Dry Eye is one of the most prevalent eye conditions in the world, affecting millions of people, with billions of dollars spent on treatment every year.

We’ve been seeing a lot of infographics circulating around the web, so we thought we’d try our hand at creating our own about Dry Eye. Enjoy!

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LASIK on the Frontlines – Update

A few months back, Dr. Paul Koch wrote a blog post regarding an upcoming documentary about the use of LASIK surgery in the United States military, titled LASIK on the Frontlines.

Since that blog post was published, PEC, the patient education company that produced the film, has begun selling it on their website. They have also released an 8-minute and a 28-minute version on Youtube.

If you’re involved in the LASIK industry, this documentary is a must-watch. We’ve provided the 8-minute version below. To see the longer version, click here.

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Dr. Paul Koch takes a critical look at whether Femtosecond Lasers are all they’ve been hyped up to be.

As many times as I have looked at femtosecond lasers for cataract surgery, I continue to wonder not so much what there place will be in our practices, but whether there will be a place. Cool and exciting technology as they may represent, they should still require filling an unmet need. And here I’m not sure we have enough information to decide.

We do not know how much a laser will cost, and we do not know how much a click fee will be. Without this information we cannot generate a purchase plan. We do not know how many patients will elect the laser procedure, how we will be able to charge them, or how much each patient will pay. Without this information we cannot generate an income plan. Hmmm, no purchase plan and no income plan means no business plan, doesn’t it?

We could ask who needs a laser to make a round capsulotomy. Fair enough.  I suppose less experienced surgeons do. But are the less experienced surgeons the ones with the cash flow to confidently obtain a laser without having a business plan? I suspect not. I also suspect that the ones with the cash flow who could get away with the purchase are probably the same ones who can make a pretty good capsulotomy by hand.

So, do we have a compelling argument for why we need a femtosecond laser for cataract surgery? I’ve yet to be convinced by any discussion I’ve had with any of the manufacturers. The theme mostly seems to be that their capsulotomy is rounder than your capsulotomy. But, does that translate into better, or even different outcomes for patients? We don’t know. There is no scientific evidence that clinical results will be any different if steps of the operation are performed with a laser. So, then, what’s the rush?

Ultimately, I think it boils down to two reasons. The first is fear that someone else will get one, advertise the bejeebbers out of it, and take away all your patients. I’ll accept that. That could happen.

On the other hand, when I see this paranoia I want to follow my experience, and here it instructs me to follow the money. Here’s what I see:

There are some very excellent laser technicians who want to use their knowledge to make enough money that they will never have to work again. They did fairly well with laser flap-makers for LASIK, but where to turn next? “Aha, cataracts,” they cried, and designed the lasers. And then they were joined by the venture investors, who also want a good return on their financial support. And these are the parties, the inventors and the financial backers, both hoping enough money flows in so they can spend the rest of their years soaking up sun in the Caymans.

And how can they find all that money? By stirring ophthalmologists into such a panic that they gleefully chip in a half million dollars each to buy a laser they might not need, and that has never been proven to make any results better. But, if they don’t spend their half-million someone else might spend their half-million, so they better spend their half-million first.

Wow, are we so predictably nuts that we could fall for that? What ever happened to performing clinical trials to see if new technology helps our patients beyond what we are doing now? I guess that’s been replaced by “I gotta be first, dang nab it!” Odd, but I do not see any other explanation except perhaps blind faith of such fervor it would make any denomination jealous.

Me, I want to see someone show me that they’re better – not might be better, or could be better – but actually do provide results better than I’m producing now. I want to make my decision based on clinical evidence that this technology will help me and my patients. I don’t think that’s too much to ask.

Contact Dr. Koch

Minimize Confusion

At the preop level, minimize premium IOL choices as patient confusion may deter surgery altogether.  No US FDA-  approved presbyopia IOL addresses astigmatism yet and dependent on your patient counseling a toric IOL upgrade  might be a better option.

Consider Lifestyle

Find out the wants and needs of your patient, such as job-related tasks (truck driver with lots of night vision needs), or hobbies (golf annually or weekly).  Avoid IOL selection based on an annual hobby such as the October 3-day hunting trip, but rather select a premium IOL for the needs of the patient the other 362 days of the year.

Take Preop Action

Patients also need to be counseled preoperatively about the need for possible Yag Capsulotomy and/or residual refractive error correction postoperatively. Topographic analysis preoperatively is critical:  a patient with Keratoconus or Forme Fruste Keratoconus (FFKC) may not be a candidate for refractive enhancement postoperatively for residual myopia and/or astigmatism.

Telling the patients more information preoperatively will reduce chair time and patient dissatisfaction postoperatively.

Avoid Postop Dissatisfaction

Lastly and unfortunately, the most chair time consuming problem is when the patient declines the premium upgrade preoperatively, has uncomplicated surgery, then complains postoperatively about the need for glasses still.

Though not out of malpractice necessity, we have our patients sign a consent waiver actually stating their decision not to upgrade so they have no place to complain postoperatively!  Good riddance and hope they enjoy the big screen TV they chose to spend their precious dollars on instead!

Look out for the next blog: Managing the Preoperative Evaluation.

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Previous doctors had tried artificial tears, corticosteroids, cyclosporine, allergy medications, oral doxycycline, antibiotic ointments and combination antibiotic/steroid drops, but all to no avail.  He was treated with hypertonic drops and ointment for recurrent erosion, which had limited success as well.  Corticosteroid drops worked the best at improving the signs and symptoms but without complete resolution. As he tapered the medications a rebound would occur and eventually the symptoms persisted even in the presence of corticosteroid drops.  Antibiotic ointments also helped but could not fully improve his condition.  The patient had been suffering on and off with this for almost three years!

The Diagnosis?

In cases of chronic SPK consider Floppy Eyelid Syndrome. The lack of a tight eyelid results in chronic inflammation to the cornea and conjunctiva as was evident by the corneal and conjunctival edema and staining.  Lifting his upper eyelids showed them to be extremely “elastic,” and they could be flipped with one finger or even pulled approximately two inches away! This condition is more common in overweight, middle-aged males as was the case here[1].  The patient also confirmed a history of sleep apnea, which is also consistent with FES[2].  The only option for FES this severe is surgical repair, which the patient underwent two weeks ago and is already showing significant improvement to signs and symptoms.  We continue to maintain the best possible ocular surface with artificial tears, punctal plugs and therapeutics for the chronic SPK associated with this condition, but it has greatly improved after surgical intervention.

[1] Pham TT, Perry JD. Floppy eyelid syndrome. Curr Opin Ophthalmol. 2007;18(5):430-3.

[2] Karger RA, White WA, Park WC, et al. Prevalence of floppy eyelid syndrome in obstructive sleep apnea-hypopnea syndrome. Ophthalmology. 2006;113(9):1669-74

Contact Dr. Karpecki

1. Obvious causes observed on slit lamp examination – Foreign body, Trichiasis, Bell’s Palsy, Conjunctivochalasis

1. Testing: Slit lamp exam, NaFL staining

2. Treatment: Remove FB, epilate lashes etc. and treat with an antibiotic if there is breach of the epithelium from the FB or turned in lash.  Epiphora should subside once the cause is removed.  This would also apply to cause such as conjunctival chemosis as in allergies in which case treatment of the cause (allergies) should eliminate the epiphora.

3. Also be sure to rule out conjunctival chalasis as a cause.  Folds in the conjunctiva can be caused by numerous previous surgeries, chronic edema or autoimmune thyroid disease (Hashimoto’).  If the cause is chronic inflammation try a corticosteroid like Lotemax qid for 2 weeks then bid for 2 weeks in addition to an anti-histamine/mast cell stabilizer such as Bepreve BID for 4 weeks.  Caution the patient that this only works in about 10% of cases but is worth trying.  Refer to an endocrinologist and order a T3, T4 and TSH to rule out thyroid disease.  The last option is a conjunctival resection with or without Amniotic Membrane Transfer (AMT).

2. Lid Laxity issue or Ectropion

1. Testing – pull out the lower lid and see if it returns to normal position quickly. If not, it could be a case of ectropion or lid laxity

2. Treatment – refer to an oculoplastic surgeon for lid repair so that the tears  can flow properly to the punctum

3. Blocked lacrimal system – Punctal Stenosis, Nasolacrimal sac obstruction

1. Testing – instill NaFl dye, wait 3-5 minutes and then under the slit lamp press on the lacrimal sac (if it is extremely tender then this is not an option and your diagnosis is dacryocystitis).  If any NaFL dye regurgitates or comes back out the punctum, then you have partial or full obstruction.  After 3-5 minutes the NaFl dye should have long passed through the lacrimal draining system.

2. Treatment – refer to an oculoplastic surgeon for a DCR.

4. If numbers 1-3 did not elicit a cause, then the likely diagnosis is dry eye from a lipid deficiency

1. Testing – First, explain to the patient that they are lacking the correct components of their tear film, so the body produces ‘water’ tears to try to compensate for a likely lipid deficiency.  Instead recommend that the patient use an oil based tear, such as Soothe XP or Systane Balance as examples, every 2 hours for the first 2 days then a minimum of qid for the next 5 days and report on the results.

2. Treatment – after the patient returns in 1 week to report improvement, then dry eye management could include artificial tears, environmental management, cyclosporine A drops, loteprednol drops, or Omega fatty acid supplements.  Also look for MGD and treat appropriately with hot compresses and a topical medication such as AzaSite, Zylet, Tobradex or Bacitracin.

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OptiMedica seems to have jumped into the fray with both feet, as its system proved to get raves among the whispering on the floor. There’s a lot to like about this system, especially the software interface for operations on which they obviously spent a lot of time and effort. It’s by far the most user friendly interface among the bunch.

LensAR showed two prospective systems, one designed for use outside the operating room, and a second for in the OR that has a built-in phaco machine. Both companies are still waiting on necessary approvals before offering units for sale, but I suspect both are still working on improving all of their systems. Good products require time before release.

LenSx was gobbled up by Alcon for a third of a billion dollars and one wonders why. It appears to have weaknesses in docking, using a system that applanates and distorts the cornea. In addition, it fails to address the common problem of eye tilt during docking. It also seems to have trouble determining the location of the posterior capsule and displays it based on calculation, not visualization. That requires it to leave behind more cataract tieeus untreated because it seems to lack confidence in actually knowing when to stop. Let’s hope these problems get fixed before release, or else they may find customers waiting on LensAR and Optimedica before making the plunge.

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But that is a sidelight to the real work of the week, the Academy meeting and the very wide scope of ophthalmology. The size and breadth of the meeting was staggering, but the highest interest seemed to be devoted to the femtosecond laser systems for cataract surgery which are very interesting, but I do not see as being ready for general use yet. Alcon has obtained the LenSx system, which looks like it needs quite a bit more work before it’s ready for release. LensAR and OptiMedica both have systems which are not as far along in regulatory, but seem to be more sophisticated in imaging and treatment delivery systems. We’ll watch with interest as these systems move towards the marketplace.

Glaucoma surgery was also high in interest and it appears Canaloplasty has finally taken its place among the primary surgical interventions. The three- year results are excellent, both in IOP drop and in stability. A tremendous advantage is that it improves normal outflow without punching any holes in the eye – which gives it a significant attractiveness compared to trabeculectomy or any of the tiny shunt devices. A hole in the eye lets fluid out, but it also causes inflammation and lets bacteria in, both unattractive sequelae.

Contact Dr. Kellan

The Delta Plug people also had a booth showing off its new punctal plug designed with stiffeners in the shaft toimprove performance. I’ve used these plugs since shortly after development and I think they’re great. The delivery system is elegant, and they stay in place reliably. They’re the plug of choice in our office and I’m glad to see they are becoming available on a wider basis.

CentraSight has finally received FDA approval for its implantable miniature telescope. Finally. That’s been a long time in coming, but finally it’s here. Now all we have to do is wait while the local Medicare carriers determine whether to pay the surgeons for putting them in. I can’t imagine they’ll say no, because we have no similar products available to us right now. The implantable miniature telescope is a prosthetic device for patients with bilateral irreversible AMD.

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