From Correction to Prevention:
The paradigm shift in vision care for the new century

By Barry Santini, ABOM

“The United States spends more than $50 billion a year on vision problems—and the prevalence and the costs to care for these conditions are rising fast,” said John Murphy, senior editor, Review of Optometry. “The annual economic burden of vision disorders is just enormous. And, it’s only going to get costlier as the number of people with vision problems grows.

Currently, more than 38 million Americans age 40 and older are blind, visually impaired or have an age-related eye disease, such as age-related macular degeneration, glaucoma, diabetic retinopathy or cataracts, according to the National Eye Institute. As life expectancy increases and medicine improves, this number is expected to grow to more than 50 million Americans by the year 2020, with a corresponding—or even accelerated—increase in eyecare expenditures.”

“But, the future is unwritten. That’s why it’s important to look at these costs and understand them. Advocates are now using these numbers to try to affect policy in order to increase funding and efforts aimed at prevention. The goals: to mitigate and reduce vision problems (especially correctable ones), and to keep in check the cost of vision problems on the U.S. economy,” Review ofOptometry, January 15, 2008.

In eyecare, good vision care has appropriately moved to include disease management and its effects on vision. However, just as management of chronic illnesses, such as diabetes now includes preventative disease-related programs on obesity, nutrition and exercise, so too must the longer-term effects of environmental radiation and sunlight and its effect on vision, be described and controlled. People are living longer and require avoiding dependence to remain vital longer. That means good vision (with the ability to drive) is critical to maintaining independence and enjoying a rewarding and productive life or retirement. Parents and grandparents can’t help their families if they can’t see. Prevention is the key.

Any discussion on preventative eyecare should start with an understanding of the causes of eye maladies and diseases. Although we are aware of the relationship of impact resistance to traumatic eye injuries, the leading causes of eye-related illness is genetics and the environment. As a result, a “Personal and Preventative Sun Strategy” (adapted from Dr. Leffell, Yale University Medcast, iTunes U) will become the essential tool for each patient to proactively manage their total eye health.

ECPs should seek to adopt a preventative approach as their primary model as well. This strategy should include broad knowledge of sunlight and radiation, its effects on the skin and eyes, preventative tools, how the right eyewear makes a difference and the best methods to communicate to the public.

Preventative medicine is a medical specialty that works to prevent disease rather than cure it. Pharmaceutical TV ads bombard us with messages about preventing various conditions, such as bone density loss or the reduction of plaque build up in blood vessel walls. The American College of Endocrinology (ACE) has a free program targeted at adults, kids and families called the Power of Prevention (POP). It is designed to teach the benefits of physical activity and proper nutrition for endocrinologist-treated conditions like diabetes, thyroid disorders, osteoporosis and obesity. It supplies pedometers to school programs and sends doctors to meetings as well as supplying printed materials and programs.

THE EYE AND THE ECP

Optical professionals serve patients best when they focus on the inclusion of preventative programs. A visit to your eye doctor for simple sight correction is, by itself, no longer enough. Today’s patients should and do expect their optical professional to offer the latest advice in delivering the full range of eyecare. Current eye health checks should always include discussion of preventative care, as well as recommending products that safeguard their own and their children’s eyesight.

Today, the public has a high awareness of the sun’s deleterious effect on skin and that we all have to be more careful than previous generations. Mothers know they must protect the skin of their children from UV and bright sunlight to avoid its burning effects and its potential contribution to skin cancer. However, how many of us have seen or know the negative effects of prolonged, unprotected bright sunlight exposure and its harmful effects on the eye and vision?

To start, the cornea is an extension of the skin (both contain compounds based on keratin). An outer layer is composed of fast-growing, easily regenerated epithelial cells that has the exact same susceptibility to UV burning as skin epithelium.

The cornea must remain clear to do its main job: providing the majority of refraction and transmitting light efficiently to the crystalline lens. While the lens also contributes to the task of focusing light on the retina, both the cornea and the lens have a primary role in protecting the retina from the radiation effects of the sun. Eyelids, pupil, the mechanism of squinting and the UV absorptive compounds found in the lens all protect the retina from excess light and ultraviolet. So an emphasis on prevention for the lids, cornea, lens and retina is as important or perhaps is even more critical than our more common attention to the skin.

Focusing on the cornea also highlights that there is no reason to distinguish between an ametrope and an emmetrope for the benefits of solar protection. Teach the same prevention techniques to the non-prescription wearer in routine check ups. Just because a prescription for eyewear is not needed does not mean the message of prevention should be overlooked. With this in mind, recommending, selecting and using the proper plano sunwear (or plano photochromics) fulfills a critical need to ensure good eye health for our entire population.

Just think about the sacrifice your eyelid makes every day as it throws itself unselfishly in front of the eye to protect the cornea, lens and retina from excess sunlight. Perhaps if nature was given enough time, it may evolve our eyelid to look like a good sun lens.

In 2008, the American Cancer Society estimates a potential of about 2,500 serious melanomas and many more of the more common secondary basal and squamous cancers on the face, scalp and area surrounding the eye. Factoring in genetic dispositions to cancer, the present increase in leisure-based outdoor activities, personal nutrition habits and it’s clear—the sun and its damaging rays play a vital role in eye illness. This suggests that every American should be more proactive about prevention for good eye health. Everything that is happening to your skin is also happening to your eyes.

RADIATION AND SUNLIGHT

Scientists classify UV radiation into three types or bands—UVA, UVB and UVC. The ozone layer absorbs some (mostly UVC), but not all, of these types of UV radiation. The UVA and UVB that reach the earth’s surface contribute to serious health effects.

UVB can be characterized as burning rays. Some is absorbed by the ozone layer, but some does reach the earth’s surface. UVA are the aging rays. They are not absorbed by the ozone layer. UVA causes skin wrinkling and mottling, and damages the collagen layer. Collagen is the second layer of the skin, which fills out the face and without which, wrinkles form. The loss of facial fat in aging contributes to the appearance of wrinkles as the collagen disappears.

Both UVA and UVB are known causative agents for skin cancers i.e., basal, squamous and melanoma cancer. UV is the only proven carcinogen found in the natural environment. Given long life and a lack of understanding, these cancers have reached epidemic proportions. In addition tanning salons contribute to the problem since they deliver not only high levels of UVA, but also reinforce the notions that a tan is inherently appealing, suggests health and is associated with wealth, privilege and mobility. As a result of the popularity and use of tanning salons, we may now be seeing the appearance of what were formally old age cancers in a much younger population (Dr. Leffell).

High energy visible (HEV) light, i.e., blue light, when accumulated over a lifetime, is of concern because the shortest wavelengths of the visible spectrum contain significant energy. Recently, it has been demonstrated that HEV light is powerful enough to injure human cells, mainly through the production of oxygen free radicals. Extended exposure to HEV blue light, like UV radiation, can cause damage to the eye and the skin around the eye.

Studies have shown a link between high levels of visible light exposure, retinal damage and AMD. The Chesapeake Bay Waterman Study suggested a link between blue and visible light exposure and AMD (but not UVA and UVB). Moreover, those with severe AMD had a statistically greater exposure to blue light over the past 20 years. This suggests that high levels of exposure to blue or visible light may cause ocular damage, especially later in life, and may be related to the development of AMD. In the Beaver Dam Eye Study, a large and long-term study also showed that those who had high levels of sun exposure during the teenage years and throughout their third decade had an increased risk of developing the early changes that result in AMD.

There is some general agreement among researchers/experts that blue light is the most damaging wavelength to the retina, and most likely to contribute to the development of AMD. Blue light penetrates to the retina; UV does not. It is high energy and is likely to cause more damage at lower exposure thresholds; initiating damage at 800 times lower a threshold than that required for similar damage by longer wavelength red light. The web site AMD.org states “…UV and blue light can damage the retina and increase the chances of developing AMD and is therefore extremely important for people to protect the eyes when outdoors.” Blue Light/HEV danger originates from the photo-chemical reactions involved in the bleaching and reconstitution of the retinal chemical rhodopsin.

PREVENTION IS THE KEY

Prevention is the key to a patient’s lifetime of good sight and eye protection. For the ECP, it starts when the patient enters the office. In reception, printed materials help describe ways to achieve and maintain good eye health. During the pre-testing phase or while reviewing health history, your staff has an excellent opportunity to teach patients about lenses that protect and prevent unwanted damage.

The doctor is the most important person to discuss prevention. Suggest regular eye exams, participate in programs like “Check Yearly, See Clearly,” review and discuss family history and explain that prolonged sun exposure will greatly increase their risk of cataracts, skin cancers and AMD. Congratulate patients for eating healthy—promote the evidence for anti-oxidants, green and orange vegetables and the elimination of smoking. Encourage parents to start preventative measures early and remind them kids are highly impacted by sun exposure. In fact, up to 80 percent of a lifetime’s sun exposure occurs in childhood and compounds over time. Promote a “Personal and Preventative Sun Strategy” for the patients.

A PERSONAL AND PREVENTATIVE SUN STRATEGY

A personal sun strategy is simple: limit sun exposure. However, UV rays from sunlight trigger Vitamin D synthesis in the skin. From the National Institute of Health, Office of Dietary Supplements web site, “Ten to 15 minutes of sun exposure at least two times per week to the face, arms, hands or back without sunscreen is usually sufficient to provide adequate vitamin D… and should be followed by application of a sunscreen with an SPF of at least 15 to protect the skin.”

So it’s a balance between sunshine and good nutrition. However, one thing is clear—too much sun is not good, so a personal sun strategy should include wearing a hat with at least a two-inch brim, limiting exposure during peak hours, using a sun lotion with an SPF above 15 and, if required, wearing sun-protective clothing. People who are fair skinned, blue, gray or green eyed, and have blond or red hair, are more sensitive to UV.

SPF is a measure of the effectiveness of sunscreen. This factor calculates the amount of time one can be in the sun before getting sunburned. If it takes 15 minutes to get sunburned without sunscreen, an SPF of 10 would allow 10 times the time to get the same sunburn or 150 minutes. Sunscreen does wear off (sweat, swimming) so regular reapplication is important.

“Sunscreen for the eyes” is well-fitted sunwear, providing the right filtration, coverage and through color. When polarized, sunwear ensures improved contrast, comfort and protection from almost all forms of glare (especially blinding glare). Glare has also been implicated as a cause of headaches, including migraines. Choosing polarized lenses that have high efficiencies (higher is better) will remove virtually all glare when outdoors or when driving. Reflections off water, dashboards or smooth shiny surfaces can create glare that can significantly impair your vision. Only polarized lenses absorb this reflective scatter and glare.

Add AR to sun lenses so sunlight reflected off the front or back surface of the lenses will also be virtually eliminated. Without AR, surface glare interferes with your ability to see clearly. Applying front surface AR to sunwear is an excellent way to reduce the redirection of harmful rays to the delicate tissues surrounding the eye, nose and face.

Choose sun lenses that are 100 percent UV absorptive so the burning and aging rays of the sun cannot reach the eye. Dark brown or gray reduces discomfort from bright sunlight. Choose colors that reduce or eliminate HEV blue wavelengths, which can penetrate to the retina, such as amber and brown colors. Reducing the scatter caused by the increased refraction of shorter blue wavelengths improves contrast sensitivity and visual acuity.

What about size and fit? Make sure there is a close fit at the brow line and around the nose. Styles with wrap-around designs help block light and, when combined with the right lenses, deliver the perfect fit.

Think about children when talking about sun protection. Promoting the early use of good sunglasses ensures that potential damage is reduced significantly, especially before the eye’s protective structures are fully developed. It is suggested that 80 percent of the damage to the eye occurs before the age of 18. So talk to all patients about their kids and the important use of sunwear. Start early to develop the life-long habits that will reduce the cumulative effects of sunlight. Be sure to include smaller-sized styles for teens and petite faces, a variety of high-quality, plano sunwear and a selection of toddler-to-age-five kids’ sunwear.

Impact and scratch resistance are important prevention properties. Prevention of accidental damage to the eyes mandates the best combination of impact and scratch protection. Consider polycarbonate lenses for their comfort and lightweight.

Participate in programs that promote prevention and protection. Consider using the materials from The Vision Council called Check Yearly, See Clearly (see www.visionsite.org).

BRAND NAMES ARE A PROMISE

The good news—there are so many lens products available for your patients to choose from. The not so good news is that the number of products from which to choose can become overwhelming and result in patient indecision. A well-known brand that already communicates the right message can make choosing easier. But why feature recognized brands?

Brand names are a promise, made to consumers. It may be style, fashion, safety or prevention. Companies work diligently to communicate their promise and more importantly, over time continually re-enforce them. Therefore, understand the brands you use and the messages they communicate to your patient. For example, what brands come to mind when you think about sunlight, sunburn or sunglasses? Do names like Oakley, Coppertone, Ray-Ban and Polaroid sound familiar? All evoke images of sun, fashion, attitude, protection and prevention that already resonate with the consumer.

Like the brand name Polaroid and its association with glare reduction,consumers would equate the brand name Coppertone with sun protection. Introduced in 1944 as the first commercial sunscreen, it continues to be a leader in skin and sun-protection technology. Coppertone Polarized lenses were recently launched and the brand communicates a promise to help guard against harmful radiation, which may contribute to the development of common sunlight related eye maladies.

Dispensers that feature well-accepted brands add that brand’s equity, loyalty and promise to their own business identity. As a result, an office’s total promise, using strongly branded eyewear products, demonstrates a commitment to the highest quality in eyewear and eyecare.

The best large companies continually police their claims to ensure their promise is uncompromised. Therefore, the use of well-known brand names automatically includes the promise that the chosen product will deliver the perceived benefit, even though the patient may not completely understand.

Brands are important in cutting through the “noise” of everything vying for a consumer’s attention. An established brand name can be (so to speak) “worth a thousand words.”

Facts that resonate with consumers are the brand’s promise. In this example, Coppertone lenses are lightweight, provide up to 10 times the impact resistance of ordinary sun lenses (CR-39), are virtually unbreakable and are four times more scratch resistant than ordinary lenses. They provide more HEV protection than ordinary sun lenses; eliminate 97 percent or more of reflected glare, and block 100 percent of UV (UVA/UVB) rays. In addition they provide 160 percent or more HEV light protection as ordinary polarized lenses.

Endorsements by agencies and associations also add to the promise delivered by a brand name. For example, in a sun program, look for The Skin Cancer Foundation recommendations for lenses that are effective UV filters for the eyes and surrounding skin. For the AOA Commission on Ophthalmic Standards, use lenses that meet the AOA specifications for blockage of UVA and UVB rays.

Understand and learn about each sun lens brand, especially since not all lenses are created equal. Some may not be polarized or deliver high-efficiency polarization, and most do not provide the latest in HEV protection. As a result, it is important to order prescription lenses from your lab by brand name. This assures that patients always get the performance they expect.

CONCLUSION

Prevention is the operative word for the evolution of eyecare and eye health management. Given the body of research showing that accumulated effects of sunlight can be harmful to population health, the doctor, dispenser and supporting staff must go beyond eye exams that focus on simple correction.

Promote the adoption of a personal sun strategy that not only informs patients of the current environmental dangers they face, but also how effective a quality pair of good sunwear can be. Use a brand’s promise to help demonstrate a commitment to fashion, protection, quality and integrity.

This paradigm shift in vision care meets your professional obligation to help protect their eyes and ensures your patients see you as their primary source for a lifetime of good vision.