NEWSLETTER - WINTER 2010
| Richard S. Hoffman,
One of the most common complaints we see patients for are symptoms related to dry eyes. Dry eyes can occur from systemic diseases such as rheumatoid arthritis or other autoimmune processes. They can also occur from oral medications such as antihistamines and birth control pills. The most common cause for dry eye is the natural aging process, and most of us as we get older will experience some symptoms related to dry eyes.
The common symptoms of dry eyes include pain, light sensitivity, a gritty sandy sensation, redness, itching, and blurred vision. In addition, many patients will experience excessive tearing secondary to dry eyes. This may seem to be a paradox that the eyes would have excessive tearing if they are dry but drying of the ocular surface can cause episodes of reflex tearing that appear as excessive tears.
Dry eyes can be a mild nuisance or a serious ocular condition that can threaten the eye with potential blindness in its most severe forms. Extreme dry eye syndrome can result in loss of integrity of the ocular surface with ulceration of the cornea and in the extreme, perforation of the cornea and loss of the eye.
The human tear film is essentially made of three layers. A layer of mucin coats the surface corneal epithelium. Above the mucin layer is a layer of aqueous tears and above the tear layer is a thin layer of oil that helps keep the tears from evaporating. A deficiency of any one of these components can cause dry eye symptoms but the most common deficiency is from the aqueous tear layer that is created in our lacrimal and accessory lacrimal glands.
The simplest treatment for common dry eye is the use of supplemental artificial tears four times a day. These can be purchased over-the-counter and the best tears are the ones that have no preservatives or a quickly disappearing preservative. When artificial tears need to be used more than eight times a day to alleviate symptoms, other modalities are usually employed. These include punctual plugs that are placed in the tear drainage ducts, dietary supplements that help the oil secreting glands coat the tear layer better, and immunosuppressive eye drops that reduce inflammation and increase tear production.
The dietary supplements include foods or capsules rich in omega 3 fatty acids. The easiest means of increasing omega 3 fatty acids in our diet are with fish oil or flaxseed oil capsules. Three to four pills (3-4 grams) per day will usually improve dry eye symptoms after 4-6 weeks. Immunosuppresive eye drops include weak topical steroids and Restasis (cyclosporine). Restasis is preferred over topical steroids because it has practically no side effects other than some burning and stinging while topical steroids can cause glaucoma, cataracts, and fungal infections in the cornea.
Reducing environmental factors that aggravate dry eyes are also helpful. Directing air conditioning vents away from our eyes or eliminating overhead fans that dry out the ocular surface can be beneficial. In addition, for severe symptoms, an air humidifier placed close to where an individual spends much of their day can help keep the ocular surface from drying out as easily. Glasses with side shields can also help prevent drying. In extreme cases, surgical procedures to narrow the eyelids and expose less eye surface area to the environment may be needed.
For most of us, artificial tears and dietary supplementation is all that is needed to improve comfort. If you think you are suffering from dry eyes, try these tips or let us help you decide which other medical and surgical options are best for you.
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Mark Packer, M.D
Dubbed the “sneak-thief of sight,” glaucoma represents a significant cause of preventable blindness around the world. In glaucoma, irreversible loss of retinal nerve fibers insidiously blots out peripheral vision. Unnoticeable in the early stages when the mind can fill in the blanks, the destruction can eventually lead to blindness. No pain and no visual symptoms alert the sufferer until late in the course of the disease.
In the United States, the overall prevalence of open-angle glaucoma for adults over 40 is estimated to be about two per cent of the population. Primary open angle glaucoma (not including the major forms of secondary open-angle glaucoma, pseudoexfoliation glaucoma and pigmentary glaucoma) affects an estimated 2.22 million people in the United States, and that number is expected to increase to 3.3 million over the next ten years as the population ages. About half of those with glaucoma may be unaware that they have the disease. In the United States, more than 7 million office visits occur each year for the purpose of monitoring patients with glaucoma and patients at risk for developing glaucoma. Glaucoma of all types is one of the leading causes of legal blindness in the United States.
There are five important risk factors associated with glaucoma:
- Elevated pressure in the eyes
- Older age
- Family history of glaucoma
- African or Hispanic/Latino ethnic background
- A thinner central cornea (the front, clear window of the eye)
Reducing pressure in the eyes represents the only proven treatment for prevention of blindness from glaucoma. Medications, laser and surgery are all currently approved methods of reducing eye pressure. The more the pressure is lowered, the more likely it is that progressive loss of vision will be halted.
Management of glaucoma revolves around the principle of reducing the eye pressure to a safe range. The upper limit of that range is known as the target pressure.
It is generally assumed that the initial target pressure selected should represent at least a 20% reduction. In general, the more advanced the damage, the lower the initial target pressure should be. During 7 years of follow-up, subjects enrolled in the Advanced Glaucoma Intervention Study whose pressure was always below 18 mmHg had minimal loss of vision compared with patients who had higher pressures.
Medical, laser and surgical therapies to treat elevated pressure are directed towards either reducing the rate of production or increasing the rate of outflow of the fluid inside the eye (called the aqueous humor). Eye drops most often represent first line treatment because the risks of these medications are small and the potential benefit is great. However, using multiple eye drops each day can be burdensome, expensive and sometimes cause intolerable side effects. Laser treatment to the outflow areas of the eye is also safe and effective, but the effect usually wears off over a few years. While filtering surgery (such as trabeculectomy) directs aqueous outflow via drainage sites outside of the interior of the eye, there are significant risks of complications associated with this approach, including too low an eye pressure, infection and scarring. The 10-year results from the Advanced Glaucoma Intervention Study indicate about 70% success of these procedures in African American subjects and 80% success in Caucasian American subjects.
These limitations of filtering surgery have led to interest in devices which employ alternative approaches to increasing aqueous outflow. Currently available procedures include endoscopic cyclophotocoagulation (ECP), a laser procedure to reduce production of the aqueous humor that has a very good safety profile and can be performed at the time of cataract surgery. Cataract surgery itself often lowers the eye pressure and provides a measurable benefit for people with both cataracts and glaucoma or who are at high risk for developing glaucoma. The Ex-PRESS Mini Shunt is a new implant that allows a controlled increase in outflow and is considerably less invasive than trabeculectomy. The i-Cath is a flexible catheter that permits intubation and dilation of the outflow channels of the eye to reduce pressure.
Innovative medical devices under investigation in the United States include the i-Stent, a tiny shunt that is placed entirely inside the eye to bridge the area of greatest resistance to outflow. The CyPass facilitates drainage of aqueous from the front to the back of the eye, reducing pressure by eliminating the gradient between these regions.
There are many other medical device scientists working at a variety of companies around the world to solve the problem of blindness from glaucoma. Treatment is available today, but screening is your responsibility. If you have any concern about glaucoma in yourself or a family member, make an appointment today to see Drs. Fine, Hoffman & Sims.
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This office is so unique in so many ways. From the moment I walked in the door and was met with warm, welcoming smiles, I felt a part of something much more than anything else I had experienced on my rotations thus far. From the incredibly friendly and helpful front office staff, to the technicians that never hesitated to answer my many questions, to the three extremely diligent and compassionate physicians, who were always willing to teach, this office is one big family. My time here has been filled with research projects, thanks to the many ongoing studies pursued here that keep pushing this field forward for the benefit of many, meeting patients in clinic, giving me a broad understanding of what it means to care for people with visual complaints, and observing in the operating room which is itself filled with the excitement that comes from the opportunity to improve vision.
Having spent the past four weeks in this office has not only solidified my decision to pursue ophthalmology as a career, but inspired me to practice someday in a way that embodies many of the same principles I have learned here.
So to all the patients I had the pleasure of meeting during my time here, thank you for your willingness to be an important part of my adventure. I will forever be grateful to you. And to everyone in this wonderful office, thank you for your patience, your grace, and for letting me be a part of your family for these four short weeks. [ top ]
Drs. Fine, Hoffman and Packer were honored for their extraordinary ophthalmic research contributions and Dr. Fine was asked to give one of three presentations at the 2009 Clinical Research Recognition Dinner sponsored by Sacred Heart Medical Center Foundation and the Peace-Health Oregon Region Board of Directors at the Fourth Annual Clinical Research Recognition Dinner.
The invited audience included all medical staff members, members of the Peace-Health Oregon Region Board of Directors and Sacred Heart Medical Center Foundation boards, members of the University of Oregon scientific community, guests from Oregon Health Sciences University and others. This program is now viewed to be one part of a much broader platform of activity surrounding collaborative research efforts of the physician and university communities. [ top ]
There are ever-increasing efforts to put “reduce, reuse, recycle” into every day practice at Drs. Fine, Hoffman & Sims.
In the staff lunchroom we have practically eliminated the use of daily disposable plastic utensils and plastic coated plates and bowls and now reuse previously owned silverware, dishes and coffee mugs. During the day, staff may make use of lunchroom receptacles for co-mingled recycling and for refundable deposit cans and bottles. Even though the conversion to electronic medical records (EMR) greatly reduced the volume of paper required for charting record keeping, there still is a need for paper recycling. Throughout the office there are both confidential and standard paper recycling bins.
In the reducing-auto-emissions arena, three staff members are year-round bicycle commuters and at least one other staff uses a practice-provided bus pass. A recent staff uniform change eliminated weekly laundry service pickup and delivery. Rooms that are not in constant use have motion detector switches for lights and fans, thus reducing unnecessary power consumption.
The doctors’ ambulatory surgery center is doing an impressive job of plastic recycling. In a recent week, over 85 pounds of plastic generated during the various surgical procedures were diverted from the waste stream.
“Never underestimate the power of a few committed people to change the world.” Margaret Mead [ top ]
FAQ: What is a Clinical Trial?
A clinical trial is a research study involving human subjects designed to answer specific questions. There are different types of clinical trials including those to study, for example, prevention of disease, new investigational drugs, devices or treatments, and screening and diagnostic techniques.
Clinical trials are conducted according to a plan called a protocol. The protocol describes what types of subjects may enter the study, schedules of tests and procedures, drugs, dosages, and length of study, as well as the outcomes that will be measured. Doctors and other health professionals conduct the studies according to federal, state, and local laws designed to protect people involved in research. [ top ]
After I graduated from the Ophthalmic Medical Technology (OMT) program, I was unable to take the certification exam at that time. I continued my schooling and years went by and I still was unable to take the exam. I finished my schooling and applied to work with Drs. Fine, Hoffman and Packer and since I started working here they have really encouraged me to get certified. After completing the home study course, I was eligible to take the first level certification exam. It was a struggle trying to study and prepare for the exam since I had just given birth to a little baby girl three months before I took the exam, but I am very happy and grateful that I was able to take the exam and pass. I am excited to continue my learning in the ophthalmology world and hope to get the second level certification in the future. Rebekah Carter, COA
Hailing from the familiar small town of Yoncalla, OR I began my relationship with this office as a young cataract patient of Dr. Fine at the age of thirteen. I never would have dreamed that twelve years later, after graduating from the U of O, living in Europe, attending a two year graduate program, I would come back to work for my childhood eye doctor. I am unbelievably thankful to join this stellar office team. Working among such high caliber professionals continually challenges and empowers me to also offer my all. I thoroughly enjoy laughing whenever I can, meeting those who will laugh with me, and being surrounded by friends and family. Thank you to all for the warm reception I’ve received thus far. I look forward to greeting many more smiling faces. Christina Roman [ top ]
It was fourteen years ago that I got my first pair of contacts. After having worn glasses for ten years, since second grade, I just couldn’t fathom a life without looking through glasses, let alone my own reflection in the mirror without glasses. The few weeks leading up to my LASIK surgery, I was constantly reminded of that feeling. Being set free from glasses was something I couldn’t fathom until it had happened, and then, it was amazing. Even with the difficulties of contacts I still thanked God everyday for them. So as my LASIK surgery approached I couldn’t help but have that same feeling, wondering what it would feel like to not be dependent on my contacts. In many ways, two weeks after surgery, I still have a hard time with the concept that I can actually see out of my own eyes. What a crazy concept to me! But one I am fully embracing and thankful for. I know there is still a healing process going on, and what I call: my brain readjusting its “software” for the new information it is getting from my eyes. I have faith and patience in this process and I couldn’t be happier with each and every person a part of Dr. Packer’s team. They were all a true joy!
Sincerely, Andria Higgins
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“I can see clearly now, my glasses are gone . . I can see all obstacles in my way . . .”
It’s been several months since Dr. Packer performed my Refractive Lens Exchange (RLE) with the Tecnis Multifocal and a day doesn’t go by that I am not in wonder at my ability to see clearly at both distance and near without glasses or contact lenses. I have witnessed firsthand the satisfaction of our patients following cataract surgery with multifocal lenses. After approval of the Tecnis Multifocal lens in January of this year, I asked myself “Why spend the next one third (or so) of my lifetime dependent on glasses while waiting for something better to become available when I could experience the freedom of life without glasses beginning right now?” So, in April I took the great leap and my life has not been the same! It is FANTASTIC!
Even now I am continually amazed at how natural my vision is and how the surgery has affected my daily life in so many ways. I’ll be reading in bed or just doing things around the house and all of a sudden I realize that I don’t have my glasses on! Sometimes I find myself reaching to remove my glasses when pulling a shirt on over my head. Once again I’m able to wear eye makeup because my eyelashes no longer rub against the back side of my eyeglasses. And it’s wonderful to no longer need to remove my glasses or wipe them dry when out in the rain (which never happens in Oregon – ha! ha!) This is truly the greatest gift I could ever have given myself and I am thankful every day that I made the decision to do it. Tina Callina
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Having Refractive Lens Exchange was one of the best things I could have ever done in my life. I’m so pleased with the results of surgery and the care given by Dr. Packer and his staff.
In the past I was dependent on glasses and contacts in order to see to do everyday things. I had my contacts designed to correct distance vision in one eye and near vision in the other. They worked OK but I found many instances where it was a hassle seeing this way. When I would go to sporting events and couldn’t see what was happening on the field I would reach for my binoculars but then I had to close one eye in order to use them. I ended up having to wear my glasses to the football and basketball games to avoid this situation. Now, I can go to the games and if I need to use binoculars I can see with no problems. I’m able to drive and read most small print without the aid of glasses. In fact the only time I need a pair of reading glasses is when I’m in dim light and need to read small print.
I still participate in track and field events and not having to deal with glasses is certainly a benefit when I pole vault, high jump or run the hurdles.
I’m so very pleased with the results of Refractive Lens Exchange and the ReZOOM lens that I would recommend this procedure to others. Becky L. Sisley
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Re: Tecnis Multifocal Lens for Cataract and Refractive Lens Exchange
Are you kidding me!!!!! I have to admit, on Thursday afternoon I was scared. But by the time I walked out at noon Friday, whew! You were all incredibly tolerant and welcoming to Karen and me. OK tolerant of me and welcoming of Karen, but anyway.
I often joke “I thank God everyday that I am alive in an age of technology and personal hygiene.” Doc, you affirmed the technology side of that equation for me this week. Just the idea that I can go from, 1950’s TV vision to 2009 Hi Def in two days is incredible.
I want to thank you and your “INCREDIBLE” staff for your warm treatment, your professionalism and your just plain friendliness. You all made the somewhat scary experience seem like “no big deal” but I want you all to know, what you do is a “BIG DEAL” and you are all amazing folks.
I will be seeing you all soon, so have your earplugs and some sedative handy.
Thank you so much again. Dale Munson
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Dear Dr. Hoffman and Staff,
I want to THANK YOU, and your staff for all that you did for me during my recent cataract surgery. Everyone was so sweet, cheerful, and caring that it took away all my (imagined) fears. They patiently explained what they were doing and really helped calm me. Everything went so smoothly, thanks to them and you. The whole procedure was over before I knew it! Since blindness is a genetic defect in our family—my sister, grandmother and aunt have this problem. I was VERY RELIEVED to find that I have clear vision now in the left eye. I won’t be so scared when you do the right one. Your knowledge and skill are unmatched. The gift of sight is truly very precious. I just want you to know how much I do appreciate all that you did for me. Thank you, Joy Knutson
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More Best Things...
Having LASIK surgery done by Dr. Hoffman was one of the best things I could do for myself. Being at the age where reading and seeing objects up close had become increasingly difficult and not having the greatest distance vision, I looked into LASIK. I wanted to go somewhere local knowing that if I had any issues I could be seen right away without the worry of traveling to another city or state and I wanted to go somewhere that had an impressive reputation for advanced technology and patient care.
My goal for having LASIK surgery was to be able to see to drive and work up close without the aid of glasses. I was given an option of monovision where one eye is corrected for distance and the other eye for near. I wasn’t initially impressed with that option, but after discussing it further with Dr. Hoffman I was able to embrace idea of monovision. Now after having the surgery it strikes me that I was so concerned about the whole idea of monovision before surgery. Because this concept was new to me I didn’t fully understand the benefits of monovision.
Now that it’s done I can say it was a wonderful idea. Not only am I able to see to drive but I can now work up close on cars and equipment in tight places without the aid of reading glasses. When I play golf I can see the ball on the ground as I hit it, I can follow the ball down the fairway, and I can read and write on the score card without glasses.
One of the other reasons for not having surgery earlier was the fear of pain. I was pleasantly surprised to find out how little discomfort I felt following surgery and how quickly I was able to resume my normal activities. I was told to rest for a few days following surgery but I honestly I felt that I was ready to hit the golf course the next morning.
I would encourage anyone who is interested in LASIK surgery that has difficulty seeing to drive and read without glasses to discuss monovision with Dr. Hoffman. Kevin Heide
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No more glasses for me!
I don’t need to wear glasses anymore after cataract surgery. Before surgery the first thing I would do in the mornings is reach for my glasses which I have now learned is a habit that’s hard to forget. I still find myself reaching for glasses I no longer need. You see, I use to wear heavy coke bottle type lenses -since I was two years old. They were very uncomfortable to say the least and distorted my vision anytime I looked anywhere but the center of the lenses. Now with the Tecnis multifocal lens (implant) my vision is great at all distances. I’m able to read sheet music easily without glasses, my golf game has improved and colors are much easier to discern. This is especially helpful in my new hobby, painting. I’ve noticed that my depth perception is so much better now and my husband has noticed that I’m not as clumsy as I used to be. Life is so much more enjoyable when you have great vision! Judith Baker
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Drs. Fine, Hoffman, & Packer Travel/Teaching Schedule —
December through July 2009
August 9–12: Sao Paulo, Brazil.
Dr. Packer was invited to perform surgery at The Eye Clinic of Dr. Walton Nosé using new intraocular lens implants not yet available in the United States. The implants are designed for the correction of high degrees of astigmatism.
August 19-23: Playa Herradura, Costa Rica.
Dr. Fine gave four lectures at the Costa Rica Ophthalmology Congress, among which he gave expert advice on refractive lens exchange procedures.
September 8–11: Neubrandenburg, Germany.
Dr. Packer consulted with Dr. Helmut Hoh, Chief of Ophthalmology at Neubrandenburg Teaching Hospital, on the implantation of a novel device for the treatment of glaucoma.
September 12-16: Barcelona, Spain.
Dr. Packer gave a total of seven presentations at the annual meeting of the European Society of Cataract & Refractive Surgeons on topics ranging from Targeting Spherical Aberration Correction in Cataract Surgery to Personal Experience Using an Intraoperative Wavefront Aberrometer. Dr. Fine taught five courses and served as expert panelist for a lively discussion on the indications in refractive surgery at the same meeting.
September 28: Portland, OR.
Dr. Packer presented a dinner symposium for cataract surgeons on Navigating the Nuances of Presbyopia Correcting Intraocular Lenses.
October 7: Chicago, IL.
Dr. Packer gave another in a series of lectures for ophthalmologists on Achieving Practice and Patient Success in the New Age of Multifocal Lenses.
October 16-17: Milan, Italy.
Dr. Fine attended the Videocatarattarefrattiva conference and received the inaugural Charles Kelman Award. In his acceptance speech, Dr. Fine focused on techniques used when dealing with difficult and challenging situations in cataract surgery.
October 24-27: San Francisco, CA.
At the annual American Academy of Ophthalmology meeting, all three of our doctors were very busy. Dr. Hoffman gave eight lectures to surgeons and won a Best of Show award for an educational video submission. Dr. Packer gave 16 presentations and had several meetings with representatives of innovative companies. Dr. Fine was the Keynote speaker at the Association of Technical Personnel in Ophthalmology’s Scientific Session, while Drs. Hoffman and Packer also generously gave presentations to a large audience of technicians. Dr. Fine taught several courses, one of which focused on new and emerging technologies which are, or very soon will be, helping more patients across the globe achieve spectacle independence following cataract surgery.
December 10: Mexico City, Mexico.
Dr. Fine attended the Centro Mexicano de Decanos en Oftalmologia, A.C. convention. He instructed doctors on his simple solutions for complex problems encountered during cataract surgery.
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