The eyes have it. Looking out, they help us behold the wonders of the world. Looking in, they give us a window into whether we may be battling conditions like diabetes, high blood pressure, and potentially Alzheimer’s.
We need to treat our eyesight as a precious gift. But we also need to scrutinize challenges to our vision health, like these: Why are eyeglasses so expensive? Should we adopt the widespread exuberance about vision-correction surgeries? And, when older eyes need specialist attention, must it also include risks and surprise costs for added exams and tests?
Focus on the details now, and we may avoid headaches later.*
Why are glasses so darned expensive?
Good eyesight can be crucial to how youngsters fare in school, workers perform on the job, and seniors stay active, engaged, and even alive. Because vision testing can help patients and their doctors determine if corrections are needed and help diagnose serious health conditions, it seems like common sense for the relatively easy exams to start earlyand continue throughout our lives. Alas, studies show that more work needs to occur to make this so, particularly with school-aged kids.
Still, huge numbers of Americans undergo vision testing, and an estimated 126 million of us find we need eyeglasses.
But as David Lazarus, a consumer columnist for the Los Angeles Times, has asked (and answered) in a series of tough and intriguing articles: Why are glasses so costly, and why are they possibly “the single biggest mass-market consumer rip-off to be found?”
He looks at the product’s low material costs in China, finding them to run around $10 for a pair of frames. That’s far below the $231 average cost for frames in this country or the $112 expense for single-vision lenses. Throw in the eye exam and the charges to prepare lenses, and many consumers pay as much as $800 for one set of glasses. Now, figure how much eyewear contributes to medical expenses for a family in which dad, mom, and a couple of kids each need specs, maybe several each.
Lazarus finds that developments in the eyewear business, practices that regulators turned a blind eye to, explain the big bills. In corporate speak, this commercial sector has undergone consolidation and vertical integration.
Translation? As he reported: “[Over the] years a single company, Luxottica, has controlled much of the eyewear market. If you wear designer glasses, there’s a very good chance you’re wearing Luxottica frames. Its owned and licensed brands include Armani, Brooks Brothers, Burberry, Chanel, Coach, DKNY, Dolce & Gabbana, Michael Kors, Oakley, Oliver Peoples, Persol, Polo Ralph Lauren, Ray-Ban, Tiffany, Valentino, Vogue, and Versace.”
Italy’s Luxottica also runs EyeMed Vision Care, LensCrafters, Pearle Vision, Sears Optical, Sunglass Hut, and Target Optical.
There’s more: Luxottica recently merged with a French concern, Essilor, which he says is “the world’s leading maker of prescription eyeglass lenses and contact lenses. Do you have Transitions lenses in your frames? You’re an Essilor customer.”
Luxxotica’s tentacles reach deeper than just products and into vision plans, coverages that are supposed to help patients with costs, including what glasses they may need. Lazarus notes, “The reality is that vision plans, headed by market leaders VSP and EyeMed, are primarily discount programs intended at least in part to promote sales of eyewear affiliated with each company.”
EyeMed, with 46 million patients enrolled nationwide, steers these customers to Luxottica-Essilor products, he reported. VSP, aka Vision Service Plan, with 96 million patients enrolled nationwide, “owns Marchon Eyewear, which controls or holds licenses for Altair, Calvin Klein, Karl Lagerfeld, LaCoste, Nautica, Nine West, Nike and other brands.” Those are the products VSP members are steered toward.
Ophthalmologists and optometrists aren’t blameless in what Lazarus terms the huge “self-interest and price-fixing, with the biggest players doing all they can to stifle or eliminate competition.” Optometrists may wish to see patients get the largest reimbursements possible by using preferred products. Their practices may depend on traffic generated by eye plans, which also may offer such low reimbursements for exams that opticians’ profitability relies on pushing high-cost frames and lenses.
(By the way, to avoid confusion: Ophthalmologists are MDs who have gone to medical school, are specialist doctors, and can diagnose eye problems, treat conditions including advance disease, and perform surgeries. Optometrists (see the O.D. behind their names) have pursued graduate education, can examine eyes, and offer limited treatment of eye diseases. They and ophthalmologists both can dilate eyes for exams and prescribe medications like eye drops. More extensive prescribing depends on state laws. Both can write prescriptions for contacts and eyewear, with lenses and glasses prepared and fitted by opticians, who cannot conduct eye exams. Your choice among these caregivers depends on the extent of your need for services.)
Can cold-eyed capitalism and the power of competition help consumers, so they don’t get robbed, so to speak, blind? Online entrepreneurs may be riding somewhat to the rescue, with enterprises like the start-up Zenni and the better-known (and more expensive) Warby-Parker offering options on style and cost. Jins, a Japanese company, is making forays into the large and lucrative California market. Experts say these operations have their pluses and minuses, especially for cost, fit, and convenience, and doing careful research on them is a must for would-be buyers.
Consumer Reports also has looked at soaring eyeglass costs, offeringcommon–sense suggestions for studying and finding options online and in brick-and-mortar outlets. CR, an independent nonprofit organization, found in its reporting that two familiar retailers may be reliable for good, cheaper glasses: Costco and Walmart.
“These retailers got high marks from readers, with Costco, our top-rated eyeglass retailer, edging out Walmart in several areas, including the quality of frames and lenses and follow-up service. But readers were not impressed by the selection of frames, especially at Costco. One workaround: You can usually have a discount store put lenses into frames you purchased elsewhere. Walmart charges an extra $10 and Costco $18 to do this. They’ll also adjust the frames while you’re there.”
By the way, while getting that periodic eye exam, you may wish to ask your eye doctor whether your aging eyes and the onset of presbyopia (near-sightedness) requires prescription correction. Many folks, if they need glasses just for reading, get along fine with “ready-made” glasses that can be found at drug stores, discounters, and, yes, big stores like Costco and Walmart.
‘Lasik’ corrective surgeries aren’t risk free
Tens of millions of Americans get fed up with the inconvenience of being bespectacled or contact lensed. With hopes of shedding gear that some may have worn since childhood, they pursue corrective surgeries that have been widely promoted and now may be considered commonplace. But caveat emptor, federal officials say: Patients should research medical procedures they plan to undergo with care, because they all have their downsides.
It’s a myth to think that corrective eye surgery is all but risk-free.Significant numbers of the 9.5 million Americans who had laser-assisted or Lasik operations may show vision improvements but also may be under-reporting problems with their surgeries, the New York Times reported.
The federal Food and Drug Administration approved Lasik in the 1990s, but the agency only recently supported the gold-standard of medical research, a randomized clinical trial, to check on long-running complaints about the surgery.
The FDA trial, involving several hundred patients, mostly provided a good way for eye specialists to get better information from patients about Lasik’s effectiveness and complications, experts say. Still, for those who have warned about Lasik’s negatives, the FDA trial raised more alarms, showing, as the New York Times reported:
“Nearly half of all people who had healthy eyes before Lasik developed visual aberrations for the first time after the procedure, the trial found. Nearly one-third developed dry eyes, a complication that can cause serious discomfort, for the first time. The authors wrote that ‘patients undergoing Lasik surgery should be adequately counseled about the possibility of developing new visual symptoms after surgery before undergoing this elective procedure.’ “
The newspaper delves into problems with Lasik, aka laser-assisted in situ keratomileusis, a procedure that typically isn’t covered by health insurance and costs on average more than $4,000 per eye. Patients, for example, emphasize that what ophthalmologists may call just “dry eyes” fails to describe what they experience as searing, sustained pain. Many complain this nightmare can’t be treated and resolved easily, quickly, or at all. Glare, halos, and double vision also vex Lasik patients, especially when they drive at night or do prolonged work on computers. In many cases, “vision aberrations” diminish over time, and ophthalmologists insist that’s typically what occurs.
But patients disagree. The FDA study raises the worry that, in fact, declines in visual performance may pop up later after surgery than specialists think they do. And the agency’s researchers found another concern — patients’ unwillingness to discuss negatives or “adverse outcomes” about this or any other surgery, because they don’t want to offend, worry, or cause troubles for caregivers.
In my practice, I see the harms that patients suffer while seeking medical services, especially when undergoing elective or cosmetic procedures. Patients may have myriad reasons for wanting to give up glasses, and some may wonder, “Haven’t all the worries about Lasik been aired after all these years?” Let’s put this matter in clearer focus, because Lasik illustrates critical concerns in medicine.
First, as the New York Times underscores, the persistent problems with Lasik ought to force lawmakers and regulators to keep questioning the process in which medical devices and procedures win federal clearance. As the newspaper reported:
“Lack of precise information about complications is a problem that plagues many medical devices, which are tested by manufacturers and often gain FDA approval before long-term outcomes are known, said Diana Zuckerman, president of the nonprofit National Center for Health Research in Washington. ‘The FDA keeps promising to do a better job of post-market surveillance, but there is no evidence of real improvement,’ she said.”
Second, researchers in the FDA’s Lasik clinical trial hit another troubling issue: Do doctors give patients robust counsel about not only what will but also what might happen to them? Are doctors patiently, fully, and appropriately discussing Lasik surgeries’ risks and benefits with hundreds of thousands of patients each year? This is what the law calls informed consent. It is a fundamental and critical right for patients. It’s the duty of every health care provider to ensure that patients know all their treatment options and that they decide what path to take without strong-arming or scare tactics from the person in the white coat.
In an argument filled with more than its share of illogic, doctors point to Lasik’s popularity as proof of its safety and effectiveness: If it wasn’t sound, why would almost 700,000 patients in 2017 have had the procedure, up from 629,000 or so the year before?
The newspaper also noted that Lasik can impede detection of the serious condition of glaucoma. It can lead to a vision-threatening condition called corneal ectasia. Besides chronic and severe pain, it can lead to vision loss and blindness. Experts say studies show that severe complications like these occur in “just” 2 percent of cases. But do that math ── it amounts to 14,000 patients in 2017 alone and 190,000 since the surgery won FDA approval. Is that acceptable? Would you choose to be one of these harmed patients? Caveat emptor isn’t enough. We need to demand more from our doctors, lawmakers, and taxpayer-supported regulators.
Cautions for seniors on care for cataracts
As we age, common ways of optimizing our health — eating well, managing our weight, not smoking, drinking alcohol in moderation, and exercising — also can be beneficial to our vision. Following a wellness routine and getting regular eye exams can go a long way to helping older adults prevent, detect early, and treat eye conditions like glaucoma, diabetic retinopathy, and age-related macular degeneration.
Many seniors may find, too, that they need cataract operations, which are performed on more than 3 million Americans each year and may be the most common surgeries in the nation.
Cataracts “typically form gradually with age, and anyone who lives long enough is likely to develop them,” the New York Times reported. “They are the most frequent cause of vision loss in people over 40. Common risk factors include exposure to ultraviolet radiation (i.e., sunlight), smoking, obesity, high blood pressure, diabetes, prolonged use of corticosteroids, extreme nearsightedness, and family history.”
Cataracts make the normally clear, transparent lens of the eye cloudy or opaque. In addition to compromising vision, they can lead to blindness. Surgeons treat cataracts by removing the eye’s natural lens and putting in an artificial replacement. The procedure—which once took hours and required general anesthesia and hospitalization—has advanced so it can be done on an outpatient basis relatively quickly, easily, and with minor inconvenience. Patients still may experience discomfort and must curtail their activities, including driving and strenuous exercise, after surgery.
The procedures have high success rates and often result in not only greater vision clarity but also greater acuity. But the operation can pose risks to elderly and sick patients, and too many seniors seeking the surgery may be hit with unneeded preoperative tests that add to expenses they already may be reluctant to take on.
The safety of the procedure, alas, was the subject of an embarrassing research reverse. Not long ago, the New York Times reported on a 20-year study published in JAMA Ophthalmology of more than 74,000 women who were 65 and older and who had cataracts. The study initially found a 60 percent lower risk of death among the 41,735 women who had their clouded lenses removed, the New York Times reported.
Researchers touted the notion that “The women in the study who underwent cataract surgery lived longer even though, over all, they were sicker to begin with — as a group, they had more heart attacks, chronic pulmonary disease, peptic ulcers and glaucoma than those who did not have surgery. … [But] those who had cataract surgery subsequently had reduced risks of death from cardiovascular, pulmonary, neurological and infectious diseases, as well as cancer and accidents.”
A reader of the study inquired about its data, leading the serious and respected experts to retract and republish their work, finding instead that: “In older women with cataract[s] … [corrective] surgery was associated with higher risk for total and cause-specific mortality (except for neurologic causes).” Researchers conceded they could not tease out the higher risks’ causes and whether they were due to “interplay of cataract surgery, systemic disease, disease-related mortality, and the best timing of when to undergo cataract surgery.”
Patients also may wish to be guarded about cataract surgery, because it may include unnecessary preop tests with their requisite expense. Yes, sicker and older seniors may need careful operative consideration. But a separate study in the New England Journal of Medicine reported that “preoperative testing is not recommended for patients undergoing cataract surgery, because testing neither decreases adverse events nor improves outcomes.”
It can’t get much clearer than that: Testing doesn’t lower the rate of complication, and it doesn’t elevate the rate of success. So why do eye surgeons love it so much? It’s a habit. As the researchers wrote: “Preoperative testing before cataract surgery occurred frequently and was more strongly associated with provider practice patterns than with patient characteristics.”
According to KaiserHealthNews.org, the testing can include blood work, urinalysis, cardiac stress tests, and more exams that haven’t been ordered for patients “for more than a dozen years.” Doctors order the exams even though they may be duplicative and even as the independent, nonpartisan health news service reported that “the eye surgery generally takes less time than watching a rerun of ‘Marcus Welby, MD’ – just 18 minutes, on average. It’s also incredibly safe, with a less than 1 percent risk of major cardiac problems or death.”
The researchers looked at data on Medicare beneficiaries undergoing cataract surgery in 2011. Of 440,857 patients, slightly more than half had at least one preoperative test in the month before surgery. Those tests added $4.8 million in costs.
A new study published in the JAMA medical journal shows that hospitals, insurers, and patients may be able to reduce wasteful preop exams by getting a nursing specialist to review orders for them, talking to providers about their necessity, as well as discussing and training colleagues on why they are “low value” care.
If you are scheduled for cataract surgery, and your ophthalmologist orders preop tests, ask why.
Individuals can protect themselves from cataracts by wearing sunglasses that block 100 percent of UV rays, and a hat, the New York Times reported. They can support their vision with vitamin E-rich foods like spinach, almonds, sunflower seeds, and sweet potatoes. They also may want to add to their diet items that are abundant in lutein and zeaxanthin (found in kale, spinach, and other dark green leafy vegetables) and omega-3 fatty acids (spinach and oily fish like mackerel, salmon, and sardines).
Although Medicare typically covers the $3,500 or so cost per eye, some seniors still may balk at the expense, inconvenience, and risk.
Savings on medical costs can be key for us all but especially for seniors. That’s because too many baby boomer retirees may have saved too little and spent too much in their lifetimes. They may enter their “golden years” with far fewer resources than needed, especially for medical services. Or, they may be reluctant, due to excess frugality, to spend for goods and services that could boost the quality and length of their lives. Jane Bryant Quinn, the noted financial columnist, has written in the AARP Bulletin, for example, that it doesn’t make total sense for an older woman with ample finances to scrimp and deny herself hearing aids, if doing so leaves her deaf and isolated from friends and family.
Experts and research have shown that seniors live longer, fuller lives if they deal not only with their chronic health conditions but also with matters like their vision and hearing, as well as their oral health—the gums, teeth, and tongues that let them taste, digest, and enjoy good food.
Of course, this is the vision I’d like to see 20/20 for you and your loved ones—that we all stay fit, healthy, well, happy, and with great eyesight throughout 2019 and beyond!
Avoid infections and injuries
To see misery personified, just look at someone who has suffered an eye injury or infection. Many of these can be prevented.
Thousands of Americans are blinded by work-related injuries that Uncle Sam struggles to prevent. If your job exposes you to “chemical, environmental, radiological or mechanical irritants and hazards,” your employers must provide appropriate gear and safety protocols and protections. If you’re tackling yard or home improvement projects that may put your eyes and limbs at risk, take safety precautions here, too.
If you, your loved ones, or your kids participate in sports, it may be more than worth your while to ensure the athletes wear protective eye gear.
Caregivers in emergency rooms across the country treat 30,000 sports-related eye injuries annually, a large majority of them in patients younger than 18 and a few younger than 10. The patients needing treatment most commonly were boys who had been playing (in order of injury) basketball, baseball or softball or using air guns, the New York Times reported. Cycling also caused many eye traumas. For girls, soccer was the leading source of eye mishaps.
Many of the injuries were minor and didn’t involve the eyes alone—bicyclists, for example, arrived in ERs with face scrapes that went up and around the eyes. Some injuries were serious, with the surrounding socket bruised or broken or the eye itself injured by objects including balls and projectiles from paintball or air guns. Patients also received care when they were poked or butted in the eyes.
Researchers said they found relatively few ER cases involving football or other sports like lacrosse or hockey in which athletes wear helmets, face masks, or visors. They said their estimates of eye injuries were likely low. They did not count cases in which kids went to their own physicians, eye specialists, or urgent care. Their study looked at a sampling from a national database that compiles information about cases handled in 900 ERs nationwide. They scrutinized cases from 2010-13 by examining medical codes that described in detail why patients visited ERs, including what sports they had participated in when injured.
Because many Americans forego glasses and wear contact lenses when active, it’s worth a reminder that hygiene and common sense can prevent problems.
The federal Centers for Disease Control and Prevention, as well as eye specialists, caution those using contact lenses against excess wear, sleeping while wearing them, putting them in the mouth to moisten them, and failing to chemically sterilize and clean them regularly. Don’t try to save money by wearing disposable lenses beyond their recommended periods of use. Don’t delay seeing a specialist if your lenses stop fitting correctly or feel stiff and scratchy. They may be damaging your eye.
Frequent and vigorous hand washing, especially before touching the eyes or anywhere near them, can be an excellent practice, not only for putting in and taking out contact lenses but also for avoiding viruses and funguses that abound on surfaces in schools, workplaces, and gyms. They can cause itchy, burning infections like conjunctivitis, aka pink eye.
The CDC, targeting young people, has campaigned for better eye hygiene (perhaps more crudely than expected from a government agency) by telling them how contact lenses can be like underwear: “Don’t over-wear, avoid that sketchy pair, and carry a spare.”
Light is needed for sight, but can cause its own issues
Let there be light, so we can see. But let’s also protect our eyes from harmful parts of sunshine.
UV-A rays from sunlight can damage central vision, while UV-B rays can injure front eye tissues, including the cornea and lens. Light-related damage can contribute to conditions like macular degeneration, cataracts, photo keratitis (corneal sunburn), and the growth known as pterygium.
Wearing a hat and sunglasses rated to protect against 99 to 100 percent of UV-A and UA-B rayscan be an important way to protect the eye. The rating matters more than lens color.
Look for sunglasses that wrap around sufficiently to cover and protect the eye. Don’t forget that hat. Make sure your eyes have sun and glare safeguards for sports and recreation, including goggles for snow skiing and appropriate protective gear for sailing and water sports.
Patients may be hearing a lot about protecting their eyes from “blue light,” exposure to a specific part of the spectrum and generated by the screens on TVs, cell phones, tablets, and computers. The research isn’t convincing for special glasses or coatings to deal with such exposure.
But consumers may want to know that studies are accumulating showing that staring at digital screens near bedtime can be disruptive to the sound sleep we all need. It is showing associations with health harms. Among the digital elite in Silicon Valley, many parents are limitingyoung people’s screen time, especially in the evenings and near scheduled sleep hours.
As for those who must spend long periods in front of a computer, experts say it may not be the devices’ blue light that causes common eye and health complaints. Instead, the reported eye strain, headaches, blurred vision, dry eyes, and pain in the neck and shoulders may be blamed on problematical work habits and situations.
Patients should take breaks away from screens to stretch and walk around. They may wish to work with their workplace IT experts to ensure their desktops and laptops are correctly adjusted and ergonomically optimized. They should be sure, if they are flipping between their desk and screen that the light is right in both spots. They may want to talk with their ophthalmologists and opticians to see if they can benefit from specialized glasses, designed for close computer work. Their specialists may be able to recommend drops or other treatments if patients experience dry, red, or irritated eyes.
Recent Health Care Blog Posts
Here are some recent posts on our patient safety blog that might interest you:
- As doctors and public health officials coast-to-coast battle infectious outbreaks — of measles, mumps, meningitis, whooping cough, influenza, as well as typhus, hepatitis, and TB — the nation is also struggling with the right response for yet another contagion: the viral spread of medical misinformation on social media. Medical nonsense isn’t new, and savvy patient-consumers long have needed to do a little work to protect themselves from what can be its real and significant harms. But a season of rapidly spreading and 100% preventable infectious diseases has forced modern medicine to confront generational dilemmas with health disinformation that is “shared” widely online and especially via social media.
- Those who are senior enough to remember the allures of sweet drinks like Tang, Hawaiian Punch, and Kool-Aid also may need to be sage enough to share a deep, evidence-based distrust and disapproval for the nefarious actions of Big Sugar and Big Tobacco. Those suspicions may need to be renewed in regulators’ crackdowns on vaping, its flavorings, and flavored tobacco cigarettes.
- If a surgical staple gun malfunctioned so seriously that it generated not a few dozen formal complaints but more than 10,000 reported incidents, shouldn’t patients, doctors, and hospitals have the right to know that information from the federal agency overseeing the safety of medical devices?Apparently not. Or maybe not without a big kick in the pants from journalists. Instead, the staff at the federal Food and Drug Administration turned a move to ease paperwork and bureaucracy into a giant and little-known system that lets medical device makers hide serious and significant numbers of reports about failures and flaws with at least 100 products, a Kaiser Health News Service investigation found.
- Diabetics and those with failing kidneys may have gotten a glimmer of relief from the staggering costs of caring for their conditions, as Big Pharma relented a tad with news it will put out a less-costly insulin product and federal officials suggesting Uncle Sam soon may be upsetting the flush profits of the dialysis industry.
- The federal Food and Drug Administration finally has pushed back at surgeons and hospitals for experimenting on patients, spending $3 billion a year for surgical robots. The devices should not be used for mastectomies and other cancer-related procedures without caution, regulators warn. The FDA acted after studies have shown that minimally invasive procedures for early-stage cervical cancer, many robot-aided, were more likely than standard, large-incision surgeries to result in recurrences of the disease and deaths.
Regulators also may have been prodded by their poor history in halting harms to women with so-called keyhole procedures, particularly the nightmares the FDA was slow to react to involving minimally invasive hysterectomies and a tissue-grinding tool called a morcellator.
Patrick Malone & Associates