NEWSLETTER - SUMMER 2011
| Richard S. Hoffman,
Keratoconus is a degenerative condition of the human cornea in which progressive thinning and change in the shape of cornea develop with time. There is a wide range of clinical presentations of keratoconus ranging from barely perceptible changes to frank cone formation of the cornea requiring corneal transplantation. Keratoconus affects roughly one person in a thousand and it appears to have multiple causes that are both environmental and genetic. Individuals with keratoconus typically develop progressive nearsightedness and astigmatism resulting in blurring and shadowing of images. The condition can be easily treated with glasses or rigid gas-permeable contact lenses.
Despite considerable research, the exact cause for keratoconus remains unknown. One of the possible environmental factors that may contribute to the formation of keratoconus is aggressive eye rubbing. There appears to be a strong association of eye rubbing with keratoconus. Originally this was felt to be a symptom of keratoconus in that patients who developed the degenerative condition might rub their eyes due to the irritation of the eyelids from the cone-shaped cornea. The assumption here was that the keratoconus developed first and the eye rubbing occurred secondarily as a reaction to the condition. However, more evidence is accumulating that suggests that the act of eye rubbing may actually cause keratoconus in susceptible patients. The observation that keratoconus is associated with allergic type conditions such as asthma and eczema lends credence to the theory that allergy-prone individuals may be causing the corneal degeneration through aggressive eye rubbing. Other observations in individuals with Down Syndrome or retinal dystrophies who have been demonstrated to rub one or both eyes since birth and then develop keratoconus in the rubbed eyes also suggests the causal association.
Does this mean that eye rubbing is dangerous? In general, occasional eye rubbing is fine as long as it not excessive and aggressive. If you have been diagnosed with keratoconus, then eye rubbing should be eliminated. I personally have seen keratoconic patients whose disease progression has slowed or stopped after eye rubbing was halted. [ top ]
Mark Packer, M.D
The LASIK procedure involves two steps. First, a thin layer of tissue called a flap is constructed on the surface of the cornea. Second, the flap is lifted and laser energy is used to reshape the bed of tissue beneath the flap to correct nearsightedness, farsightedness and/or astigmatism. The flap is then laid back in place and allowed to heal.
There are two methods of flap construction: the mechanical microkeratome, which is a very fine, rapidly oscillating blade, and the femtosecond laser, which is a source of pinpoint light energy. Debate continues today as to which method is best. According a 2010 survey of members of the American Society of Cataract and Refractive Surgery, 50% of LASIK in the US today is performed with the microkeratome and 50% is performed with the laser.1
While many refractive surgeons prefer to use a microkeratome for creating a LASIK flap, market indicators appear to be pointing toward a shift to reliance on femtosecond technology. Published studies continue to show at least equal visual outcomes for these two technologies that are used to create LASIK flaps.2
A review of published peer-reviewed, comparative scientific studies on the relative safety of the microkeratome versus the laser shows equivalence. For example, an 18-month study performed at the John A. Moran Eye Center, Department of Ophthalmology, University of Utah demonstrated that the complication rate was 14.2% in the microkeratome group and 15.2% in the femtosecond laser group (P = .5437).3 Similarly, investigation has shown that healing is the same regardless of the method used for flap construction.4
Studies of effectiveness have also generally shown equivalence of the microkeratome and laser. For example, a study performed at the Mayo Clinic showed that the method of flap creation did not affect visual outcomes during the first 6 months after LASIK. Patients did not perceive a difference in vision.5 Another study published in the American Journal of Ophthalmology last year demonstrated that there were no differences in corneal total high-order aberrations, spherical aberration, coma, or trefoil between methods of flap creation at any examination over 4- and 6-mm-diameter pupils. Uncorrected and best-corrected visual acuity did not differ between methods at any examination and remained stable postoperatively through 3 years. The femtosecond laser flap did not offer any advantage in corneal high-order aberrations or visual acuity through 3 years after LASIK.6 Other authors have concluded that corneal aberrations after myopic LASIK are similar after mechanical microkeratome and femtosecond laser flap creation. Visual acuity, refraction, and the optical quality of the cornea after LASIK remain stable through 4 years postoperatively regardless of the method of flap construction.7
There may, however, be advantages for the laser in certain circumstances. One recent publication showed slightly better results in hyperopic LASIK,8 and another showed faster recovery in uncorrected acuity with the laser.9 Authors have also reported slightly better contrast sensitivity at higher spatial frequencies after laser flap construction.10 The one situation in which using the laser makes sense is when there is a limit to the refractive effect due to the thinness of the cornea. Surface ablation (for example, PRK) which does not require the construction of a flap at all may make the most sense in these cases, but the laser does have the ability to safely create a thinner flap and may allow the faster recovery time which is a significant benefit of LASIK.
LASIK remains a wonderful procedure to reduce or eliminate the need for glasses and contact lenses for good candidates, whether a laser or a microkeratome is used to construct the flap.
1. Leaming DV. 2010 Survey of US ASCRS Members. http://www.analeyz.com/AnaleyzASCRS2010.htm (Accessed April 28, 2011).
2. Femtosecond laser use in US increasing, but some still prefer microkeratomes. OCULAR SURGERY NEWS U.S. EDITION June 10, 2009; http://www.osnsupersite.com/view.aspx?rid=40118 (Accessed April 28, 2011).
3. Moshirfar M, Gardiner JP, Schliesser JA, Espandar L, Feiz V, Mifflin MD, Chang JC. Laser in situ keratomileusis flap complications using mechanical microkeratome versus femtosecond laser: retrospective comparison. J Cataract Refract Surg. 2010 Nov;36(11):1925-33.
4. Patel SV, McLaren JW, Kittleson KM, Bourne WM. Subbasal nerve density and corneal sensitivity after laser in situ keratomileusis: femtosecond laser vs mechanical microkeratome. Arch Ophthalmol. 2010 Nov;128(11):1413-9.
5. Patel SV, Maguire LJ, McLaren JW, Hodge DO, Bourne WM. Femtosecond laser versus mechanical microkeratome for LASIK: a randomized controlled study. Ophthalmology. 2007 Aug;114(8):1482-90.
6. Calvo R, McLaren JW, Hodge DO, Bourne WM, Patel SV. Corneal aberrations and visual acuity after laser in situ keratomileusis: femtosecond laser versus mechanical microkeratome. Am J Ophthalmol. 2010 May;149(5):785-93.
7. Muñoz G, Albarrán-Diego C, Ferrer-Blasco T, García-Lázaro S, Cerviño-Expósito A. Long-term comparison of corneal aberration changes after laser in situ keratomileusis: mechanical microkeratome versus femtosecond laser flap creation. J Cataract Refract Surg. 2010 Nov;36(11):1934-44.
8. Gil-Cazorla R, Teus MA, de Benito-Llopis L, Mikropoulos DG. Femtosecond Laser vs Mechanical Microkeratome for Hyperopic Laser In Situ Keratomileusis. Am J Ophthalmol. 2011 Apr 18; [Epub ahead of print]
9. Tanna M, Schallhorn SC, Hettinger KA. Femtosecond laser versus mechanical microkeratome: a retrospective comparison of visual outcomes at 3 months. J Refract Surg. 2009 Jul;25(7 Suppl):S668-71.
10. Montés-Micó R, Rodríguez-Galietero A, Alió JL, Cerviño A. Contrast sensitivity after LASIK flap creation with a femtosecond laser and a mechanical microkeratome. J Refract Surg. 2007 Feb;23(2):188-92.
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Annette Sims, M.D
As a glaucoma specialist, patients often ask me, “Should I be worried about my kids getting glaucoma now that I have it?” It is a great question since identifying risk factors such as family history is an important task in maintaining good eye health. My answer depends on the type of glaucoma the patient has. Most people are not aware there are many different types of glaucoma requiring different types of treatment. Patients may develop glaucoma from eye trauma, angle closure, retinal detachment, eye tumors, uveitis, diabetes, hyperthyroidism or prolonged corticosteroid use. Treatment options include eye drops to control eye pressure, lasers and various types of surgery. One of the more common forms of glaucoma is open angle glaucoma. There are still many unanswered questions about the genetics of open angle glaucoma. A few gene loci have been detected, but there is not a blood test at this time to check for glaucoma. One thing we know is siblings of patients diagnosed with open angle glaucoma have a tenfold increased risk of developing glaucoma over their lifetime. The Baltimore Eye Survey, a major study published in 1994, showed family history to be an important risk factor in open angle glaucoma. It was associated more highly in siblings than in parents or children. The results of the study support the screening for glaucoma in family members of patients with the disease.
What about macular degeneration? Macular degeneration appears to be hereditary in some families but not in others. We believe if you have a family history of macular degeneration, you have four times the risk of developing macular degeneration. There has been some research that claims if you have a first degree relative with late stage macular degeneration, you may develop macular degeneration at an increased rate at a younger age. The cause of macular degeneration is unknown. Risk factors that have been identified aside from family history are smoking, obesity, Caucasian race and age.
Lastly, if your parents had cataract surgery, will you need cataract surgery as well? Cataracts develop for a variety of reasons. They include long-term exposure to ultraviolet light, exposure to radiation, chromosomal disorders, trauma or systemic diseases such as diabetes. The most common form of cataracts is from advanced age called nuclear sclerosis. The Beaver Dam Eye Study looked to determine whether nuclear sclerosis could be explained by inheritance of a major gene. The findings suggested that several genes of modest effect may influence development of cataract. But the progression of cataract formation occurs in conjunction with environmental factors, most notably cigarette smoking. Other studies have highlighted the importance of blocking ocular exposure to ultraviolet light. In summary the etiology of cataract formation is complex, with environmental factors being just as important as family history.
In short, if you have one of the above mentioned ocular diseases, discuss this with family members. It may be a good idea to encourage them to have a screening eye exam. [ top ]
What do George Lucas, Steven Spielberg and our own Dr. Richard Hoffman have in common? They are all visionaries in the world of film. We are very proud to announce Dr. Hoffman as the grand prize winner at this year’s film festival at the Annual Symposium of the American Society of Cataract and Refractive Surgery (ASCRS) in March. Dr. Hoffman’s submission titled, “Minimally Invasive External Mini-Glaucoma Shunt Implantation without Conjunctival Dissection,” showcases his breakthrough technique for implanting a glaucoma shunt with minimal impact on the patient. This can quicken a patient’s recovery time and it may also improve the overall outcome of the surgery.
Dr. Hoffman’s award is cast from the same mold from which the Oscars are made for the Academy of Motion Picture Arts and Sciences. You can check out Dr. Hoffman’s “Ascar” on display in our lobby showcase.
Dr. Fine is honored and delighted to be selected as this year’s recipient of the International Intraocular Implant Club’s Medal and Lecture. Dr. Fine will accept the award at the club’s annual meeting in conjunction with the European Society of Cataract and Refractive Surgery in Vienna, Austria this coming September. Dr. Fine was president of the IIIC from 2008-2010. [ top ]
Community is important to the FIHOPA staff. As an ongoing tradition, we donate our time to support local organizations. This year we volunteered at Food For Lane County. In January, a team of employees and family members spent an evening readying food for distribution. It was a big success. We discovered we work well as a team in any given environment, and we look forward to our next volunteering adventure. [ top ]
Brandy Hunt, is our newest Certified Ophthalmic Assistant (COA). Brandy began her career with us in 2005, working in the front office. She has been a technician in the clinic for the past two years. The COA certification is the first in a series of three exams which we encourage our technicians to complete. The process enables our clinical staff to provide exceptional care. In order to become certified, each staff member must meet criteria and demonstrate ophthalmic knowledge and expertise. We are very proud our entire clinical staff is now certified.
Laura Reynolds is now an Ophthalmic Coding Specialist (OCS), and Ricki Shipway, Michelle Ryan and Suwanna Smith have successfully renewed their OCS credentials. All four passed a 100 question exam which is designed to thoroughly test the coding knowledge of all professionals in ophthalmology, including physicians, coders/billers, ophthalmic medical personnel, office managers, administrators, consultants, and optometrists. [ top ]
Over the Moon
Dear Dr. Packer and “grand crew”: Truly, I’m over the moon with the results of my cataract surgery. 20/20 from near to eternity! No glasses for the first time in 62 of 74 years. As an artist, I’ve always been in love with color, but now it’s extraordinary, truly spectacular! I’d heard cataract surgery is a breeze; I found it a life changing event. My husband was so impressed with my results and the marvelous care I’ve received from Dr. Packer and staff, he had his cataract event in December. Frederica Stowell [ top ]
Drs. Fine, Hoffman, & Packer Travel/Teaching Schedule —
January to May 2011
January 16-21: Maui, HI
Dr. Packer and our practice administrator, Laurie Brown, headed to Hawaii in January for the annual Royal Hawaiian Eye meeting and their teaching schedules were so packed, they didn’t see much of that famous Hawaiian sunshine.
Dr. Packer spoke on a wide variety of topics including successfully integrating electronic medical records computer software into ophthalmology practices, and using the latest in technology to maximize outcomes for patients having refractive lens surgery.
Laurie shared our practice’s experience in reducing patient wait times by increasing visit efficiency; she also moderated a session highlighting challenges and advantages medical practices are finding with social networking sites such as FaceBook.
February 4-5: Rosemont, IL
In February, Dr. Packer attended the Joint meeting of the Illinois Association of Ophthalmology and the Chicago Ophthalmological Society. He shared his expertise in refractive lens surgery and detailed his techniques for handling a variety of difficult and challenging surgical cases.
February 11-15: St. Thomas, US Virgin Islands
Dr. Packer spoke on femtosecond laser cataract surgery at the annual Caribbean Eye meeting. The femtosecond laser is one of the new and emerging technologies present in cataract surgery today. The precision it offers promises to improve outcomes for patients who undergo cataract surgery.
February 24-27: Athens, Greece
In February, Dr. Fine once again packed his suitcase and headed east. This time he travelled to Greece for the 25th Annual International Meeting of the Hellenic Society of Intraocular Implant and Refractive Surgery. While at the meeting, Dr. Fine received the prestigious Kelman Award in appreciation of his great contributions to ophthalmic surgery as a surgeon and teacher. During his Kelman lecture, Dr. Fine explained his simple solutions to the complex problems he has seen in cataract surgery during his 40 years as an ophthalmologist and cataract surgeon.
March 8: Eugene, OR
Dr. Sims was a Guest Lecturer at the University of Oregon Human Physiology Course. She taught a course on Clinical Evaluation & Surgical Treatment of Eye Diseases.
March 25-29: San Diego, CA
As March roared in like a lion, our doctors were hard at work on their teaching presentations for the Annual Symposium of the American Society of Cataract and Refractive Surgery (ASCRS) held in San Diego, CA.
Dr. Fine lectured on a variety of topics, including the proper and safe way to construct a clear corneal incision for cataract surgery. Dr. Hoffman organized and led a course detailing ways a cataract surgeon can successfully maneuver through difficult and challenging cases during cataract surgery. Dr. Packer hosted multiple courses, one of which focused on the new and emerging technology and techniques available today for cataract and refractive surgery. Dr. Packer utilized the TruVision 3-D video system for one of his advanced cataract surgery techniques lectures this year.
Our clinic administrator, Laurie Brown, also showcased our practice in her courses at this year’s ASCRS meeting. She spoke mainly about the behind the scenes organization which makes our practice so unique, as well as our electronic medical records success.
March 31-April 1: Bulgaria
Immediately after the ASCRS meeting in San Diego, Dr. Packer hopped aboard a plane and headed halfway across the world to Sofia, Bulgaria. There he gained experience with a new glaucoma implant.
May 20: Wake Forest University, Winston-Salem, NC
Dr. Fine travelled to North Carolina in May to attend the annual meeting of the Wake Forest University Eye Center. While there he gave the Richard G. Weaver lecture, “Simple Solutions to Complex Problems in Cataract Surgery.” Dr. Fine’s presentation centered on his own rational approaches to challenging situations he encountered during surgery, and his innovative solutions that led to very desirable results.
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