We want to make sure that you receive all of the information that you need to make educated decisions about your eye health. Our optometrist, Dr. Christopher Keats is always available to answer your questions. Please feel free to send us your eye care questions to ckeatsod@yahoo.com
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Q: Sometimes when I get new glasses I feel more comfortable in my old ones, even if the new ones are more clear. Why is that?
Dr. Keats: Human brains have great neuroplasticity. If a patient has blur due to a cataract or astigmatism or some other reason and the vision is not corrected properly in the glasses, the brain will learn to ignore the blurred zones and pay attention only to the light rays that are clear. This process is what enables patients to enjoy multifocal contact lenses even though part of the eye is focused for distance while another part is focused for near. In glasses, if the brain has had to make a compensating maneuver to allow a patient to see decently, and then the new glasses changes the way light enters the eye, even for better optics, this can dissociate the visual systems adaptation and give the patient a feeling that their glasses are not right at first. In most cases, an adaptive period of wear will get the brain adapted to the new lenses and the new glasses will be preferred. But sometimes, the change is too much to handle even after a few weeks of adaptation, and we have to bring the glasses prescription in between the old and new powers. In a sense, some people need to take baby steps toward their best vision.
Q: Can Glasses help my unsteady loved one stop leaning to the side when they walk?
Q: Can I wear my contact lenses at the beach?
Dr. Keats: You could if you wear contacts with UV protection, But you shouldn't swim in them because of the risk of contamination and infection. Daily Disposables are perfect for this type of activity as long as you replace the pair that you wore at the beach immediately afterwards. If you feel redness or irritation in your eyes irrigate your eyes with drops like Blink or refresh artificial tears. If the problem persists call us immediately to schedule a consultation.
Q: Are you going to touch my eye with that?
Dr. Keats: Well actually… I am! But try not to freak out. This comment often comes up when I am about to test the eye pressure. Goldmann applanation tonometry has been the standard of care to access the intraocular pressure of the eye and is quite a necessary part of the eye exam to rule out the risk of glaucoma. Eye pressure can be tested with a puff of wind that makes you jump a bit, a hand held pen that taps on the eye, and a few other techniques. But Goldmann applanation tonometry remains the standard of care and is the technique I use. An anesthetic drop is placed it the eye that smarts a little. Once the eye is numb, we gently depress the eye with the tonometer device and the amount of force necessary to slightly dent the eye in tells us the eye pressure. Since the eye is numbed, patients feel no discomfort, unless they blink on the tonometer tip. I can’t numb the lids, so I try to help patients hold them open. If you try your best to hold your eyes open too, chances are, you will feel absolutely nothing, and that is a good thing. The whole test is like a kid who presses on his bike tire to see if he has the right air pressure. I am doing the same thing except I am accurately measuring the fluid pressure within the eye. The force I use is much less than the force most people use to rub their closed eyes when they have an itch. The only difference is your eyes are open, but the test is very safe.
Q: When I have cataract surgery they just use a laser and don’t cut into my eye anymore, right?
Dr. Keats: People hear about laser eye surgery all the time and confuse surgeries like LASIK and PRK, which are refractive vision change surgeries, with cataract surgery. Cataract surgery is done to clear a path for light to get to the retina in a cloudy eye. In cataract surgery, we have to remove the cloudy lens inside your body. The only way to do this is to cut into the eye with a micro-incision, and physically remove the dirty intraocular lens. Once this lens is removed, we insert a new lens made of a plastic polymer that is clear and has something close to your glasses prescription in it to help minimize your need for glasses.
Lasers can now be used to help break apart the lens, but this has traditionally been done with an ultrasonic device called a phakoemulsifier. Patients tell me, “But my friend had laser for her cataracts.” This can be partially true with the fematosecond laser I just mentioned to assist in the physical cuts and removal of the cloudy lens. But more commonly, some patients get scar tissue after cataract surgery that builds up near the back of the implant lens causing cloudy vision similar to the blur one experiences with a cataract. This scar tissue can be zapped away with a YAG laser yielding clear vision again without cutting into the eye. It is called a YAG Capsulotomy, but is not actually cataract surgery. It is only done after cataract surgery if scar tissue develops enough to obscure vision.
Q: Can I swim in my contact lenses?
Dr. Keats: Sure! But if you open your eyes under water, they will either float off, or swell up on the eye and be hard to remove and embed with chemicals that will make your eyes redder or become infected! Then you can come see me for a medical visit so I can lecture you about some of the dangers of swimming with contact lenses on and have multiple visits with you as you heal up, if you are fortunate.
Seriously though, I would prefer none of my patients swim or shower or splash water in their eyes from pools, lakes, rivers, oceans, or even tap water. Why? There are critters like Pseudomonas and Acanthomoeba that can live in treated or untreated water. These organisms can stick to the lens and take the opportunity to grow in any comprised area of the eye more easily since they don’t get readily flushed away by the lid wiper system of your eye. So if you make the choice to swim with your contacts, know there is grave risk to your eye health. This is an obvious benefit to having refractive surgery. Certainly use goggle or a mask if swimming with your eyes open under water.
After being in the water with contact lenses on, remove them as soon as possible, and clean them in a hydrogen peroxide cleaning system like Clear Care or Peroxiclear. The best approach is to use daily disposable lenses. You could also just throw the lenses away after a day at the pool. Interestingly, most water borne contact lens infections come from dirty contact lens cases. Keep those cases clean please and don’t top off the solution!
Q: Do I need to get new glasses?
Dr. Keats: Of course the answer I want to give is YES! At least 7 pair! I am running a business after all. But I think what you're asking is whether new glasses will help you see and function better. This answer is a bit tricky. Certainly if the change is dramatic, the answer is obvious. But what if the prescription only changes a tiny amount? This answer will vary depending on the personality and finicky nature of the patient. Personally, I am quite sensitive to even the slightest change and would definitely update my glasses if I could be assured any improvement. Some of my patients are less picky than me and to them, decent vision is fine. They don’t want to spend the money to have their most ideal vision. Usually, I show them the difference in the power shift and let them decide if the investment is worth it! The last thing I want to do is force glasses on a patient who later regrets their purchase.
But I must say, it is great to own, at a minimum, a primary pair, a sunglass pair and a specialty reading pair/ Few of us own only one outfit for every environment, yet many patients try to achieve all their visual needs with a single pair of glasses. If a patient has the discretional income to invest in multiple pairs, they are always seeing visually superior to those with only one. I don’t buy my wife a lot of jewelry, but she does have a large enough selection of glasses to match most of her outfits. . . perks of being married to an optometrist!
Q: Why don’t you wear contact lenses? And why did you not do LASIK?
Dr. Keats: My glasses have just a little power and a lot of astigmatism. I am also over 40 so I am in the bifocal years. I have tried many brands of contact lenses and I simply see more clearly in glasses due to the nature of my unique prescription. I like to see my very best so I can find my patient’s eye diseases better! LASIK would help my distance but I would still need reading glasses to see up close, and since I can do 90 percent of my tasks without glasses on and see decently, the surgery is not worth the risk to me. I have too little to gain. Perhaps the greatest reason is my wife thinks I look more attractive in glasses. That alone is enough for me! Plus I like the fashion of different frames I can wear. Many of my patients, however, see much better with contact lenses than glasses, so that modality is best for them. I try to help my patients understand which option will work well with their unique vision.
Q: Am I a candidate for LASIK?
Dr. Keats: LASIK has been a wonderful procedure for millions of people. To answer this question there are many factors that have to be addressed. The corneal thickness, pupil size, speed of vision changes, and potential diseases of the eye all can make LASIK a no-go for some people. Primarily, I like to first ascertain what expectations patients have. For instance, patients who expect perfect vision without glasses for the rest of their life after LASIK, will probably be disappointed. The same mild changes all patients experience will continue to occur whether the patient has LASIK or not! But if a patient is content with fairly clear vision but recognizes they may have a pair of glasses or contacts that will be worn to enhance their vision after changes occur, happiness will usually result. Personality is a big driving force as to whether a person is a good candidate.
Q: Why do my eyes water so much?
Dr. Keats: I can’t answer this specifically without an evaluation. But the most common reason is the eyes are dry! "What?" you say. And "That does not make sense!"; Your tears are essentially made of three things: mucous, water, and oil. There are different glands in the eye that make each component. If your eye gets dry, the brain tells the eye to make more tears. The watery component can be made rapidly, and so it is let down immediately. But mucous and oil secrete more slowly. Until these substances re-establish themselves to the correct proportion, the eye will feel watery. It is like a freshly waxed car that needs the hose left continually running to keep the car from forming dry spots. The eye needs a sheeting action, not a beading action. Until all three components are in the right proportions, it is very common to get a watery eye. Sometimes, however, the eye is not dry, but waters because the tear ducts that drain the tears away from the eye become clogged or malformed. I have to evaluate each patient to determine the cause and treat my patients accordingly.
Q: Why does my loved one tilt their head all the time?
Dr. Keats: A head tilt can mean many things, but aside from having heavy hair, the most common reason is an imbalance between the muscles of the two eyes, specifically the ones that move the eyes vertically. The patient tilts the head to one side in a subconscious protective mechanism to isolate and ignore the faltering muscle. I can do specialized testing of the eye muscles to isolate and quantify the amount of the deviation, Then, we will find the most appropriate prism lens to correct the deviation, often part way at first. As the patient gets accustomed to the power, we can modify the lens months later to incorporate the more complete amount and fully correct the deviation. Typically this process will help improve the posture of the patient and allow them to see more comfortably.
Q. Why are we switching to electronic health records?
Dr. Keats: As a doctor, there are many benefits to paper records. It is faster. Everything fits on 2-4 sheets of paper, and there is no risk of electronic hacking that might expose a patient’s personal information. So why change? If you remember a little law passed years ago called HIPAA, the answer is mostly in the P, but also in the A. HIPAA stands for Health Information Portability and Accountability Act. The goal of this act is to make doctor’s records and information about each patient portable. The hope is that with other doctor’s data available to all doctors using the system, there will be less room for redundancy in testing, less risk of drug interactions, and a greater ease of seeing the whole picture so as to prevent early disease and death to patients.
Q. I was told I see 20/20, but I don’t feel like I see very well. To me, it is blurry. What’s going on?
Dr. Keats: There is an old saying we are taught in school: “Vision is more than just 20/20.” Many times people can read a 20/20 line, but they feel blurry when they interact with the world. Some of these people have a very small glasses Rx and although they can read the chart well, they have to work their focusing muscles to make it clear, or at least as clear as possible. The more fatigued the focusing muscles are, the more likely they may experience some blur. Other people could have an eye disease, like mild cataracts or macular degeneration or a corneal disease, and they just can’t hone it in like they used to, giving the perception of blur even though they can physically make out the letters. Finally, some people have binocular vision disorders that prevent the two eyes from working together. Small micro-prisms could help improve alignment and overall vision. Alternatively, visual training (like physical /occupational therapy for the vision) can also help this type of problem. Some reasons can be improved upon, and others are simply a side effect of eye disorders that may have no solution. Either way, be sure to talk to the doctor about your concerns so we can do our best to help you overcome the difficulty.
Q. I like to keep my contacts until they bother me. If that is not OK, why?
Dr. Keats: I suppose it is human nature to keep contacts going until they annoy you. After all, if it ain’t broke, why fix it? Although that statement can work for many things in life, I can’t recommend that attitude in contact lens wear. Contact lenses are medical devices that have been studied in their interaction with human physiology, and approvals of maximum wear time have been regulated by the FDA to minimize risk of complications. Personally I have seen 5-6 people who are blind in one eye now because they kept those contacts in too long or did not change them often enough. The local immunity of the eye can become suppressed by old and dirty contact lenses creating opportunity for pathogens to invade the cornea and disable vision, possibly permanently. Just like it smart to change the fish tank water before the fish start to die, it is also valuable to change the contacts before the risk of eye damage begins. No one who lost their vision from over wearing contacts ever told me they were glad at least, that they saved a little money. My advice, if you are running low on contact lenses, rather than over wearing them, lean on those glasses until you come in for your visit. Your eyesight will thank you.
Q. I heard progressives can make you sick. Do you think I can wear them?
Dr. Keats: Progressives can indeed make one feel out of sorts and if you have a severe problem with vertigo or extreme motion sickness compared to the vast majority of folks who struggle with it mildly. If you are one of these people in the extreme, I might suggest you use a lined bifocal, or trifocal, or two pairs of glasses at near and far.However, the majority of progressive lens failures have to do with the quality of the lens purchased. At Northwood Vision, we have a very low progressive non-adapt rate because we fit most of our patients in higher quality lenses. Here is an extreme analogy: If you want to listen to music, you could go to the hardware store and buy an inexpensive weather radio. It will play music. But you also could go to the International Mall and purchase a high quality stereo surround system. It also plays music. Of course, you can predict which one will sound better and provide you with an experience you will enjoy the most. In fact, you will be more inclined to use the best quality stereo more frequently because of its impact on your auditory experience. You will hear more sounds, with better depth and tone. The higher price is worth it to anyone who values that experience. Progressives are just like this. The higher quality lenses come at a steeper price, but they afford a patient with less peripheral swim, wider fields of view, and a more natural, crisp experience to the level their own vision allows.
Sadly, some optical stores will tease you into their store, offering you much lower prices on progressive lenses, but when you get there, they will try to upsell you to a mid-range, off label product that is the lowest cost possible to them that will still allow you to adapt to the lens. However, if these patients could compare a very high quality lens, like the Varilux Physio Enhanced, or Varilux S series lens, they would notice a marked difference in the visual experience. (Hoya Vision and Carl Zeiss also make some premium products that can compete with Varilux, but the price is similar.) I can attest to this truth. When I worked at a store like I described, they gave me a free pair of their best product every year. I was not unhappy and I functioned well in it. So it was quite a surprise to me that the Varilux lens I purchased for myself, once I bought Northwood Vision, had much less swim and wider fields of view than my older lens. I had been told at this other optical that their premium product was just as good as Varilux, but at a lower cost. But I just did not find this to be true in my own experience.
Not surprisingly, my cost on these higher end lenses can exceed the retail cost of the mid-grade lenses they sell. So naturally these technologically advanced lenses come at a higher retail price. But when we consider that everything we do in life during all our waking hours might be interpreted through the lenses we look through, I believe the investment is worth it compared to some of the other things we spend our money on. Even the earlier, slightly less expensive Varilux models are better, in my opinion, than most of the off label lenses. So if your budget is tight, I would recommend one of the older Varilux products. But if you are willing to invest in the advanced quality that stems from emerging technology, I am 99% confident you will thrive in these amazing technologies. Give your vision the best optics you can get. The way you view the world rests on that choice.
Q. Why did you start using Electronic Health Records?
A. As a doctor, there are many benefits to paper records. It is faster. Everything fits on 2-4 sheets of paper, and there is no risk of electronic hacking that might expose a patient’s personal information.
So why change? If you remember a little law passed years ago called HIPAA, the answer is mostly in the P, but also in the A. HIPAA stands for Health Information Portability and Accountability Act.
The goal of this act is to make doctor’s records and information about each patient portable. The hope is that with other doctor’s data available to all doctors using the system, there will be less room for redundancy in testing, less risk of drug interactions, and a greater ease of seeing the whole picture so as to prevent early disease and death to patients.
For the doctor, failure to implement an electronic health record will make it virtually impossible to communicate effectively with other clinicians, and eventually, will by default prevent those doctors from participating in insurance plans offered by the affordable care act.
In fact, in order to participate in the plans, each doctor will have to show that they are using their electronic health record in a meaningful way to achieve this goal of portability to other doctors and to the patients. Doctors need to be able to communicate with you and other medical providers securely, and so a patient portal with user name and password will be required. On the upside, patients can go right on the portal and access the information, prescriptions, receipts, summaries of the findings, etc, whenever they want!
Without having a portable electronic medical record, doctors will not be able to take many medical plans in the future, so unless they want a self-pay only practice, it is a necessary step.
Also, the part of HIPAA that makes every doctor nervous is the A…accountability. As clinicians, are we doing what we say we are doing? And, are the tests we choose to run necessary to help us make good clinical decisions about our patients, or are we simply doing extra tests because we need to pay off our cool new machine. Having transparency in our record keeping allows the government and insurance companies to analyze the data we input to ensure we are following the rules of the contracts we have signed. Of course, like the legal tax code, the system is complex, and clinicians are worried they will fail to comply not because of fraud (the intent to do wrong knowing the specific rules), but rather abuse (over charging the system because of ignorance of the law).
The affordable care act is expensive, and part of the government’s plan to finance the care is to collect revenue from doctors committing not only fraud, but also abuse. It is expected that about 40% of doctors are unknowingly, ignorantly, committing abuse, and with increased audits, the government is making about $19.00 in revenue for every $1.00 they spend investigating. Electronic health records make it easier for them to investigate at a lower cost. With the implementation of ICD-10 coding (we have been using ICD-9 coding), we can expect collections to soar as doctors code incorrectly. There are 17,000 ICD-9 codes doctors have to get right. When ICD-10 coding starts, there will be 141,000 codes the busy doctor will have to try to get correct.
For instance, if the patient comes in for itchy eyes, the doctor will need to ascertain which eye is worse, how long they have had it, what makes the symptoms worse, and what they have done to help it.Then, the doctor must do the exam, keeping this in mind, and proving there are medical signs that relate to this chief complaint. Assuming there are, the doctor can then find a specific code that links the many aspects of the complaint to the various signs found. After going through a complexity rubric, the doctor will need to select a level of care given in his procedure code that links to the severity of his diagnostic code. If he does not keep every element of the rubric in mind and accidently codes one level too high, he has committed abuse, and if discovered, can owe the government penalties the thousands or hundreds of thousands of dollars. Frankly this has caused great fear in the heart of many busy clinicians, who barely have time to see their patients as it is. Now with ICD-10, there will be an even greater difficulty to provide good care as the temptation to devote most of their time energy to proper coding will be very high, and doctors might chose to spend less time evaluating the things outside the chief complaint.
This new and complex language is causing many seasoned practitioners to retire early. These doctors don’t want to lose their retirement income in fines, so they feel it may be better to cut their losses and get out now rather than to adapt. For those of us who have several decades before retirement, we are committed to learn how to do it right. Electronic Health Records will make the correct code a little easier to input properly. And this is another reason I have started to use them. I want to be able to code correctly and also make my patients feel as special as they truly are to me.