Keeping an Eye on Your Vision


About Your Eyes

Many of these questions were submitted by patients of Dr. Rabins.

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This couldn’t be further from the truth. 20/20 means average vision and represents only a small piece of the total vision “picture”. In fact, many who think they’re 20/20 actually are not. But more importantly, one can be 20/20 and have a serious, even life-threatening, problem at the same time, such as one of our patients whose retina appears at left. The black elevated mass (arrow) that is easily seen during a dilated eye examination turned out to be a choroidal melanoma, an aggressive form of retinal cancer. The important point in all of this is that this patient, who hadn’t been examined in over five years, had no idea he was toting this tumor around – he thought he was OK. This is not meant to scare you into thinking you have retinal cancer, it's to convince you that you don’t know what you don’t know -- which is why routine eye care is so vital.
Simple -- vision development occurs from birth to the early teens. That’s when the brain uses what we see to establish the pathways for vision. If the brain doesn’t get good data for any reason, then the vision pathway will not develop normally. And if these things aren’t identified and addressed during this critical development period, the child could end up with seriously decreased vision in the affected eye(s) for life. There are four common reasons for this kind of decreased vision due to developmental failure: a turned eye, a cataract, high astigmatism (that’s where the prescription for an eye is different in the two meridians), or a very different prescription between the two eyes. Believe it or not, there’s not a month that goes by in which I don’t see at least four or five patients who are well beyond the development years but, nevertheless, have not developed good vision in one eye or both. At that point, regrettably, there’s little I can do to help. Which is why I relish any opportunity to educate those who’ll listen. Remember, children will never call to set up their first eye exam.
Obviously, the child will be unable to help with subjective responses – the exam is all me (in a way). My primary job in this case is to discern whether or not vision is developing normally in each eye. I do this by evaluating eye alignment, ocular motilities, refractive error (prescription), dilated health of the eyes --- gee, pretty much the same as I do with an older patient, only that I don’t get much help from the patient here. I can learn a lot about a child in a very short amount of time.
Without question, it’s being able to intervene effectively during the developmental years by detecting a vision development problem and doing something about it while there’s still time to make a difference. Usually it’s a five or seven year-old with high astigmatism in an eye (or both eyes), or a large difference in refractive error between the two eyes. Typically his or her best-corrected vision in the affected eye is somewhere around 20/70 or 20/80. By wearing the proper correction full-time the brain has its first opportunity to develop vision in that eye. I instruct the patient to leave the glasses on during waking hours so the brain can learn how to see properly. I then see the patient in six months, and almost always observe a dramatic improvement in that eye. Sometimes it’s 20/30, sometimes 20/25, sometimes 20/20. Regardless of which acuity the patient presents at, it’s always exciting - - - and I want to shout!
Not generally, in my opinion.  Some have said to me after wearing glasses for the first time that they feel that they now need them, whereas they didn’t need them before.  I would argue that in cases like these, they have learned to appreciate good vision and thus more easily recognize the obvious contrast between correct vision and something worse.  There are instances where an improper prescription can, in fact, hasten the progression of certain refractive errors, as in the case of a young myope (near-sighted) patient.  Over-prescribing here increases the amount of focusing work the patient must exert and can, in my view, hasten the progression of myopia.  One can easily see why it’s so important to find an optometrist you can trust to take the time to do eye exams right.
This is a normal experience, happening to everyone somewhere around the age of 40.  The word presbyopia comes from the Greek and literally means “old eyes.”  That is when the lens of the eye has become less flexible and consequently is less able to comfortably generate the focusing power to see clearly at normal reading distance.  It’s when some first encounter the dreaded “B” word (the need for bifocal glasses).  Fortunately, there are many great ways, other than bifocals, to deal successfully with the situation.

All soft contact lenses require a certain amount of water to provide optimum vision.  They remain properly hydrated by pulling water from the eye.  So don’t be fooled -- all soft lenses will tend to dry the eye.  Fortunately there are new contact lens materials designed to be better for dry eyes.  These are water-retaining materials that don’t pull as much water from the eye during the day.  Ask your optometrist which material might be best for your eyes.

For Americans, age-related macular degeneration (ARMD) owns this distinction, affecting 2% of the population over 60.  ARMD involves destruction of the photoreceptors at the macula, the area of the retina involved with central viewing.  When we look right at something, we’re using the macula.  Since free radicals hasten the progression of certain degenerative processes (such as cataracts and ARMD), it makes some sense to protect our eyes from the harmful ultra-violet rays when we’re outside, and supplement our diets with anti-oxidants (your optometrist can be helpful here).

Glaucoma.  This is a symptomless disease that typically involves elevated pressure in the eye that eventually does damage to the optic nerve, resulting in irreversibly decreased vision.  Fortunately pressures can be lowered with medicines, thereby slowing the disease’s progression.  Often glaucoma is first discovered during a routine eye exam, much to the surprise of the unwary patient.  This is just one of many reasons that routine eye care is so vitally important.

This may seem a bit surprising, but I’m not a big fan – there’s still way too much that is unknown about the long-term prognoses for me to feel comfortable with the procedures.  You may recall the very first refractive surgery – radial keratotomy (RK) – which involved making radial slices into the cornea (the outer surface of the eye) in order to change its shape.  It worked, but at great expense for some folks.  Many today suffer intolerable glare from headlights at night. Others have experienced corneas that continue to adversely change shape over time due to structural integrity problems.  Unfortunately for some of these, they cannot be corrected to 20/20 with conventional eyewear.  RK is not performed anymore, for good reason.  So I must ask -- is it possible that we don’t know some things about the latest surgeries that may, in fact, contraindicate the procedures 20 years down the road?

Briefly, an ophthalmologist is a medical doctor who has graduated from medical school and who has completed a residency in ophthalmology.  He or she is uniquely trained to perform surgery on the eye, although training also includes refraction (determining glasses prescriptions) and treating and managing various ocular diseases.  An optometrist has been to optometry school and is highly trained to determine glasses and contact lens prescriptions.  Over the past 10 or 15 years, the field of optometry has grown beyond refraction to include the treatment and management of many ocular diseases, including Glaucoma.  One can immediately see some overlap in these disciplines.  An optician is an expert when it comes to glasses, including their fabrication, materials, and frame selection.  Opticians work closely with optometrists and ophthalmologists to find the most suitable eyewear for patients.

Most people seeking an eye doctor are interested in seeing better.  Now I readily admit that I’m biased, but my recommendation is that they visit an optometrist, since refraction (the art of properly determining glasses prescriptions) is what our profession has been doing so well for over a hundred years.  Good optometrists not only perform good refractions, but also recognize when a patient should be referred to a specialist for surgery, treatment of disease, or simply because his/her level of expertise has been surpassed.  Even though the field of optometry has opened up dramatically to include the treatment and management of ocular disease, including Glaucoma, I (for one) am not interested in being everything to everyone.  I’d rather do a number of things very well rather than a whole bunch of things adequately (or marginally).  Neither ophthalmology nor optometry should feel threatened by the other – there’s plenty of room for both.

Astigmatism is generally a result of the cornea (the front surface of the eye) being shaped oval like a football instead of spherical like a basketball.  Astigmatic corneas have two curves -- a steeper curve and a flatter curve.  This causes light to focus at more than one point in the eye, resulting in blurred vision at distance and/or near.  Astigmatism often occurs in conjunction with myopia (near-sightedness) or hyperopia (far-sightedness).  Contrary to popular belief, astigmatism is not some sort of disease, and most patients have at least a small amount of astigmatism.

If you think all glasses are the same, and cost is the only variable, think again.  Just as there is a difference between a Mercedes and a Yugo, there is a huge difference in lens materials, designs and fabrication laboratories.  We don’t apologize for our pricing structure.  As is so often true in life, you get what you pay for -- if you want it cheap, you get it cheap.  Of note is that we use only high-quality materials and designs, some of which cannot be obtained through many commercial vendors.  Another good reason to shop here is that if there is a problem, we’re committed to fixing it -- we want you to be delighted with your purchase.  Ask us about our materials, laboratory, and quality control measures.