Photophobia

[lensmanmd]

Good day all,

Photophobia and what to do as opticians, a most vexing issue with mixed solutions. I am reaching out to the ODs and gurus here to collect information on how our profession should actually handle this with our patients.

Now, we know that there are a myriad of causes, from medical (ocular and non-ocular) to pharmaceutical to psychological. I also subscribe the the hypothesis that some patients self induce this issue by insisting on tints that are well beyond the traditional grey 3. My favorite "I don"t want to be able to see my eyes through my lenses at all". Many opticians just say "OK" and move forward with "ADAP". The pupils only dilate so much, and being in a constant state of dilation, like any muscle memory, will fail to constrict normally over time, requiring even darker tints (indoors and out). A self perpetuating cycle.

My biggest concern is that many opticians fall for this and consistently request darker than the darkest available tint, then reject them because they are not dark enough. Um, excuse me, but at what point are you trying to interfere with the VA by eliminating the light necessary to see properly? It doesn't matter how many conversations I have with these opticians, the issue remains. As an optician, I was fairly successful in convincing my patients to gradually ween themselves of over-dark lenses by fitting them with progressively lighter tints over the course of a few years.

FL41 is great for migraines, brown, rose and amber are great for reducing the blue/green spectrum. These are great solutions for light sensitive patients, but none of these are ever 'dark' enough for the self-prescribed photophobics, even with a mirror.

So, my question to all of you. How do you handle these situations at the office, or your chair? Do you do provide a more thorough exam, refer them to an OPH, prescribe drops, recommend tints (and if so, which ones), engage in a Q&A to determine the possible cause. This inquiring mind would love to know.

TIA

[lensmanmd]

Bueller? Bueller? Bueller?

[mervinek]

I've had patients in the past that have had part of their iris removed and now have huge irregular pupils. Because of that, they are light sensitive. I use a frame that has good coverage with wide temples to block light in the periphery. Grey polarized with AR backside and a double gradient mirror on the front. That seems to do the trick. I think there are different solutions for different problems. Every patient is different and you need to address each issue individually.

[Tallboy]

People like this love Coppertone Gray polarized lenses, and Transitions Xtra-Active for their "clear pair" in my experience. I used to get ocular migraines and light sensitivity from a severe injury I had when I was younger (they lasted 18 years until I quite smoking, go figure) Transitions Xtra Active really helped me.

Lensmanmd you sound like you are desrcribing some difficult patients there also, I don't know what to tell you when they just want 95% opacity tint

[lensmanmd]

Not difficult patients, just complacent Opticians. Just trying to figure out how to better connect with them so that they can make proper recommendations. This one particular patient is complaining about light sensitivity, yet wears clear lenses in her dress pair. The optician returned a pair of mirror coated G3 Polarized with BSAR stating that they were not dark enough. 10% light transmission, not dark enough. Really?!

[drk]

1. I don't think there's any evidence of the "vicious cycle" as described.
2. There are people who have a real reason for "chronic photophobia", as mentioned, but not that many reasons.
3. "Acute photophobia" is an important symptom and should be evaluated before treated.
4. Leaving what I'll call "psychological photophobia". Patient is just OCD about dark lenses. Nutty. This is the majority, I'm sorry to say.

"Category 4" are a real pain, and never happy. I've had a few. I tell them (after all the arguing back and forth) that a lens can only get so dark. Ditto on the mirror coating, though. That will help. Any tight-fitting goggle-like sunglass will help, too. Hey wear a hat, too.

[Robert Martellaro]

Category "4" sounds a lot like Grade 4. You don't want it, but there it is.

Liberty, Wiley X, and probably a few others manufacture frames with an almost perfect light and wind seal. Liberty calls it a "dry eye cup".

Shedding Light on Photophobia

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3485070/

Hope this helps,

Robert Martellaro

[lensmanmd]

[Shedding Light on Photophobia

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3485070/

Hope this helps,

Robert Martellaro[/QUOTE]

Robert, Thanks for this. Great information. Much of what I have seen in my experience is the 'misuse of tinted lenses' As I said before, gradually decreasing the dark adaptive state has worked well for me. However, getting other opticians to grow a pair when dealing with these types of patients is like herding cats.
The particular patient that spurred me to start this thread states that she is very light sensitive, yet her dress pair of glasses have absolutely no tint on them This leads me to believe that she falls on the #4 line of drk's response, and leads back to 'misuse of tinted lenses'.

drk, your #3. As a clinician, how do you diagnose/deal with acute photophobia patients when they are in your chair?

[drk]

I would have to treat their iritis, glaucoma, keratitis, or something. That's what causes acute photophobia!

Now, chronic photophobics are probably some kind of low grade blepharitis or keratitis, or some retinal pigment issue like albinism, etc.

But the "essential photophobics", and there are some, like mega-pupil/blue-eyed-pale-retinas people YOU are best suited to treat.

Plus the crazies. You can have them, too.

[Tallboy]

I have a person coming in tonight who suffers from "connective tissue disease" (I'm not sure what that is though I've begun reading a bit in preperation) who is so extremely photophobic they wear wrap sunglasses 24-7.

I'll report back with what I do (or questions about what to do!)

Another extreme case of photophobia was someone who had been in a coma for a year and a half before regaining conciousness. She had a lot of issues with her visual system, one of which was photophobia (similar to ocular migraines but not exactly the normal symptoms)

We tried FL-41 as prescribed by her Opthm but ended up settling on Trans X-tra active with AR and a pair of sunglasses. The FL41 tint did not work for this person unfortunately.

[lensmanmd]

We tried FL-41 as prescribed by her Opthm but ended up settling on Trans X-tra active with AR and a pair of sunglasses. The FL41 tint did not work for this person unfortunately.

FL-41 is great for flicker induced sensitivity (Florescent), but is not a cure-all.

[lensmanmd]

I would have to treat their iritis, glaucoma, keratitis, or something. That's what causes acute photophobia!

Do your opticians come to you for guidance when they encounter such patients, or do they just go with the flow? I'm trying to get a panel together with our three O's to provide a more intuitive and interactive patience experience, especially for such not-so-common issues. But hey, I'm "just a lab manager", what do I know?

[LisaRayes]

Photophobia is an experience of discomfort or pain to the eyes due to light exposure or by the presence of actual physical sensitivity of the eyes, though the term is sometimes additionally applied to abnormal or irrational fear of light such as heliophobia.
The best treatment for light sensitivity is to address the underlying cause. Once the triggering factor is treated, photophobia disappears in many cases.

[mervinek]

[QUOTE=Tallboy;534973]I have a person coming in tonight who suffers from "connective tissue disease" (I'm not sure what that is though I've begun reading a bit in preperation) who is so extremely photophobic they wear wrap sunglasses 24-7.

I'll report back with what I do (or questions about what to do!)

Please do!

[drk]

Do your opticians come to you for guidance when they encounter such patients, or do they just go with the flow? I'm trying to get a panel together with our three O's to provide a more intuitive and interactive patience experience, especially for such not-so-common issues. But hey, I'm "just a lab manager", what do I know?

Yes, but we're a small office. Usually I'll see everyone first before our optican does.

It wouldn't be a bad thing to call for another opinion when faced, as an optician, with a photophobic-complaining patient. Someone will have examined him.

[Browman]

For my run-of-the-mill "I'm light seneitive" folks,, a brown #2 in a frame with good eye coverage usually seems to do the trick. Most guys are receptive to an aviator or largish-zyl. Ladies like the cateye look. For more extreme cases... See drk's #4.

[Dustin.B]

As someone who had "acute photophobia" through my teen years I can tell you that a good set of polarized wrapped sunglasses are a life-saver. My first set was Bolle' but moved on to liberty sport for hobby reasons. I've kept transitions in my everyday dress set ever since for exactly this reason. Its rough when some opticians or optometrists wont take you seriously over the matter either. ( On a side note, if you have any specific questions I'm happy to answer. Photophobia sucks. )
As an optician on the other hand I always take the time to Really explain what transitions Xtra Active does mechanically speaking. I try not to get too technical over the matter but most patients get the grasp of it and why its the best option for dealing with mild photophobia. A solid tint may sound like a great option for suns but I've always had better results with polarization for these patients.

[Pete Hanlin]

There's photophobia (which is not so common), and then there is "light sensitive" (which describes the majority of people- Transitions did some research in which 70% of Americans described themselves as "light senisitive).

Honestly, I fall in the "light sensitive" category myself. Even brightly lit rooms bug me, and going outside without sunglasses is downright annoying. As has already been posted, Transitions XTRActive really cuts down on light- they even darken inside a car (but to be honest, I find I need my polarized lenses if I'm driving). Our office has tons of fluorescent lighting, and XTRActive cuts just enough of it to make me more comfortable.

There are limits to how dark you can tint a lens (e.g., you have to be able to discern traffic lights, and some really dark brown tints interfere with this). Interestingly, we've done some clinical studies that suggest that people who are truly photosensitive can get by with a lighter tint if the lenses are polarized vs. simple tint. I guess the elimination of the reflected glare does enough to reduce the "brightest spots."

[tf50fm]

The melanopsin pathway is implicated in some types of photophobia. In patients where this mechanism is active, they will be sensitive to the blue spectrum of the wavelength. If you look at the range of wavelengths where melanopsin is sensitive to, it ranges from about 420-520nm. A complete blue blocker will typically be more helpful than the fl-41 tint. Fluorescent, LED and sunlight are high in the blue light spectrum, which is not the case for incandescent lamps. Complaints about the type of light is a big clue on whether blue light might be the culprit. Flicker is usually not a problem with modern fluorescent lights. Where other mechanisms are implicated, a wider range of wavelengths may need to be blocked out.

[Tallboy]

I have a person coming in tonight who suffers from "connective tissue disease" (I'm not sure what that is though I've begun reading a bit in preperation) who is so extremely photophobic they wear wrap sunglasses 24-7.

This poor guy, I think we figured out a great solution. He is wearing Wiley-X Boss frames with a foam insert that helps light leaks, around -3.50 sph in each eye and -4.00 cyl, single vision. Smoke Grey tint, silver flash mirror, no polarized because he wears them all day and it would mess up electronic screens for him.

He seemed extremely happy with the result.