Keene's Eye and Vision Care Blog

Hi...Big surprise! %-

New Blog site

I should have done this weeks ago, but my new blog can now be found at www.eyedocdeviney.wordpress.com.

Same blog, actually.

Trying a New Multifocal Contact Lens

Two Blind Pilots, written by Walt Mayo, O.D.

Two blind airline pilots were both wearing dark glasses. One is using a guide-dog and the other is tapping his way along the aisle with a cane. Nervous laughter spreads through the cabin, but the men enter the cockpit, the door closes and the engines start up. The passengers begin glancing nervously around, searching for some sign that this is just a little practical joke. None is forthcoming. The plane moves faster and faster down the runway and the people sitting in the window seats realize they're headed straight for the water at the edge of the airport. As it begins to look as though the plane will plough into the water, panicked screams fill the cabin. At that moment, the plane lifts smoothly into the air. The passengers relax and laugh a little sheepishly and soon all retreat into their magazines, secure in the knowledge that the plane is in good hands. In the cockpit, one of the blind pilots turns to the other and says, "Ya know, Bob,one of these days, they're gonna scream too late and we're all gonna die."

Alternative forms of Medicine

My interesting patient of the day was actually a gentleman I saw on Saturday.  He is a chiropractor, Dr. M., and came in for a second opinion after being diagnosed with glaucoma a couple of months ago.  Being a chiropractor, his philosophy was much more centered on correcting the underlying cause of his increased eye pressures, which were in the high twenties at the time of his original diagnosis (according to the records).  That also meant he had absolutely no interest in taking the advice of the other doctor who had recommended Travatan eye drops.  I could see the frustration in her chart notes as she felt the need to stress her recommendation with multiple underlines and exclamation points!!!!!!!

I took a different approach with the good doctor and explained how every diagnostic test we had run on him showed that he had the classic signs of peripheral vision loss and reduced nerve fiber layer thickness.  Knowing that the Travatan drops could indeed lower his pressure, he proceeded to enlighten me on several natural remedies that he is currently trying including Bilberry, Eye Bright, something called Carbamide, and a technique he called "Cranio-therapy" which involved the massaging of the cranial sutures.  Oh, and exercise too.

Now, I don't bring up this topic to make fun or undermine anything that Dr. M believed in.  And I didn't even bother to lecture him.  I just listened.  My ignorance of his field of knowledge puts me in no position to criticize.  In fact, I found myself both intrigued by his remedies and worried at the same time.  I am very hopeful that it works to control his pressure, but I'm worried that it won't.  Only time will tell.  And seeing that his daughter is one of our patient coordinators, I know we will see him again even though he lives 3 hours away.

Stay tuned...

Dry Eyes

Being in this profession for 10 years, you'd think I'd have diagnosed a ton of patients with dry eyes.  Well, I have diagnosed quite a bit.  But it wasn't until about four months ago that Dr. McMahon and I decided to actually create a Dry Eye Clinic within our practice.  We pride ourselves on having very little to no paperwork for our patients, but we did create a quick Ocular Surface Questionnaire checklist for our patients to fill out.  Basically, every box that's checked raises that patient's risk of experiencing problems due to decreased tear production.

Since then I feel like I've treated (and helped) more dry eye patients in the 7 months I've been here than I did in my 9+ years in Texas.  This is thanks mostly due to having just a few extra moments to talk to my patients.  I've found that most patients treat themselves with the artificial tears that are available over the counter at the drug store.  However, in almost every case, these drops only provide temporary relief and never really treat the underlying problem:  fewer tears are being produced and those that are being produced are evaporating too quickly.

So it's here that I actually have my first guest contributor:  Dr. Jill Autry, who is both a registered pharmacist and therapeutic optometrist.  Jill and I both graduated from the University of Houston College of Optometry in 2000.  She travels all over the U.S. and beyond lecturing on the pharmaceutical aspects of eye care and is part of the outstanding group of doctors at the Eye Center of Texas in Houston.  Thank you, Jill!  

Enjoy:

Dry Eye Syndrome (DES) is the most common cause of ocular discomfort.  It happens when the tears produced by the eyes are insufficient in moisture, lubrication, and other features, which usually protect and replenish the eye.  Dry eyes may also be worsened by environmental aspects such as dry weather, wind, and computer use. People with dry eyes often feel discomfort in a variety of ways including redness, burning, tearing, and a gritty foreign body sensation.  In addition, patients often complain of intermittent blurring of vision.  DES can be sporadic for some patients, but in others it is a chronic, irritating ocular disease.

 How Do Tears Prevent Dry Eyes?

Tears are a major protective agent for the eyes. Tears not only wash away dust from the eyes, but also soothe the eyes, provide oxygen and nutrients to the cornea, as well as help defend against eye infections by removing microorganisms that can colonize in the eyes. Tears are composed of three distinctive layers. The outer lipid section consists of an oily film that counters evaporation and keeps the eye moistened. The middle region is made of mostly water that moisturizes the eyes as well as some nutrients and proteins that assist in limiting eye infections. The inner coating contains mucous that allows the tear film to spread and reduces evaporation from the eye. Each layer is vital to the health of the eye and many reasons exist which can cause an imbalance in tear quantity, quality, and consistency, which can lead to dry eye syndrome.

What is the Cause of Dry Eyes?

Dry Eyes can be caused by several factors that include those relating to less tears and less moisture within the eyes. A common cause is aging. As we age we create less productive tears, which means less lubrication for the eyes. Poor tears might also evaporate swiftly. Women approaching menopause especially face dry eyes due to a change in hormones. Others are not able to generate as much natural tears as needed whether it be from aging, blockage of tear ducts, or from medication that leads to less production of tears. This problem oftentimes leads to chronic dry eyes as the person is not able to manufacture tears and the eyes are not sufficiently lubricated. Tears evaporate rapidly, and the eyes are not cleaned properly. Environmental factors can also play a factor in eyes drying up. Examples include dusty air, dry or windy weather, or fumes like cigarette smoke which can evaporate tears quickly or hamper their effectiveness. This is especially a cause for dry eyes in contact lens wearers as the lenses absorb lubrication and the tear film.  Numerous contact lens wearers regularly require rewetting drops.  Personal conditions may also cause dry eyes. A deficiency in vitamin A, some medications, and some diseases may also lead to dry eyes. Inadequate sleep or insomnia can also cause dry eyes, as the eyes are not allowed to rest and are apt to dry up faster.  In addition, heavy computer users are prone to dry eye syndrome.

Dry Eyes Symptoms

Many dry eye symptoms are persistent throughout the range of causes of dry eyes. Discomfort can range from light pain to a grainy, scratchy feeling in the eyes. The eyes may also become itchy, red, or tears may start to flood the eyes in an effort to relieve the dryness. Excessive tears are not necessarily good as it can mean the eyes are trying to over compensate for a lack of natural tear production. People with dry eyes will generally experience strain when using the eyes on focusing tasks like watching the television, knitting, and other activities.

• A gritty foreign body sensation that is worse at the end of the day.
• Redness, burning and excessive tearing without relief.
• Fluctuating vision that is worse at the end of the day or with detailed activities.

Dry Eye Testing

Testing for dry eyes can be performed through several methods. One of the simplest, Schirmer's test, is performed by placing a small piece of filter paper inside the lower part of the eyelids. The eyes are closed for a few minutes and the filter papers are then removed in order to measure the amount of tear production. The Schirmer's test can determine if there is difficulty in tear production or if the tears are not efficient in maintaining adequate lubrication.  Fluorescein eye drops may also be used to determine tear production. These drops contain a dye that can be traced with a special light as it is washed out of the eyes by the tears. This method can detect poor tear drainage and/or early evaporation of tears. Tears may also be examined to see if they contain enough moisture, proteins, and other materials.

 Dry Eyes Treatment Options

Dry eye treatments will vary depending on the cause and the level of dryness. Many people can use artificial tears, gels, or ointments that simulate the action of normal tears.  These products can provide temporary relief to the eyes and are excellent choices for episodic or mild dry eye patients.  For patients with more chronic disease marked by moderate signs and symptoms, a new medication called RESTASIS® Ophthalmic Emulsion is available by prescription. This FDA approved eye drop is the only medication proven to make more of the patient’s own tears.  It helps the eyes to produce more natural tears, which is great for dry eyes evoked by aging and other reasons for deficient tear production. Another treatment step is the use of punctual plugs. These plugs block the drainage of tears and conserve them in the eyes longer. There are temporary and permanent plugs that are easily inserted into the tear ducts.  Sealing the drainage system can also be done surgically. This method prevents tears from draining from the eyes and keeps the eyes moisturized. Contact lens wearers will often find eye drops effective especially if the lenses are removed prior to adding the rewetting drops. Primarily strenuous activities on the eyes often require a break or lots of blinking to bolster the prevention of dry eyes.

Busy Friday

Today was one of the busiest days I've had since I joined the practice...13 full eye exams.  Not as busy as I used to be in Texas where I would see that many exams in an afternoon.  But the biggest difference in scheduling here is the time that I can spend with my patients to dig a little deeper in to their vision problems and discover things that many patients say no one even bothered to look for in the past.  

Hearing patients tell you they've never had a better eye exam never gets old and I often hear it before I've even done a single thing myself.  We couldn't do it without the awesome staff that we have here.  We decided long ago that we could operate our practice like everyone else and therefore be like everyone else.  Or we could do it in such a better way that we would be so much better than everyone else.  That's why I moved half way across the country to join Vin McMahon's practice.  I worked with some truly outstanding people in Houston but have never been part of a collective team of people that have worked so well together (maybe with the exception of the 1990 Freer Buckaroos Class 3A State Championship team http://www.freerisd.org/site_res_view_folder.aspx?id=099204d5-8142-4774-8aa7-5f85fed897f0 I don't know why the picture is split down the middle).

Interesting patient of the day was a 50 year old man with eye pressures measured in the 30s a couple of weeks ago that came back in today for further testing.  His peripheral visual field test and nerve fiber analysis showed some likely signs of glaucoma, but his corneal thickness was over 600 microns.  You never like to diagnose someone with glaucoma, but the clearer the findings the better I feel about starting treatment with Travatan Z.

Well, it's quitting time.  I'm working tomorrow (Saturday), so not much planned.  Let me know if you've got anything exciting going on.  Have a great weekend!  Stay warm (if you're in Keene).

Field trip report.

Well, I was very pleased with our trip to the Eye & Lasik Center in West Springfield, Mass yesterday.  We don't seem to have a lot of patients getting LASIK in the Keene area, but those who come to see us have been traveling all the way to the TLC in Albany, NY.  That's about 3 1/2 hours away.  Yesterday's trip was about 1 1/2 hours and mostly interstate.  

We met with one OD and two surgeons, all of whom reminded me of the great ODs and OMDs that I worked with in Houston.  They were very interested in forming a relationship with us and really seemed to run a nice operation with competent support staff, etc.  So it looks as if they'll be getting our lasik and cataract patients from now on and we feel confident that these patients will be well taken care of.

Meanwhile, fresh cold air blew in from the north with some new snow.  So fresh that we'll barely get in to the teens through the weekend.  Makes us look forward to that 32 degree weather that will be back the middle of next week.

How's the weather where you are?

Field Trip today!

Today we're only seeing patients until around noon time because we're heading to Springfield, Mass to visit a lasik center that would like us to refer patients.  The lasik centers I worked with in Houston were top notch, referring mainly to Dr. Stephen Slade and then Dr. Tad Wade.  Both had great support staff and were always willing to bend over backward to accomodate the needs of our mutual patients.  I can still count on them today to help me out in all sorts of ways.  Every other lasik center I visit will be held up to those standards in my eyes, so I hope today's visit will not disappoint.

Interesting start to the day...NYer in NH.

So my first patient was an 80+ year old woman.  A New Yorker.  Gave me that look when I walked in like 'you're too young to be doing this, where is my real doctor'...  I love these kind of challenges, because it almost always ends with them letting their guard down and with us laughing together on the way out of the exam room.  Her cataracts had worsened but she had no interest in surgery, so we'll see what happens with her new Rx.  I told her to expect an adaptation with a nearly 2 diopter shift in the left eye.

But she was very light sensitive and refused to let me look in to the back of her eyes.  I wasn't going to tie her down so after the proper documentation and thanking her for breaking up the monotony of the day, we walked out of the exam room laughing.  Another happy patient, so far...let's see how she adjusts to that new Rx before closing the book on this one.