A non-wetting scleral contact lens via

If you've ever tried driving through a foggy windshield, you know the vision quality is far from ideal (or safe!).  For many contact lens wearers, lens fogging is a daily struggle.  Typically this fog is created by debris from the surface of your own eyes - tear film lipids, proteins, and mucins sticking and smearing on the surface of the contact lens and creating an oily coating.  Blinking just spreads the film around, and typically only removing the lenses and cleaning the surface will improve your vision.  In soft contact lens wearers, the solution to fogging issues is most often changing to daily disposable contact lens materials which maintain clarity due to a fresh, clean surface every day and being made from thinner and more debris repellent materials.  For hard or rigid gas permeable lens wearers, hybrid contact lens wearers, or scleral contact lens wearers, no such solution exists.  Luckily there are several options for improving clarity and busting fog with these lens options too!

Enhancing Rigid Gas Permeable Lenses
When I first started fitting scleral contact lenses, the image above was all too frequent in my exam chair.  Patients would be putting on their first lenses directly from the lab, only to immediately find their vision foggy and distorted.  Non-wetting lenses cause immediate fog issues from the moment of dispense; they look completely normal off the eye, but once on the eye the patient's tear film beads up into non-spreading droplets of tear film on the lens' surface.  There is no way to clean or polish off this nonwetting issue.  The best bet is to reorder the lens with a few pro tips:

1. Call the lens manufacturer to report the issue. 
During the manufacturing process, rigid gas permeable contact lenses are cut on a lathe. For scleral contact lenses especially, this lathing process can expose the lens to excessive heat. Higher temperatures during manufacturing can prevent the lens from being able to properly wet on the eye. The lens manufacturer will make a note when remaking the lens to reduce lathing time in this case.

2. Ask for Plasma Treatment and Wet Shipment.
Plasma treatment is not a coating, but rather a hyper-cleaning technique that removes microscopic debris on the surface of the contact lens after the manufacturing process. Rigid gas permeable (RGP) contact lens plasma treatment involves the blasting of ionized oxygen particles against the surface of the lens in a vacuum chamber.  The oxygen interacts with organic debris on the surface of the contact lens, especially effective against organic lipids and oils.  Right after plasma treatment the lens is as clean as it will ever be!  It is immediately placed in a liquid storage solution (most labs use Boston Simplus) because if the lens is stored dry at this stage, the surface will immediately start collecting debris again. Studies show plasma treatment improves lens wettability and initial patient comfort, and reduces the risk of lens fogging.

How to Care for Plasma-Treated Contact Lenses

If you have plasma treated contact lenses, the best way to maintain this level of surface clarity at home is to use the right RGP lens cleaner. Boston Simplus, Optimum pH, and peroxide based cleaners like CLEAR CARE are all compatible. Do not use abrasive lens surface cleaners like Boston Advance.

3. Talk Materials
Silicone-based materials are very popular in today's contact lens marketplace due to their better breathability, but silicone can make contact lenses more hydrophobic - meaning they collect more debris. Changing to a lens material without silicone or with lower amounts of silicone can help reduce surface build-up issues.

Fluoroperm 60 or 30
For healthy eyes without any evidence of prior scar tissue or oxygen loss (hypoxia) traditional, Fluoroperm is an incredibly debris repellent material!  Fluoroperm 30 is considered an old-school work horse for heave depositing patients, but watch carefully for oxygen issues to the cornea like neovascularization or pannus.  For patients in such low oxygen permeable lenses, changing lenses regularly is important to maintaining corneal health. For most RGP wearers, recommended disposal is 1-2 years to prevent infection or corneal scarring or warpage.

The above patient has pannus (white areas seen temporal and nasal on the cornea) associated with Salzmann's nodular dystrophy. A low oxygen transmissible lens wouldn't be a good option in this patient because it could exacerbate corneal scarring.  via

Tyro 97
For scleral contact lenses that cover more of the eye, Fluoroperm does not offer enough oxygen transmission to be safe.  In this case, Tyro 97 is an excellent option for debris repellent lens material that still provides enough breathability to be safely used in a scleral contact lens fit.

For years this was a go-to lens material, but many patients still experienced surface fogging and debris despite doing all of the above.  Enter the newest lens material of choice for scleral lenses in my clinic: Optimum Extra with Hydra-Peg

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What You Need to Know About Tangible Hydra-PEG
Tangible Hydra-PEG (Tangible Science) is an exciting new coating available across multiple lens materials.  Synergeyes hybrid lens materials and RGP Optimum lens materials are compatible currently, and by the end of 2018 it's expected that Boston materials will be available too. The PEG in Hydra-PEG stands for polyethylene glycol, a lubricant that's been used in artificial tears for decades. The Hydra-PEG coating is permanently bonded to the surface of the contact lens material, encapsulating the core lens material to improve wettability and help prevent surface lens debris.  Multiple studies have shown that the addition of Tangible Hydra-PEG to the lens surface improves both wettability of the lens and lubricity (reduced friction across the surface of the contact lens as you blink).

The addition of Hydra-PEG coating improved wettability and comfort across all lens types, gas permeable, soft silicone hydrogel based lenses, and hybrid contact lenses. via

On-eye studies performed at the University of Iowa also had compelling results.  Existing RGP contact lens wearing patients were refit into lenses with Hydra-PEG coating.  There was no change in visual acuity, but the patients classified before the study as moderate or heavy depositors in their habitual lenses reported clearer vision, better overall comfort, and less haze in their new Hyrda-PEG coated lenses.

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Removing Lenses with Tangible Hydra-PEG
The addition of Tangible Hydra-PEG can cause changes to the handling of the contact lens as well.  Because of the increased lubricity (decreased friction) on the lens' surface, the contact lens becomes more "slippery" after the addition of Tangible Hydra-PEG.  For gas permeable lens wearers, this is not typically an issue because the lenses are removed most often with plungers. But for soft or hybrid contact lens wearers, it might be more difficult to grip the lens between your fingers to remove.

If you are having difficulty removing your Synergeyes hybrid contact lenses with Tangible Hydra-PEG coating, the company recommends using a tissue over your fingers to help get a better grip.


Cleaning Lenses with Tangible Hydra-PEG
Approved lens cleaners for use with Hydra-PEG include Boston Simplus, Unique pH, and CLEAR CARE cleaning and disinfection solution. Do not use alcohol based cleaners as they could damage and strip the coating with time. Alcohol based cleaners like MiraFlow are commonly recommended for patients with heavy depositing issues, but if you switch to a Tangible Hydra-PEG coated contact lens, this solution should be discontinued.

Treating the Root of the Problem
The most common reasons for fogging, debris, and lens wetting issues are because your own tear film's lipids and proteins are smearing up and collecting on the surface of the lens. Many doctors approach fogging as a two-prong attack: changing the lens surface to make it more resistant, and changing your tear film to make it more balanced.  Patients with dry eye and meibomian gland dysfunction (MGD) are at increased risk of lens fogging because their tear film components of mucin and lipids are out of balance.  Restoring the tear film to homeostasis can help decrease the amount of protein, lipid, and debris floating around in your tear film and thus decrease the risk of it causing fogging and debris on the lens surface.

Meibomian gland dysfunction is extremely prevalent! Over 80% of the estimated 20-30 million Americans with dry eye syndrome have meibomian gland disease.  The meibomian glands express the lipid or oily layer of the tear film.

To minimize lens surface issues in patients with MGD, doctors will often advise using a nightly warm massage or Bruder mask to improve gland expression, and cleaning the eyelid margins thoroughly each morning before inserting lenses.  Avenova eyelid cleansing spray or OCuSOFT lid wipes are commonly prescribed options for daily lid hygiene. 

Lotions and Makeup
The products you use around the eyes and face could also contribute to lens fogging!  Before inserting your lenses, make sure you thoroughly wash off any lotions or creams from your hands and finger tips and dry your hands completely on a clean cloth. Makeup and lotions are heavy on oils, which can immediately fog your contact lens if they come in contact.  Insert your lenses before applying any makeup or skin cream to avoid exposure of these oils to the lens surface. And when you do apply eye makeup, make sure you avoid the waterline area!  This is where the delicate meibomian gland openings are located, and any makeup products applied here will be smeared across the surface of your eye and contact lens all day long.

Makeup applied on the waterline (as above) is a major contributor to contact lens discomfort and fogging! via

What's Next
If you've been frustrated by foggy, cloudy contact lenses, there is plenty of hope in sight! Tangible Hydra-PEG coating is continuing to expand to multiple lens materials, and we may even see it commercially applied to standard soft contact lenses in the near future.  Fighting off fog is a constant battle for patients with underlying risk factors like chronic dry eye, so working closely with your doctor to explore all causes and solutions for your particular underlying issues is essential to maintaining clear vision.  The addition of coatings like Tangible Hydra-PEG is truly just the beginning! A recent Review of Optometry article previewed a future where contact lenses are coated with anti-microbial films to reduce the risk of contact lens related infections, of where contact lenses were treated with surface coatings that allow for electro-conduction, turning your contact lens into wearable lens technology that could monitor your health status directly from the surface of your eye.

If you've been diagnosed with dry eye in the last decade, you've likely been recommended fish oil/omega-3 supplements by your doctor.  Multiple studies since the early 2000's had indicated that dietary omega-3 intake was both anti-inflammatory and could improve signs and symptoms of dry eye over the course of a few months. The newly published DREAM study (Dry Eye Assessment and Management Study) funded by the National Institute of Health however is making waves by calling into question prior studies showing omega supplementation's effectiveness. In fact, the DREAM study showed patients with dry eye taking omega-3 supplements achieved no better outcomes than placebo.  The results are raising more questions than answers as doctors try to make sense of the study that was designed to be the largest investigation of omega supplements and dry eye to date.

Recommending omega-3 supplements has been standard of care for dry eye treatment for over a decade, but new research is calling the practice into question. via

With rapid changes in healthcare technology and telemedicine, there's perhaps never been a more important time for optometrists to get involved in local and federal legislative initiatives. Deciding you want to make a difference in changing the course and direction of the profession is a vital first step, but the truth is that getting involved with legislative action can be daunting.  How do you develop a relationship with your local or state representatives?  How do you get your opinions and passion for eyecare and patient advocacy heard?

In 1901 when Minnesota became the first state to recognize and legislate the scope of practice for optometrists, ocular healthcare was quite different than today.  As technology has changed and improved to provide safer, faster, and more efficient healthcare solutions, medical providers have had to learn and adopt this new technology to best serve their patient's needs. That's the basis of continuing education hours to maintain  a medical license after all.  But by 1921 when all states in the US had passed legislation recognizing and defining optometric care, the technology that now exists to treat patients could not have been dreamed of or planned for to be written into those original defining laws.  That is the situation that optometry faces now in 2018 where the legislation written in each state that defines the practice of ocular healthcare is now also limiting how the profession can best serve patients. 

Dr. Joanna Bomkamp Gerhardt training on the YAG Laser at the Southern College of Optometry.  Training for minor surgical and laser procedures is a standard part of optometry school curriculum, but the ability to perform these procedures that were taught in school is legislated state by state.  via

The optometric work force is changing!  Women in Optometry reported last year that 66% of optometry school graduates in 2021 will be female.  Dr. Stephanie Aguilar (above) is one of this new generation of optometrists that will be the first to see the profession switch from male dominated to female dominated.

Dr. Aguilar at her residency graduation

The decision to pursue residency training after completing optometry school can be a difficult one.  Dr. Aguilar knew by her third year in school that it was the right decision for her. "All of the coolest speakers (whether AOA representatives, private practice doctors, etc.) that came to school had done residencies and spoke so highly of the experience. My professors in school also recommended a residency to improve my clinical skills, as well as gain knowledge and experience before going into the workplace. At that time, I was also considering a career in a hospital setting and knew if I wanted to ever do that, a residency was a must."

She has great advice for student ODs that are interested in pursuing a residency of their own. "The best way to prepare for residency applications is to start early. The easiest ways to stand out are to be involved in your school and excel in the areas that your residency is in."  During the interview, be prepared to discuss specifics about your clinical experiences so far, and be personable and conversational throughout the process. "Think of a few clinical scenarios that were significant to you, as this was a common topic of conversation during interviews. As always, be yourself because it’s likely that during your interview you are not only being evaluated on your credentials, but also whether or not your preceptors can stand working with you for a year!"  

Finding the right job out of school or residency is a huge milestone (or hurdle!) in a young optometry career. While Dr. Aguilar had entered her residency considering working in a hospital setting, it was a private practice back in her home town of San Antonio, Texas that became the right fit for her.  Like many great opportunities, networking was the key.  "In my case, who I knew was critical. I found my job through a previous volunteer experience. Every time I came home from optometry school, I would volunteer at the Haven for Hope I Care Clinic that provides eye care for the homeless population in San Antonio. I had a good relationship with the manager at the office. While in Boston, I called her and asked if she knew any doctors hiring in the area. She put me in contact with two doctors, one of them being my place of work now. My advice is to treat everyone with respect because you never know who will help you down the road. Keep your options open, interview with many different offices and always ask for what you deserve in compensation."  With our pay gap as it stands currently in optometry, her words of advice can't be more of a call to action!




Patient care is Dr. Aguilar's true passion, and it hasn't taken long in her young career to see her love for optometry touching lives.  Even after a residency focused on treating and managing ocular disease, it's the simple day to day mission of being an optometrist - helping patients see their best - that has left the biggest impression on her so far.  "The patient encounters that impact me the most are those in which I feel I’ve made an improvement in the patients’ lives. Whether it’s a patient that is successfully fit into multifocal contacts, a child seeing their parents clearly for the first time thanks to new glasses, or a corneal ulcer patient that is healed after two weeks of pain and blurred vision."

The future for young optometrists hold exciting promise, but plenty of challenges as well. "In my opinion the biggest immediate risk to our profession is telemedicine or optometry offices that offer a “comprehensive eye exam”, when in reality it’s someone remotely performing refraction and then reviewing anterior and posterior segment photos."  

"Another risk to our profession is the group mentality that someone else will take care of this problem. In my opinion, all optometrists should support the American Optomteric Association because they work tirelessly to support and improve our profession. Without them, there is no telling where optometry would be and I hope I never to find out. So being a member of the AOA, joining their team or lobbying on optometry’s behalf is advantageous to all of us."



Want to learn more from Dr. Aguilar?  Stay tuned for more articles written by her appearing on the blog, and you can reach out to her for advice or mentorship by email!

Stem cell treatments have promised regenerative cures for many untreatable conditions since the first successful stem cell transplant back in 1956. In the world of eyecare, where damaged retinal tissue results in permanent and uncorrectable vision loss, the prospect of recovering vision with a stem cell therapy is an understandably exciting one. Much excitement surrounded the successful Phase I/II clinical study of injecting stem cells into the eye to treat conditions like Stargardt macular dystrophy and macular degeneration in February 2015.  Of the 18 patients treated with stem cell injections in that study, there were no significant adverse events and 47% of eyes showed either improvement or no worsening in vision over a 2 year period.  But unfortunately these early successes in the field of ocular stem cell injections have led some to take risky approaches to gain financially from the excitement around stem cell treatments and the desperation of patients that are faced with living with permanent vision loss.

Pluripotent stem cells from the California Institute for Regenerative Medicine which is currently doing FDA approved stem cell research for retinitis pigmentosa.

Few cosmetic enhancements seem as desirable as longer lashes in today's beauty marketplace; from prescription serums to fiber mascaras, and false lashes to lash perming, the cosmetic industry is overrun with options for achieving gravity defying eyelashes.  Unfortunately one of the leading reasons why so many products exist for getting longer lashes is that all of the available enhancement options come with a certain risk for ocular surface discomfort and dry eye signs and symptoms. Serums like Latisse can cause redness, irritation, and chronic meibomian gland dysfunction. The preservatives and chemicals in most mascaras are known ocular irritants. And the glue used to apply false eyelashes can cause severe allergic reactions, and increase the risk for styes.  

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Social Media Tip: Tell a story with your social media accounts. Find a way to use the optical frames you want to feature as a larger brand story that says something about the person or lifestyle you want to market to. A picture of a frame on your optical board won't drive much engagement. I love featuring eyewear with other jewelry on my eyedolatry_blog insta account because it tells the story of who I am as a doc: my eyewear is a style statement that I select with as much care as any piece of jewelry I put on each morning.

Getting Started with Influencer Marketing 

Take photos in familiar locations that other social media users will recognize as part of their local community!

Hey, I'm no model, but real people with real imperfections are a beautiful way to make your social media account feel organic and authentic.  The best ads and marketing campaigns don't feel like ads, and as a small business in your local community, creating that local personal touch is essential to standing out from larger corporate chains.

You know you want to win these Via Spiga frames for your own eyewear wardrobe!