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Dry Eyes Update 2020

Jul 30, 2020 - 2 comments

2020 General Information on Dry Eyes-Now known as Ocular Surface Disorder.


Dry eyes are one of the most common conditions seen in the practice of ophthalmology. Collectively dry eyes probably cause more eye discomfort and irritation than any other condition.  The term “dry eyes” will never go way but it’s misleading.  Eye MD ophthalmologists now call this “ocular surface disorder” (OSD) and sometimes “tears dysfunction syndrome.”  There are two forms of the problem. In the first (called by Eye MDs ‘aqueous deficiency’) there are no tears or few tears; it is often associated with dry mouth and is the most severe form. In the second form, the eyes water constantly or often. It is called ‘lipid deficiency’ and is caused by eyelid oil gland (Meibomian Gland Disorder or MGD) problems.  In the first form the eye doesn’t make enough tears; in the second form the tears are of poor quality.  There are many tests for OSD, some of them quite expensive, but the diagnosis can usually be made by a careful symptom review and examination of the eye and eyelids. For persistent problems a complete medical eye examination by an Eye MD ophthalmologist is needed plus telling the Eye MD about your symptoms and how troublesome you find them. Self education on OSD is extremely important.

         If you are menopausal or post-menopausal be sure you and your gynecologist maintain optimal hormonal balance. (Many women with dry eyes have dry mouth and dry vaginal canal). If you have joint pain have that evaluated to be sure you don't have Sjorgren's syndrome or rheumatoid arthritis. You might review your medications with your ophthalmologist. Almost any cold, allergy or sinus medicine can cause or aggravate dry eye and mouth. Oil and debris along the eyelids (blepharitis) can aggravate dry eyes. Blepharitis can also cause eyelid infections such as styes, blocked oil glands (chalazion) or eyelash loss and red eyes and eyelids.  Eye lid cleaners and wipes are very useful. They are non-prescription. The easiest to find, and among the best, are Ocusoft products:   http://www.ocusoft.com/ For recalcitrant cases the new prescription Avenova Eye https://avenova.com/ has worked extremely well.

OSD treatment usually begins with use of preserved and/or unpreserved artificial tears during the day and gels or lubricating ointments at bedtime. Environmental modification is important.  Don't belittle eye drops. They are not ‘all the same”. You would never walk into a restaurant and say “Bring many any type of food, it’s all the same.”  There are over 100 different brands of artificial tears and they can't all be lumped together. Sometimes one will find the perfect drop. That means you put the drop in and your eye becomes comfortable in 5-10 minutes and remains comfortable for at least 3-4 hours. If it stings or burns, write down the name on a list you keep and give it a failing grade. If it helps but only for an hour continue your search for one that lasts 3-4 hours; give it an average grade.   YOU MUST KEEP A LIST OF DROPS YOU HAVE TRIED AND HOW THEY WORKED OR DID NOT WORK FOR YOU.
Because the OSD problem is so prevalent the pharmaceutical companies are coming out with new products all the time. Some of the newest are Systane preserved and unpreserved, Optive, Blink, Soothe, and Retaine. Eye drops for dryness are classified as unpreserved drops (individual vials that must be used within 24-48 hrs.), preserved drops, gels and ointments. The unpreserved drops are more expensive and usually only help the small percentage of people that are really allergic to preservatives. Gels and ointments are normally used at night since regular artificial tears won’t last all night.  Ointments are messy and many people dislike them.  Be sure to try Nature’s Tear’s Eyemist a spray for dry eyes that works for many people. It is available without a prescription.  http://www.naturestears.com/
Tears may need to be used as often as 4-6 times/day.  House brand or generic eye drops may work for the mild forms but moderate or severe OSD usually requires newer brand names.  Omega 3, taken by mouth, has been shown to be helpful. Sources include fish oil (which some people have trouble tolerating), creel oil and flaxseed oil.  Environmental modification means not sleeping under a fan, not blowing air into the face (example in work station, cars, planes) and humidifying home and work and sleep areas during dry winter months.
Some activities aggravate both types of dry eyes because they cause the eye to blink less frequently. These include reading, use of any video screen (computer, iPad, iPhone, video games), watching TV, going to movies.  Discomfort can be helped a great deal by looking away from the screen and focusing on a distant object and blinking forcefully 8-10 times. Do this every 15 minutes during these activities. Because of the increasing amount of time young people are spending on computers/phones/tablets/videogaming there is an epidemic of dry eyes in young people: https://www.nbcnews.com/nightly-news/video/studies-excess-screen-time-could-be-aging-kids-eyes-870691907947  (as an aside young people are also developing impaired hearing at a much younger age due to loud music via headphones/earbuds).
      Warm compresses are often helpful.  Hot washcloths may suffice but a much better way is with re-heatable, eye pads available at any drug store. They are relatively inexpensive and way more efficient that hot washcloths. Follow the directions carefully to prevent damage to the eye. Additional things that can help include a diet rich in fatty fish (e.g. salmon, sardines, etc.). Fish oil taken by mouth usually 2 to 4/day has been show to help some patients. Do not start with this many fish oil/day. Start one per day with a meal and every 2 weeks as another to the amount recommended on the bottle. Ask your physician before beginning fish oil.  In addition, there are non-prescription pills for dry eyes available at most major drug stores or by direct order from the companies. Thera-tears formula for dry eyes is probably the most widely used. You can use any search engine to pull up the websites of the companies that see these.
For people that exhaust all these first and second level treatments, whom are still moderately or severely symptomatic and/or who are using drops 4 or more times/day, they might consider Restasis or Xiidra or the new ultra-effective CEQUA.  These are not artificial tears but prescription eye drops that over a period of 4-6 months: 1. reduce inflammation on the surface of the eye and 2. promote the formation of more efficient, high quality tears.  It is important to realize the commitment one is making when considering these:  1. twice/day for the rest of your life (or until something better comes along) 2. waiting 4-6 months for them to start working 3. expense associated with them (although in the long run may be less expensive than purchasing brand name eye drops to use 4-6 times/day).    You can read about them on their websites:  https://www.restasis.com/  and https://www.xiidra.com/ and https://cequapro.com/?gclid=CjwKCAjw34n5BRA9EiwA2u9k3169FUMQQwVTjsZwdroyvSOl5MOQSIcR6YsPCvBC4Fdo4mFEvAWq9RoCyFEQAvD_BwE
This is sort of a personal testimonial. I do not receive any money from any drug company for anything.  My wife and I have moderately severe dry eyes. I have aqueous deficiency, classic ‘dry eyes” and my wife ‘lipid deficiency’.  When we did not respond to first and second level treatment we went on Restasis. After 3-4 months we saw some improvement and after 6 months were entirely comfortable with only occasional use of artificial tears. Both of us have been on Restasis over 5 years.  There is a way of using Restasis in non-preserved vials that can dramatically reduce the cost. This method does not work with the multi-drop Restasis bottle introduced the past year. We always ask for the non-preserved vials.  Xiidra has not worked well in my experience and I no longer use it.  They are advertising heavily now using Jennifer Aniston as spokesperson. It is not better than Restasis and in the testing phase in some areas was not as good as Restasis. The company is marketing that its full onset comes 4 months after starting drops whereas Restasis is 6 months.:  1. when patients hear how well Restasis did for me and my wife they want to try it. 2. In the few cases I have tried it the patients did not like it and especially 3. when the Xiidra first refill discount cards and samples are exhausted the patients have found it way too expensive.  Cequa is the newest product, twice as concentrated as restasis and has a patented carrier to make it work faster and get deeper into the cornea. It is the product for severe dry eyes. This is the website: https://cequapro.com/?gclid=CjwKCAjw34n5BRA9EiwA2u9k3169FUMQQwVTjsZwdroyvSOl5MOQSIcR6YsPCvBC4Fdo4mFEvAWq9RoCyFEQAvD_BwE
New treatments also include pulsed laser to the surface of the eyelids https://www.reviewofophthalmology.com/article/intense-pulsed-light-for-treating-dry-eye  and heat/compression to the eyelids https://tearscience.com/lipiflow/   I do not have much experience with these but patients treated elsewhere have told me they are quite expensive and may or may not prove helpful.
      If you reach a point of exhausting all the above see an ophthalmologist that specializes in "Cornea and External Disease". This is their special area of expertise. A final new treatment that they can often do is “Autologist Platelete-rich plasma” therapy. This uses eyedrops made out of your blood products. (reference Ocular Surgery News: November 1, 2007 page 46 lead author Jorge Alio MD.
     While dry eyes-ocular surface disorder cannot be cured, it is a chronic problem, is can almost always be helped a great deal. The Eye MD can only do so much and much of the success of treatment is determined by the willingness of the patient to learn about the problem and systematically work towards relief of their symptoms.





Intraocular Lens Dysphotopsia: Defining, Describing & Dealing With In Clinic

Oct 31, 2016 - 1 comments

IOL Dysphotopsias:  Defining, Describing and Dealing with in Clinic  

John F. Doane, MD Discover Vision Centers Refractive News Fall 2016  (Dr. Doane is one of this country's finest refractive/cataract/cornea surgeons and a frequent featured speaker at eye meetings world wide)

Mr. Murphy who coined Murphy’s Law was probably thinking of intraocular lens dysphotopsia complaints when he was developing his treatise on human endeavor – “ Anything that can go wrong – will. “   What a smart-alike!!   With minor joking aside the affected patient with IOL related dysphotpsias can suffer significant visual morbidity and psychological anguish .  I hope in this issue of the Discover Vision Centers’ Refractive Newsletter to share insights on diagnosing, defining and managing patients as effectively as one can that experience unwanted visual symptoms from their elective intraocular lens implant.

Modern phacoemulsification with implantation of an intraocular lens is a marvel of human endeavor yet not perfect.  Just think what our world would be like if this were not the case.  Cataract remains the leading cause of blindness in the undeveloped world.  Medical practitioners likely take for granted the incredible impacts we have on patients’ lives.  Think about some of the crazy things that have been status quo in our lives or are still status quo in some regions of the world.  What about couching of the crystalline lens?  It is certainly barbaric by today’s First World standards.  The incidence of vision loss and possible complete blindness is appalling.  Another issue is the resulting poor vision as most patients do not have spectacles or contact lenses to remedy the aphakic state.   I remind myself of  my grandfather’s cataract surgery.  He was born in 1895 and had ‘ elective ‘ cataract removal without IOL implantation in the 1960’s.  His visual restoration?  Thick aphakic spectacles with marked pin-cushion distortion.  Yikes.   The process took an advancement when aphakic contacts were an alternate option to aphakic spectacles.  In my career I have had a few patients walk-in wearing aphakic spectacles or contact lenses and some of these we have moved to secondary IOL implantation after several decades of aphakic spectacles and contacts.  These are rare occurrences in the 21st Century fortunately for all involved.  With state-of-the-art IOL implantation, as we have discussed previously, we are now trying to hit the ball out-of the-park with toric IOL’s, monovision and presbyopia correcting IOL’s to minimize or completely eliminate  corrective lens wear.  Yet, we have one unexpected side effect of modern IOL design – dysphotopias.

Defining Dysphotopsias

Dysphotopsias after IOL implanation are aberrant optical phenomena that interfere with vision.  There are two distinct types of dysphotopsias: positive and negative.   Positive dysphotopsias are “ light “ phenomenon and include rainbows, streaks, crescents, rings, halos,veiling glare, haze and fog.  Negative dysphotopsias are dark phenomenon and are defined as relative and absolute  scotomas.  The negative dysphotopsia – temporal dark crescent – is the most common dysphotopsia I encounter with patients.  It may be as common as 10 percent of all patients in the first days to weeks after IOL implantation. To date I feel Jack Holladay has described this best in his 2012 article on the topic. 1   The temporal dark arc represents a unique type of scotoma named a penumbra.   Positive dysphotopsias in my experience are much less common but inherently easier to understand and explain to patients.

Halos are most frequent with multifocal or ringed IOL’s and are directly related to the lens design.  They can also be seen with monfocal IOL’s at night if there is residual spherical refractive error.  Halos are not noted during the day but only at night from point sources of light.  Crescents and rings are caused by optic decentration and or tilt.  Waxy vision I believe is best put in the positive dysphotopsia grouping and is seen with multifocal IOL’s and is related to contrast sensitivity mismatch between what the IOL provides and the patient’s perception.

Patient Description.

On postoperative day one patients will typically describe the following two symptoms if any to me.  They will note the temporal crescent negative dysphotopsia.  They may note that they also see a shimmering effect.  I have attributed the latter to either mild movement or shaking of the IOL within the capsular bag or to patient physical movement.  The latter symptom in my experience is transient and as the capsule shrink wraps around the IOL it resolves. .

If a patient has received a multifocal IOL at some point they may note “ waxy vision “ in the first month.  When I hear this I am very concerned as this rarely if ever completely goes away and usually remains problematic.  Patients state that “ yes, I can see small print but everything has soft edges as if wax paper is over the letter “.  

If a patient had ocular trauma before or after IOL implantation the symptoms of a decentered optical system come into play as mentioned above including crescents, streaks and rings.  These are acutely disconcerting and not tolerated by patients.    

Management

An essential part of managing a patient who has a dysphotpsia complaint is to not minimize the report, brush them aside and convey they or their complaint is “ crazy “.   I have seen several patients in consultation that were referred on the brink of suicide.   These extreme cases have involved multifocal dysphotopsias.  Some of these patients have come from several states away and had been told by their surgeon or other surgeons that “ nothing can be done or live with it “.   It has been my experience that all of these patients can be completely cured of their symptoms or markedly improved.  The first step is to tell the patient “ I believe your symptom(s) are real “ and “ let us find the cause and create a solution either with me or someone I know “.

The great news about temporal cresent dysphotopsia is that if you tell patients “ I know exactly what you are describing.  It is uncommon not to notice it early and the good news is resolves for almost everyone.   Holladay states that ~ 2% of patients may still notice this at 1 year postoperatively.   I have yet to operate on a patient due to temporal arc dysphotopsia from a penumbra scotoma.  Multifocal waxy vision “ dysphotopsia “ is another issue.  I tell patients that who are considering a multifocal IOL that 1-2% of these IOL’s will have to be exchanged due to intolerable “ waxy vision “.  98+% of these patients do not notice this symptom and do great.  The remainder after IOL exchange are immensely grateful.  The key point with this complaint is that if it is noted do not be tempted to recommend or perform a posterior capsulotomy.   This makes an IOL exchange a riskier  proposition ( retinal detachment / cystoid macular edema ) and limits IOL possibilities.  For decentered IOL’s they simply have to be remedied be it centering with iris or scleral fixation, anterior chamber IOL or IOL exchangeX.   Lastly, if any of the positive dysphotopsias in scotopic conditions are related to residual refractive error or could be remedied with pupillary constriction by all means prescribe night driving glasses or trial Alphagan p for these patients.  

With proper diagnosis, timely intervention most, if not all, of the visual morbidity from dysphotposias can be resolved and a patient can be happy and productive.


1. Holladay JT, Zhao H, Reisin CR. Negative dysphotopsia: The enigmatic penumbra. J Cataract Refract Surg 2012; 38:1251-65.






Optical Upgrade Technology – What Estimates of Future Use Can Be expected?

Jul 06, 2016 - 0 comments

by John Doane, MD  Discover Vision Centers Kansas City MO & KS.


I wanted to discuss what can be expected with patients regarding refractive “upgrades” in relation to technology offerings.  Before I proceed to refractive corneal or lenticular surgery let us look at others areas of vision care.  If we look at progressive add spectacle lenses (PAL) in 1994 approximately 20% presbyopic prescriptions were PAL.  Today, PAL correction is selected by the majority of the presbyopic population.  Granted some individuals cannot tolerate the optical downsides of PAL technology overtime and with earlier introduction of PAL to the burgeoning presbyope population the acceptance has risen.  Will traditional bifocals ever go to zero?  No, but they will likely decrease.  

What about the treatment of presbyopia with contact lenses.   Multifocal contacts have improved over the last few decades but monovision with contacts is still preferred by more patients than multifocal technology.   This is even more so for the higher add multifocal required by the 50-60 year-old patient.   There remains an issue of quality of vision being still more important than the overall range or quantity of vision.  Will multifocal contact lens technology improve?  Yes, but I think there is a ceiling of patient acceptance due to the downsides.

How about upgrading technology for Laser Vision Correction?  Well, depending on where a patient has laser vision correction there can be a menu of options. For example some clinics will have a standard option where lower order aberrations (sphere and cylinder) are corrected for a price, say $ 1,500 per eye.  If the patient wants wavefront optimized treatment they may pay $ 2,150 per eye and if the patient opts for wavefront customized or guided treatment they may pay $ 2,450 per eye.  Our clinic offers only wavefront corrections for all patients treated.  We have decided by design to provide only our best visual option to all comers.  We do vary price based upon refractive error as there is distinctly more effort provided for the higher corrections.  So, penetration of the market for LVC is not so much based upon an upgrade by our philosophy as it is with patients opting for surgery or staying with their current visual aides.

Lastly, let us discuss upgrades to Toric-correcting and Presbyopia Correcting IOL’s

As a background, it has been 11 years since the “Premium IOL Channel “was legally created in the US.   Prior to May 3, 2005, Medicare and virtually all insurance companies would not allow a patient to pay out-of-pocket to upgrade to IOL technology beyond a spherical monofocal IOL.  I said prior to this time what a complete shame, embarrassment and irony this was.  We have asked America’s finest men and women to go beyond our shores to defend, protect and promote liberty and freedom but their own government would not allow for them to have the best medical devices.  In fact it was against the law for a surgeon to provide these technological breakthroughs to consenting patients.    On May 3, 2005, FDA Ruling No. 05-01 created what is known today as the “premium IOL channel.”  Under this ruling, cataract patients eligible for Medicare can upgrade from a monofocal lens to a premium refractive lens, as long as they are willing to pay the additional cost.  It was a watershed moment in the history of ophthalmology because from this day forward, patients could choose the technologies that were best for them. It also created a new market in which breakthrough technologies and treatments could thrive. Reference, EyeWorld:  http://eyeworld.org/printarticle.php?id=7407;  accessed 2016-5-5 13:58:47

Date published online: September 2014, NEWS & OPINION, Chief medical editor’s corner of the world. It never hurts to have friends in high places; David F. Chang, MD

In this vein, let us look at premium IOL adoption in the US.  Like other choices, and especially one where patients must make a value proposition decision, not all patients will opt for an upgrade.  We can look at the sheer numbers in the US.   In 2015, there were 3,960,000 intraocular lens implants placed.  201, 000 presbyopia correcting IOLs (accommodative and multifocal combined) or 5.1% of all IOL’s implanted were placed.  There were 277,000 toric iol’s implanted or 7.0% of all IOL’s implanted in the US.   The percentage breakdown is similar in other Western Countries.  What could we expect for ultimate goals of penetration for these technologies?  For toric IOL’s the basic numbers one must look at would be what % of eyes have 0.75 D or more of corneal astigmatism.  That number is roughly 35%.  So, 35% of 3.96 million is 1.386 million.   With 277,000 toric IOL’s I would call the penetration best case scenario as 20% of those eligible.  

What about presbyopia correcting IOL’s?  For the sake of argument let us subtract the toric population.  So, 201, 000 of 3,683,000 is 5.4 % penetration.   Does this means that 94.6% of the non-toric population is accepting of presbyopia postop?  Not exactly.   Let us break down our clinic.  I am very “pro” refractive correction, i.e. laser vision correction, monovison for the presbyopes, toric IOL’s, toric IOL’s with monovision, monovision with monofocal IOLs and presbyopia correcting IOLs.  If there was a perfect presbyopia correcting IOL I think monovision would go by the wayside.  Much like monovision with contact lenses still having greater penetration than multifocal contact lenses the same can be said for monovision with monfocal and toric monofocal IOLs than multifocal implant penetration.  Why is this?  First it is tolerated and the quality of vision is excellent with a relatively large near range of vision as compared to a short range of near vision with multifocal technology.  Second, it is less expensive.   For IOL technology there is no cost difference if one targets a monofocal IOL for plano or -1.5 or -2.25.  This is a non-existent financial hurdle for patients.

Will presbyopia correcting IOL penetration increase with time?  I believe so.  The over age 70 population has as a whole been wearing correction for 30 years and they are less apt to spend any extra funds than younger age demographics.  For the under age 40 crowd that gets a cataract and is looking at 3-4 decades of absolute presbyopia they are far more inclined to look at presbyopia correcting technology.  Two very important parts of the puzzle are technology improvements to extended depth of focus IOL’s which will have less unwanted imagery than current multifocal technology and accommodative IOL’s that surpass the status quo technology and secondly the next generation of surgeons and eye specialist that are willing to provide these presbyopia correcting technologies.  This latter variable should not be underappreciated as there is significant work at present to present and follow patients through this process to achieve optimal success.

NOTE: Dr. Doane is a world famous refractive, cornea and cataract surgeon, has authored many scientific papers, books, served as Editor of a medical journal and lectures extensively.  He practices in Kansas CIty MO & KS

Femtosecond Laser Technology Not Add Benefit: American Journal of Ophthalmology May 2016

May 31, 2016 - 1 comments

"So we have FLACS, this new technology that has shown steady improvement and that many support. Yet others feel its advantages are either clinically unimportant or lack convincing clinical studies to support uniform utilization in the face of increased expense and time. While this wave is far from peaking, it would seem that supporters of FLACS are remiss in not providing more robust comparative studies, especially looking at any complication differences in the very difficult cataract categories. Although the jury may be out, I think many cataract surgeons are underwhelmed with FLACS supplanting phaco alone as today's dominant cataract removal procedure. That said, future studies and/or technology advancement may change this view."

Reference:  http://www.ajo.com/article/S0002-9394(16)30063-0/fulltext

What Exactly Does Femtosecond Technology Add to Phacoemulsification Based on Objective Studies To Date?

Randall J. Olsoncorrespondenceemail
Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah