The Path of Least Resistance

Over the past few weeks I've had some distressing discussions and experiences at my new office, Highstreet Eyecare, in Abbotsford BC (shameless self promotion). These incidents are what compelled me back to my blog today.

I'll refer to one specific phone conversation which, I think, fairly represents the other similar situations as well.

A very pleasant young lady (in her mid-20's) called the office with some questions about her vision. I'll briefly summarize the conversation...
--
Young lady: I've noticed some changes in my vision. I can't see as well with my glasses on anymore. I recently went back to the place where I usually buy my glasses. They did an eye exam and said they couldn't get my vision to 20/20.

Me: Do you know if  it was an optometrist who did the exam?

YL: I'm not sure. What's the difference between an optometrist and the people I get my glasses from?

Me: (I proceeded to explain the differences between optometrists, ophthalmologists, and opticians. I explained how they are all different from the many random optical stores that have no accreditation what so ever. I also compared a complete eye exam, which includes a thorough assessment of ocular health as well as a refraction for a glasses prescription, and vision testing, which is essentially the automated refraction many unaccredited places will conduct unlawfully refer to as an eye exam.)

YL: Oh, I didn't know any of that. They just checked my vision and said the new glasses would make my vision better.

Me: (I explained again all the different things we would examine to determine her prescription and rule out any underlying conditions that could be limiting her vision)

YL: Ok. I'll see...
--

You'll see??? If I'm not mistaken, isn't that exactly what you're having trouble with right now... Seeing?!
Ok, I didn't say that. I can be a little sarcastic and condescending sometimes, but I'm not mean. Especially not to my patients.

These types of conversations bring to light many different concerns. A few of which I will try to address here.

But first, lets time a quick step back... way back... back into time... (Blackstreet reference... anyone?)

A few years ago, when I had first started practicing optometry, I wrote multiple blogs about the impending changes that my profession was about to endure. Changes that were brought on by crony politicians, whose only concern was to fill their pockets with little regard for the public, whom they were elected to serve (I'll try not to name any names... but, lets just say it was a certain "Health Minister"... who's name may or may not start with Kevin... and end with Falcon...). These were changes which ultimately contributed to the lowering of health care standards in British Columbia. And they were changes which led to the fall of a childhood hero from his perch upon a pedestal... I'll never look at Trevor Linden the same way again. But, I digress...

Today, ONLY in British Columbia, a person can walk into any store operated by any individual with absolutely zero credentials and no experience in eye care to buy glasses or contact lenses without a valid prescription. I think that makes it hard to disagree that our standards of health care, at least eye care, are lower than those of any other place in North America.

The Health Minister defended himself by saying that the average individual who has healthy eyes should not have to bother with regular exams and those who do have eye conditions will simply know to have their eyes checked regularly. So much for preventative care. I wonder if Mr. Falcon would be so kind as to describe the symptoms of the early stages of glaucoma, a disease which is one of the leading causes of blindness and affects tens of millions of people worldwide... Oh that's right, there aren't any! It is a silent disease. By the time a patient notices the symptoms, there has already been irreparable, irreversible damage. But I'm sure the average person would somehow know, right?

There is also supposed to be a regulation which, loosely translated, states that if an optical store cannot improve a person's vision to 20/20 or sees any reason for concern, they must send that patient over to an optometrist or ophthalmologist for further testing. Clearly, in the case of the young lady in the above conversation (and many others), they have not been doing that. Which means there are a lot of people walking around with a lower quality vision than they deserve AND, more importantly, potentially suffering from a vision threatening condition.

So, what needs to be done?

I've spent a lot of time pointing fingers at different people for tearing down the foundations of our health care. And there definitely are a lot people who are responsible for the failure of our system. Yes, the big companies and the crony politicians play their part. And they play it well. But, it is important to understand that WE must also bear some responsibility. By we, I mean both health care providers AND the public. It is absolutely my responsibility as a health professional to educate my patients and the public about their health. If I don't do it, then who else will? But, it is also the responsibility of the individual to actively seek out what is best for them. To ask questions, get regular exams, and do what ever else necessary to keep yourself healthy. If you don't, who else will?

Too often, I hear patients say "I've had issues for a long time, but I kept putting it off". As terrible as it sounds, I can understand, I can relate. We build routines for ourselves and follow them, often blindly (pardon the pun). Call it complacency, laziness, or anything else... We put important things off because it means going out of our way or changing our schedule.

Our bodies are made up, at the most basic level, of cells and nerves and chemical reactions. All of which are following the path of least resistance. So it is only human nature that we do what is easiest for us, to follow the simple route. But on our highest level, we are able to make the decisions about what's best for us. And I urge you, when it comes to your health, whether its your eyes or your teeth or your heart, take the time to get it done. And get it done right.


Thanks for reading. Please feel free to leave comments or questions. I'm always happy to discuss!

 

What Parents Should Not Do: An Eye Doctor's Perspective

I was initially going to break this topic into multiple segments. Each would described my experience with a different young patient (and his or her parents). Instead, to my surprise, I recently encountered a 6 year old boy whose mother unfortunately embodied all of the poor tendencies that doctors try their hardest to discourage.

To maintain the annonymity of this dynamic duo, let's call the boy John and his mother Jane.

Jane brought John in for his eye exam and mentioned that he had (not so recently) lost his glasses and may need another pair.

As I entered the exam room, I immediately noticed that, while he fiddled with all of my instruments as his mother sat idle, little John's left eye had an outward turn (aka Exotropia). I took my seat and asked Jane about the eye turn. She responded very casually with "Oh yes, his dad and his older brother both have the same thing. Its no big deal." No big deal?? I controlled my initial urge to scold this mother of two and I politely suggested to Jane that this is something we will need to discuss at the end of the exam.

Next came the refraction. Trying to determine John's glasses prescription was about as easy as teaching my dad how to use the bluetooth function on his phone (not easy). Both tasks required a lot of patience and reiteration of instructions. At the end of it all, I was able to improve John's vision with a prescription that involved a lot of astigmatism, but he still was not seeing as well as I would have liked. Especially with the left eye.

While we normally aim to have our patients seeing 20/20 with both eyes, John was only seeing 20/40 with the right eye and 20/60 with the left.

What we are seeing here is the development of  amblyopia, or a lazy eye. Basically, if the brain is receiving a blurry image or double vision, it will start to shut the blurry (or turned eye) off in an effort to make vision more comfortable.

This process occurs at a young age. In fact, after the age of 8 it is very difficult to recover the quality of vision that is lost. And the older the patient gets, the harder it is. Eventually, no amount of glasses, contacts, or lasers will help. From this point on, it is a problem with the brain and not the eyes.

In John's case, because of the high prescription in both eyes, he is at risk of both eyes becoming lazy.

Luckily he is still young and with aggressive therapy, I am confident that most, if not all, of his vision can be recovered.

But what is required? The first step is a pair of glasses with the full prescription worn every waking moment of the day. The second, is the use of a patch. It is worn over the right eye (the one that is not turned) for a certain number of hours a day to force the left eye back into action. If the eye turn is not resolving, surgery to help straighten the eye is a possibilty.

After discussing all of this with Jane, she conceded that she was provided most of this information by another optometrist a couple of years earlier. In fact, that eye doctor had also scheduled a follow up visit a couple of months after the initial exam. But, since her older son and husband have similar problems and are "doing fine", she figured that it was "no big deal" and didn't follow up. I was really beginning to lose my patience with Jane's nonchalant attitude towards her young son's vision.

After all of the things I had just finished explaining to her, Jane asked if it was ok not to get the glasses yet. She was hoping to let John decide when he was older if he wanted to wear glasses or get laser surgery. That way she didn't feel like she was forcing it on him. What??

NO THAT IS NOT OK. AND IT IS A BIG DEAL!

When your child's vision is at stake, its a big deal. When his aptitude to read and learn is affected, its a big deal. When his ability to see and experience the world is degraded, its a big deal! How could anything be more important???

While Jane is an extreme example, there are a lot of people who exhibit this type of behaviour to a lesser degree. For as long as I can remember, as a student and now as a doctor, I have watched far too many people carry a complacent disposition regarding their health. Too often, I've heard people say "its no big deal" or "it'll get better". I'm guilty of it myself. But, if there is one situation in which I can't ever imagine having that kind of attitude, it is when a child's health is in question.

In British Columbia, annual eye exams are free for all children under the age of 19. If there's one thing our government is doing right, this is it.

So bring your kids in. We'll be happy to see them :)

Lazy Eye

"Contrary to what some believe, a lazy eye is not one that doesn't like to wake up and go to work in the morning."
- Anonymous Eye Doctor with a sense of humour

The medical term for Lazy Eye is Amblyopia

So why do eyes become lazy?

• The brain is very picky! When it is not receiving a clear image or if it is receiving double images, it begins to shut off connections to the eye that is causing it the most grief
• This process usually happens during childhood and if it is caught before the age of 7, it can be reversed depending on how bad the situation is and how cooperative the patient is

There are two main situations in which this happens:

• Eye turn
• In this case, the patient probably has double vision so the brain will stop communicating with the eye that is turned in/out, which will stop the double vision
• Sometimes surgery is needed to straighten the turned eye, other times simple wearing a patch over the good eye will help force the turned eye back
• Difference in prescription
• If there is a large difference and one eye is very blurry, the brain will again shut it off because it doesn't like dealing with two eyes producing different images
• Glasses are the obvious answer. Sometimes a patch over the good eye will help force the blurry eye to work harder

As you can see a Lazy Eye problem actually becomes more of a Picky Brain problem.

And as the saying goes, "you can't teach an old dog new tricks".

So, once the brain has made all the connections it wants to make, it is very difficult to make it go back. This is why it is important to catch it early! (Before age 7 or 8)

After this cutoff, even providing a patient their full prescription may not improve their vision because no matter how clear the image is, it is not being sent to the brain.


FAQ:
Q: Can a person have 2 lazy eyes?
A: That is a fantastic question! And, yes. I recently blogged about a patient I had seen who had high astigmatism in both eyes. So the connections for both eyes were not fully formed during childhood due to blurry vision and at this point in her life, glasses did not help very much.

Q: What is astigmatism?
A: The answer to this can be found in am earlier post called "All Kinds of Blurry" along with info on other causes of blurry vision

Q: How early should kids have their eyes checked?
A: Both the Canadian and American Association of Optometrists recommend that children have their first eye exam at 6-12 months and again at age 3.

Thanks for reading. I hope this information was helpful. Please feel free to send me any questions or comments. And also pass this on to anyone who may find it useful.

The Dreaded Air Puff Test

Almost everyone who has seen an Optometrist recently has had to endure the excruciating agony of a "gentle puff of air" to their eyes. But why?!

• Purpose:
• A screening test for glaucoma
• Measures the pressure inside your eyeball
• Increased pressure inside the eye can lead to glaucoma

• Technical term for the air puff is Non-Contact Tonometry

FAQ:
Q: Does it make a difference if I'm a fidgety Nancy? And is there an alternative test?
A: Yes and yes, Nancy! Movement can affect results. The alternative involves a drop of anesthetic and small plastic probe touching the front of your eye. This is actually the most accurate method.

Q: What is a normal pressure reading?
A: The normal range is 10 to 20

Q: What is Glaucoma?
A: Damage to the Optic Nerve often due to high pressure inside the eye compressing nerve fibers. Causes vision loss, usually starting with peripheral vision.

Q: How do I know if I have Glaucoma?
A: It is important to know the risk factors: age over 50, family history, and high intra-ocular pressure. But the only way to know is to visit your eye doctor.

Questions and comments are always welcome. Please feel free to forward this information to anyone who may find it useful.

Color Blindness

• Most people have heard of Rods and Cones in our eyes

• Cones are for color and Rods are for night vision
• There are 3 kinds of Cones: red, green, and blue
• Cones don't actually sense color, they sense wavelengths of light and these are translated by the brain in to colors

• Its actually very rare for a person to be color "blind" (unable to see colors)
• More commonly people have a color "deficiency"

• This means that one type of cones is not sensing the correct wavelength
• This result in confusion between colors

 

FAQ about Color Blindness:

Q: What is the most common color deficiency?

A: Green deficiency (medical term: Deuteranomoly) is most common. This results in difficulty with greens, reds, and mixtures of these colors.

 

Q: Is it more common in men or women?

A: Men! 8% of men have color deficiency compared to only 0.5% of women.

 

Q: How do I know if I have a color deficiency?
A: If you have difficulty distinguishing between greens, reds, or mixtures of these. Take a quick test by looking at the attached image one eye at a time. If you miss more than 2, you may have a color deficiency.

As usual, all questions and comments are greatly appreciated and feel free to pass this info on to anyone who may be interested.

 

 

 

Pink Eye

What is it?
- Pink eye (aka Viral Conjunctivitis) is a Viral infection of the thin outer covering of your eyeball
- Symptoms include: redness, burning, watering, puffy/swollen eyelids (all can last 1-2 weeks)

What causes Pink Eye?
- It is most common during cold/flu season, usually a result of people touching their eyes after coughing or sneezing

FAQ about Pink Eye:
Q: Can you get pink eye if someone farts on your pillow?
A: NO!

Q: Can you get pink eye if someone licks your face?
A: YES! (Actually had a patient with this!)

Q: What is the best way to prevent it?
A: Wash your hands. And make sure nobody licks your face.

As always, all questions and comments are welcome. And please feel free to forward this information on to anyone who may be interested.

Eye Floaters!

What are floaters?
- There is a gel that takes up most of the space inside the eye called the Vitreous
- The little dots or squiggly lines we see when looking at something bright (ex. a white wall) are areas of the vitreous that are slightly thicker thus casting shadows on the retina
- Mostly these are nothing to worry about

When are floaters significant?
- Floaters can be a sign of Vitreous Detachment or, more significantly, Retinal Detachment
- If you ever notice lots of new small floaters or a new large floater, this is something to be concerned about

 Click here to watch a funny video from The Family Guy about Floaters. Forward to the 35 sec mark.

Why Do My Eyes Itch?

Allergies

- most obvious answer, but not necessarily most common
- signs: swollen/puffy eyelids, watery eyes, bumps under eyelids (seen by your doctor), diffuse and more intense itch

Blepharitis (blepharo- = eyelids, -itis= inflammation)

- so, inflammation/irritation of eyelids, very common
- could be due to mild bacterial infection or blockage of glands at the base of eyelashes
- signs: redness along eyelid margin, itchiness usually concentrated at eyelid margin or at the corners of your eyes but not as intense as with allergies, also watery eyes

As always, your questions are welcomed and encouraged.

Why Does My Eye Twitch?

There are multiple known factors that can contribute, including:

- stress
- lack of sleep or change in sleeping pattern
- low calcium levels or other electrolyte imbalances
- fatigue
- dry eyes
- caffeine
- alcohol

The medical term for eyelid twitching is Myokemia

Treatment for eyelid twitching usually involves resolving the above factors. In some rare cases, a botox injection is needed to relax the small muscles around the eye that are over-active.

Near-sightedness

• The medical term for being near-sighted is Myopia
• The term near-sighted is used simply because myopes are able to see close objects more clearly than distant objects
• The most common cause for myopia is an increase in axial length (front to back) of the eye during childhood and teenage years
• This results in images being focused in front of the retina
• Near-sightedness is easily correctable using "minus" lenses, thus a myopic person's prescription will always have a negative sign in front
  

Ex. If you consider a movie projector and screen. A myopic eye would be analogous to someone pulling the screen back so the image is out of focus.