Category: Optometry

Decoding the Numbers: Astigmatism

Welcome to Part 3 of my series Decoding the Numbers!
In the previous two posts we discussed myopia (near-sightedness) and hyperopia (far-sightedness).  Today, we’re diving into the mildly confusing topic of astigmatism.

Astigmatism

*not “a stigmatism”, not “stigmatism”, not “stigmata”*

What is astigmatism?

  • *Insert football analogy here*
  • Just kidding.  Your eye really isn’t shaped like a football in astigmatism.  Rather, astigmatism occurs when there is more than one power in either the cornea or the lens, as a result of different amounts of curvature. These differences in curvature are generally located 90 degrees away from each other.
  • Here’s a picture to try to help explain:
    • In this picture, the red is the steeper, or more curved part (think tennis ball).  The blue is the flatter, or less curved part (think bowling ball).
JaypeeDigital | eBook Reader
  • Because there are different powers, the light focuses in two different spots in relation to the retina, with one closer (either in front of or behind) to the retina, and the other further (so, more in front or more behind) the retina.

Why do we need lenses?

  • The goal of lenses in the case of astigmatism is the same as the goal of lenses in hyperopia and myopia – to put a clear image on the retina.
  • However, since there are two powers in the eye, there are also two powers in the lens with the goal of putting both images on the retina.
  • Some people are lucky and have the perfect split in the two powers that a relatively clear image falls on the retina without glasses.  In these cases, wearing lenses may make the image slightly better, but glasses aren’t a requirement.

Who gets astigmatism?

  • Refractive errors in general are thought to be inherited.  Astigmatism is no different.  If you have a history of family members with significant astigmatism, you’re more likely to have it too.
  • Astigmatism can occur in both near-sighted and far-sighted individuals.
  • Most infants are born with a moderate amount of astigmatism that tends to decrease with age (along with their hyperopia).  The concern comes when the level of astigmatism is outside normal ranges, and fails to decrease with age.
  • Astigmatism may occur after trauma to the eye that causes corneal scarring.
  • Patients of African-American or Hispanic ethnicity are more likely to have higher levels of astigmatism.

When should I suspect astigmatism?

  • Some signs of having astigmatism are:
    • Squinting, either at distance or near (or both)
    • Complaints of glare or halos around lights

Are there any complications with having astigmatism?

  • If someone has a high amount of astigmatism from a young age that is not treated, they may develop amblyopia, or potentially permanently reduced vision as a result of not having a clear image on the retina.

Can astigmatism 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.

If you have any questions or comments, please contact me!  If you’ve enjoyed this article, please subscribe, or like my page on Facebook!

Why Does My Eye Doctor… Part 3

Hello, and welcome to Part 3 of my “Why Does My Eye Doctor…” series!
*Click here for Part 1 and here for Part 2 of the series*
Today we’ll be discussing the importance of the dreaded “eye puff” test.
Ready? Let’s get started with a quick lesson on ocular anatomy!

Ocular Anatomy

Okay, so before we can really discuss the ins and outs of the “air puff” test, it’s important to know a little bit of anatomy.
I think this picture will do!
Eye anatomy: A closer look at the parts of the eye
So, where we’re focusing in this picture is the big open space between the clear front surface (the cornea) and the colored part of the eye (the iris).  This space is called the anterior chamber (anterior = front).  This chamber – or big space – is filled with a fluid called aqueous humor (aqueous = watery, humor = substance within the body).
Keep looking at the picture.  You should notice that the cornea and the iris come together at an angle.  This angle is called the anterior chamber angle (makes sense, right?).  Cells within the angle make the aqueous.
Within this angle, and unfortunately not pictured here, there is another structure, called the trabecular meshwork.  It’s really just like a fancy drainage system composed in a net/mesh-like format to allow the aqueous to flow out of the eye.
The goal?  Making the amount of aqueous that flows out of the eye essentially equal to the amount of aqueous produced by the eye so that the pressure remains the same.

What is Tonometry?

Okay, so now that we know a little bit about the anatomy of the eye, and so what causes pressure – how do we measure it?
That’s where tonometry comes in.
By definition, tonometry is the measure of the fluid pressure inside the eye.  In this, an external force is applied to the eye until the pressure of the external force equals the pressure of the internal force (as determined by slight flattening of the cornea – don’t worry, it’s not dangerous).
There are a few different mechanisms by which this pressure can be assessed.
Non-contact Tonometry

Aka the “puff of air” test.
In this test, nothing really touches your eye (except a little bit of air), therefore it’s non-contact. The air comes out at a certain pressure, that increases until the specified corneal flattening is achieved.  The air is then shut off, and the pressure reading provided.
This test isn’t always the most accurate – it tends to overestimate low pressures and underestimate high pressures.  That’s why it’s important to get at least 3 readings to provide an average pressure.
Contact Tonometry
As could be expected, in contact tonometry something actually touches your eye (though what it is depends on which specific test is used).  As before, this instrument puts pressure on the eye from the outside until that small amount of corneal flattening occurs.

Why Do We Need It?

Most people have probably heard that we check pressure in the eyes as a test for glaucoma.
It’s 100% true.
Glaucoma is a disease in which the internal pressure of the eye is too great for the eye, causing compression of the retinal nerve fibers at the optic nerve.  Unfortunately, the longer or harder these fibers are compressed, the more likely they are to die, causing vision loss – first in the periphery or outer parts, and eventually moving to the central/inner parts.
To make matters worse, the retina has no pain fibers – in other words, there’s no pain when the tissue is dying – and since it starts on the outside of your vision, even the vision loss takes time to be noticed.  For this reason, glaucoma is considered the silent blinder – there generally are no symptoms.
And, since the retina is brain tissue, once it’s gone, it cannot be replaced.
For this reason, it’s important to have your eyes examined – and their pressures checked – regularly.

Are There Other Options?

In short, yes.  There are multiple instruments that can be used to check the internal pressure of the eyes.  However, not all offices have all options.  The primary ones are:
Non-contact/Puff of Air: Considering this one of the only non-invasive procedures, you’d think it’d be everyone’s favorite.  Apparently it’s not.
Goldmann: This is the gold standard, or most accurate, way of measuring eye pressures.  I typically use this one in patients that I already know have glaucoma, in patients that I suspect may have glaucoma and am watching closely, or in patients where one of the other tests gave an unexpected reading.  Yes, it touches your eye.  Don’t worry – your eye is numb for this test.  You may feel a bit of pressure, but it won’t be painful.
Tonopen: This was my go-to at the in-patient rehab hospital that I worked at.  It tends to underestimate very high pressures, but it works well because it requires very little patient cooperation.

iCare: This one is probably my absolute favorite, because it doesn’t require a numbing drop, and is the most non-invasive of all the procedures (in my opinion).  It may tickle your eyelashes a bit, but that’s literally as bad as it gets!  Unfortunately, it’s again not as accurate, so if I get unusual readings, I then switch over to Goldmann (if possible considering patient age and ability).
Ocular Response Analyzer: This is (as far as I’m aware anyway) the newest technology when it comes to looking at eye pressures.  Similarly to the well known “puff of air” test, it uses air to determine pressures, while concurrently measuring corneal elasticity, or hysteresis.  This is another measure of corneal integrity that can provide valuable information when monitoring for glaucoma.
If you have any questions or comments, please contact me!  If you’ve enjoyed this article, please subscribe, or like my page on Facebook!

But, why blogging?

Last Friday, for a fun change of pace, I wrote a short introductory post about myself (check it out here).  As I’ve been having a hard time deciding what to write about on this dreary Saturday morning (thanks, Hurricane Hanna), I think I’ll switch it up again with a discussion on why I’m here in the first place.  Enjoy!

Why Blog?

If none of you have wondered yet, I’m sure at some point the thought would cross your mind – Hannah, you’re an optometrist.  Why in the world are you spending your days blogging?
In all reality, it’s a great question.  I just spent 5 years, including residency, learning how to treat patients in a clinic setting, and now I’m… writing?  What’s with that?
The answer?  Well, there’s a lot to it.

Writing

Anyone who has been with me – be it in life or online – for any length of time knows that I am an avid writer, and have been for essentially my whole life.  I vividly remember writing (and illustrating) short stories in Kindergarten, that then progressed to long stories in second grade, poems in fourth, daily entries in high school, and finally essays and blogs in undergrad and grad school.  Hannah Vollmer, OD is a space for me to combine my professional knowledge with my personal passion for expression through the written word.

Education

Growing up, one aspiration I never really had was to be a teacher.  It’s not that I have a problem with speaking in front of others – that doesn’t really bother me.  It’s more that I never felt particularly strong at explaining concepts and ideas to others.  Over the past several years, however, I’ve come to rather enjoy this aspect of optometry – learning how to present my thoughts in a way that makes sense to others.
Outside of the normal patient education that occurs within the exam room, this most frequently occurs at parties or family get-togethers.  As a naturally introverted individual, I generally prefer to be towards to the outskirts of these encounters.  However, when eye questions arise, which they inevitably do, I thoroughly enjoy taking the stage and fielding any and all optometry related topics that may present themselves.
These two situations together have alerted me to just how many unanswered questions people have about their eyes.  As someone who’s googled many a question, I fully understand how hard it can be to sort through information and find things presented logically enough to dispel myths, but simply enough to truly grasp the topic.  This is where I come in.
My goal is to take everything that I have learned and will continue to learn about both optometry as a profession and the beautifully complex organ that we call the eye, and present it to you in a fun, personal format that is accurate, but yet easy to comprehend.
Why?
Because, as one of my residency mentors frequently reminded me, knowledge is power.  Just as improved knowledge and understand of disease and treatments empowers me to be a better optometrist, my sharing of that knowledge and understanding empowers you to be a wiser, more informed patient, and together, we become strong.

Learning

It may be a bit weird, but I’m one of those people who genuinely enjoys learning new things.  (Though, as an ISTP, there is a limit on how much theoretical material I can process before needing to go out and just do something.)  For this blog, especially as time continues, I have to keep learning to continue providing you with new, relevant information!
This then builds on the old adage of “see one, do one, teach one”, which is most commonly associated with surgical residencies.  It’s not directly applicable, but the concept still applies: the best way to learn is to first take in the information, then apply the information, and finally share the information with someone else.

Community

In addition to education, one of the primary goals of Hannah Vollmer, OD is to foster a sense of community – between patients, between doctors, and hopefully bridging the gap between the two.
For the sake of transparency, community isn’t something that comes naturally for my introverted self.  And so, while I strive to create an atmosphere of honest authenticity that encourages and empowers others, my attempts often fall short.  Nevertheless, this blog provides a space within which this community may exist.

Branding

In this digital age, especially in the context of a career within some aspect of the public eye, we are taught from early on to think in terms of our personal brand.  From that point, it would be lying to say that this blog isn’t part of my attempts to build my brand.  As a young, semi-nomadic optometrist, within a relatively unknown specialty, my personal brand is honestly one of the greatest tools that I have, as it remains constant, regardless of my physical location, my job title, or even my place of employment.  Hannah Vollmer, OD is, and always will be, me.

Simplicity

In addition to building my personal brand, having a single location to send, well, anyone who is interested in learning about me and what I do simplifies everything.  Have questions about optometry-related topics? Check out hannahvollmer.net.  Looking for a new optometrist? Check out hannahvollmer.net.  Potential employer interested in learning more about me? Check out hannahvollmer.net – you’ll find my CV, along with a collection of posts that highlight my optometric knowledge and shed light on my personality.  Want to contact me?  Send me an email – you can find links at hannahvollmer.net.
Sorry, that was a bit excessive, but you get the point.

Trajectory

For a final point of transparency, it has been a long-term goal of mine to eventually use writing, specifically blogging, as a source of income – not to leave the clinical optometric field, but to fund my dream outpatient inter-disciplinary neuro-rehabilitation facility.  The current transitional period that I have found myself in has provided the perfect opportunity to begin working towards that goal. It is my hope that I will be able sustain the momentum created during this time, even after I find full-time employment, to the end of making both dreams a reality.
If you have any questions or comments, please contact me – I’d love to hear from you!  If you enjoy my posts, please subscribe, or like my page on Facebook!

Specs v. Contacts

It’s an age old question (well, not literally) – which are better – glasses or contact lenses?  And how do I know which option is right for me?
First things first, it’s important to know that there are many factors that go into determining whether glasses or contacts may suit you better.  I probably won’t be able to cover every specific example in this post, so if you have further questions, please contact me – I’d love to hear from you!  From there though, I’ll try to cover the pros and cons of both options and give a few final thoughts.
Ready?  Let’s go!

Specs/Glasses

Pros

  • Fashion: A cute pair of specs can add a lot to your look, bringing out the color of your eyes, highlighting your skin tones, or accentuating your outfit!
  • Protection: This is one of optometrists top reasons for encouraging glasses wear.  If you’re functionally monocular, or have reduced vision in one eye, it’s vital to wear glasses to protect your good eye!  Even if you’re fully sighted, glasses provide physical protection that contacts will never be able to provide.
  • Filters:  For people with light sensitivity and other conditions that necessitate the use of filters, it’s often easiest to wear glasses, as the filter can be included in the lens much easier than it can in contacts. Plus, if you need different filters for different environments, it’s a lot easier to have multiple pairs of glasses that you use throughout the day than to have multiple pairs of contacts that you’re taking out/putting in.
  • Clear Vision: This isn’t always true, but in some cases, glasses may provide clearer vision than contacts – just because the specs don’t move every time you move your eyes!  This is generally especially true in people who need reading glasses, as it can be hard to find a contact lens that provides perfect clarity for all distances.
  • Prism: For people needing prism in their lenses, this is once again only really able to be accomplished through glasses.

Cons

  • Limited Viewing Area: For people who are used to moving their eyes, rather than their head, to see objects, this is a very frustrating aspect of glasses. While contacts move with the eyes, spectacle lenses are obviously stationary, limiting vision to the size of the lens itself.
  • Frame Interference: Similar to the previous point, the frame of glasses may interfere with vision – providing a physical blind spot in the location of the frame edge.  As an active far-sighted individual who went most of his life without glasses, this is one of my dad’s biggest complaints with wearing specs.
  • Visual distortions: While my dad may be acutely aware of frame interference secondary to his prescription, my relatively high near-sighted prescription predisposes me to significant visual distortions when looking through the outer portion of my glasses – to the extent that I can’t stand to wear my glasses while driving.  It’s too disorienting!
  • Sports: This is often a huge factor in someone making the trade from glasses to contacts.  While specs offer protection during sports, without them being rec specs (aka frames with a strap), it can be very difficult to be active and wear glasses.  For me, this realization came in middle school when my glasses went flying across the floor during more than one basketball game.  Rather than constantly having to straighten out and fix my specs, I quickly switched over to contacts – and haven’t gone back since!
  • Changes in Eye Size: Spectacle lenses, for better or worse, also make images (including your eyes) bigger or smaller, depending on the prescription.  For this reason, people who are near-sighted often complain of things looking small when wearing their glasses, while people who are far-sighted complain of how big their eyes when wearing their glasses.

Contact Lenses

Pros

  • All the cons of spectacles: Kidding!  Well, sort of.
  • Full Field of Vision: This is probably my favorite part of contact lens wear.  I can see everything, all the time – no interference, no distortion. All I do is move my eyes to the target, and I can see!
  • Aesthetics: While some people love the glasses look, others are much greater fans of the “natural” no-specs look available with contact lenses.  Plus, there are colored contact lenses to change the appearance of your eyes if you’re not a fan of your natural eye color.
  • No Glare: Tired of always having to monitor pictures for the glare off of your glasses?  It’s never a problem with contacts!
  • Unequal Prescriptions: Some people have a large difference between the prescription in one eye and the prescription in the other.  Contacts allow both eyes to be fully corrected without different size lenses, or different image sizes falling on the retina, therein providing better vision.
  • Activities/Sports: My second favorite feature of contact lenses is probably their improved functionality for all things active.  Anyone who knows me, or at least knows me well, knows that I rarely sit still by choice (as demonstrated by the fact that I am literally bouncing back and forth from one foot to the other while writing this).  For me anyway, this lifestyle is wayyy more compatible with contact wear than glasses wear.
  • Comfort: Once you find the right brand of contacts for your eyes, they should be comfortable almost all, if not all, of the time, without the annoying pressure points (on the nose and behind the ears) of glasses.

Cons

  • Price: This is one of people’s biggest concerns with contacts – how much they cost.  I admittedly haven’t done a point by point price comparison between glasses and contacts yet to be able to provide specific figures.  However, my general thought is this: high-end contacts probably won’t be super cheap, but neither will high-end specs.  Stay tuned for another post where I specifically dive into the price point comparisons of specs and contacts for those of you who like numbers!
  • Ocular Health: In addition to price, a major concern with contacts is their impact on ocular health. As an optometrist, I would be negligent if I did not tell you that there is potential for severe ocular complications with improper contact lens wear. Contact lenses are considered medical devices.  As such, they are ONLY to be worn as directed by your ocular physician. However, proper contact lens hygiene and use mitigates much of the risk of wearing contact lenses.
  • All of the pros of specs 🙂
  • Comfort: Some people, especially those suffering from dry eye, may have harder time achieving a comfortable contact lens fit that allows long-term contact lens use.  However, this doesn’t mean that contacts aren’t an option – it may just take longer to find the best brand for your eyes.
  • Touching Your Eye: Over the years, I’ve had the pleasure of teaching quite a few people how to wear contacts for the first time.  The biggest hurdle?  Getting them comfortable with touching their eye.  Obviously, this isn’t an issue for everyone, but for some people, this poses a huge obstacle.
  • Lens Parameters: Not all soft contact lenses are available for every corresponding glasses power.  For this reason, if you have a very high prescription, you may have fewer lens options than someone with a low-moderate prescription.
  • You Still Need Glasses: From an ocular health standpoint, it is vital for every contact lens wearer to have a back-up pair of glasses to provide functional vision in case of eye infection or inflammation.

Takeaways

I, personally, am a huge proponent of contact lens wear, as was probably obvious in this post, simply because it’s worked the best for me.  However, I understand that my experience may not be everyone’s – and that’s okay!  What’s most important is finding the option that works best for you and your style of life!
If you enjoy the contents of this blog, please subscribe, or like my page on Facebook!

Pediatric Eye Exams: How Does My Doctor…

One of my absolute favorite questions in the realm of optometry is:
How are you able to do an eye exam on an infant?! They can’t even talk!
As a pediatric optometrist, I often quip back:
Exactly! Think of how much faster an exam would go without all the talking!

Okay, so that may be a bit of an exaggeration, but there were definitely days during residency when I would get thrown off by my patients actually being able to talk to me.
So, how does this process work?  Come with me and find out!

Pediatric Eye Exams 101

First things first: communication.
As adults, it’s easy to think of communication being the spoken or written word, but there’s so much more to it than that.
If you’re a parent, think back to the first years of your child’s life.  For quite a while, they probably weren’t able to speak – at least not coherently – but that didn’t mean that you couldn’t communicate.  Rather, you paid attention to their actions.  By observing and interacting, you could tell if your little one was tired, hungry, happy, frustrated, sick, or any of a million other feelings – without them uttering a single word!
These are the exact same skills that pediatric optometrists use when working with your young children: rather than relying on their words to describe vision, I watch their actions.
With that in mind, let’s take a look at the individual exam components!  To keep these posts at a reasonable length, I’ll discuss various portions of the exam over the course of several posts, so stay tuned for more updates!

Visual Acuity

In the normal eye exam, this would be the part where you’re told to look down at the end of the room and read the smallest letters that you can.
Except, obviously, most infants wouldn’t be able to understand these directions OR read letters.
BUT, they will (generally) pay attention to something that looks different – it’s a natural response!  So, we use this to our advantage.
My two favorite techniques for assessing vision in an infant/very young child are using Teller Acuity Cards (top) and Cardiff Acuity Cards (bottom).

As you can see, both sets of cards have an image on one half, and are a blank gray color on the other.  Due to the natural instinct of looking at a picture rather than a blank section of card, the child’s eyes will instinctively move so that they’re looking towards the image.
My job? Watch their eyes.
Okay, so it’s a little bit more complicated than that.
If I knew exactly where the image was, I would be biased to assume that that’s the direction that the child looked every time, falsely improving their vision.  So, with each attempt, and there are many, I spin the card around until I have no idea where the image is, and then let show it to the child while watching their eyes.  Once I’m confident with my guess as to where they looked, then I look at the card to confirm my guess.
*My card spinning skills have, on multiple occasions, evoked parent comments of, “you know, if this optometry thing doesn’t work out, you have a very promising career as a road-side sign-spinner!”  I’m admittedly never sure if I should take it as a compliment or not…*

Once my guess matches the image location 4/6 times on a single card, I move to the next hardest card, and repeat the cycle all over again, continuing until 4/6 is no longer achievable.  Each card has an equivalent 20/X measurement, that can be used for the purpose of explaining vision to parents and therapists, as well as monitoring over time.
Unfortunately, not all offices have these tests, as it costs ~$5000 for a set.  Rather, most offices use a method call “fix and follow” – which requires the child to do that – look directly at an object and follow it.  For a more precise measure, the size of these objects can be varied.
As children mature, more classic measures of acuity using matching or naming can be used – often first with just a few letters or numbers, and then progressing to the charts that you’re familiar with as adults!
If you have any questions or comments, feel free to contact me here – I’d love to hear from you!
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So You Need An Eye Exam…

It’s that time of year again..
You’ve started noticing changes in your vision.  At first they were pretty minimal, but now, it’s getting pretty bad.  You know you need to go to the eye doctor, but where do you go?
Maybe you’ve moved.
Maybe your insurance changed.
Maybe you weren’t a fan of that last optometrist.
Or maybe you’ve never seen an eye doctor before.
The stories are all different, but the question is the same: how do you decide which optometrist to see (pun intended)?
I was reminded of this conundrum a couple of days ago when, out of curiosity, I decided to see how many eye doctors there were near my hometown (which doesn’t have a stoplight to put things into perspective).
I was shocked.  I knew of, probably 4 off the top of my head, but between four towns that are within a 20 minute radius of my house, there were somewhere around 12 different practices, many with multiple doctors each!
Retrospectively, what shocked me the most wasn’t the number of doctors – it was the number that I had never heard of.  How could I live in the area so long and have no idea that they existed?!
Now, I know that, in the grand scheme of things, 12 practices is a drop in the bucket compared to say… Houston… but nevertheless, anytime that there are multiple options, the question remains: which one do I go to?  So, without further adieu – Hannah’s Top Tips to Pick Your Optometrist

Check Google

It may be scary to some, but I swear Google knows all – and it definitely will have a list of all the eye doctors in your area.  Whether you’re new to town, have never seen an optometrist, or need a new doc, Google will be able to show you locations, websites, and, which will be my next point, reviews.

Find Reviews

This is essentially my number one advice with most everything in life – check the reviews!  Regardless of how awesome a practice’s website looks, the reviews are generally the most telling.  Sure, there will always be a few people who aren’t happy with some aspect of their care, but what does the overwhelming majority say?
Additionally, when looking at reviews, check the dates.  Were all the positive reviews several years ago, with more recent information showing one or two stars? Or vice versa, were all the poor reviews ancient history?

Finally, check multiple sites for reviews.  Some sites are designed to hide negative reviews, rather than giving an equal opportunity to see both positive and negative impressions.  If you suspect that this may be the case, keep looking!

Verify Insurance

For people with vision insurance, this is often one of the biggest determining factors of which doc to see, and understandably so!  Remember, not all optometrists take all insurance plans, so it’s important to check before scheduling an appointment and getting to the office, only to discover that you’ll be paying out of pocket.  Most often, your insurance company will have a list of in-network providers to refer to during this process!

Talk to People!

If you’re introverted, this may be an uncomfortable one, but talk to the people you know!  If they’ve been around town for a while, they’ll probably know, or at least have heard of several of the providers, and can give you suggestions based on their experiences.

Go to the Office

In the age of COVID, this may be a little bit more difficult, but there is definitely something about physically going to the location that can play a huge role in your final decision.  Is it in a sketchy area of town, or someplace harder to access?  What’s your impression of the office aesthetics?  If you’re able to go in, how does the staff treat you? Are they friendly and welcoming? Or do you feel more like an unwelcome guest?

Assess Offered Services

This is especially important if you have a specific need or concern.  Are you bringing an infant in for their first eye exam?  Make sure the doc is comfortable seeing little ones!  Do you have a special needs child?  Find a optometrist that may better understand their needs.  Are you curious about vision therapy?  Don’t go to a glaucoma specialist! (And vice versa).  Just like an endocrinologist wouldn’t be comfortable performing knee surgery, not all optometrists share the same specialties, so find the eye doctor who best suits your needs.

Don’t Be Afraid to Change

It’s never to late to change your optometrist.  Do I really suggest jumping between practices every year? By no means – the more regularly an eye doctor sees you, the more familiar they become with you, allowing them to further personalize care while better monitoring for slight changes in your eyes that a doctor seeing your eyes for the first time may miss. But, if you have consistent bad experiences, or something just doesn’t feel right? Don’t be afraid to ask for your records and find someone else.

Like me. 🙂

*This is a joke! Though I would be happy to see any of you, due to my current status of being between positions, I don’t even have a physical office to see you at.. And I do not recommend driving to see me for a makeshift exam from my garage in the unrelenting heat and humidity that is otherwise known as Houston.


If you have an questions or comments, please contact me here – I’d love to hear from you!  If you like my posts, please subscribe, or like my page on Facebook!

Why Does My Eye Doctor… Part 2

Welcome to Part 2 of my series “Why Does My Eye Doctor…”! Today, let’s go into the topic of what all optometrists are known for – which is better, one or two?
*Click here for Part 1 and here for Part 3!

Refraction in Focus

First things first, what in the world is the eye doctor doing when they ask this annoying question?

The procedure itself is called refraction.  If you jump back to your physics days, remember that refraction is the bending of light as it passes through different mediums (ie air to glass).  It’s this property that we use with spectacles (or contacts) to make light focus directly on the retina, rather than in front, such as in near-sighted cases, or behind, as in far-sighted cases.

During refraction, most of the time, you as the patient are seated behind a phoropter.  This machine essentially has a bunch of lenses built in to easily allow us to find the perfect prescription for your eyes!

I hate that test… I never know what the right answer is!

This is something that I hear all the time when talking to friends, family, random strangers – almost everyone!
A lot of people put themselves under a lot of pressure during refraction, because they’re afraid that if they give the “wrong answer”, they’ll end up with crappy glasses.
But guess what?
There is no wrong answer! This is a completely subjective test, meaning it’s all about what you think looks best!  As the doctor, I can’t see through your eyes to know which one looks better to you – only you do that.  Yes, I can have an idea based on clinical experience, but at the end of the day, this is a part of the eye exam where you get to have a say.
And if they look the same?
Tell me!  This is honestly an important description, and I’d rather you tell me that they look the same than trying to figure out which one may be a hair clearer.

Do the numbers matter?

I feel like there are two ways that this question could be taken, so to clarify: yes, the answer that you give me 100% determines the next lens that I show you.

But my choice of numbers? That’s completely arbitrary.
I personally really like just using one and two, which more commonly becomes “here’s the first lens, and here’s the second” – it seems simpler, and from my experience it works really well.
That said, there’s no problem with the doctors that get all the way up to 10 with their numbers.  Or always keep the same number with the same lens.  Or use letters.
None of that really matters.
*As a fun aside, when I told my older brother about this sometime during optometry school, he begged me to do a refraction using chicken and egg instead of one and two.  I’ve been tempted on mulitple occasions, but so far haven’t pulled the trigger on trying this technique 🙂

How do you know where to begin?

Getting the numbers for a starting point for refraction depends on a number of factors:
  • If you’re a new or established patient
  • If you’re already wearing glasses
  • What technology the doctor has available
  • Your unique needs as a patient
In the case of an established patient, or a new patient who’s already wearing glasses, it’s pretty easy to either pull up the prescription for your last visit, or read the prescription in your current glasses, and use those numbers as a starting point.
With completely new patients, especially those who have never worn glasses, the options depend more on what technology the doc has available.  Most practices at this point have a device called an auto-refractor – which is exactly what it sounds like: a machine that automatically determines an estimate of the prescription of your eyes.
If this isn’t available or doesn’t seem to be providing reliable results, the doctor may also perform retinoscopy, where they shine a light towards your eye, which then creates a reflex that will move in response to movement of the light.  As lenses are added, the reflex changes, until there is very little movement, corresponding with the approximate power of your glasses prescription!
Retinoscopy is actually one of my favorite techniques, and is my preferred method of determining a preliminary glasses prescription, as it doesn’t require a machine, can be done literally anywhere, and shows me valuable information about the state of your eye and focusing system!  For these reasons, it is perfectly suited to my preferred patient populations – children, special needs, and those who have suffered brain injuries.

Wait.. so if there are machines, what’s the point of refraction at all?!

The short answer is that machines aren’t perfect.  Yes, they can provide a good estimate, but that’s all it is – an estimate! When we ask “which is better, one or two”, that estimate is refined to specifically fit your preferences.
Why?
Because you are much more than just a set of numbers.
If you have any comments or questions, please contact me – I’d love to hear from you!  If you enjoyed this post, please subscribe, or like my page on Facebook!

*To read Part 1 of Why Does My Eye Doctor, in which I discuss dilation, click here*

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!