If the above tale sounds like it’s you then save yourself a LASIK evaluation.  I have written this blog because this scenerio plays out quite often in my office and hopefully this will help someone understand one of the LASIK dilemmas and be resigned to eyeglasses or faking it.

To understand how lasers work to resurface the skin you should know something about the structure of the skin.  There are basically two layers, the outer epidermis and the underlying dermis.  Think of the dermis as the steel work upon which a building is constructed.  Once the steel work is in place it is then possible to apply the facade of the building.  The facade can not support the weight of the building, it must have the steel superstructure.  Similarly, the epidermis needs a healthy dermis for its support.  When the dermis becomes damaged as it does with sun exposure, smoking, poor nutrition and/or genetics, the epidermis will crumple, that is, become wrinkled.  The element in the dermis that gives it structure is collagen.  Collagen is adversely effected by free radicals from the degrading forces mentioned above.

There are several types of lasers used for skin resurfacing, Erbium, Neodymium and carbon dioxide.  They all work on the same principle, they heat the dermis which stimulates the collagen to remodel itself.  The revitalized dermis leads to an improvement in the health and appearance of the overlying epidermis.  The technical difficulty is how do we design a laser that will heat the deep dermis without pain and without damaging the epidermis.  Until relatively recent years, this was not possible and patients undergoing skin resurfacing had their procedures in the operating room  with long recovery times.

Enter the Fractional Carbon Dioxide Laser which has been on the scene since 2007.  This laser delivers enough energy to stimulate collagen while sparing the skin surface.  The result is rapid healing and the discomfort is minimal and the procedure can be done inthe office setting.  Folks can return to work in three days if necessary.

If you have acne scars, wrinkles or sun damage that you are not happy with, give me a call at the Miami Eye Center and we can discuss your situation  and plan an approach with the fractional carbon dioxide laser.  You will be pleased to know that the procedure is far less expensive than you might anticipate.

The key to understanding is determining whether the wrinkles are fixed or dynamic.  Botox will improve dynamic wrinkles, that is, wrinkles that arise from facial expression.  When we smile the lines around the eyes suddenly appear or the frown brings out the lines in the brow.  These are dynamic wrinkles and are treatable with Botox.  In general, the region of the face that can be managed is from the nose up to the hairline.

The fixed folds in the facial skin are the smile lines that radiate down from the nose area to the lips.  The lines that start at the outer edge of the mouth and angle down to the jaw are fixed.  This type of facial dynamic is treatable with fillers.  The deeper and longer the fold the more filler is required to give a nice contour.

Laser skin resurfacing is usually a full face treatment designed to reduce or eliminate wrinkles where the collagen of the facial skin has degraded and the overlying surface has lost its vitality.  The laser leads to collagen rejuvenation and secondary smooting of the surface.  Sun damaged skin is readily improved with this technology.

Lastly, facelift surgery is an operating room procedure whch can lead to major changes in the appearance but requires a substantial commitment of time and money as recuperation takes weeks and fees are often prohibitive.

When properly applied, Botox, Juvederm and laser skin resurfacing can be combined in a sequential manner with minimum down-time and with dramatic results.  I will be happy to discuss these options with interested folks.

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In 1986, I was introduced to the excimer laser which had been developed at IBM in New York.  It was a precision cutting device which was only used to demonstrate how you could cut a square in a strand of human hair; a party trick.  Eventually some researcers at Columbia University came up with the idea of aiming the laser at the cornea with the hope of reshaping it and eliminating nearsightedness.  The device which had been developed in New York could not be used in the USA thanks to the FDA so I traveled to London and on to Berlin where the procedures were being done.  The trips were fun and the technology was spectacular.

My first opportunity to actually use the laser was in 1996, when it finally received FDA approval.  Tne LASIK procedure at that time was not in existance.  We were aiming the laser at the surface of the cornea without creating a flap; this was PRK, Photorefractive Keratoplasty.  We could only treat myopia as there was no algorithm for farsightedness or astigmatism.  The procedure worked very nicely for the limited number of patients that were treatable.  The down side was that it was a painful postoperative coarse.  Because of the pain created by lasering the front of the cornea, the notion of cutting a flap and lasering the interior gained popularity.  There turned out to be much less pain with this approach and so began LASIK.

The process of cutting an extremely thin section of cornea became the challenge.  One of the earliest and most popular devices was actually developed in Hialeah.  These cutting devices are called keratomes.  In the early days of LASIK the application and successful use of the various keratomes was a tricky undertaking as the equipment was unforgiving if the operator made the slightest error.  There were dislocated flaps, irregular cuts and partial cuts.  But since the vast majority of folks did very well without pain we forged on.  Ultimately, the keratomes became automated and complications became rare.  Surgeons still had in the back of their minds the ultimate safety of the PRK as there is no flap and therefore no flap related problems.  At the same time there emerged a class of eye drops known as NSAIDS (non-steroidal anti-inflammatory drugs).  These drugs eliminated the postoperative pain following the PRK.  Thus began the swing back to the old days of PRK.  Ofcoarse by now we were treating myopia, hyperopia and astigmatism.

While I watched the excimer laser go through four generational changes, the newest kid on the block is the femtosecond laser.  This laser is used to cut a precise flap with minimal complications. 

All of this brings us to the present.  In my consultations with refractive surgery candidates we discuss these options.  Many people want to reduce the risk factor to as close to zero as is possible and elect PRK.  Some need to have an immediate visual result and short term recovery period and elect LASIK (the return of vision following PRK can be five to six days).  Others have thin corneas wherein PRK is the only option.  So it all comes down to fitting the procedure to the patient and not visa versa.  In the end, personalized care and attention to detail leads to a happy patient and a happy doc and we all sleep well at night.

We can start analyzing the problem from the front of the eye (cornea) and working to the back (retina).  Some of the issues are simple yet overlooked while others are complex.  If you have had a multifocal lens implant there is no margin of error as these lenses are unforgiving.  If your tear film is not good you could be losing vision.  I have many patients complain of poor acuity only to find that by putting a drop of artificial tears on their eye they recover substantial vision.  A long term program of tear film enhancement leads to continued excellent vision.

There could be residual nearsightedness, farsightedness and or astigmatism.  If this is the case and you have had a multifocal lens implant it is incumbent upon the surgeon to correct this.  If you have opted for a generic lens implant, eyeglasses is the answer.  However, with multifocals you should be offered LASIK correction which has the potential to completely correct the blurry vision.

The intraocular lens is placed into the eye on a clear membrane (like Saran wrap) called the posterior capsule.  On occassion this clear membrane becomes cloudy and impacts the vision potential.  This is easily treated with a Nd:YAG laser procedure which vaporizes the membrane and thus clears the vision.

Moving to the back of the eye there is the retina.  If there is a problem with the retina it is the same as taking a photograph with bad film in the camera.  In a small percentage of surgeries there could be swelling of the retina known as cystoid macular edema.  This has a profound effect in reducing the vision.  Fortunately, it is self limited to several weeks to months and often responds to therapeutic eye drops. 

While the point of this discussion is to inform the reader that all is not lost if at first glance the outcome of cataract surgery appears to be less than optimum, however, there are a number of complications which require extensive evaluation and complex repair.  One must keep in mind that if you lump all of the possible complications of cataract surgery into one, the risk is about 3%, one of the safest major surgical procedures performed today.

Many of my patients are merely interested in “how is my pressure today?”  While that information is significant, that number represents only part of the story.  It is true that one is at higher risk of glaucoma developing and worsening with a pressure greater than 21mmHg, there are many people with pressure greater than 21mmHg  who do not develop glaucoma, that is, their optic nerve does not show signs of damage.  At the same time there are folks with normal intraocular pressure (21mmHg to 12mmHg) who have damaged optic nerves. 

So what is glaucoma?  While clinical investigators wrestle with the answer to this question, it seems to be that it is a condition wherein the optic nerve degenerates in a specific pattern with a concommitent loss of peripheral vision.  If unchecked the vision loss closes in on central acuity.  In the classic sense this degeneration is associated with eye pressure which is too high for that individual.

It is the job of the ophthalmologist to lower the eye pressure by at least 20% from the pressure at the time of diagnosis.  Lowering the pressure has been correlated with slowing or stopping the progress of the degeneration.  Someone with a pressure of 25mmHg should have their pressure reduced to 20mmHg, while another with a pressure of 15mmHg at the time of diagnosis should have their press at 12mmHg.  The pressure being lowered with eyedrops, laser therapy or surgery.

Once the pressure has been reduced by 20%, the physician must monitor the condition of the optic nerve and confirm that there is no further degeneration.  This is because a reduction of 20% may not be low enough to stop the progression in any one individual (20% is only a statistical generalization).

So the question posed by the glaucoma patient should be: “how is my optic nerve doing?”  The answer should be that it is not getting worse.

VisionCare Ophthalmic Technologies has developed a telescopic lens which is implanted in the eye and which casts an image on the retina which is almost three times normal size.  An image of this size is large enough to be projected onto healthy retina and avoid the degenerated central macular.  Studies have shown that there is a substantial improvement in visual acuity and this improvement has been unchanging over several years.  Patients who have already received the lens have reported significant improvement watching TV, recognizing faces and facial expressions as well as reading large print books.

The best news is that the lens manufacturers have obtained FDA approval.  They are awaiting Medicare approval which is only a formality.  At present, candidates for the procedure must have severe vision loss in both eyes and be at least 75 years old.  The eye can not have had prior cataract surgery and must be healthy except for the macular degeneration.

Having worked with many patients facing the problems surrounding macular degeneration, I was very pleased to note this major advancement in technology.  I will be happy to discuss the possible candidacy for this lens with any interested patient or family member.

The first thing that should be understood is that the allergic reaction represents a complex casscade of biological events initiated by the allergen which sets off the response.  It is for this reason that eye whitening drops such as Visine and similar products (vasoconstrictors) will not have an effect on improving the symptoms.  This class of drops  constricts the small blood vessels on the surface of the eye and makes it look whiter.  Once the effect of the drug wears off, there is a rebound and the eye gets even more red than in the first place; you get into a never ending spiral.  Probably worse than vasoconstrictors is taking oral Benedryl which seems popular in Miami.  This drug will put you to sleep and perhaps that will relieve your symptoms but it will have no effect on the conjunctival reaction.The solution to your problem lies in the interruption of the allergic cascade that causes the swelling, itching and reddness.  It has been my observation that getting allergy tested has no place in the management of allergic conjunctivitis.  Firstly, the tests will not reveal the specific allergen causing your problem and secondly, even if the allergen is discovered there is no method of desensitizing yourself for allergic conjunctivitis as you might for other allergies.

The itchy eyed patient needs to obtain a product such as Pataday, Zaditor, Elestat or Lastacaft which are prescription items.  These drugs specifically interupt the release of histamine along with suppression of other biochemical reactions.  These drops have few side effects and can be used over the long term. 

The “take home message” here is don’t waste your time with  over-the-counter allergy eye drops and get a sophisticated product.