CALIFORNIA OPTOMETRIC LASER ASSOCIATES, INC. News For Co-Managing Optometrists COLA, Inc. is... An innovative optometric corporation that provides administrative services to ophthalmologists and optometrists, with the goal of fostering the best co-management of refractive and other comanaged patients. Contracted with over 800 optometrists, 10 surgeons and 12 surgical centers throughout California. The easiest, most flexible and legally safest way to practice surgery patient co-management. Inside this issue: Furlong Vision gives to HOPE Pull-Out and Save! Surgeon Panel Co-Management Marketing Basics 2 3 3 Winter, 2008 THE SURGICAL REHABILITATION OF THE POST-RADIAL KERATOTOMY EYE by Mark Mandel, M.D. Between the late 1970s and the mid-1990s, radial keratotomy was the refractive procedure of choice for low to moderate myopia. Although most of these patients continue to be stable, there are an increasing number of post-radial keratotomy patients who seek consultation either because of residual or new onset myopia, progressive (consecutive) hyperopia, and/or or the development of a cataract. In the post-rk patient who presents with myopia, it is critical to differentiate between residual myopia, regression of the RK effect back towards myopia, and the development of a nuclear sclerotic cataract. By taking a careful history and performing a diligent examination of the eye, armed with a few caveats, one can arrive at the correct diagnosis, recommend the appropriate optical or surgical treatment, and properly educate the patient as to the realistic expectations. Late regression of the RK effect back towards myopia is extremely rare. Initial undercorrection of the higher myope is somewhat more common. However, the most likely cause of progressive myopia following radial keratotomy is the development of a nuclear sclerotic cataract. If a patient does not correct to 20/20, care must be taken to rule out the possibility of irregular astigmatism rather than the cataract as a cause for decreased best corrected visual acuity. Oftentimes, irregular astigmatism and cataract coexist. A hard contact lens over-refraction will eliminate the component of irregular astig- matism and allow one to differentiate between irregular astigmatism and cataract. Additionally, the use of the hard contact lens over-refraction data in the eventual calculation of the lens implant power is extremely helpful. In the patient with progressive hyperopia, the RK continues to have a flattening effect even years following the initial procedure. This is especially true if the eye has undergone one or more post-rk enhancements, had a small optical zone, or 16 or more incisions. Also, it is important to determine whether the patient experiences diurnal fluctuation of vision throughout the day which is common in the consecutive hyperope. This must be thoroughly discussed with the patient because following either cataract surgery or post-rk LASIK surgery, the diurnal fluctuation will persist. Additionally, the consecutive hyperopia may continue to progress. (Continued on page 2) New Website and Contest ILEA - A Case Study COLA Contact Information 4 5 6 Upcoming Events 6 Surgical Options for Treating Presbyopia Baby boomers are the fastest growing segment of the population. Someone turns 50 every 8 seconds and this trend will continue until 2011. Most baby boomers are used to being very active and, for the most part, not worrying about seeing things up close. Presbyopia is certainly not a life threatening event, but is definitely a major inconvenience. We all like to think of ourselves as eternally youthful, but reading glasses get in the way of that image. Traditionally reading glasses, bifocals and contact lenses have been available to help correct this problem. They all work, but do not necessarily fit the lifestyle most of us have become accustomed to. There are now four ways to surgically correct Presbyopia: Near Vision Multi-focal LASIK or PRK, Monovision LASIK or PRK, Multifocal or Accommodating IOL, and by Michael Gordon, M.D. CK- Conductive Keratoplasty. Below is a brief description of each procedure. PML/Near Vision Multi-focal LASIK/PRK - This procedure was developed in Europe based on principles we have observed here after many years of successful vision correcting surgery. Ophthalmologist colleagues over the last five years have perfected a technique to pro- (Continued on page 2)
Page 2 NEWS FOR CO-MANAGING OPTOMETRISTS FVC Partners with HOPE Services to give Gift of Sight Dr. Michael Furlong is a strong believer in giving back to his community. In 2002, he launched Gift of Sight - a cooperative program with a local charity that provides free eye exams, vision correction and post op care to individuals in the Bay Area who cannot afford corrective procedures. The program has been a huge success, greatly improving people's lives, both personally and professionally. For the past three years, FVC has partnered with HOPE Services, a local nonprofit that provides programs and services to 3,000 individuals with developmental disabilities such as mental retardation, cerebral palsy, epilepsy and autism. HOPE enables infants, young people, adults and seniors to live and participate in their communities. On August 14th, 2008, Dr. Furlong closed his clinic and performed surgery on 10 HOPE Services clients and staff members at no cost to them. The San Jose Mercury News covered the event. Since launching the Gift of Sight, Dr. Furlong has: Donated more than $300,000 in services Helped improve the quality of life of more than 50 individuals Worked with more than 10 local nonprofits To learn more about the Gift of Sight and hear an interview regarding the program and HOPE, go to www.furlongvision.com/ gift_of_sight.html. Gordon Binder & Weiss Vision Institute has always encouraged the optometric community to partner in patient care. If you have an interest in learning more about the practice and comanagement, please contact Dr. Mick Tartaglia at (858) 455-6800. Surgical Rehabilitation, cont. Presbiopia, cont. vide multifocality, or more of a panfocus, by inducing negative spherical aberration and creating a corneal shape that is prolate. The beauty of this procedure is that it preserves one s distance vision while improving the near vision, so depth perception should not be affected as it can be in monovision. It applies to people who are emmetropes, hyperopes (<3D) and myopes (<5D). The risks are the same as LASIK/ PRK. Monovision LASIK/PRK- Monovision is an adaptive process by the brain, and can take a few weeks to be comfortable. It is a procedure we have been doing for 25-30 years and works very well. LASIK and PRK are Excimer laser procedures in which corneal tissue is removed by the laser by breaking the chemical bonds of the corneal protein (there is no heat). Because the cornea is sculpted and not bent, this procedure tends to be very stable over time, and carries the same risks as traditional LASIK/PRK. We prefer a modified Monivision in which we aim for 1 1.25D of add to preserve distance acuity while Once glasses or contact lenses are no longer a treatment option, there are a number of surgical procedures which can be helpful for these patients. In the post-rk patient with residual myopia with or without astigmatism, or the low hyperope (up to +4.00) with or without astigmatism, LASIK is an excellent choice. Although the post-operative results are not as accurate as in a virgin eye, these patients are generally thrilled with the results. Those with diurnal fluctuation must be carefully informed that the fluctuation will continue post-lasik. A surface procedure such as LASEK or PRK with Mitomycin-C can also be performed. The use of Mitomycin -C is critical to diminish the potential for surface scarring. I do not recommend EPI-LASIK because the epithelium is often adherent to the radial incisions. For the post-rk patient with a cataract or in the high hyperope with or without astigmatism, the removal of the crystalline lens with the placement of either a monofocal spherical or toric IOL, or Crystalens can have outstanding results. Again, patients with pre-operative diurnal fluctuation will continue to experience post-operative diurnal fluctuation, and patients who have pre-operative irregular astigmatism diminishing their best corrected visual acuity will also have post-operative diminished best corrected visual acuity due to the irregular astigmatism. However, in the post-rk patient with a cataract or in the providing a good range of functional near vision. Multifocal/Accommodating IOL- This technique is one where the natural lens of the eye, the root cause of the Presbyopia vision change, is replaced with a prosthetic lens. The unique design of these lenses permits them to act similar to the natural lens. Once reserved for those with lens changes that produced visually significant cataracts, we now use the same techniques in restoring reading and distance vision for those of any age. The risks of this surgery are identical with those of cataract surgery. Since this involves making a small incision in the eye and removing and replacing the natural lens, complications may include retinal detachment, glaucoma, infection and even loss of vision. These complications are rare but need to be discussed as always during the informed consent process. Conductive Keratoplasty (CK) - is a very safe and effective procedure that utilizes Radio Frequency energy to bend high hyperope, the results of lens-based surgery are excellent. These patients must understand that in almost every case, in order to obtain vision close to emmetropia, a post-lens extraction LASIK will be required. In summary, the post-rk patient with residual or new onset myopia or consecutive hyperopia, even with relatively high amounts of astigmatism, can be helped with either corneal or lens-based refractive surgery or a combination of both. These patients are often extremely visually disabled and are tremendously grateful for the improvement in vision. Of course, realistic expectations are always critical. For more photos and a diagnosis/ treatment guide, visit www.colainc.com the cornea to a new shape. This is done by contracting the corneal collagen in the periphery of the cornea to steepen the curve in the center. It does not remove any corneal tissue, but because the cornea has some elastic memory, typically some of the effect is lost over time. This may necessitate enhancing the initial surgery some months, or even years, later. It remains the simplest and safest of the procedures we perform, but is limited to emmetropes and low hyperopes. CK is a monovision procedure, so there is some compromise in distance vision. Cataract surgery should now be considered a form of refractive surgery, and as such our patients deserve sharp uncorrected vision. More than 25% of cataract patients have greater than 0.75 D of corneal astigmatism, which should be addressed by the surgeon in pre-operative planning. For these patients, successful surgery is only part of the process to achieve sharp uncorrected vision.
COLA NORTHERN CALIFORNIA SURGEON PANEL To learn more about our distinguished panel of surgeons and view their complete C.V.s, please visit the listed center websites, or visit www.colainc.com Amin Ashrafzadeh, M.D. Modesto has specialized training in performing LASIK eye surgery and other corneal procedures such as corneal transplantation and anterior segment reconstruction. Dr. Ash is a Diplomate of the Am. Board of Ophthalmology and a member of the Am. Academy of Ophthalmology and the Am. Society of Cataract and Refractive Surgery. www.mchenrylasik.com V. Nicholas Batra, M.D. Bay Area / San Jose Specializes in Corneal and Refractive Surgery as well as in the diagnosis and treatment of conditions and diseases of the cornea, anterior segment, and external eye structures. Dr. Batra is a member of the Am. Board of Ophthalmology, the Am. Academy of Ophthalmology, and the Am. Society of Cataract and Refractive Surgery, www.batravision.com Bart Carey, M.D. Bay Area / San Jose Specializes in Refractive Surgery, Cataract Surgery, General Ophthalmology and is certified to perform both laser vision correction and Intacs corneal ring segments for the correction of myopia. Dr. Carey is a member of the Stanford Refractive Network and is a Board Certified members of the Am. Academy of Ophthalmology. www.careyvision.com Michael Furlong, M.D. San Jose / Bay Area is a fellowship trained specialist in corneal and refractive surgery, specialized in small incision cataract and laser refractive surgeries. Dr. Furlong continues to teach others about the latest vision surgery advances by offering regular continuing education courses to other medical professionals in the Bay Area. www.furlongvision.com Mark R. Mandel, M.D. San Jose / Bay Area is a fellowship trained specialist in corneal and refractive surgery. Dr. Mandel teaches and lectures throughout the U.S. and abroad to eye surgeons on different aspects of cataract, corneal, and refractive surgery. He also teaches at the University of California, Berkeley, UCSF, and at the California Pacific Medical Center in San Francisco. www.optimaeye.com Lee Schwartz, M.D. Berkeley / Bay Area Is a fellowship trained corneal specialist and an Assistant Clinical Professor at U.C. Berkeley and at the Ca. Pacific Medical Center in San Francisco. He has authored numerous research and clinical articles and is board certified by both the Am. Board of Ophthalmology and by the Am. Board of Internal Medicine. www.pacificeyespecialists.com Stephen Turner, M.D. San Jose / Bay Area Is a LASIK and refractive surgery specialist. Dr. Turner is currently an Assistant Clinical Professor of ophthalmology at the University of Ca. Medical Center in San Francisco. He is a Board Certified Ophthalmologist and a trained fellow at the Am. College of Surgeons. Dr. Turner lectures extensively throughout the Bay area. www.turnereye.com Stephen Wilmarth, M.D. Sacramento is Board Certified by the Am. Board of Ophthalmology and is a Fellow of the Am. Academy of Ophthalmology. He serves as an Expert Reviewer for the Medical Board of California. Dr. Wilmarth performs state-of-the-art refractive surgery and small incision cataract removal with intraocular lens implantation and oculoplastic surgery. www.wilmartheye.com Internal Marketing: Back to Basics By Janet Walker For the past ten years, I have helped ODs and MDs market their LASIK, and more recently, lens implant, practices. For MDs, building and maintaining solid relationships with ODs who understand how to comanage and how to promote comanagement in their practices is of key importance. For ODs, covering the basics of internal marketing has been, and still is, the best way to build a LASIK and implant co-management practice. This article, adapted from a September 2002 issue of Optometric Management, holds marketing advice that is as relevant today as it was six years ago. Are you covering all of the basics to market and build your co-management practice? Posters, countertop displays, videotapes and brochures. The COLA marketing department, your surgeon's office, and device and lens manufacturers can provide in-office displays and promotional materials. These items are also available from companies that sell practice promotional materials, such as Patient Education Concepts. Place these point-of-purchase displays in your office waiting room, contact lens training area and exam lanes. Whenever possible, these items should promote your qualifications as well as your surgeon s. Staff interactions. When patients make appointments, have your staff ask, "Is this for glasses, contact lenses or Laser Vision Correction?" Doing so proactively announces that you provide full-scope refractive care. Train your staff to handle LASIK and implant inquiries and consider designating a surgery coordinator. Often times, your surgeon's office or the laser or lens manufacturer will have available staff-training materials and workshops. On-hold phone message. It's never ideal to put someone on hold, but it happens in busy practices. Take advantage of such time with an educational on-hold phone message that explains your LASIK and implant comanagement services to your pa-
COLA SOUTHERN CALIFORNIA SURGEON PANEL To learn more about our distinguished panel of surgeons and view their complete C.V.s, please visit the listed center websites, or visit www.colainc.com Carl Hartman, M.D., Orange Co. / Long Beach is a Diplomate of the Am. Board of Ophthalmology, a Fellow of the Am. College of Surgeons, and a Full Clinical Professor of Ophthalmology at the University of California. He is certified in all types of refractive care, from IntraLasik to the newest wavefront technologies and advanced surface ablation. www.longbeachlaser.com. John A. Hovanesian, M.D. Orange Co. Is a specialist in refractive surgery, cataracts, cornea and external disease. He is an assistant professor at the Jules Stein Eye Institute and teaches surgical technique to hundreds of doctors. He has published numerous research studies and has lectured internationally on refractive surgery, optics, and corneal disease. www.harvardeye.com. Michael Gordon, M.D. San Diego was the first surgeon in the U.S. to use the Summit excimer laser to correct nearsightedness and has taught excimer laser techniques all over the world. He is Fellowship trained in Corneal and External Diseases, Board Certified by the Am. Board of Ophthalmology and a member of the Am. Society for Cataract and Refractive Surgery. www.gbwvision.com Diana Kersten, M.D. Orange Co. specializes in laser vision correction and refractive procedures. Her ophthalmology training was completed at Harvard Medical School. She is a fellow of the Am. College of Surgery and is board certified by the Am. Board of Ophthalmology. Dr. Kersten has served as an associate professor at the Univ of California in Irvine. www.harvardeye.com David Wallace, M.D. Los Angeles is a board-certified ophthalmologist specializing in LASIK, PRK, and other methods of vision correction. He is a Fellow of the Am. Academy of Ophthalmology and a member of the Am. Society of Cataract and Refractive Surgery. He co-invented and developed three computer-based diagnostic instruments used worldwide. www.la-sight.com Jack Weiss, M.D. San Diego specializes in corneal and refractive treatments. He performs topical anesthesia, small incision cataract surgery. He is experienced in LASIK, PRK, Intracorneal Segments (INTACS), CK, and Advanced Lens Implant Technology. He is board certified and a fellow of the American Academy of Ophthalmology. www.gbwvision.com tients. Web site. An increasing number of optometric practices have Web sites that allow patients to request appointments, download office forms, access office hours and driving directions and reorder contact lenses. This is another excellent venue to provide information about your co-management services. Consider forming a mutual Web-link between your practice and your surgeon's office. Testimonials. Written testimonials from your LASIK patients are powerful. With your patients' permission, display them in your office. Frame them on the wall or collect them in a binder for the waiting room. You can also share excerpts of testimonials in office newsletters or on your Web site. Direct mailings. Most optometric practices send patients recall letters and newsletters (either in print or in electronic form). These are opportune vehicles for providing information about LASIK and implant technology. Some patients can enroll in a flexible spending account (FSA) through their employers. A direct mailing reminding patients to enroll can serve as the "call to action" to have LASIK. These accounts allow patients to allocate pretax dollars to have the procedure. FSA enrollment periods vary according to employer, but they typically end in November or December. "Meet the surgeon" seminars. Conduct LASIK seminars so your patients can informally meet your refractive surgeon. You can tie the seminar in with a trunk show for sunglasses or viewing a LASIK procedure. New Website & CONTEST! www.colainc.com Enter to Win! 1. Vist www.colainc.com 2. Under Contact Us send us your current e-mail address for news and notification of upcoming events 3. You ll be entered to win one of many prizes - including a new ipod! Patient Information & Financing Member Section with Fee Schedules and Form Downloads News and Continuing Education Events (Register Online)
Winter, 2008 Page 5 The Acrysof Toric IOL: The New Standard for Correcting Astigmatism at the Time of Cataract Surgery by Bart Carey, M.D. Until recently, astigmatism was corrected at the time of cataract surgery by placing limbal relaxing incisions (LRI s) along the steep cylinder axis. Though a simple procedure, the predictability of LRI s is poor, dependent upon factors such as corneal thickness, incision placement, wound healing, and the accuracy of the surgeon s nomogram. The Alcon Acrysof IOL is the most popular lens platform for patients worldwide. The AcrySof Toric IOL adds astigmatic correction to the posterior lens surface, offering precise astigmatic correction by offsetting corneal astigmatism, independent of variables such as corneal wound healing. The AcrySof Toric IOL is currently available in three astigmatic powers, correcting the following amount of cylinder at the corneal plane: SN60T3 = 1.03D, SN60T4 = 1.55D and SN60T5 = 2.06D. Greater amounts of cylinder may be corrected by adding LRI s at the time of surgery or performing laser vision correction postoperatively. Higher power toric lens models will be available next year. and placement is performed using the Alcon Toric IOL Calculator, available online at www.acrysoftoriccalculator.com. Once the desired spherical equivalent IOL power has been chosen, keratometric data is input to determine toric IOL model and axis placement, also taking into account any surgically-induced astigmatism. When placing the toric IOL (or any other IOL), it is advantageous to minimize incision size and induced astigmatism. In our practice, for some time, we have performed micro co-axial phaco through a 2.2 mm incision, with foldable Determination of proper toric IOL model (Continued on page 6) IntraLase Enabled Anterior Lamellar Keratoplasty - A Case Study Corneal Transplant Surgery was first performed in 1906, however; it has only been in the past 5-10 years that selective transplants have advanced with consideration of the diseased segment of the cornea. In the past there has been difficulty in properly diagnosing and measuring segments of the cornea and difficulty in implementing treatment to these measurements. Visante Anterior Segment Optical Coherence Tomography (Carl Zeiss Meditec, Dublin, CA) has revolutionized our ability to evaluate the Anterior Segment. It allows for precise measurements. IntraLase Femtosecond Laser (Advanced Medical Optics, Irvine, CA) has revolutionized microscopic ophthalmic surgery with giving surgeons the capacity to plan exact incision planes. This new surgical "knife" gives a level of precision never experienced in the past. Combining the diagnostics of the Visante OCT and the IntraLase FS Laser creates a powerful combination that has only been dreamt about in the past. The following case presentation is one to demonstrate the marriage of refractive surgery with classic corneal surgery. Case Presentation 19 year old patient with history of contact lens ulcer 2 months previously developed a dense central corneal scar (Photo 1). The scar reduced the vision to counting finger vision in this eye. The most common surgical option considered for this patient would be a full thickness corneal transplant surgery or possibly a deep anterior lamellar keratoplasty. On the High Resolution Visante OCT image its depth is measured to be 270 microns, (Photo 2). The patient underwent IntraLase Enabled Anterior Lamellar Keratoplasty by removing the anterior 270 microns and replacing it with clear donor tissue, cut to same exact size. The post operative change can be easily noted in the Visante image taken only 10 days after the IntraLase Lamellar Keratoplasty. The patient s vision has improved to 20/50 from counting figure preoperatively. The clinical recovery was very rapid, similar to LASIK eye surgery, and the new corneal transplant was placed without any sutures. This case presentation proves the power of Visante and the IntraLase that was able to bring this advanced therapy to this patient. The patient is able to keep his own endothelial layer and therefore virtually eliminating the possibility of corneal transplant rejection. Patient avoided a 1 year recovery period required for full corneal transplant or even Deep Anterior Lamellar Keratoplasty. Even at 10 days postoperatively with an incompletely healed epithelium, this patient was 20/50 uncorrected and back to work with greatly improved vision. At the 3 ½ month post-operative visit he was noted to have a refraction of 6.00+2.00x090 in the right eye (unaffected eye) à 20/20 and an UCVA of 20/50 in the left eye (surgical eye) and with a refraction of -1.25+1.00x104. by Amin Ash, MD Pre Op Post Op Amin Ashrafzadeh, MD (Dr. Ash) is the first surgeon in Northern California to perform the IntraLase Enabled Keratoplasty surgeries at Northern California Laser Center, Modesto, California.
CALIFORNIA OPTOMETRIC LASER ASSOCIATES A Co-Management company for optometrists, by optometrists. Setting the Standard in Refractive Surgery Management COLA, Inc. resources have allowed the development of robust comanagement systems that provide efficient communications between the surgeon and the O.D. In addition, COLA helps to ensure high quality by credentialing each surgeon, center and co-manager. PRSRT First-Class Mail U.S. Postage PAID Permit No. 1633 San Bernardino, CA 303 West Joaquin Ave, Suite 250 San Leandro, California 94577 Phone: 877.414.COLA So. Cal: 949.462.0888 E-mail: info@colainc.com We re On the Web! www.colainc.com Upcoming Events January (TBD): Orange County: PML - Presbyopic Multifolcal LASIK - Michael Gordon, M.D. and Jack Weiss, M.D. Tuesday, March 10: Los Alamitos: Solving Your Patients Vision and Cosmetic Complaints. - Carl T. Hartman, M.D. Feb / March TBD San Jose: Post RK and Refractive Procedures - Mark Mandel, M.D., Stephen Turner, M.D., Nicholas Batra, M.D. To Register, go to www.colainc.com, call 949.462.0888 or email jwalker@colainc.com The Acrysof Toric IOL cont. IOL placement through the same micro incision. The Alcon Acrysof IOL has many advantages, some particularly suited to the rotational stability needed for predictable toric correction. The hydrophobic acrylic material is flexible, biocompatible, and bioadhesive. Stableforce haptics ensure centration. As a result eyes with an Acrysof lens tend to have minimal postoperative inflammation, but maximal lens rotational stability and optimal lens centration in the capsular bag. FDA studies of the Acrysof Toric IOL have shown average rotational deviation from the intended axis of less than 4 degrees. Initially during surgery, the toric IOL is rotated to a position approximately 15 degrees shy of final desired axis. Then at the time of viscoelastic removal the lens is nudged to final position based upon preoperative corneal markings. This lens stays where it is placed (though perhaps more good news is that any rotational errors may be cured by easy rotation of the IOL in the capsular bag back to desired to position). Implantation of the Acrysof Toric IOL is the most predictable way to correct astigmatism at the time of cataract surgery, and may be the lens of choice for patients with as little as 0.75D or more of preexisting corneal astigmatism (depending on axis). In our practice, it has replaced LRI s as the preferred method of astigmatism correction for our cataract patients. The highest level of success is dependent on several factors including precise determination of IOL power and cornel astigmatism, predictable micro-incisional phacoemsulficiation, and pre- cise rotational IOL placement. Even more exciting will be the addition of this technology to the ReSTOR apodized diffractive multifocal IOL, adding the option of complete spectacle freedom for our astigmatic patients. In our next issue: Nutrition and Eye Care a medical journal update Reducing the Need for LASIK Enhancement by 65%