Correcting Laser Vision Surgery

FRED SHARP, 67, OF CHAPPAQUA, N.Y., HAD LASIK VISION correction so he could play golf and tennis without the hindrance of glasses or contact lenses. But instead of the clear vision he had hoped for, Mr. Sharp said everything after surgery looked as if it were under water.

After an attempt to correct his wrinkled flap, the patient was referred to Dr. Richard E. Braunstein, the Miranda Wong Tang Assistant Professor of Clinical Ophthalmology and director of refractive surgery. The Columbia surgeon smoothed out the flap, sutured it in place, and used a bandage contact lens to help heal the flap. Delighted with the results, Mr. Sharp says, “I have the freedom of vision that’s close to 20/20.”

The goal of excimer laser surgery is to sculpt the cornea so light rays reach their intended target, the retina. During the past decade more than 2 million people have sought laser vision correction surgery to remedy nearsightedness, farsightedness and astigmatism. The vast majority gets excellent results. But in a small percentage of cases, the outcome may not be completely satisfactory and further surgical adjustment is necessary.

Dr. Braunstein is a nationally recognized expert in performing refractive surgery and correcting poor patient outcomes. He has served as principal investigator for three clinical trials that led to FDA approval of the excimer laser for use in farsightedness and farsightedness with astigmatism. He is now studying excimer laser use in correcting eyes with suboptimal results from refractive surgeries and using new visualization technologies.

The two forms of refractive surgery widely used are PRK and LASIK. PRK (photorefractive keratectomy) uses the excimer laser to reshape the outer surface of the cornea and allow light rays to hit the proper point on the retina. In LASIK (laser-assisted in situ keratomileusis), an adaptation of PRK, surgeons use a motorized blade, or keratome, to cut an ultra-thin, circular flap of tissue from the cornea. The flap is lifted, and the laser treatment is performed on the exposed corneal surface. The flap is then replaced and functions as a protective cover and smooth optical surface reducing patient discomfort and improving visual recovery.

Columbia is among the few centers in the United States to have a state-of-the-art VISX WaveScan Wavefront System, which provides a map of corneal aberrations and allows Dr. Braunstein and his colleagues to study the outcomes of laser surgery and plan subsequent corrections to poor results in a way not possible before. Future innovations would link this diagnostic aid to the laser at the time of surgery. The WaveScan is approved only for diagnostic study in the United States and is available internationally for performing laser surgery. Columbia is studying the use of the WaveScan diagnostic unit in patients with complications of laser vision correction surgery.

Less than 1 percent of Dr. Braunstein’s own LASIK and PRK patients experience complications from laser vision correction surgery. He attributes his low complication rate partly to the fact that many people who come to Columbia do not get the surgery they want. Dr. Braunstein will not perform the surgery on the very nearsighted or farsighted, on those who have very large pupils, dry eyes, occupational concerns, other eye disease or some medical conditions, or on those with unrealistic expectations.

Dr. Braunstein’s approach to laser surgery differs from the highly commercialized one prevalent today. Patients can get the treatment in a same-day procedure at a mall or from doctors with less expertise. “Over time we have reined in the patients we treat, but the number of complications seen nationwide has increased with the volume of procedures performed,” says Dr. Braunstein.

Dr. Braunstein is able to easily fix some outcomes that create overcorrected or undercorrected vision. Other problems are more complex, such as repairing a wrinkled flap, the complication that plagued Mr. Sharp. Another poor outcome is keratectasia, in which the laser weakens the cornea during LASIK and a corneal bulge occurs. Patients also can suffer from corneal infections that do not respond to conventional medical treatment and result in corneal scarring.

Patients come to Columbia from around the world to consult with Dr. Braunstein and Dr. Stephen Trokel, vice chairman of ophthalmology. Dr. Trokel pioneered the use of the excimer laser in vision correction. “Columbia and the world owe a great deal to Dr. Trokel for his groundbreaking work in vision correction,” Dr. Braunstein says, “and his ongoing development of new technologies in refractive surgery.”

No Time for the Pain

PAIN IS BECOMING LESS OF A PAIN. CHANGES AT COLUMBIA-Presbyterian’s Pain Management Center are making pain alleviation one of the medical center’s fastest-growing areas. The center is seeing record numbers of patients, expanding treatment options, planning research, and enhancing training.

Columbia has a legacy of addressing pain and suffering among the ill. The late Dr. Leonard ”Lenny” Brand, an anesthesiologist, founded the Pain Management Center after he joined P&S in 1955. The center’s rationale was that patients suffering with pain needed it to be addressed as a discrete entity among their other illnesses. In an era when hospitals didn’t devote great resources to pain management, Columbia established one of the first pain management programs in the city, said Dr. Michael Weinberger, director of the Pain Management Center.

The Pain Management Center, a division of the Department of Anesthesiology, has grown tremendously over the last few years and has enhanced its capabilities for pain assessment and treatment. Under the leadership of Dr. Weinberger, the center’s growth can be attributed to the availability of pain management services, accessibility to inpatients and outpatients, the care of both adults and children, and affordability because it is a participant in many health care plans, including managed care, Medicare, and Medicaid.

Recognizing that pain must be addressed not only by the pain specialist, but also by other medical specialties, the Pain Management Center has become actively involved in training medical and dental students, residents, and fellows from a variety of disciplines. New accreditation guidelines require doctors to address and document a patient’s pain management routine and this has created a new acceptability within the medical community of the need for pain treatment, says Dr. Weinberger. “That has stimulated tremendous interest in the field.”

The Pain Management Center has a staff of physicians, a clinical psychologist, and a nurse practitioner and sees approximately 400 outpatients per month. The majority of patients seen at the center suffer from back and neck pain; others have pain associated with such conditions as cancer, neurological disease, renal failure, and heart disease.

The center offers services for inpatient acute pain, inpatient and outpatient chronic pain, pediatric pain, and oral, facial, and head pain. The list eventually will include palliative or end-of-life care, says Dr. Weinberger. Toward this end, the center is developing a curriculum for palliative care for medical students and interns.

The latest advances in pain management technologies, including implantable devices and pumps, are used at the center to address intractable pain. The stigma and fear associated with opioid use among patients and their providers are decreasing. The use of these potent pain relievers was traditionally tightly restricted because of real, but somewhat overblown, concerns about addiction, Dr. Weinberger says. Today, patients have a better chance at adequate pain management because of a larger repertoire of medications available to the physician.

Emphasis at the center is on pain’s physical and emotional aspects. Biofeedback, group therapy, and individual psychotherapy also are available.

“Not only do we want the Pain Management Center to be recognized for its excellent clinical care, but also for its teaching and research,” says Dr. Nomita Sonty, assistant clinical professor in anesthesiology and psychiatry. About a year ago, the center started the Pain Research Forum, a monthly multidisciplinary group of Columbia faculty and students interested in or involved in research about pain. These collaborations allow for an exchange of ideas and the opportunity to launch research programs, says Dr. Sonty. The center also has initiated an Integrated Clinical Pain Team, a multidisciplinary group that meets monthly and discusses complicated pain patients.

Clinical Programs Join Forces

Ever since Presbyterian Hospital and New York Hospital merged to form the two campuses of New York-Presbyterian Hospital five years ago, hospital and medical school leaders have sought ways the two medical schools and merged hospital could pool their strengths to benefit all organizations and, ultimately, patients.

One way to consolidate resources was to form complete mergers of or partial relationships between clinical departments and programs with the goal of creating economies of scale and synergies.

Although departments remain independent, three programs have completely merged—pediatric cardiology, minimal access surgery, and liver transplantation. Each now has a single administration and a director who holds a full professorship at both Columbia and Cornell. Other programs have developed partnerships that stop short of full mergers, such as behavioral health, the neurosciences, rehabilitation medicine, vascular surgery, plastic surgery, pediatric surgery, and oncology.

Mergers or partnerships are most likely in areas where the need for the program is clear at both institutions, but the demand is limited, says Dr. Thomas Q. Morris, vice president for health sciences and vice dean of the Faculty of Medicine.

When a program is important to relatively few patients, Dr. Morris says, it makes sense to make each campus’ services available to the other, avoiding duplicated costs and services. The extent to which those conditions are present largely determines which programs merge and which collaborate in some other way.

Pediatric cardiology exemplifies the benefits possible with a merger, says Dr. Welton M. Gersony, director of the Pediatric Cardiovascular Center at New York-Presbyterian. He is also professor of pediatrics at P&S and at Cornell’s Weill Medical College. “We have joint conferences to look at imaging data and to discuss surgery both before and after,” Dr. Gersony says. “We now have research that can utilize skills available at both campuses. And training takes place at both campuses, so there is more varied experience and a broader faculty to learn from.”

The merger has spurred a significant increase in the number of surgeries done at Cornell, Dr. Gersony adds. This improves treatment quality, since quality typically goes up at centers with large patient volumes.

Also resulting from a merger is the Minimal Access Surgery Center. The video-guided operations in which tiny cameras are inserted through laparoscopic incisions are commonly done in such subspecialties as general surgery, gynecology, urology, thoracic surgery, colorectal surgery, and pediatric surgery.

What drove this particular merger was not so much the size of the program, says Dr. Dennis L. Fowler, director of the center and professor of clinical surgery at both medical schools. It was more the fact that both campuses were seeking a leader in this field, while the hospital wanted to standardize the equipment and technologies in this highly advanced area.

One fruit of this partnership has been an improvement of videoconferencing capabilities. “Trainees can watch a live operation without having to have 150 people in the operating room. And they have a better view,” Dr. Fowler says.

Investigators from both campuses are pooling resources to develop further miniaturized and robotic technologies, Dr. Fowler adds.

The third joined program is the Center for Liver Disease and Transplantation, which offers a range of services from ambulatory care to transplantation in all forms of liver disease. The center is under the directorship of Dr. Jean C. Emond, professor and vice chairman of surgery and chief of transplantation.

“Growth in the center has been facilitated by the merger, and faculty from both schools in several disciplines are full-time members of the center, which currently has seven faculty surgeons and hepatologists and nearly 50 clinical and research support staff,” Dr. Emond says. “The program now accounts for nearly $30 million annually in patient care revenue.”

Overseeing the mergers is a committee, called the Joint Executive, representing both medical schools, Dr. Morris says. The panel evaluates opportunities for mergers and partnerships and gives approval for professors to have joint appointments.

“Our meetings have been very collegial and collaborative,” says Dr. Morris. Although no further program mergers are currently planned, the committee continues to keep an eye out for possibilities.

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