John P. Frangie, M.D.

Laser Surgery for Unilateral Amblyopia

2012-01-24T13:09:00.000-08:00

A retrospective review compiled by Orucoglu et al from Hadassah - Hebrew University Medical Center, Israel (I Refract Surg 2011), indicates that laser refractive surgery may be a good option for patients with mild-to-moderate amblyopia from anisometropic myopia, where one eye has a greater degree of myopia than the second eye. Amblyopia, or "lazy eye," is the most common cause of unilateral visual impairment in adults. Laser surgery is the procedure most often performed to correct adult ametropia, including mildly amblyopic eyes in the absence of organic disease.

The study assessed the amblyopic eyes of 30 patients. At the conclusion of their review, the authors found that in amblyopic eyes, the best spectacle-corrected visual acuity (BSCVA)

improved >= 1 line in 16 eyes (53.3%), with a maximum improvement of 4 lines
remained unchanged in 10 eyes (33.3%)
decreased by 1 or 2 lines in 4 eyes (13.3%) In the fellow nonamblyopic eyes, the best-corrected visual acuity (BCVA)
improved by 1 or 2 lines in 9 eyes (30.3%)
remained unchanged in 16 eyes (53.3%)
decreased by >=1 line in 5 eyes (16.7%)

The gain of lines of BCVA was significantly greater in the amblyopic eyes group compared with the nonamblyopic eyes. In addition, laser refractive surgery was effective and safer in amblyopic eyes to correct myopia.

"In our series, gain in BSCVA after refractive surgery in amblyopic eyes was significantly higher than fellow nonamblyopic eyes," the authors wrote. "We demonstrated that laser refractive surgery was safe and effective in mild-to-moderate adult amblyopic eyes."

Effects of Undercorrected Astigmatism on Vision

2012-01-10T12:36:00.000-08:00

A recent study conducted by Wolffsohn et al from Aston University United Kingdom (J Cataract Refract Surg 2011), revealed that even small amounts of uncorrected astigmatism in post-cataract-surgery patients can have a significant effect on vision quality and if left untreated, can affect the quality of life of older patients. Uncorrected astigmatism may also contribute substantially to falls among the elderly, the study noted.

Approximately 85% of the general population has corneal astigmatism and 20%-30% of those >60 years of age have significant astigmatism. Because cataracts and astigmatism with intraocular lenses (IOLs) offers a viable solution to both cataracts and astigmatism, but many patients do not choose IOLs to correct astigmatism due to added cost.

"Many public health services consider intraocular lenses that correct astigmatism to be premium," the authors noted. "Therefore, older patients with coexisting cataract and astigmatism must pay for the IOL as well as the cost of private surgery if they wish to achieve optimum vision."

The study assessed whether leaving patients with uncorrected astigmatism after cataract surgery had an impact on visual acuity and reading speed also decreased with increasing uncorrected astigmatism power. Light scatter was not significantly affected by uncorrected astigmatism; however, the reliability and variability of measurements decreased with increasing uncorrected astigmatic power. Driving simulator performance was unaffected by uncorrected astigmatism, although clarity decreased with increasing uncorrected astigmatic power.

"With modern IOLs implanted after cataract surgery, astigmatism can easily be corrected and the additional cost of these 'premium' IOLs is likely to be far less than the consequences of leaving the patient with uncorrected astigmatism," the authors noted. "Hence, correction of corneal astigmatism during cataract surgery and IOL implantation should be considered the standard of care."

Cataract Surgery for Patients in Their 90s

2012-01-04T12:53:00.000-08:00

Cataract surgery poses no greater risk of ocular complications for patients in their 90s than those in their 80s, according to a recent study of patients treated within the U.S. Veterans Health Administration (VHA). The study, conducted by Tseng et al from the VA Medical Center, Rhode Island (Ophthalmology 2011), used data from the National Patient Care Database to compare surgical complication rates of 554 nonagenarians and 11,407 octogenarians who received cataract surgery in the VHA. The authors collected patient demographics and preoperative systemic and ocular comorbidities, and evaluated both intraoperative complications and 90-day postoperative complications.

A previous study of 45,000 veterans undergoing cataract surgery in the VHA, which evaluated a comprehensive list of comorbidities and ocular complications, found that patients aged >= 80 years were at increased risk for ocular complications after cataract surgery. This study sought to determine whether patients at the higher end of the age spectrum - those in their 90s - were at greater risk for complications than were patients in their 80s.

For both age groups in this study, diabetes mellitus was the most common systemic comorbidity and age-related macular degeneration the most common ocular cormorbidity. The study showed that while octogenarians had a higher prevalence of systemic comorbidities overall, nonagenarians were more likely to experience ocular comorbidities.

In both age groups, the most common intraoperative and postoperative complications were vitreous loss or posterior capsular tear and posterior capsular opacification. The authors noted that within this VHA study population, the risk of having any intraoperative or postoperative complication was 13.5% for octogenarians and 13.4% for nonagenarians.

"This study was not designed to determine criteria for selecting nonagenarians for cataract surgery," the authors wrote. "However, once the decision has been made to proceed with surgery, [these data] may inform cataract surgeons and their nonagenarian patients regarding the risk of experiencing an ocular complication." Additional studies are needed to assess how nonagenarians are selected for cataract surgery and to evaluate visual function and quality of life in these patients, the authors added.

An excerpt from Dr. Frangie's book, Seeing is Believing, currently in the process of being published.

2011-12-28T08:04:00.000-08:00

The accommodating style IOLs are actually able to flex in response to the ciliary muscle contracting – in a manner similar to how a natural lens would change shape in the younger eye. Very slight motion and flexing of the lens allows the eye to gain more “power” when a patient focuses from distant to near objects.(Figure 5 A & 5 B)

A video of Crystalens implantation may be viewed at www.frangieeye.com.

The other mechanism by which an intraocular lens may replace the loss of accommodation is through multifocal optics. The multifocal system has a modified optic (lens portion of the IOL) which is able to modify the light entering the eye and focus some light for near visualization and another portion focuses the energy to allow visualization of distant images. Simply speaking, the multifocal implants, apportions the light to different focal lengths so different distances are in focus; this occurs without effort from the patient and is a totally passive system. Thus, patients do not have to worry about looking through a certain portion of their implant to see at a specific distance.

In summary, advances in cataract surgery and its outcomes have gone hand-in-hand with the evolution of intraocular lenses. The latest quantum leap in IOL technology is the introduction of presbyopic intraocular lenses. Unlike standard monofocal IOLs, these lenses restore the eye’s ability to have a range of clear vision.

Vision Screening for Young Children

2011-12-19T08:54:00.000-08:00

Children between the ages of 3 and 5 years should be seen at least once by an eye care professional to detect the presence of amblyopia or its risk factors, according to an updated statement issued by the U.S. Preventive Services Task Force (USPSTF). The 2011 recommendation was made following an initiative undertaken by the USPSTF to update 2004 statement offering guidelines for vision screening in young children.

The USPSTF reviewed multiple studies that evaluated the accuracy and outcomes of preschool vision screening tests. They also assessed the effectiveness of early detection and treatment and the harm of screening treatment.

The researchers found that vision screening tools used to assess preschool-age children accurately detected visual impairment, such as

refractive errors
strabismus
amblyopia

The task force determined that early treatment for amblyopia in children 3 to 5 years of age, including the use of cycloplegic agents, patching and eyeglasses, leads to improved visual outcomes.

The 2004 Guidelines also recommended vision screening for children between 3 and 5 years of age; this review reconfirmed those recommendations based on updated evidence. According to the statement, there is "adequate evidence that early treatment for amblyopia...for children 3 to 5 years of age leads to improved visual outcomes."

Annual Snapshot of Eye Injuries

2011-11-21T11:44:00.001-08:00

In the United States, men are 3x more likely to suffer an eye injury, according to the Eye Injury Snapshot, and annual survey conducted by the American Academy of Ophthalmology (AAO) and the American Society of Ocular Trauma (ASOT). Conducted during a 1-week period in the spring of 2010, the survey revealed that men suffered about three-quarters (73.5%) of all reported eye injuries, and the survey also found that most of the total eye injuries suffered occurred at home, while doing chores or playing sports.

The AAO and the ASOT collected eye injury data each year to help increase public awareness and to encourage behavior that can help circumvent eye injuries. The Eye Injury Snapshot survey also found the following:

One quarter of eye injuries that occur at home resulted from play/sport activities
One quarter occurred during home repair work or while using power tools.
Most home-based eye injuries occurred in the yard or garden
About 50% of reported injuries occurred in men and women 30-64 years of age; children < 12 years of age accounted for about 12% of injuries.
Almost half of eye injuries occurred between noon and 7:00 pm.

To prevent some of the most common eye injuries that happen during household chores and repairs, the AAO and the ASOT recommend that every household have at least one pair of protective eyewear approved by the American National Standards Institute (ANSI). ANSI-approved eye wear is available at most hardware and home improvement stores and can be identified by the mark "Z87". For sports activities, eye wear approved by the American Society for Testing the Materials is recommended. To locate Appropriate eyewear for specific sports, the AAO and the ASOT suggests that clinicians tell their patients to talk to their ophthalmologists or visit the AAO Web site, www.geteyesmart.org.

Statin Use and Cataracts Among Patients with Diabetes

2011-11-07T14:36:00.000-08:00

Despite data linking prolonged statin use with cataract development, a recent study shows that patients with diabetes who take statins for a long period of time have no greater risk of developing cataracts than patients who have not taken prolonged coursed of statins. Conducted by Hermans et al from Cliniques Universitaires St. - Luc, Belgium (Diabetes Metab, 2011), the analysis studied 780 patients with type 2 diabetes (T2D) at very high risk for diabetic retinopathy (DR) and cataract, and determined that chronic statin therapy was neither cataractogenic nor was cataract presence associated with increased use of statin or other lipid-lowering drugs.

According to the authors, studying patients with T2D offers "an ideal condition in which to assess the potential beneficial/detrimental effects of satins or other lipid-lowering drugs (LLD) on cataract, because T2D patients have a high prevalence of atherogenic dyslipidaemia as part of the associated metabolic syndrome, and also exhibit an increased incidence/prevalence of both hyperglycaemia and age-related cataracts(s)."

Major risk factors for cataract in T2D patients include hyperglycemia, diabetes duration and the presence of DR. Additionally, the study noted that certain risk factors or markers may differ according to cataract subtype; for example, smoking is associated with nuclear opacities, ultraviolet radiation increase the risk for cortical opacities, and high blood pressure and corticosteroids raise the odds for subcapsular cataract.

The diagnosis of cataract was made by an ophthalmologist in 16.8% of the study population during annual or biannual retinal checkups. Lens extraction was considered a surrogate for cataract prevalence in patients who had undergone prior lens surgery for cataract. Both age and duration of diabetes were significantly higher in the group with cataracts compared with those without. DR was diagnosed in 23% of the patients. According to the researchers, the "benefits of statin therapy in T2D may far outweigh any potential ocular drawbacks as a side effect which, in any case, were not supported by our findings."

Blood Pressure, Ocular Blood Flow, And Glaucoma

2011-10-17T12:52:00.000-07:00

Despite an association between increased ocular perfusion pressure (OPP) and glaucoma, increasing blood pressure in an effort to modulate OPP appears to offer no value for treating glaucoma, according to a study published in a 2010 issue of the American Journal of Ophthalmology. Caprioli and Coleman from the Jules Stein Eye Institute at the University of California, Los Angeles, conducted the study, which reviewed current literature and presented the findings of the Blood Flow in Glaucoma Discussion Group.

"There is currently no evidence that manipulation of blood pressure or blood flow improves outcomes in glaucoma," the authors wrote. "Although low OPP is now an established risk factor in glaucoma, is is not clear whether it is truly independent of the sum of 2 separate risk factor-high [intraocular pressure] and low blood pressure."

While in theory, controlling OPP via blood pressure may seem appealing, modulating OPP in practice is complicated by a range of factors, including the potential for inaccuracy in OPP measurements, the authors noted. OPP measured during a routine examination may vary significantly from a patients physiologic OPP and therefore may not accurately correlate with the perfusion of the optic nerve head.

The authors added that there is currently little evidence to identify which vascular beds are important in the development and prevention of glaucoma, and therapies not targeted to those beds could cause an unwarranted increase in overall pressure and an attendant increase in morbidity and mortality. "There is the possibility that improving optic nerve perfusion by diverting blood from elsewhere (such as retinal capillary beds) may have unforeseen adverse effects, " they wrote.

While future drugs developed to target specific pathways or receptors may offer hope for treatment of glaucoma via OPP modulation current evidence does not support such treatment. "Glaucoma is a heterogeneous group of related diseases," the authors noted. "There may be subgroups of patients in whom vascular factors are important, (but) those patients subgroups have not been well identified."

Decreasing the Risk of Vision Loss in Herpes Simplex Patients

2011-10-12T12:36:00.000-07:00

The use of oral antiviral medications in patients with herpes simplex virus (HSV) appears to help decrease the risk of recurrence of epithelial keratitis, stromal keratitis, conjunctivitis, and blepharitis, and may decrease the risk of vision loss in these patients, according to a retrospective study conducted by Young et al from Mayo Clinic, Minnesota. The results of the study were published in a 2010 issue of the Archives of Ophthalmology.

In the study, researchers reviewed the outcomes of 394 residents of Olmsted County, Minnesota, diagnosed with ocular HSV from 1976 through 2007, and compared the frequency of recurrence and adverse outcomes such as vision loss or need for surgery, among patients treated prophylactically with oral antiviral medication and those who did not receive oral antiviral medication. According to their data, the authors found that patients who were not being treated prophylactically were
- 9.4 x more likely to have a recurrence of epithelial keratitis
- 8.4 x more likely to have a recurrence of stromal keratitis
- 34.5 x more likely to have a recurrence of blepharitis or conjunctivitis

Of the 20 patients included the study who experienced adverse outcomes, 17 were not being treated with oral antiviral medications immediately prior to the adverse event.

HSV is a common cause of corneal disease, and recurrence is relatively common. Following initial exposure and primary systemic infection, HSV establishes a latent infection in the trigeminal or other sensory ganglia, disease may recur in one or both eyes, with the risk of recurrence significantly increasing over time. The cumulative effect of these reactivations may lead to stromal inflammation or neurotrophic keratitis, resulting in scar of perforation, the authors noted.

"The results of this study suggest that oral antiviral prophylaxis should be considered for patients with frequent recurrences of corneal disease," the authors concluded. "Additionally, we recommend an evaluation of possible barriers preventing compliance with antiviral prophylaxis and a reassessment of the cost-effectiveness of long-term oral antiviral therapy."

2011-10-03T11:18:00.001-07:00

10/3/11

Finding the Causes of Pediatric Cataracts

Although approximately 200,000 children worldwide are bilaterally blind from cataracts, the causes of the majority of cases remain undetermined, making prevention often problematic. A retrospective study of pediatric cataracts by Lim et al from the Hospital for Sick Children, Canada, indicates that, although the cause remains unclear in many instances, understanding associated and potential contributing factors can be a powerful tool in both treatment and diagnosis of the condition.

"Data on the characteristics of pediatric cataracts are useful for the purpose of diagnosis, genetic counseling, and selection of treatment options," the aauthors wrote in a 2010 issue of the American Journal of Ophthalmology. "Prevention strategies also require information about etiology."

The authors reviewed 1122 eyes of 778 consecutive patients suffering from cataract. About a third of syndrome-associated cataracts occurred in patients with Down syndrome. Posterior subcapsular cataract was the most common morphologic type, and more than half of all patients presented with unilateral cataracts. Almost 13% of patients examined had developed cataracts as the result of trauma, and almost 12% of cases had genetic origins. Although the most common systemic association involved diseases treated with steroids, about 58% had no clear etiology.

"Slightly over half of our patients had cataracts of unknown etiology despite examinations of their parents and siblings and, where indicated, laboratory investigations," the authors noted. "Idiopathic cataract is a diagnosis of exclusion. A metabolic and genetic examination tailored, with the assistance of a pediatrician, according to the medical and developmental history may be indicated when there are no other clear etiologic factors." The authors added that while steroid use is clearly established a relationship between the incidence of cataracts and the dosage or duration of steroid therapy."

Why the fees for laser vision correction vary among lasik providers?

2009-03-10T11:02:00.000-07:00

The advertised cost of laser vision correction is noted to have a wide variation. The operative word in the preceding sentence is ADVERTISED. In this volatile economy, many providers have been advised to advertise price point as an inducement to get their phones to ring. Almost without exception, these practices engage in a “bait and switch” technique to “up sell” the prospective patient. Indeed, one study demonstrated that patients who presented to discount chains advertising “LASIK for $599” actually ended up paying an AVERAGE of $1,800 per eye!

It has always been my practice philosophy to avoid selling patients a procedure. We have set pricing and recommend the optimal procedure for an individual’s eyes. My practice has built its reputation on delivering optimal results – we will recommend the procedure that will provide you with the best possible vision, and in some cases the recommendation may be not to have any treatment at all…

Laser vision correction is an important and exciting step in your life, it should not be an experience focused on upgrades and negotiation.

What is “Blade Free” LASIK?

2009-03-10T11:00:00.000-07:00

Patients are often surprised to learn that some providers utilize a blade during a LASIK procedure. The blade is used during creation of the protective flap, and is incorporated into a device called the microkeratome. The microkeratome is analogous to a miniature carpentry plane which passes over the surface of the eye and creates the flap. The flap is then lifted and the laser is applied to the exposed area.
Review of the literature shows that while bladed LASIK is generally safe, most complications that did occur were associated with bladed flap creation.

No Blade LASIK avoids microkeratome- related complications. Instead of a stainless steel blade, the flap is created by a femtosecond laser, an ultra-fast, highly precise system which places millions of laser spots at a precise depth underneath the surface of the eye. The femtosecond laser I have used since 2003 is the IntraLase laser. Because the laser is computerized, the surgeon has the ability to customize the flap contour and dimensions to tailor each treatment. The unparalleled precision of the femtosecond laser provides the patient with the highest level of safety.

At our center, following creation of the protective flap with the IntraLase, the patient is situated next to the Allegretto Eye-Q Laser. The Eye-Q system then performs the actual cornea modeling that corrects the patient’s vision.

Thousands of patients (including yours truly) have benefited from the precision and accuracy of our No Blade LASIK technology. Unlike bladed LASIK performed at discount LASIK providers, this technique requires the surgeon to be skilled in the use of two advanced laser systems to provide you with the clearest vision possible.

Flex Spending Benefits Make Lasik More Affordable

2009-03-10T10:57:00.000-07:00

Using your Flex Spending Account (FSA), if available through your workplace, can help save up to 30% off your procedure as pretax income is used. A few tips if considering payment for your lasik using an FSA.

Be 100% certain that you are a candidate before setting aside the money. A complete preoperative exam is the only way to be sure.

Companies either issue a reimbursement check after the procedure or a Visa/Master Card to present at the time of payment.

A tool on the web that may help you plan your finances https://www.fsafeds.com/fsafeds/fsa_calculator.asp

Keep in mind that detailed questions on your FSA accounts are best answered by your human resource department.

How does Laser Vision Correction improve your vision?

2009-03-10T10:53:00.000-07:00

LASIK is the most commonly performed elective procedure in the United States. Patients frequently as me how LASIK works. The best way to describe the procedure is to begin by explaining the eye's optical function. It may help to refer to the diagram of the eye in our animation below.
The eye can be compared to a camera. Light passes through two light bending surfaces, the cornea, or the outer window, and the internal crystalline lens. In an eye with perfect vision, these two structures focus light precisely upon the retina (analogous to the film of a camera). When a patient needs glasses or contacts to see, they are dependent upon a third lens to bring light to focus on the retina. Laser vision correction works by enhancing the eyes optical status to decease the dependence upon an external lens - be it a spectacle or contact lens. The Allegretto Eye-Q laser is the world's most precise system that allows me to make subtle changes upon the outer window (cornea) and fine tune the focusing ability of the cornea to provide crisper, clearer sight.