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Drs. Fine, Hoffman & Sims Opthalmologists in Eugene Oregon



DMEK – The Next Method for Endothelial Transplantation
By Richard S. Hoffman, MD

Richard S. Hoffman, M.D.

Corneal transplant procedures are continuing to become less invasive with quicker visual rehabilitation and safety. For years, the standard for corneal transplantation was a full-thickness transplant wherein the entire half-millimeter thickness of the patient’s central cornea was removed and replaced with a full-thickness donor cornea. This full-thickness procedure is very successful but requires a patient to maintain their stitches for a year. In addition, nearsightedness and astigmatism are usually induced with these types of transplants and the cornea is weakened and susceptible to trauma.

Patients require corneal transplants because of disease of the cells on the back surface of their cornea – termed endothelium. When patients have endothelial disease, transplanting the entire thickness of the cornea is really unnecessary unless there is scarring or degeneration of the other layers of the cornea. Several years ago, a new technique of corneal transplantation was developed in the Netherlands by Gerrit Melles, MD. With this new technique, named DSAEK (Descemet’s Stripping Endothelial Keratoplasty), the diseased back surface of the cornea (termed Descemet’s membrane) was removed along with its associated diseased endothelium, and replaced with a thin donor tissue. DSAEK allowed for the restoration or replacement of healthy endothelial cells which are responsible for keeping the cornea dehydrated and clear. The DSAEK graft was very thin and included some corneal collagen tissue, Descemet’s membrane, and endothelium. The tissue could be folded and inserted through a small 5 mm incision and visual recovery was several weeks or months compared to the several months to years for the full-thickness transplant procedure.

DMEK Procedure

A variation of the DSAEK procedure, called DMEK (Descemet’s Membrane Endothelial Keratoplasty) was developed by the same surgeon in the Netherlands and offers even greater potential benefits than the DSAEK procedure.

With DMEK, only Descemet’s membrane and endothelium (no corneal stromal tissue) are transplanted, allowing for a smaller insertion incision, faster visual recovery (days to weeks), and less refractive changes following the procedure. The DMEK procedure is more challenging to perform due to the fragility of the transplanted graft but is slowly being recognized by corneal surgeons as the next evolutionary step in endothelial transplant methods. Eye banks are currently preparing for the future transition to this new technique; however, there will still be patients who are best served with either the DSAEK procedure or the full-thickness corneal transplants, so the DMEK procedure will not totally replace the other transplant techniques. Patients with scars and keratoconus are not candidates for these “back-surface” techniques since their pathology involves the front portion of the cornea. [ top ]

The Book of Changes: Ancient Wisdom for the Modern Age
By Mark Packer, M.D.

Mark Packer, M.D

My introduction to the ancient Chinese Book of Changes or I Ching came in 1972 when I read an article in The New Yorker magazine about the history of Vietnam entitled “Fire in the Lake” (Frances FitzGerald, Annals of War, “VIETNAM I-FIRE IN THE LAKE,” The New Yorker, July 1, 1972). The title comes from the Hexagram of Revolution in the I Ching {Richard Wilhelm and Cary F. Baynes, “I Ching: Or, Book of Changes” [3rd. ed., Bollingen Series XIX, (Princeton NJ: Princeton University Press, 1967, 1st ed. 1950)]}


49. Fire in the Lake,
The Image of Revolution:
Thus the Superior Man sets the Calendar in
And Makes the Seasons Clear.

My teenage mind became curious about the source of this concept, but it wasn’t until seven years later that I became further acquainted with the original text. I was studying the ethnobotany of Traditional Chinese Medicine with Richard Evans Schultes, Director of the Harvard Botanical Museum, when I discovered the integral relationship of the I Ching to the practice of Chinese herbal medicine. Incidentally, my background in ethnobotany led to my first publication in the field of Ophthalmology when I was a medical student at the University of California, Davis, entitled “Ophthalmology’s Botanical Heritage” (Survey of Ophthalmology Mar-Apr 1992; 36(5): 357-65). The I Ching is based on the fundamental principles of yin and yang, dark and light, female and male, receptive and creative – the basic dualities of the universe. Each of the 64 Hexagrams consists of six “lines” – either yin or yang. Similarly, the Eight Principles of Traditional Chinese Medicine reflect the dualities expressed through physiology: inside or outside, hot or cold, wet or dry, strong or weak. Health represents a harmonious balance of these elements.

49. Ko / Revolution (Molting)



Fire below and the lake above combat and destroy each other. So too in the course of the year a combat takes place between the forces of light and the forces of darkness, eventuating in the revolution of the seasons, and man is able to adjust himself in advance to the demands of the different times.

The Chinese character for this hexagram means in its original sense an animal’s pelt, which is changed in the course of the year by molting. From this word the meaning is carried over to apply to the “moltings” in political life, the great revolutions connected with changes of governments.

Understanding the interpretation of the hexagrams relies on their imagery. The hexagram of Revolution, for example, depicts the symbol of Fire in the Lake. Since Fire flames upward and the Lake seeps downward, a cycle is set in motion. In the realm of nature, this cycle suggests the turning of the seasons; in the realm of society it suggests the changing of regimes; in the course of life it suggests the change from an old, worn out way of being to a new, fresh outlook on life. In confirmation of this meaning, the second translation of the Chinese character for “revolution” is “molting.”

A core teaching of the I Ching emphasizes the priority of character in life. For example, in the Hexagram of Revolution, the I Ching stresses that the “first thing to be considered is our inner attitude toward the new condition that will inevitably come.” In the Hexagram of Inner Truth, the I Ching describes “the ruler who holds all elements together by the power of his personality. Only when the strength of his character is so ample that he can influence all who are subject to him, is he as he needs to be. The power of suggestion must emanate from the ruler. It will firmly knit together and unite all his adherents. Without this central force, all external unity is only deception and breaks down at the decisive moment.” In the Hexagram of Peace the I Ching notes, “As long as a man’s inner nature remains stronger and richer than anything offered by external fortune, as long as he remains inwardly superior to fate, fortune will not desert him.” Each of these passages points to the critical attribute of character – that one remains mindful of the primacy of character in governing the events of life.

Another core teaching of the I Ching is steadfastness in what is right. In the Hexagram of Influence the I Ching underlines the importance of goodness in character: “Here the place of the heart is reached. The impulse that springs from this source is the most important of all. It is of particular concern that this influence be constant and good; then, in spite of the danger arising from the great susceptibility of the human heart, there will be no cause for remorse.”

I’ve read the I Ching for many years, through many different situations – and the readings are astoundingly apt and insightful. I continue to be amazed at the wisdom contained in the ancient Book of Changes. Our times, and our lives, are certainly full of change. The I Ching can offer wise counsel to those who put time and energy into comprehending its message.

At the time I presented this data, I became impressed by the increase in visual acuity these patients had achieved. It is important to remember that they had what was considered previously to be hopeless disease. Nevertheless, almost 60% were able to read three or more lines further down the eye chart. They could see things with the implanted eye that they had not seen for years. However, the data revealed that they had paid a price in terms of corneal endothelial cells, which declined about 20% from the preoperative baseline.

Corneal endothelial cells do not regenerate, and therefore their preservation is critical. Some cells are unavoidably lost as we age and during intraocular surgery; something less than 10% is considered an acceptable loss during routine cataract surgery. The investigational protocol for the IMT had established a safety margin of no more than 17% cell loss, and unfortunately the data showed that the subjects exceeded that margin.

Over the ensuing years since the study concluded, Vision Care worked with FDA to provide greater analysis and follow up on the patients in the study. It emerged that most of the cell loss occurred during surgery and did not continue at the same rate postoperatively. In addition, we learned that experience made a difference: surgeons lost more cells during their initial cases than they did after getting past the implantation learning curve.

If you or a friend or family member has endstage macular degeneration, please come in for an evaluation for the IMT. We look forward to improving your vision! [ top ]

Optic Nerve Imaging Options for Glaucoma Patients
by Annette Chang Sims, M.D.

Annette Chang
Sims, M.D

Much can be told about glaucoma by the appearance of the optic nerve. When assessing a patient for glaucoma, clinicians carefully examine the size and shape of the optic nerve. Characteristics of glaucomatous optic neuropathy include increased cupping, disk hemorrhage, disk asymmetry and notching of the neuroretinal rim. While doctors rely heavily on the clinical exam, certain diagnostic tests have become increasingly helpful in making the diagnosis of glaucoma and assessing for glaucomatous progression. Our office offers two of these diagnostic imaging devices.

Heidelberg Retinal tomograph (HRt)
HRT uses a confocal laser scanning system to scan the surface of the optic nerve. It provides the physician with disc rim area, rim volume and retinal nerve fiber layer thickness. The test is painless and takes only a few moments to acquire the images.

Optical Coherence tomography (OCt)
OCT uses a near infrared light to generate a high resolution image of the optic nerve. Our office uses spectral domain OCT, the newest generation of OCT. It is able to acquire 20,000 scans per second to generate a high resolution 3-D image of the optic nerve. This technology is also used to image the drainage angle of the eye. For patients who may be at risk for angle closure glaucoma, the angle can be visualized and measured.

Glaucoma causes progressive damage to the optic nerve and retinal nerve fiber layer. These diagnostic devices provide the ability to detect early anatomical abnormalities, sometimes even before damage to vision occurs. These newer techniques offer objective assessment of the optic nerve and aid in our focus on accurate early detection and evaluation of disease progression. [ top ]

Our Surgery Center Receives Top Marks from a National Health Agency

Patients get exemplary care at our Oregon Eye Surgery Center (OESC), and a government agency is taking note. According to a Medicare surveyor, OESC is the first ambulatory surgery center (ASC) in Oregon to twice achieve a perfect score from Medicare inspections since new stringent regulations went into effect in 2009. During our latest review in December, inspectors noted absolutely no deficiencies and gave OESC another score of 100%.

OESC provides surgical procedures for cataract, glaucoma, diabetes and many other eye conditions, and offers refractive procedures such as LASIK and Refractive Lens Exchange. In addition OESC facilitates our clinical investigations which result in advances in surgical techniques and technology. Congratulations to OESC and our doctors for setting such high standards for our patients! [ top ]

Introducing Two New Family Members

HeatherHello. My name is Heather and I am the friendly face awaiting your arrival at the check-in desk. I transplanted here from Santa Maria, California 13 years ago and have come to love Oregon for its diverse landscapes and beautiful people. I have worked in the medical field for 12 years, but this is the first time I have joined an ophthalmology practice. I enjoy interacting with our patients. They, and my co-workers, provide countless opportunities to laugh and to learn. The eyes are truly amazing. I look forward to delving further into ophthalmology. See you soon.

WendyMy name is Wendy. I am an Ophthalmic Assistant here at Drs. Fine, Hoffman, Packer & Sims. I was first introduced to ophthalmology when I was very young, thanks to my father and grandfather who had their own optometry clinic in San Juan del Rio, Queretaro, Mexico. Having two great role models growing up, I realized that my profession would be related to the medical field. I started working in the building first as a Spanish interpreter at our surgery center. Now I work here. I am honored to be part of this professional working team. It feels like family. [ top ]


Cleo Schroeder, Patient
Frank Blain, patient

“It was like going from an old to a young man”
I chose to have Dr. Packer do my cataract surgery. It’s been a real miracle. I can see brighter and clearer now that the cataracts have been removed. It’s wonderful not having to wear glasses to drive, watch TV or read a book. It was like going from an old to a young man. My vision before the cataract surgery made things that were white look beige and now they are white again. Colors are also brighter. Dr. Packer’s staff was professional, caring and efficient. They valued the time I spent at their office allowing for very little wait time. In a word, terrific. [ top ]

Drs. Fine, Hoffman, & Packer Travel/Teaching Schedule —

October 2011 to January 2012

October 22-25, 2011: Orlando, FL
Drs. Hoffman and Packer and our clinic administrator, Laurie Brown, travelled east for the annual American Academy of Ophthalmology (AAO) conference. While there, Dr. Hoffman won the Best in Show award for his video, “Minimally Invasive Mini-Glaucoma Shunt Implantation Without Conjunctival Dissection.” He also taught a section of the prestigious Spotlight on Cataracts Symposium and was appointed to the editorial board for the Journal of Cataract and Refractive Surgery.

Dr. Packer spoke on a variety of topics in his courses. He instructed cataract surgeons from around the world on his techniques for difficult and challenging cataract surgery cases. In addition, he highlighted the new and emerging technologies in cataract surgery today.

Laurie Brown taught two courses specifically designed for ophthalmic technicians and she presented with other administrators from around the country and the world on how small ophthalmology practices can easily assimilate and utilize electronic medical records in their practice.

November 7-11, 2011: Singapore
In November, Dr. Packer hopped onboard a plane and flew half-way around the world to the National Healthcare Group Eye Institute 4th International Ophthalmology Conference in Singapore. There he shared his expertise in femtosecond laser cataract surgery with international surgeons and he gave them tips on how to maximize patient satisfaction using the latest in multifocal intraocular lens technology on the market today.

November 10, 2011: Portland, OR
Dr. Fine shared his expertise with residents at the Veterans’ Administration hospital in Portland while assisting several cataract surgeries.

December 19-20, 2011: Eugene, OR
Dr. Fine hosted U of O pre-medicine students in the clinic. Students gained valuable ophthalmology field exposure and learned of patient treatment techniques.

January 15-20, 2012: Maui, HI
January saw Dr. Packer and our clinic administrator, Laurie Brown, headed to the annual Royal Hawaiian Eye Meeting. Dr. Packer presented groundbreaking information on the correction of astigmatism with intraoperative wavefront aberrometry, highlighted the introduction of electronic medical record systems in ophthalmology, and explained imaging and guidance technology for femtosecond laser cataract surgery.

Laurie Brown moderated a series of talks with other administrators focused on new technology in ophthalmology. She also taught an ophthalmic leadership course which detailed successful ways to empower employees and presented compliance issues related to electronic medical records use.[ top ]

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