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This page features recent developments in the field of eye care.
It is updated quarterly.


Contents:
Title Date Author
Good News for Macular Degeneration Patients May 2007 Andrew Henrick, M.D.
Accommodative Intraocular Lens Implants
Nov 2005 Andrew Henrick, M.D.
South Coast Eye Care Centers Offers Excellence in Laser Vision Correction
Oct 2005 Paul Prendiville, M.D.
Laser Vision Correction in 2005 Jan 2005 Holly Spanggord, M.D.
Dry Eye Syndrome: Treatment Options for A Complex Condition Jan 2005 Holly Spanggord, M.D.
Lose Those Wrinkles!
July 2004 Andrew Henrick, M.D.
New Developments in Macular Degeneration Research
Mar 2004 James R. Brinkley, Jr., M.D.
Vision Improvement After Cataract Surgery Oct 2003 Andrew Henrick, M.D.
Diabetic Retinopathy Jul 2003 James R. Brinkley, Jr., M.D.
The Nature and Treatment of Cataractous Visual Loss Apr 2003 Paul Prendiville, M.D.
New Laser Vision Correction Procedures for Very Near-Sighted Patients Jan 2003 Holly M. Spanggord, M.D.
A Revolution in Glaucoma Treatment? Perhaps Not! Oct 2002 James R. Brinkley, Jr., M.D.
Jul 2002
Apr 2002 Andrew Henrick, M.D.
Jan 2002 Paul Prendiville, M.D.
Oct 2001 James R. Brinkley, Jr., M.D.
Oct 2001
Jul 2001
New Advances in Contact Lenses Apr 2001 Cathy Hull, C.O.T.
What Can I Do About My Droopy Eyelids? Jan 2001 Andrew Henrick, M.D.
South Coast Eye Care Centers Using a New Laser Vision Correction Facility Oct 2000 Paul Prendiville, M.D.
Apr 2000 Denise Levin, C.O.M.T.
Jan 2000 Andrew Henrick, M.D.


May, 2007


Good News for Macular Degeneration Patients
by
Andrew Henrick, MD

New treatment is now available for patients with wet age related macular degeneration (ARMD). For background information, look at our March, 2004, article on ARMD. The new treatment is based on the understanding that vascular endothelial growth factor (VEGF) is a substance secreted by cells inside the eye which promotes the growth of abnormal blood vessels under the macula. These blood vessels may leak fluid and blood causing elevation of the macula and loss of vision. Laser treatment can cause destruction of the vessels but also damages normal retina. At best, laser treatment can stabilize vision.

Extensive research has resulted in the development of antibodies to VEGF. These are injected directly into the eye and can cause regression of the abnormal blood vessels without damaging the overlying retina. Intravitreal injections must be repeated at monthly intervals for several months until the condition stabilizes, then at longer intervals as needed to prevent recurrence. Injections will probably need to be given indefinitely. However, for the first time, not only can vision be stabilized in many cases, but it can actually improve in some patients.

Currently, there are three anti-VEGF antibodies available. The first, Macugen, has been available for two years. Results with Macugen have been limited. Two newer drugs, Lucentis and Avastin, have recently been introduced. Results with these are very encouraging. Avastin was introduced for the treatment of colon cancer and is not approved for use in the eye. However, it has been used off-label in the eye safely and with excellent results. Lucentis has been developed specifically for use in the eye. It may prove to be somewhat more effective than Avastin. However, a dose of Lucentis costs ten times as much as Avastin. Even with insurance coverage for Lucentis, the patient’s copay may be double the cash price of Avastin. Although these drugs offer great hope for patients with wet ARMD, risks exist for these injections, including severe infection resulting in loss of vision. As with any other treatment, discussion with your ophthalmologist regarding the benefits and risks of the procedure is mandatory.

As we begin to understand ARMD better, new treatments will continue to be developed. Newer drugs are already being developed and investigated for wet ARMD. Unfortunately, no new treatment is currently available for dry ARMD, the most common form.


November, 2005


Accommodative Intraocular Lens Implants
by
Andrew Henrick, MD

Cataract surgery was revolutionized with the invention of intraocular lens implants (IOL’s) a few decades ago. Previously, cataract surgery (the removal of the natural lens of the eye) required patients to wear very thick glasses to restore the optical power lost with the removal of the cataract. The introduction of contact lenses improved the visual outcomes of cataract surgery and improved on some of the vision problems associated with the post-cataract glasses. However, some patients had problems in handling the lenses or developed eye irritation or infections. When IOL’s began to be widely used in the 1970’s patients no longer had to rely on thick glasses or contacts for vision restoration. In many cases they could see at distance without glasses or would require only thin spectacle lenses for best vision. But reading glasses were almost a necessity.

Fast forward to 2005. Many patients don’t want to wear glasses at all….for anything. They want to see like they did when they were 20 years old. Witness the popularity of LASIK. Today, patients undergoing cataract surgery don’t want to rely on glasses for distance or reading. Additionally, patients who are not LASIK candidates are asking for a procedure to reduce their dependence on glasses. Furthermore, patients who have undergone LASIK find they need to depend on reading glasses as they get older, even though they have good uncorrected distance vision.

An IOL was introduced several years ago to address both the distance and near vision requirements of patients undergoing cataract surgery. It was called the Array, by American Medical Optics, and it had two optical surfaces that corrected for near and distance simultaneously. Many were implanted with varying patient satisfaction. The main complaints by patients were that contrast sensitivity was reduced and they saw halos around lights at night. Very few are still being implanted. Recently, a new generation of IOL’s has been introduced to provide distance and near vision while improving contrast sensitivity and decreasing halos relative to the Array. These are called accommodative (focusing by changing shape or position) or pseudo-accommodative (focusing through multifocal optics) IOL’s.

The first of these, introduced about two years ago, is the Crystalens by Eyonics. This lens is hinged so that it moves inside the eye as the focusing muscles contract. It has met with varying success because the effectiveness seems to diminish over time, presumably because post-operative scarring hinders its movement. Only about 17% of patients with this lens report never having to wear glasses. The rest need to wear glasses for some activities or even always.

Two other lenses were introduced this year. The Rezoom, by AMO, is a modification of the Array. Like the Array, it also has a series of concentric focusing surfaces on the front, but these are spaced farther apart and address some of the problems of the Array. The Restor, by Alcon, has an innovative front surface, referred to as an apodized surface, which provides a smooth transition between distance and near vision. It also has less contrast and halo problems than either the Array or Rezoom. In large scale studies over 80% of patients with this IOL never wear glasses. More about this IOL can be found on its website, www.acrysofrestor.com.

Our doctors have chosen to use the Restor lens over the others because of its performance and patient satisfaction. It does not require any change in surgical technique and does not affect the safety of cataract surgery. It is suitable for most patients undergoing surgery for vision-impairing cataracts. It is also a good choice for patients who wish to free themselves from glasses but do not have cataracts. For those patients without cataracts, the procedure is called clear lens extraction, but is otherwise identical to cataract surgery. However, whereas insurance pays for surgery for visually significant cataracts, it will not pay for clear lens extraction. In either case, the patient will need to pay a premium for these new technology lenses. Patients will need to weigh carefully their options for reducing spectacle dependence as there are advantages and disadvantages to each surgical procedure.


October, 2005


South Coast Eye Care Centers Offers Excellence in Laser Vision Correction
by
Paul Prendiville, MD

At South Coast Eye Care Centers we take great pride in offering state of the art ophthalmic treatments, including the latest Laser Vision Correction procedures. Our highly trained staff and our Board Certified Ophthalmic Surgeons take great pride in our excellent results, which have led to a 100% rate of customer satisfaction among our Laser Vision Correction patients.

Laser Vision Correction includes the option of three different procedures:

  1. Laser Assisted in situ Keratomileusis (LASIK)
  2. Laser Assisted Epithelial Keratomileusis (LASEK)
  3. Photorefractive Keratectomy (PRK)

LASIK has been the most widely used Laser Vision Correction method. It involves re-shaping the cornea after creating and lifting a corneal flap. We use standard flap creation technologies as well as the new “All LASER LASIK” method for creating corneal flaps. The All LASER LASIK method involves the use of a laser which fires extremely rapidly to create a flap, followed by an excimer laser treatment to re-shape the cornea. This same excimer laser is used in all three refractive procedures to change the power of the cornea and thus eliminate the need for eyeglasses and contact lenses. We are currently using excimer lasers with wavefront technology in order to be able to achieve even better results.

LASEK is done using the same excimer laser, but it is slightly different than LASIK. .Rather than mechanically creating a flap, a chemical solution is used to loosen the most superficial layer of the cornea. This layer is then gently rolled back, and the excimer laser is used to re-shape the cornea. The chemically created flap is then put back in place for a prompt surgical recovery.

The Laser Vision Correction method with the longest track record is PRK. We continue to use PRK frequently. Although there are a few days of discomfort following PRK, some patients choose it over LASIK and LASEK. This is usually because some patients worry about the integrity of the corneal flap after treatment with the excimer laser. In other cases we may find during our evaluation that PRK is the better method for a given eye.

During our complimentary screening examinations our patient’s eyes are carefully examined in order to determine which of these three procedures would be best. Measurements including eyeglass power, tear film production, corneal thickness, corneal topography (i.e. shape), and pupil size are performed and are just a few of the parameters which are used to determine which procedure is right for a given patient. The screening examination also includes time to discuss the surgery with one of our Laser Vision Correction surgeons. All pre-operative and post-operative visits are done exclusively by our surgeons.

We use only the most modern technologies including broad beam and flying spot lasers, tracking lasers, wave front analysis and treatment, and All Laser LASIK. We carefully evaluate which technology and procedure is best for each patient and take great care in ensuring our patients are highly satisfied.

You may contact us as South Coast Eye Care Centers by:

E-mail: use the “contact us” link on this website

Telephone:
(949) 588-2020 (General appointments)
(949) 588-2028 (Carol, our Laser Vision Coordinator)


January 2005

Laser Vision Correction in 2005
Wave Front, Custom Ablation, & All-Laser LASIK
Advertising Gimmicks or Genuine Advances?
by
Holly Spanggord, MD

Laser vision correction has continued to be one of the fastest growing, technologically progressive subspecialties in medicine. Excimer laser computer software has improved dramatically over the past several years with precise eye-tracking systems, smaller spot beams, and smoother ablations. Wave front technology, one of the latest advances in refractive surgery, has recently received FDA approval. This new approach to laser vision correction allows the surgeon to “customize” the treatment to the individual patient. This concept certainly sounds like a better approach to laser vision correction, but exactly what does it mean, what should we expect from it, and what are the unanswered questions? Also, what is “all-laser LASIK,” and how does this new technology impact refractive surgery?


First, what is “wave front,” and what is a “custom ablation”?

Glasses and soft contact lenses correct the most significant optical deviations of the eye: far-sightedness, near-sightedness, and astigmatism. However, the human eye isn’t simple. Each eye has additional, much smaller, irregularities referred to as “higher order aberrations.” These aberrations may cause glare and halos around lights at night, or they may account for the reason an eye sees 20/20 (normal vision) when it is capable of seeing better (20/16 or 20/12), the so-called “supervision”. Theoretically, if these tiny irregularities are removed, a patient may see more clearly than s/he did with his/her contacts or glasses before surgery. A “custom ablation” is a laser treatment that aims to correct all optical deviations of the eye including higher order aberrations.

The term “wave front” refers to the manner in which all of the optical deviations of the eye are measured. This includes the near/far-sightedness and astigmatism (corrected by contacts and glasses) in addition to the higher order aberrations. In other words, the wave front measurement is a “finger-print” of the optical deviations of the eye.


What should we expect from custom laser vision correction?

When compared to conventional laser treatments, wave front technology strives to accomplish three main goals:

1. Improved post-operative visual acuity - Recent clinical trials have reported excellent results with more than 90% of patients attaining a 20/20 result or better, 70% with at least 20/16, and 20% with at least 20/12. These results were achieved, however, under tightly controlled circumstances and it remains to be seen whether they are reproducible in clinical practice.

2. Better night vision – Conventional laser vision correction is known to induce higher order aberrations resulting in night time halos and glare in some patients with more complex prescriptions. Limited studies show that custom ablation induces fewer higher order aberrations with fewer patients complaining of postoperative night vision problems.

3. Correction of higher order aberrations occurring naturally or induced by conventional laser vision correction – Patients who suffer night vision problems naturally or due to a conventional laser vision treatment may benefit from custom ablation aimed at reducing higher order aberrations. This application of the technology has not been approved by the FDA but is performed by some surgeons. Preliminary studies have shown good results with reduced nighttime symptoms. In the near future this will likely prove a viable option for patients with significant glare and halo symptoms after conventional surgery.


So what are some of the unanswered questions regarding custom ablation?

1. Since higher order aberrations occur naturally and are an integral part of “normal vision,” should they be corrected?

2. What role does the brain play in interpreting images? Are there advantages to higher order aberrations in visual functioning?

3. What happens with age as the lens inside the eye changes?

4. Is our current technology accurate enough to both measure and treat higher order aberrations?


What is “All-Laser LASIK”?

The LASIK procedure requires a corneal flap to be created prior to the laser treatment. Traditionally, this has been achieved using a motor-driven microkeratome blade. Recently, the IntraLASE™ Corporation has developed a computer-controlled laser, which creates the flap without the use of a blade. This modification of the procedure has been referred to as “All-Laser LASIK,” “No Touch LASIK,” and “IntraLASIK,” and has been FDA-approved. Currently, it offers three, possibly four advantages:

1. Unlike the standard microkeratome blade, the laser may be stopped at any time during the procedure without untoward effects. The effect of the laser diminishes over 30 minutes and may be repeated. On the other hand, if the microkeratome blade stops in the middle of the procedure, a 2-4 month healing period is required prior to re-treatment.

2. Although complications due to an imprecise (too thick or too thin) or irregular flap cut with the microkeratome are very rare, the laser offers increased precision in creating the flap. As a result, the likelihood of suffering one of these rare flap-related complications is further reduced. Also the diameter and thickness of the flap are programmed into the computer before the start of the procedure and preliminary studies show good accuracy.

3. The IntraLASE™ laser requires the eye to be placed under less pressure while creating the flap in comparison to standard microkeratomes.

4. Early studies suggest that fewer higher order aberrations (please refer to the above discussion) are induced by the IntraLASE™ laser compared to microkeratome blades. Consequently, this new technique may improve the results achieved with wave front-driven custom ablation. More experience is required, however, to prove this initial impression.

What are the downsides to “all-laser LASIK”?

1. Cost – An additional fee is usually charged depending upon the particular surgeon and surgery center utilized.

2. The procedure requires a longer period of time to complete – approximately 30 minutes as compared to 15 minutes.

3. As with all new technology, long-term studies are not yet available.

In the hands of an experienced surgeon, traditional LASIK carries very small risk and remains the standard of care. The IntraLASE™ laser further reduces those risks while increasing precision in creating the flap. Many issues remain unresolved regarding wave front –guided custom ablation, and the implications of the IntraLASE™ laser as a platform for this technology. Wave front technology is currently in its infancy but holds tremendous promise for the future of refractive surgery. No doubt, continued refinement and experience will fine-tune this revolutionary technology to the maximum benefit of future patients.

January, 2005


Dry Eye Syndrome: Treatment Options for A Complex Condition

by
Holly Spanggord, MD

Dry Eye Syndrome, also referred to as keratoconjunctivitis sicca, affects more than 6% of the population over 40 years of age and 15 % of those over 65. The symptoms include blurred vision, foreign body sensation (feeling like something is in the eye), burning, irritation, and excessive tearing. Dry eye syndrome is a complex disease that involves much more than simply the underproduction of tears. To understand the causes and treatments of dry eye syndrome, it is important to first understand the structure of the tear film. The tear film is made up of three components:

  1. The mucous layer, which is produced by the conjunctival goblet cells. This layer provides lubrication of the ocular surface while trapping and eliminating foreign matter from the eye.

  2. The aqueous layer, which accounts for most of the tear film volume and is produced by the main lacrimal (tear) gland and the accessory lacrimal glands. A large portion of this layer is produced in response to stimulation of the nerves on the surface of the eye.

  3. The lipid layer, which is the most superficial oily layer and is produced by the Meibomian glands. These glands are found along the edges of the upper and lower lid margins. This layer prevents evaporation of the tear film.

Dry eye syndrome may result from post-menopausal hormonal changes, certain medications, autoimmune diseases, or simply age. Several mechanisms may contribute to dry eye syndrome. This syndrome is aggravated by dry climates, such as we have here in southern California.

The most obvious cause of dry eye syndrome is decreased tear secretion. Lacrimal gland disease caused by autoimmune diseases such as Sjogren’s Syndrome or Rheumatoid Arthritis may reduce tear production. Also, since stimulation of the ocular surface nerves activate tear secretion from the lacrimal gland, anything that interrupts this reflex can cause dry eye.

An important cause of reduced stimulation of the lacrimal gland is decreased corneal sensation. This may result from corneal viral infections such as Herpes Simplex keratitis or Herpes Zoster keratitis (“Shingles”). Also, surgery which cuts the corneal nerves, such as LASIK (laser in situ keratomileusis) or corneal transplantation, may cause significant dry eye by inhibiting the necessary input to the lacrimal gland to stimulate tear production.

Recently, studies have shown that dry eye syndrome results in a change in the complex chemical makeup of the tear film. These changes lead to inflammation of the ocular surface causing many of the symptoms patients report and the pathological changes we observe as ophthalmologists. It can also lead to inflammation of the lacrimal gland and a further reduction of tear secretion.

A second important cause of dry eye syndrome is increased evaporation of the tear film. Patients with a reduced blinking rate or with conditions causing the eyes to be more prominent (such as Thyroid Eye Disease) may suffer from loss of tear film volume due to evaporation. Poor lid closure due to Bell’s Palsy or prior eye lid surgery may play a role. Also, since the lipid layer is important in preventing evaporation, Meibomian gland disease (blepharitis) may also contribute to dryness.

The treatment of dry eye syndrome should be tailored to each individual patient. The first line therapy is instillation of artificial tears during the daytime with the occasional supplementation of an ointment at night. Treatment of any Meibomian gland dysfunction (blepharitis) is necessary to increase the volume of oil in the tear film,which prevents evaporation. Generally, this involves the application of hot compresses to the lids for approximately five minutes followed by gentle massage of the lid margins with the fingertips. This should be performed two to four times daily. The addition of tetracycline, an antibiotic with anti-inflammatory properties, is also useful in the treatment of blepharitis. Also, any medications that may contribute to dry eye should be minimized or discontinued. If an autoimmune disease is present, it should be adequately treated and stabilized.

The second line of therapy is punctual occlusion, which involves the placement of a collagen or silicone plug within the puncta of the lower lids. (The puncta are the openings to the canals that drain the tears away into the nose.) By blocking the outflow of tears from the eye to the nose, more tear volume remains within the eye increasing hydration. This reduces the effect of evaporation and dilutes out the chemicals within the tears that may lead to inflammation. If dryness persists, the upper puncta may also be occluded.

A third treatment option is topical anti-inflammatory medication. Since low tear volume leads to chemical changes in the tear film, which cause inflammation of the ocular surface and the lacrimal gland, a vicious cycle is created. Tear secretion is further reduced by the inflammation of the lacrimal gland caused by the low tear volume in the first place. Once this cycle has taken hold, medications that target inflammation appear to be therapeutic.

Mild topical steroids are helpful in reducing the symptoms and pathological findings of dry eye syndrome. These are generally steroid drops, which have minimal intra-ocular effects such as cataract formation and glaucoma. Fluoromethalone (FML) or loteprednol (Lotemax) are commonly used. Since the potential for long term side effects exists, the use of these medications should be limited.

Recently, cyclosporine-A (RestasisR), has been FDA approved as an anti-inflammatory treatment for dry eye syndrome. Cyclosporin-A targets the inflammatory cells that infiltrate the lacrimal gland. It also reduces the pro-inflammatory chemicals that cause ocular surface irritation. Some improvement in symptoms can be seen after one month of treatment with an increasing effect over six months. Importantly, the long-term side effects associated with steroid treatments are not observed with cyclosporine-A. Consequently, this mode of therapy appears to be a safe long-term treatment for dry eye syndrome.

Although anti-inflammatory treatments have an important role in the treatment of dry eye syndrome, it is unclear exactly when this course of action should be utilized. Should they be started before or after punctual plugs? Future studies are necessary to determine the optimal use of this important intervention. Meanwhile, each patient should be evaluated and treated individually with a tailored regimen based on his or her particular needs.


July, 2004

LOSE THOSE WRINKLES!
by
Andrew Henrick, M.D.

Our eyes, eyelids, and the surrounding area are among the first things we notice about each other. As we age, changes in these structures may cause us to appear older, more tired, and less vital and energetic than we really are. In the twenty-first century, we have a number of amazing tools to rejuvenate the area around the eyes. Botox is used to smooth wrinkles caused by underlying facial muscle movement, such as frown lines and “crow’s feet.” Skin resurfacing, such as chemical peels or laser, can improve fine wrinkles.

Deeper wrinkles, however, are not significantly improved by these modalities. New approaches are needed and we have them! They are called dermal fillers. Dermal fillers are substances injected into, or just under, the facial skin to smooth out deep wrinkles.

The best-known dermal filler is collagen. Collagen is the most commonly used dermal filler. It is derived from cattle. Since it is a foreign protein, allergic reactions can occur and allergy testing needs to be done prior to treatment. Collagen derived from humans has recently been FDA approved. It does not produce allergic reactions but there is a small concern about prion transmission. (Prions are small particles similar to viruses that can cuase the transmission of certain infectious diseases.) Collagen fillers need to be re-injected every three months to maintain a smooth appearance.

Non-biodegradable fillers consisting of minuscule plastic beads have been injected into wrinkles and depressions in the face, resulting in permanent contour changes. The main advantage of this filler, permanence, is also its greatest disadvantage. Once it has been placed into tissue it can’t be changed and an undesirable result is permanent. Plastic rods can also be placed into the nasolabial folds (the deep wrinkles on the side of the nose and above the lips) to raise these. However, minor surgery is required for their placement.

Fat transfer is the best procedure for semi-permanent results. In this procedure, the patient’s own fat is removed from the abdomen or inner thigh using a separate incision and liposuction. This fat is then injected into the deep wrinkles of the face with results lasting up to two years before the fat is absorbed. The advantage of this modality is that the patient’s own tissue is used, so allergy and disease transmission are not a concern. The disadvantage is that a separate incision is necessary for harvesting the fat, making this procedure more complex and slightly more risky.

A newly FDA approved filler shows much promise for long-term temporary results. This agent is made of hyaluronic acid, a substance that normally exists in our bodies to bind cells together. Two types of this agent are available. The first, Restylane, is FDA-approved and is synthesized by bacteria. The second, Perlane, is not yet approved and is purified from roosters’ combs, but is the same substance as Restylane. Hyaluronic acid has been used safely in intra-ocular surgery for over 20 years. Restylane injected into deep wrinkles begins to draw in water almost immediately and so noticeable swelling occurs, elevating the wrinkle. This swelling subsides over several hours but an improvement in the wrinkle persists for six to eight months, at which time much of the hyaluronic acid has been absorbed. Injections may be repeated at this time.

Restylane has many advantages: It consists of a material normally found in our bodies so there is no risk of allergic reaction or disease transmission. This substance has been used safely for over twenty years in ophthalmology. Once injected it is malleable. That is, it may be massaged into position within the skin for optimum appearance. The results are apparent immediately, with mild redness resolving after a few hours.

Restylane lasts at least twice as long as collagen. Best of all, injections take just a few minutes and are almost painless after appropriate local anesthesia is given. The patient may return to normal activities immediately. There is no limit to how often injections can be repeated.

Deep Wrinkles Before Restylane
Wrinkles Nearly Gone After Restylane


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March 2004

New Developments in Macular Degeneration Research
by
James R. Brinkley, Jr., M.D.

Age Related Macular Degeneration (ARMD or AMD) is the leading cause of legal blindness in our nation in people over the age of 65. As the baby boomers approach senior citizen status, ARMD is rapidly becoming a major public health crisis. Consequently, a great deal of effort and money is being invested in investigating potential cures and/or preventions.

The retina is the lining inside the back of the eye, analogous to the film in a camera. However, although the film in a camera is uniform, the retina has a very small, specialized area in the center called the macula. Its full name is macula lutea, which means yellow spot. It is yellow because it contains lutein. I’ll have more to say about lutein later.

The macula has one of the highest metabolic rates of any tissue in the body and therefore has a high demand for oxygen, nutrients, and the removal of waste products. Although the cause of ARMD is unknown, there is speculation that it may be due to a failure of the microcirculation that supplies the macula. It is well known that cigarette smoking, which causes damage to small blood vessels throughout the body, is a very high risk factor for ARMD. Even former smokers have a much higher risk than non-smokers, although quitting does significantly reduce the risk compared to that of current smokers. There may be a genetic predisposition as well, although certain epidemiological studies have failed to prove this.

There are two main types of ARMD: atrophic and exudative, popularly known as “dry” and “wet.” Wet refers to the fact that there is either bleeding or leakage of fluid (serum) from abnormal blood vessels beneath the macula. Dry means there is no such fluid or blood present. The dry (atrophic) type usually has the better prognosis, progressing slowly and only occasionally reducing vision to the level of legal blindness. The wet type of ARMD, however, often causes a sudden dramatic loss of vision, usually in one eye at a time.

At the present time the only approved treatment for dry (atrophic) ARMD is a specific combination of vitamins and minerals, shown in the Age Related Eye Disease Study (AREDS) to slow the progression of the disease in certain very specific types of dry and wet macular degeneration. This combination is available commercially as Ocuvite Preservision. Lutein was not included in this study and we do not yet know if taking supplemental lutein might be beneficial. It has been suggested that taking supplemental lutein might block the absorption of natural lutein from the digestive tract. Therefore I advise my patients not to take it but instead to eat fruits and vegetables rich in lutein. These include corn, kiwi fruit, red seedless grapes, zucchini squash, and spinach. Egg yolks are also high in this nutrient.

There are two approved treatments for exudative (wet) ARMD. Traditional LASER (Light Amplification by Stimulated Emission Radiation) can sometimes be used to destroy abnormal blood vessels beneath the macula. This treatment cannot be used if the vessels are under the center of the macula (called the fovea) because the visual cells (photoreceptors, also called cones and rods) are destroyed as well. A newer type of laser, called photodynamic therapy (PDT) or Visudyne Therapy can be used in a limited number of cases to slow the progress of the disease when the abnormal blood vessels are beneath the center of the fovea. Unfortunately, even these two therapies can offer help to only a very small number of people with wet ARMD.

Fortunately, there are some exciting new advances under investigation. Some of these may be approved for general use within the next few years. Investigational therapies for atrophic (dry) ARMD include laser prophylaxis of drusen, intra-ocular telescopes, retinal implants, and retinal transplants.

Drusen are yellowish deposits beneath the macula, which are often the first sign of macular degeneration. One type of drusen, called soft drusen, is often a predictor of the development of exudative (wet) ARMD with possible sudden loss of vision. In an effort to prevent the progression of dry ARMD with soft drusen to wet ARMD, researchers are trying to destroy the drusen with a laser. This treatment is called laser prophylaxis of drusen. Initial studies a few years ago showed that while the drusen were destroyed, the incidence of progression to wet ARMD actually increased. Now some scientists believe this happened because the energy used in the laser treatments was too high. Current studies are attempting to use lower laser energy, called sub-threshold laser. Initial results are very promising with not only a reduction in the number of drusen but also with an actual improvement in vision.

Several of my patients have sent me forms to fill out so that they might enroll as subjects in a trial of intra-ocular telescopes. In this study, a lens (similar to the lens implant used in cataract surgery but of much higher power) is surgically placed inside the eye. In conjunction with another lens mounted in an eyeglass frame, a telescope is created. While this sounds like a good idea, whenever I am asked about it I discourage my patients from enrolling in this study. The problem with the concept is that while the telescope magnifies things so that they may be more easily seen, it also drastically reduces peripheral vision, often making it difficult to walk, let alone perform more complex tasks. This concept was actually tried over twenty years ago and failed for this same reason.

Retinal implants are tiny computer chips inserted into the eye surgically. They are designed to bypass the function of the diseased retina by capturing incoming light and converting it to electrical impulses. These in turn are passed to the optic nerve to be carried to the brain. The concept shows initial promise but the technology required for useful sight is still probably at least a decade or two away.

Retinal transplants were long thought to be impossible but of course, nothing is impossible. Recently, retinas have been successfully transplanted in experimental animals. The transplanted retinas actually survive in the host. The problem has been that so far, researchers have been unable to establish connections between the transplanted retinas and the optic nerve, so no visual signals are actually sent to the brain.

Investigational therapies for exudative (wet) ARMD include Transpupillary Thermotherapy (TTT), Feeder Vessel Therapy, Rheotherapy, Drug Therapy, Gene Therapy, Radiation Therapy, and innovative surgical procedures.

In Transpupillary Thermotherapy, a low power diode laser is used to heat the abnormal blood vessels beneath the macula without actually coagulating them, therefore sparing the overlying rods and cones. Initial results are promising, although much work remains to be done. In feeder vessel therapy, a complicated device called a Scanning Laser Ophthalmoscope is used to try to identify the single blood vessel of origin feeding all the other abnormal vessels. If such a vessel is found, a laser can close it, cutting off the blood supply to the abnormal tissues. Although there have been some successes, unfortunately this technology is extremely expensive and difficult to use. In rheotherapy, the patient’s blood is actually removed form the body, cleansed of high molecular weight proteins, and then replaced. This is done using equipment very similar to that used in renal dialysis for patients with kidney failure. The idea is that the large proteins accumulate in the blood, blocking the transport of nutrients to the macula and the transport of waste products away from it.

Gene Therapy for wet ARMD sounds like science fiction but the first human clinical trial is actually underway in Oregon. Drug therapy may also sound far-fetched but several very promising drugs are in development. Some of these are designed for injection into the eye and some are actually being developed in oral (pill) form! Radiation therapy has been shown in the past not to be helpful and in fact, even to accelerate the progression of wet ARMD. However, new studies, using different types and doses of radiation, are currently underway.

Aggressive and complicated surgical procedures have been designed in recent years to treat exudative (wet) ARMD. Unfortunately, these are extremely complex, very expensive, and have a very low rate of success. However, since a few individuals have benefited from this approach, some clinical trials are still in progress.

In summary, there is aggressive ongoing research into the treatment of ARMD on many fronts. Some of this research should begin to result in available therapies within the next few years. Meanwhile, we recommend that everyone over 65 should have yearly eye examinations with an ophthalmologist, stop smoking, and if your ophthalmologist says you are a candidate, consider taking the nutritional supplements studied in AREDS. Please continue to check our web site for new developments.


See also our article of October, 2001



October 2003

Vision Improvement After Cataract Surgery
by
Andrew Henrick, M.D.

A cataract is the clouding of the natural lens of the eye, which focuses light onto the back of the eye. When cataract surgery is performed, the cataractous lens is removed. If it were not for lens implants, the vision after cataract surgery would be very blurred because of the absence of a focusing lens. An intraocular lens (IOL) is a focusing lens made of a synthetic, inert material that is implanted into the eye at the time of cataract surgery. It is placed permanently inside the eyeball in the approximate position occupied by the natural lens. Except in very rare instances, the implant never needs to be replaced.

Many patients ask, "Will I need to wear glasses after my cataract surgery with lens implant?" The answer depends on a number of factors, but in general, glasses will be necessary at least part-time for best vision. Most lens implants available today are single focus. That means that they are focused at some predetermined distance, usually far distance. In this case, near vision will be blurred without additional reading glasses. When cataract surgery is performed on both eyes, most people opt to have both lens implants focused for distance so that driving and sports don’t require additional use of glasses. Reading glasses are then worn for near tasks such as reading, crafts, and computer work. Patients who spend a large part of their day doing near work may decide to have both eyes focused at near and wear glasses for distance vision only. Some people may be comfortable with monovision, one eye focused at distance and the other at near. Then glasses need not be worn at all but there may be some visual confusion. Additionally, people with pre-existing astigmatism (an irregular curvature of the cornea, the clear front part of the eye, which results in blurred vision) will not have clear vision without glasses since most lens implants do not correct for this condition. If astigmatism is present after cataract surgery, laser vision correction (LASIK) may be considered to eliminate this condition.

New lens implants are being developed that compensate for some of the shortcomings of current vision rehabilitation following cataract surgery. But as so often happens, one problem is solved only to have a new one surface! Here is a listing of some new developments:

  • IOLs that correct for astigmatism. These lenses must be aligned precisely inside the eye. Unfortunately they don’t always stay put and rotate inside the eye as the healing process takes place. The result is blurred vision necessitating another operation to reposition the lens.
  • Bifocal IOLs. These lenses are a good idea but don’t work like bifocal glasses where the eye looks through a different lens for distance and near by shifting position. Since the IOL does not move inside the eye, both near and distance powers are placed in the center of the lens. The patient thus looks through both lenses simultaneously. Both near and distance images are focused onto the back of the eye and the brain must choose which one to concentrate on. Some patients have difficulty adjusting to this arrangement and may even see halos around lights, making night driving difficult. Some people have even undergone second surgeries to replace the bifocal IOL with a conventional one!
  • IOLs that can change focus inside the eye. Very flexible lenses are being developed that can move inside the eye ever so slightly when the internal focusing muscles of the eye contract, allowing the lens to focus near, far, and in between as the need arises. Sounds promising but the jury is still out on this one.

No IOLs exist that can correct for both astigmatism and focusing. With any of these new lenses, glasses might still need to be worn for some situations. The current standard of practice is to use single focus IOLs. For selected patients, one of these new technology lenses may be appropriate. It is best to discuss the choice of IOL with your ophthalmologist when cataract surgery is contemplated. But in any case, it is prudent to expect to wear glasses at least some of the time following cataract surgery.



July 2003

Diabetic Retinopathy
by
James R. Brinkley, Jr., M.D.

Prior to the development of insulin in 1922, Type I diabetes was a fatal disease. Even today it is fatal in many third world nations, where insulin is not readily available. Because diabetics did not live long, severe diabetic complications in the eye, the kidney, and other target organs were rare. In addition, since most diabetics did not live into their reproductive years, the diabetic gene pool was limited. There are now 150 million people with diabetes worldwide. This number is expected to grow to 300 million by 2025. 90% are Type II diabetics, virtually unknown until the twentieth century.

Today diabetic retinopathy is the leading cause of blindness among working age people in the United States. While Type I diabetics are more at risk for totally blinding ocular complications, Type II diabetics can also suffer severe visual loss, often to the point of legal blindness.

The retina is the inner lining of the back of the eye, analogous to the film in the camera. It converts incoming light into signals that travel along the optic nerve to the brain, allowing us to see. Damage to the retina from diabetes is called diabetic retinopathy. There are two major types of diabetic retinopathy, as well as an intermediate type.

Non-Proliferative Diabetic Retinopathy (NPDR), sometimes called Background Diabetic Retinopathy, includes the first signs of eye damage from diabetes. Weak spots in the tiny capillaries of the retina appear as tiny red dots. These capillary weak spots are called microaneurysms. Some of them rupture and bleed, producing small "dot and blot" hemorrhages in the retina. These hemorrhages alone do not cause visual loss but they do indicate that the diabetes may not be under optimal control.

As more capillary damage occurs, serum begins to leak from the capillary walls. This serum collects in between the cells of the retina. When serous fluid collects in the interstitial (between the cells) space in living tissue, the resultant swelling is called edema. The central portion of the retina, responsible for our sharp central vision, is called the macula. Consequently, swelling of the macula from the accumulation of serum in the interstitial space is called macular edema. Macular edema is one way that diabetic retinopathy reduces vision. It can occur in anyone with diabetes but it is more common in Type II diabetics.

When macular edema occurs, a diagnostic test called a fluorescein angiogram can determine exactly which capillaries are leaking and where. Then a laser can be used to seal these leaks. Once the leaks have been sealed , the serous fluid is slowly absorbed, the edema reduced, and in some cases, vision is restored. Unfortunately, sometimes lipid material in the serum precipitates out and accumulates in the macula, causing permanent damage to the visual cells (rods and cones). Although sealing of capillary leaks with the laser can lead to absorbtion of the exudates; cellular damage, and therefore vision loss, is often permanent.


Photograph of normal retina, showing optic nerve (white disc on left),
retinal blood vessels, & macula (darker area near center).



NPDR with microaneurysms, dot & blot hemorrhages (red), exudates (yellow),
and macular edema (clear wrinkles at center of photo).


When the capillary damage becomes severe enough, the retina becomes ischemic, meaning severely deficient in oxygen. The tissue responds by elaborating a chemical called Vascular Endothelial Growth Factor (VEGF), which stimulates the growth of new blood vessels called neovascularization. Since new vessels are proliferating, this is called Proliferative Diabetic Retinopathy or PDR. It might seem that the growth of new blood vessels would be a good thing. Unfortunately, these vessels are abnormally fragile. They have a tendency to rupture, producing large hemorrhages that can fill nearly the entire eye. These are referred to as vitreous hemorrhages, because they fill the vitreous cavity. Vitreous hemorrhage is the second way diabetes can cause blindness. This problem can occur in anyone with diabetes but it is far more common in Type I diabetics.

Once neovascularization occurs, it can be halted, and even made to regress, with a laser treatment called pan-retinal photocoagulation or PRP. In this treatment a large number of laser burns (often as many as 2,000) are placed in the peripheral retina. These burns are absorbed by the layer under the retina, which is called the Retinal Pigment Epithelium (RPE). The RPE subsequently becomes thinner allowing more oxygen to reach the retina from the choroid, the vascular layer beneath the RPE.


Neovascularization of the Disc (Optic Nerve) or NVD



Laser Beam Striking the Retina
(Previous laser burns are seen as white spots)

If the neovascularization is not discovered in time and a vitreous hemorrhage occurs, it usually will clear. However, if there is repeated bleeding, eventually the eye remains filled with blood and the vision is lost. In such a case, an operation called vitrectomy allows the blood, along with the vitreous gel, to be removed from the eye and vision to be restored.

Whenever new blood vessels grow within the eye, they are accompanied by a sheet of supporting tissue. This is fibrous tissue. Fibrous tissue is similar to scar tissue and over time, it always shrinks. When the fibrous tissue accompanying retinal neovascularization shrinks, it can tug on the retina and eventually cause a traction retinal detachment or TRD. TRD can also be repaired using vitrectomy surgery. After the vitreous gel (and any old blood) is removed, the attachments of the fibrous tissue to the retina can be severed, allowing the retina to settle back into place.


Early Traction Retinal Detachment (white area)

Sometimes, there is an intermediate stage between NPDR and PDR, called pre-proliferative diabetic retinopathy. This is when the retina can be shown to be severely lacking in oxygen supply by demonstrating large areas of capillary death (dropout) on a fluorescein angiogram. In this situation, the eye is at very high risk of developing neovascularization and the patient must be seen more frequently so that laser treatment can be carried out as soon as significant new blood vessel growth appears. If the capillaries in the macula drop out (die), the visual cells in the macula also die from lack of blood supply and vision is lost. In this situation, there is nothing that can be done to restore it.

In summary, diabetic retinopathy can reduce vision in four ways: macular edema, hemorrhage from new blood vessel growth, traction retinal detachment, and loss of the blood supply to the macula. We have treatments for the first three and new treatments are on the horizon. Drugs that inhibit VEGF are being developed that may be injected into the eye or even taken in pill form. Gene therapy is in the very early stages of development. Some day we may have a cure for the diabetes itself or even a way to prevent it.

For now, prevention of the retinopathy is the best approach. It has been conclusively demonstrated that rigid control of the blood sugar can prevent sight threatening diabetic retinopathy. This involves very hard work on the part of the diabetic individual. Rigid adherence to diet, weight loss, exercise, frequent testing of blood sugar, and adjustment of medication dosage in response to the test results are all necessary to achieve the rigid blood sugar control required to prevent diabetic retinopathy from progressing. For many, this means multiple blood tests and even multiple insulin injections daily. For some, an insulin pump is required. However, the results are well worth the effort: a long, healthy life with all the joys of normal sight, our most precious resource.


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April 2003

The Nature and Treatment of Cataractous Visual Loss
by
Paul Prendiville, M. D.

A cataract is an opacity in the natural lens with which we are born. Cataract is the leading cause of mild visual loss in this country and fortunately is correctable with safe, highly effective surgery. The removal of a cataract is the most commonly performed out-patient surgery, and technological advances have made surgery much less disruptive to patients.

Visual loss due to cataract is characterized by blurring. The earliest symptoms may include difficulty with night vision, glare, and/or halos around lights. The most common type of cataract is known as nuclear sclerosis. It is associated with aging and prolonged exposure to ultraviolet light. This type of cataract in the earliest form sometimes causes an increased ability to see objects up close. This paradoxical increase in vision is commonly known as "second sight." Other types of cataract display different characteristic symptoms. For instance, a posterior sub-capsular cataract often occurs earlier in life than a nuclear sclerotic cataract and may cause vision loss more rapidly. This type of cataract makes it more difficult to see up close. It can be associated with the use of certain medications and systemic medical diseases.

How does cataractous visual loss occur? Light rays travel through several structures of the eye before being translated into nervous impulses. They first encounter the cornea. The cornea is now commonly operated on to obviate the need for eyeglasses using laser vision correction methods like LASIK. Next light travels through the pupil. The pupil is the opening in the center of the iris, and the iris is colored part of the eye. The natural lens follows, and it is subject to opacification, which leads to cataractous visual loss. After passing through the lens, light travels through the large vitreous cavity. The vitreous is often associated with it's own opacities which are commonly known as vitreous floaters. Finally the light arrives at the retina where it is translated into nervous impulses which are sent via the optic nerve to the brain.

Thus cataractous change occurs just behind the iris. This is why the evaluation of cataract involves pupil dilation. Dilation of the pupil causes the iris to open widely and allows the ophthalmologist to evaluate the cataractous lens more carefully. Other important examination techniques in the evaluation of cataract include eyeglass measurement and careful examination of the optic nerve and retina. Each of these are included in a routine complete eye examination.

The initial treatment for cataractous visual changes is usually a change in eyeglasses. Typically when there is a change in vision associated with cataract, a new pair of eyeglasses will help to restore vision to an acceptable level. When vision cannot be restored to an acceptable level, cataract surgery should be considered. The decision for cataract surgery hinges on what acceptable vision is for a given patient. This is quite variable and must be considered on an individual basis. An airline pilot or a bus driver would have a greater need for sharp vision than a person who doesn't drive a car. Careful consideration of a person's visual needs relative to their lifestyle and activities of daily living by the surgeon and patient is necessary in the decision for surgery. Cataract surgery is almost never an urgent matter, and therefore there is almost always plenty of time for consideration of how a decrease in vision is affecting a patient's quality of life. Although the risk of cataract surgery is minimal, it is not completely risk free, so the decision for surgery must be made very carefully.

Once the decision for cataract surgery to be performed has been made, several things must occur. These include selection of an intraocular lens and a visit to one’s private medical doctor. The removal of a cataractous lens leads to a large decrease in the ability of the eye to focus light. A replacement artificial lens is placed in the eye at the time of surgery to restore that focusing power. The lens is chosen based on the shape of the cornea and the length of the eye. An attempt is made to choose a lens that will obviate or at least decrease the need for eyeglasses. This cannot always be done if conditions like astigmatism are present. A visit to the patient’s private medical doctor is needed to ensure that general health is sufficient to undergo the minimal medical stress associated with surgery. This visit should be timed within a month from the operation.

The evening prior to surgery antibiotic eye drops are sometimes used to help prevent the risk of infection during surgery. No food or water should be taken after midnight on the evening prior to surgery, and loose, comfortable clothing should be worn to the surgery center. The stay at the surgery center is usually about three hours, and the patient is sent home with the operated eye patched. This patch should be left on until the visit to the doctor’s office on the first postoperative day. Arrangements should be made to have a ride to and from the surgery center and the first postoperative appointment.

Usually three postoperative visits are needed, and these visits occur at one day, one week, and one month. Aftercare involves the use of two or three eye medications, keeping the eye dry, limitation of strenuous activity, and the use of a shield over the eye while sleeping. At the last postoperative visit, a measurement for eyeglasses is performed. Hopefully all would have gone well and a significant increase in vision will be noticed.

Modern cataract surgery is highly successful and although it is not without risk, it is extremely safe. With careful consideration for the timing of surgery and careful postoperative follow-up, a successful surgical outcome is almost always enjoyed by the patient.

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January 2003

New Laser Vision Correction Procedures for Very Near-Sighted Patients
by
Holly M. Spanggord, M.D.

Current laser technology is optimal for the vast majority of patients who want to decrease their dependence on glasses and contact lenses, including myself. I had LASIK done over a year ago and see 20/25 in my right eye and 20/20 in my left eye without correction. Nonetheless, new laser vision correction procedures are adding to our options for patients who are not candidates for LASIK eye surgery. LASIK (which is an acronym for Laser-assisted-in-situ-keratomileusis) involves cutting a flap in the cornea prior to performing a laser ablation. It is this laser ablation of the cornea that reduces the need for corrective lenses. When the flap heals, it is not as strong as the original uncut cornea. Usually this isn’t a problem because the flap is very thin compared to the overall thickness of the cornea. However, patients with high myopia (that is, very nearsighted people) require a lot of laser correction, resulting in very thin corneas. Patients with thin corneas are more at risk for corneal weakening after LASIK and should not undergo this procedure.They may suffer corneal ectasia (an outward bulging of the cornea) after LASIK, resulting in a reduction of vision even with corrective lenses.

Until recently these patients have been advised to avoid laser corrective surgery. However, if the creation of a flap can be avoided, a great deal of corneal weakening can be prevented. Photorefractive Keratotomy (PRK) is an established procedure that avoids creating a flap. Only the very superficial layer of corneal cells (the epithelial layer) is removed prior to performing the laser corrective ablation, leaving a stronger, thicker cornea even in very near-sighted patients requiring a deep ablation. This procedure, although slightly more uncomfortable, is just as accurate as LASIK. In the recent past, it has not been offered to very nearsighted patients because they have been more at risk for post-operative corneal haze or scarring. This scarring can lead to reduced vision even with corrective lenses.

Fortunately, an exciting new development addresses this problem. Refractive surgeons have discovered that mitomycin C, a medication used to prevent scarring in other types of ocular surgery (glaucoma and pterygium surgery), can also prevent scarring after PRK. When used as described in an article published in one of our most respected journals (Ophthalmology, January 2000 issue, Volume 107, pp. 89-94), this medication has been very effective with very few complications. For patients with haze or scarring from a previous PRK surgery, this medication can also be used to prevent recurrence after removal of the haze or scar with the laser.

A few patients treated to prevent haze have suffered over-corrections after the laser procedure and have needed a second“touch-up” treatment after the original procedure. Consequently, many refractive surgeons are adjusting their formulas for laser correction when treating patients who need mitomycin C since the final result is not as predictable as that after traditional PRK without the use of this medication. Although this new technique appears to be safe, we have only 5 years of experience, and it is impossible to be completely sure that future corneal problems will not develop many years later.

A second option is also available for very nearsighted patients. LASEK (Laser-Assisted-In-Situ-Epithelial-Keratomileusis) is exactly like PRK except the epithelium is preserved instead of discarded. Instead of scraping off the epithelium and allowing it heal post-operatively, the epithelium is carefully pulled aside prior to performing the laser procedure. After the laser ablation is completed, the epithelial layer is carefully replaced. This replacement of the epithelium may reduce some of the postoperative discomfort after PRK.

Does this replacement of the epithelium prevent the scarring and haze formation we see after deep laser treatments performed in PRK? At this point in time, we do not know. Since the two procedures are so similar, many refractive surgeons are also recommending the use of mitomycin C for patients who are very nearsighted and have chosen to undergo LASEK.

Patients with high myopia who are not candidates for even these procedures soon may benefit from an implanted intra-ocular lens. This technique involves inserting a lens through an incision into the eye without performing a laser ablation on the cornea. Although not yet approved by the FDA, this procedure may soon be an additional option for these patients.

Certainly, as refractive surgical technology continues to evolve, the variety of surgical options will broaden. Similarly, our established procedures will evolve as we gain experience. In this rapidly advancing specialty, there always seems to be something new just over the horizon.

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October 2002

A Revolution in Glaucoma Treatment? Perhaps Not!
by

James R. Brinkley, Jr., M.D.

When the results of the Ocular Hypertension Treatment Study were published in the June 2002 issue of the Archives of Ophthalmology, some in the press reported that there would be a revolutionary change in the way patients with Ocular Hypertension (elevated pressure inside the eye) are managed by ophthalmologists. Some of our patients have read these reports and have urged us to provide them with medication. Is this the right thing to do?

Glaucoma is a disease of the optic nerve, the nerve that carries visual signals from the eye to the brain. In glaucoma the optic nerve sustains gradual progressive damage of a very characteristic type. This damage in turn produces irreversible vision loss, which begins in the periphery and slowly progresses toward the center over many years. The nerve damage can be detected with a dilated eye examination and documented with photographs. The resulting vision loss can be detected with visual field testing long before it is noticeable to the patient.

Since most cases of glaucoma are caused or accelerated by elevated intraocular pressure, loss of vision can usually be prevented by lowering the pressure with medications. Individuals who have ocular hypertension without optic nerve damage are said to be Ocular Hypertensives or Glaucoma Suspects. There has long been a therapeutic controversy: should ocular hypertensives be treated with medication in an attempt to prevent or delay the onset of glaucoma?

Traditionally, a majority of ophthalmologists have followed ocular hypertensives (glaucoma suspects) closely without treatment, measuring their intraocular pressures several times a year and performing a visual field test and a dilated eye examination to visualize the optic nerves at least once a year. At the first sign of glaucoma, they begin therapy. A minority of ophthalmologists place ocular hypertensives on medication, even though they do not have glaucoma. They do this in the belief that by lowering the pressure, they can prevent glaucoma, or at least delay its onset. Which approach is best?

The Ocular Hypertension Treatment Study was designed to answer this question. It did so by recruiting a large group of people with elevated eye pressure but without glaucoma and dividing them into two groups. One group was carefully observed and the other group was treated with pressure lowering medications. Over the five years of the study, twice as many people in the observation group developed glaucoma as compared to the treatment group. At first glance, it would seem that the minority approach to the problem is the better one. So we should be treating everyone with elevated pressure. Or should we?

It is very important that scientific studies be carefully read and analyzed, lest we draw the wrong conclusions. Careful analysis of the Ocular Hypertension Treatment Study reveals that approximately 10% of the observation group developed glaucoma within the five years of the study, while only 5% of the treated group did so.

Let’s put this information in perspective. Given that glaucoma is a very slowly developing disease and that at the first sign of it, starting treatment prevents any significant loss of vision, is there really anything to be gained from“preventive” treatment? If a person with ocular hypertension receives treatment, (s)he has a 95% chance of NOT developing glaucoma within five years but if (s)he is observed, (s)he still has a 90% chance of NOT developing glaucoma. Another way to state this is that if ocular hypertensives are treated with medication, 95% of them will be wasting their time and their money.

Consider the cost. Based on the average price of a bottle of the most commonly used glaucoma medications, each patient will spend about $600.00 dollars every year (or $3,000.00 over the five year study period) to improve their chances of NOT developing glaucoma from 90% to 95%!

Consider possible side effects. While the medications are very safe, there have been reports of severe reactions in people with certain heart and lung conditions, in very rare cases even death!

Certain groups of people have long been known to be at increased risk for glaucoma and most ophthalmologists already recommend early treatment for these groups. They include people of African-American race, people with a strong family history of glaucoma, and people who have intra-ocular pressure readings over 30.

In our practice, we ask the patient to participate in the decision. Some patients choose medication but they understand that they may never get glaucoma and therefore may be wasting their time and money and exposing themselves to possible medication side effects. Most patients choose observation and they understand that they run a small risk of minimal but permanent visual loss before we confirm that treatment is necessary. They are willing to take this small risk to avoid the expense of treatment and its possible side effects.

The first thing that all medical students learn is: “primum non nocere,” which is Latin for above all, do no harm. This means that if a proposed treatment is not clearly better than no treatment, we should not use it. As we have seen, for those people without increased risk factors, treatment of ocular hypertension is neither cost-effective nor clearly beneficial. Those people with strong risk factors are already being treated. So the results of the Ocular Hypertension Treatment Study will probably not lead to any real change in the practice of ophthalmology after all!

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July 2002

Dr. Holly Spanggord to Join South Coast Eye Care

Holly M. Spanggord, M.D.
The physicians and staff of South Coast Eye Care Centers are very pleased to announce that Holly M. Spanggord, M.D. will join our practice on August 1, 2002. She will practice general ophthalmology with a subspecialty emphasis on corneal and refractive surgery, including corneal transplants, LASIK, PRK, LASEK, and other types of refractive surgery. She will be one of a very few fellowship trained corneal and refractive surgeons in south Orange County.

Dr. Spanggord did her undergraduate work right here in south county. She graduated from U.C.I cum laude and she received two Bachelor's degrees, one in biology and one in psychology. She received her medical education at the University of California, San Francisco, where she was awarded the M.D. degree in 1997. While in medical school, she received two awards for outstanding medical research. She went on to serve her internship in general medicine at Mount Zion Hospital in San Francisco.

Dr. Spanggord completed her residency in ophthalmology at the Cullen Eye Institute of the Baylor College of Medicine in Houston, Texas. She then went on to complete an optional fellowship in corneal and refractive surgery at the prestigious Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois.

Dr. Spanggord has published three original research papers in peer reviewed medical journals and she has presented the results of some of her research at three major medical meetings. She has performed hundreds of cataract, corneal transplant, and refractive surgery procedures. She will live in Aliso Viejo.

All of us at South Coast Eye Care join in welcoming Dr. Spanggord to our practice. She will be a valuable asset in our ongoing mission of providing ethical patient care of the highest quality in a friendly and pleasant setting.

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April 2002

What’s New In Glaucoma Treatment
By
Andrew Henrick, M.D.

What is glaucoma?

Glaucoma used to be thought of as a disease of uncontrolled pressure in the eye which over many years results in damage to the optic nerve and eventually in permanent loss of vision. The optic nerve conducts the image captured by the eye to the brain via electrical impulses, much like a cable brings the TV signal to a TV. The optic nerve contains one million tiny nerve fibers, each one connected to a different part of the retina in the back of the eye. The retina acts much like the film in a camera, capturing the image. In glaucoma the optic nerve is damaged and individual nerve fibers begin to drop out. Eventually the image seen by the brain is degraded and gaps occur in what is seen. This damage is permanent. There are actually at least 70 types of glaucoma but only the most common type, Primary Open Angle Glaucoma, will be discussed.

We now know that pressure is not the only story. Other factors such as blood flow to the eye, and genetically programmed “suicide” of cells also play a role. How else can we explain why some people with high eye pressure do not develop optic nerve damage while others with normal, or even low, pressures do. We now define glaucoma as a disease of the optic nerve which results in gradual permanent loss of optic nerve fibers, and hence vision, sometimes (but not always) associated with high eye pressure.

Why does the eye pressure go up?

The pressure in the eye must be higher than the air (atmospheric) pressure in order for the eye to maintain its ball shape. If the pressure were the same as that of the atmosphere, the eye would collapse! There is a constant circulation of fluid inside the eye. This is not the same as tears! In order to better understand this concept, it may be beneficial to think of the eye as a closed tank with a faucet letting water run in and a drain allowing water to run out. As long as the inflow of water equals the outflow, the pressure in the tank remains constant. But now suppose that the drain becomes partly clogged so that the inflow is greater than the outflow. Eventually the pressure in the tank increases. This is exactly what happens in the eye. Through age or disease the drainage system becomes partly obstructed and the pressure rises.

Can glaucoma be cured?

No! Unfortunately a cure has not been discovered. But the disease can be controlled, requiring a lifetime of treatment and medical follow-ups, just like high blood pressure.

How is glaucoma treated?

Although pressure is not always elevated in glaucoma, treatment is geared towards lowering pressure. No effective treatment exists to date to protect the optic nerve from further damage other than pressure lowering. It has been definitely shown that lowering pressure prevents further damage to the nerve. The goal of treatment is to lower pressure 20 to 30 percent, or more, from baseline untreated levels. In the vast majority of cases, this can be accomplished using eye drops. There are different classes of eye drop medications which may be used alone, or in combination, to achieve the desired pressure. They basically break down into two groups, those that decrease inflow of fluid into the eye, effectively turning down the faucet, and those that increase outflow of fluid from the eye, thus enlarging the drain. In addition to penetrating the eye, eye drop medications may also be absorbed into the blood stream and have an effect on the body. Be sure to ask your doctor about any side effects or drug interactions if you use such drops.

When eye drops fail to control the pressure adequately to prevent nerve damage, surgery in the form of laser or “drainage” procedures may become necessary. In the former, the laser beam is aimed at the drain in the eye to try to make it work better. In the latter, a small opening is made in the wall of the eye to allow the intra-ocular fluid to escape into a small reservoir fashioned on the outside of the eyeball. The excess fluid is then absorbed by the blood vessel lining the reservoir. The laser procedure is called Trabeculoplasty. The drainage procedure most commonly performed is called Trabeculectomy.

It is important to have the glaucoma monitored frequently by an Ophthalmologist. This monitoring includes checking the eye pressure, looking at the optic nerves, and checking the visual field. This latter is a test for optic nerve function and demonstrates any gaps in vision that have occurred. Usually a patient is not aware of gaps in vision until extensive damage to the nerve has occurred. Fortunately, in most cases, glaucoma progresses very slowly and progression may be slowed or halted with proper treatment.

What does the future hold?

Future innovations will include better pressure lowering drugs, treatment geared at improving blood flow to the optic nerve, and genetic treatment to prevent cell death. But early detection will always be the key to preventing damage. This underscores the need for periodic eye exams by an eye care professional trained and experienced in the early detection and treatment of glaucoma – your Ophthalmologist!

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January 2002

New Procedure Adds Refractive Surgical Option
By
Paul Prendiville, M.D.

Laser epithelial keratomileusis (LASEK) has added another option to our current armamentarium for laser vision correction. Hundreds of thousands of patients each year are gaining freedom from glasses and contact lenses through laser vision correction, and we are happy to offer the latest in refractive surgery technology to our patients including LASEK. Most refractive surgical procedures performed in the past have been either laser assisted in-situ keratomileusis (LASIK) or photorefractive keratectomy (PRK). The addition of LASEK will give some of our patients a new option that may be better for them.

Each of these three procedures can be used correct myopia and hyperopia with or without astigmatism. LASIK is performed by using a corneal microkeratome to create corneal flap in order to expose the corneal stroma for treatment with the excimer laser. LASIK allows for a rapid visual recovery with little or no discomfort, however in some situations LASIK is not advisable. These include inadequate corneal thickness, dry eye, and certain corneal abnormalities. Patients with these conditions may usually undergo either PRK or LASEK.

We have performed PRK on many patients that did not qualify or did not care to have LASIK. PRK involves slightly more discomfort than LASIK, and the visual recovery is not as rapid. It is however an excellent procedure, and studies have shown that in terms of efficacy and safety PRK and LASIK are totally equivalent. Sometimes a patient may be a more suitable candidate for either PRK or LASIK based on the condition of their eyes. This is usually not the case though, and generally we let our patients decide which procedure they would prefer. LASEK gives our patients another surgical option.

LASEK involves rolling the corneal epithelium off the corneal stromal bed in one sheet in order to expose the corneal stroma for laser treatment. The timing of visual recovery and the amount of discomfort are intermediate between PRK and LASIK, and initial results for LASEK have been excellent.

The procedure is extremely similar to PRK and LASIK as far as the patient’s experience. The patient is brought into the excimer laser operating suite after preparation of the eye with a surgical cleansing. The patient lies down, and a lid speculum is placed in the eye. A solution is placed on the eye in order to loosen the corneal epithelium, and the epithelium is rolled back in one sheet. The excimer laser is then used to treat the eye, and the epithelium is replaced. A soft contact lens is placed in the eye to enhance comfort and healing, and the patient is ready to go home. Like LASIK and PRK, LASEK only takes a few minutes.

We have had tremendous success with both PRK and LASIK in our practice, and we are excited to begin to offer LASEK as well. If your are interested in finding out if you are a candidate for one of these procedures, feel free to contact us about our monthly laser vision correction seminar or for a full laser vision correction work-up and evaluation.

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October 26, 2001

Special Update

Important News for Macular Degeneration Patients
by
James R. Brinkley, Jr., M.D.

The results of the long awaited Age-Related Eye Disease Study (AREDS) investigation regarding the use of anti-oxidant vitamin and mineral supplements to slow the progression of Age Related Macular Degeneration (ARMD) are finally available. They have just been published in this month’s Archives of Ophthalmology. Before I share the results with you, I would like to give you some important background information.

The inner lining of the back of the eye is called the retina. The retina receives the light rays, which have been focused by the cornea and lens. It then converts them to nerve impulses, which travel to the brain where they are converted into the visual images that we perceive. The retina is analogous to the film in a camera. However, in a camera, every bit of film is the same as every other bit. In the retina, there is a highly specialized area in the center, called the macula. This small area of the retina is responsible for our sharp central vision, including our ability to read, recognize faces, and to do fine detail work. It also provides the bulk of our color vision.

As some people get older, their macula in one or both eyes begins to degenerate, a condition known as Age Related Macular Degeneration (ARMD). There are two types of macular degeneration: atrophic (commonly known as “dry”) and exudative (commonly known as “wet”). Although both types can cause vision loss, the “dry” type usually produces a very gradual loss, with reading ability preserved for many years. An exception is a subgroup known as Geographic Atrophy, which can cause profound visual loss.

The “wet” type also tends to cause profound visual loss, often very sudden. Although this usually occurs in one eye at a time, if both eyes are eventually involved, a person may no longer be able to drive, to read, to enjoy television, to recognize faces, etc. It is therefore very important to learn ways to prevent macular degeneration and if it does occur, to prevent it from progressing to either Geographic Atrophy or to “wet” (exudative) ARMD. If either of these develop, the vision becomes much worse.

The AREDS study has given us at least a glimmer of hope in this regard. It showed that in certain groups of people with macular degeneration, certain specific anti-oxidant vitamins and minerals, taken in high doses, do slow the progression of this disease. These nutritional supplements do not cure macular degeneration. They merely reduce the risk of it getting worse.

The first recommendation of the AREDS report is that all individuals 55 or older have an annual dilated eye examination by an ophthalmologist to determine their risk of developing advanced age related macular degeneration. If they fall into one of the groups where nutritional supplements have been shown to delay progression of ARMD to its advanced forms, they should take the specific nutritional supplements in the specific doses outlined below.

Caveats:

  1. These supplements do NOT help to prevent macular degeneration and are not recommended for people who do not have the disease or who have it in its very early and mild stages.
  2. Smokers should avoid taking the beta-carotene, which has been shown in other studies to increase their risk of cancer, especially lung cancer.
  3. Other anti-oxidants, such as lutein, were not tested in this study and we do not know if they are beneficial or even if they may lessen the benefit of the ones that were tested.
  4. The supplements tested did NOT help to prevent cataracts or their progression.
  5. Taking these supplements does not eliminate the risk of ARMD progressing; it only reduces it. Patients who took the supplements still had progression of their disease; it just occurred at a slower rate. After seven years of taking either the supplements or a placebo, people in the high risk groups who also took the supplements (as opposed to the placebo) had a 34% reduction in progression of the disease to an advanced state and a 27% reduction in significant visual acuity loss.

Having said that, we recommend that people who fall into one of the high risk categories of ARMD should take daily supplements as follows:

Vitamin C 500 mg.
Vitamin E 400 IU
Beta carotene 15 mg.
Zinc oxide 80 mg.
Copper oxide 2 mg.

Only your ophthalmologist can determine if you have ARMD and if so, whether you are in one of the high risk groups that should take these supplements.

laser eye surgery
A normal macula (left eye)
(No supplements indicated)

lasik eye surgery
A macula with “dry” ARMD (Right eye)
(Should take supplements)

laser vision correction
A Macula with Advanced “Dry” ARMD (Left eye)
(Should take supplements)

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October 2001

Dr. Henrick Elected President of California Academy of Ophthalmology

Dr. Andrew Henrick, Vice President and Co-Founder of South Coast Eye Care Centers, has been elected President of the California Academy of Ophthalmology. The Academy is the professional organization that represents California’s ophthalmologists. It is the largest state ophthalmic society in the nation and one of the most active in patient advocacy. Dr. Henrick will serve as President for 2002.

This great honor comes to Dr. Henrick after many years of service to our professional ophthalmic organizations as an advocate for both patients and physicians. He began serving as an officer of the Orange County Society of Ophthalmology in 1988. He was eventually elected President and he served in that capacity from 1994 through 1996.

Dr. Henrick was appointed to the Board of Directors of the California Academy in 1990 and has served on that board continuously since. He has been Vice-President for Public Affairs since 1996, a position he will give up when he assumes the office of President on January 1, 2002.

Dr. Henrick received his medical degree from U.C.L.A., served his internship at Good Samaritan Hospital in Los Angeles, and then returned to U.C.L.A.’s Jules Stein Eye Institute for his residency in ophthalmology. He has been Board Certified in ophthalmology since 1981. Dr. Henrick has been in private practice in south Orange County since 1980.

Dr. Henrick is also Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute of U.C.L.A. where he has taught on a voluntary basis for over twenty years. He is the author of seven peer reviewed articles in the ophthalmic literature and has given numerous post-graduate lectures. Dr. Henrick’s areas of special interest include ophthalmic plastic surgery (see the “Cosmetic Eyelid Surgery” page of this web site for more information) and cataract surgery.

On a personal level, Dr. Henrick is fluent in five languages and is an accomplished classical pianist. He is an avid reader of history and he travels yearly with his lovely wife Barbara throughout Europe, where they enjoy visiting castles, cathedrals, and other historic sites. In winter, they are avid skiers. At home they enjoy gourmet cooking, wine tasting, and long walks.

All of us at South Coast Eye Care Centers are extremely proud of Dr. Henrick’s accomplishments and of the superb surgical and medical care he provides for his patients.

lasik surgery
Dr. and Mrs. Andrew Henrick

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July 2001

Dr. Brinkley Honored by U.S.C.

Dr. James Brinkley, founder and president of South Coast Eye Care Centers, has been named by the Professional Association of the Doheny Eye Institute at the U.S.C. School of Medicine as “Distinguished Alumnus 2001.” Dr. Brinkley was honored at a black-tie awards banquet held at the Ritz-Carlton Hotel in Pasadena on June 15. He joins a long list of distinguished southern California ophthalmologists.

Dr. Brinkley was honored for his contributions to the teaching program at U.S.C., where he is Clinical Professor of Ophthalmology. Dr. Brinkley first became affiliated with the Doheny Eye Institute at U.S.C. when he served a fellowship in retinal-vitreous disease there in 1975-1976. He subsequently joined the voluntary faculty as Clinical Instructor. Later he was promoted to Assistant Professor, then to Associate Professor, and eventually to Professor. He has been the recipient of eleven prior teaching awards from U.S.C.

Dr. Brinkley was presented with a plaque by Dr. Ronald E. Smith, Chairman of the Ophthalmology Department. Stephen J. Ryan, M.D., Dean of the U.S.C. School of Medicine, then made some remarks. Dr. Ryan, formerly Chairman of the Department of Ophthalmology, was Dr. Brinkley’s mentor during his fellowship. Dr. Ryan praised Dr. Brinkley for his integrity and professionalism as a physician, for his abilities as a teacher, and for making what is best for patient care his number one priority.

From 1978 until 1990 Dr. Brinkley spent every Thursday at U.S.C., where he attended morning rounds with the residents, supervised the Retina Clinic at the L. A. County General Hospital, assisted the residents with retinal detachment and cataract surgery, and gave lectures and conferences for the residents, interns, and medical students. Dr. Brinkley continues to teach at U.S.C. to this day. He gives a monthly Fluorescein Angiography Conference for the residents, attends Grand Rounds, and also is an invited guest at Chairman’s Rounds.

Attending the awards dinner with Dr. Brinkley were his associate Dr. Paul Prendiville and his wife, Bronwyn. Dr. Prendiville is himself a graduate of the ophthalmology residency program at U.S.C. and is one of Dr. Brinkley’s former medical students and residents. Bronwyn is an Emergency Room physician and was also one of Dr. Brinkley’s medical students. Our office manager, Ms. Melanie Haupert and her husband Bob also attended the banquet. Ms. Haupert has worked in the practice with Dr. Brinkley for sixteen years.

Also in attendance were Dr. Terry Nakamura-Biaggi and her husband, Tom. Dr. Biaggi, who practices ophthalmology in New York is Dr. Brinkley’s “little sister.” She in fact followed in his footsteps by taking her residency in ophthalmology at the New York Eye and Ear Infirmary. Dr. Brinkley’s other associate, Dr. Andrew Henrick, was unable to attend because of his duties as president-elect of the California Academy of Ophthalmology. Details of this great honor and achievement will be presented in our next quarterly web site update.

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lasik vision
Dr. Ron Smith, Chairman of the
Ophthalmology Department (L), presents
the award to Dr. Brinkley
Ms. Melanie Haupert presents Dr. Brinkley
with orchid lei. Dr. Jerome Tucker, Dr. B’s
former associate in Honolulu, and his wife
Alice, sent the lei.

lasik surgeon
laser eye
Mr. Robert Haupert (L), Dr. Brinkley (C),
and Ms. Melanie Haupert (R)
Dr. Brinkley (L), Dr. Terry Biaggi (C), and
Mr. Thomas Biaggi (R)

eye care
orange county
Dr. Bronwyn Pritchard (L), Dr. Brinkley (C),
and Dr. Paul Prendiville (R)
Dr. Stephen Ryan, Dean of the Medical
School (L) and Dr. Brinkley

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April 2001

New Advances in Contact Lenses
by
Cathy Hull, C.O.T.

South Coast Eye Care Centers is proud to offer the latest advances in soft contact lens design. Our contact lens patients now have a wider selection of lens types and a larger range of fitting parameters than ever before. More and more people can be successfully fit with contact lenses that will fill a variety of needs for individuals with nearsightedness (myopia) farsightedness (hyperopia), astigmatism (non-spherical cornea), and difficulty reading (presbyopia).

Until recently, quality bifocals could be provided only in spectacles. The success rate with bifocal contact lenses was only about 30%. Now Johnson and Johnson has developed an exciting new contact lens called the Acuvue Bifocal. It has a success rate approaching 70%. These contact lenses are disposable bifocal contact lenses. They are replaced every two weeks with brand new lenses. The lenses come in six-packs and one six-pack per eye is good for three months of wear. The Acuvue Bifocal has a wide power range for distance and several different powers for reading. Most prescriptions can be accommodated. Free trial fittings are available.

Another new product from Johnson and Johnson is the Acuvue 2 contact lens. This disposable soft lens has a new edge design which provides for a comfortable fit. In our experience, this is the most comfortable soft contact lens yet! Acuvue 2 lenses are also disposed of every two weeks. Free trial fittings are available.

Soft contact lenses for astigmatism (called toric lenses) have been available for many years but it is only recently that they have been manufactured in the disposable form. Several companies that are now making disposable toric contact lenses, among them Ciba Vision, Johnson and Johnson, and Wesley Jensen. These new lenses allow astigmatic patients the convenience of the two-week disposable lens. Free trial fittings are available.

A variety of new colored lenses have also recently come onto the market. Colored lenses are now available in daily wear, two-week disposable, and even toric lenses to correct astigmatism. With colored soft contact lenses you can enhance your existing eye color or even change to a different color. A wide variety of natural and enhanced tints are offered. You can try on the various colors at no charge. These trial lenses have no vision correction in them and are only for viewing your appearance with various colors.

Another popular product is the one-day disposable contact lens. These soft contact lenses are worn for one day and then discarded. They require virtually NO care so they are very convenient. They are especially popular with people who travel a lot on business, as well as with skiers and campers. Amazingly, a year’s supply of these lenses (365 pairs!) is only about twice the cost of standard soft contact lenses. A free trial fitting is available.

For your eye health and safety we require that you have a complete eye examination in our office within a year before having a contact lens fitting. This eye examination will be billed at our regular fees and may be covered by your medical insurance or your vision care plan. If you have any questions, please call (949) 588-2020 and ask for the contact lens desk.

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January 2001

What Can I Do About My Droopy Eyelids?
by
Andrew Henrick, M.D.

Our eyes are a key feature in our expressions and in how the rest of the world sees us. Do you look older than you should because your eyelids are beginning to droop? Do your friends and co-workers comment on how tired you look, even when you are feeling fresh and alert? Drooping of the upper eyelids can be caused by a number of factors and can make a person look older, appear tired, and even interfere with vision. This problem may be genetic, a result of aging, caused by certain diseases, or be associated with an injury to the face or head.

There are several different procedures designed to restore both function and youthful appearance to sagging eyelids. Before considering how to fix droopy eyelids the underlying cause must be discovered. A solution must be chosen that is geared to repairing the underlying cause; otherwise a poor result may be obtained. Your doctor will ask questions about your general medical history and may ask to look at old photographs to compare your current appearance to the way you looked prior to developing problems with your eyelids. When droopy eyelids are caused by disease, the disease itself must be treated or stabilized prior to considering surgery.

In all cases the drooping is caused by one or more of these three factors: 1) The muscle that raises the upper eyelid may be weakened or its tendon may have stretched or partly been pulled off the eyelid, allowing the eyelid to hang lower and block part of the pupil. 2) The skin of the eyelid may have stretched so that it rests on the eyelashes or even hangs over them, possibly covering the pupil. 3) The eyebrows or forehead may sag, pushing the eyelids downward. In these cases the patient often actively raises the forehead to elevate the eyelids resulting in deep wrinkles and even headaches.

Most of the procedures used to restore normal eyelid function and appearance are performed under local anesthesia, sometimes with sedation if necessary. The most common upper eyelid surgery involves removal of skin using an incision which is hidden by the normal eyelid fold. In some cases, once the skin is removed the eyelid tendon can be tucked or shortened as necessary and in other cases the tendon tuck alone is all that is required. For mild cases of brow sag, the fullness of the eyebrows can be sculpted by removing deep tissue and the eyebrows can be tacked to the bone to raise them, all through the same eyelid incision. For more severe cases of forehead sag, surgery is performed through different incisions, depending on the patient’s needs. In all these surgeries the scars are minimal and can be hidden in normal skin folds so that after some months they become invisible.

All of these procedures can be done on an outpatient basis. Some of them can be done right in our office. As with any surgery, the final results depend on how each patient heals as well as the surgeon’s experience and skill. If you would like to know more, please call (949) 588-2020 to schedule a free cosmetic eyelid surgery consultation, to receive a free brochure on cosmetic eyelid surgery, or to reserve a place at one of our complimentary cosmetic eyelid surgery seminars. These are held one evening each month at our Laguna Hills location. Refreshments are served!

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October 2000

South Coast Eye Care Centers Using a New Laser Vision Correction Facility
by
Paul Prendiville, MD

South Coast Eye Care Center is proud to announce a new affiliation with the University of Southern California - Doheny Eye Institute Laser Center at the Brea Promenade in Brea, CA. We have a long history of involvement with the Doheny Eye Institute, and we have been performing our laser vision correction surgeries at their initial laser center near downtown Los Angeles for many years. (For details on these procedures, please see our Laser Vision Correction page.) We will continue to use the downtown facility, but will be able to expand our service to our patients by using their new location as well. The Doheny Eye Institute maintains the highest standards of ophthalmic care with excellent staff, equipment, and facilities, and we know that by using the Doheny facilities to treat our patients, we will be providing the best care possible.

The downtown Los Angeles location is equipped with a state of the art VISX STAR S2 excimer laser. The excimer laser is a "cool" laser which is able to re-shape corneal tissue without thermal destruction. VISX is an absolute leader in the continued development and enhancement of this wonderful technology. The current VISX laser uses a relatively large spot size for treatment to correct nearsightedness, farsightedness, and astigmatism with great success.

The new Brea facility is equipped with an Autonomous excimer laser, which is slightly different from the VISX laser. The Autonomous laser also creates smooth non-destructive ablations and is able to treat various amounts of nearsightedness, farsightedness, and astigmatism. However it uses a smaller spot size to perform the ablation than the VISX laser and therefore has a slightly different treatment characteristic. For a small subset of patients one laser may be superior to the other, and we are very pleased to offer treatment with both of these lasers to our patients.

Obviously the decision to undergo laser vision correction is complex and highly personal. The physicians and staff at South Coast Eye Care centers hope that our laser vision correction patients will benefit from our ability to use this new facility to provide the best treatment possible. For most patients the difference between the two centers will not be significant, and obviously patients may rest assured that our surgeons will take into account any differences between the two centers which may apply to them during their examination and consultation for laser vision correction.

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April 2000

Colored Contact Lenses
By
Denise Levin, C.O.M.T.

Changing one's eye color has never been easier! Colored contact lenses have recently become available not only in standard daily wear soft contact lenses but also in disposable soft contact lenses. We can now fit both nearsighted people and also those with astigmatism.

A much wider range of natural and designer colors is now available, including green, blue, hazel, brown, and violet. We also have lenses that are designed to enhance one's natural eye color and other lenses that are actually blends of colors designed to create exciting new shades like honey, turquoise, and gray. These colors look natural even on the darkest eyes.

So no matter what your natural eye color, you can now vary it to suit your own style, mood, and occasion. For information on how you can have the eye color you have always wanted, please call our office at (949) 588-2020 and ask for the contact lense desk. One of our certified contact lense technicians will return your call by the next business day.

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January 2000

The Mid-Face Lift
By
Andrew Henrick, M.D

Excess skin on the lower eyelids can make one look older and more tired. However, removing the excess skin may not always be the best treatment. This is because such skin removal increases the downward force of the cheek skin on the eyelid and may actually cause the lower lid to sag, resulting in a round eye look.

If the lower lid skin has wrinkles or is a little loose, laser skin resurfacing can give the lower lid a smoother, rejuvenated appearance. This can be combined with fat removal as required. Lower eyelid "bags" are caused by fat from behind the eye bulging forward through the muscle and pushing the lower eyelid skin forward. This is called herniated orbital fat. This fat can be removed without a skin incision.

If more than a small amount of lower lid skin needs to be removed, the procedure can be performed through a small incision just under the lower eyelid lashes. The skin is undermined down into the cheek area so that the cheek can be lifted and affixed to the bone below the eye. This is called a mid-face lift. The advantages of a mid-face lift are that the folds on the side of the nose are smoothed which results in a more youthful appearance, round eye is avoided, and only a very small incision is used, resulting in an almost invisible scar.

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eye doctor
vision care

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