Dr. Lee Richard Katzman, M.D.

Great question. As always the answer to this question depends on your age, duration of symptoms, and of course your eye exam to determine the etiology of your complaint. As a cornea specialist, this is a common complaint in my practice. There is a condition called Fuchs’ Dystrophy, which is a condition that leads to endothelial cell loss (from the cornea) at an early age. The cornea needs to remain clear in order for you to have clear vision, as the cornea accounts for 2/3 of the refractive power of the eye. The endothelial cells serve to pump the fluid out of your cornea all day/night long keeping it clear and functioning well. As you get older and lose these cells, eventually you cross a threshold where the cornea thickens at night while the eyelids are closed (and you don’t have that added benefit of evaporation of fluid off of the corneal surface). Well, this is why patients wake up in the morning with blurry vision that gets better as the morning progresses. There are over-the-counter drops you can use (Muro 128) in the morning and ointment before bedtime. Eventually, when the vision is cloudy for several hours after starting your day, we can do partial cornea transplants (DMEK/DSEK) to restore your sight.

With your complaints, I would definitely recommend getting checked out by an ophthalmologist.

Lee Katzman, MD

The back of the eye is filled with a clear collagen mass known as the vitreous body. Think of it as a solid jello mold at birth. As we get older this jello mold slowly melts away, much like we lose the collagen in our faces leading to wrinkles. Imagine that as the jello mold melts, it eventually collapses onto itself. When this jello finally collapses, it releases itself from the parts of the retina that it was attached to at birth. The retina is the neurosensory material at the back of the eye that converts light into an electrical signal that travels through the optic nerve to the brain; it’s the most important part of the eye. Well, as the vitreous collapses, or “detaches”, it releases pigment or condensations in the back of the eye that casts tiny shadows onto the retina. These are interpreted as “floaters”. Although floaters are extremely common and we all experience them at some point in our lives, they still require an examination. The reason is that very rarely, when this vitreous detachment occurs, the retina gets torn. This small tear results in a detachment, which can cause permanent blindness if not repaired quickly. So even if the odds are low that your new floaters could be an indication of a retinal tear, you still need to be examined. When caught early, the tear can be spot welded in the clinic with an argon laser. This is quick and painless, and well worth the effort. The symptoms to look out for, in particular, are many small floating dots (an ocean of black or clear dots), a dark veil coming over your vision, a black curtain coming from the sides of your visual field, or flashes of light (arcs of light) going off in your peripheral vision. These are all signs of impending or active detachments and should prompt an exam right away.

- Lee Katzman MD

Astigmatism has to do with the shape of the cornea (the clear round most anterior structure of the eye). It is not something that you could notice by looking in the mirror. It’s a subtle shape difference that makes the cornea take on the shape of a football rather than a round basketball. There are many causes of astigmatism: keratoconus, pterygia, terrien’s marginal degeneration, corneal ulcers, and corneal scarring from other disease or trauma to the eye, to name just a few.

If there is a progressive disease process identified, then by treating the disease, you can stop the progression of astigmatism. For example, when we remove large pterygia from the eye, a majority of the astigmatism is removed. LASIK or PRK can also be performed to correct large amounts of astigmatism, if you are a candidate. If you are seeing a difference in the appearance of your two eyes, then something else may be going on and you should seek an opinion by a board certified ophthalmologist or optometrist.

- Lee Katzman MD

Great question. This comes up all the time in our clinic. Remember, contact lenses are foreign bodies sitting on your eyes – you were not born with them! When your optometrist or ophthalmologist fits you for contacts, he or she is taking into consideration the shape of your cornea, and any scarring or other ocular surface diseases such as pterygia, pingueculas, blepharitis, dry eye disease or allergies. Each contact lens brand comes in several sizes and the prescription is determined by measurements obtained in the clinic and the way the lens moves on your eye when the doctor examines you.

The first consideration involves your contact lens hygiene. Are you wearing dailies, biweeklies, or monthly lenses? Are you replacing them as you were instructed? Despite what my patients tell me, I know the 2 weekers are staying on eyes for over a month at times. The monthlies tend to go 2 months, etc. And this has been substantiated by the medical literature, so it’s not just my intuition. Everyday, these lenses accumulate microscopic debris and cause microtrauma to your ocular surface.

If you are young and healthy, the eye can repair itself quickly. As you get older or as you stress your eyes with overwear (wearing more than 14 hours per day), sleeping in your lenses, etc., eventually you become less tolerant. When the immune system (ocular surface) breaks down, it then puts you at risk for corneal ulcers which can then result in severe loss of vision. Contact lens solutions are not created equal either. Sometimes, the solutions are the culprit and need to be changed. For all of these reasons, I recommend daily wear contact lenses for all of my patients. You don’t have to worry about cleaning them, you don’t need solutions to store them, and you can’t overwear them because they get less comfortable after 24 hours or so. It eliminates many of the day-to-day problems I see with longer-wear lenses. I also recommend contact lens holidays: take the weekend or even a 7 day period of time without any wearing of your contacts. This allows your eye to restore itself and tolerate contacts better when you restart use.

Getting examined by an optometrist of ophthalmologist is your best bet. Only with an eye exam can we determine whether or not your problem is being caused by an underlying disease (dry eye, allergies, giant papillary conjunctivitis, etc.) versus a poor lens fit.

-Lee Katzman MD

Diabetes is one of the leading causes of blindness in the United States, in particular in the over 50 age group. Anyone with a diagnosis of diabetes gets an annual eye exam at the least. If there is no diabetic retinopathy, a once a year exam suffices. Some forms of diabetic retinopathy require exams every few months. Severe disease may require monthly exams. These frequent visits often require treatments, but that is beyond the scope of this question.

Understand that diabetes is a disease of small blood vessels. It affects these vessels in every part of your body from your toes to your kidneys and even brain. The reason the eye exam is so helpful to your primary doctor is that we can provide insight into the level of diabetes without taking a biopsy or doing a blood test. So it's a non-invasive way to grade the extent of diabetic damage throughout your body.

Hopefully this explains why your doctor is pushing you towards getting an eye exam!

That's a great question, however it's impossible to answer it accurately without more information about your age and other ocular history. To be safe, my recommendation is for you to be evaluated by a board certified ophthalmologist or optometrist. But I will try to respond in generalities for you.

Assuming you are in your 20s (you say you have been in glasses 10 years), the most common reasons for prescription changes year to year include the natural subtle changes that the cornea undergoes over time, accommodative-state changes as you age, and latent hyperopia. Most people hit a relatively stable prescription in their mid 20s until around the early 40s when they lose the ability to fully contract the ciliary muscle in their eyes that give them that ability to see both far distance and near targets. Latent hyperopes, or farsighted people, actually have a glasses prescription that is able to be corrected for by contracting the ciliary apparatus naturally. So they have perfect vision until they lose enough of that muscle that the distance vision starts to fade. The extent that the ciliary apparatus is contracted is called the "accommodative state". When you get checked for glasses, if your eye is contracting more than usual (you are nervous during your exam or you spent 10 hours studying for a test with your books 12 inches from your face) this will lead to the optometrist or ophthalmologist giving you a prescription slightly different than the prior year. We call this getting "overminused". We are trained to avoid this but it does happen and I can't speak to who checked your eyes this year! And let's not forget about contact lens overwear, contact lens related infections, and contact lens warpage that all can change your cornea year to year leading to changes in your prescription. I could talk about these topics all day long.

Very large shifts in prescription year to year at this age, in general, are not normal and should trigger an exam by a professional. Keratoconus, for example, is a cornea disease whereby the cornea thins and creates an out-pouching leading to high orders of astigmatism and eventually perforation. Premature cataract formation can alter your vision drastically as well, which could be due to excessive UV exposure from snow skiiing, water skiing, or tanning in a tanning bed without protection. Excessive use of systemic steroids like from a steroid inhaler for asthma or triamcinolone creams/ointments from your dermatologist can be other causes. Here in San Diego, "surfers eye" or "pterygia" cause tear film instability and prescription changes annually and eventually require surgical removal. The list goes on and on, so my best advice still remains that you should be seen by an eye doctor to be sure you have ruled the above out. Hopefully this was helpful!

Thank you for your question,

Lee Katzman MD
Cornea, Cataract & Refractive Surgeon

Great question. It depends on whether or not this is a new phenomenon for you or if it's something you've noticed your entire life. Some people have low levels of retinal pigmentation which makes them more sensitive to bright lights. This would be completely benign (not concerning for an underlying disease). On the extreme end of that spectrum is ocular albinism or oculodermal albinism, which can have significant systemic manifestations and very poor vision, so I'm sure this doesn't apply to you.

Any condition that affects the cornea (the clear, most anterior structure of the eye) leads to photosensitivity/photophobia (sensitivity to lights). This is because there are more nerve endings per square millimeter innervating the cornea than any other part of the human body (I believe the genitals are a close second place). If you've ever had a scratched cornea you would understand how sensitive the cornea can be! The common culprits for photophobia tend to be unmanaged dry eye disease, ocular allergies, contact lens overwear/keratitis, anterior uveitis, and cataracts.

Each of these conditions are managed differently, but the one that should be ruled out sooner better than later is uveitis. Uveitis is an inflammation of the uvea (particular structures of the eye) that can be associated with an underlying disease process (like lupus, syphilis, sarcoidosis, tuberculosis, Crohn's disease, etc.). When your doctor identifies uveitis they typically initiate a systemic workup with the assistance of your primary medical doctor. After treatment of the uveitis, the photophobia typically clears up quickly.

So there is obviously more historical information that will be needed by your ophthalmologist or optometrist, and there's no online source of information that replaces an examination by a medical professional. So my formal advice for you is to make an appointment with your doctor. But hopefully this has been somewhat helpful!