A Thrill of Hope…

Happy 2022 to all you lovely interwebians.

Well, it’s a new year. Do you feel any different?

When I woke up this morning to yet another cool, dreary, foggy day, I’ll admit it: everything felt the same as it did when I went to bed (at 9:30p) last night.


If I’m honest, it’s a word that retrospectively describes most of 2021 (though especially the last three months) for me: cloudy, hazy, vague, unclear, ill-defined. Like walking through a forest on a foggy day with no path.

Chances are I’m not alone.

We, as a collective people on this orbiting sphere, have been through a lot these past two years, and while I cannot claim to know or understand the pain and loss that many have experienced, I do know how easily it has been to lose sight of hope.

After all, where is hope when each new day is as an endless night?
Where is hope when the journey winds on with no path in sight?

Over this past year, as my dreams and plans and projects and goals have been thrown in my face time and time again, it’s been easy to lose sight of hope.

This morning though, as I contemplated this past year and looked ahead to the new year dawning, these words from O Holy Night came to mind:

A thrill of hope: the weary world rejoices…

How fitting.

We, as those who were awaiting the coming Messiah, often grow weary on our journey through this life – weary of waiting, weary of hoping, weary of watching.

And yet, there is reason for rejoicing; there is reason for hope.

For unto us a Child is born, unto us a Son is given;
And the government will be upon His shoulder.
And His name will be called Wonderful, Counselor, Mighty God,
Everlasting Father, Prince of Peace.

Isaiah 9:6

Y’all, in the midst of deep darkness, our morning has already broken: our Savior has already come. He is our light. He is our hope. He is our salvation.

A couple of weeks ago, one of my friends shared this beautiful thought:

It invokes the audacity of hope in the face of night.

Y’all, for us to have and to hold hope in the face of what often feels like an endless night is simply that – audacious. It doesn’t make sense. It is daringly bold and shows a blatant disrespect for the confines of the situations in which we find ourselves.

And yet we hope.

Because the hope to which we cling is not rooted in our circumstances. It is not found in the world around us. Rather, as Romans 5 states, our hope is in the glory of God.

Therefore, since we have been justified through faith, we have peace with God through our Lord Jesus Christ, through whom we have gained access by faith into this grace in which we now stand.

And we boast in the hope of the glory of God. Not only so, but we also glory in our sufferings, because we know that suffering produces perseverance; perseverance, character; and character, hope.

And hope does not put us to shame, because God’s love has been poured out into our hearts through the Holy Spirit, who has been given to us.

Romans 5:1-5

And so, here’s to 2022: the year of audacious hope.

Day 228: Power

Happy Monday and Day 228 of Another 100 Days of Hannah …and Counting, y’all!

Wow it feels good to be back in my own bed tonight! It’s been a while!!

In any case, tonight, I’m admittedly a bit frustrated with work… again. After CE this weekend, and hearing about all the ways that I would optimally be treating patients, it’s easy to feel very …powerless… in my current position.

Funny – this feeling comes right after listening to several podcasts talking about being powerful vs powerless. Coincidence? I think not.

In the episode, the pastor mentioned that when people feel powerless, they give up hope. And without hope, they cease to move forward. I definitely can relate to that right now.

But, the reality is that we’re not powerless. When we are born again and filled with the Spirit, we are promised that the same spirit that raised Christ from the dead lives in us. And that spirit? It’s one of power, and of love, and of a sound mind.

Y’all. In Christ, we’re not powerless – we’re powerful. And this power, it’s not to be used to take advantage of other people, or advance ourselves. No, this power has been given to us, as children of the King, to advance the Kingdom.

What are we waiting for?

Catch y’all tomorrow,


Optometry in Focus: Glaucoma

Hello lovely internet world and happy Monday!

It’s been another month, so I guess it’s time for another eye post from yours truly.  Today’s topic? Glaucoma!

What is Glaucoma?

Okay, let’s start out with the basics.  Glaucoma is an ocular disease in which the intraocular pressure of the eye (IOP) is too great for the eye itself.  This causes progressive damage to the optic nerve, which, if left untreated, may cause blindness.

What causes increased pressure in the eye? 

Great question!
Believe it or not, the cause of increased IOP cannot always be determined.  This is most commonly the case in Primary Open Angle Glaucoma (POAG). However, in many other types of glaucoma, the reason for increased pressure is more obvious, and may be the result of trauma, inflammation, damage to the structures that allow aqueous/aqueous humor (fluid in the front portion of the eye) outflow.

Types of Glaucoma

Because there are various different reasons for increased IOP, there are also many different types of glaucoma itself. I won’t go into details on all of them today, as that’d take forever, but here’s a brief overview. 
  • Open Angle Glaucoma
    • This is the most common type of glaucoma.  As mentioned in the previous paragraph, the cause of the increased pressure in POAG isn’t fully determined.
  • Angle Closure Glaucoma
    • This is, essentially, the polar opposite of POAG.  Rather than having an open angle (aqueous outflow system), the angle is closed, preventing fluid from moving between the anterior chamber (area in front of the iris) and the posterior chamber (area between the iris and the lens.  If this is confusing, you can read more on it in Why Does My Eye Doctor… Part 3.)  Closure typically results from apposition of the iris to the edge of the cornea.
  • Pigmentary Glaucoma
    • Pigmentary glaucoma is a condition in which the angle is physically blocked by pigment, which has, over time, rubbed off of the posterior (back) portion of the iris (colored part of the eye).
  • Pseudoexfoliation Glaucoma
    • Pseudoexfoliation glaucoma, in many ways, is similar to pigmentary glaucoma, as they both arise from physical blockage of the drainage network.  However, in the case of pseudoexfoliation glaucoma, the blocking substance is a whitish-grey protein-like material, as opposed to pigment.
  • Neovascular Glaucoma
    • As with the previous two types of glaucoma, the pressure elevation in neovascular glaucoma results from a physical blockage of the angle.  In this condition, however, the angle is blocked by new blood vessels (neovascularization), which grow in the angle itself, as a result of improper blood flow (ischemia) in the retina.


And I could probably keep going on more obscure forms of glaucoma.  But for today, I’ll call it good there.

Glaucoma Treatment

Naturally, with so many different types of glaucoma, the method of treatment is also variable.  However, most glaucoma treatment options fall under two categories – medical therapy or surgical intervention – both with the end goal of decreased intraocular pressure.
1) Medical therapy:  Most commonly, this takes the form of eye drops, with some drops actively working to decrease aqueous output (ie beta blockers like Timolol), others working to open the drainage system (ie prostaglandins such as Travatan), and others doing a combination of both (ie ROCK inhibitors like Rhopressa).
2) Surgical intervention: This is admittedly a bit of a can of worms.  Surgical treatments for glaucoma can be as simple as a laser procedure (SLT/ALT) that helps to open up the angle for better outflow, to as extreme as a trabeculectomy (which literally removes part of the angle to allow for direct communication with the end outflow vessels), and anything and everything in between.

Glaucoma Symptoms

For better or worse, glaucoma is a pretty insidious disease.  Just as arterial hypertension has been referred to as the silent killer, glaucoma has been dubbed the silent blinder, simply because, as a rule, there aren’t many symptoms.
The blindness of glaucoma stands in stark contrast to the vision loss in conditions like macular degeneration.  In macular degeneration (which affects the most central, most defined part of your vision) the vision loss is pretty much impossible to ignore – it’s literally right in front of you at all times.  With glaucoma, however, the vision loss creeps in slowly from the sides.
Additionally, in most cases, there is no pain with glaucoma.  Yes, the pressures may be too high for the eye, but they’re not high enough to cause physical discomfort.
And so, without consistent testing, glaucoma may go undiagnosed for years.

Glaucoma Prognosis

Admittedly, glaucoma prognosis is a hard one for me, because there’s no guarantee.
In school, we are generally taught that glaucoma is a slow moving disease – there’s no need to rush treatments.  And, especially in POAG, that’s true.
However, not all glaucoma is primary open angle glaucoma.
And not all POAG progresses the same.
I’ve seen patients who have been on single drop therapy for years with virtually no change to their optic nerve and visual field.
I’ve worked with patients who are on maximum medical therapy (three different eye drops with different mechanisms of action) and are still progressing.
I’ve had patients who have mild visual field loss that barely impacts their daily functioning.
And I’ve had patients who are literally blind, with no perception of light in either eye, from aggressive glaucoma and improper treatment.
It just… depends.

Glaucoma Risk Factors

What does glaucoma depend on?  Well, that’s where some risk factors come into play.
  • Age – generally, a younger diagnosis is a worse prognostic factor
  • IOP – often (but not always), the higher the IOP, the greater risk of damage
  • Being black, Asian or Hispanic
  • Family history – glaucoma is definitely hereditary.  If a close family member has glaucoma, and especially if they went blind from glaucoma, tell your eye doctor!
  • Medical conditions: Other medical conditions, like diabetes, heart disease, and high blood pressure, put stress on ocular tissues and can increase the risk of glaucoma.
  • Thin corneas – odd, but true
  • Being extremely nearsighted or farsighted
  • Eye trauma


Since glaucoma is a (generally) asymptomatic, potentially blinding disease, please go to the eye doctor regularly – especially if you have any of the above risk factors.  The sooner glaucoma is found and treated, the better the long-term prognosis.
Glaucoma is not a curable disease, but it is a treatable disease.  If you are diagnosed with glaucoma, follow your doctor’s advice.  If they say you need drops, you probably do.  If they say you need surgery, you probably do…even if you don’t notice any significant changes to your vision.
If you learned something from this post, please share it with a friend or family member!  If you liked it, please subscribe, or like my page on Facebook! And as always, if you have any questions or comments, please contact me – I’d love to hear from you!


Optometry in Focus: Macular Degeneration

Happy Friday, y’all!
First things first: if you haven’t guessed it by now, here’s the official notice – I will probably not be blogging here every week of 2021.  In fact, I know I won’t.
The 1/1/21 version of Hannah was feeling very ambitious when she made that goal… while concurrently starting a 100 day blog, increasing the daily patient load, working out more consistently, learning organ, organizing service music, and attempting to foster a social life.
Too ambitious.
And so, the 2/1/21 version of Hannah (or 2/5… whatever), is backing that goal down to something more realistic.  Like, maybe a post a month.
Okay, now, all disclaimers aside, let’s get to eyes.
As I have, somehow, managed to switch my career to the complete opposite end of the age spectrum, from pediatrics to the (often) very advanced in age (believe it or not, the exam techniques are pretty much identical), the primary diseases that I’m working with have changed as well.
The last two weeks, I have had the pleasure of discovering macular degeneration in a plethora of patients who didn’t know (or at least didn’t remember being told) that they had the condition.
Which, I guess, makes this the perfect time for a (somewhat) in-depth discussion on the disease.
Let’s get started.

What is Macular Degeneration?

Age-related macular degeneration, or AMD, most simply put, is a disease that causes a degeneration, or breakdown, of the macula, or most central part of the vision.

What happens in Macular Degeneration?

All macular degeneration starts with the dysfunction of special retinal cells called the retinal pigmented epithelium (RPE).  These cells are responsible for maintaining the health of the photoreceptors (light-receiving cells).  Without the RPE doing their job, byproducts build up, creating a toxic environment (with lipofuscin) and disruption of physical cell apposition (drusen), eventually leading to photoreceptor death.

During this process, the immune response is also activated, further damaging cells and, at times, leading to the formation of new blood vessels.  Unfortunately, the blood vessels that form, form quickly, and with improper barriers, allowing blood to leak from the vessel walls.  This blood is also toxic to retinal cells, causing further vision loss.

What causes Macular Degeneration?

The complete cause of AMD is unknown, however, all current research points to several factors coming into play in the disease process.
  • Genetics: Macular degeneration tends to run in families.  Not all of the genes responsible for AMD have been isolated, but a specific gene has been found that seems to explain ~50% of AMD cases.
  • Oxidative stress: Okay, so we all know that “oxidative stress is bad” and “anti-oxidants are good”, but how many of you have thought back to the mechanism of action behind this line of thought?  For those of you who haven’t, here’s a quick review:
    • In the process of cellular respiration (aka metabolism), glucose and oxygen are combined to create carbon dioxide, water, and energy through oxidative phosphorylation.  However, sometimes this process doesn’t work properly, and creates free radials (or reactive oxygen species) that easily react with, well, whatever they run into.  Over time, this can cause permanent damage to the cell/tissue/organ.
    • The eye, specifically the macula, has the highest metabolic rate of the entire body. Which means that it has the highest potential for free radical formation, and consequently, permanent damage from oxidative stress.
  • Inflammation: We already talked about this one, but, for those of you who missed the memo, inflammation, especially chronic inflammation, is really hard on the body – eye included.
  • Protein deposition: Again, this was mentioned above, but for a slightly different wording, physical separation, by any cause, of the RPE and photoreceptors is a recipe for cell death.

Type of AMD

Generally, AMD is divided into two types: dry, and wet.
  • Dry macular degeneration is characterized by a lack of neovascularization (leaky blood vessels).
  • Wet macular degeneration is characterized by the presence of neovascularization.

Unfortunately, these two types are not mutually exclusive.  Most individuals start out with dry macular degeneration, and may or may not progress to wet macular degeneration over the years.

Signs and Symptoms of AMD

From a patient standpoint, the earliest signs of AMD are normally distortions in central vision, or mild decrease in visual acuity.
Over time, this progresses to significant decreases in central vision.
*Note: I said central, because this condition ONLY AFFECTS the very center part of vision.  Side vision? That remains unscathed.  For this reason, patients with AMD may have a hard time reading, picking up small objects, or recognizing faces, but they won’t be running into walls, despite having a visual acuity that may be recorded as hand motion, or counting fingers at ___ feet.
From a clinical perspective, the first changes that I may see are generally drusen (cellular deposits) and pigmentation changes in the macula.  Over time, the drusen generally increase in number, and atrophy (or tissue loss) at the macula becomes more obvious.   In some (wet) cases, there may be bleeding or blood around the macula. In other (dry) cases, there may be significant atrophy – to the point where we describe it as “geographic.”  Finally, in very late stage (wet) AMD, there may only be a large (disciform) scar visible in the area where the neovascular net/membrane previously was.

Who gets AMD?

Macular degeneration has several known risk factors:
  • Age (with the risk being highest for those over 80)
  • History of smoking
  • Obesity
  • Family history
  • Being caucasian
  • History of excessive UV exposure

Treatment for (and Prevention of) Macular Degeneration

One of the greatest preventions for AMD is simple: DON’T SMOKE.
(Yes, that is in all caps, bolded, underlined, and italicized. This is the number one modifiable risk factor.  You can’t change your age.  You can’t change your family history.  You can’t change your race.  But you can change whether or not you smoke.  And yes, even if you’ve smoked before, STOPPING NOW IS BENEFICIAL!)
The second greatest prevention? Eat right.  No, I’m not a dietician, and can’t tell you 100% what you should eat, but a healthy diet with healthy fats and green leafy vegetables has been shown to increase systemic inflammation – and that affects your eyes too.
For those who already have AMD:
With dry AMD, I always tell my patients that there’s good and bad news.  The good news is, it generally progresses slower, and may never result in super significant vision loss.  The bad news? There’s not much we can do for it. Some people suggest “eye vitamins”, but really, the specific AREDs formulation has only been shown to have an effect in eyes that already have moderate to severe disease.  And so, those are the only ones that I really suggest it for.  Otherwise, just pay attention to your vision, and come in if you think you’re noticing changes.
With wet AMD – good news! There are treatments!
Unfortunately, they’re generally shots.  In your eyes.
However, these intraocular medications have been proven to reverse blood vessel growth.


If I’m honest, prognosis is probably the hardest part for me to talk about with patients, because there’s no guarantee.  Some people stay at early to intermediate stages indefinitely, and notice relatively mild visual changes.  Other people progress more quickly, and have much more significant visual concerns. At the end of the day, the only thing I can promise is this: as an eye doctor, I will do my best to help each of my patients see as much as possible for as long as possible.
Sometimes that means taking vitamins.
Sometimes that means a referral to a retinal specialist.
Sometimes that means working to find the right magnifiers for reading and other near tasks.
Sometimes that means a relatively minor glasses change that helps you feel more visually confident.
Sometimes that means finding filters that increase contrast to help in certain environments.
Sometimes that means educating about lighting – when it may be too much, or too little.
Sometimes that means connecting you with a center that works with the visually impaired.
Sometimes that means a referral to vision or occupational therapy to learn how best to use your remaining vision.
Sometimes that means having the hard conversations about not being able to drive anymore.
And sometimes that means just being there while you process the information, and being available to talk if you need to.
If you learned something from this post, please share it with a friend or family member!  If you liked it, please subscribe, or like my page on Facebook! And as always, if you have any questions or comments, please contact me – I’d love to hear from you!


Optometry in Focus: Dry Eye

Happy SaturdayMonday…Tuesday, y’all!
So, full disclaimer – I wrote this post on Saturday, only to be too tired to post it after a long day of traveling. When I finally looked at my blog on Sunday (since some of the content of my post felt familiar), I realized that I had already posted something dry eye related several months ago, in the form of a discussion on Computer Vision Syndrome.
But, who wants to let an hour or so of blogging go to waste?
Certainly not I!
Besides, considering the prevalence of dry eye in society, what harm will another post do?
Okay… now back to the post!
Today’s blogging challenge?
Coming up with a topic that I don’t need wifi to complete.  #inflightprobs
Thinking of flying though, I guess there’s no better time than now to discuss a common flight (and winter) problem:  dry eye.
So, before we can really jump into what dry eye is, let’s go over a quick ocular anatomy review!
First things first: the cornea.
    The cornea is the clear, front surface of the eye, that is responsible for a significant portion of your vision.  If this surface becomes hazy, clouded, swollen, or irregularly patterned, it causes significant distortions to vision.
    Around the cornea is the limbus – a special transition zone, where the cells responsible for corneal formation reside.
    After the limbus, we arrive at the conjunctiva.  The conjunctiva (or conj for short) is actually another thin, clear layer, that covers the rest of the front surface of the eye (the bulbar conj) and the inside of the eyelids (the palpebral conj).
    All of these anterior (or front) surfaces are bathed by tears to remain healthy and clear.
Great, we’re done now, right?
Not so fast.
Let’s take a little bit of a deeper look at the tears themselves.
Tears are, believe it or not, comprised of three layers – the mucin, or protein layer that allows the tears to remain on the front surface of the eye, the aqueous, or watery part of the tears that, well, helps them maintain the proper moisture content of the front surface of the eye, and finally, the outer lipid, or fatty layer.
These three layers work together to protect and nourish the front surface of the eye, by providing oxygen and nutrients, carrying vital immune cells, and washing away debris.
Okay, now onto dry eye!
Dry Eye

So, first things first, dry eye is an inflammatory condition affecting the anterior (front) surface of the eye. 

Dry eye, as everything else in life and optometry, comes in a couple of different forms:

  • Aqueous deficient – not enough (quality) tears are produced 
  • Evaporative – there’s not enough lipid, or fatty, component in the tears, causing them to evaporate more quickly, leaving the anterior segment dry and irritated.
These two types of dry eye, naturally, have different causes.
Aqueous deficient dry eye, as a problem with production, may be associated with age to corneal nerves, dysfunction of the lacrimal (or tear producing gland), or simply a natural age associated decrease.

Evaporative dry eye, on the other hand, is caused by improper lipid formation.  This is often due to a disease called Meibomian Gland Dysfunction, or MGD for short.

Who Has Dry Eye?
If I’m honest, literally anyone can suffer from dry eye.
Dry eye, as I’ve mentioned before, can be significantly exacerbated by external forces, such as a dry environment (ie an airplane or the desert), fans, heat, or air conditioning.
Additionally, dry eye may be worsened by excessive screen time, as screen time is proven to significantly decrease blink rate, and therefore tear distributions, as well as contact lens overwear.
Finally, dry eye has also been shown to worsen with age, disproportionately impacting post-menopausal women.

Signs and symptoms
While dry eye may affect anyone and everyone, the signs are typically similar in all age ranges of patients.
Generally, patients present with complaints of red, irritated, watery eyes, that often feel like something is in them.
They additionally also report variable vision, that seems to improve for a couple of seconds after blinking.
In addition to just physical signs and symptoms, your eye doctor may perform several tests to better understand your specific dry eye.
    Tear Break-Up Time (TBUT): In this, the doctor literally measures (in seconds) how long it takes for your tear layer to start dissipating or breaking up on the front surface of your time. This test is generally short – under 20 seconds total, 10 for each eye.  The lower your score is, the worse dry eye you generally have.
    Tear Meniscus Measurement: This test just involves looking at the amount of tears that lie on your lower eyelid while looking from behind the slit-lamp (big microscope). If it is too low, it is generally a sign that not enough tears are being produced.
    Schirmer’s Test:  Schirmer’s is another test of the amount of tears produced by the eye.  In this, a little piece of paper is put between the eye and the bottom eyelid for a (relatively) short amount of time, to quantitatively measure tear production.  This test has two varieties – one that involves numbing your eye first (decreasing reflex/automatic tearing), and one that… doesn’t.  **Not my favorite test**
    Phenol Red Thread Test: This test is very similar to Schirmer’s, however, instead of a smal piece of paper, a tiny red thread is place in between the eye and the bottom eyelid, to again quantitatively measure tear production.  This test is very quick (around 5 seconds/eye), and much less invasive than Schirmer’s – making it more enjoyable for patients and doctors alike!
    Corneal staining:  In this, a small amount of dye (generally fluorescein or lisasmine green) is placed in each eye, with the goal of highlighting inflammation on the front surface of the eye.  The staining pattern observed may help determine the cause of ocular dryness (exposure, etc).
    Meibomian gland expression: Meibomian gland expression is especially helpful when it comes to diagnosing MGD.  For this, the practitioner gently pushes on the meibomian glands (generally in the lower eyelid) to determine the expressivity and consistency of their lipid product (meibum).  Thicker meibum is generally indicative of MGD.
    Tearfilm osmolarity: Finally, or at least finally for now, some offices have the ability to test tearfilm osmolarity, typically using a device called Tearlab.  (How many of you remember back to Chemistry for what this means?  It’s something with number of particles/amount of water… right?). Higher values are more closely correlated with dry eye.
Phew. That was a lot.
Okay, so now that we know some of the ways dry eye can be diagnosed… what in the world do you do about it?
As a rule, there is a step-wise approach to dry eye treatment, that varies some depending on the original cause, however, I am out of time to write about them for today.  Catch y’all next time!
If you learned something from this post, please share it with a friend or family member!  If you liked it, please subscribe, or like my page on Facebook! And as always, if you have any questions or comments, please contact me – I’d love to hear from you!
If you’re interested in reading my first post, Computer Vision Syndrome: Addressing Dry Eye, click the link to check it out!
PS: My apologies for the formatting issues on this post.  I wrote it in Google docs (because, flying…) and then copied it over to blogger.  Lessons for next time…

Hannah Vollmer, OD: Life Update 2021

Happy 2021, y’all!
Wow. It’s been a really long time since I’ve posted in this blog – sorry about that!  It would seem that life has gotten a bit away from me.

With the new year, however, I figure it’s the perfect time to get back to publishing Hannah’s hot takes on all things optometry.  (This phraseology stolen from one of most faithful readers, and up-and-coming OD, JH.  Thank you!)

But first, let’s do a quick(ish) life update!
Okay, so, the last time I wrote anything about my actual life, I was living in Texas, had just finished residency, and was beginning the lovely process of job searching.
*News Flash*
I don’t live in Texas anymore!
At this point, I have moved back to the Midwest, to work as a mobile optometrist at long-term care facilities and nursing homes.
What does this look like?
My average day goes something like this:
  • I leave between 6:30a and 7:45a to travel to my facility for the day.  My longest drive days are ~2 hours, and my shortest drive days are 30-40 minutes
  • When I arrive, I unpack all of the equipment from my car, take a COVID screening test at the door, and then meet with my facility contact to assess the day’s patient list.
  • My contact takes me to my base for the day (usually a beauty salon, but sometimes just an empty bedroom), where I then unpack all my equipment.
    • Depending on the current facility lock-down status, I will either prepare my room to be a makeshift exam room, or I’ll load everything onto a cart to take around from room to room.
  • Once I’m set up, it’s time to see patients!
    • The optimal set up is when residents are brought to my room for their exams (normally about 20 minutes, including refraction and dilation), but bedside exam days mean lots more steps!
  • Currently, I typically see ~10 residents per day, all with varying levels of physical and cognitive abilities.
    • Exams can be comprehensive, problem-focused checkups, or simple glasses checks to make sure that what was ordered fits the resident’s needs.
  • Once I finish with all the scheduled exams (generally between 12p and 2p), I pack my equipment back up, give written orders for any necessary medications to the nursing staff, and head back home!
  • At home, I finish charting, review my following day’s patient list, and then enjoy the remainder of the day!

Perks of the job:

  • Flexible schedule:  There is no defined time that I have to be at a facility.  I typically aim to get there ~8:30a, that way I can meet with my contact before morning meetings (~9:00a).  Also, it allows me to see most of my patients before lunch (I’ve learned that some of them get very upset when you come between them and food… especially with a Tonopen or dilating drops), and before they fall asleep for an afternoon nap.
  • No defined patient count: I largely get to choose how many residents I see a day.  Most docs with the company see 10-14/day, with some seeing fewer, and others seeing up to 20.
  • Work/life balance:  My typical work day, including driving (sometimes 4 hours), working, and charting, is done by 4.  And, there is no overhead for me to worry about.  So, once my charts are submitted at the end of the day, I’m done. 
  • Incredible EHR:  The Electronic Health Records system that the company uses was designed entirely in house, and by doctors.  It is completely intuitive, allowing for fast, easy charting.  Additionally, any suggestions or complaints are submitted directly to the designers, who quickly implement necessary changes.
    • Oh yeah, and it’s all housed on a system with onboard internet, so wifi connectivity is never a problem.  
  • Fantastic support team: Despite being on my own at each facility, I have 24/7 access to my “provider support team” via email, phone, fax, or HIPAA secure text, that allows me to troubleshoot any problems while on the job. (Or anywhere else for that matter…)
  • Variety:  Since starting optometry school, I have always said that I didn’t think I could survive in a bread and butter optometry practice that primarily focuses on prescribing glasses and contacts. (Maybe this is because I find refraction – which is better 1, or 2 – to be one of the most boring procedures employed in our profession.  While shadowing docs, I have literally started nodding off during it.  Thankfully, I’ve yet to fall asleep while performing the task, but, you get the picture.)  With this job, every patient is a new challenge.  Between bedside exams, trying to get as much information as possible out of a completely non-verbal patient, learning to understand what my aphasic residents are telling me, and Macgyvering a pair of specs to hold until a new pair can come in, all while effectively diagnosing, managing, and treating ocular disease, there is literally never a dull moment.  And I love it.*

Downfalls of the job:

  • Referrals are difficult: In this lovely COVID era, getting residents to see the proper external practitioners has been difficult.  Many residents are in poor health to begin with, and thus, facilities are hesitant to risk their physical well-being for an external appointment.  Unfortunately, this means that I have seen patients who are seeing 20/400 due to mature cataracts that have been unable to be removed for over a year, or patients with retinal bleeding that have been unable to receive treatment for proliferative diabetic retinopathy, therein increasing their risk of significant, permanent vision loss.
  • No scribes or techs:  Admittedly, during optometry school, and even through residency, I dreamed of being in a practice where I had scribes to take care of all the charting, and techs to do most of the work-up.  And here I am with neither.  Thankfully, however, this gives me an opportunity to work on my own optimal exam efficiency.
  • COVID:  Obviously, nursing homes and long-term care facilities have been among the most hard hit by the effects of COVID.  Some days, nearly all of the patients on my schedule have had COVID, and many are still feeling the effects.  Additionally, there is significant concern of me bringing the virus into the facility, or taking it home to my loved ones at night.  As such, I wear enough PPE (personal protective equipment) to literally be sweating in a 60 degree room – which is hard to find in a nursing home.  You can only imagine how it is performing retinoscopy (figuring out a glasses prescription) over a heater in an already 80 degree room.  However, I’m happy to wear it all if it means that I, my patients, and my friends and family are safer! 
  • Long drives: As much as I like driving, some days the 6:30 leave time, hours of darkness, and travel through snowy areas is a lot.  Prayers for safety, alertness, and good conditions appreciated!

 Random tidbits:

  • COVID Vaccine: Being a doctor working with high risk populations, I was among the first to be eligible and subsequently receive the vaccine.  I have only received the first dose so far, but have had minimal side effects – some upper arm soreness, three days with a mild headache (though that may also be attributable to sinus pressure with changing weather conditions), and some mild fatigue (I was less ready to get up before 5 than normal for 1-2 days).  I’ll keep you posted as to how things progress after I receive the second dose!
  • COVID Testing:  Additionally, due to the patient population that I work with, I receive a COVID test a minimum of once per week.  (PS: The nasal swab is much better when you can perform it yourself, rather than having someone else try to swipe up to your brain!)  The biggest downfall with this is delay of results (especially around the holidays), which can become an issue on the first days of the week when my new results have yet to come in.  However, thankfully, many facilities have rapid-testing capabilities to allow me to test on-site before beginning patient care for the day!

Annnd I think that about covers it!

Regarding this blog, I’m currently hoping to begin a once a week pattern of posting.  The publishing day will probably be variable, depending on how my week pans out, but stay tuned for more exciting posts from your favorite young OD!
*Side note: I have genuinely been grateful for the additional training that I obtained during residency literally every day that I have been on the job.  I use tips and techniques that I gained during the past year on a daily basis, and could not imagine taking on this position without that experience.  So, if you’re a young OD-to-be on the fence about residency, or know someone who might be, this is my shameless plug for residency.  Just do it.  It may not feel like it at the moment, but residency is 100% worth it.
If you learned something from this post, please share it with a friend or family member!  If you liked it, please subscribe, or like my page on Facebook! And as always, if you have any questions or comments, please contact me – I’d love to hear from you!

Contact Lenses: Presbyopia and Contacts

Happy Thursday, y’all!

After a couple of weeks off, thanks to harvest, this cool rainy day provides the perfect opportunity to hit the blog again.  Today’s topic? Presbyopia and contact lenses!

As a quick refresher, presbyopia is the lovely condition that usually begins to rear its ugly head in people over the age of 40, in which the eye is no longer able to adjust focus from distance to near, making near tasks, such as reading and computer work, more difficult.

In my full discussion on presbyopia, I provided several spectacle options – reading glasses, bifocals/trifocals, and progressives – but what about those people who prefer to wear contacts? Are they out of luck?

Thankfully, no! There are lots of options for presbyopic contact lens wearers.  Let’s check them out!


Monovision is probably one of the oldest methods for providing near and distance correction without the use of spectacles.  In this, one eye is adjusted for near, while the other (the dominant eye) remains corrected for distance.  From my experience, this is most successful when relatively little near correction is needed, as it’s easier to adapt to small differences between the eyes, rather than large differences.  Unfortunately, with age, more and more near correction is needed, until reaching a plateau at 2.50-3.00 diopters of additional power.  This prescription difference is somewhat hard to quantify verbally, but it’s essentially like seeing the 20/20 line perfectly clear in one eye, and then only being able to see the 20/125 line with the other.  Yikes!
Naturally, this difference can cause a host of problems, from glare and halos in the near eye with night driving, to issues with depth perception, to simply discomfort during every day tasks due to the sheer power difference!
Needless to say, monovision is NOT my favorite option.  Let’s see if we can’t find something better.

Soft Multifocal Contacts

Soft multifocal contacts are a newer technology that is designed to provide both distance and near correction in the same lens.  These come in daily, two week, and monthly modalities, with a variety of designs.
For those who perform more distance tasks, but still need near help, a center-distance lens may be suggested.  Conversely, for those with more of a near focus, center-near lenses are an option.  In each of these, there is a power in the center (either your distance or near prescription) that is then progressively varied in peripheral rings to provide either distance or near correction.  Additionally, a few “simultaneous” options are provided that contain alternating concentric rings of distance and near power, where the user learns to focus on the appropriate image at the appropriate time.
Out of these, the center-distance/center-near designs are my favorites, as I find they are generally the easiest for adaptation.  However, soft multifocals are not for everyone.  Due to the dual power design of the lens, vision tends to be decent at all distances, but perfect at none. Nevertheless, these lenses provide an excellent option for those desire spectacle free optical correction, and can tolerate mild imperfections.

Hard Multifocal Contacts

For those wanting clearer vision while still wearing contacts, hard multifocal contact lenses may be an option.  These lenses work essentially like a bifocal (or trifocal) lens that sits on your eye – line included, with the premise that the lens will translate, or move, as your eye does, to allow you to reach the near portion in down gaze, and stay in the distance prescription in primary/central gaze.
Admittedly, hard multifocal contacts are generally not my go to, simply because I’m less comfortable with fitting them, and often find that only those long-standing hard contact lens wearers are interested in this option.  Nevertheless, they often provide clear vision at most distances for those who can tolerate their initial discomfort!

Spectacle Over-Wear

Last but not least, let’s cover the final option for contact lens wearers – having spectacle correction too.
In this, both the contact lens and spectacle prescriptions are up to you.  Do you prefer to be glasses free when you’re driving and looking in the distance? Or are you on the computer all day and prefer to only add your glasses for distance tasks?  Or, do you prefer to switch it up, depending on the requirements of the day?
Guess what?  With spectacle over-wear, you can do it all.
While I’m not yet to the presbyopic stage, this will probably end up being my preferred method by the time that day arrives, as it is arguably one of the most cost effective options that maintains vision quality.
For those preferring contacts for distance, great!  Buy some cheap over the counter reading glasses (of varying prescriptions based on the task distance) and store them where you’re likely to need them!
Conversely, for those who are more commonly working at near, get a cheaper pair of glasses (maybe even online…) to throw on when you need crystal clear distance vision!
Win. Win.
If you learned something from this post, please share it with a friend or family member!  If you liked it, please subscribe, or like my page on Facebook! And as always, if you have any questions or comments, please contact me – I’d love to hear from you!

Optometry in Focus: Conjunctivitis (Pink Eye)

Happy Monday, y’all!

With school back in session and cooler weather on its way, I suppose it’s time for a discussion on conjunctivitis, colloquially known as pink eye.

But first, let’s start with a quick ocular anatomy review.


Despite how tempting it would be to just post a picture with fancy labels and the like, I think this section will work the best if you stop what you’re doing for a moment and find a way to look at your eye – a mirror would probably be the easiest.
What do you see?
If you’re like most people, you’ll notice the colored part, or the iris, first.  If you get really close to the mirror or change the lighting, you should be able to see a change in the size of the dark hole in the center of the iris. This is your pupil, which varies in size to adjust the amount of light coming into your eyes.
Above the iris and the pupil is the cornea.  This clear structure is difficult to truly see in the mirror, but if you wear contacts, this is what the contact drapes over.
In addition to the colored portions, you’re surely able to see the white part of the eye, or the sclera, which functions to maintain the shape and structure of your eye, while providing a protective barrier!
What’s missing?
If you look very carefully (or wash your hands and gently touch the white part of your eye), you’ll notice that there’s an easily moveable jelly-like material that covers a majority of your eye (minus the cornea).  And, unsurprisingly, its this structure, the conjunctiva, that is highlighted in the post today!
Ready?  Let’s get to it!


Now that we’ve got the basic anatomy down, the question is: what is conjunctivitis?
For those of you fluent in medical-ese, you’ll know that the suffix “itis” means inflammation.  In this case, the inflammation is of the conjunctiva.
Now, conjunctivitis can come in various forms – predominantly bacterial, viral, and allergic – depending on the offending agent.  In each of these cases, a foreign object is identified by the immune cells circulating in the conjunctiva, which then activates the immune response to remove the unwanted material.  Unfortunately, this process creates inflammation – the symptoms of which are determined by the particle causing the immune response.

Viral Conjunctivitis

Viral conjunctivitis is inflammation of the conjunctiva secondary to an immune response to a viral particle. Common symptoms are:
  • Watering
  • Irritation
  • Mild light sensitivity
  • Pinkish red eye
  • Typically one eye, or one eye before the other
This often occurs in someone with a history of an upper respiratory infection, or exposure to someone with an upper respiratory infection.
Viral conjunctivitis is highly contagious (arguably the most contagious type of conjunctivitis).  For this reason, when people present with viral conjunctivitis should refrain from touching their eyes (it easily spreads between eyes as well), wash hands frequently, clean pillowcases, and use their own hand towels, etc, to prevent the spread of the infection to others in the household.
Unfortunately, especially considering the high transmission rate of viral conjunctivitis, there is no true treatment for this condition (just as there is no treatment for the common cold).  Rather, the focus is on reducing symptoms through cool compresses and artificial tears.  In cases of extreme symptoms, providing there is no corneal involvement, topical steroids may be used.

Bacterial Conjunctivitis

Bacterial conjunctivitis, as could be assumed, is inflammation of the conjunctiva caused by an immune response to bacteria.  Common symptoms are:
  • Deeper (beefy) red eye
  • Irritation
  • Significant discharge
  • Typically one eye, or one eye before the other
Bacterial conjunctivitis is also contagious, however, generally less than viral.  Additionally, this condition is generally easily managed with topical antibiotics.

Allergic Conjunctivitis

This topic is one that I already covered in my post on ocular allergies.  For a quick review, however, allergic conjunctivitis is inflammation of the conjunctiva in response to, well, a number of different particles (of non-viral or non-bacterial origin).  Common symptoms are:
  • Light red eye
  • Itching
  • Mild watering
  • Potential swelling of eye lids
  • Normally both eyes at the same time vs one then the other
Allergic conjunctivitis is NOT contagious, so there is no concern of spreading it at school or between family members. Additionally, allergic conjunctivitis can be treated with over the counter or prescription topical (or occasionally oral) medications.

Parting Advice

Regardless of the type of conjunctivitis, it is important to remember to wear glasses, rather than contacts, during times of ocular inflammation.
Additionally, if you are experiencing symptoms, it’s always wise to talk to your optometrist, even if you think you may know what’s going on.
If you learned something from this post, please share it with a friend or family member!  If you liked it, please subscribe, or like my page on Facebook! And as always, if you have any questions or comments, please contact me – I’d love to hear from you!

Contact Lenses: Ortho-K (Corneal Reshaping)

Happy Monday, y’all!

In today’s post, I’m taking a break from the world of neuro to answer a reader question.

JM writes: Do they still do corneal molding?  I did that for a while and loved it! I wore contact lenses at night, took them off in the morning, and could see without anything!  After a while, I didn’t even have to wear them for several nights at a time and could still see!  Freedom!!

First off, thank you so much for your question, JM!  And, believe it or not, yes we  still use corneal reshaping (or ortho-keratology) in practice! Keep reading to learn more!

Ortho-Keratology (Ortho-K)

What is Ortho-K?

As JM described in her question, Ortho-K is a process by which the cornea is molded by wearing specialty hard contact lenses over night to correct (myopic/near-sighted) refractive error.

How It Works

This process that was first introduced in the 1960s uses a gas permeable lens design that sits directly on the cornea, rather than slightly vaulting over it, to create a flattening effect.  This flattening decreases the radius of curvature of the cornea (steepness), secondary to temporary epithelial redistribution, therein decreasing its convergent power.  As myopic or near-sighted eyes have a focal point in front of the retina, this change in convergence repositions the focal point, optimally on the retina.

With that in mind, it only makes sense that different eyes will require different amounts of flattening to correct the prescription, with higher prescriptions necessitating more flattening, and lower prescriptions needing less.

This flattening is focused over a (generally) four millimeter treatment zone.


Once the decision to pursue Ortho-K has been made, the process of fitting and prescribing generally goes something like this:

  1. Complete eye exam, including refraction, dilation and thorough front surface/corneal evaluation: Ensures the health of the eye and determine the current refractive needs
  2. Corneal measuring, using a keratometer: Determines the parameters of the lens for fitting
  3. Lens fitting, or actually putting lenses on the eyes: Making mild adjustments until the appropriate fit and vision are achieved
  4. Insertion/removal training: Learning how to properly use the lenses themselves
  5. Lens dispensing: Sending the lenses home
  6. First follow-up: Generally a morning appointment after the first night of wear, with the lenses still in, to verify the fit of the lenses after wear
  7. Additional follow-ups: Often spaced at one, two, four, and eight weeks to continue monitoring stability of fit


As JM mentioned, Ortho-K can be incredibly freeing, allowing patients to go without glasses or contacts during the day (and sometimes even a few nights).  This then provides an attractive, reversible alternative to LASIK.


While Ortho-K can be an awesome option for refractive error correction, it isn’t for everyone.  Some common complaints are:

  • Lens intolerance: Ortho-K requires sleeping in a hard contact lens. For those of you who have never worn them, hard lenses are called hard lenses for a reason – they’re modestly hard pieces of plastic!  While most people adapt to the lenses well, some people cannot tolerate even overnight wear of the lenses.
  • Glare/halos/distortions: This process is literally moving some of the cells on the front surface of your eye to temporarily change the power, which can cause distortions in vision – especially when driving at night, in the form of glare and halos.  It’s the worst in patients with large pupils that extend past the treatment zone, putting those distortions directly in your line of sight.
  • Temporary correction:  While JM was one of those with a successful enough Ortho-K run to be able to go several days without retreatment, this is not the case for everyone.  Some people report visual changes before the end of the day, requiring additional lenses for clear vision in the evening.
  • Risk for infection: While this risk is relatively low, it’s worth mentioning, after all, Ortho-K requires sleeping in contacts.. which is normally highly discouraged by providers.
  • Prescription parameters:  Due to the corneal flattening nature of Ortho-K, is primarily indicated for people who are near-sighted, or myopic.  Additionally, it works best on moderate to low prescriptions, with mild amounts of astigmatism.

Additional Indications

In relatively recent years, Ortho-K has been investigated as a method of controlling myopia progression in children and teens, secondary to its creation of peripheral myopic blur.  This myopic blur serves to inhibit axial elongation (or prevents the eye from getting longer), therefore decreasing myopic progression.  While results vary by case, studies have proven that Ortho-K may reduce progression by, on average, 45%.  As such, Ortho-K is an attractive option for young, near-sighted individuals, as it provides unobtrusive day-time refractive error correction while concurrently reducing myopic progression.

Personal Experience

My first personal experience with Ortho-K was during the summer of my first year of optometry school, when I was lured by the financial gains and visual promises of a corneal reshaping study. The process went much like how I described above, with the exception of some additional study related measurements and paperwork.  All seemed to be going well until somewhere around a week or so into the study – I had even been able to go without wearing any lenses for the first time in like 13 years.  It felt so freeing!

Until I went out of the sun.

Everything was blurry. Everything had halos.  I got dizzy and nauseous just looking around.

But I was determined to succeed and convinced it would pass, if only I wore the lenses more.

(Mind you, this was over July 4th, and I was on vacation.)

I tried.  And tried.  And tried.  No matter how many hours I wore the lenses (which became increasingly difficult as the irritation of wearing the lenses increased), nothing got better.  I was miserable.

Finally, I texted my contact in the study and informed her that I could take it no longer.  Whether she liked it or not, I was done.  I threw on my brother’s glasses (which happened to be just the prescription that I needed during the transition), and never looked back.

A few weeks later when I returned to school to turn in my lenses, I discussed my results with the study coordinator.  Our best guess theory was that a combination of my relatively large pupil size and moderately high prescription (I was at the upper bounds of the study limits) created the distortions that plagued me during the study, and while we were curious of the effects of a larger treatment zone on my visual outcome, I was too over it to continue.


Considering my personal experience, it would probably be reasonable to wonder if I believe in prescribing Ortho-K lenses at all.

Admittedly, it did take me a while to come to terms with the benefits of the lenses, but now, I am happy to prescribe corneal reshaping therapy.  It definitely has its place in current optometric practice, and over time, I have come to accept that my experience was more of an exception, rather than the rule.

With this in mind though, I am more cautious with Ortho-K prescribing, typically preferring it for younger patients with fewer visual demands and a lower prescription.

If you learned something from this post, please share it with a friend or family member!  If you liked it, please subscribe, or like my page on Facebook! And as always, if you have any questions or comments, please contact me – I’d love to hear from you!