Interview with Susan Barry

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Interview with Susan Barry by Eduardo Punset on TV program "REDES" talking about Optometric vision therapy.

Refractive disorders: Astigmatism.(5) Solutions

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Solutions

Just as myopia and hyperopia, astigmatism can be corrected with eyeglasses, contact lenses and/or refractive surgery.
In any treatment, the correction is more complex because of the asymmetry of this refractive error.

• Eyeglasses, with usually the same correction to look far away and to look up close (although there are some cases in which the astigmatism may be different in one distance or another).
  
  The lenses used for compensating astigmatism depend on the kind of astigmatism we have.
  So far, the compensation of a refractive error was simple, because a spherical lens modified equally every ray that crossed it at any point of it; that is, any ray that got to the lens, got to the retina. In the astigmatism, this is MORE COMPLICATED.
  Because all surface (of cornea or crystalline lens) has not got a symmetrical curvature (there will be a meridian with more curvature and other with a lesser one), the light that gets into the eye, gets to different points regarding the retina. Therefore, if we put a spherical lens in front of a astigmatic eye, it will only correct a meridian. This way, all rays, that go through the lens and later through the eye, will keep on getting to different points with respect to the retina, because some of rays will be focused on it, but others will be focused behind or in front of the retina (depending on the kid of astigmatism).
  
  To make it simpler. Think that an astigmatic person sees the image distorted; on the other hand, it is usually accompanied by hyperopia or myopia that causes seeing blurred images. So, for you to understand it better, “this person will see blurred through one meridian, and distorted through the other”. Consequently, we need a lens with two different powers to compensate both effects: one spherical lens to compensate the blur and other cylindrical or toric lens to compensate the distortion. Each one will focus the rays that go through by each meridian, INTO the retina.
  
  The eyeglasses with astigmatism may usually make you feel a little sick when you begin to use them, mainly with refractions over 1.00 or 1.50, that is why it is advisable to start using them gradually. In fact, in high degree, firstly diagnosed astigmatism, the graduation is usually prescribed gradually, increasing it little by little.

• In the past, astigmatism could only be compensated with eyeglasses, because the cylindrical lens demands it to be worn with specific angle degrees. The contact lenses on the eye ares in constant movement because of the blinking, and in the past, this prevented that stability from happening. When said contact lenses were made, these were made with a material that lasted for a long time, because manufacturing was expensive. Latter research lead to the current situation, where there are many systems to stabilize them, and the cylindrical power in disposable contact lenses is higher and higher as time goes by.
  Therefore, nowadays, this refractive disorder may be compensated with soft contact lenses as well as with lenses; and in adults as well as in children.
  
  In the cases of astigmatism caused in keratoconus, they are usually compensated with rigid gas permeable contact lenses, with the purpose of holding the process of growth of the cornea a little bit. But sometimes we choose the soft contact lenses in the cases where the other lenses are impossible to wear due to the blinking; on one hand, because the eyelids may expel the lenses; and on the other, because they are not stabilized in the best position possible, therefore causing blurred image. Anyway, these patients usually achieve better Visual Acuities with contact lenses than with eyeglasses.
  
  Also, the astigmatism caused by a problem such as a deformation of the eyeball by palpebral disorders (as chalazion), treating the underlying cause will resolve the astigmatism. If the patient suffers a severe astigmatism, her best option is the semi-rigid permeable contact lens.

• In the other hand, vision therapy is useful when the visual system has been compensating a little difference of graduation from between some meridians and others, and the focusing (accommodation) and team coordination (fusion) are tired.
  
  We use vision therapy when symptoms exist and we have to teach the visual system to use its accommodation correctly again.
  Many times simply wearing some eyeglasses is just not enough because they do not resolve completely the problem.
  Although initially you see well with them or maybe you have started to use them and everything seems to be going better, shortly you may be uncomfortable again and unable to perform at work or when studying.
  During a time you were using your visual system incorrectly and you have to re-educate it; the eyeglasses by themselves will not do it.

• As the previous refractive disorders, the VISUAL HYGIENE AND ERGONOMIC RULES must always be taken into account.

• And finally, the refractive surgery is another option. It consist of changing the shape of the cornea, and therefore correcting the astigmatism in the cornea or in the crystalline lens.

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Refractive disorders: Hyperopia. (4) Solutions

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Solutions

Low or even medium hyperopias are difficult to diagnose because, as I wrote in one previous post, they “consume” the refraction. Besides, they are difficult to be detected by parents or teachers because these hyperopic people have a more or less clear vision in any distance. That is why these people need a COMPREHENSIVE EYE EXAM from early age and a chekup once a year.
In that comprehensive visual examination the refraction that the visual system of the hyperopic person is constantly compensating is checked, along with other skills of the visual system, specifically her accommodation which is the one that is working all time, and if it (accommodation) may have disturbed other visual skills.


In the case that the refraction error can be diagnosed or that the error is causing a certain symptomatology, these are the possible solutions:

• Eyeglasses, either if she needs them to see clear because she has a high hyperopia, or if she has a low one and needs them to avoid that constant effort for close-up tasks, and this way, avoiding certain symptomatology. In the last case, eyeglasses are not used for seeing clear.
  
  In the case of a high hyperopia, the use of eyeglasses can make sense both for short and long distance seeing, if the visual acuity for long distance is reduced.
  
  In the case of lower hyperopia, that is causing some symptoms, the option of eyeglasses is good because she does not require wearing them during all day.
  
  Hyperopia is corrected with plus, positive or convex spherical lenses (thicker at the middle than in the edges of the lens), that optically falls in front the image, on the retina.

• If hyperopia is higher than +1.50 diopter, another option for compensating it, is by wearing contact lenses for a long period of time. In this case, unlike myopia, each patient may use the best contact lens for her, that is, there is no suitable specific one. There is no one that stops the hyperopia, simply because as I have explained, the hyperopia does not increase.
  
  There exists a research about Orthokeratology, carried out specifically in Australia, which tries to find a contact lens that model the cornea and reduce the hyperopia; but even, as I say, it is under research.
  
  Hyperopic people are usually more uncomfortable wearing contact lenses than eyeglasses, because although her visual field is bigger wearing contacts, the size of images is more real; but wearing eyeglasses with plus lenses, they magnify the objects (I will explain this effect later); therefore, as they see everything bigger wearing the glasses, they are more comfortable wearing them than with contact lenses.
  
  
• Vision Therapy is the best allied in this refraction disorder. A hyperopic person does not often respond to lens correction alone, but they are required to “remediate” accommodative dysfunction. With therapy we teach her to control her accommodation and her convergence and to perform her close-up tasks without effort. We will avoid that this to happen again.
  
  Within vision therapy, besides some simple visual activities, the use of eyeglasses with a low positive refraction will be able to relieve her symptomatology in order to be able to perform the daily close-up tasks. This way, she relieves all accommodative effort that she constantly performs.
  
  
• Besides, as it happens with myopic people, some simple VISUAL HYGIENE AND ERGONOMIC RULES will help prevent her reaching that visual stress. Modification of the patient's habits and visual environment is occasionally useful as an adjunct therapy.
  
  Mainly:
  
  
  • Improving lighting or glare reduction
    
  • Using better quality printed material.
    
  • Decreasing temporal demands, with frequent rests.
    
  • Looking far away and focusing on something, frequently, when performing close-up tasks.
    
  • Etc.

• Lastly, surgery: hyperopia is a refractive defect that can be operated as well, but except for high hyperopias, it is not considered as the best option.

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Refractive disorders: Myopia (3). Solutions

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Solutions

Myopia is not an illness, that’s why it can not be “cured”.

• If you want to “compensate” a myopia or its problem of blurred distance vision, the treatments most commonly used imply wearing eyeglasses or soft contact lenses (mainly disposable ones); in order to go to the theater, to drive, to walk, to watch TV, to practice some sport,… In this case, myopia is corrected with minus or diverging spherical lenses (thicker at the edges than in the middle of the lens), that optically falls behind the image on the retina.

• But if you would like to “try to stop” that progression as much as possible, the perfect thing would be wearing contact lenses and still better, if they are semi-rigid permeable ones.
  Besides this, the ideal thing would be to perform a series of simple visual exercises, which mainly teach us how we should correctly use our ability of focusing (accommodation) and how we could teach our visual system to be less “focal”, so that, although we are performing much near work with papers, computer, books, notes, homework, and for many hours, we do not help myopia to keep on increasing. This is one of the visual functions that we can work with the vision therapy.
  
  Besides all it has been said before, if the myopic person with few diopters (less 1 diopter), removes her eyeglasses in order to perform that near work, she will help her visual system (specifically, her ciliary muscle and her crystalline lens -8-, structures that are responsible for focusing works the right way) not to be stressed. In the case of a bigger myopia, she would need another pair of eyeglasses with less degree of myopia, in order to work at near with it without performing unnecessary effort. Although it is totally proved that the use of near eyeglasses with less refraction is useful in order to reduce the myopia or to stop it, it improves the environment factors without a doubt.

• Many people choose the solution that “will put an end” to myopia, tired of using eyeglasses or contact lenses during much time, resorting to Refractive Surgery. This solution is given by ophthalmologists (not by optometrists). But I have to let you know that not all patients are suitable for this procedure. What I advice you is to go to a clinic specialized in this kind of surgery and that after a complete ocular exam, they advice you your best option.

• In the case someone wants to “reduce myopia” without getting into the operating room, there exists the option of a treatment performed with semi-rigid permeable contact lenses, called ORTHOKERATOLOGY or “corneal refractive therapy”. This is performed by optometrists. This technique consists of leveling little by little the excess of myopic corneal curvature (when the main cause of the myopia is the cornea), until the point of best vision is obtained, and respecting the health of this ocular structure. Thereby, contact lenses can be used only when we sleep (and not all nights) and then, during the day we can enjoy good vision without wearing any refractive compensation. This option is perfect for those who candidates that need to achieve a certain Visual Acuity without refraction in the medical examination, and they do not want to get into the operating room.

• Lastly, in order to “prevent” not only that myopia rises or increases, but also to avoid any symptom of visual strain, we should take into an account some RULES OF VISUAL HYGIENE, that are not detrimental to anybody, but, on the other way, can help EVERYBODY, in the carrying out of the near tasks. Again, these rules improve the environmental factors.

But I will explain all these solutions that we can offer the optometrists in later posts.

As myopia keeps on awakening many questions, research is continually performing going on in order to stop its progression and remove it. Nowadays there is an European project called “My Europia”, that is focused on the creation of special eyeglasses with different refraction in the middle of the lens and in the periphery, that causes that the eye to react different ways in order to prevent that progression.


Medicines, vitamins,… Is there anything that I can have in order to stop my myopia?

Until now, there is no medicine that can certainly works in order to stop myopia. The only thing that has been tried in different schools at USA is pirenzepine . But as you can read in the article, this medicine is able to cause myopia to progress slowly but it is not able to prevent that progression. Besides this result, there are still many concerns: secondary effects, what happens if we interrupt the treatment, or how much time would a patient need to be with it. Also, even though this medicine was safe, it had to be removed from some children because it caused ocular irritation. Therefore, there is still much research to do in this subject.

In the other hand, vitamin A, lutein and zeaxanthin are supplements that are said to help eye health. I guess this is like the rules of visual hygiene, if you perform them, they are not detrimental to you; they are vitamins and they are always good for our organism, but personally, I would not support a treatment exclusively on them.



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Who examines the Vision? Differences between Optometrists and Ophthalmologists.

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The professionals responsible for evaluating everything related to Vision are the Ophtalmologists and the Optometrists.

Ophtalmologists and optometrists, in many parts of the world, have always had “difference of opinions”, as I guess there is between architects and quantity surveyors. The difference is that Optometry is not the technical career of Ophthalmology and the optometrists’ work does not depend on ophthalmologists’. They are independent careers, with different aims and fields of evaluation.

For many ophthalmologists, we, optometrists, are just those who sell the glasses that they prescribe to their patients after they test them, or who test when the medical doctors have a very long waiting-list (as in the Social Security in Spain). Surely, many of them have always considered us “their little sister” with inferiority of knowledge. And we have always considered them the “bad people”, because many of them do not respect our work.

Simply said, each one has different vision models, with different knowledge. Each one covers distinct vision areas; therefore we all should respect each other and should not work in areas that we do not know.

In just a few words, ophthalmologists evaluate the sanity of vision and we, optometrists, evaluate the functions of vision.

I explain:

Ophthalmologists

The Ophthalmologist, as a medical doctor, is specialized in checking whether the eyes and the visual path are sane. And if any disease exists, they can prescribe the drug that is in need or perform a surgery to achieve the best cure.

It is true that they can prescribe graduated glasses. But although I do not want to generalize, many of them spend the same time testing that the time that many of my colleagues do at the optician’s. That is, their only goal is checking with what correction the patient sees better, and do not worry about anything else; for example whether it will be comfortable every day, whether it will create other different upsets, whether it really covers the patient’s initial upset,…
It is true too, that there are some ophthalmologists who have a broader vision model, they respect there are other ways to analyze the vision more complete and that a simply pair of glasses is not always the cure against a problem of wrong vision or uncomfortable vision.

Optometrists


The optometrist receives little notions at the University about possible pathologies that the visual system can suffer. But we are light- years behind the knowledge that an ophthalmologist has on the matter.
After graduating, some optometrists attend some courses of specialization where they can learn more about these pathologies, but my opinion is that as much as they can learn in one year of specialization or attending small courses, ophthalmologists study ocular medicine for 4 years specializing in them. Their pathological knowledge easily overtakes us. This is their field and not ours.


So, an optometrist is not a medical doctor and thus, in Spain:
- He can not diagnose any pathology, although we can see it and we know that a patient has a cataract, for example, we can not tell it to him; we must simply send him to an ophthalmologist, with more or less rush depending on what we see. Many times the optician or the optometrist can be the first one detecting a problem like that, and we must know to detect it and send him to a qualified professional.
- He can not prescribe any medicine: Neither any eye drops nor anything that contains a drug. We can advise artificial teardrops, vitamins or homeopathic products.

- He can not use any medicine in his office, and with that I refer to pupil dilator. The medical doctor has all responsibility for it. Sometimes, if a child does not collaborate and we can not get him to read a test while we perform an objective test - which allows to obtain the exact correction of eyes-, and we need this piece of data, using the dilator eye drops can be the only way, in these cases, to achieve it (I will explain how this works later). Then, the patient should be refered to an ophthalmologist to obtain this piece of information. In some US states, optometrists, even without being medical doctors, can use pupil dilator in their offices.


All right, I have described what the optometrist is not educated for, or what he should or should not do in those situations. But now, let me define what our functions are.

The Optometrist’s field of action is different and broader. An optometrist can find a “machine” that physically is fine, but does not work well.

An optometrist is able to test a patient in objective and subjective ways. He is the most capable professional to do it. In Spain, while an ophthalmologist studies for 4 years (besides other four previous years of general medicine) about ocular and refractive pathologies and their medical treatments (drugs and surgeries), in those four years they study very little about the optometric side, basically learning to perform sight tests, in the simplest way. But optometrists study, in the three undergraduate years, the way for testing and treating a problem of wrong visual functioning with different options.
One sample of that Optometrists finish our degree more qualified in this field than Ophthalmologists, is the “Letter to Publisher” in the Spanish Society of Ophthalmologist journal, that Dr Colome Campos (ophthalmologist) published in 2005. “The optometry: A challenge for the ophthalmologist in 21st century” (in Spanish). In this letter, he explained that he designed a study evaluating and comparing the refraction knowledge between MIR Ophthalomologist and 3rd year Optic-Optometry students. For it, they had to answer 40 questions test, about Optometry, Binocular Vision and Contactology. Result: Any ophthalmologist appeared at the test. “Only one intern was very kind, my gratitude from here, of excusing because his chief of Internal Medicine
prohibited him the collaboration owing to the questionnaire was excessively difficult.” (Dr. Colomé Campos).

All opticians-optometrists leave the University with the same taught knowledge. But later, some of us, as those opticians that works in some optician’s, whose only goal is to sell as many glasses as possible, will make a visual test similar to the one made by an ophthalmologist, and his treatment will simply be to order some glasses or contact lenses “for seeing better” (in the next post I will explain the different models of work that there is within my profession). However, some of us have specialized and updated our knowledge year after year, we know better how vision works and how its functioning can change; that is why, we can find out from the patient’s symptoms, how the visual problem is affecting the person’s life, what parts of vision we should test to find the problem and the best treatment. Many, many, many times glasses are not the solution, or not as the solution that many people know. And the optometrist knows how to use glasses, contact lenses or prisms the best possible way for removing all patient’s symptoms and for giving him other options that can help him. Not only his loose vision.

In later posts, I will explain little by little, the treatments or solutions that an optometrist can offer and what the best is in each situation. One of these possible solutions is the Vision Therapy. This treatment is necessary when the upsets are not solved with some simple glasses, can be or:

- because a disruption has taken place in the patient’s visual system owing to some cause in his life. In one moment a change occurred (e.g due to work stress, a divorce, parent’s separation, …) and the person began to use his visual system in a different way, the incorrect one; he modified the base, creating a wrong one, from which he has developed his visual skills. But as it is not the right way, the symptoms and upsets come up after some time;
- or because the development bases (visual and motor) were not created right when he was a baby.


Well, maybe this is a little bit abstract, but when I describe in another post what the Vision Therapy consists of, you will surely understand it much better. For now, what I want you to understand is that in vision there are more problems besides seeing 20/20 and optometrists are the ones meant to solve those problems. When the “eyes” do not work very well, you do not perform well too. Not only we have to see right, but we have to process right what we see, and our visual system has to be able to answer and perform the optimum way in all situations. A specialized optometrist in Vision Therapy can re-educate the visual system in order for it to have right visual bases or to establish them from the beginning if the person has never had them (strabismus, lazy eye, retained reflexes, …). He can teach the patient to use his vision the optimum way for getting the greater quality and performance in his daily visual task.

Therefore, the optometrist has different options of alternative treatments before resorting surgery.

I hope that with all this explanation, now the function of each professional of vision is clearer.

Finally, I would like to make use of this post to expose a demand: a little bit of respect by both professions. Each one has a work to do, so, we must not neither diagnose or treat what we do not know, nor underestimate or undervalue the qualified work of the other professionals if we do not know the field that we criticize. As well as ophthalmologists master pathologies and we, optometrists just “know” them; we master visual functioning and they just “know” it.

What each one of us must to do is to work as well as we know, and if both sides collaborate together, the patient will be the most favoured.

Welcome to my blog!!

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As the blog name indicates, the main subject is the Vision and everything related with it.
In this blog I am going to try to explain some concepts about vision, optometry, vision therapy and neurology related to all of this.

But this blog is not for experts on these subjects. It is for you… or for you… or for you too. It is for those people that have always wanted to know a little bit about their own eyes and how they work. Or simply those people have had a visual problem, have gone to visit a “professional of the eyes”, he has offered them as an only solution glasses or contact lenses, but really he has not solved their problem. Their inconvenience or difficulty to work, to study or basically to perform well, keep on existing.

I am going to explain how vision is not just a couple of eyes and how an efficient visual system does not depend neither on just having healthy eyes nor seeing 50 or 70 or 100 percent of vision. How a child who does not achieve good grades in the school, is not simply a lazy child who does not like reading or studying, nor he is a troubled child who does not like paying attention and also he disturbs the rest of children in his classroom. Behind all that, there can be a visual reason that upsets his perception and simply that child does not receive, process and answer the visual information from the environment the same way another child who apparently does not have any problem. I will explain that these cases can be treated and they can make the child perform much better in the school and even, enjoy reading and take a book because he wants to and not because it is mandatory.

I will start laying the bases: What is the Vision? Who tests it? Difference between optometrists and ophthalmologists. The Eye. The Visual Process. The Visual Therapy… As an entry door to other different visual problems, treatments and even some of my patients’ authorized personal opinions. I think this way everything will be much easier to understand.

I am going to explain everything in whatever easiest way possible. Therefore, do not wait for a “master class” or for a “very professional lecture” because that is not my intention, my real intention is to get your participation. If some of my entries leave you questioning, I will try to explain it again with simpler words, but I need your collaboration for this blog have the usefulness that I wish: to solve many “questions about the visual world”.

This blog will not come in useful for solving personal cases. At most, I will just give you an orientation in your questions. In order to find a better solution and a treatment of a visual problem, it must ALWAYS be examined from different points of view and, absolutely, the patient’s vision must be tested. Thereby, if in some moment, you recognize some symptoms in yourself or in your children, etc., my recommendation is that you should go visit an optometric and vision therapy office for it to give you the services in need.

I am also not going to write about ocular diseases or medicines, since I am not a medical doctor nor a physician, thus it is not my area.

So, … WELCOME TO MY BLOG!! :-)