CooperVision continues to streamline their portfolio of available contact lens products by dropping older low oxygen permeable hydrogel lenses in favor of newer technology.  Beginning in April, here are the changes in product availability:

Discontinued Trials, Boxes still Available
No trials means that doctors cannot start new fits for this lens, and they cannot order replacements for lost or torn lenses.  Usually discontinuing trials is a precursor to discontinuing the lens itself as a way to pull it off the market less abruptly.

• Biomedics XC (also called UltraFlex XC)  

• Frequency 55 Toric 

Red eye? Time to see your eye doctor via

It's that time of year again -- red eye time of year.  For every red eye patient that comes through the door I have a differential list going of 3 most likely suspects.

1) Do they wear multiple wear contact lenses?  Corneal ulcer is my first thought until I see otherwise

2) Do they itch?  Allergies and itching are almost always hand in hand

3) Is there crusting?  Viral conjunctivitis or pink eye as it is commonly called is so prevalent this time of year because of the number of viral colds going around.  Plus with back to school time, being around children is a really common infection source.  That means parents and teachers are at higher risk of coming to my office with a viral infection.

The reason that it is so important to see an eye doctor for a red eye is that your primary care doctor does not have the equipment to differentiate any of the above.  And the treatments for each of the above issues are vastly different!  You need a high powered ocular microscope to find a corneal ulcer (unless it is visible just looking at the person, in which case we are in a very emergent situation where there will almost certainly be permanent vision loss).  But the most important thing that is necessary when determining is this virus, allergies, or bacteria is a close microscopic evaluation of the under eyelid (tarsal) conjunctiva. Viruses typically have a follicular reaction in the conjunctiva, and bacteria and allergies classically have papillary reactions. Without a microscope, seeing this subtle difference is impossible.

Differentiating Papillae from Follicles

Papillary Reaction

A great example of papillae via

Giant Papillary Conjunctivitis -- Due the the chronic nature of inflammation, the papillary reaction is larger as the areas of irritation expand into each other.

Bacterial infections are very rare by comparison, so the most likely culprit when I see papillae under the eyelid is allergies.  Papillae are signs of chronic irritation, where the conjunctival tissue has become elevated and swollen due to repeated exposure to an irritant.  There are two important distinctions that are hallmark signs of papillae:

1. Red Center =  Papillae are elevations of the vascular conjuncitval tissue so there will be a red central vascular core to the lesions
2. Distinct Elvations = The conjucntival tissue has fibrous connections that limit the size and expanse of swelling.  This means distinct, well separated bumps in the papillary reaction.  The only time this logic doesn't fully apply is when the inflammation has been around for so long that the bumps begin to coalesce, creating the large cobblestone appearance we associate with giant papillary conjunctivitis.

Follicular Reactions

Follicular reaction via

While papillae are consistent with a local irritation, follicles are a sign of an immune reaction in the area.  This finding is almost always an indication of a viral infection of the eye.  Follicles have a larger appearance than papillae, and have a white central core since they are really accumulations of cellular level inflammatory agents -- lymphocytes, lymphoblasts, and macrophages if you remember your microbiology.   The big tell-tale sign of follicles are:

1. White Center = look for that inflammatory matter filling the center of the bump

Take Home

Having a hard time seeing the difference?  That's understandable because it takes doctors that are trained in this numerous patient encounters to develop a quick sense of which is which, and there are still some reactions that have questionable appearances with characteristics of both.  My real take home for any non-OD readers of this post is that a red eye takes a specialist to properly diagnose. The tell-tale anatomy is so nuanced, it is impossible to see without the proper equipment.  So please, see your eye care provider for any eye care needs so that you get the proper treatment without delay.

Somewhere in the distance a bone chilling screech breaks the silence of the exam room.  "You mean, I can't wear my contact lenses at all?  For an entire week?"  If you are a contact lens wearer, nothing chills the heart more than hearing the dreaded words: "you have to wear your glasses."

It's finally spring!  I know this fact is a blessing to me since I hate being cold, but for many Americans the transition into spring means untold suffering.  In my area, allergies are a way of life.  By the second week in March my car was permanently covered in a disgusting yellow dusting and my chair was filled with patient after patient with the first flare up of their seasonal ocular allergies.  How do you know if your irritation and discomfort is an allergic reaction? Let's discuss--

Redness, watering, and swelling of the conjunctiva are classic

SYMPTOMS
Itching. Itching.  And itching.  Your eyes may look red, water or feel dry, or you may experience a foreign body sensation, but itching is universal with allergies.  Contact lenses will feel uncomfortable and my patients complain that their lenses feel "dirty."  Mucus debris will deposit on the lenses and you may get some mucus discharge as well. Children often have a hard time telling you what they are feeling, so watch out for eye rubbing.  

SIGNS
The most classic sign I look for are called papillae: red elevations that form from inflammation of the conjunctiva (the tissue that lines the inner eyelid).  Papillae can be different shape and sizes, but they always mean allergy.  Other major signs of allergy are redness (called hyperemia) and swelling (called chemosis).

Fine papillae have red vascular cores.  Even though they are small, the number of papillae in this photo indicates a severe allergic reaction.  Photo from andrewgasson.co.uk

Large cobblestone papillae are found more often in children who suffer from a severe type of allergy called "vernal conjunctivitis".  Frequent eye rubbing is the first tip off!

TREATMENTS

• For mild cases, artificial tears may be enough.  Best for temporary relief for mild itching.

• For moderate cases where papillae are are lot less severe than the two photos above, I like to use anti-histamine/mast cell stabilizer combinations.  There are numerous over the counter drops, but my favorites are Zaditor and Alaway.  Prescription drops are much more effective, with common once daily drops including Pataday and Lastacaft.  They provide relief from itching within 5 minutes of instilling the drop

• Severe cases where there is substantial swelling, large papillary reaction, and marked discomfort, I like to also use a low strength steroid.  My favorite is Alrex, which can be used safely without risk of an intraocular pressure spike.  On really resistant cases, I have used FML or Lotemax ointment (steroid ointments) that can be applied under the eyelid to reduce swelling.

HOW TO PREVENT YOUR ALLERGIC REACTION FROM GETTING SEVERE
If you have undergone allergy testing or know certain irritants that really set off your symptoms, you can track their arrival in your area at pollen.com .  Plan ahead and start using drops as soon as you know symptoms should be forthcoming.  The drops work best when they have a few days to get into your system.  Mast cells in your body release histamine, which is the culprit behind your allergy reaction.  Any drop with a mast cell stabilizer will prevent this release of histamine, but if you start taking the drop after the histamine is released, the mast cell stabilizer isn't effective!

How often do you throw away your contact lenses?  It is amazing the responses you can get on this simple question.  As an optometrist, I have had patients that have been wearing their same trial pair of contact lenses they were dispensed at an exam 2 years ago.  Most people aren't that daring, but it is not uncommon to have people wearing lenses for months longer than FDA guidelines recommend.  And most patients are very defensive  about just how often they are throwing their lenses away.  Why do I recommend following FDA guidelines for proper contact lens disposal?  Here are 5 very real complications that I treat on a regular basis that are a result of improper contact lens wear.

New blood vessel growth is not a good thing when it means opacification of what should be clear tissue!  Picture via optometric.com

A cornea with significant scarring and neovascularization

  Treatment = Change to more oxygen permeable contact lenses or daily wear. If severe enough, contact lens wear may have to be discontinued permanently.

Acute red eye, usually after sleeping in contact lenses is classic for CLARE

A Bacterial Ulcer: definitely something you do NOT want