March 7, 2003

Surgical Eyes News

Volume 1, Number 4 

A monthly E-Journal

 
 

Your Pic HereI'm sure we are all familiar with the old joke, "If a tree falls in the woods and there is no one around, does it make a sound?" While scholars and tree experts have debated this subject, perhaps a more current question would apply for eye doctors. "If a patient is seeing 20 / 20 and they are complaining of poor night vision, are they just being whiny?" Those of us who see these types of patients and who read the stories put forth by patients on Surgical Eyes are painfully aware that these are real complaints. From a personal perspective, there was simply no way to quantify the types of issues that patients may have been dealing with as a result of their surgery. This is truly unfortunate.

With the clinical deployment of aberrometers, doctors (and patients) are going to be able to do a better job of documenting issues relating to visual quality and help develop plans for restoration. Keep in mind that we have had more than 100 years of experience with sphero-cylindrical refractions and Snellen acuity. Such technologies are woefully inadequate when trying to define how a post LASIK patient can experience wild visual fluctuations that are lighting dependent. As we all gain experience with these new devices, good things will come. Of that I am confident.

Sincerely,

Gregg Eric Russell, OD, FAAO
Chief Medical Editor
Co-MedicalDirector@surgicaleyes.org

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tIN THIS ISSUE
 
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tFEATURE CASE REPORT


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Fig. 1. Wavefront analysis showing tremendous spherical
aberration. Blue indicates the eye's performance under
bright light, green indicates dim light, and red indicates no light. Note the increase in blur anatomy size with the decrease in light.

Fig. 2. Multizone analysis showing refractions for the color zones in figure one. Zone 1 (3.5mm) corresponds to a small pupil in bright light and shows almost no refractive error. Zone 2 (4.5mm) corresponds to a semi-dilated pupil and shows almost 2.5 diopters of myopia. Zone 3 (6.5mm) corresponds to a dilated pupil at night and shows almost 5.5 diopters of myopia.
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Patient AG is a fifty-year-old Caucasian female who presented with poor vision in both eyes approximately two years after primary bilateral LASIK. Aberrations, multiple images, acuity fluctuations, loss of contrast and color discernment, dry eyes, photophobia, and pain remained unresolved after the patient saught opinions from twelve doctors around the country. Uncorrected vision was 20/30 and 20/40, right and left eye respectively, with a very mild correction in both eyes. Visual acuity refracted only one line improvement in both eyes. Flaps were smooth and free of irregularity or striae. Problems ensued with comfort and visual performance such that the patient was unable to achieve consistent reasonable vision.

After having exhausted herself with lens designs, the patient underwent a general health exam and saught nutritional counseling. Elevated ESR, eosinophils, borderline rheumatoid indicators, high cholesterol, and low magnesium were discovered. Plaquenil, Salagen and Prednisone were prescribed. Her aqueous tears improved, but pain and acuity did not.

The patient then completely overhauled her dietary intake, eliminating all refined sugars and processed carbohydrates. Specific vitamins, minerals, antioxidants, omega oils, enzyme and probiotics supplemented a diet of fruit, raw vegetables, fish, nuts and whole grains. All prescription medications were stopped. Within six weeks, the patient's contrast sensitivity and color distinction improved, multiple images were eliminated, vision stabilized, dry eye symtoms resolved significantly, visual acuity improved, and mental health (compromised by visual trauma) dramatically improved. After twelve weeks, uncorrected vision was 20/20 in both eyes and the patient's pain resolved, leaving only mild night haloes.

Case note: I have chosen to include this case for a number of reasons. First, it is important to have a clear understanding of the types of variation that this patient was experiencing and the sources of her difficulty. This patient showed variation of more than 5 diopters across the visual axis!!!! It should come as no surprise when we have to try to understand why this patient had such poor night vision and variations in acuity during the day. Secondly, and just as important, I wanted to stress the importance of patient involvement in their own care. While none of the traditional therapies provided relief to this patient on a consistent basis (tears, contacts, etc.), she was able to provide herself tremendous improvement through nutrition. While I can't prove what the nutrition accomplished (there were no changes in objective scores of topography or waveform), there was tremendous change in visual performance, visual comfort, and general physical well being. For more information on the patient's dietary regimen, please send an email to dietaryregimen@surgicaleyes.org.

To submit an article, contact lens or surgical case case report, please email
Co-MedicalDirector@surgicaleyes.org
.

tDOCTOR QUESTIONNAIRE ON POSTOPERATIVE CARE

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Since patients with large pupils treated with a 6-mm optical zone have more complaints of halo postoperatively than patients treated with a 6.5-mm optical zone does this point to the importance of pre-operative pupil size measurement?

1) Yes
2) No

Please click here to answer the above poll. s

Last months poll results:

f you have postrefractive patients with visual issues after refractive surgery, what do you recommend most often?

1) Contact lenses 86%
2) Further surgery with current technology 0%
3) Wait for newer technology 0%
4) Glasses 14%
5) None of the Above 0%

tREFRACTIVE EYE CARE NEWS

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Researchers look at mast cell role in LASIK wound healing. Francis S. Mah, MD, and Daniel S. Durrie, MD. Eyeworld, March 2003, page 48. From the article: "Mast cell derived mediators could reach the cornea via their presence in the tears, which spread over the entire ocular surface. In this way the mediators from mast cells located in the limbus and conjunctiva enter the tear film where they can affect the cornea, and similarly, corneal mediators may have a stimulatory effect on mast cells in the conjunctiva, also via tears. The possibility for error in the healing process is high, as it is a delicate and continually changing balance of numerous mediators orchestrating the process. Some of the complications seen following LASIK surgery may result from errors in these repair functions." More

Comfort most important when selecting lacrimal plugs. Other decision factors include extrusion rates, range of sizes available, reversibility and safety. Jeanne Michelle Gonzalez, Ocular Surgery News Europe/Asia-Pacific Edition, February 1, 2003. From the article: "When a surgeon selects a lacrimal plug, the device of choice is the one he or she is most comfortable using, and the one that provides the most comfort for his or her patients. Other factors influencing the choice include external profile, design and sizing options, insertion technique, reversibility, extrusion rate and material. But the prime decision factor remains comfort." The article continues with a discussion of varying opinions about the different options. More

Reliability of pachymetric measurements using orbscan after excimer refractive surgery. Olivier Prisant, Nila Calderon, Philippe Chastang, Damien Gatinel, and Thanh Hoang-Xuan. Ophthalmology 2003 110: 511-515. From the abstract: Orbscan (Bausch & Lomb, Rochester, NY) pachymetric values may be underestimated and less accurate after LASIK and PRK as compared to measurements taken with an ultrasound pachymeter. More

Using a broad-beam laser: PTK offers another option for treating chronic flap striae. Most eyes with visually significant microstriae improved after procedure without developing haze. Cheryl Guttman, Ophthalmology Times, February 1, 2003. From the article: "Overall, the procedure resulted in improved best spectacle-corrected visual acuity (BSCVA) in most eyes. Also, there was improved uncorrected visual acuity (UCVA) secondary to a slight hyperopic shift (0.87 D) with an insignificant change in cylinder (0.13 D). No eyes lost 2 or more lines of BSCVA nor developed clinically significant haze, and there were no other complications." More s

tSPOTLIGHT PROFILE

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Frank J. Holly, PhD
Dr. Holly is a humanitarian whose brilliance is only overshadowed by his humility. We are forever indebted to him for his contributions and bravery.
Sincerely,
Ron Link
Executive Director

Frank J. Holly acquired a background in chemical engineering at the Technical University of Budapest. After immigrating to the United States he received his doctorate in physical chemistry at Cornell University in 1962. From the beginning of his research career he applied his basic science and engineering background to problems in biology and medicine. He spent five years researching blood compatibility of prosthetic dental materials and one year lecturing in Central America.

In 1968 he began a ten year association with the Retina Foundation (now known as the Schepen's Eye Research Institute), in the Cornea Research Department. As early as 1969, he experimented with and proposed the use of higher molecular weight aliphatic alcohols such as heptane to decane for the removal of corneal epithelium with no observable damage to the basement membrane.

By employing surface chemical methods and principles, he and his fellow co-workers created a sound scientific basis for tear film physiology and gained unique insight into the pathophysiology of tear-film disorders. Among his major contributions to ophthalmology are the description of the hydrophobic character of the corneal epithelium surface and the discovery of the unexpectedly high surface activity of mucous glycoprotein. Holly was the first to recognize that the actual cause of dry spot formation is local non-wetting rather than local drying. He established the importance of lipid-protein and mucin-water interaction in tear film stability and explained in basic terms tear film formation and rupture.

Holly proposed a double membrane hypothesis of retinal adhesion, so far the most realistic of such models. Holly suggested a novel possible cause of contact angle hysteresis, now widely accepted in basic science and engineering, by proposing a molecular mechanism effecting a hydrophobic-hydrophilic transformation of solids, especially hydrogel and biosurfaces. Dr. Holly collaborated in cancer research with researchers in the National Cancer Institute by employing his novel techniques to the study of cellular fibronectin and its role in cellular interaction.

In 1978, he joined Texas Tech University School of Medicine in West Texas, where, three years later, he became a Professor of Ophthalmology and Biochemistry. At that institution, he and his colleagues investigated tear components in an attempt to identify the lacrimal surfactant and to develop novel clinical tests for the diagnosis of the various dry eye states. His group also studied the factors that determine biocompatibility of contact lenses.

In the early '80's, the National Eye Institute planned to establish a National Tear Research Center. Due to the unexpectedly successful International Tear Film Symposium organized by Holly in 1984, West Texas was selected as the location of such a research center. Outstanding and budding scientists and physicians from all over the world expressed their desire to spend one or two years in Lubbock to do pioneering lacrimal research under the direction of Dr. Holly.

Regrettably, these promising developments came to naught due to the shortsightedness of the local administrators. After two lecture tours, one in Europe and later one in the Orient, Holly started his own research and development laboratory, Vision R&D Laboratory, to develop novel, efficacious collyria for dry eye patients, and he retired from academia. His most recent scientific contribution together with his son has been the proposal of a new mechanism of lubrication for blinking which corrects the deficiencies of previous hypotheses and provides a solid ground for the modern formulation work of novel ophthalmic lubricants.

Unable to interest companies in marketing his novel eye drops, Dr. Holly started his own pharmaceutical company, Dakryon, to make the eye drops available to dry eye patients. After supplying a relatively small (undoubtedly due to lack of advertising) but highly loyal group of long-suffering dry eye patients for a decade, the company was discontinued due to lack of resources.

In 2001 and later in early 2002, Ron Link of the Surgical Eyes approached Dr. Holly and called his attention to the newly arisen problem the idiopathic dry eye. Sensing an opportunity where his expertise could once again be helpful to patients, Dr. Holly joined the other eye care professionals at Surgical Eyes. With the help of Joe Echols of Aqueous Pharma, the former Dakryon eye drops were made available again and with the help and co-operation of the motivated patient and doctor members of the organization, these eye drops once again proved to be efficacious in a conceptually new form of "clinical" trial via Internet for the idiopathic dry eyes.

Dr. Holly is the founder and first president of the International Society of Dakryology as well as the Dry Eye Institute. In 1993 he received the Lacrima Award in Madrid, Spain for outstanding contributions to lacrimal physiology. He is the author of one hundred and ten articles and editor of several book treatises.

Future Profiles to follow from Top Doctor Posters on our Bulletin Board:
W Trattler MD, Gregg Russell OD, Ken Minarik OD, Ophthinfo MD, James Salz MD, Clint Hoxie OD, Tracy Lynn Swarz, OD, Donald F. Ezekiel OD, Steven Lee OD, Sam Omar MD, Alejandro Tirado OD, Demetrian Dornic MD, Ricardo Trigo MD, Arthur Epstein OD, Chris Marmo OD, Hollis Stavn OD, Eirit Yonatan OD, Paul Klein OD, Robert Bard OD, Neal A. Sher MD, Jim Dillard OD, Gregg Feinerman MD, Steven Shum OD, Richard Bursua OD, Jason Jedlicka OD, Mark Ventocilla OD, Barrie Soloway MD, Carlton Chan OD, Jack Miller OD, Brian Boxer Wachler MD, Ken Maller OD, Joe B. Goldberg OD, Bruce Butts OD, Kraig Abe OD, Paul Blaze OD, Frank Goes MD, Bill Berke OD, David L. Davidson OD, Joe B. Collins OD, James Stevenot OD, Jeffrey Martin OD, Johnathan Christie, OD. s

tFEATURED POSTINGS from SE's BB

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Alcon's New SYSTANE Lubricant Eye Drops

New Prescription Drug for Dry Eye

Free cap complication

Wavefronts, Orbscans, Topography - Comments Appreciated

About Mitomycin C after PRK

Acid Burning Eyes STILL 3 years later - Comments Appreciated

Post-Lasik Floaters only vitrectomy

I had wavefront for GASH/poor night vision by Dr. Salz s

tANNOUNCEMENTS and EVENTS
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  • Washington/Oregon Support Group Meeting on Saturday, March 1st, 2003 at Vision NorthWest in Tigard, Oregon, from Noon to 4:00 PM Lunch will be provided from Noon to 1:00 PM with an open meeting from 1:00 to 4:00 PM. John Wilkins, OD will be attending and will answer as many questions as possible. Please contact organizer Brenda Ross for more information!

  • Pictures from our past meetings at Emory - Atlanta, GA and Cohosted by Gelfex - New York, NY in 2002. Some of the presentations made by doctors at both meetings will be available online.

  • Surgical Eyes Meeting in London, England - early June 2003 hosted by SE participating doctor Dan Reinstein, MD.
tCLASSIFIED ADS

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The Surgical Eyes Web Site received over 14,275,000 hits in 2002 alone. This Newsletter is now featured on the front page of our Web Site with a growing subscriber base of over 3,700 readers - a technologically sophisticated interactive forum on refractive surgery complications featuring interaction between leading MDs, ODs, PhDs and a caring global network of patient participants.
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Chief Medical Editor
Gregg Russell, OD

Editor
/Art/Production/Circulation
Ron Link

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Research Editors

• Karl Albert
• Mark Bilafer
• Paul Fitzpatrick
• John Vernosky

Copy Editor
• Kirsten Taylor

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Email
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