Eyedea magazine - Summer 2011 by Media MICE

Eyedea

published by

A BoozmanHof Quarterly Magazine Summer 2011

Illuminating Refractive Cataract Surgery Toric IOLs of paramount importance - page 6

Floppy Iris Is Under Control - page 11

Great AMD Treatment is Here - page 4

02 n Eyedea

To Our Readers

Doing What We Do Best:

Doctors

Refractive Cataract Surgery

hink back to 1981. It was a great year for movies; The Empire Strikes Back, The Shining, and Raging Bull all came out in the theater. It was also the year the first intraocular lens (IOL) implant gained approval by the U.S. Food and Drug Administration. Before that, patients could be as blind before cataract surgery as afterwards. Only very thick glasses or special contact lenses could help many. How things have changed. Today, cataract surgery truly is a refractive procedure, and we at BoozmanHof are proud to have been involved wholeheartedly in this important evolution. Dating back to our founding in 1977, we’ve historically been a high volume, progressive cataract practice. Our refractive practice began in 1985, having been one of the first centers in the United States to perform radial keratotomy (RK), which soon evolved into procedures like PRK and LASEK.

We needed to come full circle though, and we have, making cataract surgery a truly refractive procedure. We’re not just taking out the cataract anymore. We’re reducing dependence on glasses with technologies like accommodative and multifocal IOLs.

Dr. Bill Hof and I have each performed more than 20,000 cataract surgeries. I’ve also performed more than 10,000 refractive procedures. If patients are looking for experience and a world-class ophthalmologyspecific surgery center, think of BoozmanHof. In this issue of Eyedea magazine, we would like to highlight a very special topic in refractive cataract surgery: that of astigmatism correction

with toric IOLs, which sometimes is overshadowed in the press by presbyopiacorrecting IOLs. All of these technologies are very important, but we’re going to do what we can to share more knowledge in this important new field of astigmatism correction. Thank you for supporting BoozmanHof. We are pleased and humbled to serve you, and we promise to work extremely hard to be accessible for you, meet your needs, and provide superior eye care to your patients. We’re here to help. How can we best serve you today? Please feel free to write me at dreyerecole@ aol.com or call me at 479246-1700 and let me know. Sincerely,

Randall E. Cole, M.D. President, BoozmanHof Eye Clinic Medical Director, BoozmanHof Eye Surgery and Laser Center

C. William Hof, M.D. Randall E. Cole, M.D., F.A.C.S. Randall O. Bell, O.D. Darren L. Brodie, O.D. Leah B. Cate, O.D. Jim S. Myers, O.D. C. Scott Woodward, O.D.

Website www.boozmanhof.com Eyedea published by

Editor and Publisher Matt Young Copy Editor Hannah Nguyen Designer Winson Chua

Cover Image: Nick whirling with LEDs Copyright © 2011 Photographer: Hendrik Kueck, www.playpoi.com Media MICE Pte Ltd 6001 Beach Road, #19-06, Golden Mile Tower, Singapore, 199589 Phone: +65 8186 7677 Fax: +65 6298 6316 E-mail: enquiry@mediamice.com This publication is published by Media MICE Pte Ltd who is solely responsible for its editorial content. All rights reserved.

In this Issue...

Treatments for AMD

Get rid of blurred vision

Retina is the responsibility

improve vision

with toric IOLs

of primary care too

11 Punctal plugs reloaded

Eyedea n 03

O.D. Corner

Fighting, Together, for the Best Visual Outcomes By Darren Brodie, O.D. Director of Practice Development

even years ago, when I joined the Air National Guard at 35 years old, a lot of people thought I had gone crazy. But it wasn’t a knee jerk reaction to anything. The events of Sept. 11, 2001 had occurred years earlier. The Second Gulf War also had been underway for a year already. It’s just that I had never served our country, and I wanted to serve. That was a good instinct to have had. From serving in Guatemala as part of a humanitarian effort to participating in recovery efforts after Hurricane Katrina, the experience has been nothing if not positive. I remember in Guatemala we took long bus rides on narrow, curvy roads through the mountains to get to villages in order to get people with cataracts the surgery they needed. I brought enough antibiotics to treat eye infections we came across. The biggest help though was just providing glasses for local folks nearsighted and farsighted. Those really poor villages were a sight to behold. It reminds me how fortunate we are at BoozmanHof to be able to provide the absolute best care available to our patients. We’re getting really advanced in treating dry eye, for instance. Ten years ago, all we had for dry eye patients was artificial tears to ameliorate symptoms. We’d tell patients to use them and hope for the best. Now

we have much better treatments like Restasis (Allergan, Irvine, Calif.), which treat the root cause. Sometimes what we do isn’t even that obvious. There’s no “wow” effect after treating someone with glaucoma, but you know you’re making a real difference in that person’s life. I do get the biggest thrill out of refractive surgery though. Some people are 100% dependent on glasses or contacts before surgery. Then they throw them away afterwards. It’s so exciting to see that. Through it all, I always know that I’m part of a much larger regional eye doctor community that cares greatly for our patients. As a past president of the Arkansas Optometric Association, I came to know a tight knit community of doctors open to sharing clinical thought—especially when myself or fellow eye doctors felt unsure about a patient problem. It’s such a great environment to be a part of, and proud of. I can’t say enough about how much we at BoozmanHof respect the regional M.D. and O.D. professions, their opinions and their diagnoses. Serving as Clinical Director of the Optometry Clinic for the 188th Fighter Wing has its merits, but what I enjoy full-time is being part of a caring, well developed eye care community. So here’s just saying thank you to our region for doing what you do best. And please, send me an email at DLBrodie@cox.net or call me at 479-246-1700 if you ever need help answering an eye care question. We look forward to continuing to work hand-in-hand with you so that eye-toeye, everyone’s looking and seeing their very best.

Springdale Optometrist Was Academic and Athletic Champion

r. Jim Metheny, a Springdale optometrist known for his sharp, discerning mind and conquering tennis racket, has died. Dr. Metheny had a reputation for being mild mannered, but Dr. Jim Metheny when challenged, handily disposed of opposition in academia and on the court. Recently, he objected to a medical report suggesting that acupuncture could fix amblyopia, and corresponded with its publisher, Archives of Ophthalmology, with writing that only could be described as “brilliant,” according to Dr. Cole. “His critiques were amazing,” Dr. Cole said. “A month before he died, the Archives of Ophthalmology invited him to be on the editorial review board to review articles.” Dr. Cole said he was shocked and saddened to lose Dr. Metheny, who helped co-manage BoozmanHof’s cataract and refractive patients since 1992. Dr. Metheny died of a heart attack at age 63. “Years ago, he said, ‘Do you want to go play tennis?’” Dr. Cole recalled. “I was a decent tennis player, but he just beat me like a drum. I didn’t make one game off him.” Later, Dr. Cole said he found out Dr. Metheny was a city tennis champion in West Memphis. “He was way over my head,” Dr. Cole said.

Insight into AMD

No More Dark Pools

Treatments improve for AMD’s bad, bursting, blood vessels that lead to blindness Photo credit: Matt Poe, COA

very specific. It inhibited only one of the subtypes of molecule, and although it was better than the prior kind of treatment, it wasn’t ‘Oh wow.’” The previous treatment, meanwhile, sounded cool, but it wasn’t great. Standard of care then was photodynamic therapy (PDT) in which a photosensitive dye was injected into a patient’s vein, Dr. Hof holds a little bottle of a big AMD treatment—Lucentis and laser light interacted with that dye to break it down, causing he pools of bloody fluid that ions to attack preferentially abnormal accumulate around burst blood vessels. Unfortunately, it attacked vessels in age-related macular normal ones too, Dr. Hof said. degeneration (AMD) aren’t a pretty “Macugen worked better than that sight to behold among eye doctors. standard,” Dr. Hof said. “And Macugen Using a little imagination, you plus the laser worked better than either might think of it like the red-brown one alone.” runoff characteristic of acid mine Along came medical researcher drainage. Judah Folkman, who found out tumors And while acid mine drainage— would die if they could be stopped from also AMD—continues to plague the growing their own blood supply. earth (and notably gold “cursed” “If you could figure out a way South Africa, where mines increasingly to stop the blood vessels growing, compromise water systems in the heart you could starve the cancer,” Dr. Hof of Johannesburg), the prognosis is summarized. Eventually, that research getting better for ocular AMD. led to treatments for a number of “No one uses Macugen anymore,” diseases. Avastin (Genentech, South said C. William Hof, M.D., co-founder, San Francisco, Calif.) was born, Dr. BoozmanHof, referencing a drug once Hof said, and although it was primarily heralded for its ability to halt the used for colon cancer initially, it was progression of ocular AMD. “Macugen eventually applied to exudative macular [OSI Eyetech, Melville, New York] was degeneration. the first VEGF inhibitor to be Food and “The Avastin molecule was Drug Administration approved. It was reengineered to make it specific to the eye to penetrate the tissue better,” Dr. Hof said. “As the new molecule was going through FDA trials, Dr. Phil Rosenfeld at Bascom Palmer said, you know, if the genetically reengineered molecule—Lucentis (Genentech)— Wet AMD takes its toll

works, maybe the parent molecule would work too.” Avastin did work. “Retina docs all over the country picked it up in a heartbeat and the stuff was used like wildfire six months before Lucentis came out,” Dr. Hof said. “It worked, it was safe and great.” Genentech reported that in clinical studies of Lucentis, 9 out of 10 people saw their vision stabilize (which means they lost fewer than 15 letters on the eye chart), and up to 4 out of 10 people saw a 3-line gain on the eye chart, seeing an additional 15 letters. And a National Institutes of Health study recently found that Avastin and Lucentis are equally effective in treating AMD based on first-year results of a two-year clinical trial. Today, both Lucentis and Avastin (which is much more cost effective) are available to patients at BoozmanHof. “Avastin and Lucentis have totally revolutionized the care of the disease responsible for most of legal blindness in people over the age of 60,” Dr. Hof said. Preferentially, Dr. Hof uses Avastin most frequently, but customizes treatment for individual patients. Avastin may work better for some patients, while Lucentis works better for others. “Both drugs have a protein piece attached to the active molecule,” Dr. Hof said. “The protein piece can incite an antigenic reaction. Sometimes people have a reaction to one but not the other.” Lucentis (left) and Avastin (right)

Image by: Stephan Max Reinhold www.liquid-art-gallery.com

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Demystifying the New OCT Imaging technology visually unveils eye By Matt Young disorders for the first time Eyedea editor

ptical coherence tomography is an imaging technology that sounds pretty complicated, but Dr. C. William Hof takes a nuts-andbolts approach to explaining its evolution, unshrouding the device in the process and clearly showing why it’s so critical in eye disease diagnosis and treatment. He likes to use words and phrases like “pie” and “old-time TVs” in his OCT analogies, and starts out by explaining its importance very simply…. “I use it every day, several times a day,” said Dr. Hof, M.D., co-founder, BoozmanHof. Although OCT has been around for two decades, Dr. Hof provided an illuminating description of how it is importantly evolving. “Prior technology was called timedomain OCT,” Dr. Hof said. The concept involves a wavelength of laser light sent into the eye, which bounces off the retina and other structures. “There is some delay in the reflected light coming back, depending upon how deeply the light penetrates into the retina,” Dr. Hof said. “So as the light comes back out of the pupil, one little photon of light comes back at one moment, then another one comes back at a different moment, and another at a different moment.” The idea was that you could then capture those light rays coming out at slightly different times. “The time-domain method had a mirror that would move back and forth, so the light that came out sooner would hit at a different place than ones that

at BoozmanHof, which uses new came out later,” Dr. Hof said. “Then it spectral-domain OCT technology from would record what signals came from Carl Zeiss Meditec (Jena, Germany). what distance of that mirror as it moved “Let’s say there’s swelling in a back and forth.” certain area of the retina,” Dr. Hof There was only one big problem: said. “The old technology might pick the technology was limited by how fast up some hint of swelling, but you the mirror could move. couldn’t detect how much. But spectral“Think of a pie that is cut in eight domain OCT can define the quantity of slices,” Dr. Hof said. “You basically swelling.” have four intersecting lines that divide That has broadly positive the pie into eight pieces. The scan implications for diagnosing, monitoring produced by the older generation timeand treating ophthalmic problems like domain OCT would take a cut along retinal vascular diseases and exudative those lines. You would get data from macular degeneration. those lines and then have to fill in the In a disease like wet AMD, you blanks in between the spaces. The meat could tell when blood vessels are of the pie in between the lines—you swelling and leaking quite well— don’t have data for that and are just information that can be used to monitor guessing what’s there.” the progress of disease. So if you could imagine how “You could then perform a enjoyable it would be to eat pie as treatment and measure how much thin as the portion where the knife effect the treatment is having,” Dr. Hof slices through, it’s was only slightly said. “You couldn’t do that with the more gratifying to use time-domain old OCT. In those days we didn’t know OCT compared to the next generation what else to do. This is just a whole lot technology, spectral-domain OCT. better.” “Now imagine that same area that needs to be scanned,” Dr. Hof said. “This time, the A B technology is so fast, it can go back and forth and cover the whole space. It’s like a little beam of the old-time TVs. C D The scan was so fast that it produced a picture. Spectraldomain OCT fills in all the in-between spaces.” A) The macula before Avastin treatment, courtesy of the Zeiss Cirrus HDThis has major OCT. B) Resolution of choroidal neovascularization (CNV) after Avastin. clinical applicability C) Thick subretinal fluid before Avastin. D) Resolution of CNV.

06 n Eyedea

Cover Story

Unveiling a Secret Astigmatism correction comes out of presbyopia’s shadow By Matt Young, Eyedea editor

Photo credits: Eyemaginations Inc.

uring presbyopia has been referred to as the Holy Grail of refractive correction, and it’s no wonder why. Finding a cure would have visual significance of epic proportions. Anyone old enough to really know presbyopia can tell you about that uncomfortable eyestrain when reading for long periods. And reading fine print in low light conditions can be just impossible. The quest continues. Although loss of crystalline lens elasticity and ciliary muscle power have been cited as causes, presbyopia is neither entirely understood nor completely curable surgically. Of course, there are presbyopia-correcting lenses which, after cataract surgery, do provide an excellent range of expanded vision for an aging person. But what’s interesting is that despite the fact that these new technologies are getting closer than ever to the presbyopia cure, these lenses are not the most popular premium lenses being implanted today. In other words, the Holy Grail is within reach, but surgeons are grabbing another cup for many patients, and that cup is full of astigmatismcorrecting IOLs. That’s right, toric IOLs often are implanted at much greater rates. “I put in two toric implants today,” said Randall Cole, M.D., medical director, BoozmanHof Eye Surgery and Laser Center, Rogers, Ark. “Astigmatism is so common that it’s something you want to correct at the time of cataract surgery if you can afford the lens.”

What you see with astigmatism

AcrySof Toric IOL

Tecnis Toric IOL

(Image source: AcrySof image provided by Alcon. Tecnis image provided by Abbott Medical Optics)

In the last three years, Dr. Cole has implanted 300 toric IOLs (Alcon, Fort Worth, Texas) compared to 250 AcrySof ReStor IOLs (Alcon), which are multifocal lenses that correct presbyopia. Astigmatism is quite common; one in three people suffer from it. But presbyopia is even more common. It happens to everyone who lives long enough to get it. Why then are toric IOLs comparatively popular? Reports have linked toric IOLs with very accurate, excellent results. They also are very reasonably priced options. And of course, after normal cataract surgery, patients who have blurred vision resulting from astigmatism will continue to have blurred vision—unless they receive astigmatism correction, such as a toric IOL. There’s another reason too. Patients who have too much astigmatism shouldn’t have presbyopia-correcting IOLs implanted. The astigmatism would cancel the intended

What you see without astigmatism

Eyedea n 07 benefit out. Instead, they should seriously consider toric IOLs. “Even though I have done thousands of incisional surgeries like AK, these toric lenses are performing amazingly well,” Dr. Cole said. “If someone has astigmatism of a diopter or more, and if you can afford it, it’s something you want.” Toric lenses correct astigmatism better, and more safely and accurately than corneal relaxing incisions, Dr. Cole said. He should know. BoozmanHof is one of only 14 locations across the United States involved in phase III clinical trials of the Tecnis Toric IOL (Abbott Medical Optics, Santa Ana, Calif.). Although Dr. Cole can’t yet comment on results, he does cite other evidence with the lens, as well as his own experience with the Alcon toric IOL to confirm the benefits of this lens. “We can say that this lens has now been approved in Europe and is reported to be performing extremely well,” Dr. Cole said. Dr. Cole also described his surgical protocol for implanting toric IOLs versus multifocal IOLs. “If the patient has astigmatism of more than about a diopter and a quarter, I would go with a toric implant,” Dr. Cole said. “For patients with three quarters to a diopter and a quarter, I can do an AK incision for the astigmatism and a multifocal lens implant is still an option.” Patients left with three quarters of a diopter of astigmatism should not have a multifocal implant, he added, because quality of vision will be suboptimal. The toric IOL is quite comprehensive in treating astigmatism, and the future of these lenses also looks bright. “The majority of patients with astigmatism have two diopters or less,” Dr. Cole said. “Some toric IOLs are available for up to 4 diopters of astigmatism correction or more. Toric multifocal lenses will be here before long.” Perhaps astigmatism correction is a bigger part of the of the eye care Holy Grail quest than we all thought.

Arkansas O.D. Couples

Work Together—and Apart— to Advance Eye Care

ate and Dan Landis have a great relationship, but it’s a little out of the ordinary. They are Rogers-area optometrists married to one another, which means they have a lot in common, but one mutual decision is decidedly uncommon. Technically, they’re competitors. Kate owns and works at Tri-State Drs. Dan and Kate Landis Optical Center in Rogers. Dan owns and works at Landis Eye Care, with one facility at a Walmart in Rogers and the other at a Walmart in Siloam Springs. “We worked together for a while,” Kate said. “There just wasn’t enough space for both of us.” Fortunately, there is enough space in Arkansas eye care so that Dan and Kate get along just fine, both in life and in business. “Somehow it works,” Kate said. “It naturally did. We didn’t have to make any effort. Both places have some advantages. And we get to refer patients to each other. It is unusual.” Dan and Kate have something else in common. They both refer patients to BoozmanHof for eye surgery needs. “The reason I like BoozmanHof is I get great outcomes,” Kate said. “I also really have a great relationship with the doctors. It’s an easy relationship. They say, ‘Here’s my telephone number. Here’s my email.’ They give me help with anything.” As it turns out, competition is perhaps a thing of the past in Rogers eye care. “I am 7 blocks from Dan and BoozmanHof is probably 12 blocks in the other direction,” Kate said. “I also don’t feel like BoozmanHof ever tried to keep my patients there [after surgical care]. They are always sent back. Everyone is courteous and conscientious and our relationships work.” Randall Cole, M.D., medical director, BoozmanHof Eye Surgery and Laser Center, couldn’t agree more that Roger’s area eye care is like one big family— sometimes literally. “We have a very active and skilled eye doctor referring network for our cataract and refractive practice,” Dr. Cole said. “One location which has been a great partner to BoozmanHof for 20 years has been the Rogers Walmart. Initially our relationship there was with Drs. David and DeAnne Witherspoon, and then it became with Drs. Kate and Dan Landis.” Indeed, BoozmanHof’s relationship with the Witherspoons—another great O.D. husband and O.D. wife couple—continues at that family’s current practice location at Village on the Creeks.

08 n Eyedea

The of Searching for AMD in Primary Care

Do you see any AMD here? In fact, this is just an image of a mouse retina. Scientist Tom Deerinck won first place in the Olympus BioScapes 2006 international digital imaging competition for it.

esearch already has shown that educating primary care physicians to recognize diabetic retinopathy can improve detection and referral rates to eye doctors. Could education on AMD do the same? An article in the Journal of the American Board of Family Practice in 2002 concluded that it could. Early screening for AMD has four benefits: 1) physicians can recognize an early sign of AMD: drusen, 2) they can instruct patients how to perform a self-examination that might detect choroidal neovascularization, 3) they can recommend nutritional supplementation to reduce the risk of AMD-related vision loss, and 4) they can provide quick referral to an ophthalmologist as soon as choroidal neovascularization is suspected. “Although in the general population most patients recognize vision problems themselves, neovascular AMD can be asymptomatic at an early stage and remain undetected if self-examination is not performed daily, one eye at a time,” the report concluded. C. William Hof, M.D., co-founder, BoozmanHof, suggested a number of measures primary care physicians can

take in order to support early detection and treatment of AMD. “A research study came out about 10 years ago that found nutritional supplementation improved the prognosis of patients with dry AMD about 25%,” Dr. Hof said. That was compared to patients who did not receive the supplements. “Primary care doctors see lots of people who take tons of vitamins,” he added. “They might like to know whether they’re getting what they need” to help ward off AMD, he suggested. A good vitamin cocktail to prevent dry AMD (which of course also always predates the wet form) is as follows, Dr. Hof said:

peripheral vision, Dr. Hof said. “There are some specific symptoms, like dark spots in the center of vision,” Dr. Hof said. “Straight lines look bent. Those might be some initial symptoms of swelling in maculae.” Treatment includes vitamins for the dry form and an intravitreal injection of Avastin (Genentech, South San Francisco, Calif.) or Lucentis (Genentech) for the wet form, he said. One important thing to remember is that while Avastin has a lot of cardiovascular side effects when used for colon cancer, there aren’t any serious systemic side effects from the intraocular use of the medication. There’s a small incidence of spontaneous nose bleeds—that’s about it, Dr. Hof said. “In the Physicians’ Desk Reference, under ‘Avastin,’ all bad things can happen,” Dr. Hof said. “What about if we stick some in the eye—is that going to cause problems? The answer is no.” If you do suspect AMD, Dr. Hof said, “the best thing to do is to get on the phone to [an eye doctors] and say, when can you see this guy?”

• Vitamin C, 500 mg/day • Vitamin E, 400 IU/day • Zinc, 80 mg/day • Lutein, 10 mg/day • Omega-3 fatty acid, 1000 mg/day “Hopefully physicians would send the patient over for an eye consultation, but importantly, also be aware of symptoms of macular degeneration,” Dr. Hof said. These symptoms include a loss of central vision with a potential loss of

If you have a problem with your vision, Dr. Hof, pictured here, and all the eye care professionals at BoozmanHof are ready to provide you with excellent care. Call them at 800-428-3937 or 479-246-1700, or email them at info@boozmanhof.com.

he code for scanning computerized ophthalmic diagnostic imaging was deleted. What are the new codes that replace this one? Yes, you’re right. The original code for this—92135 (which was called the SCODI or OCT code) was deleted from the current procedural terminology (CPT). We have been aware that this deletion would take effect since September 2010 but it understandably continues to be an area of confusion for some, especially since it was likely one of the most used codes of 2010. That code has been deleted and replaced by three new CPT codes. These codes are: 92132 (involving the anterior segment), 92133 (involving the optic nerve and glaucoma), and 92134 (involving the retina).

All of these codes require the doctor to give his or her interpretation of the test, and report findings and a treatment plan. Further, these codes have CCI edits, and essentially that means you cannot bill certain things together because they are already included in one code’s billing. For example, you cannot bill code 92133 (optic nerve/glaucoma) or 92134 (retina) along with Fundus Photo Code 92250. If you do, Medicare will deny one or the other, and usually they will deny the one that pays the most. Further, you cannot bill for both 92133 (optic nerve/glaucoma) and 92134 (retina) at the same patient encounter due to CCI edits. Finally, each new code pays out for a bilateral examination (unlike the old

Ask Janis Veteran medical coder provides answers to your ophthalmology management questions

Photo credit: Matt Poe, COA

Eyedea n 09

Meet

Joyce:

BoozmanHof Surgery Coordinator

oyce Eggert has a pretty high opinion of Rogers, Arkansas. Originally from Kansas, she

picked up and moved 33 years ago, but where she was going she didn’t quite know. “I put my stuff in a U-haul trailer and pulled it until I thought, ‘This place is nice; I’ll stop here and live here,’” Ms. Eggert said. She has been in Rogers ever since.

Photo credit: Matt Poe, COA

Today, Ms. Eggert is surgery code 92135, which paid for each eye examined). In other words, these new codes pay whether you examine one eye or both eyes. Bear in mind that supervision rules do not apply to these codes, so a doctor does not have to be present during scans in order for the code to be billed. I hope this answer was helpful. Don’t forget, if you have further questions related to this or any other medical coding issues, call me at 479-246-1700, or email me at jgeary@ boozmanhof.com. I’ll personally respond to you, and we’ll also answer the best questions in the pages of Eyedea. Janis Geary, ACS-OH, is the BoozmanHof business office director.

coordinator at BoozmanHof Eye Clinic, which means she schedules surgeries in the ambulatory surgery center (ASC) and performs medical coding. Ms. Eggert also is a nurse by training. “I actually worked in surgery for many years,” Ms. Eggert said. That allows her to help save patients precious time by determining if patients need medical clearance for surgery. Her favorite aspect of her job is patient interaction. “When the patient comes back from surgery, they are amazed at how well they see,” Ms. Eggert said. “That’s most rewarding; that they had a good experience and see so much better immediately.”

10 n Eyedea

Surgery Center Update

Boomers Begin

Eye-care Invasion

Photo credit: Matt Poe, COA

ost-World War II babies are finally booming into retirement. Somewhere between 7,000 to 10,000 boomers are turning 65 each day for the next 19 years according to various news reports. Given that every aging person eventually develops cataracts, most of these boomers also will become eye surgery patients. A considerable number will go on to develop macular degeneration, with 10% of people between 66 and 74 being affected. “We live in an exciting and rapidly changing world of cataract and refractive vision correction,” said Randall Cole, M.D., medical director, BoozmanHof Eye Surgery and Laser Center. “The wave of baby boomers need care. We are in a position and place to help with this group of people and provide world-class cutting-edge care in a very patient friendly and efficient environment.” BoozmanHof has been preparing for this moment in time for many years, having celebrated the surgery center’s 15th anniversary on April 1. The

anniversary was marked by a small, home-style celebration in the surgery center. Staff were provided pot luck dishes of fried chicken, coleslaw and rolls—simple fare bringing everyone together before a veritable battle that lies ahead. “We thanked everyone for their years of hard work and dedication,” Dr. Cole said, but he knows as well as everyone else that fighting an enormous volume of eye care disease is only beginning. Fortuitous—although perhaps at the time unrecognized—preparations for the big boomer volume began in 1996. “In early 90s we were going through a phase of government cuts to professional reimbursement,” Dr. Cole recalled. “We were thinking of some ways to recover that and improve patient care and efficiencies.” The result was the development of BoozmanHof’s own ambulatory surgery center. “I knew it was something we needed to do,” Dr. Cole said. “I had no

idea what a dramatic effect this would have on surgical quality and customer service that would be given to the patient, and how this would transform the cataract and refractive surgeon.” BoozmanHof surgeons went from working in a hospital to their very own environment, and developed control over some very important factors, like infection prevention. “One of the goals we had in developing this surgery center was getting great outcomes,” Dr. Cole said. “One measureable outcome is infection. So we have a comprehensive prophylaxis system to achieve the fewest infections as possible. We are delighted that we went 11 years without any infection. There was only one late-onset endophthalmitis in 29,000 cataract surgeries. In terms of patient service, BoozmanHof also borrowed elements from Southwest Airlines’ culture. “The culture of Southwest Airlines is to develop outrageous customer service,” Dr. Cole said. “We do exceed patient expectations in terms of providing great care. For instance, we received an email last week from a patient’s daughter in L.A., who said that she experienced hospital care from California to Florida, and never had any experience surrounding cataract surgery that came close to ours.” So as baby boomers begin to need eye care, BoozmanHof is prepared not only for volume—handling up to 15 or 20 cataract cases daily—they are ready to give the highest quality care and customer service to each patient. Dr. Cole personally vouches for that. “I am still at BoozmanHof and alive and kicking with no plans to retire anytime soon,” Dr. Cole said.

Eyedea n 11

Cool Stuff

It’s Not Your Father’s Punctal Plug

eep patients’ visual expectations relatively low, then simply amaze them. That’s what you can do with the AcrySof IQ ReStor IOL +3.0 D (Alcon, Fort Worth, Texas). “I tell cataract patients they will need glasses less in order to read than if they had a standard monofocal lens implant,” said Randall Cole, M.D. “But it’s not unusual for people to see like a 20-year-old emmetrope with 20/20 uncorrected distance and J1 near vision, which is simply amazing.” Dr. Cole considers this ReStor lens to be a “third generation” multifocal. The first generation of a different model resulted in some problems with poor intermediate vision and some patients who complained they were looking through what seemed like wax paper. The second generation, the ReStor IOL +4.0 D was much improved. But this third generation was even better “because it moved the near point out slightly and greatly improved intermediate vision,” Dr. Cole said, adding, “The ReStor has vastly exceeded my expectations for what I would ever see in my career in terms of good distance, intermediate and near vision.” Meanwhile, expect few side effects such as glare or halos with the ReStor lens, Dr. Cole said.

Floppy Iris? No Problem.

et’s face it: an enlarged prostate happens to almost all men as they get older. It can cause urination and bladder problems, and Flomax (Boehringer Ingelheim, Rhein, Germany) is a treatment The Malyugin Ring at work that helps patients—but it doesn’t help eye doctors if these patients have cataract surgery. “Flomax is awful on the eye,” said Randall Cole, M.D. With Flomax, the iris becomes floppy and difficult to work when taking a cataract out. In small pupil cases, the pupil also doesn’t dilate well. Enter the Malyugin Ring (MST, Redmond, Wash.), which holds the iris in place so that cataract surgery can be performed in these patients more safely. “It is fairly straightforward to inject into the anterior chamber,” Dr. Cole said. “It keeps the pupil dilated longer and stabilizes the floppy iris to keep it from prolapsing into your incision. It also works more efficiently, safely and more effectively than iris hooks.” Graphic: MST

Master of Low Vision Expectations

Photo credits: Matt Poe, COA

ikipedia is going to have to change its encyclopedia entry on “punctual plug” soon. The punctal plug is referred to as a “small medical device that is inserted into the tear duct of an eye to block the duct…to treat dry eye,” but what the world doesn’t know yet is that it is soon to be part of a treatment for glaucoma. The Xalatan-containing punctal plug (QLT, Vancouver, Canada) is something totally new, and it involves using these devices to deliver needed glaucoma medications. What QLT is doing is creating a new drug delivery device where Xalatan [Pfizer, New York] is implanted within a plug and dispersed over a period of time. So why can’t patients just apply glaucoma drops as directed—once, twice or Tiny punctal plugs may give a big however many times a day that they need to? boost to glaucoma treatment Well, glaucoma medication compliance is pretty terrible . “Anything that we can do to improve compliance on these drops and not induce side effects is going to be terrific,” said Randall Cole, M.D. So having a Xalatan-containing punctal plug implanted would be better than having a doctor watching over glaucoma patients all the time, reminding them to take their meds. The plug gives the meds automatically. “But currently, plugs often fall out,” Dr. Cole said. “If we can get a plug to be reliably retained and not cause more side effects in terms of irritation or red eye, then that would be a fantastic advancement.”

12 n Eyedea

We Value Our

Relationship with You W

hen you send patients to BoozmanHof Eye Clinic, you can be confident that your patients will receive the very best care, with the latest technology, from experienced skilled physicians. We will work closely with you and your staff to ensure that your patients obtain the best possible results. Once a treatment plan is formulated, our surgical counselors will work with your office in arranging the return to your care. Since its beginnings as Boozman Eye Clinic in 1977 and later as BoozmanHof, our practice has endeavored to offer the latest innovations in ophthalmic surgery. We offer the precision of wavefront-guided LASEK and a full range of new lens options for cataract patients, including apodized diffractive optics technology (the AcrySof IQ ReStor) and accommodating IOL technologies (Crystalens). Our fully accredited, Medicare-approved surgery center accommodates every outpatient procedure we perform, including cataract surgery, LASEK, glaucoma and oculoplastic surgery. Staffed with experienced eye care professionals, our facility offers the very best in ophthalmic surgical technology in a comfortable, patient-focused environment. We look forward to working with you and your staff!

BoozmanHof Eye Surgery and Laser Center offers: • Experienced surgeons and staff • State-of-the-art operating room and laser suite

Our Surgeons

Dr. C. William Hof, M.D.

Dr. Randall E. Cole, M.D.

If you have any question or if there is anything that we can do for you, please don’t hesitate to give us a call at 800-428-3937 or 479-246-1700, or email us at info@boozmanhof.com. Visit our website at www.boozmanhof.com

• An inviting, spacious clinic • Comfortable reception and recovery areas

Procedures include: • • • • • •

Advanced Surface Ablation (LASEK) Astigmatic keratotomy Avastin/ Lucentis intravitreal injections Blepharoplasty Botox/Juvederm Cataract extraction with intraocular lens implantation (lifestyle, toric and aspheric lenses available) • Ciliary body destruction (endoscopic cyclophotocoagulation) • Corneal transplants including DSEK

• Ectropion/Entropion repair • Endothelial keratoplasty • Excision of pterygium with conjunctival flap • Focal Grid Laser • Iris repair • Laser peripheral iridotomy • Nd:YAG capsulotomy • Panretinal photocoagulation (PRP) • Removal of skin lesions

• • • • • •

Repair of laceration of cornea or sclera Repositioning of the intraocular lens Scleral reinforcement with graft Strabismus surgery Temporal artery biopsy Trabeculectomy (with Mitomycin C or Ologen) • Visian ICL (Implantable Collamer Lens) implantation • Vitrectomy