Q: I love my contacts, but I am never quite sure how best to order more when I am running out. I see online ads, store ads, and my eye doctor prefers I buy from them…can you help sort this out?

A: This is such a messy topic, and glad you asked! While the FTC has regulations about how online sellers can supply lenses to their customers / our patients, the rules are commonly ignored.

Number one, your contact lens prescription is valid for one year. Glasses have no such expiration date. Contacts are regulated as other medical devices by the FDA and the FTC because they physically sit on your eye surface and could potentially cause damage. Online sellers are not legally allowed to sell you more lenses past the one-year expiration date, and are required to verify your prescription with your eye doctor…but they commonly ignore those guidelines.

As eye specialists, we strongly recommend having your eyes examined each year when you wear contacts. Quite often, we find early signs of corneal damage because the lenses are not a precision “fit” for your eyes. Lenses that do not match the shape of your eyes can cause corneal swelling and abnormal blood vessel growth. We usually can find these problems before you have blurred vision or pain…if we can examine your eyes annually.

As for costs, most professional offices ( like ours ) these days just match the “going rate” for big sellers like 1-800-contacts. And these days, most offices ( like ours ) also offer online ordering 24/7 on our practice websites. The biggest surprise for most patients is to learn that the contact lens labs charge differently for different quantities, and they provide different rebates, depending on where you order.

All the lens companies incentivize you to buy your full annual supply by charging less per box for that quantity. They also all offer rebates for your lens purchase…but rebates also vary by the provider. This means that online sellers and retail stores have rebates, but the biggest rebates are always offered only through your eye doctor’s practice. These rebates are commonly not used by my patients, but are significant…ranging from $40 to $200!

Lastly, most contact lens we see have some sort of a vision plan, besides their health insurance. These vision plans generally offer significant cost savings for patients. Most commonly, I see those vision plan discounts to run between $100-$150 for your year’s supply. Other vision plans are structured so that you only pay a co-pay of $60, or thereabouts, for your annual supply. Admittedly, the vision plans ( and there are many! ) make the calculations fairly complicated. I do not personally deal with those issues in our practice, but most offices will have staff who routinely manage these plans every day to obtain your lowest cost.

The bottom line, when you have your next annual eye exam, take the time to have the staff run through the numbers to be sure you get the best value.

Q: I am just wondering, as I am so tired of foggy glasses and looking for my readers, do these new bifocal contacts really work? Tell me more about them, please.

A: After trying many contact lenses claiming to provide bifocal vision over the years, we too were skeptical about this new generation of lenses. But, it turns out that not only do we now have several designs of “multifocal” contacts, but we also have excellent designs to correct astigmatism also!

Unlike glasses, where the prescription changes from distance to near as you look down through your lenses, contacts are completely different. In fact, glasses are called “progressive” lenses while contacts are called “multifocal” lenses. The name reflects the different way in which your eyes can use the various prescriptions in the lenses. In glasses, the power to read “progressively” increases as you look downward. In contacts, the three powers in the lens are arranged in a “bulls eye” pattern, or concentric rings of different prescriptions. There are three focusing powers: near for your phone, intermediate for your computer or shopping, and distance for driving.

This design works, and works well, thanks to our very teachable brain. While we are looking through all three powers, our brain will “attend” to the part that gives us the clear image or what we want to see. You do not have to aim your eyes through a certain section of the lens to see, the brain will interpret your vision to make clear whatever you are trying to see!

This sounds like an unusual concept, but in reality, our brain does this all the time. If you are driving, the road before you is clear, and your brain tunes out the unfocused dashboard inside your car. If you are reading your phone in your hand, it will appear clear while your brain tunes out the other unclear things behind your phone. And for most patients, it takes from 2 to 5 days for your brain to fully learn how to use your new vision.

Lastly, we even now have multifocal lenses that correct astigmatism too. And since most people have some astigmatism, this makes for even sharper vision for most patients properly prescribed lenses. With so many people now choosing daily contacts to avoid nightly cleaning, it is especially good that we have multifocals In dailies also. This is often the most popular choice, as people can be free of glasses, yet see and read well, and have no lens care regimen to follow!

See your eye doctor soon and try a sample or diagnostic pair in your daily life for a week or so. You may be very pleasantly surprised.

Q: At my last eye exam, I was told my eye pressures were normal, but later the doctor said I may be developing glaucoma. They want to schedule a bunch of tests, and I wonder if this is really necessary?

A: Medical science is constantly improving, which is good, but sometimes older ideas about a disease become less accurate, or not correct as we learn more. This has been true with Covid-19, and is true with glaucoma too. What I mean is that most people think of glaucoma as a disease causing too much pressure inside the eyes. And this can be true. However, we now know that many people, if not most, can develop glaucoma damage with eye pressures that are NOT excessively high.

I am a good example, in that when I finished my training a few decades ago, we thought most glaucoma was pressure induced. In fact, to this day most “glaucoma screenings” at health fairs only check eye pressures. But in reality, now in 2022, we know that many people…maybe most…have glaucoma damage because of inadequate blood flow to the optic nerve. We actually consider glaucoma a “vascular disease” now, more than a “pressure disease” for many patients.

Most commonly, we may find evidence in your eye exam that your optic nerves are prone to damage, or already having damage, even though your eye pressures are within normal limits. We sometimes call this “normal tension glaucoma”. To complicate this, we cannot measure your blood pressure in the back of your eyes clinically, so we have to indirectly assess the likely damage. This requires a few tests to tell us if your eyes are beginning glaucoma damage…regardless of the pressure number.

Fortunately, we have very good tests now to evaluate the optic nerve for thinning and damage. While the treatment for glaucoma is still usually an eye drop medication to be used each day, the actual type or cause of glaucoma can vary quite a bit from person to person. I should add, that two relatively common factors in this “normal pressure” glaucoma can be blood pressure that is too low, and sleep apnea. In both cases, fundamentally the optic nerve is not getting enough blood flow and oxygen to be healthy. The optic nerve begins to literally die too quickly, and left untreated, you will eventually lose your eyesight.

Lastly, my patients almost always ask if there is some lifestyle change they can make to improve this condition. Unless you have sleep apnea, or systemic hypotension ( blood pressure too low ), the answer is no. You cannot make your eye pressure higher or lower…it is very independent. Good news: glaucoma damage can be reduced or stopped with eye drop medicines or eye surgery. Glaucoma is mostly dangerous simply because it is truly silent…no pain, no pressure feeling, no blurry vision, nothing. I would advise having the tests run ( they are painless ) and follow your eye doctor’s treatment guidelines.

Q: I have been using various artificial tears for years without much success. My eyes are mildly scratchy or gritty, and I notice I have to blink to clear up my reading vision. What else could I try?

A: Dry eye syndrome or dry eye disease is such a common, and under-diagnosed, eye condition! While still more common for women than men, and generally more of an issue with each passing birthday, we have several new treatments.

Without a doubt, the most surprising is the new medications that restore normal tear moisture by using a nasal spray! We have several now that most patients are finding helpful and providing long relief. And for many people, spraying a medication in the nose can be easier than getting a medication drop into the eye.

I must try to answer the first question everyone asks: How can a nasal spray help the eye? The short answer is that we have a major nerve pathway that supplies both our nose and our eyes. When you apply the medication to the inside of your nose it signals the entire nerve pathway to react…including the branch that takes care of our eye moisture. The result seems impressive, with patients having minimal, if any side effects, and enjoying many hours of moist eyes.

I would also add that you mention one of the most important symptoms of dry eye diseas…vision effects. In fact, for many people, the only clue they have that their eyes are abnormally dry is the fuzziness of their vision. I suppose dry eye syndrome develops so slowly that most of us just assume our eyes “feel normal” when in reality they are much drier than when we were 30.

If you ask, many people will tell you that they have unconsciously “learned” to blink their eyes to clear up their vision. This simply rewets the eye surface that restores our clear vision…especially for reading. Some simple and useful self-tests at home are to blink several times, gently rub your eyes, or instill one drop of an artificial tear drop after you have been reading a while. Generally, while reading ( especially on a digital screen ) we tend to blink less often….resulting in drier eyes. So if you notice sharper vision after trying one of these three steps, you have “diagnosed” your own dry eyes!

Best of all, your eye doctor now has another effective treatment to restore moist comfortable eyes. Do not rely on over-the-counter drops for comfort and vision, get the problem actually solved by restoring more of your own natural tear fluid. Feel better and see better!

Q: I will need my cataracts taken out soon, but in doing a little research, I am not sure what kind of implant I should choose. Any recommendations?

A: Most patients are surprised to learn that there are different kinds of implants…and they may be asked to choose. Let’s get the basics…our “natural lens” we are born with becomes cloudy and less clear as we age. Cataract surgery is an outpatient procedure to remove this foggy or discolored lens and replace it with a clear plastic one to be clear, this is inside the eye… right behind the colored iris…not on the front of the eye.

When your lens is impairing your vision to the point it can no longer correct, your eye doctor will refer you to a cataract surgeon for a consultation. Measurements are taken then so the specific implant for you may be ready for your surgery. The implant has a prescription to ideally correct your vision perfectly without glasses. It never does, but it gets very close!

Here is the choice part: implants can be for correcting your distance vision, but not close up reading, or they also they have designs for distance and reading too. Most vision specialists, including me, recommend distance-only implants. Why? Because the idea of having reading vision built-in is ideal… but in reality, many patients choosing that option afterward are disappointed with their distance vision, and changing the implant is not simple.

I advise my patients to choose the distance-only implant so they will have the sharpest possible vision for driving. All post-cataract patients see more perfectly with a new distance glasses correction, it is simple to add the reading power too and make both distances and near vision as crisp as possible. It also costs much less for our patients.

Q: I have been noticing strings and cobwebs in my vision lately. Sometimes I get a quick flash of light too. Is this normal for my 64 years of age?

A: Maybe yes and maybe no. As we age, it is true that the firm jelly inside our eye becomes more watery. Think of firm jello when you are 12 and warm mushy jello when you are 50. As this natural change occurs, the tiny fibrils that give the jelly, called “vitreous” can also clump together in this water soup.

But much like a grape has a skin, our jelly has a membrane around it. This jelly grape acts as a shock absorber for our eye…softening the trauma of a fist, or a ball, or even our own hand rubbing our eye/s! This membrane also softens and crumples up inside our eye over time. That can also cause visual floaters that assume all kinds of shapes and appearance. What you see is usually the shadow of these fibrils in whatever shape or pattern they form…cobwebs, strings, clumps, etc. Sometimes larger pieces of the membrane cause floaters more like wax paper or something cloudy.

When the vitreous membrane tugs on the retinal nerve layer, it can cause flashes of light. More commonly off to the side, not the center, these warn of traction and pulling on that delicate nerve layer.

As we examine your eyes with our biomicroscope in the office, we can see the actual fibrils and assorted floaters inside your eye/s. Because they are attached, these usually tend to stay in the same “neighborhood” of your vision…off to the side, above the center, wherever. Good news: these vitreous floaters are harmless. However…they are still attached to your very thin, very delicate retina nerve layer lining the back of your eye. Because the retina is about like a layer of cellophane, it has a risk of being tugged and pulled so much by your vitreous that is can be detached from the back of the eye. Hence the very dangerous and very unpredictable retinal detachment.

The bottom line: Call your eye doctor. We may use dilation eye drops to enlarge your pupils, but we need to see if yours are the harmless type of floaters, or the beginnings of a sight threatening retinal detachment. Time is of the essence for effective treatment to preserve your sight.

Q: I recently made an appointment for an eye exam, but when I arrived and told the staff I only wanted my vision checked, they insisted that the doctor must examine my eyes for disease also. I feel like I was misled. What gives?

A: Yours is a fairly common question we hear in our office also. I suppose that naturally when I have a change in my vision or a problem in my vision, I assume that my glasses need to be changed…or maybe I need glasses, if I have not had them before. This seems logical.

However, most of the public would be fairly astounded to learn how often a “vision problem” is actually caused by a disease. Many diseases inside our eye/s, and many diseases in our body…but not in our eye/s…give only vision changes as a symptom. These symptoms could be blurry vision, vision changes that come and go, changes in our field of vision ( peripheral vision up, down, left or right ), or even doubled vision. There are many more, but suffice it to say that vision changes can occur, totally without any eye pain, and be our only clue that something is wrong.

So when I plan to have my vision checked, I am likely not even considering any health or disease possibilities. But your eye doctor is. You can be sure that the single biggest concern for every eye doctor in America is that we might miss a serious disease issue by only testing your vision. In fact, I do not know any eye doctors who will perform “just a vision exam” without insisting on examining the interior of your eyes. I think our staff assumes that everyone knows the eye doctor will need to examine for disease possibilities. I doubt that a staff person would even think to ask if you want your eye health examined…as we see that as a “given” component of each and every eye exam.

In fact, many people are not sure if an eye exam is covered by a vision plan or medical insurance. People often plan to use their vision plan for their eye exam, but discover that because an eye health problem or other disease issue was found, only medical insurance must be billed. Vision plans generally require your eye doctor to submit all examination procedures and tests to your medical plan.

So this whole idea of what really constitutes a complete eye exam can seem confusing. As an eye doctor, I see the vision testing part of your exam to be very important, but certainly not the main reason I am very thorough. In fact, many medical insurance companies separate the vision testing ( called the “refraction” ) from the rest of the exam testing. So getting a very thorough refraction by your doctor, not a technician, is critical for seeing your best, but being certain that no disease is involved is even more important.

As the American Optometric Association says in their new public awareness ads, “Eye Deserves More!” And you really do deserve more than just a vision check. We all want to see our world as clearly and comfortably as possible, but we need to be sure that no disease is causing our symptoms.

New eyedrop eliminates bifocals?

Q: I saw an article that a new eyedrop medication may eliminate the need for bifocals as we get older. How soon and how good?

A: It is true that an eyedrop is now in FDA clinical trials to determine how safe and effective it will be. This is not actually a “new” medication, but rather is an old drug called pilocarpine. This was used many years ago as the primary drug treatment for glaucoma, because it reduced the internal eye pressure. The drug also was widely known to cause the patient’s pupils to constrict…to get very small.

This unpleasant, or unsafe side effect ( for night driving ), has now become the basis of the pending new indication for pilocarpine…..to help you see better up close. The theory is well known in the eye care world, and is called “the pinhole effect”. No matter how strong your glasses prescription is or how blurry your eyesight, if you look through a tiny opening ( think of a pinhole in heavy paper ) you will see better. This pinhole effect reduces blur and increases the “depth of field”…meaning things look pretty clear no matter how close or far they are. This is the principle used to make the simple cameras that do not require any focusing! Like those cameras, I suspect the images will be pretty good, but not really crisp. How clear or sharp you may require may be different than the sharpness I need to be happy.

So the theory is that if we can make your pupils small enough, your vision will look clearer at all distances…especially for close work. Personally, I think this will help some people and not others. My concern is with the pupil constriction effects. Will the effects on your night driving, or even walking, in the dark be uncomfortable or unsafe? The new medication will be a very low concentration of pilocarpine, but no one yet knows what will be enough to help focusing, but mild enough to avoid vision safety concerns. So, the bottom line…stay tuned for final FDA clinical studies results.

Q: I tried those invisible bifocals several years ago and had trouble getting used to them. I don’t love having lines in my glasses, but are there other choices?

A: We encounter this sort of dilemma frequently in the office…when a patient had a poor experience with some technology in the past and is seeking new options. Progressive lenses ( the real name for “invisible” or “ no line bifocals” ) have come a long way. Today’s designs are the world’s better in several ways. First, the reading area in the lower part of the lenses is much wider and sharper now. Second, the “intermediate” zone to give you clear vision at about arm’s length ( think computer screens ) is wider and easier to use. Third, the side areas are clearer now than years ago. This means your side vision is more natural and clear ( think checking your side mirrors ).

Most patients now find that today’s progressive lenses are easy to use and dramatically better than the older style they tried previously. The technology has come so far that not only do we have progressives for general everyday vision needs, but also have specialized designs. These are meant for computer users, musicians, and even younger people in their thirties with fatigue issues after a long day on the screens.

The trouble is that every old-style progressive ever made is still sold! As these older styles are less expensive, they more often are sold as a bargain-priced option. This can perpetuate the dissatisfaction as people even today commonly are sold an old style design. It is virtually impossible to be a good consumer of progressive lenses….you must rely on your prescriber’s integrity and knowledge to select the best design for your specific vision needs.

We do have some patients who prefer to stay in a standard “ line bifocal ” but usually because they cost less than any progressive. We even have a few patients who still wear trifocal lenses, with not two, but three, different powers in the lenses. But overall, progressives give you an infinite number of powers as you look down through the lenses…focusing closer and closer, as you need demand. As a general rule, I would advise you to ask your eye doctor or optician about the various progressives and invest in a new pair.

Please realize that you will likely wear these lenses every day for two to three years, so the higher cost can be justified by the fact that you may wear these for about a thousand days! What else do you use every day, all day, for a thousand days? The vast majority of people wearing progressives are very happy with them. You will no doubt hear stories of someone who hates their glasses, but that really is the exception. I would recommend you try the new technology with an open mind. You will likely be pleasantly surprised.

DP Eyecare Column: Meibomian Glands?

Q: I have used artificial tears for years to keep my eyes comfortable, but I read something about treatment to help your eyes make their own natural tears again. Does this really work?

A: Yes! In fact, some studies indicate that habitual use of “artificial tears” may actually worsen your underlying dry eye disease over time. It is not surprising that our natural tears are the very best kind. You may want to understand that your tears have three layers: a mucin layer against your eye surface, a watery layer, then a lipid layer on the outside.

This outermost layer of lipids or oils is critical to prevent evaporation. Especially these days, as we all spend hours every day staring at digital screens. And I do mean “staring”, in that normally we blink our eyes about every 5 seconds but when using a screen, that blink rate slows to about every 20 seconds! This is also why we are seeing so many younger patients now with dry eye symptoms when this used to be mostly an “ over 50 ” type of complaint.

There are a few lipid-type dry eye drops available, but most are not. And still, the type our own eyes produce is the healthiest. Along the edge of our eyelids….right inside our eyelashes….are tiny lipid-producing oil glands called “ Meibomian glands”. We generally have about 40 per eyelid, and normally the mere muscle contraction of a blink should squeeze out a tiny bit of the precious lipid oil. Really a marvelous engineering design! Unfortunately, for many people low-grade inflammation causes our Meibomian glands to produce a secretion that is too thick ( think toothpaste ) and the blink cannot squeeze out the secretion. The result? Our tear film is deficient in lipids, and so evaporation is much too quick. Dry areas form on our eye surface that makes our vision less sharp, and sometimes the next blink actually hurts a little ( rubbing over those dry spots ) and triggers excessive “reflex tears”. This is why it sounds so odd to say that watering can be a symptom of dry eyes!

Finally the good news: We now can safely heat those clogged oil glands in the office to melt the waxy secretions and express the bad stuff out. This leaves your Meibomian glands open and ready to resume normal lipid secretion. Eyelid heat treatments are not permanent, but most patients seem to maintain good comfort and vision for about half a year. So, like you should have your teeth cleaned every 6 months, likewise your eyelid oil glands need care twice a year also. Patients are generally very excited about how good their eyes feel again, and having a more crisp vision for our digital world is a real benefit!

Call Morgantown Eye Associates on 304-381-5353 to schedule an eye exam with our Morgantown optometrist.

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