Posts Tagged ‘Dr. Raymond Stein’

Dr Raymond Stein was invited to speak on the Catalys Precision Laser System at the American Society of Cataract & Refractive Surgery in San Francisco on April 18, 2013.

Wednesday, April 24th, 2013

Dr Stein presented his experience with the Catalys Precision Laser System to over 500 ophthalmologists from around the world at the Mascone convention centre in San Francisco. He spoke on the learning curve of introducing the technology and the safety profile. In reviewing all the technologies he has introduced at the Bochner Eye Institute over the past 20 years the Catalys laser had the easiest learning curve. In the first 40 cases treated, 32 were performed without ultrasound. By reducing or eliminating ultrasound energy there is less intraocular inflammation, and less chance of adversely affecting the corneal endothelium or leading to cystoid macular edema.

Dr Stein noted that Laser cataract surgery has significant clinical advantages especially in patients with Fuchs corneal dystrophy, shallow anterior chambers, dense nuclear cataracts, and weak zonules such as in pseudoexfoliation. In addition by performing an exact capsulotomy of 5 mm there is less chance that the implant will vault forward, be pushed posteriorly, or be tilted. This can result in an improved refractive outcome and quality of vision.

Dr Raymond Stein

Monday, June 18th, 2012

Dr Raymond Stein was invited to speak at the American Academy of Ophthalmology’s annual meeting in Orlando on October 21, 2011. His session was titled “Ask the Expert” and he spoke on the subject of Corneal Cross-Linking in Keratoconus.

Dr Raymond Stein was an invited guest speaker to the Vision Institute’s annual meeting in Toronto on November 4, 2011. The title of his presentation was “The Future of Cataract and Refractive Surgery”. Dr Stein discussed some of the new innovative treatments such as Laser Cataract Surgery, Corneal Inlays for presbyopia, Corneal cross-linking combined with topographic laser ablations, and Microwave technology for keratoconus. The audience was over
300 eye-care professionals.

FAQS on Corneal Crosslinking by Dr Raymond Stein- Toronto Eye Surgeon

Friday, March 16th, 2012

Corneal Crosslinking – Frequently Asked Questions

Is Corneal Crosslinking (CXL) a new treatment for keratoconus?
CXL was introduced in Canada by the surgeons of the Bochner Eye Institute over 4 years ago. In Europe, where the procedure was pioneered, it has been performed for over 14 years ago. There are many long-term studies that demonstrate the efficacy and safety of the procedure.

What is the main goal of CXL?
The purpose of the treatment is to strengthen corneas so as to prevent progressive bulging and thinning that can interfere with vision. With a stronger and more stable cornea the risk of requiring a corneal transplant is practically eliminated.

What is the success rate of CXL?
At the Bochner Eye Institute over 3,000 eyes have been treated with CXL over the past 4 years. This is more than any other centre in the world. Patients have travelled from all over North America. The success rate at preventing progressive bulging and thinning has been over 98%.

Can CXL be repeated?
In rare cases (less than 2%) where CXL is not successful in stabilizing a cornea, a repeat treatment can be performed. There is no charge for this procedure at the Bochner Eye Institute.

Is there an ideal age for CXL?
Usually, the younger the patient the greater the chance of preserving vision with CXL. Patients treated at the Bochner Eye Institute have ranged in age from 10 to 60 years age. With treatment, the corneal contour is preserved, and therefore it is best to have CXL when the shape is only mildly distorted. Patients with advanced disease can have CXL but the vision may be less than ideal with glasses or soft contact lens necessitating the use of a rigid contact lens.

Are some keratoconus patients not good candidates for CXL?
Patients must have satisfactory corneal thickness for the procedure to be performed. A thickness of 400 microns is required prior to the ultraviolet light application. Corneas with a thickness between 320 microns and less than 400 microns can usually be treated by using specialized hypotonic drops to swell the cornea to 400 microns or greater prior to the ultraviolet light application. Also, corneas with significant central scarring that interferes with vision are not good candidates for CXL.

Can vision be improved with CXL?
Although the main goal of CXL is to stabilize the cornea, 60% of patients actually have an improvement in their vision. This is due to the fact that the corneal surface becomes less irregular with CXL as the steep areas are flattened and the flat areas are steepened.

How is the procedure performed?
The procedure is divided into 3 steps. Most patients find the procedure very easy and are comfortable. Anesthetic drops are instilled, which numbs the surface of the eye, and makes the procedure pain free. The first step of the procedure is the removal of the central corneal epithelium. A very gentle brush is used to polish away the soft cells of the front of the cornea referred to as the epithelium. The second part of the procedure is the instillation of specialized drops containing Riboflavin. Drops are typically used for 20 minutes. The third part of the procedure is the use of ultraviolet light, which is typically used for 10 minutes.

Why does the ultraviolet light treatment time vary from clinic to clinic?
The original treatment protocol in Europe was the use of ultraviolet light for 30 minutes at an energy level of 3mw/cm2. With the development of new CXL devices the energy level can be increased which shortens the treatment time said Dr Raymond Stein.

Can the corneal epithelium be left intact or does it have to be removed?
The long-term clinical studies have shown outstanding results when the epithelium is removed prior to CXL. New techniques are being developed to perform a transepithelial CXL approach in which the epithelium is left intact. It is essential for the success of this technique that the Riboflavin drops penetrate an intact epithelium to reach the deeper layers of the cornea in a high enough concentration. Early results with this technique are encouraging but we do not know the long-term results.

What is required after the treatment?
Immediately after the procedure a soft bandage contact lens is inserted which is worn for approximately 5 days. This allows enhanced comfort and promotes healing of the corneal epithelium. An antibiotic drop is used for 5 days and a steroid drop is used for 2 weeks. Artificial tears can be used as needed for comfort.

Is the vision better immediately after the procedure?
Usually the vision is slightly blurrier during the first month and then gradually improves. The blurred vision is related to the healing time of the corneal epithelium. Initially when the epithelium becomes intact it tends to be somewhat rough. With times it undergoes thickening and thinning in different areas to smooth the corneal contour.

How do I know if the treatment is successful?
Repeat corneal mapping is performed to demonstrate corneal stability or flattening. The mapping is typically performed at 4 to 6 months postoperatively and then annually. Sophisticated mapping techniques can evaluate both the front and back surfaces of the cornea to determine stability, improvement, or progression.

What are the potential complications of the treatment?
The complication rate is extremely low with CXL. The risk of infection is rare. In fact ultraviolet light can be used to kill bacteria and parasites in patients with corneal infections. Occasionally there is a delay in the healing of the corneal epithelium, which can delay the return of best vision.

When can I start wearing contact lenses?
After the procedure it is best to wait 2 weeks before returning to contact lens wear. If you have never worn contact lenses and would like to start lens wear it is best to wait at least one month before a consistent refraction can be obtained and lenses fitted.

How can I improve my vision so that I do not need rigid contact lenses?
There are two surgical options to reduce the irregular astigmatism so that you can see better without rigid contact lenses. An intracorneal ring (Intacs) can be performed in which one or two rings are inserted into the cornea to flatten steep areas. The other option is a topographically-linked photorefractive keratectomy (PRK) in which an excimer laser is used to flatten the steep cornea and steepen the flat cornea to enhance vision. Both these procedures can be performed at the same time as CXL or at later date.

More about Dr Raymond Stein

Dr. Raymond Stein Discusses Corneal Crosslinking with Eye World

Wednesday, February 22nd, 2012

Dr Raymond Stein was recently interviewed on Corneal Crosslinking, which was published in Eye World an international publication of the American Society of Cataract & Refractive Surgery. Click here to read the entire article.

Dr. Raymond Stein Lectures On New Innovative Treatments

Monday, November 14th, 2011

Dr. Raymond Stein was an invited guest speaker to the Vision Institute’s annual meeting in Toronto on November 4, 2011. The title of his presentation was “The Future of Cataract and Refractive Surgery”. Dr. Stein discussed some of the new innovative treatments such as Laser Cataract Surgery, Corneal Inlays for presbyopia, Corneal cross-linking combined with topographic laser ablations, and Microwave technology for keratoconus. The audience was over 300 eye-care professionals.

Dr. Raymond Stein’s Session Entitled “Ask the Expert”

Monday, November 14th, 2011

Dr. Raymond Stein was invited to speak at the American Academy of Ophthalmology’s annual meeting in Orlando on October 21, 2011. His session was titled “Ask the Expert” and he spoke on the subject of Corneal Cross-Linking in Keratoconus.

Dr. Raymond Stein’s New Textbook Now Available

Wednesday, August 31st, 2011

Ocular EmergenciesDr. Raymond Stein’s textbook: “The Management of Ocular Emergencies” (5th edition) is now available. This medical book has been made available through an unrestricted educational grant by Alcon Canada and distributed to over 50,000 ophthalmologists, family doctors, emergency doctors and optometrists. The book is divided into clinically relevant sections: red eye (trauma or non-trauma) and white eye (decreased vision or double vision). The book has an abundance of color photographs to illustrate the various ocular emergencies. The textbook can also be viewed on the website OcularEmerg.com.

Over the course of his impressive career, Dr. Raymond Stein has authored and co-authored several books and book chapters. His years of education and clinical experience, during which time Raymond Stein, MD, has performed more than 50,000 vision correction procedures, have helped him gain extensive insight into the various medical conditions, ocular emergencies and diseases of the eye.

Background of Raymond Stein

Thursday, May 5th, 2011

Dr. Raymond Stein, MD, FRCSC, is an esteemed global leader in refractive surgery who has successfully performed more than 80,000 vision correction procedures. He obtained his medical degree at the University of Toronto Medical School, where he currently serves as an Assistant Professor of Ophthalmology. Dr. Stein completed his ophthalmology residency at the world-renowned Mayo Clinic and a cornea and external disease fellowship at the prestigious Willis Eye Hospital in Philadelphia. He serves as the Medical Director of the renowned Bochner Eye Institute in Toronto.

Raymond Stein has established himself as an expert and pioneer in refractive and implant surgery and was the first surgeon in all of Canada to perform corneal cross linking with Riboflavin for keratoconus and ectasia. He was also the first eye surgeon in Canada to implant the ReSTOR and Tetraflex IOLs for improved distance, intermediate and near vision. Dr. Stein was the first surgeon in Canada to use the IntraLase IFS femtosecond laser for creation of the LASIK corneal flap.

Dr. Raymond Stein is frequently invited to lecture at medical conferences throughout the world. He has authored numerous published articles, more than 15 book chapters and books on various subjects pertaining to refractive surgery. In fact, Dr. Stein is the author of the first clinical textbook on laser vision correction for instruction on advanced surgical techniques.

As a testament to his prolific career and unsurpassed surgical skills, Dr. Stein was chosen to serve at the Chief Eye Surgeon for W Network’s “Style by Jury,” a popular makeover television show in Canada. He is also the editor of the prestigious scientific journal “Clinical and Surgical Ophthalmology.”

In recognition of his accomplishments in refractive surgery, Dr. Stein has been honored with numerous prestigious awards from both national and international professional organizations, including the American Academy of Ophthalmology, the International Intraocular Implant Club and the Contact Lens Association of Ophthalmologists. He has also served as the President of prestigious Canadian Society of Cataract and Refractive Surgery.
Dr. Stein is the Chief of Ophthalmology at the Scarborough Hospital in Toronto and Cornea Consultant at the Mount Sinai Hospital

Education:

Undergraduate:

University of Pennsylvania, Wharton School

1975-1977

 

Medical School:

Doctor of Medicine

University of Toronto Medical School

1978-1982

 

Residency:

Mayo Clinic

1983 -1986

 

Fellowship Training:

Willis Eye Hospital, Philadelphia

1986-1987

Experience:

Bochner Eye Institute

Medical Director, Eye Surgeon

1997- Present

 

Scarborough Hospital, Toronto

Chief of Ophthalmology, Ophthalmologist

1987- Present

 

Mount Sinai Hospital

Cornea Consultant, Ophthalmologist

1989 – Present

 

University of Toronto Medical School

Assistant Professor of Ophthalmology

Professional Affiliations:

Contact Lens Association of Ophthalmologists

Wills Eye Hospital Alumni Association
American Academy of Ophthalmology

Fellow of the Royal College of Surgeons
Mayo Clinic Alumni Association

Ontario Medical Association

International Society of Refractive Surgery

American Society of Cataract and Refractive Surgery
Canadian Society of Cataract and Refractive Surgery

International Implant Club

Academy of Ophthalmic Education

Raymond Stein, MD, Honors and Awards:

1987 – 1988 Award for most outstanding article of the year published in the University of Toronto Medical Journal, titles “Lifesaving Ocular Signs.”

1990- 1991 Award for outstanding teaching, Ophthalmology Residents Research Day, University of Toronto, Toronto, Ontario, April 1991.

1991 – 1992 Nominated for Atkinson award, outstanding undergraduate teaching, University of Toronto.

1993 – 1994 Award for outstanding undergraduate and post graduate teaching, Mount Sinai Hospital, University of Toronto.

1997 Honor award of American Academy of Ophthalmology

1997 Honor award of Contact Lens Association of Ophthalmologists

1998, ‘99, ’00, ’01, ‘02
Best paper of session, American Society of Cataract and Refractive Society

2001 Awarded membership into International Intraocular Club

2003 Best paper of session, International Society of Refractive Surgery

Books:

1.      Raymond M. Stein, Bernard J. Slatt, Harold A. Stein. A Premier in Ophthalmology: A Textbook for Students. Mosby.

2.       Raymond M. Stein, Melvin I. Freeman, Harold A. Stein. The Ophthalmic Assistant: A Text for Allied and Associated Ophthalmic Personnel. Mosby, 2006.

3.      Raymond Stein, Harold A. Stein, Melvin I. Freeman, Lynn D. Maund. Residents Contact Lens Curriculum Manual. Mosby.

4.       Raymond  Stein, Harold A. Stein, Melvin I. Freeman, Lynn D. Maund. Contact Lenses: Fundamentals and Clinical Use. Slack Incorporated, 1996.

5.      Raymond Stein, Bernard J. Slatt, Harold A. Stein, Melvin I. Freeman. Fitting Guide for Rigid and Soft Contact Lenses: A Practical Approach. Mosby, 2002. 

6.      Raymond Stein, Harold A. Stein, Albert Cheskes. Laser Vision Correction: Welcome to a World Without Glasses or Contact Lenses.

7.      Raymond Stein, Harold A. Stein. Management of Ocular Emergencies. Medicöpea International.

8.      Raymond Stein, Bernard J. Slatt, Harold A. Stein. Ophthalmic Terminology: Speller and Vocabulary Builder. Mosby, 1991.

9.      Editor. Raymond M. Stein. Proceedings of the External Eye Meeting. Medicöpea International, 1995.

10.  Raymond M. Stein, Harold A. Stein, Albert Cheskes. The Excimer Fundamentals and Clinical Use. Slack Incorporated, 1997.

Peer-Reviewed Research Papers and Articles:

1.      Raymond M. Stein. Laser vision correction: 20 years of personal experience. ASCRS EyeWorld.

2.      Raymond M. Stein. Corneal Collagen Cross-Linking with Riboflavin (C3-R) and other Surgical Options in the Management of Keratoconus. Academy of Ophthalmic Education (AOE).

3.      Raymond M. Stein. Ten Pearls for Treating Hyperopic Astigmatism. Refractive Eyecare for Ophthalmologists.

4.      Raymond Stein. Techniques for Advanced Surface Ablation. Refractive Eyecare for Ophthalmologists.

5.      Raymond M. Stein. Phakic Implants Can Expand a Refractive Surgery Practice. Refractive Eyecare for Ophthalmologists.

6.      Raymond M. Stein. Patients to Avoid Personality Screening. Refractive Eyecare for Ophthalmologists.

7.      Raymond M. Stein. Keratoma-Assisted ASA. Refractive Eyecare for Ophthalmologists.

8.      Raymond M. Stein. Defining Safety in Keratome Technology. Refractive Eyecare for Ophthalmologists.

9.      Raymond M. Stein. Clinical Experience with the Allegretto Wave in Custom and Standard Treatments. Refractive Eyecare for Ophthalmologists.

10.  Raymond M. Stein. Advances in Refractive Surgery. Ophthalmology Rounds.

Raymond Stein Reviews

Computerized Topography to Rule-Out Keratoconus Prior to LASIK

Friday, January 21st, 2011

Dr Raymond Stein of the Bochner Eye Institute wrote the following clinical update. We hope you find it of interest.

Keratoconus is a well-recognized contraindication to LASIK. The creation of a corneal flap and removal of tissue by an excimer laser can weaken a cornea making it structurally compromised. This can lead to corneal instability with progressive ectasia characterized by steepening and thinning. Although there are a variety of clinical signs of keratoconus the use of computerized topography and pachymetry usually allows for the detection of the earliest stages of keratoconus. The most advanced topography units measure both curvature, elevation, and pachymetry. The Pentacam is our unit of choice at Bochner.

We typically make the diagnosis of keratoconus when one or more findings are present:

1. Inferior steepening of greater than 1.5 Diopters compared to superior cornea.

2. Elevation of the posterior cornea of greater than 17 microns compared to a best-fit sphere.

3. Elevation of the anterior cornea of greater than 21 microns compared to a best-fit sphere.

4. Central steepening of greater than 49 Diopters.

5. Steepest corneal location associated with thinning of less than 500 microns.

6. Advanced clinical signs include corneal iron deposition at the base of the cone, Vogt’s striae or stress lines, and apical scarring.

In addition to the clinical findings above we are reluctant to perform LASIK if there is an immediate family history of keratoconus.

Careful preoperative evaluation prior to laser vision correction can greatly reduce the risk of corneal ectasia.

Phakic Implants for High Refractive Errors

Friday, January 21st, 2011

Dr Raymond Stein of the Bochner Eye Institute wrote the following clinical update. We hope you find it of interest.

Phakic implants are used in vision correction for high refractive errors that cannot be treated by laser vision correction. Over the past 13 years we have been inserting the Implantable Contact Lens (ICL), a posterior chamber phakic implant made by Starr Surgical. Clinical outcomes for high myopia and astigmatism have generally been excellent with 95% of eyes achieving 20/30 or better uncorrected vision. The main indications are refractive errors that are too high for laser vision correction. In general patients are candidates for a phakic implant if they have myopia greater than 10 D or hyperopia greater than 5 D.  Astigmatism can be treated up to 6 D. Patients must have a satisfactory depth of the anterior chamber (distance between the corneal endothelium and the crystalline lens) of greater or equal to 2.8 mm. Most of the high myopes will qualify unlike the high hyperopes. Patients should also have a pupil size of 7 mm or less.

Another surgical option, which patients need to know about in the informed consent, is a refractive lens exchange. Our preference is not to perform a lens exchange for high myopia because of the increased risk of retinal tears and detachment.  This is not the case with the treatment of high hyperopia, which is associated with a minimal retinal risk.

In patients that are good candidates for the ICL, a refraction is performed, the limbal white-to-white distance is measured to determine the length of the implant, and two small YAG laser iridotomies are performed to reduce the risk of elevated intraocular pressure from papillary block. The implant is custom ordered from Switzerland.

The surgical procedure is relatively easy for patients.  At the Bochner Eye Institute we perform this procedure in our sterile operating room approved by the Ontario College of Physicians and Surgeons. Under topical anesthesia a 2.8 mm limbal incision is constructed. Intraocular xylcaine is injected to numb the contents of the eye. After the implant has been carefully folded into a cartridge it is injected into the anterior chamber where it gradually unfolds. Using a specialized instrument the haptics are gently placed behind the iris. Miochol is then injected to constrict the pupil.  Intraocular Vancomycin is injected to prevent infection. The patient is then checked one hour postoperatively to be sure the intraocular pressure is normal. Follow-up examinations are usually 1 day, 1 week, 1 month, and 3 months.

Complications are rare. The main risk is inducing a cataract (1%). If patients are not satisfied with their level of uncorrected vision then laser vision correction can be performed. We have not had a case of infection over the past 13 years.

Specialized indications for the ICL include patients with keratoconus and those following radial keratotomy. In keratoconus patients if they have satisfactory best-corrected spectacle acuity (20/40 or better) then consideration can be given to the ICL. Patients may require an Intracorneal ring to reduce the degree of irregular astigmatism prior to a phakic implant. In the situation following radial keratotomy if patients have developed a hyperopic shift then this can be corrected by the ICL. Unlike a natural hyperope the post-RK eyes were previously myopic and usually have a satisfactory anterior chamber depth.