Seeing for Real

Our CEO learns that a lifetime of eyesight worry can be solved by a few seconds by the most revered LASIK surgeon

By Dennis Clemente

Nonette Teodoro, CEO of JUNO Healthcare Staffing System Inc., was almost resigned to her nearsightedness until she met Dr. Emil William Chynn, New York’s most revered LASIK surgeon.

After undergoing the breakthrough LASIK treatment from Dr. Chynn a few months ago, Nonette says she has never been more productive in running her fast-growing staffing business, thanks to her 20-13 vision.

“I now have a 20-13 vision, which is better than 20-20. Dr. Chynn outdid himself. I am very satisfied with his treatment that I wasted no time having my daughter treated also for her own eyesight problems,” said Nonette.

Nonette is just one among the thousands of Dr. Chynn’s patients who look up to Chynn for his impeccable vision correction treatment and customized service.

After undergoing Dr. Chynn’s LASIK treatment, Nonette now finds more time to enjoy outdoor fun activities. One adventure even took her snorkeling in the marine life wonders of Cebu in southern Philippines, just days after her treatment.

Unlike other surgeons, Dr. Chynn administers the outpatient procedure personally--giving his personal pager number, not the number of an "answering service" or "coverage doctor," so they can call him 24-hours a day in an emergency.

From the pre-op consultation to the post-op care, Dr. Chynn makes sure he answers all his patient’s questions, and examines them thoroughly to ensure that they will be the perfect LASIK candidate.

“I’ve had LASIK myself,” says Dr. Chynn, “and I can tell you that it is quick, painless and incredibly effective. I was seeing 20/20 within days!”

The LASIK treatment is fast becoming popular as the treatment that can help almost anyone restore one’s failing vision. In fact, Dr. Chynn has such confidence that he was the first LASIK surgeon in New York City to have LASIK himself. He was also one of the first surgeons in New York to perform the bladeless LASEK procedure.

Dr. Chynn’s Laser Vision Correction can reduce or eliminate your need for

contacts or eyeglasses—fast!

Dr. Chynn’s LASIK treatment took less than 30 seconds to erase Nonette’s doubts about finding the cure to her old malady. Nonette’s daughter, Charm, also took just a few seconds to make her feel “as if I’m wearing contacts all day” in ecstatic reply to her newfound crystal clear vision.

The recovery period is just as fast.

“The average LASIK patient will see well the next day, and be able to return to work on the second day. Of course, your vision will continue to gradually improve for several weeks,” he said.

Nonette also didn’t have to spend as much as she thought. The initial consultation is free, and clients receive 0% financing for 18 months plus a free gift.

Dr. Chynn offers the best value in LASIK in New York, including a lifetime guarantee, free lifetime enhancements, free lifetime check-ups and best of all, a money back guarantee.

Patients can pay using either a credit card, or sign up for a special financing plan (as little as $3 per day). You may also use your FLEX account at work, and save up to 33%. Some insurance may pay for LASIK.

“Think about it. If you give up the specialty coffee that you buy daily, you can save enough for the treatment and still have money after,” said Dr. Chynn.

Having worked at many of the prominent LASIK centers in Manhattan before he opened his own center, Dr. Chynn has experience that is unmatched by any other surgeon in NYC.  

Asked who can be cured by laser vision correction, Dr. Chynn said people with nearsightedness, farsightedness and astigmatism can in most cases reduce or even eliminate their need for glasses and/or contacts after LASIK.

You will never find a better-trained LASIK surgeon. Dr. Chynn is a graduate of Dartmouth College and Columbia Medical School.  He completed his ophthalmology residency at the Harvard Medical School/Massachussetts Eye & Ear Infirmary.

Currently, Dr. Chynn operates at the best LASIK center in New York, with the most up-to-date equipment and the best trained technicians. With Dr. Chynn, you have nothing to lose except your glasses. 

For more information or to schedule an appointment, please call Dr. Chynn at (888) I-WANT-2020; (888) 492-6820. Mention JUNO Healthcare and receive $100 off!

 
Highest Prescription Ever Corrected by Laser Eye Surgery

Dr. Emil Chynn's innovative, non-cutting, LASEK Surgery corrects vision impairments too difficult to be corrected by other forms of laser eye surgery and without complications.

NEW YORK, March 4, 2011: There is now hope for those who were once told their vision was too poor to be corrected even by laser surgery. Dr. Chynn's non-cutting LASEK surgery has corrected a previously unthinkable prescription of -22, the highest prescription ever corrected by any type of laser eye surgery in New York City! For comparison, a prescription of -3 is considered legally blind, and the highest prescription contacts are manufactured to correct is -16. LASIK or IntraLase surgery can commonly only correct a prescription as high as -9, and on average -5; LASEK's average is at least -7. What makes LASEK surgery so different?

Other forms of laser eye surgery, such as LASIK and IntraLase, require a flap to be cut in the cornea, which limits their ability to correct severe impairments and significantly increases the chance for complications. In order to correct the vision impairment, further tissue must be removed from the cornea depending on the severity of the impairment; the higher the prescription, the more tissue must be removed. For example, to correct a prescription of -7, the amount of tissue required for removal is about 100microns. In order to compensate for the eye's natural changes in the future, another 50microns must be removed. Because cutting types of laser eye surgery (LASIK and IntraLase) already remove 100-150microns for the flap, a total of 250-300microns of tissue is removed from the only 500-550micron thick cornea, leaving the patient with only 200-300microns. The necessary thickness to prevent the cornea from possibly bursting post-operatively is 250microns. LASIK cannot even correct a prescription of only -7 safely, while LASEK can safely, and easily, correct a prescription of -22.

LASEK surgery, only offered in NYC by Dr. Emil Chynn, requires no flap cutting, and therefore leaves the patient with a much thicker and safer cornea; in this example, 350-400microns, as opposed to the mere 200microns left by LASIK surgery. By eliminating the need for the flap, much less tissue is removed from the cornea, allowing for correction of even the worst prescriptions and without the risk of complications. LASEK is the safest laser eye surgery procedure, and as the -22 patient can attest, it is the only one that can correct vision in patients with high prescriptions.

DR. EMIL CHYNN featured on fox news (WNYW-TV)

Park Avenue Laser Vision Center recognized for creative Internet marketing

New York, NY – July 2, 2008…Dr. Emil Chynn of the Park Avenue Laser Vision (PALV) Center recently appeared on Fox Weekend News on Saturday, June 28, 2008, as a featured guest to discuss the issue of offering his patients discounts for posting videos of their laser surgeries on the popular video sharing site, Youtube.

Dr. Chynn, who heads the Park Avenue Laser Vision Center in Manhattan, currently offers any of his patients who undergo the laser vision correction surgery at his Center a small discount off the procedure if they post a video of their surgery on YouTube as a way of endorsing PALV. In the Dr. Chynn interview, he explains on the segment that he uses this promotional technique as a way to reach people in their 20s, 30s, and 40s who frequently use the Internet and may be interested in laser vision surgery.

When questioned on Fox News (WNYW-TV) last Saturday if this practice was at all unethical, during the Dr. Chynn interview, he explained that it was simply a way for the younger Internet-savvy generation to share their surgery experience with their friends and also a way to educate that demographic about the difference between LASIK (cutting) and LASEK (no-cut, no-flap) vision correction and perhaps remove any trepidation they may have towards the surgery.

"We only give them a $100 gift certificate to compensate them for their time if they choose to do this after the surgery," Dr. Chynn explained on Fox News. "Probably only about 5% of our patients actually take the time to do it. So you see it's not really a conflict of interest, otherwise we would have 90% of the people doing it." The Fox News segment can be viewed on YouTube at http://www.youtube.com/watch?v=VllFdueyRfU.

Emil Chynn MD, who has been successfully performing laser vision correction surgeries for over a decade, is getting more attention with his "eye-popping" marketing tactics. In a New York Times article published 26 June 2008, PALV was also featured for its unique patient endorsement campaign on YouTube.

Dr. Chynn, who holds an MD from Columbia University and an MBA from NYU. has performed over 11,000 laser surgeries without a single lawsuit. He was also the first eye surgeon in New York City to receive the LASIK surgery himself and to perform the most advanced laser vision correction procedure, CustomVue WaveFront MonoVision (just approved by the FDA in March 2008.)

Dr. Emil Chynn also entices new patients by holding bi-monthly free seminars that are open-to-the-public and allows people to stand next to him in the procedure room to observe as he performs a surgery. In addition, the PALV has launched their new website that includes a simulator that enables viewers to experience a simulation of a laser vision correction procedure.

Excerpt from Dr. Emil Chynn's article "Consultation with Confucius: A Weekly Guide to Better Business"

Confucianism is often cited as one of the world's six great religions (including Buddhism, Christianity, Hinduism, Islam, and Judaism). Unfortunately, most Westerners have only the vaguest perceptions of Confucian philosophy. This limited knowledge, while regrettable, is understandable, given the fact that the contact Westerners most frequently have with "Eastern philosophy" comes in bastardized form: within a fortune cookie. To those with some knowledge of Eastern philosophy in general and Confucianism in particular, it may seem incongruous, even heretical, to link the name of Confucius with business. After all, the moral code founded by Confucius conspicuously admonishes against both commercialism and materialism:

"Riches and fame are what men desire. If they cannot be obtained properly, they should not be held." (Confucian Analects, Le Jin (ch. v.))

Such quotes, taken out of the broader context, may leave one with the feeling that Confucius was somehow anti-business. Nothing could be further from the truth. Confucianism, at its heart, is an eminently practical, socially-oriented philosophy that stresses the relationships between individuals and society. Fostering and modulating these same relationships form the basic tenants of both Confucianism and Western business management. Indeed, both Confucianism and Western business management models arose out of a similar need: to identify organizing principals among individuals, and apply the found commonalties more formally to larger groups.

Protect Your Eyes on July Fourth By Emil William Chynn, MD, FACS, MBA

New York, July 3, 2008 (PressReleasePoint) World-renowned eye surgeon Emil Chynn MD, MBA, writes the following article to educate the public on how to avoid fireworks-related injuries for the 4th of July celebration.

As befits any birthday, Americans will celebrate this July 4 with food, pageantry, and, of course: fireworks!

Who cannot remember the thrill of their first fireworks display, the childish wonder that is rekindled each 4th? Fireworks are a big part of this holiday.

But would anyone claim that such celebrations are worth $100 million -- the amount that fireworks-related injuries cost Americans each year? Each year, over 10,000 Americans seek treatment in emergency rooms and almost a dozen people die from fireworks-related injuries. Nearly half of these injuries occur during the July 4th holiday weekend.

Most frequently, fireworks-related injuries involve the eyes -- nearly a third of these ER visits are for serious eye injuries. And 33% of ocular fireworks injuries result in a permanently blind eye (U.S. Eye Injury Registry Data). With nearly 50% of the victims being children, about seventy-five children lose an eye each July 4th weekend due to fireworks.

According to the volunteer organization Prevent Blindness America, in 2004 there were 9,600 firework-related injuries for that year: 300 more than in 2003. And 6,600 of these were treated around the Fourth of July. Forty percent of all fireworks injuries are to those aged fifteen or less.

But we respond to people, not to statistics.

Carleen was your average, happy fifteen year-old when some of her friends were playing with bottle rockets. Two rockets went up. When Carleen glanced at the third rocket that didn't launch, it exploded, crushing her left eye.

She was brought to the hospital for emergency surgery. Despite the heroic efforts of her ophthalmologists, who performed seven surgeries over a period of five years, she never saw again. Eventually, because of constant pain from glaucoma, her eye had to be removed and replaced with a prosthetic eye.

This case illustrates the enormous danger of bottle rockets. Although they account for only a fraction of all fireworks, bottle rockets caused 70% of all ocular fireworks injuries in 2000 -- half resulting in blindness. In a seven-year analysis by the Eye Injury Registry of Alabama, bottle rockets accounted for 100% of fireworks injuries requiring surgical removal of an eye. The average age of the victims: thirteen.

Bottle rockets were invented by the Chinese in the thirteenth century, not for entertainment but as a weapon of war. A small Class C bottle rocket can take off at seventy-five miles per hour with an explosive payload. Yet over twenty states still allow the sale of bottle rockets, according to the U.S. Consumer Product Safety Commission.

The American Academy of Ophthalmology advocates legislation banning the sale, resale, use, and possession of bottle rockets, except by trained professionals. A wide range of organizations support this ban, including the American Medical Association, the American Academy of Pediatrics, Helen Keller International, the National Fire Protection Council, and the National Safety Council.

But it is not just bottle rockets that pose a significant hazard. Even sparklers, those seemingly innocuous toys, can be extremely dangerous in the hands of young children. In 2004, 300 children under the age of five were hurt by sparklers. Don't forget, a burning sparkler can reach 1800 degrees at its burning tip -- not something that a young child should be waving around!

Keeping all fireworks, including sparklers, away from children this holiday season is critical, as 43% of injuries happen to children under 15 years old, 23% in children under age 5--and 69% occur in the month surrounding July 4th!

While Americans do not want to see an end to fireworks, most would support a specific bottle rocket ban; half of the states have already adopted such legislation. A uniform ban in every state would be much more effective, preventing individuals from purchasing bottle rockets in neighboring states.

What can one do as a parent? Write, call, or fax your elected representatives, telling them you support a bottle rocket ban. Encourage your children to attend only professional fireworks displays, rather than using fireworks themselves. If your child must use fireworks, while nothing can eliminate the danger, the following guidelines (adapted from the American Academy of Ophthalmology) can help decrease risk:

• Always have adult supervision and use protective eyewear.

• Use a specially designed stick, or "punk," rather than a match to light fireworks.

• Have a bucket of water ready.

• Always follow manufacturers' directions and dispose of used fireworks properly.

• Never give a firecracker or sparkler to a child. Never use a bottle rocket.

• Do not light firecrackers bigger than your pinkie, do not light them indoors, and avoid relighting duds.

• Never put fireworks in your pocket, throw them while lit, or make homemade firecrackers.

• In case of eye injury, do not touch the eye. Tape a clean paper cup over the eye to prevent contamination or further injury. Immediately seek medical attention from an ophthalmologist (eye MD).

As a first-generation Chinese-American ophthalmologist , I have a unique perspective. A beautiful fireworks display can be among the most moving of cultural expressions, evoking a visceral reaction, whether on Chinese New Year or July 4th.

At the same time, fireworks, invented for war, hold great destructive potential, which I am unfortunate enough to witness each year. I am proud of my ancestors for their invention. I would be many times as proud of my fellow Americans if they joined together to end needless blindness caused by fireworks.

PARK AVENUE LASER VISION – "VISIONARY" marketing ideas at work

Recognized by the New York Times for creative Internet marketing

New York, June 26, 2008 (PressReleasePoint) Dr. Emil Chynn of the Park Avenue Laser Vision (PALV) Center Recognized by the New York Times for creative Internet marketing to attract new patients for elective Eye Laser (LASEK) Surgery.

Emil Chynn MD of the Park Avenue Laser Vision (PALV) Center www.ParkAvenueLaser.com is setting the standard for medical professionals practicing not only the latest techniques in laser vision correction but employing innovative marketing techniques as well. In a recent review of Dr Emil Chynn in the New York Times, Dr. Chynn was recognized as a pioneer in marketing his services through the popular video sharing site, Youtube. Dr. Chynn, who was the first New York City eye surgeon to perform the most advanced laser procedure, CustomVue Wavefront Monovision, also uses cutting-edge marketing practices through a unique combination of open-to-public surgery seminars, patient referrals, and the Internet.

Dr. Emil Chynn, who has been successfully performing laser vision correction for over a decade, is also staying ahead of the curve by employing innovative marketing techniques for his Center. In a New York Times article published 26 June 2008, PALV is recognized for its unique patient endorsement campaign in which patients are offered an incentive to post the videos recorded during their surgeries on YouTube in exchange for discounts off their surgery or on a future procedure (Botox, etc.) While the practice of offering patient remuneration in exchange for endorsements has raised some eyebrows among medical ethicists and consumer advocates, Dr. Chynn sees nothing wrong with the practice. "In the end, it comes down to the integrity, experience and reputation of the surgeon," says Dr. Chynn, who has performed over 11,000 cases without a single lost or settled lawsuit. He also holds an MD from Columbia University and an MBA from NYU.

Dr. Chynn also entices new patients by holding bi-monthly free Live LASEK seminars that are open-to-the-public and allows visitors to observe right in the procedure room next to him during a patient's surgery. There is also a video camera directly above the patient's eye recording the entire procedure as it is taking place and linked to TV screens that can viewed both in the reception area as well as from the sidewalk directly outside the Center.

In addition, PALV is currently launching their new website which features a "simulator" that enables the viewer to experience a simulation of the actual laser surgery. The new website also includes a video gallery (put together by SalemGlobal Internet Website Marketing) that includes segments of Dr. Chynn's recent TV appearances and a patient surgery narrated by the patient himself. There is also a rotating carousel with patient testimonials and a way to browse through the first chapter of Dr. Chynn's upcoming new book Laser Vision Surgery. "All of this helps remove any mystery around laser eye surgery and perhaps trepidation one may have towards the procedure," explains Dr. Chynn.

Park Avenue LASEK – First in Area to Offer ZYTAZE™ to Enhance Botulinum Toxin Results

New York, NY (November 16, 2010) - Park Avenue Laser Vision Center, one of New York’s top cosmetic enhancement centers, is pleased to offer ZYTAZE™ (OCuSOFT, Inc.), the first and only prescription supplement proven to enhance the efficacy and duration of botulinum toxin injections.

Formulated with a proprietary, patent-pending blend of highly bioavailable, organic zinc and phytase (an enzyme that effectively breaks down phytates and increases zinc absorption), ZYTAZE™ has been reported to extend the duration of botulinum toxin treatments by nearly 25%. By supplementing with ZYTAZE™ four days prior to and on the day of receiving botulinum toxin injections, patients will not only see better results, but also added savings.

Among the lucky few chosen to preview ZYTAZE™ is Manhattan's own, Megan McCombs of Manhattan Medical Magazine.

"Park Avenue Laser Vision is known for their cutting edge reputation and I am thrilled to be one of the first in Manhattan to evaluate ZYTAZE™. The idea of better, longer lasting Botox without costing an arm and a leg is truly exciting," remarks McCombs.

ASCRS Ask The Experts with Dr. Emil Chynn

Dr. Chynn has the most Refractive Fellows working for him of any surgeon in NYC. In fact, Park Avenue LASEK is the largest Refractive Fellowship Program in NYC! We have 4 Refractive Fellows at all times, 2 Senior Fellows and 2 Junior Fellows. All are full MDs! They have chosen to spend 1-2 years learning the intricacies of Refractive Surgery from Dr. Chynn, since he was at Columbia when the excimer laser was invented, and at Harvard when LASEK was invented. So they can learn from a true pioneer!

Why we safely treated the highest Rx ever lasered in NYC: -22.00! And why LASIK is unsafe for extreme Rxs.
Click here for Proof we’re the Only center able to treat Extreme prescriptions. You should get the Safest LASEK too!

Dr. Chynn is recognized as a National Expert in Refractive Surgery – read this article to see his advice to other laser surgeons.
In this article, 3 national “thought leaders” including Dr. Chynn were asked their opinion on how to treat a complicated case. Dr. Chynn advocates using the VISX WaveScan CustomVue to create a PreVue lens. Using the PreVue lens, Dr. Chynn can show complicated patients (e.g., LASIK patients with flap complications) how they would see after he fixes their problem by performing a totally non-invasive, surface LASEK over their prior (failed) LASIK.

This case is interesting both for its complexity and realism, as it demonstrates a common situation encountered by the refractive practitioner--namely, the situation of a patient presenting with incomplete records, having had surgery elsewhere, and desiring further surgery, " but only if it's safe."

The patient has had prior refractive surgery OD for a metallic foreign body scar--either a PTK or a PRK. He reports ghosting or monocular diplopia in that eye, which is most likely due to his superiorly decentered ablation with respect to the optical zone, which can be seen on his topography OD. Again, it is difficult to be certain if this represents the postoperative result of an intentionally decentered PTK to remove his scar, or an unintentionally decentered PRK to remove his scar and simultaneously address his refractive error. I would guess the former, although as a rule I prefer to treat such cases with a PRK, as in my hands the final refractive result is more predictable and patient satisfaction higher after performing a PTK with an (uncontrolled) hyperopic shift.

We can address OD as if it's simply a (complicated) refractive case. The cornea is clear, so although I think we would all agree that the chances of scarring in a surface ablation is always higher in retreatments, I do not think this risk is significant. That said, I always try to minimize this risk in surface retreatments by giving oral steroids, branded Pred Forte, and intraoperative MMC.

The other safety consideration for reoperating OD is answered by the Orbscans, which shows sufficient corneal thickness both centrally and peripherally for the rather minor intended refractive treatment, with no signs of keratoconus OU.

The question then arises whether one can successfully treat this situation simply with standard wavefront algorithms, or whether decentered ablations are best treated with a specialized retreatment algorithm or topographically-guided ablation, one of which is available from each of the major laser manufacturers.

Reviewing the CustomVue map OD, the fact that higher order aberrations comprise 56% of total error is neither impressive nor concerning to me, since the underlying refractive error is quite minor, with a spherical equivalent of only -0.51. I actually wish that this percentage was somehow normalized for spherical equivalent, as I think such a index would be more useful clinically when comparing aberrated eyes.

More importantly, the WaveScan refraction of +0.20 - 1.41 x 142 is similar to the hard lens over-refraction of +0.75 - 0.75 x 180. This reassures me that the WaveScan is objectively measuring a global refractive error similar to what the patient is experiencing subjectively.

Before retreating this or any complicated patient, I like cut a PreVue lens and have the patient hold it up, documenting both his objective improvement in visual acuity, as well as subjective improvement in symptomatology. In this case, I would need to see at least a 1-line improvement of acuity to 20/25, as well as a significant subjective improvement of his ghosting/diplopia OD. In my practice, a PreVue lens that demonstrates both objective and subjective improvement will usually lead to a visual outcome that is satisfactory from a patient point of view. I am a strong proponent of using the PreVue capability of the VISX system, which I believe is underutilized. Beware of performing complicated enhancements without a PreVue lens, or where vision out of the PreVue does not show both objective and subjective improvement!

In CustomVue retreatments, I am more hesitant to adjust treatment parameters, particularly the physician adjustment, because I feel that the results of doing so are more unpredictable than in primary treatments. Another reason I don't like to adjust these cases is that I commonly utilize the PreVue feature, which makes less sense when you then wind up shooting something dissimilar to what you PreVued. This is why I like that the WaveScan refraction is similar to my manifest, so I don't feel I need to adjust it. If it is very different, I will just try to keep capturing WaveScans until I get one that is similar to what I think I "need."

In terms of staging, the question arises whether to operate on OD or OS first. I never operate OU in enhancements, both for prudence and medical-legal reasons. In this case, I would actually leave this decision up to the patient, as either choice seems reasonable medically.

I could perform LASEK or epi-LASEK OS (I only perform advanced surface ablations), make that eye 20/20 or potentially better, eliminate his anisometropia, and by doing so actually reduce his symptomatology, since his uncorrected vision with both eyes open would excellent. I have staged many cases like this, and a significant minority of patients will then decline to have further surgery on the fellow (abnormal) eye, after gaining good functionality.

On the other hand, most patients would elect to operate on OD first. I would then counsel them about their increased risk of scarring from a second surface procedure, as well as steps we would take to reduce this risk. I never promise the patient that his final result in the reoperated eye will be as good as in the fellow eye, or perfect, because what we are actually trying to do is fix an "imperfect, damaged" eye. However, provided I have postive results from the PreVue lens, I would tell the patient that his visual acuity should improve, and his subjective symptoms should somewhat diminish.

In terms of which advanced surface procedure to perform, I would only perform a LASEK, not an epi-LASEK in such cases, because of the slightly increased risk of an intra-stromal incursion by the epi-LASEK separator in retreatments and cases with prior foreign bodies, which I have seen.

By carefully reviewing the preoperative data, confirming the safety of a reoperation, utilizing the PreVue lens feature, appropriately staging the two procedures, and managing patient expectations, I would be fairly confident that this patient could be retreated with a standard CustomVue ablation, with highly satisfactory results.

 --

Emil William Chynn, MD FACS MBA

Dartmouth/Columbia/Harvard/Emory/NYU-trained

1st surgeon in NYC to have LASIK!

10,000 cases - 100% Legal To Drive!

Member FACS, AAO, ASCRS, MENSA

www.ParkAvenueLaser.com

NY's Only 100% No-Cut/Flap, All-Laser Vision Center

#1 LASEK Center in NY - CBS News TV,

Daily News, Fox, Ch. 9, SNL, WPLJ

Aberrations After the Treatment of a Corneal Scar

REFRACTIVE SURGERY
COMPLEX CASE MANAGEMENT
SECTION EDITORS: KARL G. STONECIPHER, MD;
PARAG A. MAJMUDAR, MD; AND STEPHEN COLEMAN, MD
BY JAY BANSAL, MD; EMIL WILLIAM CHYNN, MD, MBA; AND ROY S. RUBINFELD, MD

A 30-year-old male engineer presents with a complaint that he has seen “images stacked right on top of each other” through his right eye for several years. He has a history of a metallic foreign body in his right eye at age 15. Several years later, he underwent excimer laser treatment in that eye to remove the resultant corneal scar. Since then, he has used no correction for his right eye but has worn a soft contact lens in his left eye.

The patient expresses a desire to be free of the contact lens in his left eye. His UCVA is 20/30 OD, which improves to 20/20 with a hard contact lens overrefraction of +0.75 -0.75 X 180. His UCVA is 20/400 OS, which corrects to 20/20 with a spherical equivalent of -4.25 D. The slit-lamp examination is normal in both eyes, with no evidence of scarring in his right eye. Central pachymetry readings with the Orbscan topographer (Bausch & Lomb, Rochester, NY) are 557 µm OD, with no peripheral areas of thinning, and 593 µm OS. In the patient's right eye, the Visx WaveScan Wavefront System (Advanced Medical Optics, Inc., Santa Ana, CA) shows a refraction of +0.20 -1.41 X 142 (4.00 Rx calc) with 55.8% higher-order aberrations and a root mean square error of 1.19 (Figures 1 to 3).

How would you proceed?



Figure 1. Preoperative measurements of the patient's right (A) and left (B) eyes with the TMS-4 (CBD Ophthalmic/Tomey, Phoenix,AZ).




Figure 2. Preoperative measurements of the patient's right (A) and left (B) eyes with the Visx WaveScan Wavefront System.




Figure 3. Preoperative measurements of the patient's right (A) and left (B) eyes with the Orbscan topographer.

JAY BANSAL, MD

The visual distortion in this patient's right eye is related to the high amount of coma and other higher-order aberrations. The decentered ablation visible on the topography of his right eye could cause these higher-order distortions. The patient would benefit from either a topographyguided ablation, which is not yet available in the US, or a wavefront-guided enhancement. Because he has had previous laser treatment with induced higher-order aberrations, I would consider the possibility of a hyperopic outcome following his customized enhancement. I would therefore explain to him that he might require additional surgery following the enhancement.

Assuming I used a Visx Star excimer laser platform (Advanced Medical Optics, Inc.) for the enhancement procedure, I would first perform a trial with the Visx PreVue lens (Advanced Medical Optics, Inc.) and confirm there was a subjective improvement in vision for the patient. With a normal corneal thickness, the patient can undergo a LASIK enhancement in his right eye. I would prefer to use a femtosecond laser for the LASIK enhancement, and I would be sure to make the flap thicker than normal (130 µm or more) because of possible epithelial hyperplasia following the patient's previous PRK procedure. I would recommend customized IntraLASIK (Intralase FS laser; Advanced Medical Optics, Inc.) for his left eye.

The important aspect of this case is the patient's education so that his expectations are realistic and he understands the possibility of additional laser vision correction.

EMIL WILLIAM CHYNN, MD, MBA

This case is interesting both for its complexity and its realism. It demonstrates a common experience of refractive surgeons—namely, the presentation of a patient with incomplete records who underwent surgery elsewhere and desires further surgery, but only if it is “safe.” The patient reports ghosting or monocular diplopia in his right eye, which is most likely due to his superiorly decentered ablation with respect to the optical zone, as evident on topography. It is uncertain whether the original surgeon intentionally decentered the phototherapeutic keratectomy (PTK) to remove the scar or if the PRK was unintentionally decentered to remove the patient's scar and simultaneously address his refractive error. I would guess the former. In my hands, the final refractive result is more predictable with PRK, and patients tend to be more satisfied than after experiencing a (uncontrolled) hyperopic shift after PTK.

The cornea of the patient's right eye is clear. Although the chance of scarring with surface ablation is always higher in retreatments, I do not think the risk is significant. Nevertheless, I always try to minimize the possibility by prescribing oral steroids, Pred Forte (Allergan, Inc., Irvine, CA), and intraoperative mitomycin C. In this case, Orbscan topography shows sufficient corneal thickness, both centrally and peripherally, for the rather minor intended refractive treatment, and there are no signs of keratoconus in either eye. The question is whether I can successfully treat the patient with standard wavefront algorithms or whether the decentered ablations are best treated with a specialized retreatment algorithm or a topographically guided ablation. According to the Visx CustomVue map (Advanced Medical Optics, Inc.) of the patient's right eye, the higher-order aberrations compose 56% of the total error. This measurement does not concern me, because the underlying refractive error is quite minor, with a spherical equivalent of only -0.51 D. This points to one disadvantage of reporting higher-order aberrations as a percentage of the total: namely, the resultant percentage is highly dependent on the size of the denominator, so one may get 56% higher-order aberrations in an eye with a low total refractive error. More importantly, the Visx WaveScan refraction of +0.20 -1.41 X 142 is similar to the hard lens overrefraction of +0.75 -0.75 X 180. I am therefore reassured that the Visx WaveScan objectively measured a global refractive error similar to what the patient is experiencing subjectively.

In complicated cases, I cut a Visx PreVue lens and have the patient hold it up in order to document both his objective improvement in visual acuity and his subjective improvement in symptomatology. For this patient, I would want to see at least a one-line improvement in acuity to 20/25 as well as a significant subjective improvement in the ghosting/diplopia in his right eye. In my experience, a Visx PreVue lens that demonstrates both objective and subjective improvement will usually lead to a visual outcome that is satisfactory to the patient.

In Visx CustomVue retreatments, I hesitate to adjust the treatment parameters, particularly the physician adjustment, because I feel that the results of doing so are more unpredictable than in primary treatments. Adjustments also make using the Visx PreVue lens difficult. For example, placing a trial lens of -0.50 D over a Visx PreVue lens makes the already tiny optical zone almost impossible for the patient to look through. If I do not obtain a Visx PreVue lens that demonstrates both subjective and objective visual improvement, then I prefer to recapture another Visx PreVue lens that demonstrates both and agrees with my gestalt of what the “correct” refractive correction should be.

I would allow the patient to decide on which eye I operated first, as either choice seems reasonable medically. LASEK on his left eye could achieve a visual acuity of 20/20 or better, eliminate his anisometropia, and thus reduce his symptomatology. My choice of LASEK versus epi-LASIK is based on my observation of a slightly higher risk of an intrastromal incursion by the epi-LASIK separator in retreatments and cases with prior foreign bodies. If the patient requested surgery on his right eye first, I would counsel him about his heightened chance of scarring from a second surface procedure as well as steps we would take to reduce this risk. I would not promise that the final result in his reoperated eye would be perfect or as good as in his fellow eye, because the goal is to fix a damaged eye. Given positive results from the Visx PreVue lens, I would tell the patient that his visual acuity should improve and that his subjective symptoms should diminish somewhat.

ROY S. RUBINFELD, MD

It might be helpful to obtain this patient's old records to determine specifically what excimer laser treatment was performed on his right eye to correct the corneal scar. Most likely, the original surgeon applied PTK inferiorly only, without an attempt to spread the corneal flattening effect toward the superior cornea. This would explain the currently high levels of coma visible on aberrometry and also on Placido disk topography of his right eye. It would also be interesting to know the BSCVA for his right eye, as it might have a bearing on the optimal management of this patient. Essentially, this is a case of inferior flattening, high levels of coma, and irregular astigmatism in a right eye and an essentially normal myopic left eye with no evidence of topographic or other abnormalities.

I would cut several Visx PreVue lenses using the Visx WaveScan measurement of his right eye with multiple plus and minus physician adjustment settings. I would carefully determine which lens provided optimal postoperative correction and consider treating the patient's right eye with wavefront-guided PRK followed by a brief intraoperative application of a low dose of mitomycin C. If the PreVue lenses did not seem able to correct the coma effectively, then I would consider a topography-guided ablation as a one- or two-staged procedure, most likely with the Allegretto Wave excimer laser (WaveLight, Inc., Sterling, VA), because I have seen excellent results with this system in similar patients.

After I had corrected the visual acuity of the patient's right eye to his and my satisfaction, then his left eye could undergo LASIK at a later date. One could argue for treating both eyes on the same day. This case is somewhat complex, however, and the decision should be made after an extensive informed consent discussion with the patient.

Authors

Email Chynn featured in Glaucoma Today Magazine Cover, for Testimonials, Resume, Research, Patents, Ground, Zero, and Charities Section editor Karl G. Stonecipher, MD, is Director of Refractive Surgery at TLC in Greensboro, North Carolina. Parag A. Majmudar, MD, is Associate Professor, Cornea Service, Rush University Medical Center, Chicago Cornea Consultants, Ltd. Stephen Coleman, MD, is Director of Coleman Vision in Albuquerque, New Mexico. They may be reached at (505) 821-8880; stephen@colemanvision.com. Jay Bansal, MD, is Medical Director of the LaserVue Eye Center in Santa Rosa, California. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Bansal may be reached at (707) 522-6200; bansal@laservue.com.

Emil William Chynn, MD, MBA, is Medical Director of Park Avenue Laser in New York. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Chynn may be reached at (212) 741-8628; dr@parkavenuelaser.com.

Roy S. Rubinfeld, MD, is in private practice with Washington Eye Physicians & Surgeons in Chevy Chase, Maryland. Dr. Rubinfeld is also Clinical Associate Professor at Georgetown University Medical Center/Washington Hospital Center in Washington. He has served as a consultant to Alcon Laboratories, Inc., Visx Incorporated (now a part of Advanced Medical Optics, Inc.), and WaveLight, Inc. Dr. Rubinfeld may be reached at (301) 654-5290; rubinkr1@aol.com.