Envision Newsletter - Wills Eye

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w i l l S e y e C o R n e a S e R v i C e n e w S w i n t e R 2 0 1 2
High Tech Teamwork Yields Amazing Recovery:
Teen Injured by Fireworks Heals Thanks to Wills Eye
It was a hot summer day last July,
and 17-year-old Ben Spair was
hanging around his backyard in
New Hope, Pa., playing basketball
and jumping on the trampoline
with his younger brother. ey
could hear neighbor kids setting off
firecrackers. But the firecrackers
sounded kind of small and dinky,
and Ben thought he could do
better. He had some bigger, louder
fireworks of his own. He went into
the house and returned with his
firecracker: a Double Impact Mine.
As Ben knelt down to touch the
match to the fuse, the firework
exploded in his face. He fell
backwards, reeling in pain.
“I knew it was bad, obviously;
I couldn’t see. It hurt all over my
face, burning like crazy,” Ben
remembered. “I heard screaming.
My mother and brother had seen it
all happen.” ey guided him into
the house to splash his face with
water and try to assess his injuries.
“His eyes were completely white,
no iris, no color,” his mother,
Giuliana, recounted with a shudder.
“His eyelids were blackened and
all of his hair was blown back. His
eyelashes were gone. His eyebrows
were singed off.”
Doctors say that a fireworks
injury to the eyes can be one of
the most devastating because it is
both a thermal (heat) burn and a
chemical burn.
e family quickly went to
Doylestown Hospital for medical
treatment. “ey put some kind
of cool liquid on my face and it
felt better, but I still couldn’t see,”
Ben said. “Everything was blurry
and gray.”
For the next few days, the family
consulted a local eye doctor, but
Ben’s situation was not improving.
en Ben’s dad, David, noticed
blood coming from his son’s eyes.
“We knew Ben needed expert help.
We felt we had to see whoever was
the best and we knew Wills Eye is
the best,” David said. e family
came to the Wills Eye Emergency
Room at Jefferson late on a
Saturday night, and immediately
the situation improved.
Photo: Roger Barone
So proud of her son’s wonderful recovery, Giuliana Spair (second from left) poses with
her son, Ben, and Mila Heersink, M.D. (left) and Christopher Rapuano, M.D. (right).
“When I first met Ben, he could
barely count fingers held in front
of his face,” recalled Dr. Mila
Heersink, a second-year resident at
Wills Eye. “He had a devastating
injury. It made me mad, because he
was such a young guy. I thought he
would have bad vision the rest of
his life. It was a terrible feeling.”
“We thank God and the
doctors at Wills Eye.”
Dr. Heersink explained that
although the eye does have great
abilities to heal itself, Ben’s injury
was so severe that was not
possible in his case. He had a lot
of scar tissue and swelling. “Left
alone, his tissues would have
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continued on page 4

Shingles Vaccination Is Vital
Recently retired Director of the Wills Eye Cornea Service
Dr. Elisabeth Cohen is intimately familiar with the dangerous
ocular complications that can occur when an adult contracts
shingles. As a doctor, she is trained to recognize the symptoms
and she knows that it’s vital to seek medical treatment as quickly
as possible. at knowledge may have saved her own eyesight.
About three years ago, Dr. Cohen
developed shingles around her
eye. It ended up affecting her
cornea, retina and ultimately,
her vision.
“I remember the day so clearly,”
recalled Dr. Kristin Hammersmith,
Cohen’s former partner
and one of the doctors who
treated her. “We were walking to
the elevator and Elisabeth said she
thought she had a bad mosquito
bite. en we both looked at it
and we knew that it wasn’t a bug
bite. She had shingles and she
was smart enough to start medical
treatment immediately. She knew
shingles could be serious.”
Dr. Hammersmith explained that
because Dr. Cohen identified the
disease quickly – and worked in
a world-renowned eye hospital–
she got the fastest treatment
possible. “She started taking
antiviral pills an hour later. She
had eye specialists treating her
immediately,” Dr. Hammersmith
explained. “Still, with an
extraordinary level of care, she
had significant vision issues due
to the shingles in her eye.”
Shingles generally affects only one
side of the body, but can have
serious consequences if it involves
the trigeminal or fifth cranial
nerve: the nerve responsible for
sensation in the face. Dr. Cohen
had shingles on her forehead and
in her eye.
According to the Centers for
Disease Control (CDC) one
out of every three people in the
United States will develop
shingles sometime in their life.
at’s an estimated 1 million
cases each year. Shingles in
adults is caused by the same
virus (herpes zoster) that causes
chicken pox in children. If you’ve
had chicken pox as a child, you
may develop shingles as an adult
because the virus stays inactive
in the body, dormant in certain
nerve cells. Doctors think that
as you age, or if your immune
system is weakened, the virus
can reactivate, causing shingles.
Because it affects nerve cells,
the rash from shingles is
especially painful.
“It’s excruciating nerve pain,”
explained cardiologist Dr. Stanley
Spitzer, who said that sometimes
there is pain before the rash
appears on the body. “I’ve seen
patients who thought they were
having a heart attack, the chest
pain was so intense. en, a day
later, the rash broke out on their
torso.” e nerve pain from
shingles, called post-herpetic
neuralgia, can linger for months.
One of the treatments for
shingles is steroids to manage
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Dr. elisabeth Cohen
Photo: Roger Barone
inflammation, but steroids can
lead to cataracts. “Cataracts are
the clouding of the lens of the
eye,” Dr. Hammersmith
explained. “When you have
cataracts it’s like looking through
a dirty window.”
During more than 50 visits to
Wills Eye, Dr. Cohen was treated
by Dr. Jonathan Myers, a glaucoma
specialist, Dr. Joseph Maguire,
a retina specialist and Drs.
Hammersmith and Rapuano,
cornea specialists. Unfortunately,
Dr. Cohen continues to have
vision issues related to her bout
with shingles. She has dry eyes,
corneal scarring from inflammation,
some cataract clouding and
retina inflammation. She had to
give up practicing ophthalmology
due to her vision limitations.
But she has taken up the cause
of educating the public to the
dangers of shingles and the benefits
of the vaccine.
“At New York University Langone
Medical Center and Bellevue
Hospital in New York City, I am

doing research to increase the use of the shingles
vaccine according to current national recommendations,”
explained Dr. Cohen. “We’re looking at
various interventions that could increase vaccination
rates, including patient education, making the
vaccine more readily availability in the hospital
pharmacy so it can be administered by a nurse and
health maintenance reminder alerts. We’re also
surveying NYU primary care physicians’ knowledge
and practices regarding herpes zoster and the vaccine
before interventions and one year after.”
Are cases of shingles on the rise? As more and more
children get vaccinated for chicken pox, that disease
becomes less common. Doctors think that if
children don’t contract chicken pox, adults will
have fewer opportunities to boost their immunity
through mild exposure to the virus.
According to the CDC, the risk of shingles increases
as a person ages. About half of all cases occur among
men and women aged 60 and older. e CDC
recommends that adults ages 60 and older be
vaccinated against shingles. e shingles vaccine
is FDA approved for ages 50 and older, but it is
often not covered by insurance until age 60.
Without insurance coverage, the vaccine costs
between $200 and $250 at local pharmacies.
Inspired by their colleague’s experience, Drs.
Rapuano and Hammersmith and the fellows of the
Cornea Service gathered data from patients, trying
to determine the average age of onset of shingles
around the eye. eir results confirmed their
suspicion: a little over half of their shingles patients
were younger than age 60. Out of a total of 112
patients studied, 58 were younger than age 60;
54 patients were ages 60 and older. eir research
is being published in Ophthalmology, in an effort
to encourage physicians to recommend shingles
vaccinations to adults ages 50 and older.
“We want patients to ask if they are eligible for the
vaccine, and doctors to strongly recommend it to
immunocompetent patients, ages 50 plus, if they
are willing and able to pay for it,” said Dr. Cohen.
Dr. Rapuano and his colleagues encourage their
patients ages 50 and older to consult their primary
care physician for more information about getting
the shingles vaccine.
‚ FuRTHER InFoRmATIon:
Wills Eye Cornea Service study on onset of shingles:
http://www.ncbi.nlm.nih.gov/pubmed/21788078
Centers for Disease Control information:
http://www.cdc.gov/shingles/about/index.html
Ten Commandments of Contact Lens Care
In 1508, Leonardo da Vinci
sketched drawings and
calculations of a corrective lens
that could be part of the eye. In
the 1800s, English astronomer
Sir John Herschel came up with
a glass lens that would sit directly
on the eye’s surface. In 1961,
Dr. Otto Wichterle, a Czech
chemist, used a water-absorbing
plastic to produce the world’s
first soft contact lenses and in
1971, Bausch and Lomb began
mass production of contact
lenses.
Today, about 34 million people
in the United States wear contact
lenses; and the vast majority of
them do so easily and safely. But
contact lenses are so common
that it leads some wearers to take
them for granted and get sloppy
with lens cleaning and care.
Doctors will tell you how
quickly vision troubles and eye
complications can occur, if
proper contact lens usage guidelines
are not carefully followed.
“We see patients several times a
month
who have
corneal
ulcers from
falling
asleep wearing their lenses,” said
Dr. Parveen Nagra. “If a speck
of dirt or dust gets behind the
contact lens it will irritate the
cornea all night long. If you
wear contacts you have to be
meticulous about care and
keep them clean to avoid
contamination. If your lenses
continued on page 5
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Fireworks, continued from page 1
contracted, and then the eyelashes grow inward and
create havoc on the surface of the eye,” Dr. Heersink
said. Because a normal cornea is clear, scar tissue
clouds the cornea and obstructs vision. e doctors
at Wills Eye decided to use a combination of
treatments with Ben and determined that vigilant
monitoring of his condition would be necessary to
give him the best chance to heal.
“When we first saw him, he was missing most of
the surface cells, the epithelium, in both his eyes,”
explained Dr. Christopher Rapuano, director of the
Cornea Service. “Ben was treated aggressively with a
regime of several different lubricating and anti-inflammatory
medications. We were concerned about
damage to the cells that heal the surface of the eye,
the limbal stem cells, and whether or not they would
be able to recover. He also had physical damage to the
eyelids and lashes.”
Dr. Rapuano recalled that many attending and
resident doctors at Wills were involved with Ben’s
care. e doctors saw the teen on a daily basis, to
constantly monitor his condition and adjust his
medications accordingly. “We were all on the
lookout for him,” Dr. Rapuano said. “It really
took a team effort to frequently check the condition
of his eyes, assessing if there was improvement and
determining which medications he was responding
to best. Monitoring his status and communication
amongst the doctors who saw him were vital.”
this is the ProKera ® ocular
device that helped Ben Spair’s
eyes recover. Doctors inserted
them into his eyes, and the rings
helped protect his corneas and
allow for healing.
In addition to
the various
medications, Ben
was treated with
ProKera®, a unique
ocular-wound
healing device
made by Bio-
Tissue, a tissue
and medical
device company.
ProKera® is
comprised of
cryopreserved
amniotic
membrane, which has anti-inflammatory, antiscarring
and wound-healing properties, clipped into
a plastic ring. e rings were inserted into Ben’s eyes,
like contact lenses, by Dr. Heersink and Cornea
Service attending ophthalmologist Dr. Kristin
Hammersmith. e ProKera® not only protects the
eye with a moisturizing barrier but it helps maintain
the normal anatomy of the eye as it heals. “Between
the eyelid and the eye there is a small space. When
the eye is injured and there is inflammation, that
space is lost,” Dr. Rapuano explained. “In that
condition, the eyelid can adhere to the eyeball and
if left untreated the patient would have terrible
infections and probably lose the eye.” e ProKera®
ring helps maintain that open space and the normal
anatomy of the eye, throughout the healing process.
In the beginning, Ben had to come to Wills Eye
daily to have his condition monitored and get eye
drops. e family traveled together, making the 80-
mile round trip from New Hope to Center City.
His need for round-the-clock care demanded a lot of
his parents.
“We’re religious, so we did a whole lot of praying,”
Giuliana recalled. “We had to trust in Him and
know that it would be OK. Many people were
praying for Ben.” Ben’s doctors say that the family’s
vigilance in taking good care of their son during his
long healing process played a big part in his recovery.
Giuliana kept a notebook to record her son’s various
medication schedules.
“We felt better when he was at Wills, than when he
was home lying on the sofa,” David said. “We felt
like he was in good hands at Wills.”
Now, five months later, Ben’s recovery has astonished
nearly everyone. His eyesight is 20/20 in his right
eye and 20/25 in his left – more than good enough
for him to read, do his homework and recently get
his driver’s license. His eyes get tired more easily and
he’s had to undergo surgery by Dr. Robert Penne,
Chief of the Oculoplastics Service at Wills Eye, to
correct some scarring of his eyelids. But other than
that, he’s almost back to normal. He’s just like any
other teenager, but he is one young man who will
always be grateful for the gift of sight.
“I was one of those kids who thought something like
this could never happen to me,” Ben said. “Your
eyesight is so important for everything you do.
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Your life can change in an instant. When I was lying
on the sofa in the summer and couldn’t see, it was
like being in prison. It’s just not worth taking a
chance playing with fireworks. I’m really grateful to
the many wonderful doctors who helped me and
took care of me. I’m very thankful.”
“It is like a miracle,” said Giuliana. “We thank God
and the doctors at Wills Eye.”
Even Ben’s doctors are a bit amazed at his recovery.
“It’s a much better outcome than we ever could have
predicted,” said Dr. Rapuano. “All of us who saw
him at the beginning were very concerned that his
eyesight would never return to normal. We would all
say that Ben has made an amazing recovery.”
Dr. Heersink said that experienced doctors say they
have one or two cases in their career that they will
never forget. For her, Ben is that case. “It was so
gratifying to see him getting better and better every
visit,” she said. “He really is a medical miracle.”
Ten Commandments,
continued from page 3
are contaminated, you are
putting those germs right in
your eye.”
Dr. Nagra cautioned that
although some contact lenses
are approved for overnight wear,
wearing them overnight
significantly increases the risk of
infection. “Even if you practice
good lens hygiene, keeping your
contacts in overnight increases
the possibility of contamination
and I generally recommend
against it,” she said.
One way to avoid many of the
issues with contact lens care is to
use daily disposable soft lenses.
is means opening up a new
package of contact lenses each
morning and taking them out
of your eyes and throwing
them in the garbage at night.
Disposable lenses can be
somewhat more expensive than
frequent replacement lenses that
must be cleaned every night,
but daily disposable lenses are
generally a safer option.
Here are the guidelines for safe
contact lens care from the
American Academy of
Ophthalmology:
• Before handling contact
lenses, wash your hands with
soap and water. Rinse and dry
them with a lint-free towel.
• Minimize contact between
your lenses and water. is
means remove your lenses
before swimming.
• Contact lenses should not
be rinsed or stored in water–
not tap water, not sterile
water. Only use approved
contact lens solutions for
contact lens care.
• During cleaning, rub your
contact lens with your finger,
and then rinse the lenses with
solution. is “rub and rinse”
method is considered by some
experts to be a superior way
to clean contact lenses even
if the solution you use is a
“no rub” variety
• Rinse the contact lens case
with fresh solution–not
water, each time. en let the
empty case air dry.
• Keep the contact lens case
clean and replace it regularly,
every three months. e case
can become a source of
contamination or infection
if it becomes cracked,
damaged or dirty.
• Do not re-use solution or
mix bottles of contact lens
solution.
• Do not transfer solution
to smaller bottles.
• Do not allow the tip of the
bottle to touch any surface
and keep the bottle tightly
closed when not in use.
• People who wear contact
lenses need to be examined
annually, even if they are
not having any problems.
An annual exam gives
doctors a chance to check
overall eye health, update
prescriptions and reinforce
proper lens care.
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MEET THE TECHS
Dana Webster
Putting patients at
ease when they’re
anxious and in pain
sounds like an
impossible task,
but it’s the part
of her job as an
ophthalmic assistant
that Dana Webster
likes best.
“Eye problems can
be very painful
and our patients often have to come back for many
visits,” Dana said. “e waiting room is usually full
of people who are anxious, nervous and often, in
pain. When they’re called back to the exam room,
I try to reassure them, get them to relax a bit before
they see the doctor. I like to think that I can smooth
the way for patients to have a meaningful office
visit,” she explained.
In addition to preparing patients to see the
doctor, the techs’ tasks include taking medical
histories and updating current health status. A tech
also performs several noninvasive diagnostic tests,
including corneal topography, which maps the flat
and steep areas of the cornea in colors, and autorefraction,
the test that measures visual acuity and
helps determine prescriptions for corrective lenses.
is saves the doctors valuable exam time because
the pertinent data is already entered into the
computer for their review.
When she’s not behind the autorefractor, Dana
considers herself a homebody. She enjoys lots of
different crafts and watching movies with her fiveyear-old
daughter, Sara, and their black labrador,
Max. e family also has a pet turtle, Tuck. Dana is
an accomplished cook, who concentrates on savory
foods rather than the usual baked goodies. She
has tried her hand at Chinese cuisine and is now
tackling Indian food. “I like following the recipes
and seeing how it all turns out,” Dana said, but
as any parent could guess, her daughter is not an
adventurous eater. “Of course she would rather have
chicken nuggets and french fries for dinner every
night.”
Being part of a team that works to restore people’s
vision is something Dana appreciates every day.
“Problems with your sight can be so overwhelming,”
she said. “When you can’t see clearly it affects
everything you do, every part of your life. It is so
exciting when we can help patients–they have
cataract surgery or get a better pair of glasses and
all of a sudden they can see. ey’re excited
and happy. It’s gratifying to be part of that.”
Meg Nace
Many of the
Wills Eye Cornea
Service patients
have complicated
vision problems or
ongoing eye diseases
and the technicians
often help them
better understand
their condition.
“If patients
understand what is
happening, not only does it empower them, but it
helps them to be their own advocate,” said Meg
Nace. “When patients understand all the medication
options and why they have to come back to the
office for another visit, it helps them have a better
grasp of their own healthcare. ey can be proactive.
It also helps them to have productive discussions
with their doctor.”
Training is a hallmark of Wills Eye’s mission and
the doctors routinely teach and explain medical
procedures and treatment plans, not only to the
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esidents and fellows, but to the techs and the
patients, too. At the end of the office visit, helping
explain the doctor’s instructions and making sure
each patient understands his medications and
instructions, are aspects of the job that Meg
welcomes.
“I really enjoy it when I can see it all click with
the patient,” she explained. “It’s important when
the patient begins to understand what the
ophthalmologist orders. e doctor might say,
for example, ‘warm compresses,’ but then I explain
in common-sense terms why warm soaks are so
important for their eyes.”
Meg said that she usually sits in with the patient
during the doctor’s exam, so she can be part of
what is discussed. “Techs help with documentation,
we read the charts and clarify what the doctors
want,” she said. “Some of the treatments we can
offer are life-changing. It’s very uplifting to be part
of that. I like to think that we are a working team,
the technicians with the doctors.”
Dr. Rapuano considers the Allentown native to be
a vital member of his team. “We depend on the
techs to teach the patients certain procedures such
as how to put drops in their eyes correctly,” he said.
“e patient has time to ask any questions and the
techs make sure the patients understand everything
before they leave the office.”
Meg feels that the office staff is a very close-knit
group that has strong feelings for the patients. “We
see people with complicated vision problems who
need to have many, many appointments with the
doctors and we get to know them and their
families,” she said. “When we ask about their
children or how their gardens are, we really mean it
because we know them. We build relationships.”
Don’t Suffer Alone:
Dry Eye Support Group
Coming Soon
For people with dry eye syndrome, every day can feel
like a dusty, allergic day. the eyes burn or itch and
often don’t produce sufficient tears. the pain is
constant and irritation comes with every blink.
“it’s like an itch that won’t go away,” says certified
ophthalmic assistant Carrie larrivee, who will be
facilitating a dry eye support group in the future.
What is dry eye syndrome?
Dry eye syndrome is a fairly common medical
condition. tears are made up of three layers: lipids
(oily), water, and mucus. the oily layer helps prevent
evaporation of water, while the mucus helps spread
tears evenly over the surface of the cornea. if the
tears evaporate too quickly or do not spread, dry eye
symptoms can develop. the most common form of
dry eye is from an inadequate amount of water from
decreased tear production. this is known as
keratoconjunctivitis sicca or KCS. Problems with
the lipid layer created by oil glands in the eyelids
are also common and often accompany decreased
tear production. these can be caused by eyelid
inflammation, blepharitis.
Who is at risk?
Dry eye syndrome is an unfortunate side effect of
common medications including antihistamines,
blood pressure drugs and antidepressants. exposure
to environmental irritants like smoke or air conditioning
increases one’s risk, as does wearing contact lenses
or having had refractive eye surgery. Dry eye syndrome
affects women more than men, because the
hormonal changes of pregnancy and menopause
are thought to be contributing factors. increasing
age is another risk factor. in some cases, the cause
of dry eye syndrome is unknown.
What can we do?
the Cornea Service at wills is working to establish
a Dry eye Support Group so KCS patients can come
together for emotional support and to exchange
information. it will be a chance to learn which
medications have worked for others and share
thoughts on everything from pain-management
techniques to dietary tips for maintaining water
intake. For this type of chronic condition, doctors
have found that a supportive, discussion group can
be helpful to patients. we are seeking philanthropic
support for this initiative and will keep you updated.
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Cornea Service
840 Walnut Street, Suite 920
Philadelphia, PA 19107-5109
non-profit
organization
U.S. poStage
paid
philadelphia, pa
permit no. 2081
Doctors of the Cornea Service at Wills Eye Institute
Photo: Jack Scully
Get to know the faces behind the ophthalmoscope. Pictured are (front row
from left) Parveen nagra, M.D., Kristin Hammersmith, M.D., Christopher
Rapuano, M.D., Peter laibson, M.D., Brandon ayres, M.D., (back row from left)
Melvin Roat, M.D., Brad Feldman, M.D., Colleen Halfpenny, M.D., Sadeer
Hannush, M.D., and irving Raber, M.D.
Christopher J. Rapuano, M.D.
Director, Cornea Service
Kristin M. Hammersmith, M.D.
Director, Corneal Fellowship Program
Brandon D. Ayres, M.D.
Brad Feldman, M.D.
Elad Feldman, M.D.
Colleen Halfpenny, M.D.
Sadeer Hannush, M.D.
Jennifer Kim, M.D.
Parveen K. Nagra, M.D.
Jayrag Patel, M.D.
Irving M. Raber, M.D.
Melvin Roat, M.D.
Sara Rapuano, Administrator,
Cornea Service
Ellen Scolnic, Writer
Phone: 215-928-3180
www.cornealdocs.com