If the eye is our window to the world, then the cornea is the glass of that window. Like a frosty-covered window on a winter’s day, a damaged cornea can obscure one’s view of the world. This normally transparent tissue can lose it clarity due to scarring from injury, infection or disease. Practicing in one of the world’s top specialty hospitals in Ophthalmology is Dr. Dimitri Azar, Associate Professor of Ophthalmology, and Director of the Cornea & Refractive Services of the Massachusetts Eye & Ear Infirmary in Boston, U.S.A., a teaching hospital affiliated with the world-renowned Harvard Medical School. Dr. Azar and his colleagues encounter the widest range of corneal diseases of the eye. From curing the diseased eye through corneal transplantation to improving the vision of healthy people through refractive surgery, all corneal conditions, no matter how challenging or menacing, are willingly confronted.

According to Dr. Azar, the cornea is the clear front of the eye that covers the colored iris and the round pupil. Light is focused while passing through the cornea, which in turn focuses on the retina and allows one to see. To maintain good vision, the cornea must be healthy and remain clear to allow that light to pass through.

Dr. Azar, of Lebanese origin, and who speaks fluent Arabic, welcomes patients from all over the globe, including the Arab World. Dr. Azar’s supporting team of physicians include Claes Dohlman, M.D, Deborah Pavan-Langston, M.D., Anthony P. Adamis, M.D., William J. Power, M.D., M. Reza Dana, M.D., Kathryn Colby, M.D., Ph.D., and Sonia Yoo, M.D. All have been extensively trained in the treatment and management, surgically or otherwise, in all aspects of the cornea and the anterior segment of the eye, as well as in refractive surgical procedures to correct myopia (nearsightedness) and/or astigmatism (an irregularity of the corneal surface) which aims to substantially reduce one’s dependence on glasses and contact lens.

One of Dr. Azar’s most recent patients traveled from Egypt, a 53 year-old gentleman who presented with a past ocular history of retinal surgery in 1994 to correct retinal detachment with a best corrected vision of 20/70+1 in his right eye and best corrected vision of 20/80-1 in his left eye which required 19 diopters of spectacle correction. After extensive review of his history and multiple tests performed, Dr. Azar proceeded to operate on this Egyptian official with lens extraction in both eyes, resulting in a substantial improvement in vision without prescription correction to 20/40, improving to 20/25 with very thin lenses, and the patient was able to function (driving and reading) without glasses after his surgery.

More recently in March of 1998, another patient from the United Arab Emirates recently sought his advice. This was a 29 year-old gentleman with the condition of unilateral keratoconus in his left eye and severe strabismic amblyopia in his right eye, with his vision on presentation to the clinic of only 20/200 in his right eye best corrected and 20/100 in his left eye best corrected. Following Dr. Azar’s decision to proceed with penetrating keratoplasty procedures in both eyes (corneal transplantation) using the patient’s own donor cornea extracted from the patient’s left eye with unilateral keratoconus, this patient’s ocular condition improved subjectively and his vision in his left eye has already showed signs of improvement to the level of 20/40 with pinhole testing at even this early stage in his postoperative recovery.

While the above are but a couple of examples where patients have almost circled the globe in search of expert specialized treatment, an extensive array of corneal diseases and conditions are treated by Dr. Dimitri Azar and his team of physicians, which include:

Of all transplant surgery performed today - including hearts, lungs and kidneys - corneal transplants are by far the most common and the most successful in outcome. Ophthalmologists throughout the world perform more than 40,000 corneal transplants every year in the United States alone. Conditions which warrant corneal transplants include corneal failure after other surgery, such as cataract extraction surgery; keratoconus (a steep curving of the cornea); hereditary corneal failure, such as Fuch’s dystrophy; scarring after infections, especially after herpes; rejection after a first corneal transplant; and scarring after injury. All the physicians at the Infirmary’s Cornea And Refractive Surgery Service, including Dr. Dimitri Azar, perform corneal transplants routinely and frequently. In fact, hundreds of corneal transplants are performed by the Service annually.

Patients suffering from corneal diseases who are not candidates for corneal transplantation have hope of restored vision through a procedure known as keratoprosthesis (commonly known as an artificial prosthetic), a clear plastic window that is inserted into the damaged cornea. Dr. Azar and one of his colleagues, Dr. Claes Dohlman, a pioneer who has devoted over 30 years of his career to the development of this procedure and the design and improvement of these devices, routinely perform this procedure, as it is often the only option for people with severe corneal opacification (cloudiness) from chronic inflammation or dryness, after chemical burns or multiple grafts, or when standard corneal transplantation has failed the patient.

Since the discovery of the first drug to treat herpes simplex keratitis 30 years ago here at the Cornea Service of the Massachusetts Eye & Ear Infirmary, scientists have developed many of the treatment programs now used worldwide for this and other blinding diseases. Herpes simplex is a member of the herpes virus family that includes the varicella/zoster virus, which causes painful and destructive shingles in the cornea. These viruses are the leading infectious cause of blindness in the Western hemisphere striking more than 500,000 Americans alone each year. Dr. Deborah-Pavan Langston, a colleague of Dr. Dimitri Azar here at the Cornea & Refractive Surgery Service of the Massachusetts Eye & Ear Infirmary, has developed a treatment to prevent the recurrence of infectious herpes in high-risk patients that is now 95% effective.

Corneal melting, a condition that may lead to corneal perforation (open injury), is often an indication of a systemic disease such as rheumatoid arthritis or lupus, and therefore requires systemic treatment rather than just topical eye drop application. It is extremely important that patients be treated by an expert physician who specializes and understands the process of eye melt which can be a presenting sign of serious systemic disorder that can benefit dramatically with systemic treatment. The team of physicians at the Cornea Service of the Massachusetts Eye & Ear Infirmary, led by Dr. Azar, are experts who provide ocular and systemic care to patients with such disorders. Drugs used in the treatment of these eye diseases can have significant side effects, including bone marrow suppression, and improper use or dosages can also have devastating side effects. However, the corneal melt itself can be equally devastating to one’s vision, potentially leading to perforation of the cornea and/or loss of vision. Therefore, the risks and benefits are heavily weighed and an informed decision is made as to the best course of treatment.

 Conjunctivitis, Dry Eye, and Blepharitis

Conjunctivitis, dry eye and blepharitis are the more common conditions that are a significant cause for concern to patients. Although these conditions are often more of an annoyance than anything serious that might threaten one’s vision, they are not entirely innocuous. Conjunctivitis (commonly known as red eye), can lead to corneal infection, which in turn can lead to loss of vision. For example, genococcial conjunctivitis is an ophthalmic emergency and must be treated immediately and properly to prevent corneal involvement. Dry eye (a condition where the eye does not produce tears), can lead to corneal melts if severe and left untreated. Blepharitis (an inflammation of the eye lids), can be the first sign of herpes, which may continue to involve the inside of the eye and should be treated promptly and properly to prevent it from further progression.

For more than a decade, Dr. Azar and his team of physicians here at the Infirmary have been at the very forefront of refractive surgery, which includes a variety of procedures aimed at reducing one’s dependency on glasses and/or contact lenses by reshaping the cornea. These procedures include photorefractive keratectomy (PRK/PARK) and laser assisted in-situ keratomileusis (LASIK). According to the American Society of Cataract and Refractive Surgeons, as estimated 250,000 cases of PRK will be performed in the United States alone this year, and many, many more worldwide.

PRK/PARK reshapes the cornea with the use of an excimer laser by reducing the level of myopia in patients with low and moderate degrees. This procedure starts with the removal by a spatula, blade or dilute alcohol, the cells of the epithelium (the outermost layer of the cornea). The laser is then applied to the surface of the cornea to remove a small amount of tissue. The laser emits an ultraviolet light which ablates (removes) the cornea tissue without altering the surrounding and underlying structures. Dr. Azar’s results to date clearly showed in patients who were good candidates a level of vision of 20/40 or better in 94% of patients treated.

LASIK is an option for patients with higher degrees of myopia. In this instance, a thin layer of the cornea is peeled back, and the underlying surface reshaped with the excimer laser. After the laser has been applied, the tissue that was peeled back (the flap), is carefully repositioned back over the treated corneal surface.

For 28 years, the first thing Michelle Tercho would do each morning would be to reach for her eyeglasses. "Before I had surgery, everything was a blur," she explains. "Since surgery, I wake up to a brand new world. Everything is clear." In December, the 30 year-old data support specialist had a new type of refractive surgery performed on one eye, and then on her second eye in June.

Catherine Accardi, 31, who is in sales, tells a similar story. She has always had poor vision, and decided to do something about it, permanently, after she lost a contact lens while driving. "There I was, driving down the street and I couldn’t see," she explains, "It was horrible." She underwent refractive surgery in her first eye and then sooner after her second eye. "I’ve worn glasses since I was 10 year old, so seeing well is so totally amazing to me. I started crying with happiness after the surgery."

Laser assisted in-situ keratomileusis (LASIK) is a relatively new method of refractive surgery and has been tested and performed by me, said Dr. Azar. "In LASIK, the front part of the cornea is peeled back with a device called a microkeratome. When this is done, the excimer laser is applied directly to the cornea. The thin corneal flap is then folded back into place, restoring the normal corneal anatomy." "Because there is reduced surface abrasion, there may be less pain and discomfort and a more rapid recovery of vision. Another advantage is that higher levels of nearsightedness can be corrected with the LASIK method," Dr. Azar said.

Dr. Azar began performing LASIK about two years ago and he has quickly earned the tag as a "renowned and worldwide" pioneer in this surgical specialty. Dr. Azar has also recently published two textbooks on the topics of refractive surgery and excimer laser surgery.

When Zagloul Ayad first met Dr. Azar at the MEEI, he had myopia and astigmatism such that his irregular cornea would not allow him to function without glasses or contact lenses. Less than two months later, Mr. Ayad’s vision without correction in both eyes is excellent at both distance and near, thanks to refractive surgery. Dr. Azar treated the first eye, then monitored it postoperatively before performing surgery on the second eye. The wait was worth it—both corneas are now smooth and regular. The measurements involved in refractive surgery are less than the width of a human hair, and the procedure itself takes little more time than cleaning a contact lens, yet the results are dramatic. Mr. Ayad and hundreds of others like him, from Boston and around the world, are now living an entirely different life than the one they led before their refractive surgery. "Nothing pleases me more than to hear patients speak of waking up in the morning with perfect vision, or partaking in activities which were closed off to them prior to refractive surgery because of glasses or contact lenses," says Dr. Azar. Nevertheless, in the bustling and lucrative field of refractive surgery, Dr. Azar remains a cautious and conservative surgeon, one whose fundamental commitment is to the best interests of his patients. He utilizes decades of ophthalmic experience in deciding which course of action is best for each patient. The quality of Dr. Azar’s care—and the care provided by all the physicians at the Massachusetts Eye & Ear Infirmary—is evidenced by the enormous, international community of patients who have chosen to entrust him with their vision.

Other procedures include, with the use of special cutting devices, radial keratotomy (RK), astigmatic keratotomy (AK), and automated lamellar keratomileusis (ALK).

In addition to his clinical services, Dr. Azar leads the Service in its endeavor to remain one of the leading centers for post-graduate training in Ophthalmology. Founded by Dr. Dohlman, and now spearheaded by Dr. Dimitri Azar, the cornea fellowship training program has trained physicians who have aspired to become leaders in Ophthalmology. To date, 35 professors and chairmen of departments worldwide have completed this program, which is the largest number of any training program in the United States, if not the world.

In the corneal research program, investigators are trying to understand how corneal surface irregularities occur" Why does a cornea scar? How can we best treat the scarring? We need to understand the physics of the scar, its morphology, its typography and its biochemistry and to look at the molecular basis of wound healing to help us better understand the problem and improve vision," Dr. Azar said.

The Infirmary’s vast research and clinical experience enables it to offer patients the latest and highest quality of eye care. Through the teaching of national and international physicians and scientists, the benefits of such experience are felt literally around the world.

William W. Montgomery, M.D.Professor of Otology and Laryngology at Harvard Medical School and the Massachusetts Eye and Ear Infirmary in Boston.

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