This will be a recurring series on Eye to the Future, where we will be looking into some of the more peculiar and odd eye conditions out there.  Hopefully you will find these topics interesting, and if nothing else, maybe you can astonish your friends and family during Jeopardy!

Yes!!!  Amazingly enough…

In addition to being a thinly veiled sexual euphemism made famous by rocker Ted Nugent, Cat Scratch Fever (or more accurately Cat Scratch Disease), is actually a relatively common condition that can cause some substantial eye related problems.

Cat Scratch Disease is a constellation of various systemic (and eye) symptoms that results from, logically, a cat’s scratch or bite.  The underlying cause of Cat Scratch Fever is a bacterium called Bartonella (below, right) that was confirmed by Robert Debré in 1950 to be naturally occurring in cats and potentially infectious to humans.  Bartonella is more commonly found in kittens/young cats and is most likely to occur in outdoor cats as fleas are the main method that Bartonella is spread within cat populations.  Cats pick up this bug through fur cleaning of flea debris and foster this bacterium in their saliva which results in the spread to us through bites and scratches.

When Bartonella is transmitted to humans it has a latent period of 1-3 weeks from the initial bite, but it is not uncommon for symptoms to only pop up 1-2 months later when the memory of the cat scratch has long faded.  Cat Scratch Fever commonly presents with tender, swollen lymph nodes near the site of the scratch/bite and the afflicted also suffer from severe flu like symptoms with malaise, aches, fever, headache, and joint/muscle pain.  In very severe cases, Bartonella can also can meningitis (infection/inflammation in the brain) or endocarditis (infection/inflammation in the heart).

Patients with undiagnosed Cat Scratch Fever will often make a trip to their local eye doctor during this time because Cat Scratch Fever can cause a severe conjunctivitis (pink eye) and even very blurry vision from optic neuritis or neuroretinitis (inflammation of the optic nerve and retina).  The optic nerve carries the signal from to the eye to the brain and inflammation of this nerve results in decreased vision (left photo is normal, right has an inflammed optic nerve and retina).  The blurry vision from Cat Scratch Fever neuroretinitis is usually temporary.

Now, take a breath…. I know you are likely glancing at your friendly, family feline with a mixture of repulsion and horror…  Fear not!  Cat Scratch Fever from Bartonella is usually very benign and all symptoms typically abate within a couple weeks without any treatment.  In fact, Bartonella infection is estimated to be quite under-diagnosed simply because severe complications are rare and symptoms are similar to the flu, and like the flu, improve on their own.  If severe complications from Cat Scratch Disease do present, it is possible to shorten the length of symptoms through oral antibiotics, but the medical literature is conflicted on which medicines work best and how much treatment actually improves the condition.

I hope you’ve enjoyed this quick talk and the next time you hear Nugent’s risqué anthem playing on the radio… let it be a reminder to think twice before petting stray cats!!

–  Nick Wolf, OD

Last time around on Eye to the Future, we discussed in detail What is a Cataract?.  This time around we will be addressing what we do about it!  Mainly, cataract surgery.

As discussed before, it is common for clouding of the human lens to be present on most individuals over the age of 50; this condition is called a cataract.  However, it typically takes a long time (as in over a decade or more) to reach the point where the human lens has clouded enough to require surgical intervention.  It is possible to tweak glasses prescriptions, improve lighting, and use anti-reflective coatings on the lenses to cut down on the symptoms associated with cataracts.  However, the best method for addressing this condition head-on is through cataract surgery.

Cataract surgery permanently removes the clouded cataract and replaces our human lens with a crystal clear, man-made lens.  Above is an advanced cataract on the left and the same eye after  the cataract is removed and the implant positioned.  It’s not hard to imagine the improvement this will have on vision.  And the way in which this surgery has evolved as well as some newer implant options available is just…. awesome!

It should also be clearly stated that there have been no peer reviewed, credible studies to suggest, support, or confirm that any other treatment exists (supplements, vitamins, medications, etc) to improve the symptoms or severity of cataracts – other than cataract surgery.

Cataract Surgery Procedure

Cataract surgery is an outpatient procedure performed under general anesthesia which means you are awake but sedated.  Cataract surgery is done one eye at a time (separated by one or more weeks of healing).  During this procedure a cataract surgeon will make two small incisions in the cornea  to allow instruments to be inserted into the eye.  The crystalline lens sits in a thin membranous bag and to get to the lens, the front surface of the membranous bag is removed.  In the past, the lens was removed whole, requiring a very large incision and a long recovery time.  Nowadays, the surgeon uses an ultrasound probe to break up and remove the lens inside the eye.  Now that the clouded lens is removed, a man made lens is put back in it in place allowing clear vision once again. The incisions are self-healing and no stitches are required. The entire surgery takes about 10 minutes.

Below is a great video of a routine cataract surgery as well as easy to understand narration of the steps.

Disclaimer for the squeamish:  There is little to no blood, but this is a video of a surgery.

Cataract Surgery Risks, Recovery, and Rewards

All surgeries should be taken seriously, however, cataract surgery is the most frequently performed outpatient procedure in the United States with a very low risk for permanent vision complications (only about 1-2%).  The standard post-operative for monitoring is usually one month. During this post-operative period, eye drops are used frequently to prevent infection and inflammatory complications and follow up visits are required in order to check on the healing process.

Recovery is usually rapid with substantial vision improvement within a few days of the operation.  A large study recently found that 95% of adults were satisfied with their vision and quality of life after cataract surgery.  Furthermore, having cataract surgery also decreased the risk of car accidents by 2.5 times and serious falls and fractures by 34%.

Cataract Surgery Implants

When the cataract is removed from the eye, there is an opportunity for the surgeon to put any powered lens back in its place.  Measurements are taken before the surgery to measure what powered lens is needed to correct for any underlying prescription like nearsighted, farsighted, or astigmatism.  A lens is then chosen to correct for your individualized glasses prescription which results in most individuals being far less reliance on distance glasses after cataract surgery.

Even more exciting is that in the past decade, more advanced lens implants have come to market like the Restor Lens at right.  In addition to making distance vision clear, these lenses can also focus for up close reading tasks as well!  While not a perfect system, this type of lens up-grade can actually free patients from all glasses for most activities!!

All surgeries can be stressful, scary, and uncertain times, but at Precision Family Eye Care we see cataract surgery as an opportunity and only work with the very best surgeons in our area to give our patients a comfortable experience and a rewarding outcome.

As always, if you have any additional questions.  Please feel free to contact us.

–  Nick Wolf, OD

What is a cataract?  Are there different types?  Why does it form?  What are the symptoms?  What can you do about it?  All good questions that eye doctors get asked on a near daily basis.  Today on Eye to the Future we will seek to answer these and more as we demystify Cataracts.

A cataract is the most common ocular disease that results in decreased vision and usually occurs from the normal aging of our eyes.  Inside our eyes, we have a clear, round lens (left) that is used to focus light onto the retina.  When this lens is clear the light passes easily through.

Over time, however, this lens becomes cloudy and yellowed resulting in a cataract.  This change results in two problems: First, the amount of light that is able to pass through the cloudy lens is decreased so the eye continues to need more and more light to function.  Second, the light that is able to pass through the cloudy lens bounces off the cloudy areas and is scattered, resulting in increased glare and starbursts around lights.

Common symptoms that are observed when a person has a cataract include: generalized blurry vision, difficulty distinguishing colors, glare (especially at night), difficultly seeing to read books, and having to use more and brighter light to read up close.

Common Types of Cataracts

Nuclear Sclerotic cataracts are by far the most common and occur from a yellowing of the lens (seen at right).  This change is normal and occurs naturally with age, although certain things like smoking can increase the speed of development.  Although some yellowing of the human lens is often seen as early as age 50, it usually takes a decade or two for this type of cataract to cause visual problems.

Cortical cataracts look very similar to spokes on a wagon wheel.  These cloudy spokes begin at the outside parts of the lens and grow toward the center causing visual problems.  This cataract is also common with age and is highly associated with systemic Diabetes.  Cortical cataract also develops more quickly than Nuclear Sclerotic cataracts.

Posterior Subcapsular cataracts are less common.  This can be a normal aging change, however this type is most commonly associated with long term oral steroid use or a history of past eye surgery.  This type of cataract is a cloudy area on the back of the lens and tends to develop the fastest and cause the most vision problems of all three types.

Treatment of Cataracts

Regardless of the type, when cataracts are first forming it is common to simply monitor them every so often and record their progress.  However, over our life time, our cataracts will often get to the point that light is no longer able to get through that clouded lens, resulting in permanently decrease vision.  Furthermore, there is little that new glasses will help with, because the problem is inside the eye.  At this point, the only option available to improve vision is cataract surgery.

I hope this has dispelled some myths about cataracts, next week we will be going into detail on cataract surgery.  What is involved?  How is it done?  What are the risks?  We’ll even include a video of an actual surgery!

As always, please do not hesitate to contact me with additional questions and we’ll see you next time!

–  Nick Wolf, OD

In this connected day and age, everyone reading this knows about the epidemic of Diabetes worldwide.  November is American Diabetes Month and I wanted to bring additional awareness because the statistics from the CDC in the US alone are stunning…

9.3% of the US population has diabetes and over 1/4 of those are undiagnosed cases

28% of the US population is pre-diabetic with a strong likelihood of progression

The projected statistics suggest that this epidemic of diagnosed Diabetes may reach 25% by 2050

The total cost of Diabetes to our economy and health care system in 2012 was $245 billion (yes that is in billions, with a B!)

In addition to health risks like kidney disease, heart disease, stroke, and amputations; Diabetes is also the number one cause of new blindness in the United States.

Even more concerning to eye care providers is that the incidence of ocular changes in Diabetic patients has increased by 90% in the past 1o years.  This percentage outpaces even that of new diabetic diagnoses and suggests that the blindness rates from Diabetic complications will only continue to rise…

While these are grim statistics, there is a substantial silver lining.  While the rates of blindness and eye complications have risen, eye care has also evolved greatly with better ocular testing equipment and vastly improved treatments for diabetic complications of the eye.  The key to preserving vision is earlier diagnosis of eye problems, close monitoring, and better patient understanding of what eye problems can occur and lead to blindness.

If you or a loved one has Diabetes it is absolutely imperative that you receive yearly dilated eye exams with an eye care provider.  Schedule your exam today!!

For a far more thorough discussion on the eye complications that can arise from Diabetes please visit our webpage on Diabetic Eye Disease.

Please take care of those eyeballs!

– Dr. Wolf

Every contact lens wearer remembers their first experience with contact lenses- the excitement, the freedom from glasses.  However, what is often forgotten is the tips, training, and recommendations given by the eye care provider.  Today we will be doing a quick refresher on proper contact lens care.

Why is this even necessary?

Simply put, getting into the habit of proper contact lens care goes a very, very long way to ensuring you have a comfortable and healthy experience while wearing these medical devices.

I could put up picture after picture of the horrible things I’ve personally seen that were caused by contact lens misuse and abuse.  However, let’s just say that complications from contact lenses are a leading cause of preventable blindness in US.  If you’re inclined to horrible graphic pictures, type “contact lens corneal ulcer” into google images…

We don’t like seeing these complications so here are the recommendations for contact lens care that we try to instill at Precision Family Eye Care:

• Always wash and dry your hands before handling the contacts and avoid moisturizing soaps that will leave a film.
• Contacts come first – put in the contacts before applying makeup or creams to prevent cosmetics from adhering to the lens.
• Use only the multipurpose cleaning solutions recommended by your doctor.  Eye drops, saline, or tap water will not disinfect your contacts and will cause a problem.
• Please rub to clean the contacts.  Rinsing and soaking is not sufficient.  A simple cleaning will go a long way to keeping the lenses fresh and clean.
• Never, ever reuse or top off contact lenses solution!!  This cannot be overstated.
• Each time you remove you contact lenses from the case you should dump the solution, rinse the case, and allow it to fully air dry before the next night’s use.  We recommended this position for the case throughout the day (picture right).  A closed case will not air dry and grow bacteria and a face up case will collect hairspray.
• Even with perfect care, a case will begin to grow bacteria over time.  Cases should be boiled or replaced at least every 3 months.
• Please do not wear your contacts while swimming.  Chlorine is very rough on contacts and there are plenty of critters in both hot tubs and fresh water that would love to start growing on your eyes.
• Sleeping over night in contacts increases your chances of getting an eye infection by 15 times!  If you absolutely must, please let you eye care provider know so they can prescribe lenses made for overnight wear.
• Contact lenses carry a FDA approved wearing time for a reason.  If you use eye irritation as the judge of when you change your lenses, you are already doing microscopic damage to the surface of your eye that could lead to an infection.

If you notice pain, redness, light sensitivity, blurry vision, or irritation remove your lenses and contact you eye care provider.

Please follow these contact lens care recommendations.  Your eyes are too important to take a chance on!

Click here to see the FDA recommendations on contact lens care and potential risks

– Nick Wolf, OD

As eye doctors, we will often get asked the question…

“So what exactly is my vision?”

For us, it is very easy to simply answer this question by giving the patient a number: 20/20, 20/50, 20/100, etc.

BUT WAIT A SECOND!!

• What exactly are these terms?
• Who invented them?
• How did they come to be used to describe vision?
• What do these measurements really say about the quality of your vision?

Today I will answer those questions and more!

Why are numbers like 20/20 important?

The first thing to understand is that these values for vision (which we call visual acuity) are simply that: values or amounts.  It is no different than adding 10 gallons of gasoline to your tank or using 2 cups of flour in a cake recipe.  What makes these numbers so important is that (like gallons, cups, or feet) these visual acuity levels are standardized.

Covering an eye and reading a sign across the parking lot, doesn’t tell eye doctors very much about your vision.  However, with a standard visual acuity measurement, any eye doctor, at any time, or at any location knows immediately how well the patient saw the vision chart that day.

This allows us to monitor vision over time and to measure how much vision improvement a patient receives through medical treatment or a new prescription.

Where did 20/20 come from?

The first person to understand the need for a standardized way of measuring vision was a German ophthalmologist named Heinrich Keuchler.  Around 1842, Keuchler created the very first visual acuity chart.  Actually, he created 3 different ones to prevent his patients from memorizing the letters… you all know who you are.

A few years later in 1862 the vision chart was refined even further by Herman Snellen (pictured right) who created what he called optotypes.  Optotypes are simply specifically sized characters printed in a grid form.  This ingenious decision to start using standard font sizes of the time made these charts easily reproducible and they quickly became the global standard.

So popular was this invention, that the vision chart you read at the doctor’s office today still bears his name and the Snellen Chart (above) has sold more copies since it’s invention than any other poster in history!

Another fun fact about the Snellen and other vision charts is that the letters G, I, J, M, Q, W, X, and Y never appear.  See, reading the chart isn’t that hard, I just made it even easier!

What do the numbers in 20/20 stand for?

When Snellen first designed his reading chart, his optotype characters were meant to be read from 20 feet and if you could, you were considered 20/20.  Therefore, the first 20 in 20/20 simply stands for 20 feet.  This distance is important because past 20 feet the focusing of our eyes is the same as it is for any distance further out.  This distance is called “optical infinity” and is the distance that vision is measured.  In the past, it wasn’t uncommon to be examined in 20 foot long exam lanes.  These days however, it is far more common to use electronic charts or to incorporate mirrors to make the Snellen chart seems further away.

The second 20 in 20/20 is a little trickier to understand, but it basically compares how well you can see the chart compared to a normal 20/20 person.

For example, what if your vision is not the perfect 20/20 but only 20/40?

Well, this means that the smallest line of letters you can read at 20 feet is the same as for someone with normal vision who is 40 feet away.  And, if you could only see the 20/100 line of letters at the standard 20 feet, a normal person could see those same letters from 100 feet away.  This system is the same for every other measurement in between like 20/30, 20/80, 20/200, etc.

It also works the other way.  If you are blessed enough to have better than normal vision at 20/15 or even 20/10 vision, then you can see at 20 feet what a normal person can only see at 15 or 10 feet.

Best Corrected Vision

The last thing that it is important to discuss when it comes to visual acuity is the concept of Best Corrected Vision.  Best corrected vision is the very best that you can see when you have the best glasses or contact lens prescription possible.  This is typically the way that visual ability is described.

Therefore, the question of, “What is my vision without glasses” really isn’t important.  If you take your glasses off and can barely see the “Big E” on the Snellen Chart (which is 20/200) but with glasses you easily read the 20/20 line – you are not legally blind, your vision is considered the normal 20/20.

I hope this has cleared up some confusion around visual acuity, but if you have any additional questions or topics for future discussion, please contact me at [email protected].

We love to educate!

Thanks again for stopping by and take care of those eyeballs!!

• Nick Wolf, OD

Color Blind is a term that is often thrown around and usually with negative connotations.  But for someone who is color blind, what does it actually mean and how did it happen?  What does it mean if your child is diagnosed with color deficiency?  What does the world look like to someone who is color blind?

All great questions we will answer today on Eye to the Future.

What is Color Blind?

Before we get into what it means to be color blind or color deficient, let’s first look at how we actually see color.  As discussed in a past blog post on how animals see in the dark, there are two types of light sensing cells in the retina: Rods and Cones.  Rod cells in the retina are good at sensing movement and work well under dim illumination.  Cones cells, by contrast, need lots of light to work properly, but are capable of discerning incredible detail as well as sensing color.

What was not discussed before, is that there are actually three different types of cones cells in the human eye that each sense different wavelengths of light: one type that senses the color Green, one for Red, and one for Blue.  When light enters the eye, these three cells are activated to varying degrees based on the color or wavelength of the light.

Astonishingly, with just these three different color sensing cones types, the human eye is able to distinguish over 7 MILLION different colors!!  Now that’s pretty cool.

But what happens if one, two, or even all three of these color cells are either not working properly or completely absent?  The result is color deficiency or color blindness.

Types of Color Blindness

There are two forms of color deficiency: acquired and hereditary (i.e. genetic).  Acquired color blindness occurs from some uncommon eye diseases or as a rare side effect of some medications, however, today we will discuss the far more common hereditary form.

Hereditary color deficiency is very common and has a strong male tendency, afflicting just over 1 in 12 males but only 1 in 200 females.  Females are much more likely to “carry” the gene for color deficiency and pass it to their sons, whereas males are more likely to “express” the condition and actually be color blind themselves (more detailed explanation).

Many people believe that color blindness means a total lack of color vision.   True color blindness can occur when just one of the three color sensing cells develops: this condition is called monochromacy.  In actuality though, this condition is exceedingly rare (about 1 in 1 million new births).

Ironically enough, the vast majority of “color blind” individuals actually do see color.  However, they see color differently because they only have two of the three cone types (suffix –anopia) or they have all three cones cell types but one of them is not functioning properly (suffix –anomaly).  These conditions are named for what color cell type is defective and statistically it is most often the Green color cone cell type that is affected.  As you can see below, if any cone cell type is missing or ineffective it has a dramatic effect on the way color is perceived.

Normal Vision

Protanopia or Protanomaly – Red Cone Cells absent or defective

Deuteranopia or Deuteranomaly – Green Cone Cells absent or defective

Tritanopia or Tritanomaly – Blue Cone Cells absent or defective

Diagnosis, Treatment, and Impact of Color Deficiency

Diagnosis of color deficiency is very straightforward during a normal eye exam.  This is done by using colored plates with dots in various patterns to spell out letters, numbers, lines, or shapes.  These color plates (like the Ishihara plates at right) use specific colors chosen to be difficult for color deficient individuals to tell the difference.  As a result, these individuals have trouble identifying the number or numbers on the plate, but for a color normal individual this will be very easy.

Considering that color vision defects are mostly a generic/inherited condition, there is really no effective treatment to regrow or fix cone cells that are either absent or not working properly from birth.  The good news is that most of the time being color blind or color deficient has very little impact on an individual’s day to day lives.  There are some professions that simply require normal color vision like an artist or painter, airplane pilot, policeman or fireman, as well as licensing for some commercial vehicles.  However, for the most part, being color blind or color deficient, is quite common and does not prevent normal eye development, academic achievement, or professional success.

Aside from some occasional gentle ribbing by a spouse or coworker about a questionable attire selection, these individuals live normal and colorful lives.

As always, thank you for stopping by Eye to the Future and keep those questions coming!

Take care of those eyeballs!

– Dr. Wolf

For Loads more great information on Color Deficiency as well as some shocking examples of vision with color deficiency please visit the Colour Blind Awareness website.

As I’m sure you can imagine, as eye care professionals we get asked about eye dilation A LOT!  Although patients are frequently aware that eye dilation is part of a comprehensive eye exam, they often use the side effects of dilation as a reason for not doing it – we’re all friends here, you can admit to this tactic.

This article will try to convince you of the importance of eye dilation by exploring what eye dilation actually is as well as how the benefits of this simple test can save eye sight.  We will also dispel some eye dilation myths and misconceptions.

The Anatomy of Eye Dilation

The reason that eye dilation is even necessary is because of the anatomy of the human eye.  Assessing the health of the front of the eye is a fairly easy task using our light microscopes; however, viewing the inside of the eye is a challenge.  When light enters the eye through the pupil, there is a pretty nifty little neurological loop from your eyes to something called the Edinger-Westfall nucleus in your brain.  This part of the brain links with the muscles of your iris to constantly control the size of the pupil and thus the amount of light allowed into the eye.  Being in dimmer environments makes the pupil open wider to let light in to improve vision, while being in brighter environments causes the pupil to constrict to decrease light sensitivity and glare.  This is a great system for humans but a terrible system for eye doctors because the very bright lights from our microscopes makes the pupil so small we can’t see through it!  It’s like trying to look through a keyhole into a room and reduces our view of the inside of the eye to only about 10-15%!!  Going to an eye doctor and NOT getting your eyes dilated it like getting a physical but only letting your primary care doctor look at one leg.

Eye Dilation for Complete Eye and Systemic Health

In truth, eye dilation on adults is done to make sure ALL parts of your eyes are healthy and at Precision Family Eye Care, we would argue that eye dilation is the MOST important part of a comprehensive exam.  By dilating the eyes we are able to see 100% of the interior of the eye and rule out all eye diseases: from Glaucoma and Macular Degeneration, to Cataracts and even eye tumors.

The benefits of eye dilation don’t stop with the eye.  The interior of the eye is unique in that is it the only place in the body where nerve tissue and blood vessels can be viewed without any advanced procedures or expensive testing.  This allows your eye doctor a perfect opportunity to use the information gleaned from your dilated exam to identify problems and conditions elsewhere in the body.  There are quite literally hundreds of systemic conditions (the short list) that can result in changes to the interior of the eye but some of the more common conditions are Diabetes and cardiovascular disease.  The photo at right is a great example.  This patient had no complaints, but a dilated exam found a cholesterol plaque in a retinal artery.  This patient needs emergent care and testing due to a high stroke risk.  At Precision Family Eye Care, we work closely with doctors from all specialties on cases like this to communicate eye health findings and improve care.

Side Effects and Myths about Eye Dilation

First of all, it is important to note that there is NO substitute for dilation, although some offices may try to sell you alternatives.  The newer digital systems these companies offer can take relatively good pictures of the retina.  The problem is that these photos are only able to image about 65-70% of the retina and the 2-dimensional picture with poor resolution is not adequate to diagnose most eye diseases.  Simply put, this technology does not reach the standard of care needed for a Comprehensive eye exam AND this testing is an additional fee whereas eye dilation is an included service with any visit.

With eye dilation, there are some temporary side effects.  The most obvious side effect is light sensitivity because the larger pupils allow in more light.  This is easily solved with sunglasses and temporary shades can be supplied by your eye doctor.  Secondly, if you are under 50 years of age, the dilation drops also affect your ability to focus on up-close objects.  These two side effects are temporary and only last 2-4 hours.  Dilation will not affect your distance vision to the point where you will have trouble driving a car; a dedicated driver is an option but is certainly not a necessity.

How often should eyes be dilated?

Eye dilation is necessary at every visit for patients with certain systemic diseases like diabetes or in patients with confirmed eye disease.  The vast majority of early staged eye diseases do not cause obvious symptoms (like blurry vision).  Therefore it is necessary for patients to received routine dilation to rule out disease every couple years up to the age of 50 after which yearly dilated exams are strongly recommended.

Eye dilation definitely falls under the category of “necessary evil” but we hope that this discussion has convinced you of the importance of this procedure.

If it has been a few years since you have had your eyes dilated, we strongly recommend that you schedule a visit with an eye care professional.

See you next time on Eye to the Future and remember to take care of those eyeballs!

– Dr. Wolf