Marc J. Hirschbein, M.D., F.A.C.S., director of Aesthetic Eyelid and Laser Surgery, and James W. Karesh, M.D., F.A.C.S., are pleased to announce the recent acquisition of the Sciton Laser System for the Krieger Eye Institute. The Sciton Laser System is the first to combine four unique lasers into one unit – allowing for the minimally invasive treatment of a variety of skin aging changes.

Perhaps most interesting is the new generation Erbium:YAG laser. This laser will perform a variety of skin resurfacing procedures. With the laser micropeel, physicians will be able to remove microscopic layers from the skin surface in a precise and controlled manner. The procedure may be performed in the office with only minimal discomfort. Recovery (redness and some mild skin peeling) will take days rather than weeks or months. The end result is smoother, more youthful skin with better texture and improvement in skin discoloration.

The 1319 Infrared laser is designed to treat deeper wrinkles without damaging the overlying skin. The unit uses a precise surface cooling mechanism to allow this to occur. Three to six treatments may be performed to achieve results.

The long-pulsed 1064 Nd:YAG laser will allow for treatment of vascular lesions (spider vessels and varicose veins, as well as permanent hair reduction.) This laser performs hair reduction with a unique random-beam program to prevent overheating from overlapping beams – improving patient comfort. Multiple treatments may be required in some patients.

The final laser available will be the IPL, or intense pulsed light. While not technically a laser (this is a non-focused beam covering multiple wavelengths), IPL has shown particular benefits in treating facial redness associated with acne, rosacea and other facial discoloration.

By combining the available lasers, Drs. Hirschbein and Karesh will be able to tailor a treatment plan to reach each patient’s individual goals. To schedule a free evaluation, call 410-601-8283.

The use of lasers to treat ocular disease began about 40 years ago with the treatment of diabetic retinopathy and glaucoma. Since then, lasers have found a prominent role in the management of a growing number of eye diseases, and are also an important tool for cosmetic and refractive surgery. This issue of Eyelights will be devoted to the use of lasers in ophthalmology.

The acronym “LASER” stands for Light Amplification by Stimulated Emission of Radiation. The first successful demonstration of the laser phenomenon was in the late 1950s and employed a ruby crystal for the laser media. Lasers have been used in ophthalmology since the early 1960s. Three components are required:
1) An energy source, usually electricity.
2) A laser medium, such as ruby, neodymium, argon gas or carbon dioxide.
3) A cavity, a space enclosing the laser medium bounded by parallel mirrors.

The energy source, for example an electric discharge, stimulates the electrons of atoms within the laser medium to a higher orbit. As the electrons spontaneously return to their original, low-energy orbit, excess energy is released in the form of photons. These photons oscillate between the two mirrors bounding the cavity and stimulate the release of many additional photons. These photons are coherent, in phase, have a predictable wave length and are unidirectional. When all of these photons are released from the cavity, they emerge as very bright laser light that is coherent (such as red or blue), in phase and unidirectional.

Comparatively, slow delivery of photons to a target tissue causes local coagulation and burning. This is the type of energy used when performing trabeculoplasty to treat glaucoma with the argon laser or cyclophotocoagulation with the diode laser (see “Use of Lasers to Treat Glaucoma”). More rapid delivery of photons to the vicinity of the target tissue causes local ionization and rupture of the nearby structures. This is the type of energy used to perform a laser iridotomy in the treatment of glaucoma (see “Use of Lasers to Treat Glaucoma”). Other lasers can ablate surface tissue (such as the excimer laser) or cut tissue like a knife (carbon dioxide laser).

Three very important advantages of laser surgery are:

• Lasers have provided the ophthalmologist with a tool that can perform ocular surgery without bleeding and preserve vision or, in some cases, improve it.
• Using lasers one can perform intraocular surgery without opening the eye.
• One can perform very exact and precise surgery of the eye and skin that could not be so exactly performed with the knife.

Glaucoma is usually classified as either open-angle glaucoma or narrow-angle glaucoma, depending on the anatomical structure of the anterior chamber. Under normal conditions, a thin fluid, called aqueous humor, comes from behind the iris, passes through the pupil into the anterior chamber (the chamber in front of the iris and behind the cornea) and then leaves the eye through microscopic channels located at the periphery of the iris. These channels, the trabecular meshwork, are located at the juncture of the iris and cornea, also known as the angle of the anterior chamber.

In open-angle glaucoma, the angle of the anterior chamber is wide open, but the aqueous humor cannot pass freely through the trabecular meshwork. This resistance in the meshwork results in a buildup of pressure in the eye, and the elevated intraocular pressure (IOP) can damage the optic nerve and lead to loss of vision.

In narrow-angle glaucoma (also known as angle-closure glaucoma), the flow of aqueous humor is blocked at the pupil. Pressure builds up in the posterior chamber behind the iris and the peripheral iris is pushed forward to occlude the angle structures, including the trabecular meshwork. The aqueous in the anterior chamber cannot leave the eye because of the narrowed or closed angle.

An anatomical block at the pupil causes narrow-angle (angle-closure) glaucoma and the aqueous humor is trapped behind the iris. Using a neodymium-YAG laser, the ophthalmologist aims the laser beam at the peripheral iris, through a contact lens. After repeated applications, the surgeon makes a hole through the iris. Aqueous humor can now pass through this opening and bypass the blocked pupil to leave the eye through the trabecular meshwork. In some cases where the initial intraocular pressure is very elevated (acute angle-closure glaucoma), a dramatic fall in pressureoccurs after the iridotomy has been completed.

After treatment, the patient uses healing eyedrops for several days and returns after one to two weeks to be examined. The iridotomy may close during the first one to two weeks in a small number of cases and may need to be reopened. Once the iridotomy is open for two-three weeks, it nearly always remains permanently open. The goal of treatment is to bring the glaucoma under better control, but glaucoma eyedrops may be required to achieve the desired level of pressure.

Aqueous humor enters the eye behind the iris, where it is produced by the ciliary body. This important ocular tissue is located in the periphery where it is connected to the iris. In some cases, the glaucoma is severe and the intraocular pressure cannot be lowered by either medical or conventional surgical procedures. One can aim a diode laser beam at the ciliary body by placing a special probe on the white sclera near the cornea (See photo below). Generally, 15 to 20 laser applications are made and the patient is discharged 30-60 minutes later.

Using CPC, the pressure can be lowered dramatically if it is very high to begin with. The procedure takes only a few minutes to perform and it can be repeated if the IOP increases again in the future.

Stitchless surgery may not be the best way to go.
At least one well-controlled study has shown that the rate of infection may be higher if no sutures are used to close the cataract wound.

Marijuana lowers eye pressure.
Marijuana (also called cannabis) has been shown to lower intraocular pressure. However, it has many side effects including ocular redness, postural hypotension, rapid heartbeat, palpitations and changes in mental status. These adverse side effects occur with such frequency that marijuana treatment of glaucoma is not feasible. Researchers are trying to develop an eyedrop containing the pressure-lowering ingredient of marijuana.

Eye exercises do not cure eye diseases.
Although several books have been written about how exercises can cure eye diseases, there is only a small set of circumstances where they can truly be helpful and effective. The most common reason for entering a successful eye muscle exercise program is to treat convergence insufficiency. This condition occurs in people who cannot keep the eyes aligned and who are unable to focus on near work. This is a common cause of eyestrain with extended reading.

The retina is actually a miniature outpost of the brain, lining the inside wall of the eye.
It is made up of millions of tiny cells arranged in multiple, highly organized and interconnected layers. When light enters the eye, specialized cells, called photoreceptors, receive the light energy and then transmit chemical signals throughout the layers of the retina. These signals stimulate other cells, which communicate with even more cells organized in larger groups. This form of structured cross-talk between different types of cells is a form of neural processing, similar to the higher processing that occurs in many areas of the brain. This processed information then leaves the eye through the optic nerve, which is made up of over 1.2 million tiny fibers that connect directly into the visual centers of the brain, allowing us to experience vision. Each one of these nerve fibers belongs to both the retina and the brain. Thus, the retina is really a highly specialized piece of brain attached to the inside of the eye.

Age-related Macular Degeneration (AMD)

Age-related macular degeneration is the most frequent cause of vision loss in people over age 50 in developed nations. Its destructive effects involve the very center of vision (macula), making it difficult or even impossible to read, drive or recognize faces.

There are essentially two basic forms of this disease: the dry (atrophic) type and the wet (neovascular) type.

In dry AMD, cells living beneath the retina in the the macula simply wither and fade away, causing retinal function to decline. At this time, there is no effective treatment for this form of AMD.

In wet AMD, abnormal blood vessels and scar tissue grow beneath the retina, and cause a decline in central vision. Although there is no permanent cure for this form of AMD, there are a number of available treatment options including use of the laser.

Laser Treatment Strategies for Macular Degeneration

1. Thermal or (hot laser) destruction of the underlying abnormal blood vessel complex: Thermal treatment produces a full thickness burn involving both the abnormal blood vessels and healthy overlying retina. We prefer not to damage the healthy retina, especially if it includes the macula. Therefore, the hot laser treatment is now reserved for cases in which the abnormal blood vessels do not yet involve the macula, where reading vision located.

2. Non-thermal (cool laser) destruction of the abnormal blood vessel complex: This approach requires injection of a unique and highly selective photosensitizing dye that collects in the abnormal blood vessel complex beneath the retina. This dye is then activated by application of the cool laser, causing more selective destruction of the underlying abnormal blood vessels while sparing the overlying healthy retinal tissue. Cool laser treatment, also known as photodynamic therapy (PDT), has recently been proven in a major multicenter, randomized, controlled clinical trial to be effective in reducing vision loss in wet AMD.

3. Focal destruction of selected blood vessels that feed the abnormal vessel complex (feeder vessel laser): Feeder vessel laser treatment has promise, but more controlled clinical data are needed to determine its long-term benefit.

Diabetes Mellitus

Diabetes can weaken retinal blood vessels, leading to swelling in the retina and/or bleeding within the eye. Lasers may be used in small doses to selectively treat leaky blood vessels at or near the center of vision (macula) in order to decrease retinal swelling in the macula (macular edema) and stabilize central vision. Laser treatment can also be used to prevent the growth of abnormal blood vessels in the retina (neovascularization) and reduce the chances of bleeding and/or scar tissue formation within the eye. This is accomplished by placing many laser burns in the periphery of the retina, away from the macula. We refer to this type of treatment as “pan retinal photocoagulation,” or PRP, and it is a highly effective treatment for diabetic eyes that develop neovascularization.

Retinal Detachment

A retinal detachment occurs when the clear gel (vitreous humor) inside the eyeball cavity pulls away from its attachment to the retina (the nerve layer that lines the inside of the eyeball and transmits images to the brain). Sometimes the vitreous gel pulls hard enough to create a tear in the retina in one or more places. Fluid can pass through the tear and underneath the retina, causing the retina to become detached from the eye wall. Key warning signs are:

• Flashing lights
• New floaters involving either the central or peripheral vision
• Loss of peripheral vision
• The perception that a “gray curtain” is moving across your field of vision
  
  Retinal tears can be repaired easily in the office with laser treatment. Laser burns are applied so that the tear is completely surrounded, forming a barrier preventing fluid from getting under the retina and causing a detachment.
  
  

The Excimer laser is used to correct nearsightedness, farsightedness and astigmatism for refractive surgery. An outpatient procedure requiring minimal time commitment, refractive surgery involves a gentle reshaping of the cornea to better focus light rays on the retina. The result is improved vision, often to 20/40 or better.
Over the past few years, the computerized software used in the laser has improved so that the results are far superior to what they were several years ago. Indeed, refractive surgery is reported to be the fastest growing medical procedure in history, and LASIK takes refractive surgery to a higher level. Using the cool light of the Excimer laser, the surgeon reshapes tissue beneath a protective flap created on the surface of the cornea. This reshaping of the cornea can correct farsightedness, nearsightedness and astigmatism.

Comprehensive Ophthalmology
Joseph W. Berkow, M.D.
Assistant Professor (part-time), Ophthalmology,
The Johns Hopkins University

Gilbert N. Feinberg, M.D.
Cornea and Anterior Segment Disease, Refractive Surgery

Glaucoma
Donald A. Abrams, M.D.
Ophthalmologist-in-Chief, Sinai Hospital of Baltimore
Assistant Professor (part-time), Ophthalmology,
The Johns Hopkins University

Anthony C. Castelbuono, M.D.
Assistant Professor (part-time), Ophthalmology,
The Johns Hopkins University

Irvin P. Pollack, M.D.
Professor (part-time), Ophthalmology, The Johns Hopkins University, Emeritus Chief of Ophthalmology and
Director of the Krieger Eye Institute

Orbital Disease and Oculoplastic Surgery
James W. Karesh, M.D

Marc J. Hirschbein, M.D.
Instructor (part-time), Ophthalmology,
The Johns Hopkins University

Pediatric Ophthalmology and Strabismus
Michael E. Altman, M.D.
Instructor (part-time), Ophthalmology,
The Johns Hopkins University

Retina Vascular Disease
Joseph W. Berkow, M.D.
Assistant Professor (part-time), Ophthalmology,
The Johns Hopkins University

Joseph B. Harlan, Jr., M.D.
Assistant Professor (part-time), Ophthalmology,
The Johns Hopkins University

Vitreo-Retinal Surgery
Joseph B. Harlan, Jr., M.D.
Assistant Professor (part-time), Ophthalmology,
The Johns Hopkins University

NOTICES AND HAPPENINGS

Dr. Marc Hirschbein was elected to the executive committee of the Maryland Society of Eye Physicians and Surgeons (MSEPS), where he will serve as treasurer. The MSEPS met on October 17, 2003, at the Columbia Hilton Hotel at the time of its annual Scientific Symposium.

On October 31, Dr. Michael Altman spoke at the Greater Baltimore Medical Center during a symposium dealing with “Pediatric Ophthalmology for Pediatricians.” The title of his talk was “Ophthalmic Manifestations of Common Pediatric Neurologic Disease.” Dr. Altman also discussed “Neuroimaging in Neuro-Ophthalmic Disease in the Current Concepts” course at the Wilmer Eye Institute in December.

Three new volumes were donated to the Samson Feldman Library:
Phacoemulsification, two volumes. Donor: Dr. Marc Hirschbein
Glaucoma: Science and Practice. Donor: Dr. Irvin Pollack

Dr. Irvin Pollack served as a moderator of the annual glaucoma symposium
held during Subspecialty Day at the meeting of the American Academy of Ophthalmology. The meeting was held in Anaheim, Calif., and over 13,000
people attended.

Dr. Jay Katz, co-director of the Glaucoma Service at Wills Eye Hospital in Philadelphia, was guest speaker for the monthly resident conference in December. Dr. Katz presented examples of difficult glaucoma case histories for discussion with the residents and faculty at the Krieger
Eye Institute.

The annual Krieger Eye Institute symposium, “New Strategies in Diagnosis and Treatment of Eye Disease,” will take place on June 18, 2004 at the Sheraton Inner Harbor Hotel. Dr. Paul Palmberg, a nationally known glaucoma specialist from the Boston Palmer Eye Institute, will be an invited speaker.

Lights, Camera, Action…Questions!
No, this isn’t the formula for a new reality TV show. It was the successful format for Krieger Eye Institute’s recent “Ask the Expert,” an innovative way to get the word out about the top-notch medical services offered at LifeBridge Health centers.

“The planning started months before the actual television appearance,” said Carol Friedman, director of Professional Practice Operations. “Scripts had to be written and doctors’ schedules had to be coordinated. None of that could be done without help from Krieger’s entire staff.”

Finally, the big day arrived. That’s when ophthalmologists and technicians from Krieger and the Woodholme Medical Office Center hit the airways on December 3, 2003, manning a live phone bank on WJZ-TV. It gave viewers the opportunity to talk directly with 16 eye-care specialists. They took nearly 1,000 calls between 12:30 and 6:30 p.m., with questions about everything from cataracts to eye disease to laser and cosmetic surgery. More than 830 people requested appointments after speaking with a KEI expert.

“We were thrilled to be part of ‘Ask the Expert.’ It showcased our exceptional physicians and raised awareness of the excellent services we offer,” said Dr. James Karesh.

In fact, several people had no idea they were on the verge of losing their sight until they called that day. They didn’t realize the flashes of light they were seeing or the eye infections they had were serious. Fortunately, their conditions were flagged, and they got immediate help.

“Everyone who called in with a problem was given an appointment or arranged to come in during an open-screening session in January,” said Dr. Irvin Pollack. Dr. Donald Abrams added, “It was a long day, but worth the time and effort.”

Dr. Karesh, Dr. J.B. Harlan, and Dr. Marc Hirschbein a were interviewed live during segments on WJZ’s Eyewitness News.

The Krieger Eye Institute - "Ask The Expert" was one of six LifeBridge Health “Ask the Expert” call-in events that occur each year.

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