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Transcription of Radio Show 3/31/14

Female Speaker:  Umhmmm…

Announcer:  Last phonetic] [00:00:03] Hope Radio

Male Speaker:  Eyecare Radio will be on the air the second Monday of every month.

Male Speaker:  Eyecare Radio will be on the air many Monday evenings.  Our broadcast include interesting guests who help educate our listeners about important eye care topics.  We would like to extend our appreciation to some of our partners in eye care for helping us with this meeting for the discussion of timely eye care topics.

TLC Laser Eye Centers -North America's largest LASIK provider.  More than 2.2 LASIK procedures have been performed at TLC.  Their exceptional experienced surgeons with the help of North America's largest network of affiliated optometrists aim to safely take away the limitations and inconvenience of glasses and contact lenses.  Only TLC offers the TLC Lifetime Commitment.  In the unlikely event a LASIK enhancement is needed down the road as your eyes change, this program provides qualified patients no charge, same technology enhancement procedures for life.

Please visit tlcvision.com or call 1877TLC2020 for more information.

Johnson & Johnson Vision Care -makers of the Acuvue disposable contact lenses with a new 1-Day Moist for astigmatism and 1-Day TruEye – the latest in their product selection of daily disposable contact lenses.

EyeScience vitamins – specifically formulated for all your eye health needs.  EyeScience is unique, leading edge blend of vitamins, minerals, and antioxidants will give your eyes the protection they need to stay healthy and keep you seeing well into the future.  These vitamins can be purchased through our website at nynjoptometrist.com. 

zocdoc.com – Founded in 2007 with the mission of improving access to healthcare.  Zocdoc is a free service that allows many of our patients to find a nearby doctor or dentist who accepts their insurance, see their real time availability and instantly book an appointment via zocdoc.com or ZocDoc's free apps for iPhone and Android.

Dr. Alan Schlussel:  Hello, this is Dr. Alan Schlussel coming to you live from Downtown Manhattan.  I will be your host and moderator tonight.  I would like to welcome everyone to our monthly eye care talks.  I would also like to thank everyone for taking time out of their evening to listen to our discussion.  Most of you on the call are familiar with myself and my offices.  For those visiting our discussion and are not currently a patient of our practice, I would like to introduce myself.  I am a doctor of optometry and I have been in private practice for over 29 years in midtown Manhattan on the 33rd street in Third Avenue and suburban New Jersey in West Orange.  You can also visit our website at nynjoptometrist.com or with any additional questions, email me at dral@nynjoptometrist.com. 

As we go along tonight, I want to go over a few ground rules about the show.  We will be presenting some new information about LASIK eye surgery and new advances in LASIK cataract surgery.  If you want to ask a question during the show, just press 1 on your phone.  That will alert us that you would like to ask a question.  We will take questions as we go along.  Some questions might be best answered at the end of each [indiscernible] [00:03:32] discussion.  If you are listening to show on the web, you will have to call in our call in number which is 646-716-7770 and then hit one on your phone right now.

Let's…tonight we are going to be talking about new advances of LASIK eye surgery and improvement to laser eye…laser cataract surgery.  Tonight our special guest is Dr. Anne Ostrovsky, an esteemed ophthalmologist surgeon of Laser and Corneal Associates in New York City and White Plains, New York.  Dr. Ostrovsky practices general ophthalmology, refractive cataract and laser surgery and is a specialist in corneal diseases.  She specializes in small incision cataract surgery with implants including the multifocal, accommodating and Toric intraocular lenses. She has also has performed a number of cases with the femtosecond laser, the Catalys laser, Precision laser system by OptiMedica, which has gained approval for capsulotomy and lens fragmentation during cataract surgery.

Dr. Ostrovsky also performs Bladeless Laser Vision Correction including Custom LASIK and PRK.  She has also had extensive experience treating keratoconus by the new Corneal Collagen Cross-linking with Riboflavin which is becoming an exciting new treatment for keratoconus  She will discuss this exciting new treatment during the show and let's say hello to Dr. Ostrovsky.

Dr. Anne Ostrovsky:  Hello everybody.

Dr. Alan Schlussel:  [indiscernible] [00:04:54]

Dr. Anne Ostrovsky:  It's nice to be here.

Dr. Alan Schlussel:  Hi.  Okay.  Welcome to the show and secondly we have Ms. Cecilia Iglesias who is a surgical consultant with TLC Manhattan.  She has had LASIK herself many years ago and will be able to go over pricing questions and the TLC Lifetime Commitment.  Hello Cecilia. 

Cecilia Iglesias:  Hello there.  Thank you for having me.

Dr. Alan Schlussel:  Okay.  Thank you for being part of the show.  I just want to go over a couple of basics about LASIK and Dr. Ostrovsky will then go into more experience that she has personally with patients.  LASIK as we some of us know is laser-assisted in situ keratomileusis, which is the most commonly performed laser surgery to treat myopia, which is near sightedness, hyperopia which is far sightedness, and astigmatism.  Like other types of refractive surgery, LASIK procedure reshapes the cornea to enable light entering the eye to be properly focused onto the retina for clearer vision.  In most cases, laser surgery is pain-free and completely completed within 15 minutes for both eyes.  The result is improved vision without glasses or contacts can usually be seen in as little as 24 hours.

The surgeon typically uses the femtosecond laser to create the thin, circular flap.  With this bladeless LASIK, people with thin corneas who once were deemed unsuitable for LASIK now become good candidates.  Most patients have corneas between 500 and 600 thick to maintain corneal stability and avoid serious LASIK complications [indiscernible] [00:06:25] surgeons may want to leave happily with certain amount of thickness under the flap as possible.

So, generally speaking, the thinner the corneal flap the better because this leaves the greater amount of tissue under the flap for retreatment.  Dr. Ostrovsky can you go over any of your examples of patients that would not be good candidates?

Dr. Anne Ostrovsky:  Certainly.  Some patients who have very high levels of near sightedness or myopia such as prescriptions that are greater than about 8 to 9 diopters very frequently, those patients – their corneas do not have enough corneal tissue to have either a LASIK or PRK surgery performed.  Additionally, some patients don’t have a healthy curvature of their cornea – something we call topography.  We look for a normal topography on some imaging that we do preoperatively for all patients who decide to have LASIK surgery and we screen patients to specifically look for the abnormal topography.  Those patients who have abnormal topography are predisposed to having issues if they receive laser surgery or may have to have an underlying condition called keratoconus and just not be candidates for laser surgery.

Dr. Alan Schlussel:  Thank you, that’s great.  I think one thing that I have noticed with patients and you can chime in also and even Cecilia is that patients probably…most patients going through it don’t realize how short a procedure it is and how easy and how pain-free it is.  They don’t realize how good the vision will be almost immediately. 

Dr. Anne Ostrovsky:  Yes, [overlapping conversation] [00:08:10]

Dr. Alan Schlussel:  You notice that yourself [overlapping conversation] [00:08:12] people just sit up?

Dr. Anne Ostrovsky:  Yes, absolutely.  I think most patients are quite surprised at the quick turn around in their vision and on the first postoperative day, patients come back and are very frequently within one to two lines of perfect vision within 20/20.

Often…oftentimes also patients get up from the table just having had the procedure a minute ago and can already see clearer than they could before the surgery without their glasses.  That’s pretty incredible technology.

Dr. Alan Schlussel:  Do you find…I mean at least I have been finding with our patients the reproducibility, the accuracy of the laser is as good as it has ever been and continues to improve just from the new ones that they put in the software and some of the upgrades they actually have had in technology.

Dr. Anne Ostrovsky:  Absolutely, yes and you know prior to having the lasers to create our blade free flap that we currently make, we used to use knives or they were called microkeratome and the flaps that we used to make in the cornea had much, much, much, much predictability…in fact every…every time that we would create a flap we would be you know not completely certain as to how thick it would be.  With the current technology, we are really within 5 to 10 micrometers of the thickness of the flap and that is very important as you had mentioned earlier that we don’t want to go too deep into the cornea for safety reasons and that’s having a very predictable and thin corneal flap creates greater safety and better visual outcomes for the patient.

Dr. Alan Schlussel:  Cecilia, can you give some insight into your experience of LASIK.  I know you had it a number of years back, but you continue to see patients in the offices that come through.  What's your experience?

Cecilia Iglesias:  Oh absolutely.  So, I had my surgery way back in 2001 and what I can tell you is that it was superfast.  It was as if it was too fast.  It felt like it wasn’t possible and because you are still comfortable with the numbing drops and the Valium that we dispense, it is just a very, very smooth sailing procedure and then you are so relaxed afterwards that I slept like a baby.  I don’t think I have ever slept like that ever again.  So, it’s very, very comfortable procedure and I will tell you for being in the LASIK field for now 10 years, the most common feedback that we get from patients when they come out of surgery is I wish I would have done it sooner.

Dr. Alan Schlussel:  Exactly.  I was going to mention that yes.

Cecilia Iglesias:  It’s more mentally draining than anything else and I can totally understand and relate because you are given only one set of eyes, but as soon as patients come out of that surgery room they are amazed on how quickly it went, how comfortable they were, and how we just turned back the hands of the clock by 10-20 years.  So, it's pretty amazing procedure.

Dr. Alan Schlussel:  I agree and we continue to see that.  I mean I see a lot of the patients on day one as Dr. Ostrovsky does and the people just will continue to say, "I wish I did this before," but it is an amazing procedure and the precision is quite amazing too and just the visual outcomes we are seeing is incredible.

Dr. Anne Ostrovsky:  [overlapping conversation] [00:12:06]

Dr. Alan Schlussel:  [overlapping conversation] [00:12:09] high amounts of…what's that?

Dr. Anne Ostrovsky:  I just wanted to add that you know each treatment, each patient is unique to their type of cornea and we take pictures of…the topography pictures that I was talking about before are a unique sort of footprint of each person's corneal surface and the treatment is customized to each person uniquely.  So, the results are very, very good and very, very precise and custom tailored.

Dr. Alan Schlussel:  Again I think we are seeing that many patients are getting better night vision or even better vision than they did before LASIK because with the custom treatment that’s done with the footprint or the actual fingerprint of the eye, we are treating things that glasses and contacts couldn't treat.

Dr. Anne Ostrovsky:  That’s correct.  That’s correct.  That’s [overlapping conversation] [00:13:01]

Dr. Alan Schlussel:  I think another misconception…I think a misconception, some people get.  I don’t know if you also experienced that a patient will think that you can't correct astigmatism and I get that all the time and patients who I mentioned are good candidates, they say, "I have astigmatism.  Can I have it done?" and I think that’s just the connotation people had when laser was first FDA approved, it wasn’t approved for astigmatism, but it has been approved that way since the beginning.  It’s just people don’t realize that I think.

Dr. Anne Ostrovsky:  That’s very correct and many people…many people have astigmatism.  In fact most people have a little bit of astigmatism and I think as long as your astigmatism is within sort of a range of less than about you know 3.5 to 4 diopters, there is a very good chance that you actually are a LASIK candidate.  So, I get that a lot as well when patients come in and they are very surprised to find out that they in fact are able to correct all of their astigmatism and they are great candidates for LASIK.

Dr. Alan Schlussel:  Correct.  Let's go onto the next part of LASIK which is a common topic we get with a lot of our patients that are approaching their 40s or are already into their 40s and 50s.  How do we correct for the near vision presbyopia or the problems with people reading in their 40s.  Up to now, what we have done is in many cases we created a monovision effect, which is under correcting one eye, usually the non-dominant eye a little bit so that the end result is that they will see 20/20 in their dominant eye, but they may see 20/30 or 20/40 in the non-dominant eye and that seems to get them through the early years of presbyopia in the mid to maybe late 40s, but there are some new developments in corrective options for presbyopia that is still not technically approved yet, but will gain approval probably over the coming year.  Dr. Ostrovsky, can you go over some of those developments that you have experience talking to the colleagues about?

Dr. Anne Ostrovsky:  Yes.  There are some of the latest and the greatest sort of things on the forefront in treating are what are called corneal inlays and these are basically very small…very small discs sort of that…that are thinner than a contact lens.  Now, several of them that are approaching FDA evaluation, but the one that is actually the closest to FDA approval is called the Kamra Inlay and they anticipate that it may be approved by the end of this year and what it is is like I said it is this very small, film like ring with an opening in the center.  It looks like a donut and is smaller and thinner than a contact lens and it is implanted into a small pocket that’s created with a femtosecond laser in one eye only, the non-dominant eye, and it works on the pinhole principle.  What it does is it improves the near vision by actually increasing depth of field.  Now, it is very, very thin.  It’s about 5 micrometers thin and what's great about this is that it's removable, which you know most other things are not like monovisions for example.  The inlay actually has very minimal effect [overlapping conversation] [00:16:30]

Dr. Alan Schlussel:  [overlapping conversation] [00:16:30] reversible.

Dr. Anne Ostrovsky:  It is a reversible procedure, yes, that is correct, yeah and about 20,000 of these have been implanted worldwide and speaking to some of my colleagues specifically in Japan, where a lot of these were done, they have very, very good outcomes.  Now, this inlay is already commercially available in almost 50 countries around the world and like I said it is in the later stages of FDA approval here.

Dr. Alan Schlussel:  [indiscernible] [00:17:01] and I think that’s going to be a welcome addition.  Now patients who have had LASIK are as good candidates as people…fresh patients that will get LASIK coming forward?

Dr. Anne Ostrovsky:  Absolutely yes and in fact in order to be a candidate to have this lens placed, the patient really has to be close to emmetropia[phonetic] [00:17:12] or not having a distance prescription; somewhere between 0 and -1 of a distance prescription.  So, if a patient is not…does not have that level of a prescription, we may actually treat them first with LASIK to achieve you know a sharp distance vision and then perform the implantation of the inlay in the non-dominant eye.

Dr. Alan Schlussel:  Great.  It sounds exciting.  I would like to touch upon briefly about your experiences with people that are far sighted with the LASIK procedure.  I know early years of LASIK and PRK those patients didn’t get as good results with, but what is your experience with some of those patients now?

Dr. Anne Ostrovsky:  Most far sighted potns who have mild to sort of moderate degrees of hyperopia or far sightedness can actually have very, very good LASIK results.  It’s the patients that have very high levels of hyperopia like +3, +4 and patients with…that are younger with high level of hyperopia that probably would still not be the best LASIK candidate.  However, if you have a +1 or a +2 prescription, you may do very, very well after laser surgery and the current technology really supports that much better nowadays.

Dr. Alan Schlussel:  Now, how do you…how do you judge those patients in terms of whether they are candidates and whether they are still in the fluctuating part of their prescription because many of those patients in their early 40s are still getting more hyperopic or more far sighted as they get older.  Is there an ideal time to do it in terms of age or how…how…how good does the vision have to be stable for how long?

Dr. Anne Ostrovsky:  So, the trick with…with far sightedness is that our eye is actually able to generate accommodating power, plus power.  So, if you are let's say in your 20s and you have a +2 prescription, your actual number of plus diopters that you have is actually much higher than that.  You probably are about a +4 maybe or +5 and your own eye is so flexible that is able to generate that extra plus power and that’s the sort of the trickiness with treating far sighted patients is that you want to try to uncover the entire amount of the plus prescription so that can be treated.  That’s the first part of it.  The second part of issues with far sightedness is that the far sighted treatments with the laser can regress or sort of revert back to where they were more so than the treatments for near sightedness.  So, we warn patients who have moderate degrees of far sightedness that they may need more touch ups than someone who let's say has a moderate near sighted prescription.

Dr. Alan Schlussel:  Great.  Thank you.  I would like to touch upon briefly a little bit about the TLC's role and TLC Lifetime Commitment.  We want to go into some of the topics regarding LASIK cataract surgery and then some discussion about keratoconus so we have about 25 minutes left in the program.  So, why don’t we touch upon that with Cecilia?

Cecilia Iglesias:  Sure.  So, at TLC Laser Eye Centers, we stand behind our results, our technology and our surgeon.  So, therefore, we want to see our patients have great vision for the rest of their lives and so if by chance and this is unlikely and a very low percentage of our patients have to return for an enhancement, but if the patient is in need of an enhancement, they would…they can return to any of our 58 centers nationwide for an enhancement.  Now, of course, they would have to go through the entire process by getting screened and confirmed a candidate once again in order to move forward with the enhancement.  That is part of our Lifetime Commitment program.  Now, there is one rule of thumb, which is patient needs to return to see a TLC affiliated doctor which in this case would be you Dr. Schlussel for annual routine eye exams, which is something everyone should be doing regardless if they have LASIK or not.  That is billable to the patient's insurance or out of pocket.  So, by maintaining annual exams, they maintain the Lifetime Commitment program, which means that their enhancements would be at no charge.

Dr. Alan Schlussel:  Great.  That sounds like it's a great program and I think people I have seen in my practice have taken advantage of it and I think it’s good peace of mind for patients that they know that their…you know if they do have…they need a touch up or their vision does change, we can go back and improve the vision back to what it was right after LASIK which is generally 20/20.

Next, I would like to switch gears to talk about LASIK cataract surgery.  This is relatively new addition to the cataract surgery technology field.  The femtosecond laser we spoke about before that created a LASIK flap is now advancing cataract surgery.  In traditional cataract surgery, the eye surgeon uses a hand-held metal or diamond blade to create a small incision and the goal is to create a small incision so that you can access the cataract and break it up with something called phacoemulsification.  Phacoemulsification is just a suction and device that breaks up the cataract with energy and heat.  By using the femtosecond laser, we can now create a small, maybe smaller[phonetic] [00:23:20] incision, but have less energy going to the eye and cause less peripheral damage.  The other advantage of the femtosecond laser can actually correct certain degrees of astigmatism and create a much more accurate incision so that when the intraocular lens goes in, it goes in more appropriately into the proper space.

Dr. Ostrovsky, can you maybe go into a little bit more depth and your experiences with the LASIK cataract surgery?

Dr. Anne Ostrovsky:  Yes, absolutely.  We have been performing laser cataract surgery for about the past year or so and just to sort of go back and go through…again, just like Dr. Schlussel like you said, the cataract surgery, the easiest way to link it is inside of the eye there is a little crystal.  It looks like an M&M candy, just much smaller.  That crystal is what's called the lens of the eye.  When that lens becomes hazy and yellow and brown, it starts to block the light rays that normally go into the eye and normally hit the retina and focus.  Once it gets cloudy, the light rays are scattered and you get a very blurry image and the vision is significantly decreased.  What we do during the surgery normally is we remove the top shell of the M&M candy and then the chocolate essentially is the cataract.  So, that is scooped out during the surgery by using heat energy and removed and a plastic lens is slid into the intact rest of the candy shell.  Now, all of these things that usually were done manually and the byproducts of the manual surgery was heat.  Now, heat applied to some of the ocular tissues like the cornea or front window of the eye or the iris, which is the colored part of the eye, can cause collateral damage to those tissues and such as for example, if heat touches the back side of the cornea, significant amounts of heat, the cornea can swell and that can lead to a slower healing time and more blurry vision for a longer period of time after the surgery.  With the advent of laser surgery, laser assisted cataract surgery, it does a couple of things for us.  Number one, the opening in the top candy shell of the M&M is very, very predictable, accurate, reproducible, and we can target the size and centration of it.  Now, why is that important?  With the advent of some of these new premium special lenses that are now in the market, such as the multifocal lenses or the accommodating lenses, it’s essential that the size of that opening is of a certain size and that it is completely centered on the pupil.  That will determine whether the lenses work as they are supposed to.  As good as we are, as good surgeons as we are, studies have shown that even in the hands of the most experienced surgeons, there still are…there is still some variability, you know, in the size and shape of these openings that we make manually.  So, that’s the first part that’s advantageous.

The second part is that the heat energy that I was talking about.  When we remove that…the chocolate bit from the M&M candy, we actually pulverize it with heat that comes from the phacoemulsification instrument.  The amounts of heat sort of determine how much damage we will get to the surrounding tissue.  Laser cataracts are able to prefragment the cataract.  So, it breaks it up before we even enter the eye surgically and then all we do when we go inside the eye with our instruments is we suck out the little pieces instead of applying heat.  Now, that basically translates into shorter recovery times and faster…with faster vision recovery times.

We have seen that with our patients and patients are very, very happy with the results of the surgery.

Dr. Alan Schlussel:  Oh, sounds amazing, you know.  I guess that we you know [indiscernible] [00:27:47] a lot of patients in the past I have always thought if they had laser surgery or laser surgery was done by…with cataracts, but this is really the first true laser; the phacoemulsification that Dr. Ostrovsky mentioned is not technically a laser.  What we really use now is the femtosecond laser which does create the breaking up of the cataract and then the small bits get vacuumed out with a small bit.  The other thing that Dr. Ostrovsky mentioned that we are seeing great outcomes is the accommodating or the multifocal intraocular lenses that allow patients not only to see better in their distance vision than they ever saw before with most patients after cataract surgery even with a traditional intraocular lens, their far vision or whatever correction they wore in the top part of their glasses can be completely eliminated or corrected for, but now it can correct for moderate to high amounts of astigmatism.  We can also correct for the near vision part of their bifocal if they wear bifocals or people that wear separate reading glasses.  These multifocal intraocular lenses are similar to the multifocal contact lenses we are having good success with and they give great visual outcomes and great results and patients feel like they are seeing like they did when they were 20. 

Dr. Ostrovsky, can you comment on your experiences working with patients?

Dr. Anne Ostrovsky:  Yes, definitely.  There are really two broad categories that you mentioned of these lenses that allow you to have a greater freedom from spectacles after cataract surgery.  The first group is called multifocal lenses and these lenses truly allow you to have terrific distance vision and very, very good near vision, essentially eliminating the need for glasses, for reading glasses and distance glasses post surgery.  The second type…the second group of lenses is called the accommodating lenses and that works with a slightly different mechanism than the multifocal, but essentially the final result is the same.  It’s greater independence, greater spectacle independence post surgery.  It’s really truly incredible you know the choices of these special lenses that we are able to offer patients now because in the past you know even maybe 20 years ago, you know we had one type of lens with a monofocal lens and we could only offer the patient vision in one area.  So, we could say we could make you have clear vision at distance without glasses or at near without glasses, but you will have to wear glasses for one or the other.  So, it’s quite exciting that we have these [indiscernible] [00:30:30] technologies now that we can offer to our patients.

Dr. Alan Schlussel:  Yeah, lot of times we are with…dealing with patients who are not quite at a point where the cataracts are mature enough to remove.  I know some surgeons in the past…I have never used this, but some people say you have to wait until the cataract is mature.  I am sure you are seeing and I am seeing in my practice we are recommending it for younger patients in their 50s who might traditionally not have had cataract surgery 20 years ago now are able to have cataract surgery.  What is your experience with taking cataracts out when they are not at a mature or moderate level?

Dr. Anne Ostrovsky:  Well, we always try to wait to take cataracts out until the vision is of a certain level or if the patients are having significant visual disabilities such as glare or difficulty driving at night or some sort of visual symptom.  Usually, the vision that we consider appropriate for cataract removal is about 20/40 or worse.  However, there are patients who are walking around with 20/25 vision which is nearly perfect for distance, but in dusk and dark conditions, their vision decreases significantly and they have a lot of glare and they have given up driving for example because the cataracts are causing symptoms.  We also can take out the lens like I had talked about without it having a cataract, but at that point it wouldn't be called cataract surgery, we would call it a clear lens exchange.  So, folks like in the beginning of the program when we spoke about the patients who for example are not LASIK candidates who let's say have very, very high degree of hyperopia or far sightedness, we can offer them the ability to remove their crystal and have a lens placed inside as a treatment to get them out of their glasses and we do do that in some patients; usually, in patients who are over 40 years old.

[phone ringing] [00:32:39]

Dr. Alan Schlussel:  Interesting.  That’s very interesting that you can offer that and I think it's great that we have the ability to do that.  Do you think [phonetic] [00:32:46] I think that a lot of patients have inquired about is the ability to correct high amounts of near sightedness for those patients that aren’t candidates for LASIK as in the people…is the people that have a -10s or -12 prescriptions, those patients do very well with cataract…with the Visian[phonetic] [00:33:09] lens, which is I think the lens that’s currently available to correct high amounts of myopia.  How has your experience been with those patients and what is the procedure, how that’s done, they have the implant put in first and then they have LASIK done a month after once they heal, what is the procedure for that?

Dr. Anne Ostrovsky:  Yes, so…the implantable collamer lenses or ICL are great technology that have been around for several years that really has allowed us to treat these patients who really are disabled because of their visual prescriptions.  You know these are patients who have prescriptions of -…higher than -9, usually -10, -12.  They are patients who actually are debilitated without their glasses and contact lenses, unlike most of us who even if we have a prescription we take off our glasses and we can sort of see shadows and you know we can get around our own houses.  These folks take off their glasses and they see nothing.  They see just haze and grey.  They are legally blind and in fact one of the patients that recently came to our practice had a -23 prescription and you know these are people who are completely reliant on…most of them are reliant on their contact lenses for vision and if they become intolerant of those lenses you know their world is over.

Now, these implantable collamer lenses have really revolutionized the treatment of these high prescriptions which before if these patients came into our office, we would tell them you know, "I am sorry, you are not a good candidate for refractive surgery for LASIK nor PRK" and we would just send them on their way and they would have to deal sort of with their contact lens intolerance as best as they could. 

Now, we have…I particularly implant the Visian[phonetic] [00:35:01] intraocular collamer lens and it is approved in the United States to treat high levels of near sightedness up to -16 diopters.  So, if somebody comes in [overlapping conversation] [00:35:11] yeah, with very, very high levels…if somebody comes in and they have under 16 diopters of near sightedness, we can correct their prescription just by implanting the lens.  They do not need any extra procedures.

If somebody has a prescription that is above -16 like the -23 gentleman that we saw in our practice, what we will frequently do is we will combine a LASIK procedure together with the ICL procedure to treat all or most of their prescription and get them out of their glasses and contact lenses.  Now, the [indiscernible] [00:35:48] wear the contact lens.  That’s exactly what it looks like.  It's very thin and pliable and we implant it into the eye between the iris which is the colored part of the eye and the lens which is the crystal inside of the eye.  You cannot see it when you look at somebody who has it implanted.  It is removable.  So, if somebody let's say down the road develops a cataract, it’s very easy to take this lens out and proceed with cataract surgery as usual.  The results are incredible.  There is really very minimal side effects.  People don’t complain of glare.  The quality of the vision is superb and we frequently will even recommend this…this surgery to patients who have moderate to high levels of near sightedness like a -8 for example, -7, -8 let's say they are still…they still maybe able to get the LASIK done, but if they are getting up close to that sort of maximum number, their quality of vision may even be better with an implantable collamer lens.  So, we may even recommend it to patients who theoretically could have LASIK, but are really up and maximum…maximal level [overlapping conversation] [00:37:08] prescription.

Dr. Alan Schlussel:  Prescription [overlapping conversation] [00:37:07] Yes.  That’s amazing.  We have a few minutes left in the call so I want to go into the keratoconic treatment or keratoconus that we deal with.  A lot of us are seeing patients, it's not a common phenomena, but it is something that is fairly…something we see reasonably often in our practices, that’s called keratoconus.  Keratoconus is the thinning of the collagen of the cornea whereby the cornea becomes misshapen or irregular where we can't correct your vision with traditional contact lenses or glasses.  Many of these patients up to now have suffered through wearing rigid contacts which does correct your vision very well, but they have the nuisances[phonetic] [00:37:51] of wearing contacts that can pop out or contacts that aren’t as comfortable.

So, we have a relatively new treatment available in the United States, but a treatment that’s been done in Europe and Canada for quite a few years and is the standard of care of treating keratoconus is using cross-linking, which is using a UV light with riboflavin drops that increase the density or the strength of the cornea so that the cornea is not…no longer misshapen or irregular.  It’s an exciting new advancement[phonetic] [00:38:25] because we can actually take patients in their 19-20…19-30th age where they first get keratoconus and actually keep it at that level and prevent it from getting worse.  In addition, we can treat patients that have had keratoconus that have been intolerant of wearing hard contacts and keep their eyes from changing or getting worse.

Dr. Ostrovsky, can you comment in the last few minutes of your experiences with patients that have had this?

Dr. Anne Ostrovsky:  Yes.  We are…we are very fortunate that this treatment has come to the United States and as you said Alan, it has been out in Europe and Asia and in the Middle East for over a decade and the truly the only treatment that we have for this progressive disease and the normal nature of keratoconus is a progressive one.  Folks get it around in their teens and 20s and what happens is the cornea goes from a normal rounded shape to kind of a cone shape and progressively glasses don’t work, then they get into contact lenses and contact lenses no longer work and the last stage of sort of trying to treat this is to actually do a corneal transplant to remove the chronically abnormally shaped window and put a different one on and obviously that’s a pretty invasive procedure and one we would like to avoid in patients if we could.

Now, what the cross-linking procedure does is as you had mentioned Alan, it takes…the cornea is made up of corneal collagen fibrils and the best way to describe that is as if it’s a carpet and it's made of a carpet weave.  When we administer riboflavin, which is a vitamin B, together with UV light, it strengthens the fibrils and actually makes them more rigid and prevents the cornea from deforming, which is what the problem is in the first place is that the cornea deforms and protrudes and thins and becomes this cone shape.  So, if we are able to do this procedure for even you know young…young adults right as they start to develop this progression, we may be able to prevent them ever needing a corneal transplant.  Though[phonetic] [00:40:57] certainly a wonderful procedure and something that we are excited to be doing.

Dr. Alan Schlussel:  Yes sounds very exciting and we have certainly…I have started to see some great results from it for patients that we commenced[phonetic] [00:41:11] together.  Do you see a day where this might be extended to help patients that are very near sighted in terms of possibly using new special design contacts so do you think that’s something that’s probably not going to happen?

Dr. Anne Ostrovsky:  Well, the principles from the procedure may be…the corneal cross linking itself actually causes some flattening of the cornea.  It's just not very predict…it’s not very predictable at this point, but you do get about 1 to 2 diopters of corneal flattening as a result of it.  So, the principle I think may actually be using a [indiscernible] [00:41:49] to create some other therapeutic advances in the field.

Dr. Alan Schlussel:  Thank you for your information.  We have I think about 2 minutes or 3 minutes left.  If there is anyone out there that has questions, I think we would be happy to take any questions now.  If not…if no one has questions about that, our patients that listen to this broadcast or radio show online off our website can share with their friends or people they know that might have an interest in this.  They would be welcome to listen to this in entirety or part of the discussion because a lot of good information we gave you guys, lots of interesting information about the new advances in laser and cataract surgery and in the treatment of keratoconus. 

I want to thank Dr. Ostrovsky for being part of the call.  Thank you very much for your time and Cecilia…

Dr. Anne Ostrovsky:  [overlapping conversation] [00:42:42]

Dr. Alan Schlussel:  [overlapping conversation] [00:42:43] Cecilia Iglesias from TLC, I would like to thank you for being part of it.

Cecilia Iglesias:  [overlapping conversation] [00:42:50]

Dr. Alan Schlussel:  And I want to [overlapping conversation] [00:42:53] Nope.  Thank you very much.  I appreciate your time and I hope people that are listening in or will listen in off the broadcast, you know, call our office or email us with any questions or just learn something new about LASIK eye surgery.

We plan on having future discussions.  We usually have them on Monday evenings.  We will communicate this through our patient database through our newsletters that we send out.  I would like to also have patients call our office if you are interested to have a consultation about getting LASIK.  We are available for consultation.  Dr. Ostrovsky's office is also available.  Her office is on Fifth Avenue and 39th Street.  Their phone number is 212-832-2020 and their website is lasiknyc.com and our website Dr. Alan Schlussel is nynjoptometrist.com.  We hope to listen in, having lot more people coming in, call in in the future episodes and I thank you for tuning in and I hope everyone has a great evening and have a good night.

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