As another summer season approaches, the issue of sunglasses once again resurfaces. Eye care specialists are frequently asked questions whether sunglasses are necessary, and is there really a difference between the cheap ones and the expensive types? The short answer is YES to both questions.

Light, in general and, sunlight in particular is comprised of many units called wavelengths. Each wavelength has a different level of energy ranging from low energy at the red end of the spectrum, to high energy at the blue end. The ubiquitous UV light we hear so much about is situated next to the blue light, and has the highest and most dangerous amount of energy. It is this wavelength of light that we are most concerned with in regard to damage to the eyes.

When this high energy light enters the eye, it is absorbed into the ocular tissues. This energy then acts as a catalyst for an increase in tissue metabolism, and that is when the trouble begins. Individuals with a genetic predisposition toward Macular Degeneration can expect a dramatic increase in the severity of the condition, and a substantially earlier onset of the disease. Systemic disorders such as Diabetes will also put an individual at risk for this disorder. The natural lens in the eye is comprised of Alpha proteins; which are clear. When exposed to UV light, they undergo a chemical change that transforms them into Beta proteins which are yellow. This process is called cataractogenesis and results in cataract formation.

UV light is also absorbed into the outer layers of the eye, and will result in Pinguecula and Pterygiua. These are the yellowish bumps that form near the cornea, on the white part of the eye and the whitish growth on the cornea, respectively. Both are caused by UV exposure. These anomalies are more often found in individuals living close to the equator who are exposed to much higher amounts of UV light then northerners.

Last, but certainly not least is skin cancer. The tissue around the eyes is very thin and highly vascularized (many blood vessels) making it a perfect location for cancer. Both Basal Cell Carcinoma, and Squamous Cell Carcinoma are the result of overexposure to high amounts of UV light.

The best protection for UV light is GOOD quality sunglasses. Good being defined as one that absorbs all the harmful rays of the sun, and covers both the eyes and surrounding areas. While many cheap sunglasses claim to absorb 100% of UV light, the fact is that these do not give the maximum amount of protection that is possible. They do absorb some, but not enough of what will ultimately damage our eyes. Sunglasses bought on the street for $10 will do nothing except increase exposure to UV light. By that I mean; the tint in the lens will dilate the pupil letting in more of the damaging UV light .

The least expensive of the good quality sunglasses are the Ray Bans. They will afford maximum, efficacious protection. At the other end of the cost spectrum is Maui Jim. There are 7 layers of laminates which filter all bad light out, and give perfectly clear vision. All other sunglasses have fewer layers of laminates, but still will give good quality. Other good brands include but are not limited to Oakley, Revo, Vuarnet, Corning, Serengetti, and too many more to list. All prescription sunglasses should include an ophthalmic quality lens and UV coatings. This will make them good sunglasses as well.

When it comes to sunglasses you do get what you pay for. Years of UV light exposure will cause permanent damage to the eyes, and surrounding tissues. It would be most prudent to put aside economics, in favor of competent protection. In the long run, protection is a wise investment.

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Aging is a fact of life and all the trips to the gym, nutritionist, and Dermatologist for Botox, will not prevent your eyes from needing reading glasses when you approach the ripe age of 40. While multifocal eye glass lenses have been around for many years, recent developments in contact lenses now permit comfortable, clear vision in the distance and at near.

In years past, bifocal contact lenses fell short in their goal of clear distance and near vision because of limitations in the technology. Common complaints included poor distance or near vision, glare, fluctuating vision and discomfort. Most people had to sacrifice some visual acuity and comfort in order to avoid reading glasses with the contact lenses. Some eye doctors even fit patients with Monovision, which is the wearing of one distance and one near contact lens. While in concept it seemed acceptable, in clinical practice it most often resulted in visual discomfort in the distance, near or both. In addition, monovision results in the elimination of binocular vision and thus depth perception. In my practice, only approximately 20% of these patients were happy with their vision.

Fortunately, today there are better alternatives. The ability to combine spherical and aspheric curves results in a gradual change in power from the distance to near and a more natural visual experience. In addition, the biggest development in this arena is the ability to correct astigmatism as well as near and farsightedness along with the near prescription. While there are several lenses available, I have found the Ultravue 2000T progressive soft contact lens the be the best. The edge design and availability of parameters makes it great for most patients. Once the eye doctor becomes familiar with the subtleties of the lens, fitting is straight forward and the results are spectacular. There are several Gas Permeable lenses also available and have wonderful results as well. My favorite is the Aspheric Progressive Multifocal from ICL. Fitting is more difficult, but for the right candidate, the results are outstanding.

In short, if you wear contact lenses and are having trouble reading with them in, ask your eye doctor for the new multifocal contact lenses. They will turn back the clock and make contact lens wear great again. We fit well over 95% of our patients over 40 with one of these lenses. We can’t keep your eyes young, but we can keep them seeing well.

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Selling water to someone who is thirsty or a coat to a person who is cold is easy. The need is there and the results are immediately positive. There are rarely if ever any negative issues resulting from these obvious situations.

On the other hand, elective cosmetic surgery takes on a whole other set of rules and expectations. The need is NOT there and the expectations may be unrealistic. I have found in my 24 years of practice, that patients do not always listen to everything that I say and often hear only what they want to hear. This can be frustrating since I always go to great lengths to fully explain all the positive and negative aspects of what I am suggesting for treatment.

While we as doctors must always do our best to inform our patients about their treatment options, there still lies a great responsibility with the patients to first listen to us and second to understand themselves realistically. Patients must realize that they can say anything they want, but will have to live with there answers if they are not truthful.

This concept is especially important when dealing with refractive surgery. The potential complications are always explained prior to surgery by all responsible surgeons, but only the patient really knows themself and can answer if they can or want to live with possible side affects.

A case history of this exact point can best explain my point. A 34 year old male came to our office wanting to get rid of his glasses. He told us that he had worn contact lenses, but never liked them and was tired of his eye glasses. A very comprehensive case history was performed and he stated that while his eyes were occasionally dry they never caused any problem for him. Presurgical testing was normal and he underwent PRK. His post operative visits were normal as he saw approximately 20/20 in each eye and his corneas fully healed. Unfortunately, he started coming in 2-3 times per week after the first month stating that he was in excruciating pain and could not live his life this way. He claimed to be putting artificial tears in his eyes every ten minutes, could not work because of the pain, and could barely see the numbers on his blackberry so he was forced to use only land lines to make calls. Please keep in mind that he was always 20/20 with clear corneas upon all his follow ups.

We treated him with steroid eye drops, lubricating gel, bandage contact lenses, wet cell eye glasses, punctal plugs and nothing cured his ” excruciating” pain. He usually told a few jokes to the front office staff on his way in and out and most often smiled despite the ” obvious” pain he was in. Approximately 4 months following his surgery with no remediation of his ” pain” he told us that ever since he was a child the smell of recent grass cuttings by the gardener made him faint. He also disliked shaving because the fumes from the shaving cream made his eye tear and frequently fainted from the pain. In college, the gravy from the mashed potatoes made his eyes turn red and riding in taxi cabs made his vision blurry. Must I go on!!!

We were finally about to lessen the pain by prescribing a “special”‘ eye drop
that was formulated for people that have excruciating pain following PRK. After using it for 3 weeks, he finally admitted it made his eye only about 30-40% better. We expect to see this patient for some time to come to “manage” his pain.

Prior to any procedure it is imperative that we all look honestly at ourselves and ask if we will be better off with that treatment. We must be willing to accept the good with the bad and know that if we have “issues” that injecting something new and different into our lives may make us a little nuttier then we already are. I for one sit at home writing these articles since I know that I do not like change and know that if I complained to my partner in the office about silliness he would close the door on me. I only wish all people were able to be honest with themselves.

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The many benefits of LASIK are obvious, vision without glasses, however several side affects must always be considered prior to surgery. One of the most significant, and bothersome is Dry Eyes. Most individuals that undergo the procedure will experience at least some dryness, yet others will be greatly affected.

There has been a great deal of research, and clinical trials performed in an effort to determine the exact cause of the post operative dry eye, but the specific etiology has yet to be determined. One such theory is the Neural Feedback Loop Theory. This theory suggests that the disruption in the corneal nerve fibers; as a result of the flap creation and stoma layer ablation decreases corneal sensitivity. Consequently there is a decreased blink rate leading to an increase in tear film evaporation; thus the eyes become dryer. Clinical trials have shown that this anomaly corrects itself in most, but not all individuals.

The second theory is Goblet Cell Damage. Goblet cells manufacture the mucin layer in tears preventing tear film evaporation. Microkeratome pressure on the cornea during flap creation can damage conjunctiva Goblet cells resulting in an unstable tear mucin layer. An unstable tear mucin layer will cause the tears to evaporate quick and leave the exposed cornea dry.

Next theory is the Change in Corneal Curvature. Changing the corneal curvature is required to alter one’s prescription, but also affects how the tear film overlays the cornea. This change causes an iron stained epithelium, resulting in a very dry eye.

In all cases, osmolarity changes because of the decreased blink rate results in damage to the cornea called Keratopathy. These are the most widely accepted theories on why eyes become dry following LASIK. It should be noted that dryness rates are much lower for PRK because there is no flap creation and many of these factors do not exist with that procedure.

Extensive dry eye testing should be performed prior to LASIK to determine if there is an underlying dry eye condition. Some routine tests that must be done are Tear film evaluation, Schirmer test, Lissamine green staining, tear meniscus height measurement, Phenol red thread testing and Fluorescein staining. While all of these need not be done, some must be performed because the surgeon must know not only if there is a dry eye condition, but how bad it is.

In cases where there is an existing dry eye, preoperative treatment can be done. The use of artificial tears, and in more serious cases, Cyclosporin commonly known as Restasis can be prescribed prior to surgery. In addition, topical steroids can also be employed to help re-mediate the condition.

During the procedure the surgeon can also lessen the dry eye affect by creating the flap with a nasal hinge instead of a superior one. This appears to cause less dryness since only one side of the nerve is severed, while with the superior hinge both sides are cut; this affects corneal sensitivity. Some studies have not supported this theory while others do. The method of flap creation is a much greater factor. The microkeratome definitely creates more damage to the corneal nerves and thus dryer eyes. The better alternative is flap creation with the femtosecond laser commonly called Intralase. Corneal tissue disruption is much less and corneal sensation returns much faster.

Post operative dryness can be dealt with most commonly with artificial tears. The best of which is Celluvisc. Restasis is also often employed, but must be used for at least 3-6 months to be affective. Inserting a collagen plug in the area of the lid where tears drain is also used in extreme cases to retain tear volume in the eyes.

In summation, extreme dry eye patients should carefully consider, and discuss with their surgeon whether LASIK is appropriate, and all refractive surgery patients must be prepared to suffer from dry eyes post operatively for at least several months and perhaps even longer.

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