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!


[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!


[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.

Glaucoma: Putting the Pieces Together

Disclaimer:  I’ve retooled this post because it’s being published in the local newspaper – thus I’ve toned down the goofball humor; I know, I’m a sell-out.

Ask someone to name an eye disease and one of the answers you’ll hear the most is “glaucoma.”  Everyone’s heard of it, but not many are familiar with the complexity of the disease.  It used to be simple:  if you had an eye pressure above a specified reading, then you had glaucoma, end of story.  Those were the old days of eyecare, and in this age of evidence-based medicine, glaucoma has become more of a chimera than a pitbull.  Nowadays there are many more factors to consider when the diagnosis of glaucoma is explored; so, how exactly is it diagnosed?

First, eye pressure still plays a significant role, and that is why measuring eye pressure is an integral part of any routine eye examination.  Many people associate the feared “air-puff test” with measuring ocular pressure, but today there are a number of different ways to obtain this important reading.  And though ocular pressure is a large part of diagnosing glaucoma, it is not a definitive measure any longer.  That being said, it is unfortunately still the only factor that is treatable.

There was me, that is Alex, and my three droogs, that is Pete, Georgey, and Dr. Smith.

Also of consideration in diagnosing glaucoma is the appearance of the optic nerve.  After all, this is a disease which causes peripheral vision loss secondary to the destruction of nerve fibers.  If enough of these fibers are eliminated, observable changes will be exhibited in the optic nerve itself, which is sort of a bundle of all the nerve fibers of the eye.  Viewing the optic nerve after dilating the eyes  is another significant portion of an eye examination.

Looks like glaucoma is sticking its tongue out at you.

Yet a third piece of the glaucoma puzzle is an evaluation of a patient’s visual fields.  Optometrists and ophthalmologists utilize visual field analyzing technology to essentially map out what a person sees when they are viewing the world.  In glaucoma, telltale defects may appear in the visual field which are indicative that functional changes are occurring due to optic nerve damage.  Usually the results of the visual field test are correlated with the appearance of the optic nerve and thus a diagnosis of glaucoma can be made.

Example of a visual field test printout. And not a normal one.

Recently, more technological advances in eyecare have led to retinal imaging devices which can provide even more information as to changes in the nerve fiber layer of the eye.  Many times these imaging studies can detect glaucoma sooner than it takes for visual field defects to show up, making imaging an invaluable tool in the arsenal of eye doctors.  Once again, the results of this sort of testing must be compared with other findings of the eye examination to properly diagnose the disease.

If there is any good news about glaucoma, it’s that the disease is one of slow progression.  If diagnosed with glaucoma, you will not lose your vision overnight; however, it is likely you will be placed on medication indefinitely since the disease is not curable.  Topical pressure-lowering eyedrops are the mainstay of glaucoma treatment and can drastically slow the destruction of ocular nerve fibers.  Due to its insidious nature, glaucoma is a disease that makes it important for all people to have a regular eye examination.  With early detection, vision loss can be minimized.

End local newspaper section.

I hope that wasn’t too boring.  I find it hard to believe that anyone would read something like that in a newspaper.  Heck, does anyone read the newspaper, period?  I doubt it.  You know what newspapers lack?  Explosions.  People like explosions – like Arnold Schwarzenegger-style explosions.  If your newspaper was called The BOOM Gazette, I’d read it.

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?


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.

The Stigma of Astigmatism

Dear Diary,

I’m giving up.

I can’t take it anymore.

For as long as I can remember I’ve been misunderstood.  I get blamed for things that aren’t my fault, most people don’t know anything about me, and I’m never spoken of in a positive light.

I mean, for starters, most people seem to think that I can cause irreparable damage to their vision, and that’s a dirty lie!  If only they knew how prevalent I am and all of the different types of vision correction that can make me pretty much unnoticeable.  Glasses, contacts, laser surgery.  And yet they still say that I have an effect on their vision!  Dude, your LASIK surgeon obliterated me when you had your procedure – if you still can’t see clearly, then it’s not me, it’s you.  Maybe you need laser BRAIN surgery HAHAHA.

I’m sorry Diary, that was crude.

But darnit, it’s just so FRUSTRATING.  I’ve never purposefully done anything to hurt anybody.  I mean I guess there was that one guy in Minnesota who slid off the road because he couldn’t clearly see the patch of ice ahead of him.  Or the lady from San Francisco who was injured in that car accident because she was squinting to see a billboard.  But that’s not MY fault.  I mean it is, but it isn’t.  I don’t deserve this.

Two foci are better than one!

To make things worse, all those eye doctors explain what I am in the same way.  It’s always “your eye is like a football not a baseball.”  What the heck is that supposed to mean?  Personally I’ve never seen a person in side-profile whose eye jutted out from their head like the cone of Madonna’s bra.  A football?  Really?  Let’s call a spade a spade:  all I am is a difference in the steepness of the cornea; that’s it.  Kind of like if you held a balloon and gently squashed it between your hands – in one direction the curvature of the balloon would be steeper than in the other direction.

But NooOOooOOoo, I’m a football.  Most people are pear-shaped or apple-shaped, but I’m a pigskin.


And then there are those people that say they can FEEL me.  Really?  I’m a microscopic change in steepness in your cornea and you can FEEL me?  Maybe your eyes are dry, or you have allergies, or you have some other foreign body in your eye, but your astigmatism is not something you can feel!  Does anyone ever think about how I FEEL?  It’s depressing to be thought of as a blinding eye disease when all that’s really needed are glasses.

Diary, I know I’m complaining a lot today.  I guess I should just be thankful that so many people know me.  What I need is a good PR campaign to put a positive spin on things.  Like a catchy slogan or something.  Let’s do some brainstorming, Diary.

Astigmatism:  It’ll Make You A Sandwich.

Astigmatism:  It Won’t Get Mad When Your Dog Poops on the Sidewalk.

Astigmatism:  At Least It’s Not Dysentery.

Astigmatism:  It Doesn’t Think Twilight is the Epitome of Fiction, But It Won’t Judge You if You Do.

Astigmatism:  It’s a Party in Your Eye!

Any other ideas?

Eyes Like to Move It Move It

By the end of this post you will know how to beat a field sobriety test.


You’ve heard that the eyes are windows to the soul, but they can also be windows to your blood alcohol content. Police officers, just by looking at your eyes, can tell if you have had one too many Natty Lights (or Milwaukee’s Best, whichever is your drink of choice). Most of this detection comes down to eye movements, of which there are several different types.

I’m either going to test your eye movements or erase your memory.

EYE MOVEMENT TYPE #1: Smooth Pursuits

Smooth pursuits (which, to me, sounds like a buddy-cop show from the 70’s) are the eye movements we use to follow moving objects; they are just what they say they are: smooth movements used to pursue visual targets. For a very unexciting illustration, hold your finger out in front of your face and watch it as you move it from side to side. Go ahead, do it; I’ll wait…

…You’re not really doing it are you?

It’s okay, you get the point. So this is the type of eye movement that police officers use to determine whether or not you’re fit to drive (and let’s face it: you’re not). They actually look for a very specific aspect of the smooth pursuit which throws up a red flag that you’re buzzing, and we’ll get to that a little later. Suspense!


Saccades, as opposed to smooth pursuits, are jerky movements (they might steal your lunch money or egg your car; the jerks). That is, saccades allow your eyes to jump back and forth from target to target, and they are voluntary. In face, you’re performing saccades right now as you read this, your eyes jumping from word to word. Look at you go!


Eye movement types 1 and 2 are both examples of eye movements in which the right and left eye move in the same direction. Conversely, vergences are eye movements in which the eyes move in opposite directions, either towards or away from each other. This most often occurs when you look from something that’s close to you to something that’s far away, or vice versa. When you’re looking up-close, your eyes converge. When you look far away, they diverge.

And, just in case you thought eye movements was a boring subject (how could you EVER think that?) then check this out. To summarize the article, people who are victims of “locked-in syndrome,” which is a disorder in which a person is fully conscious but unable to move, can actually communicate through eye movements using state-of-the-art technology. I’ve seen enough Twilight Zone and Outer Limits episodes to know just how terrifying “locked-in syndrome” can be, and if there’s something out there than could potentially spare patients that horror, then yay.

Oh, and I guess I need to fire the Chekov’s gun that I loaded at the beginning of all this. I’ll come clean, I honestly don’t know how to beat a field sobriety test; however, I can tell you specifically what police officer’s look for in your eye movements.

First and foremost, they look for a lack of smooth pursuits; that is, jerkiness in your eye movements. Second, they look for a specific disruption in your smooth pursuits when you are looking in an extreme sideways direction. It’s called end-point nystagmus. Essentially your eyes start to bounce back and forth, like they’re at a rave.  Unfortunately, these things are involuntary so you can’t control them even if you want to.

Sorry.  Stay thirsty my friends.

Let’s Get Superficial

Optometry has the unique distinction of being a profession that encompasses both medical care and fashion (although I guess you could include podiatry in this category; those big metal orthopedic boots are pretty chic).  In honor of the more superficial side of my chosen occupation, I thought it’d be fun to explore some of the more memorable trend-setting styles in eyewear and the people who have made them famous.  That’s right, get ready for

Apertis Oculis:  FASHION EDITION

Kicking things off in our retrospective of fashionable face-wear is a fairly recent entry in the Great Gallery of Glasses.  Her politics may be controversial, but her fashion sense is not.  Just four short years ago she single-handedly ignited a trend in eyewear that had opticians everywhere scratching their heads trying to find “Sarah’s frames.”  Nowadays rimless/drillmount frames are definitely in, and it’s hard to dispute that she played a big part in their popularity.  Of course I speak of Sarah Palin:

Even grizzly moms can be near-sighted.

Say what you will about her social views, the woman can rock a pair of spectacles.

Next up is a look that’s been championed by many a celebrity, so it’s sort of hard to trace it back to its roots.  Personally, I think of them as “Buddy Holly glasses.”  They’re the thick plastic dark/black specs that make it easy to identify nerds everywhere.  They’re plastic, they’re sturdy, and if you sit on them, they’re cheap to replace.

Musicians wear them.

Modern musicians wear them.

Actors wear them.

Screenwriters/directors wear them.

And then there are some people with their own sense of style.  You can see it in their clothing, you can see it in the things they create, and sometimes you can see it on their face.  Well, in this case, you can definitely see it on his face.  He hasn’t exactly started a trend with his eyewear, but no list of fashionable glasses would be complete without a mention of the man who waved goodbye to the Yellow Brick Road, the Crocodile Rocker, the Piano Man (…no wait, the OTHER Piano Man)…Sir Elton John.

Now that guy has style.  Or something.


This one has sort of flown under the radar, but is becoming iconic nonetheless.  Sometimes fashion takes a backseat to functionality, but at the same time functionality can breed fashion (philosophical, no?).  Now I’m not claiming that the following design of spectacles is going to start a trend (although hipsters have done stranger things), but I can say with 100% honesty that when I turn 50 I will be rocking these glasses, with the utmost capacity that they can possibly be rocked.  I give you Walter White:

Anti-reflective coating, Transitions, and morality are optional.

It’s not flashy, it’s not ground-breaking, but when you have to throw on a gas-mask and cook some meth, it gets the job done.  Legal note: the author of this blog does not condone the cooking of meth, no matter what kind of glasses you’re wearing.

That rounds out some of my personal favorites.  I’m sure within the next year or two, some celebrity or political figure or television character will show up on the scene with a never-before-seen style of eyewear, and we’ll all be drooling over them and trying to find where we can get our own.  Just remember that glasses only improve your eyesight if your peepers work properly, so get an annual eye exam.

See what I did there?