Wednesday, January 27, 2016

The Law of Diminishing Returns and the Contact Lens Follow Up Appointment

So the standard way contact lens fitting works is this: we docs take all the appropriate measurements, grab a lens we think will work, check the fit and vision...and 90+% of the time it works great and we're done. Occasionally a patient (mostly astigmatism, monovision and multifocal wearers) will return a few days or weeks later with some complaints and we look at the fit (for rotation), maybe take some more measurements with the lenses on (over refraction), and make some adjustments and try a new pair of lenses. That takes care of another 5% or so. Well what about the final 5%? The ones who are not happy with their vision through the contact lenses after 2 distinct visits? IMO most of them are just not good contact lens candidates. Either their visual demand is too high (20/20 "not clear enough"...this is the vast majority of contact lens follow-ups) or they need too many distances to be crystal clear (driving, computer and reading, for instance, all equally crystal clear). It is at this point that I usually give up. Not because I'm "lazy" or don't want to fool with it but because in 15 years of doing this I have learned that the more contact lens follow ups you schedule, the *LESS* likely you are to find a Rx that the patient is happy with. You'd think we could just endlessly "fine tune" the Rx and get closer and closer to the "perfect" pair of contacts, but actually the reverse is true. More contact lens appointments past the 1st two generally yield zero improvement and sometimes it's WORSE. Some patients have this idea that trying endless materials, brands, designs and incremental changes in Rx will eventually get them to where they need to be, but the reality is...we are very, very good at fitting contacts. When we choose the first pair it is HIGHLY probable that it's "right" and that you'll see as well as you will ever see in contact lenses with that 1st pair. So if/when you're not thrilled with the vision out of the 1st pair, you may assume it's because we didn't get it "right" or it needs some "fine tuning", but reality is usually that your expectations are too high, either because you think we should be able to duplicate your glasses vision in contacts or you have some preconceived notion of how your vision should be in contact lenses, usually from remembering your contact lens vision from before you needed bifocals. The vast majority of contact lens wearers are myopes (near sighted people). As I have blogged before, myopes often see *INCREDIBLE* up close without glasses on, and they incorrectly assume that we are able to duplicate that up close vision in multifocal contacts, which is fantasy. One thing I have learned about people who are "thrilled" with multifocal contacts (and multifocal cataract IOL implants also, BTW) is that they are not very picky about their vision. They are willing to put up with some amount of blur in order to gain the convenience of not wearing glasses or reading glasses. But for people who need to see *incredible* at multiple distances and they're over 45, multifocal contacts are almost never the answer, and for everyone of every age: if we can't get it "just right" in 2 visits...it probably cannot be done, by anyone.

Monday, December 21, 2015

the "Blue Light" Craze

I am not sure I am a believer in this "blue light is bad for your eyes" thing (Google it, you'll see what I mean). It's the new medical eye theory and it proposes that blue light can cause eyestrain, myopia progression and even macular degeneration, not to mention sleep deprivation. I'm not so sure. I am not saying it doesn't cause those things, I'm just not sure it's a huge risk. I mean the Irlen people have proposed for decades that blue light is actually GOOD for your eyes (or your visual processing, anyway), especially when reading and especially for dyslexia...now we are being told that the opposite may be true. Okay, yeah whatever. But anyway I just downloaded and installed an app called "Twilight" for my Samsung Galaxy s5 that automatically adjusts the color of the screen by applying varying levels of red filters to try and alleviate the eyestrain (and damage?) thought to be associated with blue light from the device. The app varies the filters based on on the time of day, and claims to be able to increase your daily sleep cycle by "up to 1 hour". Cool idea, anyway, and not a terrible one. TWILIGHT APP FOR ANDROID IN THE GOOGLE PLAY STORE (A similar iphone app called "f.lux" was recently shut down by the Apple Overlords)

Tuesday, December 8, 2015

Disneyland vs Disney World - Which is Better?

We just returned from a trip to Disneyland (Disneyland Resort in California or "DLR"), having previously visited Walt Disney World (WDW) in Florida twice (Christmas 2013 & 2014). We had a great time in California, but of course we're Disney people so no surprise there. Now that we've seen both parks, everyone who knows us asks "which one is better?", a question which as an optometrist I am well versed. So I'll do to you the same thing my patients all do to me when I ask them "which is better 1 or 2?" - I'll answer "let me see them both again"! Here's a short list of some of the differences: WDW is bigger. Way bigger. More parks, more things to do and see, etc. But DLR has a "classic" look and feel that I didn't think WDW matched. DLR has some better rides: Pirates of the Carribean is considerably longer and better in DLR, and there's no Matterhorn in WDW, which both of my children said was their all time favorite Disney ride. DLR Indiana Jones just absolutely kills its WDW counterpart "Dinosaur", it's not even close. Space Mountain is longer and better in DLR, and we got to do the Star Wars themed "Hyperspace Mountain", which is absolutely awesome and not yet available in WDW. Our son loved California Screamin', which is only in DLR. All of us loved Radiator Springs Racers, which is significantly better than it's WDW counterpart "Test Track". But WDW has it's share of unique and better rides as well: There is no Rockin' Roller Coaster in DLR, and all of us were THOROUGHLY disappointed in the DLR version of Tower of Terror. DLR Tower of Terror sucks. It's about half as long as the WDW version, there's very little story to it and it doesn't do anything but go up and down - no "track" at all. I will likely never ride that one again at DLR. The WDW version of Tower is exponentially better. Two of my personal favorite rides of all time are Spaceship Earth and The Great Movie Ride, neither of which have DLR counterparts, and all of us missed riding the WDW People Mover through Space Mountain. There are quite a few rides that are identical or virtually so between the parks: Peter Pan's Flight, Soarin', Star Tours, Astro Blasters, etc // The people at DLR are generally ruder haha...I feel like a bunch of the California locals and season pass holders kind of act like they own the place. Didn't get that feel at all from WDW, where everyone was generally friendlier. Also apparently the DLR annual pass holders get all kinds of discounts and special prizes and stuff, because at every checkout we were asked if we were pass holders and we got the sad face "oh, sorry wah wah waaaah" response when we said no. We love the FastPass Plus system at WDW and DLR has no real counterpart. The DLR Fastpass system works totally differently and is confusing to an outsider/newbie. It took us a whole day to really figure out and master it. We ended up making great use of it and it works okay but being "planners" we much preferred being able to make our fastpass selections weeks/months in advance and not have to hurry into the park to wait in a fastpass line to draw a fastpass that we couldn't choose the time for, hoping it didn't conflict with some dinner or show reservation we already made. The "rope drop" ceremony at DLR is a total downer - nothing at all like the grand show of the WDW rope drop. It was, however, very handy to walk to the DLR park from our hotel down the street in Anaheim - in Florida you must ride a bus or monorail to pretty much every park from nearly every resort. It was also handy to have a CVS closeby in Anaheim...when our daughter jammed her thumb on our 1st WDW trip I had to literally fabricate a makeshift splint from popsicle sticks in the Pop Century gift shop because the nearest pharmacy was like 25 blocks away and we had no car! // So which is better? Well, they're different. They're both great. We will likely go to both again! But if I *HAD* to choose...I guess we'd probably do Orlando's WDW over DLR in Anaheim if we could only do one. It's very close but the Fastpass Plus system, the more friendly atmosphere and the sheer volume of attractions/rides edges WDW ahead of DLR by just a little. It is really very close, tho! Have you been to DLR or WDW? Tell me about your experiences in the comments below!

Thursday, November 19, 2015

Refraction is not an "Eye Exam".

Refraction is the process you all remember from the annual trip to the eye doctor: "which is better, 1 or 2?". That's the part where we fine-tune your glasses Rx. It is usually *NOT* the part where we diagnose anything or "figure out" whether you need glasses. We already know all that by the time we start asking questions. Refraction is just fine-tuning. That's it. So many patients expect to have a refraction every time and many of them put a LOT of stock into whether they had a refraction and how long it took. A longer refraction is considered to be a "VERY THOROUGH EXAM", and a quick refraction is sometimes perceived as being a shoddy exam. Neither of those are true, because a refraction is not an "exam". It's just a prescription fine-tuning. I recently had a discussion with a 29 year old healthy patient who had 20/15 acuity. The autorefractor literally spit out "0.00" as her estimated refractive error. I performed all the health stuff: pupils and entrance testing, slit lamp, pressures, ophthalmoscopy, etc etc etc. At the end I announced she was fine. She asked when I was going to do an eye exam! Ha! Uh, I did an eye exam. She just wants a refraction because she expects to have a refraction. Why? Am I going to give a symptomless 20/15 29 year old some glasses? For what? Why would I "fine tune" her 0.00 "prescription"? Because "refraction" is listed on some "21 point exam" protocol? Because some insurance provider lists it as a "standard of care"? Technically we already DID a "refraction"...we performed an autorefraction on her. Do we really need to ask her "which one is better"? No. We do not. And I did not. I explained she didn't need that test. That's not an "eye exam". Also: having your acuity tested at the DMV (or anywhere else) is also not an "eye exam". Not even close.

Tuesday, October 20, 2015

Asteroid Hyalosis

Got a nice shot of some asteroid hyalosis today: Technically AH is a form of "vitreous degeneration" known to happen in many mammals. It's cause is unknown, possibly hereditary, possibly diet-related, possibly systemic disease-related...studies are as of yet inconclusive. We do know that it is for the most part benign and symptomless. One would think the patient would see "floaters", and some of them do, but from my experience *MOST* of them do *NOT* see floaters and have no symptoms at all. The patient in the above photo has 20/20 vision and literally no symptoms, not even floaters, despite the macula being totally obscured by debris. The reflectile debris is thought to be some combination of calcium and lipid, although the exact makeup is unknown as far as I know. AH mostly occurs in only one eye, for reasons that are again unknown. It's not very common, approx 0.2% of healthy patients under 55 have it according to one study. No treatment is necessary in the vast majority of cases. In extreme cases where vision is affected, a vitrectomy can be performed, but again most people do not need this. I jokingly call it "Goldschl├Ąger Eye", as the reflectile bodies have this appearance