason why having better vision leads to a healthier existence and therefore a lower risk of death.

 

Why are these results important? They demonstrate that there may be an additional benefit to having cataract surgery besides the improved vision (which is enough of a benefit on its own) as it may also help you to live a longer more enjoyable life.

 

Article contributed by Dr. Brian Wnorowski, M.D.

This blog provides general information and discussion about eye health and related subjects. The words and other content provided on this blog, and in any linked materials, are not intended and should not be construed as medical advice. If the reader or any other person has a medical concern, he or she should consult with an appropriately licensed physician. The content of this blog cannot be reproduced or duplicated without the express written consent of Eye IQ.

Have you ever wondered what happens to the visual system as we age? What does the term "second sight" mean? What is presbyopia? What are the eyes more susceptible to as the aging process occurs? What can be done to prevent certain aging factors of the eye? The answer lies in a theory known as apoptosis (no that's not the name of the latest pop artist).

Apoptosis is the pre-programmed life of every cell in our body. Most studies show that it's a function of our programmed DNA. It's the ability for cells to survive and thrive in the anatomical environment. The body's ability to withstand and thrive during the aging process depends on proper nutrition, good mental health, exercise, and adequate oxygen supply. That's why studies have shown smoking can shorten your life by a decade or more.

In regards to aging and the eye, there is a phenomina during the 6th to 7th decade of life called "second sight". This is simply progressive nearsightedness in older adults secondary to cataracts. Close to 50% of the population over 60 years old has cataracts. Cataracts are a clouding of the natural lens of the eye that can impair vision causing glare and loss of detail. When patients experience second  sight, it is sometimes quite convenient for them: they see up close without their reading glasses they have been depended on since their 40s.

Another aspect of the aging process is loosing your reading vision you had all your life. This is called Presbyopia. Presbyopia is a Latin term which means "old eyes."

What happens in Presbyopia?

Before our mid-forties, the natural lens of the eye is very pliable and can easily focus on items up close. But in our mid forties, the lens tends to lose it's elasticity. While experiencing presbyopia, you generally hold reading material farther away to see it more clearly. Presbyopia can be managed through Bifocal or multifocal  glasses or contact lenses, and some surgeries.

As aging occurs, the eyes are more susceptible to cataracts, glaucoma, macular degeneration and vascular disorders of the eye as well as dry eye syndrome.

To help prevent and manage these conditions, there are a variety of options.

  1. Maintaining yearly dilated eye exams for preventative care.
  2. Protect your eyes against the sun with UV sunglasses.
  3. Take antioxidant vitamins to help bolster the protection of the macula of the retina.
  4. Use artificial tears to hydrate the eye and keep your body hydrated by drinking plenty of water.
  5. Keep emotional, physical, and mental stress to a minimum.

Being Educated on how we age is the first advancement of good ocular health and diminishing the chances of early apoptosis.

It is safe to say that many people prefer shopping online to shopping in stores for many of their needs.

With technology constantly improving and evolving, people tend to take advantage of the convenience of shopping online. Whether it’s clothing, electronics, or even food, you can easily find almost everything you need on the Internet.

Eyeglasses, unfortunately, are no different. Many online shops have been popping up in recent years, offering people that same convenience. But what they don’t tell you is that it comes at a price, and this article’s purpose is to shine a light on the negatives of shopping online for eyeglasses.

Here are some important reasons to avoid the temptation of ordering glasses online.

  1. Accuracy- Instead of saving the most important point for last, we will focus on the main reason that ordering eyeglass online is a bad idea first. Product accuracy is a huge reason that the online market has not completely taken off. Every person who needs eyeglasses needs to understand the process for how their prescription is obtained in order to truly understand why shopping online is a bad idea. It is called an eyeglass prescription for a reason. Your ophthalmologist or optometrist is prescribing your lenses as if they were prescribing any form of medication. To take that prescription and hand it over to a website that does not require licensed workers to interpret the prescription is not the wisest choice. Equally as important as the prescription itself are the pupillary distance (PD) measurement, and the optical centers. These measurements are not given at the time of the examination by the ophthalmologist or optometrist, but instead are administered by the optician at the point of sale. Not having these measurements done accurately will negatively affect the quality of vision as much as an error in the prescription.
  2. Quality- Similar to the accuracy of the lens, the quality of the product you are purchasing is affected when making the decision to purchase online. The saying “too good to be true” is the case more times than not, and this purchase is no exception. When you see enticing advertisements for pricing that seems to be too good, there is a reason. This product is often not inspected or handled by a state-licensed optician. These websites rely on mass production in order to operate. Factory workers operating machines pale in comparison to the experience you will receive in a professional office. Skilled opticians licensed to interpret and manufacture your eyeglass prescriptions and are held to a much higher standard than factory workers.
  3. Warranty- Due to their low prices, most of these websites do not include any form of product warranty or guarantee. Opticians, however, stand behind your purchase. If there are issues with adjustment or a patient not being comfortable in a specific lens or product, professional opticians are willing to work with you. This personal experience is not attainable on the web.
  4. Coordination with your doctor- With the complexity of eyeglass lenses, the ease of working in house is always a benefit worth keeping in mind. Eyeglass lenses can be very complex products. Having the benefit of being able to work directly with the doctor gives the optician the best chance to put you in the exact lenses you need. There is a substantial difference in the percentage of error between shopping online and the care you get in a private practice.
  5. Personal Experience- Probably the most important factor for many people, the personal experience you get when shopping in person is something you cannot obtain by using the Internet. Dealing with the same opticians year in and out is something patients emphasize and appreciate. Just like people tend to keep the same doctors over the years, patients like knowing that the same people will be in charge of making their glasses. Shopping online will not offer that experience.

All of these factors should be carefully weighed when making the decision to shop online. While the initial price difference could entice you at first, know that it does come at a price. Whether it be a warranty, quality, or convenience all of these are very important factors when buying glasses. People sometimes tend to discount how intricate eyeglasses are.

Purchasing eyeglasses is handled best in person by professionals who can provide you with the utmost care and quality.

 

Article contributed by Richard Striffolino Jr.

 

Do you have floaters in your vision?

Floaters are caused by thick areas in the gel-like fluid that fills the back cavity of your eye, called the vitreous.

Many people, especially highly near-sighted people, often see some degree of floaters for a good portion of their lives. Often, these floaters are in the periphery of your vision and may only be visible in certain lighting conditions. The most frequent conditions are when you are in bright sunlight and are looking toward the clear blue sky. This I know from personal experience as I have a floater in my left eye that I most often see when swimming outdoors. Every time I turn my head to the left to breathe I see this floater moving in my peripheral vision.

This is totally harmless other than when I’m swimming in the ocean and swear that sudden object in my peripheral vision is a shark bearing down on me. Some people who have floaters are not as lucky and the floater can be very central and almost constantly annoying, especially when trying to read.

The second scenario in which floaters occur is during the normal aging process.  The vitreous gel in the back of the eye starts to shrink as we age and at some point it collapses in on itself and pulls away from the retina. This sometimes results in a sudden set of new floaters.

When that happens you need to be checked for signs of a retinal tear or detachment.  As long as your retina survives that episode without any problems, the floaters themselves may stick around for a while and can be rather annoying.  

Most people eventually adapt to the floaters; the brain learns to filter them out so you are no longer aware of them. The vitreous can also collapse more as time goes on and the dense floater you are seeing initially may move further forward and drop lower in the eye so the shadow it is casting is less intense and more in the periphery of your vision where it is much easier to ignore.

The first line of treatment for floaters has been, and still is, to live with them. Once you have your retina checked and there is nothing wrong there, the floaters themselves are harmless and will not lead to any further deterioration of your vision, which is why, if at all possible, you should just live with them. This is especially true if the floaters are new because the overwhelming majority of people with new floaters will eventually get to the point where they are no longer seeing them or at least where they are not interfering with normal daily activities.

If you have tried to wait them out and live with them but they are still interfering with your normal daily activities, you may want to consider having them treated with a laser.

This treatment relatively new and involves using a special laser to try to break down large floaters into much smaller pieces that may no longer be visible. In a recent study of the laser treatment involving 52 patients, 36 were treated with the laser (a single laser treatment session) and 16 people had a sham treatment (meaning they went through everything the treated group did but did not actually have the real treatment done).  In the people who were actually treated, 54% reported a significant improvement in the floater symptoms while 0% in the sham group reported any improvement (no placebo effect). There were no significant side effects in either group.

Some points to note in the above study:

Fifty-four percent of people treated noted a significant improvement in their floater symptoms with a single treatment. That’s clearly not anywhere near a guaranteed improvement.
Other people have noted an improvement after more than one session, bringing the total expected improvement into the 70% range, with one or more treatments.
Another point to note is that there were no significant side effects to the treatment.
Although true in this small study, it does not mean that there are no risks to the laser treatment. Although rare, there have been reports of damage to the retina, optic nerve or the lens of the eye.  

Another treatment that can be used to treat floaters is a surgical procedure called a vitrectomy. This involves surgically going inside the back of the eye and removing the vitreous. This surgical procedure carries a higher risk than the laser treatment and is not 100% effective.

In summary, this new laser treatment is a good addition to the tools to deal with significant floater problems. If you have floaters for at least six months and they are central and interfering with your normal daily activities such as reading or driving and you want to see if this laser treatment could be right for you, check with your eye doctor.

 

Article contributed by Dr. Brian Wnorowski, M.D.

After a lot of hard work with EyeMotion, our website company, we’re pleased to be launching our brand-new website.  Our goal has been to create a site that would assist you in learning about us, whether it’s finding our location or email form, reading about our wonderful eye doctors, or discovering some of our quality products and services.

Have questions about an eye issue?  We think you might also benefit from our great optometric content on eye diseases and conditions.

Our plan is to use this area to keep you informed on new offerings, sales, trunk shows, events, and so much more.  Check back here from time to time to keep updated.

We’re glad you found us, and we hope to see you soon!

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