eyes

(PUBLISHER'S NOTE: There has been a lot of forum traffic over the past couple of months on how to handle vision issues while racing—contact lenses, prescription goggles and sports glasses, LASIK surgery, etc. It became obvious that a particular person answering questions asked by forum readers knew a whole lot about the subject. We asked him to write an article. It is below).

Many of us wear spectacles or contact lenses to correct our vision. A small percent see "20/20" without any correction, and a growing number of people are choosing LASIK, or laser vision correction, to correct their prescription. We all put a premium on sharp, crisp vision and you shouldn't have to forego crisp vision while you are racing.

It is amazing to me how many people accept the fact they must train or race without the ability to site a buoy or see a pothole. The fact is, there are some very good options for vision correction while swimming, cycling and running, or whatever you decide to do outside.

As triathletes, we start in the water, so that is where I'll begin. While swimming, good options for correction include contact lenses worn under your goggles, or prescription goggles, or goggles with prescription inserts. Whether you wear soft conatct lenses (SCLs) or rigid gas permeable lenses (RGPs) you will want to make sure you get a good seal on your goggles to prevent leaks. A soft lens could absorb bacteria, etc., from the water into the lens polymer and potentially set the stage for an infection. The risk is the same for pool water, a lake or an ocean. I don't think one goggle design is any better then another as long as you are comfortable with the fit, and it seals well. If you do not wear one-day disposable contact lenses it is important to remove the lens that evening and disinfect the lens in a contact lens solution overnight. Some solutions can adequately disinfect now in minutes.

Most doctors will not recommend swimming with contact lenses, but the safest alternative with the lowest chance of infection would be to wear a one-day disposable contact lens. These lenses (Ciba Daily, Acuvue 1-Day, Soflens 66 1-Day) are clean and sterile upon insertion and worn for one day and then thrown away. This minimizes build-up on the lens in the form of protein, microorganisms, and so forth. I would not recommend continuous wear (extended wear) to swimmers or triathletes as this modality of lens wear has the highest chance of infection. Extended wear lenses (some lenses are FDA approved for 6 nights of continuous wear, and two new lenses—Purevision by Bausch and Lomb and Focus Night and Day by Ciba—are approved for up to 30 nights of continuous wear) become more coated over the period of wear, and more organisms can bind to the lens.

Prescription swim goggles can be custom-made with your prescription. This is done by inserting a clip which is bonded to the inside of the goggle, or by actually grinding the prescription into the goggle itself. These custom clips or custom goggles are a good idea if you have a significantly high prescription, high amounts of astigmatism, or for farsightedness (hyperopic). The other alternative is wearing goggles bought "off the rack" with a pre-made prescription already in them. These are found in minus (myopic or nearsighted) power only. The range of power is limited to spherical (no astigmatism) amounts of -.50 to -8.00 diopters, in one-half diopter steps. No hyperopic (farsighted) goggles are available off the rack that I know of. A diopter is the term for the power of the lens, or the amount that it bends light. The disadvantage to these pre-made goggles is your prescription needs to be symmetric or very close to symmetric to work well, or you will end up with one eye that is blurry and one that is sharp. The other disadvantage is these goggles don't incorporate any correction for astigmatism. When choosing these if you cannot find your exact power round down to the next lowest power instead of up . Goggles that you can buy off the rack with minus-power include, but are not limited to, Speedo, Barracuda, and Vju.

There are over 25 million contact lens wearers in the U.S. at this time. Triathlon and sports in general mesh well with contact lenses. Contact lenses allow a natural, wider field of view, move quickly on the plane of the eye for quick changes in eye movement, reduce distortions which can come from looking peripherally through some spectacle lenses, and don't fog up like glasses do. Contact lenses are also generally safer for sports. I will only discuss soft contact lenses as that is what the vast majority of athletes wear.

Soft contact lenses (SCL's) are made of polymers that contain mostly water. Even the highest prescriptions can be corrected with contact lenses. The most common modalities of lens wear today are one-day disposable lenses, 2-4 week disposables, 3 month disposables. "Conventional" one-year daily wear (lens is worn during the day and then removed at night and cleaned, disinfected, etc, and then worn the next day) lenses are still fit these days, but are much less common, as the disposable lens options are much greater now. As a general rule, the more often you replace the lens the better for the health of the eye. The fewer total hours the lens accumulates on the eye, the lower the chance of problems, lens discomfort, blurring of vision and infectious risk.

Continuous wear of lenses, or "extended wear" (sleeping in the lenses for multiple nights in a row) is now on a bit of a resurgence because of the introduction of a new lens polymer ( Ciba Night and Day lens, as well as the Bausch and Lomb Purevision lens) which is approximately 8 times more oxygen permeable then previous lens polymers. I don't recommend the extended wear modality for swimmers or triathletes because of the increased risk of infectious keratitis which accompanies swimming with lenses and then sleeping in them. The risk of infectious keratitus (an infection of the cornea, the clear window of the front of the eye) with continuous wear is about fifteen times greater then two daily wear disposable lenses (taking the lens out at night and soaking the lens in a disinfecting solution and then replacing the lens the next day, a new lens is inserted after 2 weeks). But the risk is higher with swimming.

For any swimmer or triathlete I recommend a one-day disposable contact lens. This is probably the cleanest and healthiest way to wear lenses. Currently these lenses are available in spherical powers only (no astigmatism) from approximately +6.00 diopters to -10.00. A toric (for astigmatism) one-day disposable should be available within a year or so, as well as a possible bifocal design. I like these lenses because they are safe, convenient and healthy. From a professional standpoint I don't think I have seen a case of infection with these lenses. These are thin lenses so they sometimes tend to dry a bit more. Cyclists and runners are sometimes concerned with lenses feeling scratchy or dry. A simple artificial tear or contact lens rewetting or lubricating drop will most likely solve many of these problems by rehydrating the lens polymer. These can be placed in the transition area, or even carried on the bike or run. A few drops in T2 after an IM bike ride could mean the difference in comfortable lenses for a 26.2 mile run, especially when faced with more heat and wind over the next several hours. Another advantage of contact lenses is you can choose your favorite sunglasses without regard to getting prescription lenses put into them. Certainly larger, wraparound type designs will protect the eyes from wind and UV light.

The material and low water content of the new silicone hydrogel Night and Day (Ciba) and Purevision (B and L) lenses can make these lenses good options for people who have dryness symptoms (a scratchy feeling, like something is in your eye, burning, mild redness). Copious use of artificial tear lubricants are sometimes also needed. If dryness persists, small silicone plugs can be placed in the area where the tears drain. These plugs keep more tears on the eye, and give the contact lens a larger tear lake to float on.

Recently, more and more people have been forgoing contact lens and spectacle wear for forms of laser vision correction to correct their prescription. LASIK is the reshaping of the cornea, by eximer laser, to focus light onto the retina. Many triathletes have chosen this route, including Lori Bowden. With the media frenzy concerning LASIK, both positive and negative, one must remember that LASIK is a delicate surgical procedure performed on one of the most delicate tissues in the body, and shouldn't be considered without serious thought given to all the risks, benefits and alternatives. Certainly the benefits can be immediate and astounding but so can the complications even though sight-threatening ones are very rare (less then 1% by most studies). Most "complications" with Lasik are in the form of delays in recovery.

Certainly the freedom from spectacle wear or contact lenses while racing and training for triathletes is a big incentive for considering LASIK. The best candidates for LASIK have a healthy cornea and overall healthy eyes without signs of any eye disease, including significant dry eye. You must be in overall good health as well, without diabetes, autoimmune or other collagen vascular disease. You must be over 18 years of age and have a stable prescription, without changes for at least a year. Their is no upper age limit for LASIK. The range of treatable prescription includes from -12.00 diopters to +6.00 diopters (though I wouldn't recommend LASIK to anyone above +4.00) with astigmatism amounts up to -5.00 diopters. These ranges may vary slightly depending on the specific model of laser used. Different models have different FDA approved ranges of treatment.

As a triathlete, if you consider laser vision correction you may want to do so during the "off-season". Following the procedure you may not swim for the first 7-10 days, and no vigorous workouts for 7 days. Everyone heals differently so your uncorrected vision may fluctuate a bit for the first 12 weeks or so. This is normal, though most people have better then 20/40 uncorrected distance vision the first day and feel comfortable driving. A feeling of dryness is common as well for the first couple of months, these symptoms may worsen while riding or running the few weeks following the procedure. Supplementation with preservative-free artificial tears is very important to keep the cornea well lubricated during this time.
Much has been written in the popular media about LASIK complications, a lot of it about debilitating night vision problems, halos and glare. These are very subjective symptoms, and I have had many patients who were in the "higher risk" group for these symptoms and have had no problems whatsoever, and I have had people who were seemingly in a " low risk" group who following the procedure did have symptoms. Most patients experience these symptoms to a certain extent, and these symptoms fade over the first 4-12 weeks as the cornea heals. Risk factors for night vision problems include high initial prescription, high amounts of astigmatism, and large pupils while measured in dim lighting conditions.

For you Masters triathletes (40 years and older), if you have bilateral distance correction with LASIK, you will need reading glasses—eventually (trust me)—for your near work. I know there are many tough, hardened, multiple Ironman finishers out there, but eventually you will have to reach for your friends' reading glasses and painfully admit that your "eyes have given out", and your "arms aren't long enough" to read the menu at your favorite restaurant. This also includes reading your splits times off your watch as well as reading your cycling computer. One solution to this with LASIK is to leave one eye—generally your non-dominant eye—slightly myopic (nearsighted). This gives you a small amount of natural vision for near in one eye, so you can do these near tasks without reading glasses. Remember though this eye will not have 20/20 vision for distance, though probably somewhere in the 20/30-20/40 range. This is called "monovision" and is something to discuss with your surgeon or assistant prior to surgery. It is wise to wear monovision contact lenses prior to having LASIK to assure you can adapt to it as a visual modality. It is something that your visual system has to adapt to, but millions of people are sucessful monovision contact lens wearers.

Finally, think deeply about how troublesome your contact lenses or glasses really are and don't undergo an elective surgical procedure just because your training partner did. Educate yourself about the procedure and read all you can about the good and the bad outcomes. If you choose to have a Lasik evaluation be prepared with specific questions regarding your active lifestyle and what you can expect. Research and choose your surgeon wisely and make sure he is very experienced.

Good luck , and may you always be able see the finish line clearly.