Eyedolatry: April 2013

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Increasing Glaucoma Treatment Compliance

25% glaucoma patients take no drops 10:54 AM

A Visual Field test is use to detect glaucoma damage and monitor
for progression. In many cases, early damage that shows up
on this test is not noticeable to the patient in their daily life.
Glaucoma damage would go entirely undetected if left untreated until
the disease had resulted in permanent peripheral field loss
via

Glaucoma is a really difficult disease (read here for more details on what glaucoma is!). Imagine that you have to tell a person that they have a disease where they have to take an eye drop every single day for the rest of their life. The drops aren't going to make you feel any better; the disease is painless, and if you have had vision loss already they won't give you the vision back. You can see how there is little incentive to use those drops every day. This is a conversation that eye care professionals have very frequently, and for many of us, we have to have it every time our patients return for their follow-up appointments because they are routinely missing their drops!

One thing we do know; even if your patient reports good compliance with their glaucoma medication, they probably aren't taking it as often as they tell you. Studies estimate that as high as 25% of patients prescribed glaucoma medication actually take NONE of the drops prescribed. Only 25 to 35% of patients in the same study had full compliance. This means that most people have "partial compliance" - -getting the drop in irregularly. Usually they remember when it gets closer to their next appointment (just like flossing your teeth before you see the dentist!). When the patient has their pressure checked, it may read normally if they have used their drops more regularly over the past few days, but their peripheral vision or optic nerve scans may show increased damage. What is the doctor left to think?? Well, if your doctor thinks you are getting your drops in regularly and you are still having progression of glaucoma, they are going to prescribe more drops!

We all know that the more drops you prescribe, the less likely a patient is going to be able to afford their glaucoma treatment and remember to get the drops in. If a patient can have good control of glaucoma with just one drop, it is definitely ideal. Before adding more drops to a patient's regimen, I always like to investigate to see if they are using the drops regularly by asking these questions:

How often do you miss your drops? If they say a few times, does that mean a few times a month? Or a few times a week? It makes a big difference to get these details!
When did you last use your drop? Did they get it in last night or this morning? Or was it a few days ago?
What is the name of your drop? Not everyone is going to remember this, so it also works to have them bring their drops in to their appointment. I love looking at the drops because you can see how much is left in there and when their last refill was. If they have a full bottle and the refill date was a few months ago, you know they aren't using their drops. Sometimes they are using a drop by mistake that isn't even the one for glaucoma. They could have had an old antibiotic, or worse a steroid! that they have been using daily by mistake!
What grade would you give yourself on using your drops? Asking a person to take accountability for themselves can sometimes lead to more honest answers. If they tell you they get their drop in regularly, and then give themselves a "B" you need to know why.
Ask them to show you how they put their drop in. I don't do this often, but if I am getting concerned that a patient might be having trouble, it is a really good idea. Sometimes they will miss their eye altogether when they try to put the drop in. I heard a story at the VA Hospital where I interned about a patient who put the drop on his tongue when the doctor asked him to demonstrate. No wonder his pressure was so high that day!

Increase Compliance by Changing How You Prescribe

For years, we have been making it hard for patients to remember to put drops in by telling them to use them "at bedtime". The most popular glaucoma drops called prostaglandin analogues (like Xalatan, Lumigan, and Travatan) have been dosed as "bedtime" drops traditionally. If you instead tell the patient to use them "at dinner" or when brushing their teeth, it is a lot easier for them to remember. How often do you fall asleep before you mean to, watching TV or reading in bed? The drop is going to work a lot better if they can get it in before they pass out for the night!

Helping your patient comply with their drops can save not just their vision from permanent damage, but their money if it means you don't have to add more drops to their daily regimen. Many patients HATE using the drops due to price, convenience, and side effects like redness, and they ask me about surgical options. Even the lowly-invasive laser surgeries like SLT may not work in as high as 30% of glaucoma patients (as reported at a local continuing education seminar), and they often still need to use drops afterwards. If we can control progression of glaucoma with just one drop a day, it is a great option for both the patient's health and their personal finances.

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Best Frame Choices for your Lifestyle

glasses for driving 10:30 AM

We've talked about selecting frame choices for your face shape (see these posts), but your frame selection has more importance than just style. If you wear your glasses most of the day, they need to be specialized to perform for your daily activities. The shape and sizes of frames can have a big impact on how happy you are with your glasses on a daily basis! Here's a breakdown of the best choices for frame design depending on your occupation/lifestyle.

1) Computer Use

Computer users spend often long hours at the screen. In addition to anti-reflective coatings and tints, your frame size can really improve comfort at the computer. Your best choice depends on your personal work set-up and prescription:

Single Vision Lenses; 1 computer screen: In this case, smaller sized glasses can be better. You want your glasses to be light weight, and smaller frames will limit the amount of bulk on your face. When there is only one prescription in your lenses, you can always look through the center of your glasses and be in the right "spot" for your best vision. Most of my patients prefer frames with nosepads at the computer so they can be adjusted to sit in the right place and with minimal pressure. Frames without nosepads are comfortable too, but tend to slide around easily depending on the shape of the bridge of the nose.

Dolce and Gabana rimless frames with adjustable nosepads--perfect for work

If you prefer plastic frames, try smaller eyesize brands like Kate Spade; light weight and comfortable all day long

2 computer screens: My patients often do better with slightly larger frames in this case. The smaller your lenses are, the less area you have to be able to cut your eyes from side to side, meaning more head and neck turning. With 2 large screens, a slightly larger lens size means less turning of your head back and forth to stay in the central area of the glasses.

Deeper segment, larger lens size, adjustable nosepads, and semi-rimless to reduce weight on your nose. These Ray Bans would be perfect for work if you need a larger lens size

Progressive or bifocals: If you are wearing bifocals or full progressives (no-line bifocals) at the computer, you know that turning your neck up all day to be in the right spot is brutal on your spine. I often recommend larger frame sizes for progressives to distribute the power better through the lens, but if it is too large, you are going to have to tilt your head back quite a bit to enter the computer area. One solution is having separate computer glasses. Smaller lens sizes will put the computer zone closer to the optical center of your glasses, but don't go too small! If you computer zone is only 1-2 centimeters of the lens, it's going to be a lot more tedious to find than if you had larger glasses where the computer zone was 4-5 centimeters. This is why your optician is so vital to helping with frame selection when you wear multifocal glasses!

2) Long-Hour Drivers

Put Transition lenses in these Linda Farrow frames
and they could easily look just like normal sunglasses when
in sunlight. Larger frame size means you are less likely to see
over the edge of the frame in your peripheral vision

If you spend a lot of time in the car, you know that sun protection and peripheral vision are really important for the performance of your glasses. I like larger frame sizes for road warriors because if you can see the outline of your frame all day in your peripheral vision, it is going to be very distracting to checking your blind spots. Many drivers find that Transitions (where the lens turns dark in sunlight) are not great in the car for sun protection because the UV blocker in your windshield keeps the lenses from turning truly dark. They now make more active materials that darken better in these conditions, but many drivers prefer a fully tinted pair of sunglasses. Wrapped frames are a great option if your prescription allows to protect delicate eyelid skin from too much UV exposure from your side windows! And while polarized is a great option for vision quality, it will keep you from being able to see different digital panels, like your radio.

Oakley wrapped frames are great options for
people exposed to a ton of dangerous UV light

3) Outdoor Workers

If you spend a lot of time outside, sunglasses are a must. The more wrap, the fuller, better protection. Skin cancer is so common in today's

world, so remember that wearing sunglasses not

only protects your eyes from sun damage, it also protects your sensitive eyelid skin, where the skin cancers are very commonly found!

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What is a Contact Lens Evaluation (and why do I have to pay extra)?

contact lens evaluation; extra cost for contact lens evaluation; components of contact lens evaluation; contact lens complications; contact lens versus glasses prescription 9:13 AM

Have you ever found yourself wondering why you have to pay extra to have a prescription for contact lenses? My patients often tell me the same things: their prescription hasn't changed in years, they like the comfort of their lenses, they just want their same prescription again. At my office, I never renew a prescription without evaluating the contact lens on the eye, testing vision, and checking the eye carefully for any signs of damage from contact lens wear. These actions are the contact lens evaluation, an additional piece of the exam that glasses wearers would not need. Typically your vision insurance has a separate copay for a contact lens evaluation because they also understand that it is a separate part of the exam. What are the components of a thorough contact lens evaluation?

1) Evaluation of the cornea without contact lenses

Neovascularization via

In the slit lamp microscope, your doctor will be painstakingly checking the corneal tissue. The cornea is the clear surface over top of the iris where your contact lens sits. The tissue functions like a window, allowing light to pass through into the eye. Contact lenses can cause major damage to the corneal tissue if they are fitting too tightly, too loosely, or not allowing enough oxygen to pass through to the cornea underneath. I look for several tell-tale signs of contact lens complications. Are there small scars in the otherwise clear corneal tissue? Those could be from old bacterial infections or areas where the corneal tissue died from lack of oxygen. Are there blood vessels growing into the corneal tissue? This is called corneal neovascularization and is a hallmark of poor oxygen passage. The cornea should be clear, and if blood vessels are invading the cornea, you not only have a "red rimmed" eye appearance, you have cloudy corneal tissue and areas that are at higher risk for infection. Scar tissue and blood vessel growth means that we need to either change your contact lens to a higher oxygen material, or change how you are wearing your lens if you are not following federal guidelines for your particular contact lens material.

2) Prescription Selection and Vision Evaluation

Your glasses prescription helps guide the contact lens powers that your doctor selects, but your glasses Rx is NOT the same as your contact lens prescription. If you have a high prescription in glasses, or if you have astigmatism, your doctor performs mathematical calculations to change the glasses Rx into an appropriate contact lens power. Glasses sit on your face, but contact lenses sit on your eye. The higher your prescription, the more that difference in distance matters. You should ALWAYS have your vision checked in your contact lenses at some point during your eye examination. I also trial different lenses over the contact lenses to make sure I don't need to go stronger or weaker with the correction to improve visual acuity.

3) Evaluation of the Contact Lens on the Eye

The contact lens must fit the eye properly to offer safe,
clear vision correction. via

I often tell my patients to think of their contact lens like a shoe. They come in all different shapes and sizes (there are a ton of brands out there!), and your contact lens needs to be shaped correctly to properly fit your unique eye. There is no one contact lens brand that will work for every patient. Think about how much your foot hurts when your shoes are too tight or too loose. And that is your foot! The eye is so much more delicate and vital to your life! If your contact lens fits improperly, you are at higher risk of scarring and infection. The lens should move a little as you blink to let oxygen and tears pass underneath, but not too much as to be easily dislodged. Even if you have worn that brand for years, the shape of your cornea may change with time and the fit must still be carefully evaluated every time you see your doctor.

The biggest take home? Your doctor is not trying to waste your time by evaluating contact lenses on your eye. I often meet with annoyance when I ask my patients to put on contact lenses for me to evaluate when they have "worn these for years!". But after a discussion of the importance, my patients understand that I am just making sure that they are safely wearing contact lenses for the rest of the year. Contact lenses are a medical device, and they are sitting on one of the most sensitive and vital structures of your body all day long. It requires a vigilant doctor and a vigilant contact lens wearing patient to prevent potential permanent damage to the eye when you wear contact lenses.

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Retinal Photography: Macula

Age Related Macular Degeneration 6:47 PM

We all know that 20/20 is perfect vision, but there is a very small, central area of the eye that makes those fine details of 20/20 possible. This central vision area is called the macula. In this ocular structure, you have the highest density of photoreceptor cells in the entire eye. As a result, in retinal photographs this high density area looks like a dark spot in an otherwise light pink or purple retina. Most of my patients ask me if that dark area is a problem, but as long as the color is uniform, your macula should be nice and dark. Color variations in that area are indicative of possibly permanent, devastating visual conditions. Here are some that I have seen in my practice to date:

Normal, healthy retina with a dark central macula. This is your comparison photo for mine below!
photo via

Diabetic Retinopathy with exudates and macular edema

In the above picture, diabetic changes have caused leakage of blood vessels near the retina, and a condition called macular edema. The macular tissue is swollen around the yellow appearing exudative material. This will cause blurry vision and distortion. The hope is that as blood sugar levels normalize, the swelling will resolve and the macular tissue will return to normal.

Geographic Atrophy from Macular Degeneration

Age related macular degeneration is a disease of the eye where central vision can be permanently destroyed, as is the case in the above picture. This patient has permanent vision loss, and the macular tissue is nothing but a devitalized scar.

Macular Scarring withWet Macular Degeneration

Unfortunately, this is the other eye of the patient with macular degeneration above. This eye had wet macular degeneration; the more aggressive type of the disease where bleeding causes extensive swelling and scarring. This eye had several injection treatments, but this is the best ophthalmologists could do to stabilize damage. Smoking and sun exposure are huge risk factors for macular degeneration (as well as genetics), and this is a condition that your doctor is evaluating for at every single eye examination.

Toxoplasmosis

Toxoplasmosis is a more rare parasitic infection of the eye. The infection is typically spread through cat feces, but similar infections can be contracted from exposure to dog and bird excrement. This patient had permanent scarring from a childhood infection, but the parasitic infection is no longer active. There is no treatment after scarring has developed to restore vision.

Plaquenil Retinopathy

Plaquenil is used for treatment of malaria, but more commonly in the United States for inflammatory conditions like Rheumatoid Arthritis. In higher doses or with long-term use, plaquenil can cause macular scarring and vision changes. When changes to the macula are seen, plaquenil should be discontinued. In the majority of patients taking this medication, plaquenil use can be safe and without visual effects. If you are taking this medication, a yearly eye examination is required to monitor for this potentially permanent visual change! The patient in this photograph had been using Plaquenil for years, but gone a without an eye examination for 2-3 years and in that time this macular change occurred!

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