I attended a CE earlier this week and came away with knowledge of a great new service for optometrists and their patients.  Age Related Macular Degeneration is a potentially blinding condition that typically affects central vision in patients over the age of 60.  There is a large hereditary component (in addition to environmental factors), and since the conclusion of the Human Genome project, we now know a number of genes directly linked to the severe forms of the disease. Before I go into more detail I would like to add a disclaimer that I have not yet used this service, and I am in no way affiliated with them.  I do plan on possibly offering this genetic testing to my patients in the future; the results are actually very inspiring!

No blood tests needed, just a quick, easy cheek swab.

The Process
As an optometrist, all you need to do is sign up with the Macula Risk company (at no cost of course) and you will be sent packaging and sterile swabs to perform a cheek swipe for DNA sampling.  For any patient you want to genetically test, you would swab the inside of the cheek, package the swab in the provided sterile container, and FedEx the swab to the testing center in a prepaid envelope.  In 2 to 4 weeks, the company will have the DNA samples analyzed and sent you a full report as to the patient's risk factors.  You can schedule a 1-2 month follow-up visit after your initial sampling to discuss these results with the patient and set a plan for future management.  Like I said, I haven't tried this yet, but the process seems simple, easy, and free to the doctor and patient (as long as they have medical insurance).

What genes are being tested?
Age Related Macular degeneration can be linked to genes that control numerous ocular pathways.  Genes that control the Complement Cascade inflammatory response (CFH and Y402H genes specifically), genes that control cellular response to oxidative damage (like the ARMS2 gene), and genes found in mitochondrial DNA are all found to be linked to ARMD incidence at various rates.

ARMD is found in 10% of the population over age 60 and 25% of the population over age 75, so there are more and more patients being diagnosed with this disease every day with our aging baby boomer population.     The good news?  80% of patients diagnosed with early or dry ARMD will never have advanced vision loss. But that leaves 20% of patients that will develop devastating central vision destruction for the disease, and doctors have had few ways to predict which patients will belong to that 20%.  Unfortunately, the majority of these 20% of patients with severe or wet ARMD will not go to a doctor for treatment until they already have  permanent vision damage.  The goal of the Macula Risk genetic testing is to red flag that 20% of the ARMD population that will develop advanced disease when they still have great vision based on their genetic markers for the disease!

DRY ARMD photo courtest avclinic.com

WET ARMD photo rustoneye.com

The company sends you a print out of the patient's "Macula Risk score" based on their genetic profiles.  I'm not sure of the details, but if the patient's risk number is between 3 and 5 (with 5 being the highest) they are much more likely to develop advanced ARMD.  This signals the doctor to follow the patient more closely than just yearly exams, and the patient is also more educated to pursue lifestyle changes that can improve their ocular health (such as quitting smoking, eating more green leafy vegetables or adding vitamin anti-oxidant supplementation).  If the patient knows they are at a high risk, they are going to be much more likely to be compliant with regular exams and the disease processes can be caught earlier before vision is irreparably damaged.

Ocular Vitamins can be even more strongly recommended in younger patients  with drusen changes if their  genetic testing reveals higher risk factors.  Interestingly, even the presence of peripheral drusen has been found to genetically link to ARMD progression.

When would a genetic test for ARMD be warranted?


While we would all like to be able to do a screening of all patients with known family history, at this time the company can file medically with diagnoses of ARMD or retinal drusen (peripheral and macular drusen are both billable).  The company files to the patient's medical insurance directly for coverage, so the doctor does no billing and the patients will not be getting a bill.  At this time, there is no copay for the procedure.

I'm really looking forward to possibly implenting this genetic testing into my practice.  Please let me know if you have any opinions: if you have used this product before and if you would find it beneficial as a patient!

This blog has a lot of posts dedicated to sunglasses trends, but as an optometrist, wearing sunglasses means more than just a fashion statement.  Yes, I recommend sunglasses for ocular protection to my patients.  And yes, I truly believe that sun protection is beneficial.  If you are still on the fence about why your doctor is recommending sunglasses, here are the top reasons that your eyes do need UV protection!

Macular Degeneration photo courtesy spectoreye.com

Early basal cell carcinoma photo courtesy willseye.org

polarized lenses reduce horizontal surface reflections photo courtesy findingsun.wordpress.com

Wrapped Oakley frames--great for outdoor  sports due to their full coverage protection

I never suspected my most popular post on Eyedolatry all time would be a short segment on NBA players wearing glasses.  (Click here to access the post that sparked my realization of the original eyewear obsession).  Fortunately (or unfortunately in some player's cases) the trend for the NBA's top players to sport the latest eyewear fashions is rolling full steam ahead.  Here's the latest look at some of the top eyewear sported in this year's playoffs so far:

Paul Pierce


The Celtics star gave a post-game interview in these large rimmed zyl frames.  My verdict: these frames are much too large.  Look at all of the excess space between the side of Pierce's head and the outer rim of the frame.  If you see more air than face, this is a big indicator that your frames are too large.  Even when purchasing oversized frames for the "geek" eyewear trend, it is still best to get a deep frame (which will give you that oversize look) that actually fits your face for a tailored appearance. For more information on properly fitting  oversize "geek chic" frames to your face, please visit this post.

LeBron James
James has been photographed in glasses so many times, but honestly, there's a reason he is the poster-child of this trend.  He knows how to wear these glasses.  His frames fit his face; his eyes are perfectly centered in the lenses both horizontally and vertically, and there is no excessive air visible between the line of his face and the edge of the rim.  Somehow he gets it right every time!

Kevin Durant
Durant (pictured here on the right) actually does a great job with his glasses as well.  Let's ignore his less fortunately styled teammate to the left for a moment, and focus on the fit of Durant's frames.  They are sized appropriately, and  they appear to be well-centered even when we are viewing him from this angle.  The color of the frame is a little washed out, but clear and caramel colored plastics are having a major moment right now, despite being very difficult to wear.  Overall a good job.

Russell Westbrook
Let me start with this photo from Westbrook's own facebook page.  I admire his willingness to take fashion risks (and what is fashion but one risk after another anyway?) but these frames are really not helping anything.  Again, they are WAY too large, his eyes are positioned very high in the frames giving too much excess lens inferiorly, and with his round face shape, a round rimmed frame is never going to be the best choice.  (See this post for more information on better options for round faces)

Does Westbrook (or any of these NBA players) actually need glasses?  Definitely not in Westbrook's case at least.  Here is an excerpt from a "Daily Thunder" interview (courtesy http://blogs.thescore.com/tbj/2012/05/15/russell-westbrook-talks-fashion-ive-been-knowing-how-to-dress-for-a-while/)

Reporter: Your wardrobe last night drew national attention. I loved the glasses. Where’d you come up with that style? 

Westbrook: I’ve been wearing glasses all season. I think last night was probably just the night they finally seen it.

Reporter: Now why no lenses in the frames? 

Westbrook: I see better without ‘em.

Reporter: So why wear ‘em at all then? Just a fashion statement? 

Westbrook: There you go. 

Reporter: Where’d you get the idea? 

Westbrook: I’ve been knowing how to dress for a while.

Well, I think that last comment has sparked quite a bit of internet debate, but I am definitely not qualified to judge overall fashion statements.  Let me stick to glasses.


Compare Westbrook's (right) to Durant's frames here.  These frames aren't terrible, but again, too round for his face.  A frame like Durant's that is slightly more rectangular in shape would be much more flattering.  Conversely, Durant's face shape is much longer and he could wear a round frame like Westbrook's more easily.  Just some nuances of the glasses world.


And to the right we have Westbrook's now infamous "Gone Fishing" ensemble.  I'm not going to give any serious critiques here because that would be positively ridiculous.  I am still a big fan of red frames in case anyone is wondering.  The point that I respect about Westbrook's glasses choices is that he is obviously just trying to have fun.  And I think any celebrity encouraging the world that glasses are fun and stylish is a great thing to do!

So in my first year of practicing, insurance billing has been the biggest learning curve I have faced.  They try to prepare you in school.  They try to prepare you at your externships.  But the problem is that billing and coding seem to be changing every couple months.  Here is a review of the latest coding conundrum I have faced:

Insurances for Medically Necessary Contact Lenses
First off, not all insurances are going to offer any coverage for contact lenses.  With time and experience, you will learn which insurances reimburse anything.  So far I have successfully filed to VSP, Eyemed, and Superior Vision for visual conditions that require contact lens correction.  Medical insurances like Blue Cross are not going to cover anything for vision correction.   Medicaid (at least in NC) will offer some base level of reimbursement if filed correctly.  On the contrary, if you have a corneal abrasion or another condition where a bandage contact lens is appropriate, medical insurances like Blue Cross WILL offer coverage and vision insurances will not.

Medically necessary contact lenses for post-RK

Not all vision insurances cover medical contact lenses for vision correction to the same amount of reimbursement. Some insurances will reimburse cost of lenses and evaluation fee.  Some will only give a certain amount of dollars to be applied toward eval or lenses.  Just remember, if you are going to try to bill for contact lenses, do NOT use the patient's insurance benefits towards glasses.  Once the insurance has been used, they won't provide for anything else.

What Conditions Typically are Covered
Again, different insurances have different guidelines, but here are the most commonly accepted reasons for medically necessary lenses:

• Keratoconus, pellucid marginal degeneration, or a corneal degenerative condition where vision improves in contact lenses versus glasses
• High anisometropia (usually there are guidelines about how much, typically between 3D and 5D minimum)
• Condition where best corrected vision improves by at least 2 lines with use of contact lenses versus glasses (this includes high refractive error conditions)
• Bandage contact lenses for treatment of ocular surface conditions (this is typically with a medical office visit code and is billable to medical insurances, unlike the previous items)

Synergeyes ClearKone lens is a great option for medically necessary keratoconus correction

I know I don't need to convince anyone why daily soft contact lenses are often the best option for comfort and convenience for the average patient.  No solutions, no cleaning, no storage.  Sure you have a lot of packaging, but dailies are ideal for people who want to spend basically no time worrying about their contact lenses.  Here's a breakdown on how I have made dailies a large part of my practice:

A new study out of Tokyo published in this month's American Journal of Ophthalmology (link here) reports that caffeine may improve tear film secretion.  The true implication for dry eye treatment gleaned from this study's results are obviously in their infancy, but here is a breakdown of what researchers have found:

Pictured in blue is the layer of tear film that coats the surface of the eye,  The tear film meniscus is the  thickness of tears measured at the lower lid margin.  In a patient without dry eye, the tear film meniscus would be greater than 2 mm.  Picture courtesy University of Oxford