Presbyopic patients they must either wear reading glasses or in some cases choose to have monovision where 1 eye is corrected for distance and the other eye for near. The ongoing search to correct both distance and near has resulted in an intrastromal procedure using the Femtosecond laser. According to “Ophthalmology Times” Dr Goeker of the Istanbul Surgery Hospital this procedure is fast, safe, minimally invasive, does not adversely effect contrast sensitivity and has no risk of flap complications. It can be done on pseudophakic and post LASIK patients with equal success.

The procedure was developed by Dr Luis Ruiz from Bogotá, Colombia and involves a three dimensional intrastromal ablation creating five or six concentric rings that are 75-80% of the corneal depth. These rings are placed with in the central 5 mm corneal zone and are .3-.4 mm apart. The procedure takes approximately 20 seconds and leaves Bowman’s layer intact.

While this new procedure must still receive FDA approval, it is the first refractive procedure to correct both distance and near refractive errors. According to Dr Marc Werner, a well known New York Ophthalmologist and refractive surgery specialist, he has reservations as to how effective this procedure will be. Time will tell.

The pursuit of a better treatment for the dry, burning, scratchy eyed patient, has led us to change our approach. More contemporary therapies include keeping more tears in the eye for longer periods of time and increasing tear production.

With regard to the first point punctal occlusion is the best alternative. By inserting absorbable punctal plugs partially obstructing the outward tear flow, an immediate remediation or reduction in dry eye symptoms can be accomplished. They last approximately 2-3 months and can be reinserted if needed. Since they are covered by most major medical insurance companies, the patient may only have a copayment which will make them twice as happy. Obviously, the doctor must know how to bill properly to insure correct payment for this procedure.

Increasing tear production can be done with the use of Restasis eye drops. When used twice daily, most patients report increased comfort and a decrease of dry eye symptoms.

According to a recent study published in Optometry Times, “there is objective evidence that punctal plugs provide rapid and durable benefits when used for the treatment of dry eye.” These studies employed the OCT to quantify the tear meniscus and demonstrated an increased tear film when punctal plugs were inserted.

Dry eyes are common today and effective therapy is required to best treat our patients. Punctal plugs are fast, easy, effective and are covered by insurance which makes patients less resistant to their use.

Corneal health can be evaluated by the use of a corneal topographer which gives the exact shape of the outer most layer of the cornea. It is also employed when refractive surgery is performed. Endothelial Cell counts measures the inner most layer of the cornea which is responsible for pumping fluids out of the cornea when there is corneal swelling form contact lens wear, surgery of pathology.

Ocular Coherence Tomography evaluates the integrity of the Optic nerve and macular region of the eyes. This instrument can best follow potential glaucoma patients and macular degeneration conditions.

Retinal photography has been brought to a new level with cameras that take high resolution pictures in undilated eyes. These same cameras also take external photos with incredible quality. Pachometry measures corneal thickness, while visual field instruments follow changes in one’s ability to see all area accurately. Glaucoma, head aches, head trauma and pathology can all changes our visual fields.

Insertion of punctal occlusion plugs and new dry eye medication can often remediate symptoms related to dry eyes. The list goes on and on. In short, IT IS VERY IMPORTANT FOR ALL EYE DOCTORS TO USE ALL AVAILABLE TECHNOLOGY when caring for their patients. Not doing so reduces the level of care rendered to a patient.

Common side effects include post surgical dry eyes, light sensitivity, fluctuating vision and halos around lights. As the procedure has evolved some of the side effects have been reduced while others have started. Development of the Femtosecond laser resulted in a neater, sharper flap that heals faster and better then when the lathe is used.
However, this new laser has resulted in a new side effect in some post surgical individuals

Transient Light Sensitivity Syndrome
(TLSS) occurs in some patients that have had LASIK when the Femtosecond laser is used. According to Dr William Miller, this occurs in less then 1% of the patients employing the Femtosecond laser. However, as they say “if it is in the chair, it ain’t rare.” So we must all be aware of this condition and how to treat it.

While DLK and epithelial cell in growth under the flap are not uncommon side effects, neither one will cause the symptoms of TLSS.
TLSS patients will complain of moderate to very severe light sensitivity, but will show no other clinical signs. Many of these patients will even keep their sunglasses on while in the examining room.

Current theories as to the etiology of TLSS include the increased energy levels employed by the Femtosecond laser causing elimination of the gases located in the intrastromal space. These “bubbles” relocate to the peripheral cornea and episclera resulting in a secondary irritation of the cilliary body. It should be noted that this is only a theory.

Treatment of TLSS includes prednisolone acetate drops with varying frequency depending on the severity of the photophobia. Their use may last between a week to more then a month, always tapering their use to prevent a rebound reaction. Recently, the use of cyclosporine in addition to the Pred has shown a positive effect in remediating the condition.

In short, post LASIK patients require careful follow up and for the doctor to be aware of the entire possible short and long term complications and how to best treat them.

Conventional therapy included patching of the better seeing eye to force the weaker eye to perform better. While this treatment has been successful in improving the visual acuity of the amblyopic eye it did not reduce the sensory dominance of the better eye and thus no improvement in depth perception or visual function.

Research recently published in the journal of Current Biology described a new technique called push pull therapy that not only improved visual acuity in the weaker eye, but also reduced sensory dominance of the better eye therefore improving over all visual function.

Push Pull therapy involves stimulating both eyes with different visual stimuli in an effort to reduce sensory dominance of the better seeing eye, while stimulating the weaker at the same time. The result is better stereopsis and visual function. It is accomplished by exposing each eye to opposite stimuli such as the weaker eye to vertical gratings and the stronger eye to horizontal gratings. This causes the weaker eye to be excited by a stronger stimulus while only partially suppressing the better eye with a weaker stimulus.

While this therapy requires more study, it is a new approach to an old problem and has shown great promise thus far.

The Femtosecond Laser was originally designed to cur corneal flaps during LASIK, but has evolved into much more. The first version emitted optical pulses at 3KHZ and creating a flap took about six minutes. The new lasers emit pulses at 60KHZ and the same procedure takes approximately 30 seconds. The Femtosecond Lasers create thinner, more exact corneal flaps then any mechanical method. In addition, the flaps created by the laser have better adhesion and a reduced incidence of epithelial in growth post surgically. Another important advantage of the laser is that it results in a lower incidence of dry eye in LASIK procedures.

New procedures currently under investigation using the Femtosecond Laser include reduction of presbyopia (age related decrease in near vision) by creating a flapless, intrastromal, corneal reshaping. Myopia correction can be done by a new procedure that creates an intrastromal lenticule of 3-5 mm that is removed by an incision reshaping the refractive property of the cornea.

Lens bleaching to remove the yellowing of the natural crystalline lens with an 800nm pulsed laser is showing positive results in reversing cataracts. This procedure must be repeated every 3-7 years.

Cataract surgery can be done with this laser as well. The surgery is done from the inside out as opposed to the outside in. First a capsulotomy (opening) in the front surface of the lens is created and then the interior part of the lens is fragmented. Next a corneal incision is made with the laser so the lens particles can be aspirated out of the eye. This corneal incision heals faster and does not require any hydration to self seal.

This cataract surgery is much better suited for the new multifocal implants that require exact placement with in the eye.

In short, the Femtosecond Laser will improve both refractive and cataract surgery while decreasing patient discomfort and improving the final results.

Recent studies conducted in Britain may change our thinking about exercise and its’ effect as we age. The researchers studied active, athletes as they aged and the condition of their hearts. The individuals were broken down into two groups. The first was for people between the ages of 26 and 40 and the second for the old timers over the age of 50 but under 67. All of the subjects were very healthy and active. The groups were also divided into those that trained regularly at moderate levels and the other group worked out very strenuously.

The results of the study were surprising to the researchers. They found that the younger group of both strenuous and moderate work out people as well as the older group of moderate individuals had normal heart function with no signs of any damage to the cardiac tissue. However, the older group of folks that worked out strenuously demonstrated mild to moderate signs of fibrosis or scarring in their heart tissue. These changes can lead to stiffening and thickening of the heart and then can contribute to irregular heart function and even heart failure.

This study found the same results as a similar study conducted in Germany in 2008. In summary, while exercising has always been advised as a way to stay healthy, a very strenuous workout over a long period appears to damage the heart muscle. The best way to live should be to follow the adage “everything in moderation.”

The Demodex Mite is a small organism that lives in and near the lash follicles. They dislike light and a result remains in the follicles during daytime hours. They come out of their hiding places at night to mate and lay their eggs returning “home” before dawn. Early morning itching and irritation is common among patients as the mites slide back into the skin follicles. This symptom often leads to the wrong diagnosis of allergies. It is only after the allergy treatment does not work that the eye doctor realizes there is a different condition at play here. In addition, the pathogenesis of skin lesions is often also these demodex mites in conditions such as Rosacea.

When conventional treatments for the blepharitis do not work, Dr Tseng form the Ocular Surface Research & educational Foundation at TissueTech in Miami, Florida has an answer. Dr Tseng has been using Tea Tree Oil to eradicate the mites. He cuts the oil 50% with Macadamia nut oil and instills tetracaine prior to applying the tea tree oil. He applies the oil 3 times per session 10 minutes apart for several visits. His goal is to get the oil deep into the lash root to kill as many or the mites and their eggs as possible.
In addition, the patient is instructed to use tea tree shampoo and soap replacing all current shampoos and soaps. Women must also discard all make, have their spouses checked for mites, as well as any pets that get close to them in bed. Sheets must be carefully cleaned or replaced and cleaned regularly during the therapy period. If inflammation follows the treatment sessions, Tobradex drops can be used for about a week.

Some patients even experienced an improvement in their visual acuities following this treatment. The reason given by Dr Tseng is that a reduction in corneal inflammation and better tear film quality improves the refractive surface resulting in better vision.

If there are patients whose blepharitis does not improve with standard therapy, demodex mites must be considered as the etiology and alternative treatment such as tea tree oil should be considered.

In an effort to make contact lens care easier, less time consuming and therefore increase patient compliance, no rub solutions were introduced in a variety of forms. While many of them were quite effective in cleaning the contact lenses, there were those that did not have a large enough spectrum of efficacy to keep their users safe form serious ocular infections. With the outbreak of Fusarium in 2005 and the increase in Acanthamoeba infections, contact lens solution manufacturers tried to improve their products while still keeping patient comfort high on the list of requirements.

Biotrue multipurpose contact lens solution is the newest addition to the list of contact lens solutions. It is unique and different in that it is very effective against both Fusarium and Acanthamoeba organisms while maintaining a neutral Ph matching normal healthy tears.

The disinfection is accomplished by the use of 2 agents. PHMB and polyquaternium-1. This combonation is effective against the trophozoites and cysts of Acanthamoeba as well asteh fungal agent Fusarium. Biotrue also removes denatured proteins while protecting the lens against the denaturation of the beneficial proteins. Patient comfort is accomplished with the use of the natural lubricant hyaluronan. Maintaining a natural Ph makes the solution comforting when instilled in the eyes.

While this new solution has only been used for a short time, it has the potential to revolutionize contact lens care is if stands the test of time.

Dr Theo Seiler and his associates pioneered this revolutionary procedure for the treatment of patients with keratoconus, ectasia and post refractive surgery complications. The process involves removing the corneal epithelial layer and then soaking the cornea is vitamin B2, riboflavin. This is followed by exposure to UVA light of 370 nm for 30 minutes. The riboflavin acts as a photosensitizer that absorbs the UVA light and then produces a highly reactive oxygen singlet. This form of oxygen results in cross linking of collagen fibers and extracellular matrix proteins which are thought to strengthen the cornea.

A side effect of this procedure is damage to the surrounding keratocytes and nerves in the area of treatment. Therefore careful area selection must be made in advance of the treatment. The riboflavin blockes deeper penetration of the UVA light and therefore protects the endothelial layer.

There has been some debate as to weather epithelial layer removal is required for this procedure. Clinical studies in the US and Europe have demonstrated that better cross linking occurs when the epithelial is removed prior to therapy.

While this treatment is still not available in most practices if the current studies continue to show such good results, it may be the treatment of choice for certain anomalies.