The Other Side OF The Coin……

My mother has had some health issues which have landed her in the hospital the last few days.  Mom’s doing pretty well, and I’m not writing here about her condition.  I just wanted to talk a bit about what I’ve been reminded of as I’ve dealt with her health care issues and getting information and education from her doctors.

One of the hospitalists that is caring for my mother is not only a good diagnostician, he’s a good communicator.  When he and I talk about what’s going on, or not going on, he’s great at explaining the situation, what any changes mean and what we may or may not need to do about them.

I think that I do a pretty good job of doing the same with my patients, but this week has been a reminder to always think about the issue that my patients and I are dealing with from the patient and the patient’s family’s perspective.  This point was driven home to me by one of the other hospitalists caring for my mother.  I’m sure that he’s a very compitent doctor, he had a difficult time communicating with me, even though I know enough to be dangerous.  While I’m sure that he was busy with other patients, I didn’t get the feeling that he felt the need to bring me up to speed on the situation since there weren’t really any decisions to make at the time.

So, besides a rambling blog post, I wanted to reiterate my commitment to open and complete communication with my patients.  If you ever feel that you need more information or that I’ve not explained things clearly enough, let me know and I’ll spend all the time necessary to do so.

Dr. Warren

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What Are We Looking For During An Eye Exam? Part III

After the your pupils are dilated, its time to take a close look at the eyes lens and then examine the health of the back portion of the eye.   I take another look at the lens in the eye after the pupil is dilated due to the fact that the lens sits directly behind the pupil.  I am unable to see the outer aspect of the lens until the pupil is dilated.   It is this portion of the lens that many cataracts start at and are first visible.

The image below is from Wikipedia and is a good cross section of the human eye:


The picture below shows a cataract, notice how cloudy the lens is.


After a careful examination of the lens, I next look at the optic nerve and macula (labeled as the “Fovea Centralis” in the ocular cross section above) utilizing a biomicrocsope and a lens to focus on the back portion of the eye.  I look at the shape, size and contour as well as the color of the optic nerve.  In a patient with Glaucoma, the optic nerve will have a larger indentation on its surface and may look a bit pale in color.  I look for any change in the optic nerve between exams as this can be an indication of the development of Glaucoma.  The picture below shows a healthy optic nerve as well as the arteries and veins that enter and leave the eye with the optic nerve.


This is an image of an optic nerve in a Glaucoma patient.  The arrows point out the edges of the depression on the optic nerve that is referred to as the “optic cup”.  This optic cup is enlarged and quite deep, due to damage from Glaucoma.


The next image is a 3D Reconstruction of a patient’s optic nerve.  This image shows the size and depth of their optic cup, information that is very useful when evaluating the health of the optic nerve.


Once I’ve evaluated the optic nerve, I then evaluate the Macula.  The Macula is the area in the retina where all of our detailed vision occurs.  The Macula has a typical appearance and structure.  I evaluate the structure with the Retinal Thickness Analyzer.  The photo below shows a healthy Macula.


The next image is a Retinal Thickness Analysis of a normal Macula.  Each color represents a different thickness in the Macula.  Thickening or thinning of the macula are usually indicative of one or more eye diseases.  Using this technology allows me to detect many conditions earlier in the disease process, allowing me to take preventative or corrective action sooner.


Once the health and structure of the optic nerve and macula have been evaluated, I then look at the rest of the structures in the back section of the eye.  I utilize a Binocular Indirect Ophthalmoscope and a lens.  This combination allows me to evaluate the structures that are located further away from the optic nerve and macula.

Summing It All Up

Once the ocular health evaluation is completed, its finally time to “sum it all up” for you, the patient.  Taking your previous vision and vision correction devices as well as your current prescription into account, I will inform you of all of your vision correction options, which may include; glasses, contact lenses, Vision Shaping Treatment, refractive surgery or a combination of several options.  I will also make recommendations about eyeglass lens materials, designs and treatments that will maximize your vision and enjoyment of your new eye wear.

I’ve started using an iPad to show and share information that we’ve gathered during the course of your examination.  Images of your corneal endothelium, your Retinal Thickness Analysis and other data are easy to share this way, and I’ve found that patients are able to understand the information, what it means and how it impacts their eye health, vision correction and ocular health.

If I have detected any ocular diseases, I will either recommend further testing to better understand the condition, or any treatment that is indicated.  If necessary, we will discuss a referral to a surgeon if your condition warrants surgical care.  Fortunately, this doesn’t happen too often, but its not rare either.

That’s it, you’ve just completed your eye exam at Warren Eye Care.  From start to finish, we strive to keep our patients comfortable, informed and involved in their eye examination and their eye care.

Dr. Warren

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Loss Of A Mentor

When I started practicing in September of 1992, I had the good fortune of practicing with Dr. Robert Anderson. He retired at the end of 1992, but in the short 3 months that we practiced together, he taught much about the “art” of eye care.

We stayed in loose contact over the next 18 years, having the occasional lunch with a discussion of eye care and his other love, cars!

Dr. Anderson passed away last month, after leading a full and rewarding life. He was a true healer, putting his patients needs first at all times. For any of his former patients and friends, here is a link to his obituary:

Dr. Warren

Weather, Dry Eye And Allergies

A subset of various brands of artificial tears...

Image via Wikipedia

I’m hoping that this warmer weather is helping some of my worst Dry Eye patients with the slight increase in environmental humidity and the lower frequency of furnace running.  But I wonder what all of this heavy melt this early in the winter (it still is winter) will do when it comes to the early spring allergy season.  Last year was a bear thanks to the tree pollen levels, hopefully we won’t have a repeat of last year’s spring allergy season.

Remember, if you’re a Dry Eye patient, keep using your artificial tears as prescribed, even if your eyes are feeling pretty good right now.  If you wait for symptoms to strike, you’ve let your eyes get too dry and stay dry for too long!

Dr. Warren

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What Are We Looking For During An Eye Exam? Part II

Once we have gathered the data during the “Entrance Testing” step of your exam, I then put all of that data to work in the exam room.  I review the data from the 3D wAve using software that allows me to view all of its information at any computer in the office.  This data tells me what type of Rx to expect each patient to need, whether their night time vision is adversely impacted by a change in Rx from normal light to dim light conditions and how well I can expect the patient to see when I have gotten to their optimal Rx.  All of this data allows the patient and I to complete the portion of the exam devoted to determining what Rx to use for distance and near vision (referred to as the Refraction).  We can usually complete this process much faster than with older technology, usually in a minute or two.

The technology that greatly speeds up the refraction and makes the whole process easier and more comfortable for the patient is referred to as our “Total Refraction System” or TRS for short.  wpid-rt3100-box_hd_jm-2011-02-15-06-00.jpgBy combining the information from the 3D Wave, the Lensometer and the patient’s vision with their current vision correction, the TRS allows me to control the entire refraction process from a digital control panel.  All of the lens changes, changes in eye chart and testing conditions are managed via this control panel.  The TRS has an advanced testing mechanism for the astigmatism portion of the patient’s Rx.  Instead of showing alternating views of a chart to determine the astigmatic power and orientation, the TRS shows the patient both lens choices simultaneously, allowing you to make a direct comparison between the two Rx’s.  This really speeds up the refraction process and makes the decision between “lens #3 and lens #4” much easier for the patient.


wpid-1140-2011-02-15-06-00.jpgAfter the refraction is complete, its time to get down to the ocular health evaluation portion of the eye exam.  I examine the front portion of the eye (the cornea, lens, iris, conjuncitva, eye lids etc) with a bio-microscope that provides me with magnification ranging from 10x up to 40x which allows me to detect any ocular disease of the front portion of the eye.




Once I’ve evaluated the health of the front portion of the eye, its time to check the pressure inside the eye.  The Intraocular Pressure (or IOP for short) can be an indicator of Glaucoma.  I never use the “air puff” test, in fact, I haven’t used it in 18 years of private practice.  I instill a numbing drop into each eye to make this test easy and comfortable and then use a device called an Applanation Tonometer to measure the pressure inside the eye.  After this quick and painlesswpid-perkinstonometerinuse-2011-02-15-06-00.jpg test, it takes less than 10 seconds to measure the IOP in both eyes, I instill the dilating drops and you’re on your way out to the lobby to await that final portion of your eye exam, the evaluation of the internal structures of the eye.


Dr. Warren

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What Are We Looking For During An Eye Exam?

Besides determining what will be the optimum correction for our patients, we also examine the eye from front to back looking for any abnormalities or ocular diesease. Most ocular pathology does not cause symptoms that are evident to the patient until fairly late in the disease process. For this reason, routine examination is the only way to insure that if a patient starts to develop a condition such as Glaucoma or Macular Degeneration, we will find and diagnose the problem early in the disease process. This increases our chances of a good outcome for the patient and the least chance for permanent vision loss.

Because so much of what I do is fairly technical, I thought it might be interesting and beneficial to explain the eye exam process, what I’m looking for and what the results of specific tests tell me about your vision and ocular health. I’ll pretty much walk you through en eye exam, explaining things as we go along. This similar to a course that I teach to optometric technicians over a two hour period, so I’m going to break this process up into a couple of parts.

Entrance Testing
This is the initial step of data gathering, where we talk to you about how you are doing, any medications you may be taking as well as any specific concerns that you want to be sure to have addressed during your examination.

We also check your distance and near vision with your glasses or contact lenses, or without any correction if you don’t have a current correction.wpid-vi7_visual_acuity-2011-02-8-16-18.jpg

We also take some preliminary measurements that are used to start both the process of determining what will be your final vision correction solution (either glasses, contact lenses or Vision Shaping Treatment). The first set of these measurements is taken by our Lensometer which reads the Rx out of your glasses. Telling us the sphere power, astigmatic power and orientation of the astigmatism correction as well as the near power of your lenses (if you are wearing a multifocal pair of lenses).

The second set of measurements utilizes a piece of equipment called the 3D Wave.

wpid-3d-wave-2011-02-8-16-18.jpgThis amazing device measures your eye glass Rx throughout your entire pupil. It breaks the prescription down into what is called the spherical component of the Rx, the astigmatism portion of your Rx and indicates how the astigmatism Rx is oriented. The 3D Wave gives me three different Rx’s, one in the very center of your pupil, one when your pupil is 3mm in size (similar in size to when you are out on a sunny day), one at 5mm (approximately the size of your pupil in a dimly lit room or outdoors at night). When a patient has a significant change in their Rx due to the size of the pupil, I will use this information to either alter their Rx slightly to improve vision in all conditions or if there is a large enough change in the Rx, create a “low light specific” Rx for glasses and/or contact lenses. Click here to view some example reports from the 3D Wave. This is one of the dianostic instruments that I teach other eye doctors how to use.

The 3D Wave also provides very accurate measurements of the curvature of the cornea (the tissue in the eye that contact lenses rest on).

wpid-aberr-2011-02-8-16-18.jpgThis data is incredibly useful when fitting or designing contact lenses as well as when looking for an explanation when a patient isn’t seeing as well as they should. I’ve been measuring my patients corneal topography ever since my office opened, but the 3D Wave now gives us this information faster and easier.

The 3D Wave also tells me how “regular” each patient’s visual system is, helping me know just how well I should expect my patients to be able to see once I’ve determined the optimum Rx for them. As we age, the eye changes, specifically the lens inside the eye. In more advanced stages of these changes, I see Cataracts develop. Earlier in this process, while the lens isn’t cloudy like it is with a cataract, the patient’s vision can be adversely effected and require adjustments in their Rx to optimize their vision.

As you can tell, the 3D Wave gives me a wealth of information about my patients’ vision correction needs, and their ocular health. The next measurement that we take is only used on some of our patients, those over the age of 30. We measure the Macular Pigment Density of our patients as it is a predictor for the risk of developing Dry Macular Degeneration.

This is tested using the MacuScope, in a test that takes about two minutes to complete. This non-invasive test measureswpid-macuscope200-2011-02-8-16-18.gif the density of three pigments in the patient’s macula. Having a low level of these pigments indicates an elevated risk of developing Dry Macular Degeneration. I use this data when discussing each patient’s ocular health and our plan for maintaining it.

The final step in the Entrance Testing portion of the exam is also only evaluated on some of our patients. Those over 40 and all of our contact lens wearing patients.

wpid-2_14368_2-2011-02-8-16-18.gifThe Corneal Endothelium is in charge of controlling the fluid concentration in the cornea. Too much fluid and the cornea swells and becomes cloudy. There is a layer of cells on the back side of the cornea that are in charge of controlling the amount of water that is allowed into the cornea. Our specular microscope provides me with numerical and graphical information about the health of my patients’ corneal endothelium (an example of the test results are just to the left). If the corneal endothelium fails, either due to aging of the eye or damage from trauma or contact lens wear, permanent vision loss can occur. For this reason, we screen all of our patients who may have this issue, in order to modify their contact lens wearing habits or other ocular health concerns.

In an upcoming blog post, I’ll discuss the “middle portion” of the exam and in the third installment, I’ll cover the last third and the conclusion of the exam. If you have any questions about the information I’m providing, or would like to know more about anything related to this topic, please email us at

SnowMageddon-Watering Eyes

wpid-snowmageddon2-2011-02-1-13-541.jpgMaybe I’m just a cranky old guy now that I’m in my mid 40’s, but it sure seems like we’re becoming a society of wimps. Granted, we may get a ton of snow tomorrow and not be able to get out of our driveways, but the number of Wednesday closings posted as of 2:00pm on Tuesday is staggering. What happened to dealing with the problem if and when it happens? If we get 3” of snow and moderate winds, will we really need to have so many businesses closed? I can understand closing the schools so that families can plan in advance to some degree.




wpid-getty_rm_photo_of_watering_eye-2011-02-1-13-54.jpgWith that being said, I also wanted to answer a question I get from many patients this time of year. “Why do my eyes water so much when I’m outdoors in the winter?” The answer’s two fold, the first is that the colder dryer atmosphere sets our eyes up to water a bit more due to dryness, the second is that the cold wind is quite irritating to our eyes, causing them to water in response to the irritation. Watering eyes when out in the cold, especially when its windy is normal and not typically a sign of any other eye problems.

Dr. Warren

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