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

Tuesday, October 13, 2015

Acuvue Oasys 1-Day Contact Lenses

Acuvue Oasys 1-Day Contact Lenses from Primary Care Optometry News: J&J announces launch of Acuvue Oasys 1-Day contact lenses September 9, 2015 Johnson & Johnson Vision Care Inc. is launching a new contact lens with a tear-infused design, the company announced in a press release. The Acuvue Oasys Brand Contact Lenses 1-Day with HydraLuxe Technology will be introduced worldwide in 2016, the company said. “We honed in on the human insight that patients need contact lenses that can keep up with the daily demands of today’s modern life,” Millicent Knight, OD, vice president of professional affairs, Johnson & Johnson Vision Care, North America, said in the release. “This includes looking at computers, smartphones, or even living in air-conditioned buildings. Each one is a potential contributor to destabilizing the natural tear film throughout the course of the day, causing a decline in contact lens performance.” J&J said that the lenses feature four advances in technology designed to keep wearers comfortable. "Tear-infused material, complementing the natural tear film with an enhanced network of tear-like molecules, that integrates with contact lens wearers’ own tear film each day; electrolyte-balanced packaging solution to mimic human tears; enlarged optics to help wearers to see clearly even when their pupils may be enlarged due to low-light; and increased lens diameter to ensure full corneal limbus coverage during blinking," the company stated in the release. J&J noted that tear-infused contact lenses have a smooth surface, even composition and stable performance. ---------------- Okay so in my mind this is a response to the popular Alcon product "Dailies Total One". Acuvue's "Tear-infused design" sounds like Alcon's "water gradient" design. If so, this is a welcome addition to the contact lens market. I was never a fan of Acuvue's older 1-day silicone "TruEye". It just wasn't a great lens IMO. Maybe this one will be more like DT1, which is, IMO the best contact lens made to date.

Thursday, October 1, 2015

Concessions Confessions: Working a Concession Stand at a Major Sporting Event

I have been “lucky” enough to have worked at a food concession stand at a major sporting event. I’m not talking high school football games, here. I’m talking 102,000+ people at Kyle Field in College Station, Texas, home of the 12th Man and Texas A&M University. Recently there was quite a bit of grumbling on Twitter and Facebook about the “inefficiency” and long, slow-moving lines at the concession stands at Aggie Football games. I am not going to dispute that this occured. It probably did! And Texas A&M has already hired 200+ more workers to try and alleviate this problem. I just wanted to inform some of you who do not know about how the typical concession stand order goes and I am quite confident that you will see where some of the problem lies. None of the things I am about to type are an exaggeration, I assure you. All of these things happened, usually over and over again every 10min or so. me: Howdy! what can I do for you? patron: FINALLY! do you know how long I have waited in this line!!?? OK we want 6 cokes and uh… 2 dr peppers and a sprite JULIE!! JULIE!! did you want sprite? ok make that last one a tea. me: ok I’m sorry we do not have coke or sprite, we only carry pepsi products. patron: YA’LL ARE OUT OF COKE?? that’s the stupidest thing I’ve ever heard of!!! well WHEN do you think you’re going to be GETTING some MORE?? me: no sir we are not out of coke. we do not carry coke. we only serve pepsi products. so is pepsi and sierra mist ok? patron: are you SURE you don’t have any coke? NONE AT ALL?? not even in the BACK?? So it’s PEPSI AND THAT’S IT!!?? SIIIIIIGH I guess we’ll order all dr peppers then because I refuse to drink that pepsi crap. it’s NASTY!!! I don’t know WHO would drink pepsi. it’s GROSS!!!! me: ok so 7 dr peppers and a tea? patron: no, SPRITE. me: remember sir we don’t have sprite. sierra mist ok? patron: UGH! that’s right. no I guess sweet tea me: we only have unsweet. sorry! there are sugar and splenda packets right over there. patron: NO SWEET TEA!!?? YOU REALIZE YOU’RE IN THE SOUTH DON’T YOU!!?? HUHUHUHUHUHHHHHHH!!!!!!!! me: ok so 7 dr peppers and a tea. got it. anything else? patron: yes we need 4 hamburgers, 2 with lettuce and 2 without, 1 with mustard, 1 with ketchup, 1 with mayo and ketchup… me (interrupting): sir the burgers just come with a patty and a bun. you put the fixings on it yourself patron: ya’ll won’t put anything on them AT ALL? so it’s just DRY? me: yes sir. you can put lettuce, onions… patron interrupting: I DON’T LIKE ONIONS!!! me: haha ok but the point is you can put whatever you want on there, and you can leave the onions off if you want to patron: SIIIIGH OKAY. you getting all this so far? I’m going to miss the entire 1st quarter!!!! uhh I guess next I want 2 orders of…how much are nachos? me: regular nachos are $4, super nachos are $7 patron: what’s the difference? me: regular nachos are just chips and cheese, super nachos are made to order with cheese, chili, jalapenos, olives, etc patron: well just give me 2 orders of regular nachos but I want some jalapenos on the side. you know, in a little cup or something me: ok sorry unfortunately I cannot do that. if I give you jalapenos I have to charge you for super nachos. patron (incredulous) WHY?? me: that’s the policy sir. very sorry. patron: you can’t just put a few on a napkin or something? me: unfortunately, no. patron: THIS IS TAKING FORVER! I’M GOING TO MISS THE ENTIRE GAME AT THIS RATE!!! me: ok so just the 7 dr peppers, the 1 tea, the 4 burgers and the 2 nachos? patron: NO NACHOS! unless you’re gonna GIVE ME SOME JALAPENOS!!! because I’m not PAYIN’ $7 for a few JALAPENOS!!! me: ok sorry sir. that total comes to…$56 patron: FIFTY SIX DOLLARS!!!???? me: yes sir. 8 drinks at $3.50 each, and 4 burgers at $7 each. patron: I can eat at CHRISTOPHER’S (local 5-star restaurant) for that!!! (throws 3 $20 bills at me, I give him $4 change and go on to the next person in line while the people behind me fill the burgers and drinks order) NEXT PATRON: it’s about a 6 year old boy with a very elderly man accompanying him me: howdy! what can I do for you? patron 2: mumble mumle mumble me: I’m sorry I can’t hear you! could you please repeat that? patron 2: (very softly): what kind of candy do you have? PATRON 1 INTERRUPTS: THIS TEA IS WAY TOO STRONG!!!! HOW LONG’S IT BEEN UP HERE!!?? ALL MORNING!!?? DON’T YA’LL HAVE ANY FRESH TEA!!?? me to patron 1: ok sorry sir hold on 1 second me to patron 2: we have snickers, skittles and peanut m&m’s… patron 1: I WAS HERE FIRST!!!!! me ignoring patron 1 now, looking at patron 2 patron 2: mumble mumble mumble me: I’m sorry what was that? patron 2 (very softly): i want milk duds me: I’m sorry we don’t have any milk duds patron 1 interrupting YEAH THEY DON’T HAVE ANY COKE EITHER!!!! patron 2: ok then skittles me: ok skittles. got it. here ya go, that’ll be $2.50 patron 2: slowly hands me 1 crumpled, wet $1 bill and about 40 various coins. elderly man smiles and tells me how he’s doing this himself for the 1st time. I smile back while separating his sticky, wet change, thinking this might not be the absolute best time for this life lesson… patron 1: IS SOMEONE GOING TO GIVE ME ANOTHER TEA!!?? AND THIS TIME NOT SO MUCH ICE!!! YA’LL ARE RIPPING PEOPLE OFF FILLING UP THE CUP ALL THE WAY WITH ICE!!! me: sir, if we give you tea again, it’s going to be from the same pitcher as last time. do you want something else instead? patron 1: YA’LL HAVEN’T MADE ANY MORE YET!!?? me: since 3min ago? no sir. patron: ya’ll have water? me: yes sir. a bottle of water is $3? patron: well the TEA was $3.50!!! you going to give me back my $0.50 change!!?? me: uh, sure. (reaching in pocket and handing him my own 2 quarters rather than get the stand manager to go thru the incredibly tedious process of filling out the forms for a $0.50 refund. I estimate that I do this 15-16 times every game that I work concessions, costing me personally about $10 a game, so that’s awesome) patron 3: 1 dr pepper please (hands me exact change in cash) me: BLESS YOU KIND SIR!!! MAY THE LORD’S GRACE SHINE DOWN ON YOU AND MAY HE GRANT FAVOR TO YOU AND YOURS FOR ALL OF YOUR DAYS

Tuesday, September 22, 2015

Pressure Behind Eyes

This is one of our pretty common complaints, and a confusing symptom for both patients and referring MD's. When a patient presents to them with a complaint of "pressure behind eyes", they often immediately make the leap to "glaucoma" because glaucoma is usually associated with high intraocular pressure. Turns out a complaint of "pressure" in or around or behind the eyes is almost never glaucoma. The most common and likely cause of a feeling of pressure is SINUS INFECTION, or at least sinus pressure, not high intraocular pressure. It ends up being a little bit humorous that the MD refers them to us to "check their eye pressure" and we usually end up sending them right back to the referring primary care provider to manage sinus pressure. Intraocular pressure is measured in "milimeters of mercury" (mmHg). It's a pressure reading like PSI for your tires, but obviously much lower. The worldwide average normal intraocular pressure is about 16mmHg. Most eye care providers agree that a pressure over about 22 (along with many other factors, by the way) is usually considered "suspect" for glaucoma. A pressure over 30 is almost always glaucoma. Almost no patient can feel a pressure under about 40. That's why glaucoma is called "the silent sight stealer" - it's generally symptomless until it's too late and you've already lost vision. And when a patient does feel a high pressure, it does not feel like pressure! It feels like PAIN. Patients with high eye pressure between 22-40 feel NOTHING, not even pressure...and patients with high eye pressure over 40 don't feel "pressure" either! They feel PAIN (and redness, and blur). So basically almost no one who says the words "I feel like there's pressure in/on/around/behind my eyes" has that symptom from undiagnosed glaucoma. It's just that the MD's pick up on the keyword "pressure" and leap to "eye pressure" (intraocular pressure) and start thinking glaucoma, or the patients Google "eye pressure" and come up with glaucoma. I, of course, am not saying that it's impossible for a patient with a complaint of "eye pressure" to have glaucoma. I'm sure some of them do, because glaucoma is generally symptomless! I'm just saying that when someone says the catchphrase "pressure behind eyes", I am making the leap to probable SINUS PRESSURE, not intraocular pressure.

Tuesday, September 8, 2015

U8 Smartwatch Review and Help w/ "Please Install BT Notifier in Smartphone" Error

Ok so I have blogged about these cheap Chinese smartwatches before, which I am a fan of. Here's my review of the M26, and here's the update for the "Please Install BT Notifier in Smartphone" Error. I liked my M26, I did. It wasn't perfect, but it mostly worked, and for $35 it's hard to complain. I used it all day every day for 6 months UNTIL...the band broke. Specifically the little groove that holds the pin that holds the band on got "stripped". A new band or a new pin will not help. So! I was going to just re-buy the M26 but I found the U8 for $18 (!) on Amazon and took a chance and boy, I'm glad I did. PROS: It is smaller and thinner than the M26. When I unpaired the M26 and paired the bluetooth with the U8 and the software I already had (see link above for "Please Install BT Notifier in Smartphone" Error blog post), everything immediately worked! The screen is brighter and nicer than the M26. The 1 button is firmer. I like this watch a lot. CONS: there are only 3 watch face settings, and only one of them is digital, the other 2 are analog watch faces with hour and minute hands. Well the one digital watch face is MILITARY TIME! And as far as I can tell this is unchangeable. There is no setting I can find to make it be not military time. So right now as I type this the watch says "14:18" (2:18pm), which is a little weird having never served in the military. I'm getting used to it, as the digital face is the only one that shows the date. It's not so bad. Also once a day or so I get an error that it has disconnected from my Galaxy s5, however all functions seem to still work even after this error, so I have been ignoring it. I still get my texts, emails, weather, etc "pushed" to the watch even after the once-a-day disconnect error. Whatever. I am liking this one better and for $18 its pretty cool and fun! If you have questions, please comment below!

Tuesday, September 1, 2015


I often get asked what I think of Similasan eye drops. They're a whole line of common, OTC home remedies for "tired eyes", "itchy eyes", "styes", "computer eye relief", etc. They're safe and FDA approved. They will not harm you. They're not, however, very effective IMO. 1st of all the name "Similasan" has to do with the herbal concept of "similitude", which says basically that plants that have parts that look like a human eye should help "heal" a human eye if used on a human eye. So herbs like "eyebright" and "marigold", etc have stems/stalks/bulbs that resemble the shape of a human eye, so therefore we should use them on a human eye. Ok well that does not sound very scientific to me. Another common theory subscribed to and appearing in many herbal medicines is that of "infinitesimal concentration", which says that the LESS concentrated a substance is, the MORE "potent" it becomes. Well ok I am not a big believer in that, either. So what do I think of Similasan? I don't think it works. I think the carrier (buffered saline/water) is probably somewhat soothing and the preservative (silver sulphate) is bacteriostatic/virostatic (prevents active growth of bacteria/virus). Other than that, I think most people would be better off using a good artifical tear like "Systane Ultra" if their eyes are irritated, and if they are itchy they should try an OTC ocular antihistamine like "Alaway" brand eye drops. Similasan won't hurt you, but it probably won't help you much, either.