This Blog Will Cure Your Blindness

“I was legally blind before I had LASIK.”

“I can see ten miles away with my glasses on, but without them I’m legally blind.”

“My vision is great; I don’t need glasses or contacts. But you should see my wife’s thick glasses; she must be legally blind!”

NO.

NO NO NO.

memegen

Now, I don’t want to sound belligerent, but we really need to have a dialogue about the definition of “legal blindness.” Its misuse is something that really shouldn’t make me angry, but lately it’s been grinding my gears a little bit. I know, I know; there are better things to be miffed about – the Middle East is still in turmoil, unemployment numbers in the U.S. are still not great, they took away the McRib again – but gosh darn it, the record needs to be set straight. So I’m sorry for my ill-masked disgruntledness. Hopefully by the end of this post I’ll feel more gruntled.

Before we get into the real educational portion of this post, let me first attempt to justify or at least explain my anger (which by the way isn’t really anger, but more like anger’s little brother; I’d like to think that I never get truly angry about anything, except maybe when contestants on Wheel of Fortune buy vowels when they obviously already know that the vowel they’re buying is in the place they expect it to be – like “Well Pat, that word is three letters and starts with a T and an H, I’d like to buy an E.” Those vowels cost you money, dummy! I don’t care if there might be other E’s in the puzzle; it’s the principle of the thing.).

Anyway, my mini-anger. It’s just that I have yet to hear a single person in casual conversation use the term “legal blindness” correctly. Heck, I probably did the same thing before I went to optometry school. But now that I have a blog and a few people actually read it, I’m going to use this chance to give people the knowledge that I never received as a youngster. Frankly, I’m tired of cringing every time I hear one of the statements that I put at the beginning of this post. I guess you could call it a pet peeve. If you’re a patient of mine and you’re guilty of this and have said it in front of me, I hope I concealed my inner pain well enough (just kidding; you know I love you).

On to the definition. The United States government defines “legal blindness” as a visual acuity of 20/200 or worse in the better seeing eye, with best correction, or less than 20 degrees of visual field irrespective of visual acuity. If you need a refresher on how visual acuity works, click here.

Let’s break this down.

Possibly the most important phrase in that definition is “with best correction.” What does this mean? Glasses and contact lenses qualify as vision correction, so your best vision with your glasses or contacts would be your “best correction.” Thus, the statement “I’m legally blind without my glasses” makes no sense, because in order to meet the definition of legal blindness, you have to have poor vision (i.e. worse than 20/200) WITH YOUR GLASSES OR CONTACTS.

To use myself as an example, with my glasses on, I can see 20/20 on a standard visual acuity chart. Without my glasses, I can see about 20/800 (essentially I can see blobs of color. For reference, look at a Monet painting). Despite my awful vision without my glasses on, I am not legally blind. If you have a driver’s license, you are not legally blind.

That’s the long and short of it. If you feel absolutely inclined to portray to another individual just how poor your eyesight is, may I suggest the phrase “figuratively blind?” It may not roll off the tongue as nicely, but it’s much more accurate.

Thanks for reading! I’d continue, but I have an anger management class to attend.

Rod and Cone S01E02

*Back from commercial, the setting is a dimly lit restaurant where Cone is meeting his date, Photon.  The camera zooms in on a table at which a male and female sit, talking and laughing.  The man, Cone, is dressed in a bright red three-piece suit, while the woman, Photon, is dressed all in white with a string of pearls around her neck.*

Cone:  “So then I said, ‘well it’s not Tony Danza under that sheet!’

*Both Cone and Photon laugh loudly, as does the audience.*

Photon:  “Oh James.  Your stories are so outrageous and nonsensical.  You have such a sharp wit!”

Cone:  “Well thanks babe.  You should tell that to my roommate, Rod.  He doesn’t laugh at any of my jokes; always looking on the dark side of things.”

Photon:  “Well, that’s his job, isn’t it?”

*The audience chuckles, but an uncertain air engulfs the studio simultaneously.*

Cone:  “I’m not sure I catch your meaning.”

Photon:  “Allow me to shed some light on the issue.  It’s sort of what I do.  Surely you know that you and Rod, and myself for that matter, are players in a much larger game.”

Cone:  “Well of course, my dear, the game of life is much bigger than us all.  But I’m not sure – ”

Photon:  “No no no, James.  What I mean is that we are, the three of us, representations of a larger construct.”

*Cone, the smile fading from his face, slowly leans forward within whispering distance of his date.  The audience is dead silent.*

Cone:  (whispering) “What are you doing?  We’re not supposed to acknowledge the audience.  The first rule of sitcoms is that you’re not allowed to acknowledge that you’re in a sitcom.”

Photon:  “Oh don’t be silly.  And, you’re still thinking too small.  The audience of which you speak is part of the show of which I speak.  There is another audience for whom the audience of which you are aware is the entertainment.  And we, my friend, are a part of the same entertainment.”

Cone:  “…okay.  Well don’t keep me in the dark then.  What do we represent?  Who is watching us?”

*The audience begins to turn its collective head 180 degrees.*

Photon:  “Let’s start with the basics.  Your name is James Cone, whereas your roommate’s name is Rod Johnson.  Rod and Cone.  Ring a bell?”

Cone:  “You’re losing me.”

Photon:  “Oh come on.  If there’s one part of ocular anatomy everybody knows, it’s rods and cones.  Photoreceptors?  The cells of the eye that make it possible to absorb light and essentially facilitate vision as we know it?”

Cone:  “Sounds familiar.”

Photon:  “Boy, for the character that represents the photoreceptor cell most responsible for sharp, distinctive, detail-oriented vision, you are not very bright.  Maybe a better plot would have been one in which I went on a date with Rod; at least it would make sense that he was left in the dark, given that he represents the photoreceptor cell that allows for good night vision, peripheral vision, and detection of motion.”

Cone:  “Oh…”

Photon:  “Also, as we speak, I’m fulfilling my obligation as a character named for a light particle.  I’m illuminating things for you, no?”

Cone:  “Well, yeah, I guess.”

*Nothing can be heard throughout the studio audience at this point except for a random cough or sniffle.*

Photon:  “I suppose I’ve said too much.  To summarize, we are characters who are being used to illustrate a concept to an audience; we are the tools of education.”

Cone:  “I think I get it now.  But where does the circle close?  If there is an audience that can see this audience, how does the audience twice-removed know that it is not being watched?”

*Photon and Cone smile and look at each other across the table, then turn their heads and make eye contact with you.  Cue commercial break.*

Re:

In answer to my last post regarding writing letters, I have prepared the following as a response to the sample patient letter I composed.  Fellow optometrists, I encourage you to have a stack of these handy so that you’re prepared when a patient hands you the previously typed letter.  I do accept monetary donations.

Dear [patient name],

I appreciate your forethought in preparing the letter you have given me, which outlines your concerns about your eyes.  It takes a person with a large amount of [intelligence, kindness, good looks] to come up with such a well-worded document.  Anyway, let’s talk about your eyes.

You may take this as an indication of your age, but I recommend a [bifocal, trifocal, prosthetic eye].  I know this kind of thing is not good for your vanity, but I’m an optometrist, not Tim Gunn.  We have many different choices in spectacle frames, however, and I’m sure you can find something that makes you look [distinguished, flirty, other adjective]; that is, until your glasses inevitably get [lost, broken, eaten by the dog or vice versa].  In which case it’s probably a good idea to go ahead and buy a second pair as well.  Hey, seeing well and looking good ain’t cheap.

All health-related aspects regarding your eyes look good, although your ocular surface looks a little dry; I recommend [Restasis, artificial tears, looking up when it rains].  Your eyes don’t feel dry, you say?  They actually water all the time and are the exact opposite of dry?  Well, believe it or not, it’s possible that your eyes water because they are dry – this is a common occurence in people with dry eye syndrome; basically the tears your eyes are producing are [not of good quality, not coating your eye properly, crocodile tears].

I did not see any signs of serious ocular diseases such as glaucoma or macular degeneration, although you do you have very early cataracts forming.  Not to worry, as these are generally very slowly progressive and at worst will only cause you to have trouble with [reading, glare, thinking your spouse is attractive (kind of like nature’s beer goggles)].  When the time is right and you feel like your vision is no longer acceptable to the point that you can no longer perform everyday tasks, then we can talk about referring you to the local ophthalmologist’s [office, clinic, van] for cataract extraction.

Oh, I can see as you’re reading this that you have to hold the paper pretty far out from your face; either you are presbyopic or the paper just smells really bad.  If it’s the former, the bifocals I prescribed earlier will help; if it’s the latter, it’s probably because our paper is made from [recycled products, card stock, Soylent Green] kind of like those old Weekly Readers from grade school.  Remember those?  God did those things reek.

In summary, you should be good to go until your next annual eye exam, and I do mean annual, rather than the decade-long gap since the last time you were here.  Speaking of which, you should probably dispose of the trial pair of contact lenses that we gave you at that last visit; they’re probably a little [protein-deposited, worn out, nah nevermind they’re fine].  Call me if you need anything, otherwise I’ll SEE you then!  Haha, eye doctor humor!

Sincerely,

[Doctor’s name]

Aaaaaaaand scene!

To all of you optometrists out there who read this, see if you can get me an honorary Fellowship in the Academy for this great service I have provided you; writing case reports is so overdone.  And besides, what good does yet another case report do?  Either it reinforces previously known treatment protocol or it presents such a rare variation that no one will ever see such a thing again.  (What you’ve just witnessed is me justifying the fact that I’m writing on a blog rather than writing case reports.)

Like any doctor-patient relationship, communication is key.  And nothing communicates how much you care about your patient like a letter typed by a stranger on the internet.  So until next time, keep it real.

Know Your Letters

I’m a big fan of referral letters.  I write letters to other doctors all the time as a service to my patients who have systemic disease which may manifest in their eyes.  I think it’s a good way to keep other healthcare providers in the loop.  I always appreciate reading a progress letter about a referred patient that lets me know how they’re doing.

And then I thought to myself, what if a patient were to write me a letter.  What would it look like?  In that line of thinking, I figured I’d go ahead and whip up a template for all future patients.  I’ve left some fields alterable so you can fill in the blanks as necessary.  Think of it as a healthcare Mad Lib.  Your eye doctor (whether it’s me or not) will (possibly) thank you.

Dear Dr. [optometrist’s surname],

I am concerned that I might have [astigmatism, the glaucoma, hypochondria].  I’ve also been told that I have [migraines, cataracts, carpal tunnel].  During my eye exam today, I would appreciate it if you would address all of these problems including the ones that I will tell you about when the exam is over.

I would also like to renew my contact lenses.  I’m not sure what I’ve been wearing, but I mean who really knows what they put in their eyes, right?  My contacts are supposed to be replaced every [two weeks, month, Olympics], but I’m pretty bad about sticking to a schedule.  I was also wondering about contact lens solutions; I generally use [Opti-Free, something generic, breast milk], is that okay?

Oh, are you going to dilate my pupils today?  The last time I had that done it made me [nauseous, dizzy, dance on the ceiling].  If we could skip that today I’d really appreciate it; I have to [drive, go to work, make a list of excuses to not be dilated], and having my pupils dilated would really make that difficult.  I mean, I’ve heard that the side effects of those dilating drops can include [light sensitivity, impaired near vision, erectile dysfunction] and I really don’t need that right now.

In the event that my glasses don’t work, I hope you have a [return policy, cash-back guarantee, forgiving temperament].  That whole test with the “which is better, one or two” stuff was really tough and I hope you knew what you were doing because my eyes can be really [dry, sensitive, indecisive].  Also, can you show me ‘number 2’ again?  I think you tricked me the first time and that’s the one I’d actually like in my [glasses, contacts, actually nevermind I’d like ‘number 1’].

Anyway, thanks for your time and for helping me to see better.  Oh by the way, I think I forgot to mention that I have [diabetes, sickle-cell anemia, leprosy], but I figured that since you’re only an eye doctor you wouldn’t need to know that. Thanks again and see you in a year!

Sincerely,

[Patient’s name]

Me again.

Hopefully that didn’t seem too snarky.  Basically all you have to do is print this out and circle the pertinent answers; then when you go to your next eye examination just hand it to your optometrist.  Trust me, it’ll save some time and result in a more accurate prescription.

For my optometrist subscribers, I’ll post the appropriate response letter in the weeks to come.  Expect equilateral snark.

Trail of Tears

Are all artificial tears created equal?

This is a question that I imagine many people must ask themselves when they walk down the eyecare aisle at Wal-Mart, or Target, or Jewell-Osco, or Costco (I actually don’t know if Costco has an eyecare aisle, but if they do I like to picture 10-gallon drums of Opti-Free).  I admit, until recently, I couldn’t recall the last time I had ventured down the eyecare aisle; as an eye doctor, I benefit from freebies at work.  But now that I’ve taken the time to wander down that aisle flanked by multicolored boxes of artificial tears and contact lens solutions, I can understand why people feel a little overwhelmed.  It’s a veritable Rainbow of Uncertainty.

It’s a similar experience to those times when the wife tells me to buy her some shampoo; all the bottles look the same to me, so I pick the cheapest one.  Honey, I’m sorry you ended up looking like James Carville.

Did that say “Pantene” or “Paint Thinner?”

So when your eyes are feeling dry and you just want a little relief, how do you pick which artificial tears to use if they all look the same and promise the same things?  Maybe you heard Ben Stein say on TV that Clear Eyes will help.  Or maybe you have a co-worker who swears by Systane.  Or perhaps you read an article online about a woman who poisoned her boyfriend with Visine.  Stay away from Visine.

Luckily for you, you have me.  I’ll admit, I don’t have a strong opinion on a lot of things, but boy-howdy do I have one when it comes to artificial tears.  Stop laughing at me.

First and foremost, I’m a big proponent of looking at ingredients.  Whether I’m buying artificial tears or artficial sweetner, I want to know what’s going in my body.  With eyedrops, the active ingredient you’re mostly likely going to see is the lubricant itself, such as glycerin, polyethylene glycol,  or carboxymethylcellulose.  You may also see a preservative, such as polyquaternium or benzalkonium chloride, listed.  Preservatives can be sort of a mixed bag; they’re good in that they keep bacteria from contaminating the bottle, but they may also be responsible for causing ocular toxicity if used too much, thus defeating the whole purpose of an artificial tear in the first place.  For this reason, I generally prefer a preservative-free drop, such as Theratears, for those times when frequent dosing is necessary.

Exciting stuff, right?

YES THAT IS EXCITING

Another thing to consider, after ingredients, is the specific application of different types of artificial tear.  Some claim to be better for certain types of dry eye, some are better for night time, some give you X-ray vision.  You don’t want to buy the wrong drop at the wrong time.  That is, if you were to pick up some Genteal ocular ointment and put that stuff in while you’re at work, have fun looking at life like it’s a dream sequence for the next 15 minutes – you might as well smear vaseline on your face.  So be careful about the indications on certain products; if there’s a moon and stars on the box, it’s probably not indicated for high noon.

“Okay almighty optometrist,” I can hear you saying to your monitor, “so which artificial tears do you recommend, specifically?”

Well, for your everyday run-of-the-mill mild dryness, I use a lot of Systane Ultra and OptiveSystane Gel and Blink Gel are both good if you like a thicker drop.  For dosing more than four times a day, I use Theratears.  If overnight lubrication is needed, an ointment like Genteal is great.  I try to stay away from Clear Eyes and Visine if possible (and it’s usually possible).

Now you know, and knowing is half the battle.  “What’s the other half of the battle?” you ask?  I…I’m not really sure.  G.I. Joe only ever gave me 50% of the formula for winning the battle.  Let’s say the other half involves artificial tears.  Aaaaaaand we have closure.

The End.

6 Signs You’re a Hypochondriac

Recently I came across this link while checking the headlines of Yahoo news.  Yahoo and other news sites of its ilk have the habit of putting together lists like these for the reading pleasure of anyone with a few minutes of boredom to spare.  You’ve seen them:  topics ranging from “Top 10  Ways to Drop 27 Pounds Before This Episode of Modern Family is Over” or “Best Ways to Train Your Dragon” or “Why Nobody Loves You (It’s Probably Because You Spend All Your Time Reading Lists).”

Lists were better before the internet.

I love a good list as much as the next eye doctor, and as you all know, I’m a big advocate of educating the general public on eye-things.  However, the fields of online journalism (in all of its incarnations) and medicine rarely mix well; in fact they mix about as well as tequila and Pabst Blue Ribbon in your stomach.

A fairly new practice I’ve begun employing when I read these types of “articles” is name-checking the author.  Is the person who wrote this list an expert on the subject at hand?  If they’re not, why am I wasting my time reading this? (Please don’t ask yourself this question as you’re reading this.  Besides, I’m an expert on eyes as well as internet criticism.)

Regarding the above article, I’m sure Paula Spencer Scott is a very nice and knowledgeable person (I Googled her – anyone who can coin a term like Momfidence is okay in my book), yet I can’t help but poke fun at the alarmist tendency of articles like these.  It’s the type of worst-case scenario, sky-is-falling, apocalypse-fearing, hyphenated-phrase internet writing that spawns hypochondriacs.  In that spirit, let’s dissect this with a little ‘he said, she said’ or rather ‘Yahoo says, I say’:

6 EARLY WARNING SIGNS OF VISION LOSS

6. Vision is clear one minute, fuzzy a few hours later

Yahoo says: Diabetic retinopathy.

I say: Dry eye syndrome.  Blink.

5. You’ve had a recent and inexplicable traffic accident

Yahoo says: Glaucoma.

I say: Lead foot.

4. A dark or empty patch at the center of your vision

Yahoo says: Age-related macular degeneration.

I say: Glasses smudge.

3. Your eyelid looks funny

Yahoo says: Skin cancer.

I say: Funny like a clown, here to amuse you?  How is my eyelid funny?  HOW IS MY EYELID FUNNY?

2. A brownish tint to your vision

Yahoo says: Cataracts.

I say: You might be full of-

Nevermind.

1. A flurry of “flashes” and “floaters”

Yahoo says: Impending retinal detachment.

I say: Hallucinations.  You’ve gone off your meds, haven’t you?

In all seriousness, the Yahoo article is correct in that the given symptoms MAY be early signs of a serious eye problem.  That is why you should have annual eye examinations and develop a close relationship with your eye doctor – he might actually be a nice guy who’ll chat with you about the latest episode of Fringe.  Most serious eye diseases can be detected early by your optometrist, who can then initiate treatment and may even prevent you from ever experiencing symptoms in the first place.  On that note, I’ve decided to add one more possible complaint/diagnosis:

0. Your eyes just don’t feel “right”

Yahoo says: Bacterial conjunctivitis.

I say: There might be a worm in your eye.

The Problem is the Solution

One of my earliest memories regarding contact lenses dates way back to grade school when I played on the basketball team (yes, I am mildly athletic).  This was long before I had any aspirations of being an eye doctor; believe it or not I did not exit the womb holding an ophthalmoscope (and my mother thanks me everyday for that).  We were in the middle of a game against a neighboring town when one of the better players on my team froze and covered his right eye with his hand.

“I lost my contact!” I heard him shout to the referee, resulting in an ear-splitting blow of the whistle.

Somebody either lost a contact or there is something VERY interesting on the floor.

The rest of the players on the court froze and all six parents in attendance went dead silent while the half-blinded boy knelt down to look for his lost lens.  It didn’t take long for him to find it, and what he did next is forever frozen in my mind (now that I know better) as one of the most cringe-inducing thoughts in my optometric mind.  You can probably guess what he did with that lens.

Like it was a piece of bubble gum or Pez, he popped it in his mouth and ran to the sidelines while our coach substituted a replacement player.  And after sucking the dirt off that contact lens…yes, he re-inserted it.  In his eye.  Let’s take a time-out while I stop shuddering.

Okay, time-in.

It’s amazing what some people will put in their eyes.  Most of the offenders use questionable methods for cleaning their contacts before inserting them – I’ve actually read stories online of people using Coca-Cola as a solution.  Let’s pause while I think of a good joke for this.

Putting your contacts in Coke: almost as bad as putting them on Lady Gaga.

However, incomprehensible behavior aside, a lot of well-meaning contact lens wearers simply do not know that there is a difference between all of those cleaning/storing/multipurpose/peroxide/no-rub/miracle solutions that they come across in the pharmacy aisle.  I can attest to this fact because I was once among them.  It’s a confusing world out there and I can’t even decide on what to make for dinner, let alone decide between the green box versus the blue one for my contacts.

Let’s look at some of the big players.  There’s Opti-Free (and its many variations including Replenish, Express, and PureMoist), Renu (which also has a couple variations), Complete, Clear Care, Revitalens, Biotrue, and those are just the ones I can think of because I have them in the cabinet down the hall.

To put it bluntly, there’s really only one solution I feel comfortable recommending for ALL patients, and that solution is Clear Care.  I say this because Clear Care is hydrogen peroxide…and that’s it.  No preservatives that may irritate your eyes, no other chemicals that may cause issues, just peroxide.  The only real downfall is that your contact lenses have to soak in it for a MINIMUM of 6 hours, and if you ever make the terrible mistake of putting it directly in your eyes, get ready to mimic Macaulay Culkin in Home Alone…AHHHHHHHHHHHHHH!

Not there’s anything wrong with the other solutions; most of the others will work well for most people.  The only solution I will not recommend is generic, and the primary reason for that is because it’s never the same from year to year; companies basically take bids and the cheapest one wins the generic solution contract for that time period.  It’s like the mystery meat of contact lens solutions – you don’t even know what you’re putting in your eyes.

Do you know what you’re putting in your eyes?

Although I guess that still beats the heck out of using Diet Coke.

Edit from the (relative) future:  Since I’ve written the main text above, apparently there’s been an uproar about the safety of using Clear Care.  One of the things I stress to every single patient I dispense a sample to is that you CANNOT put it directly in your eye.  I demonstrate the red ring on the top of the bottle as well as the red tip and repeat that you CANNOT put it directly in your eye.  As long as you follow instructions, Cleare Care will not burn your eyes.