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Our Research

Pterygium Research

Visionary Eye Doctors’ Clinical Research in Pterygium was created in August 2014. At Visionary Eye Doctors , we see thousands of pterygium patients per year and perform the most surgeries in the eastern United States. We are proud of our 0% recurrence rate since the initiation of our study in August 2014. In our in-house operating room, patients receive sterile, efficient, and loving care from our team members who firmly believe the importance of pterygium research.

What is a Pterygium?

A pterygium is abnormal tissue that grows from the conjunctiva (the outer tissue layer of the eye) onto the cornea (the transparent outermost layer of your eyeball). Pterygia may grow from the inner portion of the eye near your nose towards the outer portion of the eye towards your ear (nasal pterygium) and from the outer portion towards the inner portion of the eye (temporal pterygium). Genetics and increased sun exposure are well known-risk factors for this disease. However, the exact etiology of pterygia remains unclear.

Pterygium is associated with symptoms such as foreign body sensation, itchiness, redness, burning pain, light sensitivity, tearing, dryness, and unsatisfactory cosmetic appearance of the eye. In addition, pterygium induces astigmatism as it grows towards the center of the cornea, causing distortions in vision. These factors warrant the surgical removal of a pterygium. The ideal surgery results in improved vision, decreased discomfort, cosmetic satisfaction and ultimately prevent recurrence of a pterygium.

Why are we doing pterygium research?

Pterygium is one of the lesser-studied topics in ophthalmology research. Visionary Eye Doctors has recently initiated a pterygium research protocol that supplements our existing clinical evaluation and post-operative care. With our state-of-the-art technology, we strive to produce research that incorporates technology and the expertise of our doctors, to contribute to the limited medical knowledge of the disease and most importantly achieve the best outcomes for our patients.

Our Clinical Research Team

The research team is led by J. Alberto Martinez, MD, founder of Visionary Eye Doctors and board-certified ophthalmologist with sub-specialty expertise in corneal, refractive and laser surgery.

J. Alberto Martinez, M.D. (Pterygium surgeon) – Dr. Martinez graduated from American University and Georgetown University Medical School. As a cornea specialist, Dr. Martinez performs pterygium surgery on a regular basis. This research was started by Dr. Martinez because he had many questions about this disease. Pterygium not only affects himself, but also his family, making this research not only an academic endeavor, but a personal one as well. Patients from many different backgrounds and geographic locations seek pterygium surgery from Dr. Martinez.

Sandra L. Cremers, M.D., F.A.C.S. (Pterygium surgeon and dry eye specialist) – Dr. Cremers graduated from Columbia University and completed the Brown University and Dartmouth University Joint Program in Medicine. She has research and clinical experience from Johns Hopkins University and Harvard University. Dr. Cremers also performs pterygium surgery and is a dry eye specialist.

Jenny Ha, B.S. (Research Director) – As the Research Director, Jenny oversees data collection and performs data analysis. She graduated from the University of Rochester with a Bachelor of Science in Neuroscience and a Minor in Public Health. She is a published author with previous research experience at the University of Rochester and New York University, which include neuroimaging, cognitive sciences, stem cells, and translational medicine. The pterygium research is expanding her knowledge of medicine and her relationships with patients.

Surgical Techniques

At Visionary Eye Doctors , we see hundreds of pterygium patients per year and perform the most surgeries in the Eastern USA. We are proud of our 0.8% recurrence rate since the initiation of our study in August 2014. In our in-house operating room, patients receive sterile, efficient, and loving care from our team members who firmly believe the importance of pterygium research.

For over 20 years, our ophthalmologists have been perfecting their surgical techniques, based on research and clinical experience:

The surgeons make sure to remove harmful tissues in the underlying layers of the pterygium, after the pterygium is removed. This has been shown to significantly decrease recurrence.

  • We harvest a carefully measured autograft from the healthy portion of the same eye to cover the defect caused by the pterygium excision.
  • Compared to other techniques, the autograft is superior in healing the eye and preventing recurrence.
  • Cryopreserved human amniotic membrane tissue, which is FDA approved for wound covering and healing, is commonly used on ocular surfaces, including during our pterygium surgery to provide protection and prevent inflammation and angiogenesis (the development of new blood vessels). This tissue comes from the innermost layer of the placenta and supplements the body’s restoration of healthy tissue.
  • Our surgeons do not use cautery, which is a commonly used electrical surgical technique to stop bleeding, as it may damage tissue and increases inflammation in the eye. Instead, they carefully identify the source of the bleeding, hold the vessels shut, and wait for the natural clotting processes in the body to halt the bleeding.
  • Fibrin glue mimics the body’s clotting cascade, which has many surgical uses including controlling bleeding. Instead of using sutures, this glue is used by our surgeons to adhere the grafts to the ocular surface. The surgeons complete this in less than one minute, decreasing the time the eye is exposed to trauma. In addition, compared to the use of sutures, fibrin glue results in less post-operative pain and inflammation. Research has shown that fibrin glue does not increase the risk of recurrence and secures tissue just as well as sutures.
  • A non-prescription bandage contact lens is applied to protect the cornea in the early stages of the healing process. Patients are given eye patches for sleeping and sunglasses for additional protection.
    Due to the surgeon and surgical staff’s expertise, only 15-17 minutes are required for the removal of one pterygium.

What Data are we Collecting?

All patient information is protected in accordance with HIPAA. De-identified data is entered into our database. No one will be able to identify our patients in the analyses performed. A high standard of care is given to all patients, regardless of voluntary participation in our study.

We are interested in looking at the differences between:

  • A patient’s pterygium eye versus the patient’s healthy eye: to see which factors change as due to pterygium
  • Different severities of pterygium: to see which factors worsen with by the severity of pterygium
  • Pre-operative versus post-operative measurements to see:
    • a. how the eye tolerates surgery
    • b. which factors affect the healing process and
    • c. which factors may contribute to recurrence
    • d. how much patients improve after surgery

With our expansive modern technology we collect:

  • External photos to not only for clinical documentation, but also for patients to see the how their eye has healed. In addition, these photos are used to accurately quantify different aspects of the pterygium and eye.
  • Endothelial cell count to see the whether density of cells in the inner layer of the cornea is affected by pterygium.
  • Pentacam to automatically calculate astigmatism and different topographic aspects of the eye.
  • Anterior segment optical coherence tomography to visualize the underlying layers of the pterygium and post-operative changes after pterygium removal.
  • In a subset of patients we have collected
    • a. Tear osmolarity measurements to see if eyes with pterygia have “dryer eyes”, and if this is alleviated after surgery.
    • b. Impression cytology to see the location of specialized cells before and after surgery.

Before Pterygium After Pterygium

Cosmetic Outcomes

Dr. Martinez performs the most surgeries worldwide with 350 pterygiectomies performed in 2015 alone. With a recurrence rate of 0.8%, recurrences are rarely seen. There is an increased interest in achieving the best cosmetic outcomes after pterygium surgery. We strive to provide patients with state-of-the-art services to cater to the aesthetic aspects of pterygium surgery.

These services include corneal tattoo, which is offered to address cosmetic concerns. During your pterygium evaluation, the doctor may suggest corneal tattoo as some patients may develop an opacity, unrelated to the pterygium. The final decision will be made during the surgery when the extent of the pterygium is more clearly defined.

The eye can be affected by both a pterygium and a pinguecula. For optimal cosmetic results and decreased trauma from a second surgery, the pinguecula can be removed while the pterygium is removed.

Accomplishments

Our pterygium research has been published in peer-reviewed journal(s) and presented at national, international, and institutional meetings.

PEER REVIEWED PUBLICATIONS

Ha J, Cremers SL, Korchak M, Koppinger J, Martinez JA. A Novel, Automated Method to Grade Pterygium Severity Using Scheimpflug Imaging. Ophthalmology. 2016;123(11):2345-6. doi:10.1016/j.ophtha.2016.06.024.

Ha J, Martinez JA, Korchak M, Cremers SL. “Intraoperative Fluorescein Staining of Cryopreserved Amniotic Membrane Grafts to Improve Visualization During and After Pterygium Surgery: A Novel Technique.” Cornea. 2016;35(3):413-416. doi:10.1097/ICO.0000000000000725.

PRESENTATIONS

Ha J, Mekhail J, Cremers SL, Martinez JA. “Reproducibility and Reliability of a New Automated Scheimpflug Imaging Pterygium Severity Measure.” To be presented at the Association for Research and Vision in Ophthalmology (ARVO) Annual Conference 2017, Baltimore, MD.

Martinez JA, Ha J, Cremers SL. “Outcomes of multiple-dose fibrin glue during in-office pterygiectomy.” To be presented at the ARVO Annual Conference 2017, Baltimore, MD.

Martinez JA, Ha J, Cremers SL. “Largest Report of Simultaneous Double-Headed Pterygiectomy: Outcomes of a New Cautery and Suture-Free Technique with Autograft and Amniotic Membrane.” To be presented at the American Society of Cataract and Refractive Surgery (ASCRS) Annual Conference 2017, Los Angeles, CA.

Ha J, Martinez JA, Cremers SL. “Outcomes of in-Office Pterygiectomy: Postoperative Patient Appointment Adherence, Treatment Compliance, Complications, and Costs.” To be presented at the ASCRS Annual Conference, Los Angeles, CA, May 2017.

Mekhail J, Ha J, Korchak M, Cremers SL, Martinez JA. “Anterior Segment Optical Coherence Tomography Confirmation of New Automated Measure of Pterygium Severity.” To be presented at the ASCRS Annual Conference, Los Angeles, CA, May 2017.

Ha J, Martinez JA, Calaro K, Cremers SL. “Largest Report of Simultaneous Double-Headed Pterygiectomy: Cautery and Suture-free with Autograft and Amniotic Membrane.” Presented at the American Academy of Ophthalmology (AAO) Annual Meeting, Chicago, IL, October 2016.

Ha J, Martinez JA, Cremers SL. “Pterygiectomy in an Office-Based Surgery Suite is Safe with a Low Complication and Recurrence Rate.” Presented at the AAO Annual Meeting, Chicago, IL, October 2016.

Ha J, Martinez JA, Hosseini Y, Korchak J, Koppinger J, Cremers SL. “First Report of Simultaneous Double-Headed Pterygiectomy with Conjunctival Autograft, Amniotic Membrane and Fibrin Glue.” Presented at The ARVO Annual Meeting, Seattle, WA, May 2016.

Korchak M, Ha J, Koppinger J, Martinez JA, Cremers SL. “Tracking Changes in Corneal Tomography After Pterygium Excision to Aid Planning Future Refractive Surgery.” Presented at the ARVO Annual Meeting, Seattle, WA, May 2016 and at Medstar Health Research Symposium, Columbia, MD, March 2016.

Midgley K, Ha J, Korchak M, Koppinger J, Cremers SL, Martinez JA. “Largest Report of the Effect of Primary Pterygium on Corneal Endothelial Cell Density.” Presented at The ARVO Annual Meeting, Seattle, WA, May 2016 and Top 3 Winner of MedStar Washington Hospital Center House Staff Research Day, Washington, DC, June 2016.

Ullman MA, Ha J, Cremers SL, Korchak M, Koppinger J, Martinez JA. “Pterygium in a VEGF Nightmare: Report of Multiple, Early Recurrences in a Patient with a History of Cancer and External Beam Radiation.” Winner of Highest Scoring Abstract at the 2016 Medstar Health Research Symposium, Columbia, MD, March 2016. Presented at ASCRS Annual Conference, New Orleans, LA, May 2016.

Korchak M, Ha J, Koppinger J, Cremers SL, Martinez JA. “Wavefront Aberrometry Changes After Pterygium Excision: Support for Earlier Excision.” Presented at ASCRS Annual Conference, New Orleans, LA, May 2016.

Koppinger J, Ha J, Korchak M, Martinez JA, Cremers SL. “First Report of Posterior Corneal Changes after Pterygium Excision: Considerations for Future Refractive Cataract and Corneal Surgery.” Presented at ASCRS Annual Conference, New Orleans, LA, May 2016 and at Medstar Health Research Symposium, Columbia, MD, March 2016.

Koppinger J, Martinez JA, Ha J, Korchak M, Hosseini Y, Cremers SL. “First Report of Palpebral Fissure Height and Marginal Reflex Distance After Pterygiectomy with Autograft, Amniotic Membrane, and Fibrin Glue.” Presented at ASCRS Annual Conference, New Orleans, LA, May 2016.

Ha J, Korchak M, Koppinger J, Hosseini Y, Martinez JA, Cremers SL. “A New and Reliable, Automated Measurement to Quantify Corneal Involvement of Pterygium.” Presented at ASCRS Annual Conference, New Orleans, LA, May 2016.

Ha J, Korchak M, Pereira A, Martinez JA, Cremers SL. “New Measurement for Pterygium: A Comparison of Two Methods to Analyze Corneal Involvement.” Presented at The ARVO Annual Meeting, Denver, CO, May 2015.

Korchak M, Ha J, Pereira A, Martinez JA, Cremers SL. “Evaluating Pentacam Corneal Tomography and Tear Osmolarity in Pterygium.” Presented at The ARVO Annual Meeting, Denver, CO, May 2015.


Cataract Research

In addition to pterygium research, we perform cataract research without any financial relationships to disclose, allowing us to contribute unbiased findings.

What is a Cataract?

Cataract is the leading cause of reversible blindness and visual impairment in the world affecting nearly 20.5 million Americans aged 40 years and older. A cataract is an opacification of the intraocular lens that prevents light from reaching the retina, most commonly secondary to normal age-related lens changes. As the lens ages, new layers of cortical fibers are formed concentrically compressing and hardening the lens nucleus (sclerosis) and forming protein aggregates. These aggregates scatter light and interfere with visual function. As nuclear sclerosis progresses it creates the opaque quality of a cataractous lens.

Surgical Techniques

At Visionary Eye Doctors, our surgeons regularly perform a high volume of cataract surgery. Today, cataract surgery is the most commonly performed surgery in the world with approximately 19 million operations performed annually in the US alone. Current conventional cataract surgery involves making a small incision at the periphery of the cornea followed by a continuous curvilinear capsulorhexis (a central radial cut in the anterior capsule is dragged in a circular manner creating an anterior defect in the lens capsule). The lens cortex and nucleus are then emulsified with an ultrasonic handpiece, termed phacoemulsification. Following aspiration of the capsular contents, an artificial intraocular lens is placed in the empty capsular bag.

Recently, we have reported Phaco-Smash as a new phacoemulsification technique developed by Dr. Sandra L. Cremers. By incorporating the Phaco-Smash technique, an experienced, high-volume surgeon, experienced a CDE decrease of over 15%. Phaco-Smash is an extension of the chop technique, which previously been associated with lower CDE than the divide and conquer technique. Less CDE is better for the corneal endothelium.

In an effort to further improve clinical outcomes and reduce complications associated with cataract surgery, femtosecond laser assisted cataract surgery (FLACS) was developed. FLACS utilizes a femtosecond laser (1053 nm infrared laser that produces photodisruption of optically transparent tissues) to automate several steps of the surgery. It allows for primary and side-port corneal incisions, limbal relaxing incisions for astigmatic corrections, and performs the anterior circular capsulotomy (replacing the manual continuous curvilinear capsulorhexis). The femtosecond laser can also soften the cataract through phacofragmentation prior to use of the aforementioned phacoemulsification handpiece. It is well known that excessive phacoemulsification ultrasound energy is directly toxic to corneal endothelial cells, which are essential in maintaining the clarity of the cornea and final vision outcomes. Phacoemulsification time measures the total amount of time that ultrasonic power is delivered in seconds, termed cumulative dissipated energy (CDE). FLACS has been proposed to lower the required phacoemulsification time and CDE in cataract surgery.

Accomplishments

Our cataract research has been presented at national, international, and institutional meetings.

Cremers SL, Ha J, Martinez JA. “Phaco-Smash: 29% Reduction of Experienced Surgeon’s Cumulative Dissipated Energy in Femtosecond Laser Assisted Cataract Surgery.” To be presented at the ASCRS Annual Conference, Los Angeles, CA, May 2017.

Ha J, Cremers SL. “Non–Industry Sponsored Report of Triamcinolone-Moxifloxacin Dropless Cataract Surgery: Initial Observations.” Presented at the American Academy of Ophthalmology (AAO) Annual Meeting, Chicago, IL, October 2016.

Koppinger J, Martinez JA, Ha J, Korchak M, Ullman MA, Hosseini Y, Cremers SL. “Largest Comparison of a Single Surgeon’s Intraoperative and One Day Postoperative Outcomes between Traditional and Femtosecond Laser Assisted Cataract Surgeries with Two Different Laser Platforms.” Poster abstract submitted to The ARVO Annual Meeting, Seattle, WA, May 2016.

Martinez JA, Ha J, Korchak M, Koppinger J, Cremers J, Cremers SL. “First Report Comparing Intraoperative Epinephrine Use and Cumulative Dissipated Energy between Two Femtosecond Lasers during Cataract Surgery.” Presented at ASCRS Annual Conference, New Orleans, LA, May 2016.

Ha J, Cremers SL, Korchak M, Koppinger J, Ullman MA, Martinez JA. “Comparison of Phacoemulsification Techniques Between Traditional Surgery and 2 Systems of Femtosecond Laser Assisted Cataract Surgery.” Presented at ASCRS Annual Conference, New Orleans, LA, May 2016.

Cremers SL, Ha, J, Ullman MA, Korchak M, Koppinger J, Martinez JA. “Phaco-Smash Approach to Phacoemulsification: New Technique Initially Developed to Help Residents Decrease Total Intraocular Phaco Energy.” Presented at ASCRS Annual Conference, New Orleans, LA, May 2016.

Korchak M, Cremers SL, Ha J, Koppinger J, Hosseini Y, Martinez JA. “1300 Femtosecond Laser Assisted Cataract Surgeries: What CDE Informs Us About Different Platforms”. Presented at ASCRS Annual Conference, New Orleans, LA, May 2016.

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