How does the cornea affect your vision?


The cornea is the first structure light passes through as it enters your eye. You can think of it as a transparent dome that vaults iris, the tissue inside your eye that gives the eye its color. If you look at your watch it would correspond to the watch glass and the iris to the face of the watch. If the watch glass becomes scratched or opaque you will not be able to see the face of your watch as well. Similarly, if your cornea becomes cloudy, you will not be able to see as well.
The effect of a cloudy cornea can be similar to a cataract.



What are the reasons for a cloudy or distorted cornea?


Factors that affect the cornea are varied. They range from an infection of the cornea (corneal ulcer) to inherited diseases. These include corneal dystrophies, which lead to cloudy corneas over time and thinning diseases such as keratoconus, which lead to a distortion of the cornea. Fuchs’ corneal dystrophy or endothelial dystrophy as well as endothelial damage can lead to corneal swelling and cloudiness over time. This is because the endothelium, a layer of cells on the backside of the cornea, prevents swelling by pumping fluid out of the cornea. Fuchs’ dystrophy causes these cells to slowly deteriorate and decrease in number. When you don’t have enough of theses cells, fluid builds up in your cornea leading to swelling.



One of the treatments for the above mentioned conditions is a corneal transplant. The first successful corneal transplant was performed in 1906. Over the last 100 years we have experienced improvements in preservation and surgical techniques. In addition to the full thickness transplant we are now able to selectively replace the parts of the cornea that are not functioning properly. For Fuchs’
endothelial dystrophy as well as for corneal edema only the thin layers of cells/pumps (endothelium) is replaced. This procedure is called DSAEK. In cases where the endothelium is still healthy only the anterior parts of the cornea can be replaced, a procedure called DALK.
The same LASER used to create the flap during LASIK procedures can now be used to shape the interface between the patient’s and the donor’s cornea creating a better and more secure fit. These LASER created wounds can be compared to dovetailed joints interlocking in a much more secure fashion.



As the cornea specialist at Barnet Dulaney Perkins I am excited to be able to offer all of these options to patients who need a corneal transplant. Consider helping these patients as well.  Consider becoming an eye donor and discuss it with your family. You too can help restore another’s sight.

Robert Fintelmann, MD
Cornea, Vision Correction and Cataract Surgeon

Your tears are made of 3 layers:

1. Lipid (oil) layer: lubricates and prevents evaporation

2. Aqueous (water) layer: nourishes and protects the cornea

3. Mucin layer: adheres tears to the eye

Meibomian glands: create the lipid (oil) layer of the tear film　

Warm compresses become a regular ritual, sometimes several times a day. A bottle of some form of eye drops is never far out of reach. Blinking exercises might be on the agenda, or maybe lid scrubs.

Contact lenses can only be worn for a limited time, if at all. Extended sessions in front of a computer are off limits. Relaxing with a good book may be too painful to contemplate. Even just deciding on the spur of the moment to go outside and enjoy a nice spring day could be out of the question.

Does any of this sound familiar?
If so, you need to know about the LipiFlow system, a technological breakthrough that has been developed to potentially make the discomfort, inconvenience and limitations of Evaporative Dry Eye a thing of the past.

The LipiFlow Thermal Pulsation System is a significant technological shift in evaporative dry eye treatment, effectively relieving blockage of the eyelid glands during an in-office treatment. Opening the blocked eyelid glands allows the body to resume the natural production of lipids (oils) needed for the tear film. Treatments last up to 1 year!

Imagine: Just a short time after a successful treatment with the LipiFlow system, you may go long periods of time without thinking about your eyes at all, just like most people do. You may no longer have to plan your day around your symptoms. Coworkers may no longer stop and ask you why your eyes are red or have you been crying.

After a few weeks, you may even start to forget about how much the condition was controlling your life. The constant drops, the warm compresses, the limits on how long you could sit at the computer or wear your contacts. Months later, you may no longer worry about the faintest breeze.

You can live your life again.

Arizona Republic, Living Well

Andrew Rabinowitz, MD, fellowship trained glaucoma specialist at Barnet Dulaney Perkins Eye Center, discusses the facts on Glaucoma in an article published today in the Arizona Republic (Living Well). For more information, read the attached article, it may just save your vision.

Andrew Rabinowtiz, MD

To find out more about Glaucoma visit www.goodeyes.com

At Barnet Dulaney Perkins Eye Center, Dr. Scott Perkins recently performed the first femtosecond blade-free cataract surgery in Arizona. The LenSx laser, installed in early November, is the first laser approved by the FDA for commercial performance of anterior capsulotomies and corneal incisions, all of which were previously performed with blades prior to the introduction of this state of the art technology.

Cataract surgery is among the most commonly performed eye care procedures in the nation. Over 3 million procedures are performed annually in the United States and 18 million world wide. Until now, multiple steps of a cataract procedure were performed manually and guided by the surgeon’s hand. With the introduction of the first FDA approved femtosecond cataract laser, surgeons at Barnet Dulaney Perkins Eye Center can provide improved precision of several of the most critical steps in cataract surgery.

Recent data shows that this custom blade-free laser performs some steps of the procedure up to 100 times more accurate than manual techniques, even in the hands of very experienced surgeons, which is why Dr. Perkins is excited to implement this latest technology at Barnet Dulaney Perkins Eye Center. “Laser cataract surgery is the most advanced option for patients with cataracts. We are thrilled to be able to offer it to Arizona residents.”

Alcon Laboratories Corp. in Fort Worth, TX, reports less than 30 LenSx lasers are in place in the U. S. at this time. The cataract surgeons at Barnet Dulaney Perkins Eye Center say they have been committed to improving patient outcomes and providing excellence in eye care with the use of leading technology for over 35 years.

Dr. Scott Perkins, Medical Director at BDPEC, has performed over 50,000 cataract surgeries. “It was an honor performing the first LenSx surgery in the state. I believe that the precision and reproducibility of the laser will improve the results of our surgery as this technology continues to advance. Our reputation has been built one patient at a time because we are committed to providing the best possible results with every procedure.”

About Barnet Dulaney Perkins Eye Center

Barnet Dulaney Perkins Eye Center was founded in 1993 with the merger between the Barnet Center of Ophthalmology and the Dulaney Eye Clinic and Cataract Institute. Although Drs. Dulaney and Barnet are now retired, the center has grown to over 35 doctors on staff committed to providing patients with quality eye care in multiple locations throughout the state of Arizona. The Eye Center offers comprehensive eye care with specialists in multiple fields of ophthalmology including cataract surgery, vision correction, cornea, retina, glaucoma and neuro-ophthalmology. As recognized innovators in the field of Ophthalmology, Barnet Dulaney Perkins Eye Center was also the first practice to introduce the German-engineered Allegretto Wave Laser to perform LASIK in the United States.

For further information and details about Laser Cataract Surgery or Barnet Dulaney Perkins Eye Center, please contact Darla Espinosa, Director of Marketing 602.508.4829 or Mark Rosenberg, Executive Director at 602.508.4808. Barnet Dulaney Perkins Eye Center can also be found online at www.goodeyes.com, or facebook.com/bdpec.

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Barnet Dulaney Perkins Eye Center Now in Mesa AZ

Barnet Dulaney Perkins Eye Center is announcing a new Flagship Center to support the eye care needs of Arizona. The ophthalmologists and eye surgeons say the new center is located in Mesa, AZ, and is the most forward thinking eye care center in the state.

The eye surgeons and ophthalmologists at Barnet Dulaney Perkins Eye Center (BDP) are announcing the opening of a new Flagship Center for eye care in Mesa, AZ. The doctors say their eye centers remain on the cutting-edge when performing a number of procedures, including cataract surgery and LASIK eye surgery in Arizona. They add that the new Mesa location is built to advanced standards and includes a state-of-the-art 5,000 square foot Ambulatory Surgery Center, a separate Retina Clinic, IE Smart Screens and LUMA Eyemaginations, and the latest application for electronic medical records. The doctors at Barnet Dulaney Perkins say the Mesa office is designed to enhance their extensive experience and expertise to ensure all patients receive the best eye care possible, regardless of whether they are in need of vision correction, or procedures such as diabetic retinopathy in Arizona.

The doctors at Barnet Dulaney Perkins specialize in a number of eye care procedures, including cataract surgery in Arizona, and say the new Mesa Eye Care Center allows them to reach even more patients while providing a more convenient and positive experience with the eye care specialists. The doctors say they hope the additional convenience will enable their patients to continue to develop and maintain healthy eye care habits by making it easier to visit their offices on a routine basis.

Whether performing routine eye care or a procedure for vision correction in Arizona, the doctors at Barnet Dulaney Perkins say the technologically advanced Mesa Eye Care Center will improve their ability to provide their patients with comprehensive care aimed at improving their overall visual health. While the new location creates a more convenient patient experience, the doctors say that including the latest technology in eye care treatments and procedures can also improve the overall safety and satisfaction of their patients, which is always a top priority.

Barnet Dulaney Perkins Eye Center

The Barnet Dulaney Eye Center has been serving the eye care and surgery needs of Arizona for over thirty years. The center has consistently remained a world leader in introducing new eye care technologies, and was the first center to introduce the innovative LASIK procedure performed with an Allegretto Wave Laser. As a world renowned research and educational facility, which regularly participates in clinical trials, Barnet Dulaney Perkins strives to bring the latest technology to patients and doctors throughout the world. They offer complete eye care for every stage of their patients’ lives, ranging from routine eye care, to cataract and glaucoma procedures, to the treatment of retinal diseases and other conditions.

Barnet Dulaney Perkins Eye Center has a number of locations throughout Arizona, which can be located at (866) 742-6581, http://www.goodeyes.com/index.asp or the Barnet Dulaney Perkins Eye Center Facebook page.

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“We had the honor of serving a small group of Hondurans who were too poor to pay for needed cataract surgery, despite being legally blind. The team that went with me donated their time and worked tirelessly to make this cataract mission a success. All of us in the group participated for different reasons. To me the reason doesn’t matter, just actively pursuing the desire to help less fortunate fellow humans is a gift we can give to others. The patients we served expressed sincere gratitude for the cataract surgeries we performed and that was the greatest gift we got in return”. Scott Perkins, MD

The team traveled out of Phoenix at 12:00am on March 20th and arrived in San Pedro Sula, Honduras at noon on the 21st. All the surgical supplies including the microscope and phaco-emulsification machine (for cataract removal) traveled with the team as checked baggage on the airplane. The team then set up the operating room after unpacking the 20+ boxes of supplies and equipment. They began operating on Monday the 21st and performed 42 total cataract surgeries in the 2 ½ days of operating.

Most of the surgical supplies were donated by Alcon Surgical. The surgical representative from Alcon, Mathew Greer, assisted in getting the supplies donated and also proved to be an essential team member of the surgical mission. All 42 cataract surgeries were performed by Dr. Scott Perkins. A large percentage of the patients had “hand motion” or “count fingers” vision and were blind from their cataracts. The patients went from being blind one day to seeing their family member’s faces for the first time in years. It was a very successful and rewarding trip for all involved.

If you would like more information or would like to donate to the non-profit organization please visit www.azvisionaries.org to make your tax deductible donations. 100% of proceeds from donations go toward their efforts to vision preservation for the poor and underserved.

There are several types of laser procedures used in the treatment of glaucoma.  The most important aspect of laser use in the management of glaucoma is understanding who is a candidate.  It is also important that the patient have realistic expectations about what lasers can achieve. In general, lasers do not “cure” glaucoma.  Rather, they serve as an important “treatment” used to control this lifelong disease.

Historically, the primary treatment for glaucoma has been eye drop medications. When a patients’ glaucoma can no longer be controlled on eye drops alone, or if they cannot tolerate the eye, they are considered candidates for laser therapy.

An important concept to understand in glaucoma is that of a patient who is on a “Maximally tolerated medical regimen (MTMR.)  Many different scenarios can be considered MTMR. Here are a few examples.

1.   A patient who is on three or four eye drop medications but who still has a pressure that is higher than the target set by their eye doctor.
2.    A patient who is on one or two eye drop medications but who is intolerant to all other medications and who is running a pressure above the target set by their eye doctor
3.    A patient who has no problem tolerating eye drops, but who has severe arthritis or Parkinson’s disease.  This patients may have limited use of her hands and have difficulty putting in eye drops.  If this patient lives alone, and has no one to rely on to instill her drops, she would be considered MTMR

Thus, you can see from these examples, that laser treatment may become necessary at different stages for different patients.  There is no question that eye drop medications should be tried as initial therapy.  If medical therapy is ineffective, the patient becomes a candidate for laser therapy.

Laser therapy is an effective way to lower pressure.  Laser therapy is used to complement the effect of eye drop medications.  Laser therapy does NOT replace eye drops medications in most instances.  Instead, laser is used to augment the effect of the existing medications.  It should be carefully explained to patients that they may still need to use glaucoma medications following successful laser therapy.
Laser therapy does not provide permanent pressure reduction. The benefits of laser can last anywhere from 6 months to 6 years.  Often the treatments can be repeated at least once.  There are a small percentage of patients in whom laser may not lower the eye pressure to a significant degree.

LASER SURGERY FOR GLAUCOMA

WHAT IS THE DOWNSIDE OF LASER THERAPY?

In most instances, the downside is very small.  I tell my patients that the worse thing that can happen is that they do not get any benefit from the treatment.  Because the procedure is non-invasive, patients are not exposed to the risk of severe bleeding or infection, which are notable risks with surgery.  A small percentage of patients may experience a transient rise in their eye pressure over the first 24 hours following the procedure, but this is short-lived.

Thus, I offer laser treatment to my patients as an option to help control their pressure and avoid surgery.  I also tell my patients that the benefits of most laser treatments are not forever, and that if they live long enough, they will likely need surgery in the future.

Laser therapy is an excellent bridge between medical and surgical management of glaucoma.  There is a limited downside, and a moderate but not permanent upside.

WHAT IS NEW IN LASER THERAPY?

There are at least two new lasers on the horizon for the treatment of glaucoma.  One laser called the “diode” laser is now in use in our practice. Within the next 12 to 24 months we will see the incorporation of a new type of laser for the treatment of glaucoma.  This new laser is called the Selecta 7000.  This laser is a breakthrough because it will allow us to perform laser treatment on patients who have already undergone “complete treatment” with our existing lasers.  Prior to the inception of the Selecta 7000, laser treatment was performed only twice. It was felt that additional treatment could do more harm than good.  With the Selecta 7000, we are achieving excellent results in treating people how have had “complete treatment” with our standard lasers.

WHAT TYPES OF LASER SURGERY ARE THERE FOR GLAUCOMA?

The most common procedures performed for glaucoma are:

1.    Laser trabeculoplasty
2.    Laser iridotomy

I will discuss the indications and procedures for both of these treatments.  Many patients may require both treatments over the course of their lives.  These treatments were introduced into ophthalmology nearly 30 years ago.  The main changes since their inception have been related to improved laser technology.  The fundamental principles and goals of these treatments remain unchanged.   The goals are to improve drainage of the fluid which fills the eye.

LASER SURGERY FOR GLAUCOMA-ARGON LASER TRABECULOPLASTY (ALT) &  DIODE LASER TRABECULOPLASTY (DLT)

Argon laser trabeculoplasty is a laser procedure, which is performed in an office setting.  The patient is seated in a comfortable position, and the eye numbed with eye drops.  The treatment takes less than 5 minutes to perform, and usually causes only mild pain.  Most patients tolerate the procedure without difficulty.  There is little to no discomfort following the procedure.

Argon laser trabeculoplasty (ALT) is an important adjunct to medical and surgical treatment of open-angle glaucoma.  Diode laser trabeculoplasty (DLT) is apparently equally effective.  The indications and techniques for performing ALT have become standardized since its introduction in 1979.

PATHOPHYSIOLOGY:

The mechanism by which ALT lowers eye pressure is not known, although an immediate “mechanical” effect on the trabecular meshwork (drain of the eye) is widely accepted.  Besides the immediate thermal effect of the burns on surrounding tissues, including tightening of the meshwork (circumferential shortening), there may be a long-term metabolic effect.

INDICATIONS:

ALT should be considered for patients with open-angle glaucoma who cannot be controlled by a maximum tolerated medical regimen (MTMR.)  Additionally, it should be considered in those patients who are intolerant to or unable to use topical medications.  ALT is also appropriate as a method of delaying filtering surgery, especially for the systemically fragile elderly patient.  A follow-up of patients enrolled in the Glaucoma Laser Trial (GLT) showed that initial treatment with ALT of newly diagnosed patients with open-angle glaucoma was at least as effective as initial treatment with eye drops.

ALT is relatively successful in patients over 50 years of age with primary open-angle glaucoma, especially in cases associated with pseudoexfoliation and pigmentary dispersion.  ALT has poor success in eyes with congenital or juvenile-onset glaucoma, inflammatory glaucoma, and post-traumatic glaucoma with angle recession injury.  The effects are relatively unpredictable in patients who have undergone prior cataract surgery.

EXPECTATIONS:

ALT produces an average decrease in eye pressure of  7 to 10mm Hg.  The amount of eye pressure drop obtained increases as baseline pressure increases.  Eye pressure tends to drift back toward the baseline following ALT.  The average benefit in eye pressure control lasts 2 to 5 years.  By 5 years after ALT, about 46% of treated patients remain better controlled.  The failure rate is approximately 10% per year and, by 10 years after ALT, one half of treated eyes have undergone filtering surgery.

SUMMARY:

ALT is a safe, widely performed procedure.  The following pages illustrate the treatment process.

LASER SURGERY FOR GLAUCOMA -LASER IRIDOTOMY

INDICATIONS:

Laser iridotomy is indicated in the treatment of acute and chronic angle-closure glaucoma, combined-mechanism glaucoma, pseudophakic and aphakic papillary-block glaucoma, and incomplete surgical iridectomy.

ANGLE CLOSURE GLAUCOMA:

Angle-closure glaucoma must be given a high priority among eye diseases because its effects can be devastating.  Bilateral blindness can result in 2 to 3 days from onset.  Angle-closure glaucoma, can be prevented with proper recognition and therapy.  Few conditions in ocular disease offer such a great opportunity for relief of human suffering.  There is a dramatic difference between the devastation of untreated angle-closure glaucoma and its permanent prevention with early recognition and appropriate treatment.

NARROW ANGLE GLAUCOMA:

Narrow angle glaucoma can and should be recognized by all eye care physicians.  The condition, if treated promptly with laser iridotomy, can greatly reduce the chances of visual impairment.  The INITIAL treatment for narrow angle glaucoma is laser iridotomy.  This procedure is done in an office setting, with the patient seated in a comfortable position.  The eye is numbed with anesthetic eye drops.  A special contact lens is placed on the eye, and the laser used to make a small hole in the colored part of the eye known as the iris.  This small hole is usually not detectable with the naked eye.  The hole is usually placed superiorly, in an area covered by the upper eyelid.  Narrow angle glaucoma can occur in people of ALL ages.  It is not uncommon to first diagnose this condition when patients are in their late 30’s or early 40’s.  Many patients when initially told that they have this condition become quite alarmed.  Their alarm grows when the doctor informs them that the initial treatment for this condition is laser surgery.  Patients often want to know if they can use eye drops instead of having laser surgery.  Unfortunately, this is one disease where eye drops CANNOT take the place of laser treatment.  Equally disappointing to the patient at first pass is the fact that some people will require drops even if laser surgery is successful.  Those patients have what is known as combined mechanism glaucoma.

Most important, however, is the fact that this is a treatable disease.  The laser treatment usually takes only a few minutes, but its benefits can last a lifetime.  .

If a patient has doubts about the diagnosis and the need for treatment, they should seek a qualified second opinion immediately.  This often allays their fears, and allows them to proceed with the procedure without hesitation.

GLAUCOMA SURGERY-LASER IRIDOTOMY

SURGICAL TECHNIQUE:

The patient is premedicated with a topical anesthetic.  Pretreating the patient with a miotic agent such as pilocarpine is advantageous.  The miotic pupil provides greater iris surface area for treatment, ensures a thinner iris for easier penetration, and minimizes the chance of errant laser energy causing retinal injury.  Pre-treatment with medications which lower eye pressure is recommended, because 30% of patients develop elevated pressure after laser iridotomy.  Pretreatment with alpha-adrenergic agents such as apraclonidine (Iopidine,) or Brimonidine (Alphagan,) may prevent a post laser spike in IOP.  These topical medications also may limit the amount of iris bleeding when the Nd:YAG laser is used.  In addition to these medications being given 1 hour before the laser surgery, a second drop is applied at the completion of the treatment.

RESULTS:

The end point of treatment for both laser modalities (Argon, YAG) is a well-defined, clean, hole.

POSTOPERATIVE CARE:

After treatment, the patient should be examined during the subsequent 1 to 3 hours and again within the next week.  Patients should be given topical steroids to be used hourly on the day of the procedure, then q.i.d. for 4 more days.

The following page demonstrates the type of iris burn attained with the two types of lasers used to create the iridotomy.  The procedure can be performed using either one or two lasers.  Some patients are treated using only one laser, while other patients require the use of two lasers. The decision of using one or two lasers is made by the surgeon.  This decision is based upon the unique anatomy of each individual’s eye.