As an optometrist, I get a lot of questions.  People ask me about their eyes during their exam (of course), but also when I meet strangers on vacation, at the grocery store, or am just hanging out with friends.  Talking about eyes this much, some of the same questions inevitably get asked over and over. So here is one I know you all want answered:  what are those spots you see in your vision sometimes?

First, we need to break down the kind of spots you are seeing.  Remember, this is just a general guideline, so if you are seeing strange visual changes, you should see your doctor to be sure what you are seeing is normal and not a serious medical problem.

• Floaters: Small dark or outlined shapes
•  move when your eyes move
•  most easily seen in bright or white backgrounds
•  can be normal as the vitreous jelly that fills the eye breaks down during our teenage years
• If you see a swarm of new ones at all once, see your doctor immediately as this could be a retinal tear!
• Click here for more info

• Phosphenes: Balls of light that can be seen even when the eyes are closed
• Ever rub your eyes and seen spots afterwards?  These are phosphones.  Mechanical pressure can also cause the retinal photoreceptors inside the eye to trigger.  Since the retina cells only know how to communicate "light" they will respond the same to mechanical pressure as they do to incoming light!
• Stand up to fast and see spots?  This is a type of phosphene resulting from orthostatic hypotension.  Basically with your quick change in positioning, blood flow to the eye was momentarily minimized, causing the eye to see these spots.  Remember, the retina can only say "light" so when the cells are getting less oxygen and nutrients than they need, they only can communicate that issue with a light signal. When blood flow returns to normal levels, the spots go away.  This can also occur if you are about to faint!

  Want to see some interesting art?  Check out this site for work depicting the artist's ocular migraine symptoms!

• Visual Auras: Changing visual phenomenon
•  Commonly described as waterfall motion, kaleidoscope changes, tunneling of vision, or a light that starts in the center and then expands out.  Medically this is termed scintillating scotomas or ocular migraine
• Visual auras typically last around 15 minutes, but can last as long as 2 hours
• Often followed by a migraine headache, but they don't have to be.  It is possible to just get an ocular migraine where only the visual symptoms occur
• Vision will return 100% to normal within 2 hours.  If it does not, see your doctor immediately!
• What's the cause?  Scientists believe a vascular spasm is the cause of these ocular migraines, and remember, when the eye gets blood flow disruption, it can only communicate by processing light.

Hehehe I could't resist myself.  Optometry jokes are always the best.

Ray Ban RB4171 comes in so many colors!  I love this bright yellow/orange, but they also have a great teal.  If you are interested in more subtle options, of course you can also get black or brown, but where's the fun in that?

Maui Jim just does sunglasses right.  If you are looking for the tops in quality and performance, I can't recommend them more.  Their Hawaiian Time frame is my personal favorite this year -- great for someone who likes the look of aviators but has a small face shape that can be easily dwarfed by common aviator shapes on the market!

Prodesign has really stepped their game up this year, and I am so impressed by their men and women's lines for the season.  For the special man in your life, these wood-inspired frames (Zense 7622) are made from biodegradable materials, so not only is the aesthetic so visually appealing, but you are supporting a company who is putting environmental concerns first too.  A win-win.

Doesn't it seem like everyone in blogland has these Karen Walker Super Duper sunglasses?  Maybe I stalk Atlantic-Pacific too much.  Or maybe they are just that universally good.  They literally go with everything, and would like to personally thank Blair Eadie for being such a great advocate for wearing sun protection because she incorporates it into almost all of her looks!

Is there anything more overwhelming than the artificial tear aisle at your drug store or pharmacy?  Take 10 minutes and stake it out if you are curious.  You will see poor lost souls wander up and down in frustration, comparing bottle labels that could be written in a foreign language for all they tell you, and then landing on the familiar: Visine.  Oh no!  Everyone, please let me help you break this terrible cycle of doom.

This time of year, allergies are typically subsiding so the most likely reason that your eyes are red, irritated, itchy, burning, or watery is that they are DRY.  Dryness is prevalent in winter due to the lower humidity in the air, and the drying action of heaters in homes, offices, and cars.  In mild cases of dryness, usually a good rewetting drop is all you need to get your eyes performing back to their normal standards.  But for more persistent and chronic dryness, your doctor's intervention with more aggressive treatment is often required.

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If you are in the mild category, you need to pick the right drop in order to get successful relief.  To aid in your selection, please ask yourself these simple questions to see which drop works best for you:

1) Are your eyes infrequently dry, red, watery, itchy, burning or irritated?  Usually after certain environment exposures (like going for a run in the cold air) or at the end of your day?

• Best Choice:  Moisturizing or Lubricating Artificial Tears
• Examples:  Systane Ultra, Refresh Optive, Blink Tears, Soothe XP, Theratears
• Dosage:  1 drop in both eyes as needed, up to 4 x a day

You can also use all of these over top of contact lenses.

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2) Do you have the above issues, but eye drops usually sting when they hit your eye, or cause any other discomfort after using them?   Do you need to use drops more than 4 times a day for relief of your symptoms? Have you recently had a surgical eye procedure (like LASIK) causing you to have more frequent dryness issues?

• Best Choice:  Preservative Free Artificial Tears 
• Why? Prevents irritation from unwanted preservatives that are toxic to the eye but found in all bottle-stored eye drops
• Examples: Systane Ultra in Vials, Refresh Optive Sensitive, Retaine MGD in individual vials
• Dosage:  1 drop in both eyes as needed, can use as often as you want

3) Do you have crusting of your eyelid, or see white dome-like growths on your eyelid margins near the lash roots? Do your eyes sometimes feel filmy between or after blinking?

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• Best Choice: Lipid Based Artificial Tears 
• Why?  The questions above are aimed at diagnosing Meibomian Gland Dysfunction, the most common cause of dry eye.  Click the link to learn more.
• Examples: Refresh Advanced, Systane Balance, Retaine MGD
• Dosage:  1 drop in both eyes as needed, up to 4 x a day (or more with Retaine MGD since it is preservative free)

• Best Choice: Gel Artificial Tears or Ointments
• Why?  Gel tear drops are thicker, and will last through the night to rehydrate the eye or protect the eye if your eyelids do not close fully.
• Examples: GenTeal, Systane Gel, Refresh Gel or Celluvisc, Blink Gel, Nighttime ointments
• Dosage:  1 drop in both eyes at bedtime

I always love reviewing retinal photos with patients, because so much can be going on inside the eye without ever causing any vision issues!  Here is one such example: that circular deformity at the optic nerve in this photo is a congenital condition called an optic nerve pit.  When the eye is developing in the womb, a structure called the optic vesicle (the precursor to the optic nerve) turns in upon itself to create a channel through the center of the nerve fiber where all of the blood vessels to the eye will eventually pass through.  This grove or hole is the "cup" we often speak of when determining glaucoma risk.  If the optic vesicle doesn't close completely after this fissure or groove is created, an optic pit is formed.  Basically this is a little hole or excavation in the nerve where the tissue didn't close up properly during development. In and of itself, it is typically asymptomatic and will only be found by a doctor examining the child after birth.

Most of the time, an optic pit is harmless -- you may have an enlarged natural blind spot in your field of vision, but most people are not bothered by this (optic pits are usually only in 1 eye).  There is an association with serous retinal detachment, however.  Since the optic pit it is usually located near the macula (central vision area), a detachment in that area can be devastating to vision. Therefore, a person with an optic pit is watched closely for signs of swelling or fluid leakage inside the eye.  If this occurs, laser treatment can minimize the damage if caught early enough and prevent permanent severe vision loss.

Without someone looking, you would never know if you have an optic nerve pit, so make sure you are seen by an eye doctor for routine health care even if you have no vision complaints!

If you wear multifocal contact lenses, you know the pitfalls: vision is often a compromise between clear distance and clear reading, lighting has huge affects on vision quality, and finding a balance between good computer vision versus clear reading vision is often a struggle in higher prescriptions.  Multifocal contact lenses on the market today are leaps and bounds better than their predecessors, but I always counsel my patients on what to expect, because vision won't be as clear as it is through glasses, no matter what power multifocal contact lens we chose.  This is all the function of the lens design, since in a contact lens you are only looking  through the center of the lens, the multiple powers for distance and near must be layered in rings one on top of the other.  That means your brain is processing a distance and a near image at the same time, and having to select the clear image to process.  But luckily, multifocal designs are continuing to improve, and Bausch and Lomb's new design has been a true upgrade to the market!

Via Parameters available +6.00 to -10.00, approved for 30 days extended wear!

The PureVision2 Multifocal uses the company's new thinner silicone hydrogel material, that has also received approval for overnight monthly wear due to its high oxygen transmission (130 dk/t in a -3.00 lens).  It is a monthly disposable contact lens, just like the best soft lens designs on the market.  The design is tailored from the the innovative C-Vue multifocal designs that have found a regular place in my arsenal.  Previous multifocals have a 2 power design: 1 for distance and 1 for near.  The PureVision2 offers a "3-Zone Progressive" design that offers blended distance, computer and reading vision.   The result?  A much stronger reading vision effect without compromising distance clarity to the extent other lenses on the market do!

How to Fit the Lens

I've had this lens in my office for less than a month, so fitting is still a work in progress.  I have had good results with the company's recommendations for fit, so here's a quick break down:

Glasses add up to +1.50D  = Fit both eyes in LOW Add
Glasses add +1.75 or up = Fit both eyes in HIGH Add

My rep recommended letting the lens settle for 10 minutes for best vision results, and I have found that near tends to focus quickly, but it does take a few minutes for best distance vision to come into view for the patient.  You need to give it that focusing time, just like you would an astigmatism contact lens. Trouble shooting? B and L recommends splitting adds if the patient is suffering from blur before over-refracting:

• Low add lenses with near blur?  Bump the non-dominant eye to a high add lens
• High add lenses with distance blur?  Bump the dominant eye down to a low add

Like most multifocals on the market, the PV2 MF doesn't mask astigmatism well.  Apparently up to -1.00D cyl you may be able to get acceptable vision, but past that the results are mediocre.  Still waiting on a good soft contact lens with astigmatism and multifocal correction (keep dreaming right now...).

Liking this lens?  Have any trouble shooting advice or want questions answered?  Please post in the comment section and I will try to help out!

Time to bring out the boots and scarves, everyone.  But one thing not to put away for the winter? Sunglasses are important to protect your eyes year-round.  The UV damage that can occur from direct sun exposure to the eye and sensitive eyelid skin is not season dependent, and if there is snow or ice in your area, don't forget that the reflections off snow can also be harmful for the eyes.  And there is no shortage of great sunglass fashion inspiration out there to take a page from.  Here's some of my winter-highlights so far:

Celine sunglasses with a wool coat via

Olivia Palermo via

Want a little more color in your winter wardrobe?  The new ZEAL line of sunwear is offering great color options with an earth conscious approach to manufacturing.

Zeal Sunglasses offer 100% UV protection, polarization for the sharpest vision, and are also 100% biodegradable

I probably don't need to wax poetic anymore about my love affair with scleral lenses, but click the link if you are interested in why I think they are such a great alternative for irregular cornea patients.  Since I first started fitting sclerals, there has been a major learning curve and the excellent reps at Essilor have really helped me triage difficulties.  My first few fits were a bit like walking in the dark -- no one seemed to be publishing information about sclerals!  Now you have Contact Lens Spectrum devoting almost entire issues to sclerals, and excellent resources at the Scleral Lens Education Society page.  But if anyone wants a cliff notes version of how I fit scleral lenses, here it is:

1) Flatter is Better

The concept of sclerals is that they don't interact at all with the cornea, so there should never be touch.  But a lens that is too steep causes a lot of vision, comfort, and fit problems. There is some debate about just how much vault you want centrally in your lens, but I have been ascribing to the around 250 micron rule with excellent results.  Apparently there may be some settling to the lens after a few hours or days of wear, so it is not a bad idea to check a patient back after dispensing lenses in a few days to see how they are doing (have them wear the contact lens in, and tell them to have had the lens on for at least 3-4 hours before coming).  Not sure what 250 microns looks like?  Don't worry, I don't have microscopic eyes either (or an anterior segment OCT).  The average cornea is around 540 microns, so just aim for a vault that is about half the thickness of the cornea in an optic section beam on your slit lamp.  Works like a charm!

2) Size Matters

When I first started reading about fitting sclerals the theory was that a larger lens is easier to fit.  Well that is true if you have a large cornea, but so many people out there have small/tight eyelids.  A large lens is going to be really difficult to fit in this case!  I like to measure corneal diameter (I never did this at first and it caused me a lot of headaches) with my slit lamp --just turn the beam horizontally and measure width.  If you have a small diameter cornea (anything around 10 mm) then a smaller diameter scleral is a better bet.  Maybe start between 14 to 16 mm in diameter on your lens.  In some cases, the cornea is too small and the lids are too tight to ever make a scleral fit appropriately, so if you are having no luck getting rid of bubbles in this type of fit, I have been advised to abort.  The new toric peripheral curve lenses may help in future.

3) You Do Need a Perfect Fit (or at least really close to perfect if you want optimal lens performance; this means no bubbles, no conjunctival entrapment, and no scleral blanching)

Blanching is Bad via

To me a perfect fit means a nice even tear film under the lens.  Scleral blanching is a huge no-no; check for this by letting the lens sit for 20 minutes in office.  If the lens is too tight, the sclera will be blanched white underneath and result is a ton of discomfort and suction when the person tries to remove their lens.  Small bubbles tend to not worry people much; they may be insertion related.  But I have found bubbles do matter - - even small ones cause poor comfort after a few hours of wear, and can really wreck havoc on vision, even if you think that it is just a little peripheral bubble.  Believe me, you want it gone.  A central bubble means the lens is too steep of course. A reverse geometry design is sometimes necessary to get rid of those pesky mid-peripheral bubbles. Conjunctival entrapment, where the conjunctiva folds over the limbal cornea under the lens, used to be no big deal in the literature.  Now there is evidence that this can cause neovascularization to form in the limbal tissue underneath, where the corneal tissue is being deprived of oxygen under the conj.  Flattening the lens tends to help solve this issue (read here for more details).

4) Poor Comfort?  Check the Edge
The peripheral edge is a major source of lens awareness in this lens.  We spend a lot of time with sclerals looking at the central and mid-peripheral fit, but you need the edge of the lens as flush as possible against the conjunctiva.  If the patient can feel the edge with blink, it is going to be exceedingly uncomfortable.  A great tool in knowing if you have achieved a good fit is by checking the suction when the patient removes their lens with a plunger.  Too steep centrally = a lot of suction.  Too much peripheral edge lift = a lot of suction.  Believe it or not, a properly fit lens will actually have very little suction when the patient removes it properly.  It is a really nice feed back tool for your fit if you don't have the luxury of having an anterior segment OCT.

Oh No!! Another non-wetting lens!  There goes another 2 weeks to order a new lens to check if vision is acceptable or we need another over refraction!  Via

5) Choose the Right Material
Nothing is more annoying than having that perfect fit lens, but the patient can't see out of it because the surface is non-wetting.  In my experience, Tyro 97 is your best material to prevent that non-wetting surface issue.  With that being said, Optimum Comfort is the material my Essilor rep tends to recommend for better comfort, but I have had too many wetting issues with Optimum Comfort to go that route anymore.  Especially if the patient has MGD issues.  Tyro 97 every time for me now.