Month: July 2020

Decoding the Numbers: Hyperopia

Welcome to Part 2 of Decoding the Numbers!
In the last post of this series, I discussed near-sightedness, or myopia.  This time we’re switching gears and talking about hyperopia! 
*Note: From my experience, far-sightedness is a bit harder for people to grasp (unless, of course, they are hyperopic) than near-sightedness.  I’ll do my best to make it easy to understand, but bear with me, and don’t be afraid to ask questions if something is confusing!*

Hyperopia

  • Patients with hyperopia, or hypermetropia, are commonly referred to as being “far-sighted”.  This is because they are able to see more clearly at distance than at near.  This becomes more pronounced as patients age.

What causes hyperopia?

  • All refractive errors (essentially the reason for needing glasses) are caused by a mismatch of power in the eyes.  In the case of hyperopia, the power (created by the cornea/clear surface and intraocular lens) is too little for the length of the eye, or, conversely, the length of the eye is too short for the power of the eye.  Either case means that light is focused behind the retina (back part of the eye), resulting in a blurred image.
For those of you who are asking how in the world light can be focused behind the retina – you’re not alone.  Let’s go back to myopia for a second.  In this case, light from a distance is focused in front of the retina.  As objects get closer to the retina, so does the image, until, at a certain distance, the image falls exactly on the retina!
Unfortunately, this doesn’t happen with hyperopia.  Distance light is already behind the retina, and no matter how you physically move the source of light, it will never be on the retina.  What changes is just how far behind the retina the focal point is.  As objects come closer and closer, the image moves farther and farther behind the retina.
However, in hyperopia, there’s a bypass mechanism called accommodation (think focusing the eyes).  When your eyes accommodate, the physical lens within your eye changes shape and, consequently, power.  It takes work, but, with modest amounts of far-sightedness at younger ages, the lens can compensate for the prescription!

Why do we need lenses?

  • At younger ages, people with mild to moderate far-sighted prescriptions often don’t need glasses for distance, because, like I said, they can compensate!  However, the higher the prescription, the harder this is.
  • Though many younger people with hyperopia are able to compensate at distance, they may need reading glasses to help relax their eyes at near.  Remember, as objects get closer to the eye, the image moves further behind the eye, causing the eye to even harder at near.
  • Additionally, as we age, the eye naturally loses its ability to focus due to changes in the structure of the lens.  For this reason, people with a far-sighted prescription eventually become unable to compensate… at any distance.  Sorry guys!
  • Because of the mismatch between the retina and the image, plus (convex) lenses are prescribed.  Due to their structure (thicker in the center, thinner on the edges), convex lenses cause light to converge (get closer together).  This convergence moves the eye’s natural focus point forward  – putting it right on the retina, and providing a clear image.

Who gets hyperopia?

  • Refractive errors in general are thought to be inherited.  Hyperopia is no different.
  • Almost everyone starts out far-sighted in infancy secondary to the eye being shorter at birth and growing over time.  In most people, this gradually decreases over the first several years of life in a process known as emmetropization.  However, with high far-sighted prescriptions the amount of hyperopia is less likely to decrease over time to normal ranges.
  • The most common genetic condition associated with far-sightedness is Down Syndrome.

When should I suspect hyperopia?

  • Some signs of being hyperopic are:
    • Complaining of headaches, eyestrain, or fatigue when reading/doing near tasks
    • Some people may have an inward eye turn that gets worse when they’re looking at things close up
    • (Occasional) squinting when looking at distance (normally only with higher prescriptions)

Does hyperopia get worse?

  • Unlike myopia, hyperopia rarely increases!
  • Rather, at young ages, far-sightedness naturally decreases (more so if it’s not super high to begin with)

Are there any complications with being far-sighted?

  • High amounts of uncorrected hyperopia (greater than +5.00) at a young age may cause permanently (with some nuances) reduced vision (amblyopia).
  • As hyperopia is often associated with a shorter eye, with age, far-sighted individuals may be more prone to developing problems with the outflow of fluid in the eye (angle-closure, or angle-closure glaucoma).
  • Far-sighted patients have an increased likelihood of having an eye turn (strabismus).

Can hyperopia be treated?

  • Most often, patients are prescribed glasses or contacts to improve vision.
  • Refractive surgery can also be used to change the power of the eye.

Why does my eye doctor… Part 1

Have you ever gone to the eye doctor and wondered “why do they do that”?
I know I have.
Before optometry school, despite my strong biology background, I honestly had very little understanding of the questions asked, the procedures done, and the outcomes discovered – let alone the actual workings of the eye!  And I’m guessing I’m not alone.
As optometrists, we can get push-back for asking questions or wanting to do procedures – which is totally understandable!  In a world where we’re taught to be skeptical of everyone and everything, it’s only natural to be on the lookout for someone trying to take advantage of you – making an extra buck by doing extra testing, etc.
This skeptisim is where I come in.
My goal in this series is to simply demystify the eye exam.
    -not to make all of you optometrists
    -not to try to be Dr. Google and help you diagnose all your problems.
Only to educate.

First up?  Everyone’s favorite: Dilation.

Understanding Dilation

Okay, let’s go back to biology for a moment.  Remember the autonomic nervous system?  It’s the one that automatically controls things in your body, and can be split into two components: the sympathetic nervous system, and the parasympathetic nervous system.
  • Sympathetic = fight or flight
  • Parasympathetic = rest and digest
Dilation is controlled by the sympathetic nervous system (because you need more light in your eye to see to run away from things trying to eat you!)
When it comes to the eye, the size of the pupil (black part) is determined by the iris (the colored part).  In the iris, there are two muscles – the sphincter (parasympathetic, shrinks pupil) and the dilator (sympathetic, dilates pupil) – that obviously then control pupil size, depending on the task and the situation.
Because two muscles and two systems are responsible for pupil size, we can target either (or both) of them to achieve dilation!
The first way is to activate the sympathetic nervous system.  The fancy name for these drops are sympathomimetics – which just means that they mimic sympathetic responses. The most common drop that we use is phenlyephrine (think epinephrine, or adrenaline).
The second way is to DE-activate the parasympathetic nervous system. Of course, that sounds too simple, so they’re called parasympatholytics – or medications that inhibit parasympathetic responses.  There are a number of drops in this category that we may use, but most general optometrists use tropicamide.
Here’s where it gets a bit tricky though.
The parasympathetic system, which is tied to the sphincter, causes more than a smaller pupil (miosis).  It also controls your eyes’ ability to focus (accommodate) and turn in (converge).  Together, these three components make up the near triad.

What does dilation do?

Now that we’ve got the science down, the effects are pretty simple.  First, dilation makes your pupil bigger.  And second, it makes it difficult to focus (especially at near).
These effects last for varying amounts of time, depending on the person in general.  For me, my near vision is the first to come back, generally within a few hours.  My (blue) eyes often remain dilated for at least 4-6 hours, sometimes longer, depending on the number of drops used.

Why dilate?

The basics purpose behind dilation is simply to get a better view of the back of the eye.
But, Hannah, can’t the doc see the back of the eye without adding the drops?
My favorite explanation goes something like this:
Have you ever tried to look into a room through a keyhole?  You can probably see a little bit, right? But it’s hard. And you have to move a lot to see just a little.
But what if someone opens the door? Of course, then it’s easy to look in and examine the whole room!
The exact same principle holds true with the eye.  Before dilation, sure, I can see some.  Most of the time I can get a look at the optic nerve and the macula, but seeing the rest of the retina?  It’s really hard.
With the dilating drops, however, it becomes significantly easier to see out into the far reaches, or the periphery, of the retina.

What is the doctor looking for?

Honestly, this depends a lot on your personal history in combination for your reason for exam.
For instance:
  • In near-sighted people: we’re especially looking to the peripheral retina, because that’s the most likely location for thinning, that may lead to a hole, tear, or detachment.
  • In people with diabetes: we’re looking for any spots of blood (hemorrhages) and other signs of diabetic changes.  As diabetes is one of the leading causes of blindness in the United States, finding changes and monitoring them is vital for optimal visual outcomes.
In general, optometrists may often be the first practitioners to see signs of systemic diseases (diabetes, hypertension, autoimmune disorders, brain tumors, and certain types of cancers) – all of which have better outcomes the earlier they’re found and treated, and so we’re looking for anything out of the ordinary.
Why?
Because we care about you, as an individual, not just your eyes.

 How often do I need to be dilated?

This again varies some by personal history.
In general, every adult patient (over age 18 and below age 65), with no known ocular or systemic history, should be dilated once every two years.  Those over 65 should be dilated yearly.
I am a firm believer in dilating every pediatric patient (under 16 years of age) at their first exam, and most subsequent exams (I’ll discuss this more later in a peds specific post).

What about that retinal picture? Isn’t that good enough?

Short answer: no.
Retinal photographs can, honestly, only show so much.  Yes, the wide angle imaging systems are improving, but they still may miss pathology that would be seen with dilation.  While I don’t view these as a full replacement for dilation, I understand advocating for their use as a measure of retinal documentation every other year in adults without known ocular or systemic conditions.

But, I’ve never been dilated…

Trust me, you’re not alone.  I personally was never dilated until my first year of optometry school.  While I do not judge the docs who do not dilate frequently, according to the American Optometric Association, routine dilation, as described above, is the standard of care for all optometric pracitices.

Can I drive after dilation?

The short answer, is: yes (for probably 90% of patients)!
If you are properly corrected with lenses (glasses or contacts), or have no prescription, your vision (at distance) should be minimally impacted by dilation.
However, due to the increased pupil size, everything will be brighter, so make sure you’ve got a good pair of sunglasses with you!
If you are uncomfortable with the thought of driving after dilation though, don’t worry! You’re always welcome to bring a driver, or to defer dilation to a day when you have a driver – just make sure you come back for the rest of the exam!
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If you have questions, or a topic that you’d like me to discuss, contact me here.  I’d love to hear from you!

Introductions: Hannah Vollmer, OD

Happy Friday, y’all!
For a change of pace on this Friday morning, I’ve decided to do a (fun?) introduction post in the ever popular interview format.  Enjoy!
I: Easy question – what’s your name, and what do patients call you?
OD: I’m Hannah Vollmer.  Immediately after graduation I had considered having my patients call me Dr. Hannah since it felt less formal, but at this point I’ve pretty solidly adapted to Dr. Vollmer.
I: Where did you go to school, Dr. Vollmer?
OD: I attended The Ohio State University College of Optometry, and graduated in May of 2019.
I: May 2019 – that’s over a year ago now. What have you been doing over the past year?
OD: I decided early on in my optometric career that I wanted to pursue a residency after graduation to become further specialized.  In March of 2019, I matched with University of Houston College of Optometry as their Brain Injury Vision Rehabilitation resident for the 2019-2020 academic year.  So, in June of 2019, I moved down to Texas, where I have resided ever since.
I: Ohio to Texas – that’s a pretty big change!
OD: For sure. Thankfully, I had lived in both North Carolina and New Mexico as part of my optometry school rotations, so the heat wasn’t a huge shock.  Plus, I’ve always dreamed of a world of endless summer.  I think Texas fits the bill.
I: I think you may be right. Do you think you’ll stay in Texas?
OD: That’s a great question that I’m honestly trying to decide right now.  I’ve always figured that I’d move back to the Midwest at some point – the question is really just when – be that 2 months, 6 months, 1 year, 3 years, etc.
I: Well, good luck as you make that decision.  Let’s switch gears.  Did you always know that you wanted to become an optometrist?
OD: Absolutely not. I honestly always tell people that I chose optometry because I didn’t know what I was doing with my life.  As a lifelong musician, I initially planned on becoming a cognitive neuroscientist with research emphasis on how music impacts the brain. It was really only after my junior year of undergrad, after several neuroscience internship opportunities fell through, that I found myself shadowing several optometrists, and then landing a summer internship with one of the offices.  At the end of the summer, I figured I had nothing to lose and decided to give it a go.
I: That seems a little late in the game – was it hard to apply for schools from that point?
OD: After talking with other optometry students after getting into school, I realized just how late in the game it was – considering most other applicants were already applying at the time that I was taking the prerequisite courses.   At the time though, it didn’t seem like all that hard.  I think the biggest challenge was taking the Optometry Admissions Test (OAT) before I had taken several of the prerequisites – I had no real understanding of OChem, but it was one of the largest sections of the test. Thankfully, however, it all worked out, and by August of 2015, I had packed my bags and moved to Columbus for school.
I: I’m glad it all seemed to work! You said that you decided pretty early that you wanted to do a residency – what drove that decision?
OD: When working in the private practice for both my internship, and then as a summer job the next year, I realized pretty quickly that I would get bored just asking people “which is better, 1 or 2” all day.  I had always loved working with kids, and so figured that I would specialize in pediatrics.  However, during my time at OSU, I saw relatively few peds, but a ton of brain injury patients.  I fell in love with them and their stories, and so decide to pursue a career in neuro-rehabilitation instead.
I: Was that as significant of a change as it sounds?
OD: Honestly, no.  There is a surprising amount of overlap between the two populations.  Severe brain injuries can leave patients non-verbal – very similar to young pediatrics – therefore requiring virtually identical exam techniques.  In addition, both patient subsets may exhibit binocular vision deficits that optometrists trained in vision therapy are able to assess and treat.  If I’m completely honest, my favorite population is actually combination of the two fields – neuro-peds.  It can be heartbreaking to work with these little ones who have been through devastating circumstances, but to be able to give even a glimmer of hope to patients and families who have been through the unimaginable is incredible.
I: That sounds awesome. Is there a certain type of practice that will allow you to provide this care?
OD: Great question! I’m still working out what exactly this may look like.  It has been my dream to be a part of an out-patient interdisciplinary neuro-rehab team that includes OT, PT, speech, optometry, and potentially neuro-psych.  Finding that team, thus far, has been difficult though.  So, for the time being, I’m planning on starting small – joining a private practice and building a patient population, until I am able to move on and create a facility that will provide the care that these patients deserve.
I: Incredible.  Well, I think that concludes the questions for today. Thanks, Dr. Vollmer!
OD: My pleasure!  If anyone has additional questions or topics that you’d like for me to discuss, you can contact me here.  If you enjoy the content found here, please subscribe at hannahvollmer.net, or like my page on Facebook!

Specs: Do I Really Need…

When it comes to buying glasses, there are a TON of options.  Whether you’re new to buying specs, or an old pro, it can be difficult to determine what you really need.  Sometimes your doctor or the optician will may make suggestions, but what if they don’t?
In this post, I’ll dive into some common glasses options and try to provide some doctoral advice on what you do (and don’t) need.  Let’s get started!

Transitions

I pretty vividly remember a speaker coming in during optometry school and lecturing on the benefits of transitions and why we need to promote them to every patient.  At the end, as with all such lectures, we were polled on our likelihood to suggest these lenses at the end of an exam.  My vote? Not at all likely.
Why?
I don’t believe in promoting products that I personally will not wear.
But, for the sake of discussion in a spirit of fairness, here are the pros and cons:
  • Pro: You’ve got built in sunglasses, which are supposed to protect the eyes.  Hello 2 for 1?
  • Con: They’re getting better, but they struggle in the cold (#OhioWintersSuck), often don’t change in vehicles, and are an up-charge.
The story?  Some patients love them (ie my mom, who has worn transistions as long as I can remember).  Some patients hate them (ie me, who put transitions in a pair of glasses during optometry school and wore them literally once – I couldn’t stand looking like a backwards 90s kid).
Takeaway?  If you want to try them, great! If you don’t, great! Don’t feel like you have to, but I am obligated to inform you that a good pair of sunglasses promotes better ocular health.

Anti-Reflective Coating

As an OD, I, once again, have first hand experience with the difference that AR-Coating makes.  My primary pair of specs (aka the pair without transitions) doesn’t have AR-Coating.  I don’t notice it 100% of the time (mainly because I typically wear them for maybe 10 minutes/day), but the reflections are miserable.
Though I rarely wear the other pair which has one of the best AR-coatings, I never notice reflections with these.
Takeaway: 10/10 would recommend.

High Index Lenses

The need for high index lenses is entirely dependent on your prescription.  If you’re less than a +/-4.00 and have minimal astigmatism, don’t spend the extra.  If your prescription is higher and you wear your glasses frequently/all the time, go high-index.  The difference in weight will be noticeable.
Takeaway: For high prescriptions, use high index.

Blue Blockers

In theory, blue-blockers have not been definitively proven to have an effect on vision/eyestrain/etc, especially considering that natural light produces significantly more blue light than screens.
However, I personally am a huge fan of blue-blockers.  Regardless of study results, I generally appreciate reduced eyestrain when using blue-blocking lenses, and I know many others that report the same improvement.
From there, blue-blocking lenses are definitely not a necessity, however, I would be inclined to suggest them (as well as improved ocular habits) for patients with ocular complaints secondary to excessive screen-time.

Progressive Lenses

Progressive lenses, or no-line bifocals, could really be a post of their own (and probably will at some point.) For now though, let’s stick with the basics.  These line-free lenses aim to provide clear vision at all distances – far, intermediate, and near, with a transition zone that adds progressively more power as needed.
  • Pro: They’re bifocals, but without the line!
  • Pro: Clear vision at (theoretically) all distances.
  • Con: Putting variable powers into one lens makes for a lot of “peripheral distortions” – or blurry/unusable vision when you’re not looking through the center.
  • Con: Some people have a really hard time adjusting to them (normally those who are more likely to move their eyes than their head for tasks).  I normally tell patients to give a new pair of progressives 2 weeks for adjustment, but this isn’t always enough.
Takeaway: Progressives are not a requirement.  It never hurts to give them a try, but they’re definitely not for everyone.  If you try them and can’t adjust, don’t be afraid to go back and ask for something different.  I know plenty of patients who are perfectly happy in a lined bifocal (or trifocal…)  The key? Find what works for you.

Specs: When the Price is Right

First things first: let it be known that I am not a good salesman (or saleswoman).
During my time as a student at OSU Optometry, one of my most frustrating classes was our business class.  Though I understood its necessity, considering the high percentage of most graduating classes that go on to join or form private practices, a business mindset never came naturally to me.  So, while the professor was lecturing on how to create our frame-board, set our prices, and push products for maximum sales, I was fighting the urge to run out of the classroom screaming.
Naturally then, I was overjoyed when I had the opportunity to work with several medically based optometrists who, rather than pushing products, would provide the prescription and say, “you can fill this at any optical.”

Honest optometry.
As I look the potential of a career in private practice in the face, however, the questions posed in the hours of business classes come back to haunt me.

Frame and lens sales are often the primary income of general optometry practices, compensating for the meager returns from insurance payments.
How do I do what’s best for my patients while making enough income to pay off debts and keep the business open?

When it comes to specs, when is the price right?

 Optometry Practices

Some optometrists that I have worked with who have an in-house optical push their patients to get glasses from their optical.  Like I said before, the thought of pushing someone to do anything for my profit sickens me. But, there are some definite benefits to buying local.
  • It supports local businesses.  As I already mentioned, many practices earn their living by optical sales – not eye exams.  I’m a firm believer in showing appreciation by action. If you’re a fan of the doc and the staff, consider buying products from their practice to help  them continue to provide quality care.
  • Better customer service.  This isn’t always the case, but in most of the private practices I’ve worked with, the staff genuinely care about you as a patient.  Your kid broke his glasses and you don’t have a back-up? They’ll be the ones to jerry-rig them back together with spare parts until the new one comes in.  Broke a nosepad? They’ll replace it, sometimes even for free.
  • Experience. In the best opticals, the staff are trained as opticians.  They know what the best products are for your needs, and they know what modifications to make to best suit you. They’ve tried the products (I rarely know an optician with less than 6 pairs of glasses) and can give you the inside scoop.

Online Retailers

In most aspects of life, I’m a huge bargain shopper.  Why buy one thing for twice the cost if you can get it for half the price somewhere else? (Especially when you’re living on a resident salary and trying to pay off school loans beside.) For this reason, it can be super tempting to buy online from retailers such as Zenni Optical.  Sometimes that’s okay. Others? Best stay away.
  • (Maybe) Buy Online: Simple prescriptions. If you’ve got one set of numbers on your prescription pad (just a relatively low near-sighted or far-sighted prescription, without any astigmatism, add, or prism) you’re probably okay to try buying online.  I can’t guarantee the quality of the material, but if you need a simple no-frills pair, you won’t be out much giving it a shot.
  • (Maybe) Buy Online: Back-up glasses.  Little Johnny has broken his third frame in 6 months. You’re past the warranty.  Your benefits have been used, and you frankly don’t have the money to go out and buy yet another pair full-priced pair.  Try online.  Again, it may not be perfect, but it’s at least something to hold him through til you’re in a better spot.
  • (Maybe) Buy Online: Frequently changing prescriptions.  This may be a near-sighted child who seems to need a new pair of lenses every 6 months.  Or maybe you’re a diabetic and the doctor has said that your prescription isn’t stable secondary to blood sugar fluctuations, but you’re not legal to drive with your current visual status. Try online.  You already know that your vision is going to change, but getting something fast and cheap while waiting for things to fluctuate is better than having nothing at all.
  • Don’t Buy Online: Difficult prescriptions. This is pretty much the opposite of my first point above.  If you have lots of numbers, or anything that sounds out of the ordinary, don’t waste your money on the online up-charges and end up with a pair of glasses that don’t work at all.  Spend the money and make sure it gets done right the first time.

Retail Opticals

From my experience, retail opticals (ie Walmart Optical, Costco Optical, etc, etc, etc) can be super hit or miss.  Some of them are awesome, and my patients rave about the specs they’ve gotten.  Others of them are crap, and I’ve sent 3 patients back for remakes within the course of a few hours.  For this reason, my advice regarding retail optometry stores is identical to that of online retailers.

Takeaway

Buying the perfect specs, like life, can’t be fit into a binomial. There are times to buy from your local optometrist, and there are times to bargain shop and buy online or at a retail optical. At the end of the day, what matters most is simply finding someone who you trust to keep you seeing and looking your best.