1. Don’t smoke, or stop smoking.  Smoking is the biggest modifiable risk factor in macular degeneration, the biggest cause of legal blindness.
2. Wear eye protection.  It only takes a second for a eye injury to occur.
3. Get your eyes checked.  Some eye conditions, and especially glaucoma, don’t give symptoms until the condition is advanced and harder to treat.  Early detection and treatment is important.
4. Know your (family) history.  Find out from your parents, and older generations before it’s too late,  if there are any hereditary eye conditions in the family.
5. Try to not develop diabetes.  Diabetic eye disease is a major cause of vision loss for people of working age.
6. Take contact lenses seriously.  Follow instructions, clean them well, get any concerns checked out  right away.
7. Don’t hang around on eye symptoms.  If something feels wrong about your eyes or your vision, get it looked at.  Some conditions need immediate treatment.
8. Chemical burns in the eye need to be flushed with lots of water straight away.
9. Protect your eyes  from UV.  UV exposure has both acute  and long-term effects.
10. Take extra care over an only eye.  If you’ve only got one eye that sees well, the rest of the list above is even more important.

So, if someone notices that they have a pupil bigger than the other, especially of sudden onset, it’s important to get the eyes properly checked straight away.  This is not so much to do with having one pupil bigger – which of itself won’t cause much bother to the vision apart from perhaps some extra glare in the eye with the larger pupil  – but it’s because abnormal pupils can be a sign of more serious, even in some cases life-threatening conditions.

Don’t let reading through the rest of this slow you down from making arrangements to get your eyes checked.

Sudden changes to pupil function can be caused by some eyedrops, and medications.

It can also be because of some fault in the pathway between the eyes and the brain (on the way in), or some fault along the pathway from the brain to the eyes (on the way back out).

• The pathway in to the brain is virtually straight inward from the eyes, along the optic nerve, via the optic chiasm and optic tracts to the midbrain, where pupil function is processed.
• The pathway back out is far more circuitous, travelling down the neck and as far down as the top end of where the lungs are before looping back up and into the back of the eyes.

Injury or problems anywhere along this route can affect pupil function, and it takes careful examination to try and work our where the problem might lie.

There’s a number of ways people describe dry-eye symptoms with contact lenses:

• ‘lens awareness’ – can feel the contact lens moving around, especially towards the end of the day.
• variable vision – perhaps getting better and then worse again, especially towards the end of the day.
• gritty feeling eyes, scratchy, lenses feel dry
• can’t wait to get lenses out in the evening

and while there’s more than one possible cause for each of these symptoms, but most of the time, its a lens gradually dehydrating over the day, with its surfaces gradually becoming less wettable, leading to a less stable tear film.

If you’re having troubles like this with your  fortnightly or monthly contact lenses, and perhaps even thinking of going back to glasses, it’s worth bringing up a month or two’s trial in daily disposable contacts.

There’s a few reasons why they might work better:

• a new lens each day means your starting with a perfectly clean lens – especially relevant if you’re cleaning routines with longer term disposable contact lenses is minimalistic.
• daily disposable lenses are made as thin as possible.
• there’s an added thing you can do with a contact lens if it’s only used once – use it as a delivery system for an eye lubricant.  Some brands of daily disposable contact lenses contain a wetting agent, like an artificial tear, that gradually releases over the course of the day.  (In fact its possible some day that daily contact lenses will be used regularly as a treatment in dry eye. )
• the Proclear lens material, used as a best-choice contact lens material for dry eye in longer term contact lenses, is also available in a daily disposable.

So the thing is this: if you’re contemplating giving up contact lens wear, a month or two’s trial in daily disposables will help you reach your verdict – because if you can’t get comfortable wear in daily disposable lenses, you’re unlikely to find any other soft contact lens that will work better.  On the positive side, you may well discover that you can wear contacts lenses comfortably after all.

I spend time with people who already have vision loss, trying to help them out with magnifiers and visual aids, and while they can help a little, the look of struggle and frustration on so many faces says that they’d much rather just have their previous good vision back.  The more people that can avoid degeneration of their macula, the better.

Recently there has been some good treatments become available that, for the wet type of macular degeneration, can often maintain or improve vision.  But even then the treatments need to be repeatedly given, so the fear of vision loss can still hang over someone whose doctor is ‘very pleased’ with the way things are going. (Having said that,  it’s far better than just a few years ago where there was very little that could be done.)  In the more common, dry type, there are no mainstream treatments yet. Overall, prevention if possible is the way to go with this condition.

Some of the risk factors aren’t modifiable.  You can’t change your genetics, or your age, which are two important risk factors.

But you can stop smoking, if you smoke, and that will be the single biggest thing you can do to reduce your risk of macular degeneration. (… and although they may not like it much at the time, if you can stop someone else smoking, that will also be the biggest thing you can do to reduce their risk of macular degeneration).  Even if you (or they) have been a smoker for a long time, quitting reduces their risk, so it’s not too late to stop.

Other things you can do:

• UV protection: there is some link between UV light exposure and macular degeneration.  Sunglasses, hat outdoors.
• Nutrition : Fats – people with lower overall fat intake have reduced risk. Of the fats you do eat, omega-3 fats (fish and some nuts) are better, and always choose less processed fats over highly-processed.
• Nutrition : Antioxidants – Vitamins A,C,E and zinc were tested in a large scale study and found to be beneficial in reducing the worsening of vision in people with moderate macular degeneration.  Lutein and zeaxanthin, yellow pigments as you’d see in egg yolks and corn, and some of the dark leafy green vegetables like kale, are being tested in the next stage of the study.
• Nutrition: Overall – go for unprocessed foods, go for brightly coloured fruit and vegetables.

• Keep up regular eye examinations, especially as you get older, even if your vision feels fine.  Ask ‘how’s my macula?’ at the end of the appointment, and make sure you get an answer.
• If you notice any sudden vision change, get it checked without delay.

1. Are floaters common?     Yes
2. Do they need to be taken seriously?    Yes
3. Can they be a sign of something that needs urgent treatment?    Yes

Where do floaters come from?

The inside of most of the eyeball is filled up with a jelly-type substance called vitreous.  Various things can happen to it to make parts of it just opaque enough to cast a shadow on the back of the eye.  Its the shadow of these vitreous opacities that make up the variety of shapes and forms that we call floaters, and degree to which the opacities are fixed in position or mobile that determines how much we see them moving across our vision.

People experiencing floaters for the first time call them all sorts of things

• a dot
• a spot
• a bit of thread
• like a bit of a spider’s web
• like a piece of hair

The further back in the eye the opacity lies, the more distinct a shadow it will cast, and so it will be seen as blacker and more definite in shape.  The further forward in the eye it lies, the less distinct will be its shadow, often appearing ghosty, faint, and its shape will be harder to describe.

Get floaters checked out

Floaters need to be checked out because they can be a symptom of retinal damage,  and because it’s not just vitreous opacities that can cause spots or dots in the vision.  The worst case is when they are a symptom of a retinal tear, which can lead to a retinal detachment, with loss of vision.  Most of the time that’s not the case, but because it is sometimes, and because retinal tears need to be seen to straight away, you should always take new floaters (especially when accompanied by flashes of light or a feeling of restriction to your field of vision) seriously. Most of the examination of a person with new floaters is not about looking at the floaters in the eye (they’re not too hard to find), but looking at the health of the retina.

Then what?  will they go away?

If there’s nothing more serious going on, then what? If a floater is fixed in position, you may notice it for quite a long time.  Sometimes a floater will ‘sink’ to the bottom of the eye (which in vision terms  means it floats ‘up’ out of sight).  Sometimes the opacity will gradually move further forwards in the eye, gradually getting more and more indistinct.

Watching your floaters

• Floaters are more easily noticed against bright uniform backgrounds – computer screens, walls, the sky. A bright blue sky is the best place to look at your floaters.
• Floaters, for some reason I’m not sure of, are more noticed when people are tired.  Maybe it’s just easier to get distracted or irritaed by them when you’re tired.
• A fairly common position for a floater is about 10-15 degrees ‘out’ from your line of sight (ie opposite side to your nose).  This is close to where you’re blind spot is, so a floater in this location can easily move just a little and suddenly become visible, or not visible.
• If it is fixed in position, that’s the sort of floater you can chase across your vision with your eyes but never catch up to.
• If it is mobile, it may at times drift across your line of sight.  Sometimes a sudden movement will bring the floater back into view.

Why talk about how to view your floaters?  Because once you’ve got a floater, the thing you have to keep on the lookout for is changes to that floater, or new floaters.  So the more familiar you get with your ‘normal’ floaters, the better you’ll be able to notice if the situation changes, requiring re-examination.

Only when there’s an answer to that, can you then look at what treatment should be used, and also how intense that treatment should be.

Let’s be clear: some eyes are red for reasons that if not treated properly, can lead to loss of vision.

Red eyes, especially if accompanied by pain or reduced vision or getting worse rather than better, need to be properly assessed.  There’s no way around this, because some of the most important signs in determining the cause of a red eye, such as eye pressure and the presence of inflammation inside the eye, can only be done by proper examination – they can’t be distinguished just by looking in the mirror.

What can cause red eyes?

This isn’t a complete list, but is there to show the variety of different causes, and to give you an idea that the ‘best drop’, or other treatment, really does rely on identifying the cause (or at least ruling some causes out).

• Acute glaucoma
• Trauma, foreign bodies, inturned eyelashes
• Burns – thermal (heat), acid, alkali (lime, caustic), UV (sun, welding flash, snow)
• Bacterial infection
• Viral infection – adenoviral is common, but also herpes (cold sore, shingles) viruses.
• Other infections – fungal, chlamydia, amoeba.
• Allergy – hay fever, dust mite, preservatives in eye drops, ingredients in eye creams/ makeup, deposits on contact lenses.
• Internally caused inflammation – auto-immune conditions.
• Exposure – incomplete lid closure, hot & dry environments, eyelid abnormalities
• Poor tear film quality – dry eye, complications from contact lens wear.
• Lumps and bumps on the lids or surface of the eye – benign and malignant.
• Secondary to other general health conditions, or the medications used to treat them.

What about red-eye (eye whitening) drops?

Some people seem to love ‘red-eye’ drops – drops that contain a vaso-constrictor to shrink the surface blood vessels on the eye, thus causing white eyes and ‘fixing’ the problem.  Here are some things to think about regarding these drops:

• They are most effective when they are used least often.  For my clients that I’ve ruled out more serious causes of red eye, the only way I recommend these sort of drops is for cosmetic use on special and infrequent occasions.  This is because the active agent works best when used rarely.  If their eye is red on an ongoing basis requiring more frequent treatment, there are better treatment options.
• The eyes ‘get used to being dropped’. If used regularly, the eyes will go red when they are not used, thus easily starting an ongoing cycle of drops and red eyes that never get better.
• They target the redness of the eyes, not the underlying cause of the redness.  Since they don’t work towards a cure, if you rely just on these drops, you might end up subjecting your eyes to a lot more drops than they need.
• They target the redness of the eyes, not the underlying cause of the redness.  Since they take the redness out of the eye, you be lulled into thinking you are treating the eyes, when the underlying cause is actually still there, and could be doing damage.
• They target the redness of the eyes, not the underlying cause of the redness.  Using treatment that targets the cause will be more effective at getting the eye back to normal long-term.

I hope I’ve been able to lead you to the answer for ‘what’s the best drops for red eyes?’, that being – it depends.

Actually, you would have to be a pretty good observer to see a cataract in your own eye.  That’s because the eye’s lens, the tissue that goes cloudy in cataract, sits behind the pupil, right inside the eyeball.  A quite advanced cataract may be seen as a slight greying of your pupil (rather than the normal black), but it wouldn’t generally be noticed.

The two most common things that are seen growing on the front of people’s eyes are either a pingueculum or a pterygium.

• A pingueculum is an accumulation of fatty tissue, that stays on the white of the eye, not getting onto the clear cornea.
• A pterygium is a growth of connective tissue that can gradually move across the front of the eye, in advanced cases right across the pupil.

Both are usually white in colour but my get inflamed.  Both can irritate the eye because they interfere with the normal wiping function of the eyelids.  Both are more common in people that spend lots of time outdoors exposed to UV, and in countries with higher UV levels.

Treatment

• Pingueculae are not normally treated, although they could be removed for cosmetic reasons.
• Pterygia are surgically removed once they get to a stage of interfering with the vision.  Historically there is quite a high rate of recurrence, and so a variety of surgical options are available to reduced the chances of it coming back.
• For either condition, lubricant drops may be helpful to reduce irritation when inflamed, and reducing exposure to UV and dehydration by wearing sunglasses outdoors is also advisable.

Pingueculae and pterygia, whilst being the most common things that grow across people’s eyes, are not the only things that can do that.  There is also a whole range of other growths, both benign and malignant, so if you’ve got something growing across your eye, it’s best to get it checked out.

People can get dry eyes for a number of reasons, but most of the time, it’s not lack of tears (quantity) that’s the problem, but rather instability (quality) of the tear film that creates the dry eye symptoms.

The eyes have a thin film of tears on them all the time, and to keep clear vision, that film needs to be stable.  After a blink, when the tear film gets reset, the tear film will remain stable for a number of seconds.  Hopefully this period is long enough to preserve a smooth front surface to the eye until your next blink occurs.  If you hold your eyes open long enough, you’ll feel the sting, and perhaps the blur, that comes as that tear layer loses its structure, and dry patches develop on the front of the eye.  The sting comes because the nerves in the cornea are very sensitive, and let you know as soon as the tear film has broken down.  The blur comes because the front surface of the eye, a very important part of the optics of the eye,  is no longer as smooth.

A rough front surface to the eye means that light falling on it will not be focussed regularly, but instead, light will get scattered in different directions.  This may be

• seen as blur if you’re looking at fine detail,
• seen as a flare or a halo around a bright object especially at night,
• seen as a vague haziness/ filminess or loss of contrast as you look at things,
• felt as the symptom we call glare.
• accompanied by the dry, gritty, ‘something in your eye’ feeling.
• seen as blurred vision that needs a few blinks to clear it.

Usually, having a blink will restore the regularity of the tear film, but if the eyes have been getting dry for a while, then even the ‘reset’ tear film won’t be as stable, and the symptoms will remain no matter how much you blink.

Therapy for dry eye can be targetted towards:

• adjusting the environment to reduce tear instability
• adding drops to increase the volume of tears, or the stability of tears
• working on co-existing conditions of the eyes and lids that are contributing to poor tear film quality.

Dry eye vision symptoms seem to be more common amongst people working at computer screens and contact lens wearers.

There are of course, many other things that can cause blurry vision, but dry eye is definitely one of them.

It can happen in two ways.  Contact lens wear can ‘amplify’ any underlying dry eye – that is, make things more noticeable to people who already knew they have dry eye, and sometimes give symptoms to people that had low-grade, non-symptomatic dry eye.  Contact lens wear can also, it seems, give reversible dry eye symptoms to people who have no detectable dry eye signs before contact lens wear.

There are environmental things that can push a non-symptomatic contact lens wearer to being symptomatic -

• Type of work – screen based work is generally done at a higher level of gaze than paper based work, leaving more of the eye exposed to the environment.
• Type of work – spending longer periods staring at the same place is more likely to give dry eye symptoms than if your work involves more visual variety.
• Type of work – people blink less the more they are concentrating on a task.
• Type of work – people are more likely to report dry eye symptoms if they are doing ‘boring’/repetitive tasks than if they are doing creative work.
• Environment – hot air, strong air flows, low humidity environments all increase tear evaporation of the eye, making dry eye symptoms more likely.  Where I live, there’s always a surge of contact lens dry eye at the beginning of winter once the heaters get turned on.
• Medications and medical conditions can affect dry eye symptoms.

So, without doing anything to your contact lenses, you may be able (or maybe not) to reduce dry eye symptoms.

There are a number of things that can be done to help contact lens wearers through dry eye symptoms – ask at your next eye exam if any of these might help:

• Lens design – if a contact lens fits too tightly, it may be comfortable to start with but get worse as the day goes on.
• Lens material – material softness, and wettability vary from one lens to another.
• Lens hydration characteristics – most soft contact lenses are about 60% water, and they can lose water content during the day, leading to changes lens fit, and thus lens awareness on the eye. Some lens materials ‘hold their water’ better than others.
  • Rehydrating the lens part-way through the day by adding lubricant eye-drops, or
  • Rehydrating the lens part-way through the day by taking them out, popping them in their case with solution for a few minutes, can often give lenses a new lease on life for the second half of the day.
• Lens depositing – some lens materials collect more deposits during the day, and during their lifespan than others.
  • Also being more careful with recommended disposal cycles, or
  • Moving to daily disposable contact lenses, can make a big difference to people who are problem depositors.
• Contact lens solution choice – an interesting study found some combinations of contact lens solutions and contact lens materials led to more dry patches on the eye than others.
• Don’t minimise your contact lens cleaning routine – do all the steps, keep your lenses as clean as possible.
• Wearing times  - try not to push your eyes to their limit.  Keep an up-to-date pair of specs, so that you don’t have to keep wearing your contacts if your eyes are feeling dry.
• Disposal periods – Many of the dry eye contact lens wearers I see are people who push their contact lens disposal periods out too far.  It’s just not good for the eyes to keep wearing each pair of lenses until your eyes complain.  It may not seem like economic sense, but the ideal in disposable contact lenses is to start a fresh lens before the previous one is giving you problems.
• Daily disposables are a good option for some dry eye contact lens wearers, for two reasons.  Firstly, each day is a fresh lens.  Secondly, because the lens is only used once, some brands of daily disposables actually contain a lubricating agent that gradually disperses out of the lens during the day.
• Help out your eyes tear production by keeping your eyelids in good order.  A warm compress on the lids at the end of the day, and/or a lid hygiene program like LidCare, can help support the functioning of the glands in the eyelid that produce components in your tears.
• Lubricant eye-drops can be helpful to keep the lens hydrated, and to restore a clear, clean layer of tears over the front surface of the contact lens.  Lubricant drops always work best preventatively – that is, learn your eye’s patterns, and then use drops to prevent the symptoms.  Once your getting dry eye symptoms, drops can be helpful, but the opportunity for them to do their best work has been missed.  The preservatives in some drops are not recommended for use during contact lens wear.

Everyone’s eyes are different – what works for your friend may not be what’s needed for you.

Dry eye symptoms in contact lens wear can come from a lot of different sources. And there are lots of possible fixes, so be sure to talk about it at your next eye exam if dry eye symptoms are a problem for you.

It can come on pretty suddenly for some, this inability to focus up as close as before.  Actually the changes in the eyes that cause the reduced near vision have been happening slowly and constantly for a long time.

The eye focusses for close by changing the shape of the lens inside the eye.  The lenses is surrounded by a circular sphincter muscle, connecting by a series of little fibres.  When the muscle tightens, the tension goes out of the fibres, and the lens ‘relaxes’ to a fatter, stronger shape that gives close focus.  When the muscle relaxes, the tension in the fibres increases, and the lens is pulled to a flatter, weaker shape that gives long distance focus.

Often people imagine that it’s loss of strength in the muscle that causes reduced near vision, but actually the muscles keep good tone throughout life.  It’s the properties of the eye’s lens itself that changes – a young lens is quite flexible, and easily changes shape, and an older lens is stiffer and can’t change as much.  The gradual loss of flexibility means you can’t focus as close as you get older.  Once the eyes are corrected for clear long-distance vision, an average child can happily focus on objects as close as 7 or 8 cm from them; through teens and twenties the limit will be 10 cm or so, in the thirties working its way out to 20cm – but most of that time the change is unnoticed, until it’s suddenly discovered usually in the early-mid forties.

So how come it’s noticed suddenly when the change has been gradual?  30-40cm from the eyes is about as close as most people use regularly, so the loss of clear focus for things nearer than that will usually not be noticed.

The stiffening of the lens process continues, and most people will notice a worsening of their close vision through their forties and into their fifties.  By mid-late fifties, the lenses have lost most of their flexibility.

This is the ‘average’ situation.  Individuals will have different stories, mainly due to how long- or shortsighted they are, or because of difference in strength between the two eyes.