October 2015 - Northwest Eye Surgeons

October
October2015
2015
October 2015
NWES
NWESPhysicians
Physicians
NWES Physicians
Finish
FinishSTP
STP
Finish STP
InIn
July,
July,
three
three
NWES
NWES
optometric
optometric
In
July, threeBrett
NWES
optometric
physicians,
physicians,
Brett
Bence,
Bence,
Mike
Mike
Giese
Giese
and
and
physicians,
Brett
Bence,out
Mike
Giese to
and
Landon
Landon
Jones,
Jones,
headed
headed
out
together
together
to
Landon
Jones,
headed
out together
toto
th annual
th annual
take
take
part
part
inin
the
the
3636
Seattle
Seattle
to
th
take
part(STP),
in(STP),
the Bike
36
annual
Seattle
to
Portland
Portland
Bike
Ride.
Ride.
The
The
course
course
Portland
(STP),
Bike
Ride.
The
course
covered
covered
206
206
miles,
miles,
but
but
these
these
doctors
doctors
covered
206
miles,
but
these
doctors
completed
completed
210
210
allall
told,
told,
including
including
their
their
4-4completed
210ride
allride
told,
including
their
4mile
mile
round-trip
round-trip
onon
Saturday
Saturday
evening,
evening,
mile
ride
onpizza
Saturday
evening,
toto
a local
around-trip
local
Castle
Castle
Rock
Rock
pizza
joint,
joint,
after
after
to
a
local
Castle
Rock
pizza
joint,
setting
setting
upup
camp
camp
forfor
the
the
night.
night. after
setting up camp for the night.
AtAt
the
the
5555
mile
mile
marker,
marker,
they
they
stopped
stopped
atat
At
theBase
55
mile
marker, theyto
stopped
at
Joint
Joint
Base
Lewis-McChord,
Lewis-McChord,
to
marvel
marvel
atat
Joint
Base
Lewis-McChord,
to
marvel
at
numerous
numerous
planes
planes
and
and
assault
assault
vehicles.
vehicles.
numerous
planes
and
assault
vehicles.
The
The
final
final
3030
miles
miles
into
into
Portland
Portland
typically
typically
The
final 30
miles
into
typically
presents
presents
riders
riders
with
with
a tailwind,
aPortland
tailwind,
but
but
not
not
soso
presents
riders
with
a reported,
tailwind,
but
not
so
this
this
year!
year!
Brett
Brett
Bence
Bence
reported,
“We
“We
had
had
this
year!
Bence
reported,
“We
a bit
a bit
ofof
a headwind.
aBrett
headwind.
But
But
all-in-all,
all-in-all,
it was
it had
was
aa
a
bit
of
a
headwind.
But
all-in-all,
it
was
a
fun
fun
ride
ride
and
and
good
good
memories.”
memories.”
fun ride and good memories.”
Bence’s
Bence’s
review
review
ofof
their
their
riding
riding
styles:
styles:
Bence’s review of their riding styles:
(Landon)
(Landon)“Strong
“Strong
upup
the
the
hills,
hills,
a bit
a bit
(Landon)
“Strong
up
the
hills,
a
bit
choppy
choppy
legleg
action
action
but
but
this
this
didn’t
didn’t
slow
slow
him
him
choppy
action
but
this
didn’t
slow
down
down
atleg
at
allall
and
and
hehe
was
was
able
able
toto
keep
keep
ahim
a
down
at
all and pace.”
hepace.”
was able to keep a
very
very
consistent
consistent
very consistent pace.”
(Mike)
(Mike)“Slow,
“Slow,
smooth,
smooth,
seemingly
seemingly
(Mike)
“Slow,
smooth,
seemingly
effortless
effortless
biking
biking
stroke;
stroke;
powerful
powerful
legleg
effortless
biking
stroke;
powerful
leg
action;
action;
larger
larger
frame
frame
allowed
allowed
forfor
improved
improved
action;
larger
frame
allowed
for
improved
drafting
drafting
if you
if you
were
were
behind
behind
him.”
him.”
drafting if you were behind him.”
(Himself)
(Himself)
“Basically,
“Basically,
rode
rode
inin
survival
survival
(Himself)
“Basically,
rode
in
survival
mode
mode
most
most
ofof
the
the
trip.”
trip.”
mode most of the trip.”
Intrepid
Intrepid
Riders:
Riders:
Landon
Landon
Jones,
Jones,
OD,
OD,
Mike
Mike
Intrepid
Riders:
Landon
Jones,
OD, Mike
Giese,
Giese,
OD;
OD;
and
and
Brett
Brett
Bence,
Bence,
OD.
OD.
Giese, OD; and Brett Bence, OD.
The
TheClinician’s
Clinician’sChallenge:
Challenge:AACase
CaseofofUnremitting
UnremittingIritis
Iritis
The
Clinician’s
Challenge:
A
Case
of
Unremitting
Iritis
ByByDavina
DavinaKuhnline,
Kuhnline,OD
OD
By Davina Kuhnline, OD
Background:
Background:
Iritis
Iritis
is is
inflammation
inflammation
ofof
the
the
irisiris
Background:
Iritisby
isby
inflammation
of the
iris
and
and
is is
measured
measured
quantifying
quantifying
white
white
blood
blood
and
isand/or
measured
by quantifying
white
blood
cells
cells
and/or
protein
protein
floating
floating
inin
the
the
aqueous
aqueous
cells
and/or
protein
floating
in
the
aqueous
humor.
humor.
It It
may
may
present
present
asas
granulomatous
granulomatous
humor.
It maywith
present
asmutton-fat
granulomatous
inflammation
inflammation
with
large
large
mutton-fat
keratic
keratic
inflammation
large mutton-fat keratic
precipitates,
precipitates,
orwith
or
non-granulomatous
non-granulomatous
precipitates,
orwith
non-granulomatous
inflammation
inflammation
with
fine
fine
keratic
keratic
precipitates.
precipitates.
inflammation
with
fine keratic
precipitates.
Causes
Causes
may
may
bebe
infectious,
infectious,
auto-immune,
auto-immune,
Causes
may
be infectious,
auto-immune,
traumatic,
traumatic,
idiopathic,
idiopathic,
oror
phacolytic.
phacolytic.
Iritis
Iritis
that
that
traumatic,
idiopathic,
or
phacolytic.
is is
severe,
severe,
chronic,
chronic,
recurrent,
recurrent,
and/
and/Iritis that
is
severe,
chronic,
recurrent,
and/
beam
photo
showing
presence
of of
cells
beam
photo
showing
presence
cells
oror
bilateral,
bilateral,
warrants
warrants
a workup
a workup
toto
rule
rule
out
out
a a SlitSlit
Slit
beam
photo
showing
presence of cells
and
flare.
Source:
reviewofoptometry.com
and
flare.
Source:
reviewofoptometry.com
or
bilateral,
warrants
a
workup
to
rule
out
a
systemic
systemic
cause.
cause.
and flare. Source: reviewofoptometry.com
systemic cause.
Case:
Case:
AnAn
8585
year
year
oldold
white
white
female
female
presented
presented
with
with
a four
a four
day
day
history
history
ofof
red
red
painful
painful
Case:
An
85concurrent
year oldwith
white
female
presented
with
a four
day
history
of red painful
right
right
eye
eye
concurrent
with
a one
a one
day
day
history
history
ofof
waking
waking
upup
with
with
mild
mild
mucopurulent
mucopurulent
right
eye concurrent
with
a one day history of waking up with mild mucopurulent
discharge
discharge
ofof
the
the
right
right
eye.
eye.
discharge of the right eye.
History:
History:
Positive
Positive
forfor
type
type
II diabetes,
II diabetes,
hypertension,
hypertension,
sleep
sleep
apnea,
apnea,
and
and
rightrightHistory:
Positive
for
type
II
diabetes,
hypertension,
sleep
apnea,
and
rightsided
sided
herpes
herpes
zoster
zoster
ophthalmicus,
ophthalmicus,
V1V1
dermatome.
dermatome.
sided herpes zoster ophthalmicus, V1 dermatome.
Ophthalmic
Ophthalmic
History:
History:Herpetic
Herpetic
keratouveitis,
keratouveitis,
neurotrophic
neurotrophic
keratitis,
keratitis,
and
and
mixed
mixed
Ophthalmic
History:
Herpetic
keratouveitis,
neurotrophic
keratitis,OD.
and
mechanism
mechanism
glaucoma
glaucoma
––
POAG
POAG
OUOU
and
and
steroid-induced
steroid-induced
glaucoma
glaucoma
OD. mixed
mechanism glaucoma – POAG OU and steroid-induced glaucoma OD.
Ophthalmic
Ophthalmic
Meds:
Meds:
Ophthalmic Meds:
Restasis
Restasis
b.i.d.
b.i.d.
OUOU
FML
FML
q.d.
q.d.
OD,
OD,
Restasis b.i.d. OU
FML q.d. OD,
Latanoprost
Latanoprost
q.h.s.
q.h.s.
ODOD
Celluvisc
Celluvisc
q.h.s.
q.h.s.
OUOU
Latanoprost q.h.s. OD
Celluvisc q.h.s. OU
Cosopt
Cosopt
b.i.d.
b.i.d.
OUOU
Artificial
Artificial
tears
tears
asas
needed
needed
Cosopt b.i.d. OU
Artificial tears as needed
UCDVA:
UCDVA:OD:
OD:
20/400
20/400 OS:
OS:
20/20-1
20/20-1
UCDVA: OD: 20/400
OS: 20/20-1
OD:
DEFERRED
DEFERREDOS:
OS:
18mmHg
18mmHg
IOP:
IOP: OD:
OD: DEFERRED OS: 18mmHg
IOP:
Slit
Slit
Lamp
Lamp
Exam
Exam
(OD):
(OD):
Lateral
Lateral
tarsorrhaphy,
tarsorrhaphy,
3+bulbar
3+bulbar
injection,
injection,
corneal
corneal
haze,
haze,
1mm
1mm
Slit
Lamp Exam
(OD):
Lateral
tarsorrhaphy,
3+bulbar
injection,
corneal haze,
1mm
peripheral
peripheral
infiltrate
infiltrate
with
with
.25mm
.25mm
overlying
overlying
stain
stain
and
and
neovascularization
neovascularization
x360
x360
peripheral
infiltrate
with
.25mm
overlying
stain
andfrom
neovascularization
x360
degrees;
degrees;
1+anterior
1+anterior
chamber
chamber
flare
flare
vs.vs.
light
light
scatter
scatter
from
corneal
corneal
haze,
haze,
no
no
anterior
anterior
degrees;
1+anterior
chamber
flare
vs.
light
scatter
from
corneal
haze,
no
anterior
chamber
chamber
cell.
cell.
chamber cell.
Impression
Impression
and
and
Plan:
Plan:
Diagnosis
Diagnosis
was
was
neurotrophic
neurotrophic
keratitis
keratitis
with
with
bacterial
bacterial
Impression
and Plan:Started
Diagnosis
was Acyclovir
neurotrophic
keratitis
with
bacterial
keratoconjunctivitis.
keratoconjunctivitis.
Started
800mg
800mg
Acyclovir
byby
mouth,
mouth,
55
times
times
per
per
day,
day,
Zymaxid
Zymaxid
keratoconjunctivitis.
Started
800mgFML
Acyclovir
by Follow-up
mouth,
5 times
per day,
Zymaxid
every
every
two
two
hours
hours
OD,
OD,
and
and
increased
increased
FML
toto
q.i.d.
q.i.d.
Follow-up
scheduled
scheduled
forfor
24
24
hours.
hours.
every two hours OD, and increased FML to q.i.d. Follow-up scheduled for 24 hours.
Follow-Up:
Follow-Up:
AllAll
findings
findings
were
were
similar
similar
atat
follow-up
follow-up
except
except
anterior
anterior
chamber
chamber
showed
showed
1+1+
Follow-Up:
Allwas
findings
wereOD
similar
at
follow-up
except
anterior
chamber
showed 1+
cell
cell
and
and
IOP
IOP
was
19mmHg
19mmHg
OD
byby
Tonopen.
Tonopen.
Initiating
Initiating
more
more
potent
potent
corticosteroids
corticosteroids
cell
and
IOP was
19mmHg
OD
by Tonopen.
Initiating
more
potentAtropine
corticosteroids
was
was
delayed,
delayed,
due
due
toto
patient
patient
being
being
a steroid
a steroid
responder.
responder.
Instead,
Instead,
Atropine
1%,
1%,
was delayed, due to patient being a steroid responder. Instead, Atropine 1%,
Continued
Continued
onon
page
page
4 4
Continued on page 4
Practice Update
Providing More For Patients: Website Enhancements
We are excited to introduce you and your patients to some new
interactive features on our website. We have added over 20 short
educational videos, ranging in topic from cataract surgery to the
latest corneal cross-linking procedures, to comprehensive diabetic
eye care. Videos are easy to navigate to from the list of services on
our home page: www.nweyes.com.
We also want to
assist patients in
connecting with
you. We keep your
practice
information up to
date on our
website for those
who are in need of a primary eye health provider. If you have an
update or want to be added to our search list, please email us at
[email protected].
Many of your patients have shared their Vision Correction
experiences on our website. We’ve also included perspectives from
their surgeons, about deciding on a Vision Correction plan that
addressed their unique vision goals. If you or your patients want to
share your Vision Correction successes, please contact us at
[email protected], for more information.
Both audio and
closed-caption
viewing options
are available
for patients
Closing the Information Exchange Gap
If you are using an EMR system, we want to know your direct electronic address(es), so we can begin to send secure medical records
to you. If you do not yet have an electronic address, or are unsure, contact your EMR service representative for more information.
Practice Name:
Phone:
Address:
Doctor Name & Direct Address:
Doctor Name & Direct Address:
Fax to: 206-522-1479, Attn. Barbara
Fax:
Femtosecond Laser Assisted Cataract Surgery Allows
Unprecedented Control of the Capsulorhexis
NWES Top Doctors
By Victor Chin, MD
Mr. R was a very easygoing 72-year-old man who wanted cataract surgery in order to
see better to enjoy more camping trips with his grandchildren. Based on his desire to
improve his vision for hiking and outdoor activities, I recommended Vision Correction.
We also discussed some additional benefits he could gain with having Vision Correction
at Northwest Eye Surgeons.
Considering the Risks Due to History of Injury
On dilated exam, I noted a slightly decentered pupil with slight iris atrophy nasally. Mr. R
reported a possible history of blunt injury while playing basketball over 40 years ago.
Due to these findings and his history, we discussed his slightly increased risks of
unexpected complications during surgery, but I also explained that use of the
femtosecond laser could help facilitate a successful Vision Correction outcome.
Femto Makes Personalized Vision Correction Possible
With femtosecond laser assisted cataract surgery, the laser cut capsulorhexis is not
only perfectly circular, but can also be controlled in size and position. The femtosecond
laser system, provided good imaging and scans are obtained, can be used to slightly
adjust the location of the capsulorhexis and adapt to the position of a patient’s pupil. In
this case, Mr. R’s pupil was slightly temporally decentered due to his nasal iris atrophy.
In addition, since the laser delivers the energy directly to the capsule, there was no
direct tension or traction against the zonules, which may have been compromised due
to his prior trauma. With femtosecond technology, we would be able to avoid the need
to compromise on his Vision Correction goals.
Precise Adjustments Made in the Operating Suite
On the day of his surgery, Mr. R received the femtosecond laser treatment prior to his
cataract surgery. The laser correctly imaged the iris border and I adjusted the
capsulorhexis position slightly temporally based on the pupil position. I also decreased
the size of capsule opening by a precise 0.2mm to ensure good overlap with the optic of
the IOL.
Both of these capsulorhexis adjustments could have been readily accomplished
manually by a skilled cataract surgeon. However, using the femtosecond laser allowed
for an increased level of control of the exact location and size of the capsule opening.
By creating a predictable capsulorhexis, I was able to simplify a potentially complex
cataract surgery to better ensure Vision Correction success.
Corrected Vision, Thrilled Patient
Mr. R tolerated the laser very well and the rest of his surgery went smoothly. Also as
part of his Vision Correction plan, he received a toric IOL that was adjusted and
confirmed with ORA (intra-operative aberrometry) measurements on the table.
Postoperatively, Mr. R reported he was thrilled with his vision which was 20/25 without
correction, and 20/20+ with a manifest refraction of -0.25 +0.50 @ 80 degrees.
Our physicians would be glad to talk with you further about incorporating femtosecond
laser into your patient’s Vision Correction planning. For more information reach us at
800-826-4631 or [email protected].
NWES is proud to congratulate so
many of our providers for being
recognized as Top Doctors in two
Seattle publications.
Seattle Met Magazine
Brett Bence, OD
Werner Cadera, MD
Bruce Cameron, MD
Victor Chin, MD
Michael Giese, OD
Susan Hoki, MD
Landon Jones, OD
Audrey Talley Rostov, MD
Ashley Fedan, CRNA
Patrick Klimczyk, CRNA
Seattle Magazine
Brett Bence, OD
Werner Cadera, MD
Bruce Cameron, MD
Victor Chin, MD
Michael Giese, OD
Landon Jones, OD
Meng Lu, MD
10330 Meridian Ave. N.
Suite 370
Seattle, WA 98133
10330 Meridian Ave. N.
Suite 370
Seattle, WA 98133
CONTINUING EDUCATION
Clinician’s Challenge: Iritis, continued from page 1
OCTOBER 13 | TUESDAY
Great Catch: Pediatric and Strabismus
Case Studies
1 drop twice daily, was added, along with an increase in FML to 1 drop every two
hours.
Dr.
Carlson
CONTINUING
EDUCATION
Jalapeno’s Mexican Restaurant,
OCTOBER
13 | TUESDAY
Bellingham
Great
DinnerCatch:
6 p.m. Pediatric and Strabismus
Case
Studies
Program 6:30 p.m.
Dr. Carlson
Observe
Cataract
Surgery
for CE Credit
Jalapeno’s
Mexican
Restaurant,
Optometric
Bellingham physicians interested in
Dinner
6 p.m.
observing
cataract surgery for CE credit
Program
can now 6:30
do sop.m.
at our Seattle, Mount
Vernon
and
Renton
ASCs. for CE Credit
Observe Cataract Surgery
Optometric
physicians
in
This grand rounds
styleinterested
CE is approved
observing
cataract surgery
for CE
by
the Washington
State Board
of credit
can now dofor
sotwo
at our
Mount
Optometry
CE Seattle,
credit hours.
Vernon call
and800-826-4631,
Renton ASCs. or email:
Please
[email protected],
more
This grand roundsfor
style
CE information.
is approved
by the Washington
Boardabout
of our
Please
send us yourState
thoughts
Optometry for
two CE efforts:
credit hours.
continuing
education
Reach us
Please
call 800-826-4631,
or email:
at
800-826-4631,
or [email protected].
[email protected],
for
more
information.
Thank you for sharing your comments.
Please send us your thoughts about our
continuing education efforts: Reach us
at 800-826-4631, or [email protected].
Thank you for sharing your comments.
On
the third
day ofIritis,
follow-up,
slightly
Clinician’s
Challenge:
continuedvision
from page
1 improved to 20/200+1, IOP was
21mmHg, the cornea and anterior chamber appeared stable. Clinical intuition
1 drop twice
daily,
added,IOP
along
FML to 1 drop every two
suggested
that
thewas
increased
waswith
duean
toincrease
a steroidinresponse.
hours.
So, FML was decreased to q.i.d., Zymaxid to b.i.d., and follow up scheduled for
On thedays.
third day of follow-up, vision slightly improved to 20/200+1, IOP was
three
21mmHg,
the the
cornea
and
anterior
chamber
appeared
stable.but
Clinical
intuition
Six days after
initial
visit,
the eye
was reported
improved,
IOP was
suggested
that
the
increased
IOP
was
due
to
a
steroid
response.
30mmHg. This was the beginning of a roller coaster ride that lasted several
So,
FML and
wasultimately
decreasedconcluded
to q.i.d., Zymaxid
to b.i.d., and
follow up
scheduled for
months
after a peri-bulbar
Kenalog
injection.
three
days.
Discussion: Since the eye pressure rose after decreasing the steroid, the
Six
days after
thedays
initial
visit,
the eye waswas
reported
improved,
but
IOP was
elevated
IOP six
after
presentation
most likely
due to
contiguous
30mmHg.
wasthan
the a
beginning
of a rollerThis
coaster
ridehad
thatanother
lasted several
trabeculitisThis
rather
steroid response.
patient
flare up
months
and ultimately
concluded
after
injection.
after tapering
off of topical
steroids
but aitperi-bulbar
was quicklyKenalog
and easily
brought under
control by a Since
short course
Durezol.
After
adequately
suppressing
thethe
ocular
Discussion:
the eyeon
pressure
rose
after
decreasing
the steroid,
inflammation,
the
patient
received
a
slow
taper
on
1%
Prednisolone
acetate.
elevated IOP six days after presentation was most likely due to contiguous IOP
has
remained
stable
and
the patient
has notThis
experienced
any
additional
trabeculitis
rather
than
a steroid
response.
patient had
another
flare up
recurrences
on
Prednisolone
using
1
drop
every
other
day.
after tapering off of topical steroids but it was quickly and easily brought under
control
by a short
course
on Durezol.
After adequately
suppressing
As
a reminder,
iritis
can cause
sight-threatening
complications
suchthe
as ocular
inflammation,
the patient
received
a slow taper
1% Prednisolone
glaucoma,
macular
edema,
and cataracts.
Early on
aggressive
treatmentacetate.
with IOP
has remained
and the
patient
has not
experienced
any additional
topical
steroidsstable
minimizes
ocular
sequelae
and
should always
be employed even
recurrences
Prednisolone
using
1 drop
every other
in
aggressiveon
steroid
responders
with
glaucoma.
Treat day.
the iritis aggressively, but
be
concurrent
elevated
IOP and treat
accordingly. such as
As acognizant
reminder,ofiritis
can cause
sight-threatening
complications
glaucoma, macular edema, and cataracts. Early aggressive treatment with
topical steroids minimizes ocular sequelae and should always be employed even
in aggressive steroid responders with glaucoma. Treat the iritis aggressively, but
be cognizant of concurrent elevated IOP and treat accordingly.