Thursday, January 28, 2010

Internet or "Squinternet"?

Has the internet become the "squinternet"?

What I mean by this is that usage of the computer for hours at a time to access the internet, do social networking, surf, etc. has placed tremendous demands upon our eyes. This has caused a great deal of problems for those that participate. The various issues that patients confront can vary from eyestrain, headaches, blurred vision, double vision, neck ache, as well as pain to the wrists and forearms, numbness etc.

The way we often react with our eyes to difficulty in focusing or eyestrain is by squinting. Hence, the "squinternet".

So how do we best deal with these issues? Here are some suggestions:

1. Without being self serving the first thing I recommend is that you see your eye doctor and get an eye exam. Make sure that your prescription is correct for you and that it best represents what you specifically need to be able to focus on the computer screen. This may sound simple but it can be complicated. Your screen is at one distance and the keyboard is at another. You may be using different computers at work and at home. The distance for you to focus on a lap top is different from a desk top. All of these issues can affect how you focus and how you use your eyes when on the computer. Some patients need different pairs of glasses depending upon where they are working at the time. Some patients only need simple reading glasses. Your doctor will be able to determine the best approach for you. When you go in for your appointment it is very helpful if you can bring in data that accurately describes how far you sit from the various screens that you are working on. Assume your normal position in front of the screen and have someone measure the distance from the screen to your eye and the distance from the keyboard to your eye. This will help the doctor to best prescribe for you. New lens products have been recently introduced that provide tremendous help for computer users. There is a new progressive multifocal available that has in the center of the lens a large area designed to focus on the screen distance. In the top of the lens is a smaller distance viewing area and in the bottom of the lens is more magnification for small text. This allow the computer user to have a large "sweet spot" for their computer viewing and also see distances as well as up close for text viewing. There are also greatly improved glare free coating that allow more light to get into the eyes.

2. Glare can be a big problem for computer users. It is best to have your computer in an area where you will not have an open window in front of you as you view the screen. It would be better to position the screen, if you can, with the window behind you or off to the side. If you cannot accomplish this you can use blinds or drapes to cover the window. Many patients are bothered by overhead glare from overhead light sources. In the case of flourescent lighting, it can be helpful to remove some to the "tubes" to cut down on the amount of light upon the screen. It can also be helpful to wear a hat or visor to cut down on the glare from above. If reflections from the screen are an issue, make sure that the screen is as clean as possible. The new flat screens are a big improvement. It is also possible to make a "bonnet" for the screen itself. Take a piece of cardboard and cut it so it will fit over the computer screen and extend out five or six inches. You can tape it to the back of the screen with duct tape. This will get that overhead glare off of the front of the screen.

3. Sit at a distance that allows you to see the screen without leaning forward. If you lean in this will take a toll on your neck and back. Make sure that your chair has good back support. Pillows are available to give you better lumbar supprot. In an ideal situation, the screen is supposed to be slightly below eye level. If you can make this happen this is great. If you cannot, make sure you discuss the positioning of the screen with your eye doctor.

4. Sometimes, the difficulty a patient has with their vision is not just focusing but has to do with the ability of the eyes to point together at the screen distance for an extended period of time. If a patient has difficulty in this area, exercises can be prescribed to strengthen the eye muscles that allow us to point our eyes at the appropriate distance. Exercises can also help relax the eyes and strengthen them to help with focusing between distance and near. Eye doctors talk about the 20/20/20 rule. This pertains to taking the time to relax your eyes regularly by looking away from the screen every 20 minutes for 20 seconds and blinking 20 times. This accomplishes several things: Looking away stretches the muscles in the eyes allowing them to relax after looking up close for a long period of time. Physically, it allows the computer user to get back from the screen and to also relax the neck muscles, shoulder muscles, etc. Blinking rewets the tissues of the eyes and makes eyes more comfotable.

5. Dryness of the eyes is a common complaint among patients using the computer. Following the 20/20/20 rule above will help. Here are some other suggestions: Drink enough water. Blink more in general: To accomplish this take a "post it" and write the word blink on it. Stick it on the computer near the top. When you see this during the day make sure that the blink you make is a full blink. Research has shown that our blink rate goes way down on the as much as two thirds. This contributes to dryness, burning and general visual discomfort. Blinking more really helps. It is also helpful to have some wetting drops by the work station. Not all wetting drops are the same. Your eye doctor will make a recommendation for the drops that best suit your particular needs. In general, the best drops are those that are non-preserved. They are a little more expensive, but the preservatives that are in over the counter eyedrops can cause problems and irritation that can be avoided by using the non-preserved variety. Severe dryness problems require more attention and a more complicatead solution than can be provided by eyedrops. Your eye doctor will be able to help you if your are still experiencing dryness even when using eyedrops or in spite of having tried the above suggestion.

I hope these suggestions have been helpful. Please visit your eye doctor for a thorough evaluation of your computer vision needs and keep the internet from becoming the "squinternet".

Monday, January 25, 2010

Optometrists Ophthalmologists & Opticians (The Three O's)

I am an optometrist and I have been in practice in Westwood Village, a suburb of West Los Angeles, since 1971. Patients will still refer to me as an ophthalmologist or optician from time to time. I think the reason that there is confusion among the public is due to the fact that there is a great deal of overlap in terms of what the three professions provide. All are involved with various aspects of vision care. In addition, the definition of optician and optometrist varies from country to country. In some countries, optometrists can only refract (test vision) and provide eyeglasses and contact lenses. They can not treat eye diseases or do eye health evaluations. Opticians can refract in some countries and not in others. In the United States, opticians can fill prescriptions for eyeglasses and contact lenses but they cannot refract and test vision. Optometrists in the United States can treat eye infections, dry eyes, eye allergies, and eye diseases as well as test vision and refract. This has not always been the case. When I graduated from optometry school optometrists did not have the ability to treat eye diseases. We were trained to detect them, but we always had to refer out to a medical doctor when we detected a medical problem. If the problem was an eye problem, we would refer to the appropriate ophthalmologist. If the problem was with a general medical condition such as hypertension or diabetes, we would refer to an internal medicine specialist or general practitioner.

Things have changed over the years. The scope of practice of optometry has expanded. The laws that govern the practice of optometry have changed over the years to include the treatment of eye diseases and eye medical problems. This has occurred on a state by state basis. Here in California, once optometrists were granted an increased scope of practice, they had to take and extended number of additional hours of specialized education and pass a comprehensive examination. In addtion, they had to work side by side with ophthalmoligists according to a schedule specified by the state Board of Optometry before they could begin utilizing their new skills. Optometrists can now treat eye diseases such as glaucoma. We can treat eye infections and eye allergies as well as dry eyes. This increased treatment capability was originally only available within the realm of ophthalmology. If optometrists do detect or diagnose a problem that is beyond our expertise, the patient is referred to the appropriate medical practitioner.

Optometrists are well connected with the best medical specialists in their respective areas. Patients that are referred out for specialty care are then referred back to the referring optometist for continued care. This is called "co-management".

So, is it still confusing for patients to understand the difference between "The Three O's"? The answer is probably yes. Due to the overlap of services that is frequently provided is is only normal that patients can confuse "The Three O's". It is up to the optometrist, the ophthalmologist and the optician to fully explain the services that can be offered to their patients.

Saturday, January 16, 2010

Eye Exams and Eye Doctors: What to Expect

Here are some comments about Eye Exams and Eye Doctors that pertain to patient visits at our office in West Los Angeles, Westwood Village, California.

Patients can be very apprehensive about their eyes when they visit their eye doctor. It is important to choose an eye doctor that takes the time to listen to your symptoms and prescribes the best mode of vision correction for the individual patient. If the visit is for a yearly eye examination this visit is really like a physical for your eyes. Eye health is tested frequently via a dilation of the eyes. Eye muscle coordination is tested as well. The eye is looked at from the front all the way to the back. The eyes are tested for glaucoma and evaluated for dryness and signs of allergies. A prescription is determined by a process known as a refraction. It is important that the doctor is as accurate in determining the prescription as is possible. Once all the information is gathered, the doctor will make recommendations as to the best way to treat the patient's individual vision problem. The recommendations can be anything from a single vision lens for either distance or near to a multifocal correction. Often the doctor will recommend sunglasses to block out the sun's harmful rays. In addition, reflection free coatings are often prescribed to help allow more light get into the eye and provide the clearest vision possible. At times the solution will involve eye exercises instead of eyeglasses. The correction can also include contact lenses. If contact lenses are desired it is best to choose an eye doctor that has a great deal of experience in contact lens fitting. This will provide the patient with the most favorable outcome.

The above description relates to routine yearly eye exams. Of course, there are urgency and emergency visits as well. Here the visits are confined to a problem solving situation, depending upon the problem that the patient faces. Eye infections are treated with the necessary medications. It is important for the doctor to determine the exact cause of the problem and prescribe the correct therapy. Eye allergies can often be treated with anti-histamine eye drops. Dry eyes can present a perplexing problem. The cause of the dry eyes must be determined. In addition, there can be issues with tear quality that can often compromise eye comfort. The doctor must not only deal with the dry eye issues but must make sure that the tear film is as normal as possible. Again, it is best to choose a doctor that has lots of experience with these issues.

Friday, January 15, 2010

Yellow Growths on the Sides of the Eyeball

I am frequently asked by patients about a yellow/whitish/sometimes glistening growth on the sides of the eyeball. Typically these growths are at the 3:00 and 9:00 positions to the side of the colored part of the eye. There are two official descriptions for theses growths.

The first description applies to when the growths are only on the white part of the eye. In this case the growth is called a pinguecula. These growths are thought to be more common in individuals that spend alot of time outdoors. Here are a few examples: Farmers, gardeners, skiers, surfers, lifeguards, people living in tropical climates, and people who spend a lot of time outdoors and do not used any sun protection. The pinguecula is not a serious problem, but it can be irritating to the patient as the growth is elevated compared to the other parts of the eye. Because it is elevated, it is more exposed to wind, sun, irritation and it can dry out earlier. Pingueculas can become reddened when irritated and can become cosmetically unpleasing.

The second description of the yellow growths applies to when the growth actually grows onto the cornea (the clear "window" that covers the colored part of the eye...the iris). In this case the growth is described as a pterygium. The causes of the pterygium are the same as with the pinguecula. It is just a farther advanced case of the tissue growth. When the tissue grows onto the cornea it can become more irritating and red. It also becomes more cosmetically unacceptable as it is red and uncomfortable most of the time. There is a risk that the pterygium could grow far enough on the cornea that it could cause some loss of vision. This can be prevented by seeing an eye doctor early enough to take care of the problem before it becomes too serious.

Not all pingueculas become a pterygium. It depends upon many factors. It is important to realize that if you have a pinguecula there is a risk that it could become a pterygium. The best way to avoid the change is to protect the eyes from the sun and wind. The patient should wear good quality sun protection when outdoors and wear a hat for extra protection.

Both pingueculas and pterygia can be surgically removed if necessary. This can best be achieved by an ophthalmologist that is a corneal specialist. If you have any questions or would like the names of corneal specialists that I work with please email me at

If you have any questions please contact your eye doctor for a thorough evaluation.

Thursday, January 14, 2010

What Makes a Disposable Contact Lens Disposable???

I remember when I first started to practice and the only contact lenses we had were hard contact lenses. Then along came soft contact lenses in 1971. The first soft contact lenses were designed to be kept for a long least a year. A few years thereafter the first disposable contact lenses came along. They were initially not very good. Technology improved and today the majority of soft contact lenses that are dispensed are of the disposable variety. Custom soft contact lenses are still being made, but they are often used for specialty purposes. Todays disposable soft contact are excellent. But, what makes a contact lens disposable and why do patients need to consider them?

Technically all contact lenses are actually disposable. The yearly ones are disposable except that you dispose of them yearly. Todays disposable soft contact lenses come in a wide variety of options. There are quarterly, monthly, bi-weekly and daily disposable contacts available. Patients that have eye allergies, very sensitive eyes, dry eyes, etc. often do better changing their contact lenses more frequently. This could mean every day. This is perfect for a daily wear disposable. Daily wear disposable lenses also lend themselves easily to part time wear. Let's say you just want to wear them for sports. O.K. Put on your daily single use contacts and go for it. When the activity is over...just toss them!

Weekly and Bi-weekly disposable soft contact lenses are also very popular. They come in a wide variety of materials. In my office, I prefer the monthly lenses in many cases. This product is easy to maintain and it is always easy to remember when to change the month: toss the old ones and open another pair. The plastics that the lenses are made from is constantly improving. Todays materials are so permeable that, in terms of oxygen transmission, it is almost like a lens is not on the eye.

Because the care of contact lenses has become easier and the product can be purchased in a wide variety of locations including on line sources, patients often forget that soft contact lenses are medical devices. This means that when used properly they are safe and effective, but patients must pay attention to their eyes and seek regular eyecare to make sure that they are not having any negative consequences from their contact lens wear. The safest modality for contact lenses is "daily wear". This means that each day the lens is placed upon the eye and worn for that day. At the end of the day the lens is removed and either discarded (as is the case with single use disposable contacts) or cleaned and disinfected so it can be worn the next day.

The disinfecting systems have gotten better over the years too. Originally, the only system for disinfecting the old style soft contacts was by heating them. Patients had to make their own saline solution using distilled water and salt tablets. We have come a long way since then. Now several companies make multipurpose disinfecting systems that make the care of the lenses much easier. Patients should always thoroughly wash their hands before touching their eyes or working with their contact lenses. The key, when using these multipurpose disinfecting systems, is to make sure that each day the lenses are rubbed between the fingers or in the palm of the hand with fresh disinfecting/cleaning solution. In addition, the old solution should be discarded and fresh solution should be added. The case should be cleaned and air dried every week. The case should be changed every few months to make sure it is clean and functioning properly. There is another system that I like that relies on hydrogen peroxide to disinfect the lenses. This system is especially helpful for patients with sensitive eyes and those that have an abnormal amount of protein in their tear film.

Soft contact lenses can be enjoyed for either full time or part time wear. They offer an excellent way to have an alternate system for vision correction. They are great for sports, social activities and general wear. They come in a wide variety of options including single vision, astigmatism correcting (toric) and even multifocals. They can be used for daily wear or extended wear (leaving them in overnight). The key for patients is to recognize that the lenses are a medical device and need to be evaluated on a regular basis. It is best to see you eye doctor to ensure that you are a good candidate for contact lens wear and for regular maintenance of the contact lenses.

Blood In The Eye

When you look at your eye and see blood in the white part of the eye, this is called a "sub-conjunctival hemmorhage". This can occur in response to trauma or it can even occur randomly. Most of the time, especially if the hemmorrhage occurs in a random fashion, this is a painless event. It is not uncommon for a patient to wake up in the morning feeling normal until the patient looks in the mirror and sees the blood. This naturally becomes a cause of concern.

Here is what happens: The white part of the eye is called the sclera. It is covered with a thin and transparent membrane called the conjunctiva. Below and within the conjunctiva are many small blood vessels that have a diameter about the size of the point of a pin. It does not take much to rupture these vessels as they are very delicate. Once ruptured, the blood has to go somewhere so it spreads out until our system causes the blood to clot and the bleeding stops. Once the bleeding stops, gravity takes over and some of the blood just drains downward as well as outward. Our lymphatic system gets rid of this blood over takes up to two + weeks depending upon the amount of blood collected. The last part of the eye to clear of the blood is the part nearest to the colored part of the eye as the cornea does not have any lymphatics. Drops designed to "get the red out" won't do anything...they are designed to shrink dilated blood vessels that are engorged due to inflammation. This blood lies below the surface and it takes time for the blood to go away.

The causes can be from any cathartic event...sneezing, coughing, straining, heavy lifting, etc. It can also occur randomly without the above causes. Patients taking blood thinners can be more likely to experience the event. The event can also occur more frequently if the blood pressure is elevated. The best way to be sure of the cause and to make sure that your eyes are healthy is to see your eye doctor when the event occurs and to have your blood pressure tested.

Eye twitching

Eye twitching is a very common complaint voiced by my patients at our West Los Angeles office. Patients report irregular and random twitching of the upper and lower eyelids. Typically, the patient feels the twitch and looks in the mirror and cannot see that much movement in the eyelids. So, why is this happening and what are the causes and the treatment???

The technical description for this is "myokymia". In most cases it is due to a muscle fiber in the eyelid just randomly firing. This creates the twitch. This is the same phenomenon that occurs when you are sitting down and notice a twitch in a muscle of the legs. There are these twitches ongoing all over your body most of the time, but they are usually not noticed. When this happens in your eyelid it is more noticeable.

The causes of this condition have been attributed to stress, need for a new eyeglasses prescription, eyestrain, not getting enough sleep, drinking too much coffee and on and on. What can you do to stop the twitching? Most of the time the twitching stops after a period of time. I remember having the problem and having it last almost a month before it stopped. This is quite common. There were some reports that using a topical antihistamine eyedrop was helpful, but I have not seen this documented lately. The most important thing is to not worry about an eyelid twitch, but to have your eyes examined to make sure that your eyeglasses prescription is correct and to rule out any more serious causes.

The eyelid twitch is not to be confused with a blepharospasm. In the blepharospasm, there is a forced closure of the eyelids. This is a more serious and more troublesome event. The bottom line: Get checked out by your eye doctor if you have any of these symptoms.

Tuesday, January 12, 2010

Myopia Treatment & Bifocals for Children

There was an article in the Los Angeles Times today reporting about a new study that was just completed that will be published in the Archives of Ophthalmology. The article discusses the increase recently noted in myopia and a possible treatment for myopia.

There are several theories about the cause of the increases in myopia, but most of them hint at a causal relationship between all close work children are doing and the myopia increase. Kids are playing video games, watching television, using a computer and looking at their telephone displays. On top of that they have their homework and whatever pleasure reading they may do. This all amounts to lots of close work.

The article reported on the treatment of myopia with bifocals. The theory is that the bifocals allow the children to read through a lesser powered part of the lenses....basically this is what happens in a bifocal design...and thereby they are not having to focus as much when they do their close work. The kids that used the bifocal eyeglasses had a 38% decrease in their myopia compared to the group that used traditional single vision distance only eyeglasses.

In addition to the usage of bifocal eyeglasses, it should be mentioned that it is possible to treat children that are myopic with contact lenses that are bifocals as well. I have done so in my practice and found that myopia changes have been less in children that use their contacts in this manner. This can be done with soft lenses as well as rigid gas permeable contact lenses.

There is also a technique, known as orthokeratology, in which special contact lenses are fitted to the corneas to be worn at night. This technique causes the cornea to flatten overnight. When the lenses are removed the nearsightedness improves significantly.

While all of this is still relatively controversial, there is increasing evidence that points to the fact that these different approaches can help retard the deveolpment of myopia. Make sure that you discuss all this when you next bring your children in for their yearly eye exams.

Sunday, January 3, 2010

Eye Exams for Children


When should kids have their eyes examined?

Near vision
Distance vision
Eye teaming (binocularity) skills
Eye movement skills
Focusing skills
Peripheral awareness
Eye/hand coordination


Scheduling your child’s eye exam:


Eye testing for infants:

Eye testing for pre-school children
Eye and vision problems that affect children





Vision and learning:


The above article is credited to "All About Vision". The link to their web site is:

Friday, January 1, 2010

Dry Eyes: Causes and How to Treat

Dry eyes can be a very challenging and uncomfortable problem for those patients that suffer with this condition. Dry eyes can sometimes be a mild problem that only causes inconsistent discomfort. On the other extreme it can be severly debiltating causing blurred vision, constant discomfort, and even eye pain. Dry eyes can even make the patient more susceptible to eye infections.

The causes of dry eye can be physical as well as environmental. Some patients just do not make enough tears. Tears are primarily created in a gland that sits just above the outside part of the eye and behind the bone that sits above the eye. This gland is called the "lacrimal gland". With age this gland produces fewer tears. There are other sources of tearing, called accessory lacrimal sources, but the majority of tearing comes from the lacrimal gland. It is confusing for patients to be told by their eye doctors that their eyes are dry when the primary complaint that is often offered to their eye doctor is that their eyes often tear or "water" at the end of the day or in the morning or during certain tasks. Here's what's happening: There are two types of tearing that patients encounter. The first is the normal slow and constant tearing from the lacrimal gland that keeps the tissues of the eye lubricated. If this mechanism is working there is normally not an issue with dry eyes. If there is not sufficient lacrimation from the lacrimal gland this causes the tissues of the eye to dry out. This results in dry and irritated eye tissues which causes the eyes to produce a reflexive amount of tearing in response to the irritation which yields a great deal of tears in response to the irritation. A similar abundance of tears occurs when we respond to something that makes us cry because we are saddened or are extremely happy. This excessive tearing is what causes the watery eyes that often bother patients when working on a computer at the end of the day.

The key to keeping the eyes comfortable and normally hydrated is to make sure that the slow constant tearing from the lacrimal gland is maximized. This can present as a real challenge due to many factors. Certain medications cause the eyes to be drier than normal. Certain activities increase eye dryness....especially using a computer...because our blink rate is significantly reduced. Climate can play a role as well. Working indoors in an air conditioned environment can contribute to eye dryness as the air conditioning system pulls water from the air. Not drinking enough water can also contribute to eye dryness.

In addition to the amount of tears that our eyes produce it is important that the quality of the tears is proper. It is important for the eye doctor to not only work to increase the amount of tears that are produced, but to make sure that the quality of the tears is such that there are no inflammatory components in the tear film.

Luckily there are a number of things that can be done to improve tear quantity and tear quality. Sometimes all that is needed is a simple eye drop. If using eye drops on a consistent basis it is important for the drops to be of the "non-preserved" variety. The preservative that is often included in over the counter eyedrops can often cause irritation if used on a long term basis.

Other techniques involve the use of "puntal plugs". These are tiny plugs that are easily inserted into the inside areas of the eye lids. These plugs "dam up" the eye and capture your tears before they can drain away. We have all had the experience of crying and then having to "blow our noses" in response to the tearing. The excess tearing causes some of the tears to spill over onto our face. In addition, some of the tears drain away into an area in the back of our nose through passages that connect this area with the openings in our eyelids that I have mentioned above. It is these openings in the inside area of our eyelids that are "plugged" to "dam up" the eyes. The plugs can be inserted in a simple painless procedure that takes about ten minutes per eye. It is important that the tear quality be good before plugs are inserted. If the plugs are inserted and the tear quality is not good, this can lead to further inflammation and irritation. There is also a medication that can be used to increase tear production. The product is called "Restasis". It consists of topically applied cyclosporin and it is dosed twice a day. This product can be used in conjunction with contact lens wear.

Please contact your eye doctor if you have any issues with dry eyes. Several treatment options exist and your eye doctor can determine the best treatment options for you. Solving dry eye problems can lead to greater eye comfort, healthier eyes, and to more successful contact lens wear.