The Fine View: Summer 2010
| Richard S. Hoffman,
Traumatic injuries to the eye can cause a multitude of problems including cataracts, infection, corneal scars, retinal detachment, and many more. In the best case scenario, minimal damage occurs to the eye and full recovery of vision is preserved. In the worst case, complete blindness or loss of the eye results. When trauma to the eye involves a full perforating injury, many times the colored iris of the eye can be lost or damaged. These abnormal iris defects can have both implications for anatomic function and cosmetic appearance. Severe glare, blurred vision, and light intolerance may result from these anatomic abnormalities of the iris. When the iris is completely lost, the disability can be severe. There are a host of iris prosthetic devices that have been available internationally to aid in repairing or reconstructing these iris defects but their availability to US surgeons has been slow due to regulatory restrictions. Most of these prosthetic iris devices are attached to intraocular lenses and require very large incisions that need to be made in the eye in order for them to be safely implanted. In addition, the color options for many of these devices are limited giving a less than ideal cosmetic result.
A new foldable artificial iris will soon be undergoing clinical trials within the US to address many of these issues. This device will be made out of a pigmented silicone elastomer and its color can be matched to a patient’s natural iris color. The soft foldable material will allow its implantation through a very small incision which will result in a safer procedure with less surgically induced astigmatism. The device can be placed behind the patient’s remaining iris tissue when the amount of iris tissue loss is small (see photos), or it can be sewn to the wall of the eye to replace the entire iris when complete loss of the iris tissue resulted from the original trauma. The artificial iris can also be trimmed to fit inside the patient’s capsular bag at the time of cataract surgery along with a standard intraocular lens.
Clinical trials for this new device will be starting soon. We are very excited to have been chosen as the US investigators for the Pacific Northwest region for the foldable artificial iris. [ top ]
Mark Packer, M.D
Presbyopia means declining up close vision. It is a loss of accommodation. Accommodation is the term used to describe the process of focusing at near, for example, when reading or using a computer screen. Presbyopia is one of those signs of aging that people find alarming at first and, in the long run, frustrating. Most frequently we treat presbyopia with progressive bifocal glasses or contact lens monovision (one eye for distance, one eye for near). Recently, surgical options for the treatment of presbyopia have grown and are providing high levels of satisfaction. In particular, multifocal intraocular lenses significantly reduce the need for glasses. Accommodative lenses can also reduce the need for glasses, although not as predictably. On the other hand, accommodative lenses create less trouble with halos around lights at night.
These implants have been studied primarily in patients having cataract surgery. For example, in the US clinical investigation of the Tecnis multifocal IOL, of which I was Medical Monitor, 292 subjects implanted in both eyes gave a mean rating of satisfaction for vision without glasses of 4.46 on a scale of 1 – 5, with 5 being the best. 88% of these subjects stated that they never wear glasses, and at one year after surgery 94.6% stated they would elect the Tecnis multifocal again. Similarly, in the clinical trial of the AcrySof ReSTOR IQ +3D IOL, 138 subjects gave a mean self-rating of vision of 8.6 out of 10. 76% were completely free of spectacle wear, and over 95% stated they would choose the ReSTOR again. Nevertheless, 24.3% of Tecnis multifocal subjects and 31.1% of ReSTOR IQ +3D subjects noted moderate or severe halos. Although the satisfaction is high, there is still some room for improvement in the surgical correction of presbyopia. It may be that matching the optical properties of a particular multifocal lens to a particular eye improves the outcome.
Because presbyopia fundamentally represents deterioration in the function of the natural lens it makes sense that the solution lies in somehow treating or replacing the lens to restore or mimic its youthful power. In terms of treating the lens to restore accommodation, one company, LensAR, recently received a patent for using a femtosecond laser to increase the flexibility of the crystalline lens. In terms of replacing the lens, a successful accommodative intraocular lens implant should effectively harness the action of the eye as when it was young. The crystalens remains the only approved accommodative lens in the US. The mechanism of action was thought to be due to the contraction of the muscles in the eye causing the lens to move forward. However, more recent data has left unsettled the mechanism by which the crystalens provides accommodation. Outside the US, the dual optic Visiogen Synchrony has demonstrated promising results. Ultrasound has shown movement of the lens in response to stimulation of accommodation. We also served as investigators in the US clinical investigation of the Synchrony and eagerly await the results.
While technology continues to evolve and we continue to pursue perfection, our experience with the currently available implants demonstrates that we can achieve high levels of satisfaction today. In fact, the satisfaction achieved in the studies of multifocal implants described above equal the levels achieved historically with LASIK (about 95% of people globally say they would have the procedure again). We will always strive to do better, but in the meantime, how about losing those specs?
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Following these recommendations will make your eye exam go more smoothly and help us give you the best possible care.
- Please read the information in your new patient packet. We want to keep you informed.
- Complete and sign both sides of the patient registration form in advance of your appointment. You can even do this through our website’s secure Patient Portal here.
- Complete your medical history form. Also available online through our secure Patient Portal here.
- Find out if you have a family history of glaucoma or other eye diseases. Also, be prepared to tell your doctor if anyone in your immediate family has diabetes.
- Let us know what insurance company to bill. Bring your insurance card(s) with you.
- Let us know why you are coming in. Is it time for a new pair of glasses? (vision benefit) Do you have blurry vision and can no longer read the road signs? (medical benefit) Do you have diabetes? (medical benefit) Do you have a family history of glaucoma? (medical benefit)
- Let us know if you are using a vision benefit through your vision insurance company or using a medical benefit through your medical insurance company.
- Bring your eyeglasses and contact lenses with you to your appointment.
- Get plenty of rest before your exam. You play a key role in determining the outcome of your refraction. You will be shown different lenses and asked which provide the clearest vision, so you’ll want to be fresh and alert.
- Plan on being with us for at least an hour to an hour and a half for a comprehensive exam and approximately two hours for children.
- Please arrive at your appointment time. Being late for your eye exam affects not only you, but the patients scheduled after your appointment.
Our desire is to work together with you to ensure we are able to give you the best possible eye care. Thank you for choosing us as your eye care provider. [ top ]
Community events, meaningful contributions, and social responsibility play a significant role in our practice. These activities connect us to people in our community in a way that goes beyond the office setting.
A few of the ways we’ve participated in our community for the past several years have been to offer contributions benefiting Women’s Space, being involved in silent auctions to raise money for schools in the Eugene and Springfield area, and underwriting of National Public Radio.
Another important activity is our involvement in the ASCRS Foundation which has helped allow for the construction of a medical facility and its outfitting with the surgical equipment needed to provide full-service care to patients in Ethiopia.
In addition, Drs. Fine, Hoffman and Packer are ongoing partners with Oregon Health & Science University in teaching residents to perform ophthalmic surgery by serving as attending surgeons for fourth-year medical students at the VA hospital in Portland, as well as serving as the site for their elective clerkship in ophthalmology rotation.
We also host premedical students from the University of Oregon continually throughout the year to give them their first exposure to the field of clinical and surgical ophthalmology.
Recently we have begun adopting social media tools to allow us to connect with you in an entirely new way. It makes sense that we would explore these tools to engage in conversations that are important to your daily lives.
Visit us on Facebook or Twitter at “Fine, Hoffman and Packer” to see what we are up to.
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FAQ: Who can participate in a clinical trial?
All clinical trials have guidelines about who can participate. Using inclusion/exclusion criteria is an important principle of medical research that helps to produce reliable results. The factors that allow someone to participate in a clinical trial are called "inclusion criteria" and those that disallow someone from participating are called "exclusion criteria". These criteria are based on such factors as age, gender, the type and stage of a disease, previous treatment history, and other medical conditions.
Before joining a clinical trial, a participant must qualify for the study. Some research studies seek participants with illnesses or conditions to be studied in the clinical trial, while others need healthy participants. It is important to note that inclusion and exclusion criteria are not used to reject people personally. Instead, the criteria are used to identify appropriate participants and keep them safe. The criteria help ensure that researchers will be able to answer the questions they plan to study. [ top ]
Dr. Fine is the 2010 recipient of the Binkhorst Medal from the American Society of Cataract and Refractive Surgery (ASCRS). Each year, the organization chooses to honor a surgeon who has made significant contributions to the science and practice of ophthalmology throughout his or her career. The award is named for Cornelius D. Binkhorst, MD, who played a major role in the development of the intraocular lens. Dr. Fine delivered his Binkhorst lecture at the annual meeting of the ASCRS in Boston, in April. His speech detailed the transformation of cataract surgery during his 40 year career into the miracle of 20th century medicine.
Dr. Fine also remarked on the new and emerging technology that cataract surgeons and patients will most likely experience in the near future. Dr. Fine is also this year’s recipient of the Charles Kelman Medal from the Brazilian Society of Cataract and Implant Surgery in recognition of his contributions and innovations in the art and science of cataract surgery. The award is named after Dr. Kelman, who was the first surgeon to emulsify a cataract with ultrasound through a very small incision. Kelman’s technique, now called phacoemulsification, is today’s standard cataract surgery world-wide. In his Kelman Medal lecture, Dr. Fine thoroughly analyzed the types of lenses available for cataract surgery patients today, and what could be available very soon.
I am so pleased with my results from the cataract surgery performed by Dr. Packer. I can’t remember ever seeing fine detail this well, I mean, I feel like a teenaged eagle! Unfortunately, Dr. Packer couldn’t produce any improvement on the buzzard-like body that received the new lenses. With the palette of bright new colors I’m enjoying, I think I’m in Disneyland. The fact that Dr. Packer had to overcome two pronounced astigmatisms (due to the two uneven corneal surfaces resulting from RK surgery 20 years ago) makes this positive outcome all the more astonishing. Thank you, Bernie Christensen
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Enjoying Life More
I’ve had poor vision my entire life. I’ve worn contact lenses since junior high and I’ve always wanted to be rid of my contacts and glasses. I wanted to wait until the technology was advanced enough to reduce the risks and yet fully correct my vision. I ended up having my LASIK procedure in 2003 and my vision has never been better. I am so happy with my vision and would recommend it to others.
Having your vision corrected doesn’t just affect your vision. One of the indirect changes I’ve noticed since the procedure is the social aspect. To others I seem more open and friendly because I no longer squint or frown at them to try to see their expressions which in the past made me seem a little stand-offish.
One of my biggest concerns involved deciding whether or not to have the procedure was the cost. To me it seemed like a lot of money but I can tell you now it was money well spent. I now enjoy freedom from glasses and contacts which is also allowing me to enjoy life more. By Shannon Schmitt
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Drs. Fine, Hoffman, & Packer Travel/Teaching Schedule —
January through June 2010
January 18 - 22. Kauai, HI
Dr. Packer delivered presentations on Same Day Bilateral Refractive Lens Exchange, Allergic Conjunctivitis Therapy and Electronic Medical Records at the Royal Hawaiian Eye Meeting. Dr. Packer won a Speaker of the Day award! Laurie Brown was a Day Chief for the administrators’ session and spoke on Keys to a Successful Research Program.
January 26: Eugene, OR
It gave Dr. Fine great pleasure to be invited back to the University of Oregon to lecture in Dr. Susan Verscheure’s Human Anatomy course for the seventh year in a row. Dr. Fine spoke to medical students about how surgeons change human anatomy to correct visual defects or enhance vision electively.
February 26: Salt Lake City, UT
Dr. Packer was a featured speaker at the Utah Ophthalmological Society Annual Meeting, where he gave presentations on refractive cataract surgery and state-of-the-art micro incision surgical techniques.
March 4-6: Sao Paulo, Brazil
Dr. Hoffman was an invited speaker at the Federal University of Sao Paulo and gave presentations on Managing Dislocated Intraocular Lenses, Multifocal IOLs, Teaching Residents, and Difficult and Challenging Cases Best Approached with Biaxial Phacoemulsification.
March 12-13: Portland, OR
Dr. Fine participated in the 2010 Oregon Academy of Ophthalmology Post Graduate Convention. He spoke on his solutions to complex problems in cataract surgery. The Oregon Academy hosted a reception in Dr. Fine’s honor to thank him for his contributions to ophthalmology during his career.
April 9 - 13: Boston, MA
All of our physicians and some staff members had extremely busy teaching schedules at our premier specialty meeting of the year, the Annual Meeting of the American Society of Cataract and Refractive Surgery (ASCRS). Dr. Packer moderated three key symposia in his role as Chairman of the Cataract Clinical Committee; they were: Complications and Challenging Cases in Cataract Surgery, Retinal Disorders and the Anterior Segment Surgeon, and Ethical Considerations Surrounding Premium Intraocular Lenses. In addition he gave more than fifteen presentations on topics ranging from intraoperative aberrometry to 3D high definition imaging during the five day annual meeting. Dr. Hoffman was awarded First Place Winner for his video entitled Recurrent Vitreous Hemorrhage, In-House Productions category of the ASCRS Film Festival. He participated in several courses, including chairing the Difficult and Challenging Cases in Phacoemulsification course, presenting in courses on Retirement Done Right with Dr. Fine, and Subluxed IOLs. Dr. Hoffman was also appointed as a Board Member of the Outpatient Ophthalmic Surgery Society (OOSS). Also during the annual meeting of the American Society of Cataract and Refractive Surgery, Dr. Fine taught several courses and spoke on a wide variety of topics, most of which related to his surgical techniques. However, this year Dr. Fine did something new. He led a focused panel discussion on retirement with the help of his colleague, Richard S. Hoffman, MD, clinic administrator Laurie Brown, COMT, COE, OCS, Tom Fauria, PhD, and medical consultant Bruce Maller. Together, they detailed the process of Dr. Fine’s own retirement and the role each one individually had in making the transition as seamless as possible for Dr. Fine, the clinic, and most importantly, our patients. Finally, Laurie Brown and Belinda Baldwin, CPC participated with Oregon Eye Associate colleagues to give a course on electronic medical records, entitled EMR: What are you waiting for? Our Steps to Success. As a topic of great importance for ophthalmology practices, the course was standing room only. Laurie also participated in a live interview with Dr. Packer on Physician-Administrator Relationship Pearls, in addition to being a part of the ASCRS Health Information Technology Symposium.
April 23 - 25: San Francisco, CA
Dr. Packer attended a working meeting of the American Academy of Ophthalmology Preferred Practice Pattern panel for cataract surgery.
May 7: Menlo Park, CA
Dr. Packer consulted with Transcend Medical, Inc., manufacturers of an investigational surgical shunt implant for the treatment of intraocular pressure.
May 19-22: Natal, Brazil
At the 11th annual International Congress of Cataract and Refractive Surgery in Brazil, Dr. Fine delivered the Charles Kelman Medal lecture. In his talk, Dr. Fine addressed all aspects of refractive lens exchange. He also detailed the different lenses available now for implantation. Dr. Fine taught additional courses at the meeting and spoke on a variety of topics, including clear corneal incisions and strategies for incorporating premium IOLs into a thriving ophthalmic practice.
June 1: Winter Park, FL
Dr. Packer consulted with LensAR, Inc., on the topic of femtosecond laser cataract surgery.
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