Vision is Subjective

A few things that I frequently talk to my own patients about that might be of some use to you out there is internetland:

1) Vision is subjective. What do I mean by that? Mostly what I am referring to is that the perception & description of "blur" varies greatly between patients. It is anything but standard. We're talking about "how blue is the sky" and "on a scale of 1-10 how much does it hurt to have your foot smashed when someone steps on it" kind of thing. What is & is not "blurry" and how to describe to another person exactly what you see is virtually impossible to ACCURATELY PINPOINT. And even if we could exactly pinpoint to the Nth degree how blurry your vision is...as eye doctors we really can only do TWO things: a) eliminate refractive error and b) treat existing eye disease. If you have no eye disease and you're wearing the correct Rx...that's all we can do. Most people are happy with that, but some 20/20 patients will still tell us "it's so blurry". Ok, we believe you! But...we're limited by what we can do about it. There are other things besides disease & refractive error that cause blur, mostly optical aberrations: spherical aberration, coma, pincushion/barrel distortion, chromatic aberration, field curvature, etc, also macular cone spacing...but we can't really DO anything about any of those here in the real world. Just measuring them in a human eye takes special expensive lab equipment, and we cannot (yet) make a pair of glasses that would eliminate any of those other optical aberrations. Sometimes we have to tell healthy patients with good Rx's that we're at the limit of how "clear" we can make their vision.

2) Subjective testing is what it is: subjective. Ok so we just got finished reading a diatribe on how vision is subjective...but don't we optometrists base our glasses Rx's off of "subjective refraction"? Well yes & no. By the time we have you in the chair & behind the phoropter we've already taken multiple OBJECTIVE measurements on your eyes & refractive status. So we know basically what we're going to Rx you...possibly exactly what it's going to be. So we let you "fine tune" your Rx by offering you a little more or a little less, a little to the left & a little to the right, etc. But there are no "wrong" answers here. If you "choose" something way off, we're not giving it to you. Plus a lot of the time we're "bracketing" anyway...showing you just to the left & just to the right of your Rx but NOT RIGHT ON. So there REALLY isn't a wrong answer there...they're BOTH BLURRY choices. This is one reason why so many people get frustrated by the process of subjective refraction: they assume (incorrectly) that the lenses are "supposed" to be getting subjectively clearer with each successive choice. But they're not. That's not how it works. You're really relying a lot more on the skill & experience of the doctor than you are on your own choices behind the phoropter. That's why it's important to find an optometrist that you connect well & communicate well with.

3) If you hear hoofbeats, think "horses", not "zebras". This is a derivation of Occam's Razor: the simplest solution is probably the correct one. If you're a contact lens wearer & your eye is red, it's probably from contact lens wear. It is probably not "pink eye", etc. It *could be* contagious viral or bacterial conjuntivitis, but that's not the MOST LIKELY cause. If your head hurts it's probably a tension headache, not a tumor. Ok it *could* be a tumor...but statistically it's probably not. Especially in the age of the internet, often patients Google their own eye symptoms/conditions & come up with some very IMPROBABLE scenarios ("zebras"). Even some docs do this. I had a patient with known, longstanding neurological deficits and known, longstanding ataxia (can't walk w/o falling down), and his neurologist referred him for another eye exam saying it "could be" his glasses. Well ok yes it "could be"...but the patient had been here annually for eye exams and his refractive status was virtually unchanged in 20 years. His ataxia is PROBABLY NOT the result of an incorrect glasses Rx. That's a "zebra" for sure.

4) A lot of eye conditions have the same symptoms: The human eye can only respond in a limited number of ways - pain, redness, foreign-body sensation, vision loss, light sensitivity. That's pretty much it. Consequently many patients will call me asking me to please refill their eye drop Rx from 2.5 years ago b/c "it's the same thing again." Well, how do you know it's the same thing? You don't. There's no way for you to know it's the same, or even for ME to know it's the same unless I *LOOK* at your eye. Listing the symptoms again (foreign body sensation, redness, blur, etc) over the phone does not help much, b/c most symptoms are the SAME for most eye conditions. Someone has to LOOK at your eye anyway.

2-day Underwear

The staff & I have heard so many statements/excuses on how patients justify overwearing their contacts that we recently decided it would be funny (to us anyway) if we used those same arguments to justify overwearing our underwear.

I just keep wearing them until they're uncomfortable.

I have "2-day" underwear.

I wear my brother's underwear. We share. Especially colored underwear.

I hardly ever change my underwear unless they start bothering me. I know when it's time.

Do I really have to wash my underwear? Can't I just soak them in water?

I can't afford to be buying underwear all the time...what's *THE CHEAPEST* underwear I could POSSIBLY have?

If my underwear feels like something is in there, can I put it in my mouth to clean it?

There are different SIZES & kinds of UNDERWEAR!!?? I thought they were all the same.

I buy my colored underwear at the flea market.

I want the underwear that you never have to change.

Sometimes my underwear gives me a rash, when that happens I can still wear it, right? I don't have to change it, do I?

I ran out of new/clean underwear a few months ago, so I just made this final pair last.

My old doctor told me I can wear my underwear twice as long as they're supposed to be worn. That's ok, right?

What size & material of underwear do I have on, you ask? Uh, I don't know...Hanes.

I got a rash from never changing my underwear & so I started changing them faithfully every day. But as soon as the rash is gone I can go back to wearing them all the time & never changing them again, right?

New Acuvue Lens Coming

Just got this sent to me:

Latest & Greatest Acuvue Lens

Its going to be unveiled at SECO on March 1, 2012 apparently. We'll see what it is! If I get info before then I'll post it!

Ortho-k + Corneal Cross-Linking

Ortho-k is a non-surgical way of going glasses-free during the day. Wear "retaining" lenses at night, wake up 20/20. I've blogged about it repeatedly (just search this site with the box in the upper left for "ortho-k") and we perform this procedure in our office with a high success rate.

Corneal cross linking is a procedure that uses riboflavin eye drops and UV light exposure to stiffen corneal stromal fibers. Its currently a treatment for arresting keratoconus progression.

Well Dr. Sami El-Hage (a pioneer in ortho-k and one of the most interesting people I have ever met) has proposed combining the two; the idea being to initially get the patient seeing well with ortho-k, then perform the cross-linking procedure to make it permanent or semi-permanent. This article is kind of technical, but SUPER INTERESTING (to me, anyway b/c I'm nerdy & into this stuff!):

ortho-k + corneal cross linking

Pawn Shop Rescue Bass

A few months ago now I saw a used bass guitar in a pawn shop for under $50. It was a kind of "vintage" mid-1970's "Memphis" brand knock-off copy of a Fender Precision Bass. Natural finish with a weathered "yellow-y" look, maple neck, white pickguard. I loved the way it looked & felt, but nothing worked. No sound from the pickups and the neck was cracked. I got the guy to sell it to me for even less than the $50 asking price and took it home. Took it all apart, cleaned it all up, made the pickups work (loose connection) & made it playable. Still had the cracked neck & it turns out the truss rod didn't work so it was shot. Couldn't adjust the "relief" or "action" (height of strings from neck).

So a few weeks later I ordered a replacement neck for it (and new tuners and a new pickguard and new knobs...and flatwound strings! gotta have "flats"). It all came in & I spent a night assembling it all (great fun) and now this "pawn shop rescue" bass is my main bass. It just "feels" right and I love the playability & sound. I REALLY love the vintage look. Here's a picture of the finished product...I'm pretty proud of it:



My other bass and former "main player" is a 5-string Squier Jazz. I still like that bass and I'm not getting rid of it. There are plenty of times when a 5-string is needed, especially with the recent "low tuning" & "alt tuning" craze in music (Eb tuning, "drop-D", etc). But I think I'm figuring out that given the choice, I'm a "4-string guy". I like the extra hand positions of the 5 string, but there's something cool about a simple 4-string precision bass.

Allergic Conjunctivitis

This is my bad time of the year for ocular allergy. For most people its spring, but for me its Sept-Oct-Nov-Dec. I don't know what I'm allergic to but whatever it is, its out in those fall months. I get the nasal congestion, etc but worst of all is the ITCHY THROAT (palate) and itchy/watery eyes. My eyes are also very gooey/sticky in the mornings (mucous). I know, TMI right?

I just wanted to discuss what personally works for me b/c I'm using Rx antihistamines daily right now. Here's what I use myself and what I Rx for patients and why:

1) Bepreve: I really like this drug and its recently been one of my "go-to" Rx antihistamines. It clears the "goo" quickly, stops the itch & even helps with the itchy throat (palate), no kidding. This stuff really works. It has a pretty bad aftertaste, tho...which I personally do not mind at all, but patients (and my wife) absolutely detest. So that's a downer. To be used twice a day.



2) Lastacaft: This stuff works really well too and has zero aftertaste. This is what my wife uses (a GPC sufferer, since I blog about GPC a lot). I don't think it helps with the itchy palate, so for that reason I still like Bepreve a little better for my own use. But for the actual ocular symptoms that most of you are asking the O.D. about, this one is as good as you can get. Plus my wife & daughter both greatly prefer this one b/c it has no sting & no aftertaste. 12/14/2011 edit: I just found out this is ONCE a day (QD) not twice a day (BID!) I can't believe I didn't know that! I mistakenly thought it was BID. Oops. Hey I can admit when I am wrong! My excellent Allergan rep corrected me.



3) Pataday (olopatadine 0.2%): Also a great drug. Designed for once-a-day dosing, this is the successor of the wildly successful "Patanol" (which was twice-a-day). I'm not sure I ever bought the idea that simply doubling the concentration of Patanol (olopatadine 0.1%) lengthened the effectiveness of the drug another 8 hrs, but I guess it's possible. This is probably the most-Rx'd eye drop right now (edit: Allergan rep says the most Rx'd drops are XALATAN & RESTASIS). Very popular.



4) There's one OTC antihistamine that I think works pretty well, and it's not Visine-A, Opcon-A nor Clear Eyes-ACR, as all of those are mainly vasoconstrictors with old, not very effective antihistamines. Over the counter I like ketoifen fumarate, which is sold under at least 4 (and probably more) brand names: Alaway, Zaditor, Wal-Zyr (Walgreens brand Eye Itch Relief), and Zyrtec Itchy Eye Drops. This drug works better (IMO) than any other OTC anti-allergy eye drop, and almost as well as the Rx ones above, at a fraction of the cost.














5) When the patient has significant redness, swelling or inflammatory signs beyond just the symptoms of itch & mucous production, I typically get more aggressive & Rx steroids. My steroid of choice for this is Bausch & Lomb's Alrex. This stuff is very safe, even for long term usage, and eliminates itch as well as swelling, redness & inflammation. The only downsides are the sometimes-overhyped stigma of steroid usage (glaucoma, cataracts, etc), and the fact that usually steroids don't INSTANTLY eliminate the itch, like the antihistamines above do.

Lotemax Ophthalmic Ointment

ALL RIGHT! I guarantee I'll be Rx'ing this. Finally a new ocular steroid ointment on the market, so I can stop using dexamathasone & hydrocortisone, both of which can & do raise intraocular pressure. It's funny the little things I get excited over, but this will change the way I practice, I promise:

LOTEMAX OPHTHALMIC OINTMENT

Now if B+L would just please, please, pretty please combine a fluoroquinolone with Lotemax so I can have a decent combo drug that doesn't contain 40-year old tobramycin! Is anyone at B+L listening? Please?