Q: I am hearing more about macular degeneration lately and how it can wreck your central vision, what can I do to prevent this as I get older

A: You are right to be concerned because as of today we still have no real solution to repair or correct the damage from macular degeneration ( often called AMD ). However early detection of the beginning stages, along with preventive treatments can slow or prevent damage for many patients.

First, we now have a simple in-office genetic test to tell you your risk of “wet” AMD ( the leaking progressive form ) in the coming 10 years. This test also will indicate which supplements may help or hurt your eyes.

Second, we now know that the earliest damage to the retina occurs deep in the then layers of our nerve layers in the back of the eye. This means that our “dark adaptation” can indicate if our deepest layer of vision receptors….the “rods”, not “cones”, is being damaged. This early warning test is simple and non-invasive, and studies say this may warn of damage up to 4 years before patients experience vision impairment in normal life. We have never had such a good early warning technology till now, and this extra lead time can be put to good use with preventive treatments…before the patient has lost even one line on the eye chart!

Third, preventive steps include wearing full spectrum UVA and UVB blocking sunglasses when outdoors. Personally, I prescribe polarized lenses for this protection as they block out the harmful radiation directly, and the blinding glare from reflected light on the highway or water. We also recommend certain nutriceuticals for the eye in some cases. Anti-inflammatory carotenoids are chemicals found in green leafy vegetables, but more easily ingested in a daily pill form.

Lastly, retinal scans and retinal performance measurements can help us monitor for progression of AMD, and if needed, to begin injections inside the eye to slow the damage. The really great news is that today we can identify AMD very early in the first eye….unlike ten years ago, when we often only diagnosed AMD after the patient had already lost some vision in one eye……making our goal to save your second eye.

Protect your sight: be proactive.

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Q: At my last eye exam, my eye doctor mentioned that I had a “freckle” in my eye. He seemed not very concerned and ordered no other tests. Should I be concerned and what might be next?

A: This is not rare, but it is uncommon. We fairly often identify pigmented lesions or spots inside the human eye. I think it is common that we might refer to this as a “freckle” inside the eye. The term freckle just means some pigmented lesion or tissue, and this harmless-sounding term is used to prevent undue patient anxiety.

Understanding Choroidal Nevi

In reality, the majority of these pigmented lesions are benign and never develop into anything needing surgery or radiotherapy. In our clinic, when this pigmentation the retina is discovered we routinely order other tests. Experts recommend that the tissue be visualized with pupil dilation to facilitate a three-dimensional view of the area. Also indicated would be ocular ultrasound to provide imaging through and behind the eye. The basic idea to be sure that what we see in the retina is not the “tip of the iceberg”, meaning a tumor behind the eye. Lastly, we use chromatic filtering in retinal imaging to help localize the layer involved.

If these tests still indicate a benign pigmented lesion, we call that a choroidal nevus. The choroid is the layer of the retina involved, and nevus just means it is pigmented. If this is the first discovery of the pigmented tissue, a return evaluation in three to six months is prudent. Our goal is to establish that this lesion is not changing or growing.

Treatment

For the small percentage of these that are progressive or malignant, treatment is primarily to devitalize the tissue with radiotherapy. The ultimate goal is to prevent any spread or metastasis of any cancerous tissue outside the eye to other parts of the body.

Unfortunately, malignant lesions can develop at any age. We routinely recommend full interior retinal imaging for all age patients…..even children! It is more difficult to thoroughly examine the retina of a young child, so new non-dilated imaging can show us the whole retina far more easily as a screening tool. For you, and really all people, retinal imaging is an excellent diagnostic procedure to find diseases such as this……long before any symptoms appear or before any vision is lost. Too often, people mistakenly think that a change in vision just means time for new glasses….when far more serious issues may be to blame.

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DP Eyecare Update

Q: I just got my second pair of glasses online, and still feel like my eyes are not “working together” and wonder how I can know if these are right?

A: Most people have very little idea what goes into making your new glasses perfectly for you. The problem today often begins with the eyewear salesperson not really trained to take the proper measurements so your new prescription lenses align perfectly with your eyes. Getting these precisely…..in the new frame you select….is essential for the optical laboratory to grind the lenses exactly as your eyes will align through your lenses.

Now, imagine you order online….as you did….who took the measurements for the prescription design? You likely used the online “fitting tool” to get some dimensions, but how good are those? In truth, not very good. For the simplest, mild prescription this method may be “close enough”. As your prescription power goes up, and if you have other complications like astigmatism and/or progressive lenses for reading…..the accuracy is increasingly critical. Both the measurements to order and the precision of the optical laboratory to actually produce what you need are essential to end up with a well-fitted pair of glasses, with the optics perfectly aligned with your eyes.

The American Optometric Association reviewed hundreds of online eyewear orders and found that less than 50% actually had the correct prescription as written by the eye doctor, and commonly the lens misalignments made even “correct” powers uncomfortable to wear. I tell our patients, honestly, it is very difficult to be a good consumer in eyewear. There are countless details that make or break a perfect prescription. There are over 300 progressive lenses sold for those of us over 40…..each a little different in design! How can a layperson possibly know how to select a lens design?

To get you started in solving this issue, you should call your eye doctor’s office and schedule to see one of the opticians in the office. This professional can “read” the prescription in your glasses, and determine if the powers are accurate, and if the lens design is accurate for your eyes. There may be a fee for this service. If the eyewear is found to be incorrect, ask your eye doctor’s office to generate a new prescription for you. You may have a fee for that service. If you are due for your eye exam, do that.

You could then contact the online supplier to see how, or if, they will remake your glasses to accurately match your doctor’s specifications. Frankly, I would recommend having the professionals in the office take the measurements best for today’s digital lenses, and have them make your glasses. You may pay more than online, but your likelihood of getting accurate eyewear for you is excellent this way. Seriously, you will wear your glasses for about two years. What else do you buy and use every day, for over 700 days? Invest in accurately measured and precisely made optics. Usually, these professionals are also well trained to guide your choice in frames to the shape and size that complements your facial appearance and accommodates your new lenses attractively.

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DP Eyecare Column: Summer Eye Damage Prevention

Q: My wife and I have the same discussion every summer. I wear my ball cap outside all the time to shade my eyes. I contend this protects my eyes well enough, but she harps at me to wear sunglasses too. I don’t like wearing glasses when I’m working in the yard or playing golf, and think the shade from my hat is enough. Who is right?

A: Each summer brings several high-risk activities for our eyes. Besides the increased risks of injury from using grass trimmers and chain saws and the like, the increased exposure to ultraviolet (UV) radiation is the most prevalent risk for our eye health.

It is well known the UV damages our skin and contributes to skin cancer, but many people do not realize the way UV also damages our eyes internally over time. UV is dangerous for the delicate and ultra-thin skin around our eyes, leading to about 11% of all skin cancers right around our eyes. UV also causes our crystalline lens inside our eyes to become cloudy faster, meaning we develop cataracts earlier in life.

Lastly, the critical nerve tissue in the back of our eyes, called our retina, can develop damage we call “macular degeneration”. The macula is the most valuable “real estate” we have in our eyes…..the very tiny and unique tissue that gives us 20/20 vision. Certainly family history of macular disease is critical, but blocking out more UV radiation over your lifetime can be very important in preserving your sharpest vision in your later years. Unlike a lot of medical problems, damage to our retina cannot be repaired or replaced to restore normal vision like before. Keeping your sharp central vision for reading print and seeing faces clearly depends on UV protection. It is purely based on prevention during our lifetime.

So, I hate to tell you, but your wife should keep in “harping” at you, as just wearing a hat is not enough protection from UV radiation.

• Full-spectrum UVA and UVB filtering are essential to block out the “toxic” radiation from the sun…..both direct and reflected.
• Ophthalmic quality, or medical-grade sun lenses, have this protection built into the lens….not sprayed on the surface as many inexpensive versions use.
• Dark is not enough. In fact, dark is not essential at all. The UV blockage can be clear in your lenses.
• Most people also prefer polarized sun lenses, as that feature actually blocks or erases glare on the highway too. Polarized lenses make the safest driving lens for us all.

As we advise our patients, everyone should invest in medical-grade, ophthalmic sunwear….ideally with polarization. And whether you like wearing sunglasses or not, you need to get used to it. Wear your hat if you like, but blocking out UV with full coverage sunwear ( not smaller lens, dress indoor eyewear ) gives your eyes and eyelids the best chance to remain healthy and damage-free as we age.

One last comment, if you have a family member with macular degeneration, or if you have had cataract surgery, you have an even higher risk of retinal damage and need even more protection.

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DP Eyecare Column: Scleral Lenses: prosthetic surface for eyes

Q: I have been told I have unusually shaped corneas, and suffer with chronic dryness. Glasses are not very clear for my vision, and contacts are too dry for me. What else is there?

A: There are actually many causes for this sort of thing, and commonly they can make vision less clear and less comfortable. This means that the common ways we prescribe glasses or contact lenses may not be satisfactory for you.

I just read an update from The Johns Hopkins Wilmer Eye Institute, probably the finest research and surgical eye center in the world, located in Baltimore, where they are trying to inform the public about a new treatment for patients just like you. They announced that they are now prescribing “scleral lenses” to correct eye surface disorders. Guess what….we have been prescribing these for several years right here in Morgantown!

Scleral lenses are larger than normal contacts, and made of a breathable plastic that is not soft and floppy, and not rigid like glass, but somewhere in between. The prosthetic lens is filled with sterile saline and placed on the eye surface. This fluid-filled scleral lens covers any dry areas of discomfort, and the large perfect surface corrects vision more sharply. Patients are generally amazed right away how good their eyes feel, and how sharp their vision is! The lenses are inserted in the morning and removed in the evening. With good care, scleral gas-permeable lenses should last a year or more.

Scleral lenses are not widely known, I think because they are seldom prescribed and are more expensive. While anyone could wear a scleral lens, we generally reserve them for patients with certain eye disorders or diseases. Sclerals also cost more. We have found mixed success in getting vision plans to pay toward scleral lens prescribing….some do, and some do not. While this is a medical eye problem, we find most medical insurances do not cover “medially necessary contacts”. Many patients these days can use a medical credit card like Care Credit, or their Flexible Spending Account, to pay for the treatment.

Step one, ask your eye doctor if they prescribe scleral contact lenses. If not, ask for a referral, or seek a provider that is prescribing these specialty medical lenses.

But good news…..you certainly do not need to drive to Baltimore for this level of specialized care.

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Q: I usually buy my sunglasses at the drugstore or some retail place, but wonder if there is any real difference between mine and the ones costing over $100?

A: You raise an important point: everyone should be wearing some sort of ultraviolet-blocking sunglasses when outdoors.

First, please realize that UV radiation is invisible to us, but is an enemy to our skin and our eyes. About 11% of skin cancers can involve the very thin and delicate tissue of our eyelids. Prevention is fairly simple, but many people ignore the science and wear their indoor glasses, or no glasses when exposed to the sun. It may seem small, but even the frame your wear affects your protection. Most “dress” glasses for general usage allow a lot of UV radiation to reach your eyelids and your eyes right over the top of the frame. This is why your best sunglasses are larger and are shaped with more “wrap” to closely fit your face and block more UV.

Second, while “over the counter” sunglasses are generally dark in color, so you feel protected, the actual ultraviolet filtering is often a “sprayed on” coating. This sort of protection is not permanent, as a coating is can wear off with handling and rubbing……leaving you with dark lenses ( allowing your pupils to enlarge outdoors ), but little or no UV blockage. In contrast, better grade lenses, called ophthalmic grade, include UV filtering built into the lens. This protection cannot degrade or wear off over time.

I should add that some contact lenses now come with some UV filtering built-in. However, the level of protection is such that the FDA still recommends true sunglasses over them. And speaking of needing extra protection……cataract patients need to use extra care. While you are developing cataracts, blocking more UV radiation can slow down the clouding of the lens in your eye, and delay the need for surgery. And after cataract surgery, when a plastic replacement lens is placed inside your eye, you need more protection than before. The man-made plastic lens used ( called an intraocular lens ) does not block enough UV radiation. This can allow dangerous radiation to reach your retina and cause more irreparable damage to your eyesight.

Lastly, I often hear people say “ I lose my sunglasses all the time, so I don’t want to spend much”. I hear you, but I believe it is a matter of perceived value….meaning, if you invest significantly in any item, you will take better care of it. For example, how often do you lose your cell phone? The bottom line: invest in ophthalmic grade sun lenses and give your eyes and your eyesight the best protection you can. Seeing well all your life is our mutual goal.

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Q: I just realized that my daughter is struggling with her reading assignments. I first thought it was just all the tablet use this year, but now I think she is reading slower, loses her place too easily, and doesn’t enjoy reading just fun. Where should I start?

A: In general, children just never complain about eye problems. I suppose they naturally assume that everyone sees like them, and of course, they have no perspective to differentiate “normal” vision from “abnormal”. Fortunately, these days a thorough pediatric eye examination can identify the cause/s of reading disorders.

To give you a brief overview, unlike an adult eye exam, for children:

• we specifically measure eye alignment at distance and near
• we evaluate how accurately their eyes track across a line of print and can find the next line
• we measure the focusing range and ease for near-vision work like reading.

These are called “oculomotor” skills, and for many children are developmentally delayed.

These eye skills are like tools you need to read and perform all manner of near vision tasks. If you do not have adequate tools, the job is much harder. Sometimes slower. Often inaccurate. And almost always….silent. Too often we find very smart kids struggling to keep up in school, or actually reading with one eye at a time, all because their binocular vision is not developing normally. Some use their finger to keep their place, and some hold their work too close.

The good news is this: with proper lenses to sharpen focus or to assist eye alignment, or both many children can catch up and regain those eye skills to make reading easy again. And if lenses alone are not the answer, just like you would use physical therapy or occupational therapy, we prescribe vision therapy to train those oculomotor skills! Sometimes also called “orthoptics” or “eye exercises”, this treatment has a very high success rate but is unfortunately scarce in West Virginia. We are fortunate here in Morgantown to have access to a vision therapy specialist!

As a general rule, all children should have a professional pediatric eye exam by age 3, and annually through elementary school. Screenings at school and in other settings are great…but very limited. Do not confuse a screening with a true Optometric examination for children. While all eye exams should look for disease and making vision clear on the eye chart, many children need more. Ask some questions…..be sure your child is really getting a pediatric eye examination. Be sure your child has the vision tools to make learning easy and enjoyable!

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Q: I was looking at the pharmacy last week for some drops to make my eyes feel better, but with all the choices I really had no idea how to choose. Can you help?

A: You are right about having too many choices on the shelf, but let me give you some direction. First,
try to identify exactly what symptom or problem you are trying to help.

• Is it a matter of your eyes feeling dry?
• Are they red?
• Are they itchy?
• Do they burn?
• And also what time of day or with what activity are they most a problem…..morning or evening, while on your computer, more indoors or outside?

These kinds of clues can help direct you to the right type of treatment. For example, if your eyes feel dry or scratchy then dry eye disease may be beginning. A good OTC ocular moisture drop can be fine to use up to three times a day. The proper artificial tears or lubricant drop should not also “take the red out” or “stop the itch”, as those actions require agents in the drop that can worsen dryness. Likely the most common error I see is a patient buying an eyedrop that “takes the red out” when what they really need is moisture enhancement. Likewise, an “allergy” eye drop to reduce itching may do just that, but also will make your eyes more dry!

Computer use is a common problem these days. We spend hours and hours staring at “digital devices”….our desktop, our laptop, our tablet, our smartphone and more. Turns out we all blink only about a third as often as we should when we look at these screens. We really do tend to stare at the screens, unlike a book or paper on your desk. Computer glasses can reduce eyestrain for digital use, and a moisture drop when you first sit down is a good idea.

If itching is the issue, good chance you have an ocular allergy. There are many “allergy” drops on the shelf, and some good ones that used to be by prescription only. But still today, the “strongest” and longest lasting eye allergy drops are only by prescription from your eye doctor. So try an inexpensive OTC drop first, but if two times a day is not enough to restore comfortable eyes, ask your eye doctor for a medical grade eye medication.

Lastly, many people have an underlying condition we call dry eye disease that causes or worsens all these symptoms. This especially true over the age of 50, and more so for women. We can use painless in-office tear samples to determine if your eyes have inflammation causing the dryness, or is it more a matter of too many birthdays! Inflammation caused dry eye is well treated with one of the excellent eye medications by prescription. Non-inflammatory dry eye is often better solved with tiny tear saver plugs we place in the tear drainage ducts of our eyelids, to retain more natural moisture on the surface of your eyes.

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DP Eyecare Column: Eye infections and injuries……who to call?

A: My kids have had their share of pink eye and eye injuries over the years, but I am never sure who to call. Seems too little for a hospital ER, but not really what urgent care offices are made for either. Who should I call?

Q: Yours is a very common question, and one that we eye doctors should address. Generally, you should call your regular eye doctor first.

While many people think their eye doc only prescribes glasses or contact lenses, in reality, most eye doctors also diagnose and treat eye problems as you mention. I suppose it is normal, in that if you have only experienced “vision care” at your eye doctor’s office, you likely assume that is all we do.

In fact, most parts of a “normal” eye exam deal with determining if your eyes are healthy. But many patients already know that their eye doc will diagnose and treat eye injuries, infections, and most every “primary care” need for attention. It has been said that your Optometric Physician is your “family practitioner of eye care”. In our practice, we see patients of all ages, every single day, with some type of eye inflammation or infection, or an injury of some form, or an eye symptom caused by a “systemic” ( non- eye ) disease. Even many medications can cause eye and vision symptoms….and your eye doctor is the best trained to sort out and handle these problems.

You are right, hospital emergency departments are not focused on eye problems. They have life and death issues to handle. While urgent care offices are convenient, they are not equipped or trained to sort out the myriad of problems that present with eye/vision symptoms. We receive a lot of urgent care referrals, and most patients could have saved time and cost by calling their eye doctor in the first place.

Whether you are 5 or 95, your eye doctor is best equipped to take care of your eyes. That’s all we do! Whether it is our biomicroscopes, or our internal eye imaging technology, or just or experience is treating only eyes……eye doctors are the first call you should make for virtually anything involving your eyes.

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DP Eyecare Column: Readers without wearing glasses?

Q: I have been needing “readers” for a few years now, and while putting them on and off has been a nuisance, the fogging I have now with my Covid mask makes them even worse! Any suggestions?

A: Yours is a very common problem these days for people wearing readers, and for folks wearing regular glasses too. There are some very good anti-fog solutions you apply to your lenses to reduce fogging, but they vary widely in how well and how long they last. Ask your eye doc or optician for recommendation.

We have had many, many patients since Covid choose to begin or resume soft contact lenses to truly solve this problem. For everyone over 40, our near vision begins decreasing so that reading becomes more and more frustrating. Good news, however, in that just since 2019 we now have excellent “multifocal” contacts that are designed to give you good near vision, and they can be prescribed also with your distance vision correction if needed!

These multifocal contacts provide up to three different focusing ranges…..meaning we can prescribe your lenses to give you clear vision up close for your phone, plus a focus for arm’s length for your screen, and even distance if needed for driving. And thank heavens our brain is pretty “smart”…..it will learn to use the part of the lens you need automatically. So unlike bifocal or progressive glasses, you don’t even need to move your eyes up or down to find the right power.

These new contacts are not perfect, and not everyone finds their vision perfect at all distances. But most people, about 80%, find their vision so comfortable and more normal compared to glasses ( and without the annoying fogging ) that they love wearing contacts to be free of glasses. Our practice, like most, will prescribe your contacts and have your wear them in your normal life for a several days before you decide to continue and actually buy lenses. Some patients do need some “fine-tuning” in the lens prescriptions after a few days to improve some aspect of their vision. If so, you may have one follow up visit with your eye doctor to achieve your best all around vision.

If contacts would be new to you, rest assured that now days the lenses are extremely soft and moist and thin, so that most people do not even feel the lenses after just couple minutes. And learning how to place a lens on your eye, and to remove it that evening, is not difficult but takes a little practice. We typically show patients a lens handling video, and then personally teach them how to easily handle their new contacts. So again, nothing is medicine is 100%, but these new lens designs have been very successful and well received by most people. Talk to your eye doctor about your multifocal contact lens options and take a pair for a “test drive”!