Category Archives: Ophthalmologist

Vision & Vitamins: No clear evidence Coenzyme Q10 helps eye health

By | Calgary, Cataracts, LASIK, Mayo Clinic, Ophthalmologist, Refractive Surgery, Vision & Vitamins | No Comments

eyelabeledCoenzyme Q10 (CoQ10) has become a popular supplement which is said to help with a number of health issues including cataract and macular degeneration in the eye, but the Mayo Clinic gives it a “C” grade for its benefits in the eye (meaning the evidence is unclear to support its use).  CoQ10 is also called Q10, Vitamin Q10, ubiquinone, and ubidecarenone.  It acts as an antioxidant in the body and has a role in producing ATP which is a molecule which provides energy to cells.  CoQ10 deficiency has not been reported in the general population and it is estimated that a varied diet will provide up to 25% of the measured plasma CoQ10 and that the body naturally makes the remainder.  Primary CoQ10 deficiency is a rare inherited disorder that causes neurologic and muscular dysfunction.

For healthy individuals there is not strong evidence to show that CoQ10 supplements improve athletic performance or prolong life.  There may be some specific circumstance where CoQ10 supplementation may be helpful.  There is some scientific evidence to show that it may be helpful in chronic heart failure and in the treatment of high blood pressure but more studies are needed.  CoQ10 has also been thought to be helpful in specific cancer patients who are undergoing chemotherapy.  There are not enough studies to show that CoQ10 is helpful for eye conditions such as macular degeneration.  According to some sources CoQ10 should not be used for diabetes, hepatitis C, or Huntington’s disease.

There have been some studies that use CoQ10 eye drops for some specific conditions affecting the retina, cornea, and optic nerve.  While early studies are promising for specific diseases, more studies are needed.  More commonly studies have used a tablet or capsule, injection, or intravenous (IV) CoQ10.   There are some side effects including insomnia, elevated liver enzymes, rash, heartburn, and fatigue that have been reported when using CoQ10.  As with all supplements be sure to check with your doctor or pharmacist before starting to take CoQ10 as it may interact with other medications (in particular blood thinners).

Foods that contain higher amounts of CoQ10 include beef, herring, chicken, soybean, canola oil, rainbow trout, roasted peanuts, sesame seeds, pistachio nuts, broccoli, cauliflower, orange, strawberries, and eggs.  A varied diet is helpful in providing a wide variety of nutrients and since CoQ10 appears to act in concert with other vitamins such as vitamin E, having a dietary source of this vitamin may help provide CoQ10 along with other nutrients and co-factors that will aid in absorption and in action.  CoQ10 naturally declines with age so maintaining a healthy diet is increasingly important.  Given the scientific evidence to date it seems unlikely that CoQ10 supplementation is helpful for vision in healthy people.

If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.

 

 

 

LASIK (flap) versus Surface PRK (no flap)

By | Calgary, Dry eye, Epi-lasik, Epilasik, Intra-LASIK, Laser Eye Surgery, Laser vision correction, LASIK, Ophthalmologist, Ophthalmology, Opthamologist, Photorefractive, PRK, Refractive Surgery, Surgeon, VISX | No Comments

STAR S4According to some reports over 28 million laser vision correction surgeries have been performed worldwide since the excimer laser was developed in the 1980s.  Both PRK surface laser and LASIK surgeries use the excimer laser to reshape the corneal surface.  The main difference between the two types of laser vision correction methods is the creation of a corneal flap with LASIK and treatment on the surface of the cornea after removing the thin layer of epithelial cells with PRK.  eyelabeled

 

Advances in both the excimer laser and in flap creation technology have resulted in a variety of names for laser vision correction surgeries.  Flap surgeries include LASIK and IntraLase and no flap treatments include PRK, LASEK, and Epi-LASIK.  With LASIK a small oscillating blade in a device called a microkeratome is used to cut the LASIK flap.  With IntraLase the femtosecond laser is used to create a corneal flap.  Originally called “flap and zap”, with LASIK and Intralase the flap is lifted and the excimer laser reshaping is done on the underlying corneal tissue.  With no flap treatments the excimer laser energy is applied directly to the surface of the cornea.

PRK surface laser vision correction gained in popularity from it’s introduction in the 1980s over the next decade.  LASIK was introduced in the 1990’s  and became the most popular laser vision correction by the early 2000’s due to faster recovery.  Within the past several years there has been a shift back towards surface treatments due to the improvements in post operative management and in excimer laser technology.  It has also been determined that for some people PRK surface treatments may be a better choice.  The reasons that PRK may be recommended include:

1. Risk of flap shift or trauma with job or sports activities.

2. Thin corneas that may be a risk for ectasia (unstable cornea with progressive thinning) with LASIK flap.

3. Very steep or very flat corneal curvatures that may increase LASIK flap complication risk.

4. Previous injury or eye or eyelid surgeries that may raise the risk of LASIK flap complications.

5. Moderate dry eye might be worsened by the deeper disruption of corneal nerves with LASIK flaps.

Both LASIK and PRK have be demonstrated to produce equally good results over 6 months or more.  In the short term of days to weeks LASIK patients will recover vision more quickly.  So taking a short term perspective it makes sense that people may choose a LASIK flap laser vision correction method.

Taking a long term approach there are advantages to forgeting the LASIK flap and choosing a no flap PRK surface treatment.  Advantages of a no flap PRK approach include:

1. no LASIK flap = no flap complictions such as incomplete flaps, buttonholed flaps, partial flaps

2. no LASIK flap eliminates the risk for flap dislocation in the future

3. no LASIK flap means there can not be complications like epithelial ingrowth, diffuse lamellar keratitis, interface debris, flap wrinkles,  or other LASIK flap related complications.

4. Less risk of a weak and unstable cornea called corneal ectasia due to the LASIK flap disrupting the cornea more deeply than surface PRK.

5. Possibly less risk of severe dry eye with surface PRK.

To make the choice that is right for you, first find out if you qualify for laser vision correction and then learn the pros and cons of the treatments available to you.  If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.

 

Vision & Vitamins: Can supplements prevent nearsightedness?

By | Cataracts, Diabetes, Laser Eye Surgery, Laser vision correction, Ophthalmologist, Ophthalmology, Opthamologist, Optometry, science, Vision & Vitamins | No Comments

Nearsightedness (also called myopia) affects from 20% to 50% of North Americans and up to >80% of some populations in Asian countries.  The need for nearsighted correction with glasses or contacts can run in families and is more likely to be present if both parents are myopic.  The natural course of nearsightedness is that it can start in childhood or young adulthood and continue to progress up to age 20 or in higher corrections into the 30’s.

There are some conditions that may be associated with nearsightedness so regular eye examinations are recommended even if the prescription has stopped changing.  Nearsighted people and parents of nearsighted children are of course interested in finding ways to slow or prevent the progression of myopia.  There has been conflicting scientific evidence to support the relationship between reading and near work and higher myopia, however there was no proven association between nearsightedness and computer work.  There has also been some evidence to suggest that more time spent in natural light (outdoors) can help to reduce the increase in prescription over time.

There have been a number of studies to try and find a link between nutrition and nearsightedness and to this date there has not been anything proven to prevent natural progression of myopia in children and adults.

It is important for anyone affected by nearsightedness to have regular eye examinations with and optometrist or ophthalmologist even if the prescription isn’t changing.  Sudden shifts in the degree of nearsightedness can indicate conditions like diabetes or cataracts if changes are happening at an older age.

Correcting nearsightedness is usually involves using glasses or contact lenses.  Laser vision correction can be considered after the prescription has stabilized for at least 2 years.

If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.

Western Laser Eye Associates Welcomes Dr. Deepak Khosla, Ophthalmology Associate

By | Blepharitis, Calgary, Cataracts, Dr. Khosla, Dry eye, Eye health, glaucoma, Laser Eye Surgery, Laser vision correction, macular degeneration, Ophthalmologist, Ophthalmology, Opthamologist, Optometry, Photorefractive, PRK, Refractive Surgery, Uncategorized, VISX | One Comment

Western Laser Eye Associates is excited to welcome Dr. Deepak Khosla as the newest member of our eye care team.  Dr. Khosla has a special interest in medical retina and general ophthalmology.  He speaks a number of languages including Hindi, Punjabi, Urdu, and Tamil and has a number of years of experience in ophthalmology.  Urgent eye care problems and new patients are welcome.

Dr. Khosla is a general ophthalmologist which differs from an optometrist in the training and scope of practice.  Ophthalmologists are “Eye MD”s with a medical degree and training in all systems in the human body.  An optometrist has specialized training in eye health and also may have more experience and training in the optics of prescribing glasses and contact lenses.  Western Laser Eye associates has a diverse team including 2 optometrists who specialize in eye health including dry eye, glasses and contact lens prescriptions, and eye muscle testing.  Dr. Khosla joins Dr. Anderson Penno as a second ophthalmologist and together they cover a wide array of eye health problems including screening for diabetic patients and treatment of many common eye diseases such as glaucoma and macular degeneration.  Dr. Khosla and Dr. Anderson Penno also care for urgent conditions including foreign body, eye infections, styes, and retinal tears.

Dr. Khosla offers Saturday appointments for select appointments.  To inquire about an eye health exam call 403.247.1477 or ask your medical doctor to fax a referral to 403.247.9774.

If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.

Vision & Vitamins: Ginkgo Biloba, Glaucoma, and Macular Degeneration

By | Epi-lasik, Epilasik, Eye health, FDA, Food for thought, Ginkgo Biloba, glaucoma, Health Canada, Laser Eye Surgery, Laser vision correction, macular degeneration, Mayo Clinic, Ophthalmologist, Ophthalmology, Opthamologist, Optometry, Pubmed, Refractive Surgery, science, Uncategorized, Vision & Vitamins | No Comments

Vitamins and natural herbs have become more and more popular for alternative treatment as additional treatments for medical conditions.  Ginkgo Biloba has been used for centuries as a traditional treatment which may help blood flow to the brain and aid in treatment of dementia or Alzheimer’s disease.  It might help treat leg pain that results from blood vessel disease, and there is some suggestion that ginkgo biloba might also help PMS symptoms, depression, multiple sclerosis, and ADHD.  Ginkgo Biloba is extracted from the leaves of the Ginkgo Biloba tree.  As far as vision and eye health are concerned, it is possible that Gingko Biloba might be helpful to eye health but as with many natural products the scientific studies show some favorable and some unfavorable results.

There are some scientific studies that have been reported in the peer reviewed literature which is a data base of articles that have been reviewed by scientists with expertise in the particular field of study before the article is allowed to be published.  Peer review helps to make sure that studies are done in a way that will provide strong statistical evidence for or against a specific area of study.  The most powerful studies are randomized and double-blinded which means the researcher and the subject who is taking the supplement do not know if it is the actual supplement or a placebo being taken.  The “placebo” effect has been well studied and up to 30% of people taking a fake pill who are told it will have beneficial effects will report that it helps whether or not there is any measurable effects.  By double-blinding and using large and randomized numbers of subjects the results will show with more confidence that a particular supplement is helpful or not for a specific condition.  Because there are a lot of different conditions that are being studied, so far there are only a few published peer reviewed scientific studies that have been done to find out if Ginkgo Biloba is good for your eyes.

According to the Mayo Clinic there is some scientific evidence suggesting that Ginkgo Biloba may be helpful in preventing worsening in age related macular degeneration which can lead to central vision loss, but there is little evidence to suggest it might be helpful for treatment of glaucoma.  In the peer reviewed literature there are a few studies including this 2012 study by Cybulska-Heinrich, Mozafferieh and Flammer that suggests supplementation with Ginkgo Biloba might be helpful in addition to traditional medical treatment in cases that are not responding as well as needed to these traditional treatments.  They suggest that antioxidant effects along with a variety of other effects on blood flow might be responsible for the beneficial effects of supplementation with Ginkgo Biloba.  The American Academy of Ophthalmology reported there was a single small randomized trial that showed promise for using Gingko Biloba to slow macular degeneration.

A commonly reported dose of Ginkgo Biloba is a standardized extract, standardized to 24% flavone glycosides and 6% terpene lactones starting at 40 milligrams of that extract three times daily, but there does not seem to be enough evidence in the scientific studies to prove the most effective doses for a specific condition.  Risks and side effects of Ginkgo Biloba supplements include headaches and dizziness, bleeding, and other side effects.  If you are on a blood thinner or aspirin, or are on other medications you should talk to your pharmacist and/or doctor to make sure that there won’t be dangerous interactions.  There is also some question about the quality of the products in some cases and as with all supplements it is important to be sure you are getting a high quality product.  In Canada a DIN or NPH number can be found on products that have been reviewed by Health Canada.  In the US the FDA does not require approval of supplements before the product is marketed but does collect information on adverse events.  The other thing to consider is the cost of a product like Ginkgo Biloba versus the proof that it will be helpful for your health.

Whether you already had LASIK, Intralasik, EpiLasik, PRK, wear glasses or contacts, reading glasses or no glasses at all you should be sure to get regular checks with your eye care specialist (optometrist or ophthalmologist) in order to optimize your vision for the rest of your life.  If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.

 

 

Vision & Vitamins: eat your carrots!

By | Eye health, Food for thought, Laser Eye Surgery, Laser vision correction, Ophthalmologist, Refractive Surgery, Uncategorized, Vision & Vitamins | No Comments

Is the old wives’ tales about eating carrots fact or fiction?  Carrots are high in beta-carotene which the body converts to vitamin A.   Carrots also provide vitamin C, iron, calcium and fiber.  Carrots and other foods rich in vitamins C and E, zinc, lutein, zeaxanthin, and omega-3 fatty acids DHA and EPA benefit eye health and general health, as hown by the the Age-Related Eye Diseases Study (AREDS), funded by the National Eye Institute. These nutrients are linked to lower risk for age related macular degeneration (AMD) and cataracts.

The myth that eating carrots can improve your vision seems to have been made popular during World War II when a propaganda campaign was run to convince the Germans that Royal Air Force pilots had superior night vision due to eating carrots.  This campaign was started to cover up the fact that the pilots were using a secret new radar technology that allowed them to strike under cover of darkness.  According to the Smithsonian Magazine and the World Carrot Museum (a virtual museum about all things carrot) RAF fighter pilots told newspaper reporters that carrots improved their night vision and it was picked up in the popular press of the time.

In reality carrots and other deeply colored fruits and vegetables do contain vitamins that are important for healthy eyes, but in most developed countries vitamin A deficiency is rare so eating carrots is not likely to result in a noticeable improvement in vision.  It is possible that in ancient societies there may have been improvements in vision from eating carrots in areas where vitamin A deficiency may have been common due to seasonal changes in diet.

Eating too many carrots will turn your skin orange but is not likely to harm you.  According to the USDA 1 cup of chopped carrots contains 0 fat, 0 cholesterol, 88mg sodium, 12gm carbohydrate (4gm dietary fiber, 6 gm sugar), 1 gm protein, 428% daily recommended Vitamin A, 13% daily recommended Vitamin C, 4% daily recommended calcium, and 2% daily recommended iron.  There are some reports that pesticides can build up in the skin so peeling carrots may be a healthier option.

In general it is good advice to –  eat a little bit of everything and not too much of any one thing.  As it turns out the stories about carrots are both fact and fiction!

 

If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.

 

Vision & Vitamins: What is really in your vision supplement?

By | Laser vision correction, Ophthalmologist, PRK, Refractive Surgery, Vision & Vitamins | No Comments

Do you know what is in that herbal pill or vitamin you are swallowing or if it will really help?  The American Academy of Opthalmology (AAO) recently published a study that compared ingredients in top selling brands of supplements marketed for macular degeneration.  The Age-Related Eye Disease Study did show evidence that a formula called the AREDS and now the AREDS2 did lower the risk of vision loss from macular degeneration for some people.  The 11 top selling brands of ocular nutritional supplements in the United States were studied were reviewed for ingredients and manufacturers claims.  All of these vitamins contained some of the ingredients from the AREDS or AREDS2 formulas, but none of them contained all the ingredients.  According to the study all of the ocular supplement marketing included claims that the products support, protect, help, or promote vision and eye health even though there is no proven benefit in using supplements for primary prevention of eye diseases (the Age-Related Eye Disease Study was done in patients with macular degeneration and the formulas studied were intended to prevent further vision loss rather than prevent macular degeneration from starting).

Health Canada has a license program that provides consumers with some assurance that vitamins and supplements are manufactured correctly and contain the ingredients that are listed on the product.  These Licensed Natural Health Products will have an eight-digit Natural Product Number (NPN) or Homeopathic Medicine Number (DIN-HM) on the label. Products with a NPN or DIN-HM marking on their label have been reviewed by Health Canada and found to be safe, effective and of high quality according to their recommended conditions of use.

Should you take vitamins or supplements to prevent eye diseases?  There are some scientific studies that show some vitamins and supplements might be helpful and other studies that show that these products do not help prevent eye diseases – and in some cases scientific studies have linked supplements like beta-carotene to an increased risk of cancer.  There are also numerous reports in the scientific journals of harmful contaminants in unregulated supplements from arsenic to steroids. The bottom line is that vitamins and supplements may not prevent eye disease so you may be wasting your money and products without an NPN or DIN-HM in Canada have not been assessed by Health Canada.  If you take other medications be sure to talk to your pharmacists to be sure that supplements will not interfere or create dangerous interactions.  So if you choose to take nutritional supplements do your homework to be sure you aren’t putting yourself at risk by taking certain products.

There are other ways to prevent eye disease and vision loss that don’t involve buying ocular nutritional supplements.  Keep in mind that anything that is good for your heart is good for your eyes.

1. Don’t Smoke

2. Exercise

3. See your family doctor for regular check ups including blood sugar and blood pressure checks.

4. Eat your carrots – and other deeply colored fruits like blueberries and citrus and veggies like leafy greens, as well as nuts like almonds, eggs, and fish

5. Get your eyes checked regularly and follow up as recommended by your ophthalmologist or optometrist

 

If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.

 

Should you have laser eye surgery (PRK or LASIK)? Answer these three questions.

By | Laser vision correction, LASIK, Ophthalmologist, PRK, Refractive Surgery, Uncategorized | No Comments

1. Do the benefits outweigh the risks (low but not zero)?

The vast majority of people who have laser vision correction (PRK or LASIK) are satisfied with the outcome, and in a large FDA study of LASIK (PROWL 1&2) <1% of people experienced “a lot of” difficulties following surgery.  The most common side effects at 3 months in that study were dry eye and some increase in halo at night; these side effects may improve in some people beyond 3 months.  If this sounds like a reasonable risk versus benefit then read on; if you need a 100% guarantee of the outcome of PRK or LASIK then laser eye surgery may not be a good choice for you.  If you would like to have laser vision correction and are looking for the lowest risk then PRK may be your best choice.  This no-flap treatment avoids cutting into the cornea to create a LASIK flap.  Eliminating the need for a LASIK flap will avoid any complications that could happen when cutting the flap and also will eliminate the risk of a LASIK flap shift in the future if you suffer an eye injury even months or years after surgery.  For some people with high risk occupations PRK is a better choice.  Surface PRK also does not disturb the cornea as deeply and may be a better alternative in thinner corneas.  Surface PRK does involve a longer recovery (7-10 days) before returning to usual activities, but provides equally good results without the need to cut a corneal flap.

2. Do you have the right expectations?

The goal of laser vision correction is for you to function as well without glasses or contact lenses as you do now with your corrective lenses.  PRK or LASIK will not be expected to make your vision better than it is with your glasses or contacts.  If you already need reading glasses over contact lenses or a bifocal in your glasses, then laser eye surgery can correct for distance but you will still need reading glasses.  For people that have PRK or LASIK at a younger age, they will need reading glasses in their mid-forties as the focusing declines naturally with age.  This is called presbyopia and there is no treatment available for this natural age change that has been shown to be effective at this time.  In most people their night vision will be similar to what it was with glasses or contact lenses before surgery, but it does take longer (up to 6 months or longer for some people) to improve than vision during the day or in bright light.  For most people if they have dry eye with glasses and contact lenses this means their eyes will be dry after surgery.  Dry eye can also be worse for the first three to six months and generally returns to baseline – PRK and LASIK do not cure dry eye (some people think that if they can get rid of the contact lenses then the dry eye will be solved, but this is usually not the case).  There are a number of treatments for dry eye, so if this is a problem then working with your eye care provider to improve your comfort is recommended before considering PRK or LASIK.

3. How do you find out if you qualify for laser eye surgery?

There are some eye conditions and also systemic conditions that may disqualify you from PRK or LASIK.  An assessment with specialized corneal mapping and other testing is the next step if you answered yes to the first two questions.  During the assessment a medical history is also taken.  If your testing shows that you are a good candidate then there will be an opportunity to discuss any questions and to learn more about laser eye surgery.  At Western Laser Eye Associates Dr. Anderson Penno will examine your eyes at the assessment and answer any questions that you may have about laser eye surgery.  Once you have all the information you can make the choice that is right for you.

If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.

 

What is up with that White&Gold (or is it Blue&Black) Dress?

By | Fashion, Food for thought, Ophthalmologist, Uncategorized | No Comments

Most people who spend even a little time on the internet will have seen this photograph of the striped dress that has created a firestorm of debate about the true colors.  This explanation from an article on the New York Times site is probably the most concise, however it is not completely understood even by eye specialists why there is such a difference in perceptions between different people viewing the same picture.  Interestingly there is still a difference when the picture is printed which means that the viewing angle when looking at an electronic display versus paper does not completely explain the effect.  Although not a scientific study, in a small sample size of ophthalmologists and engineers, the ophthalmologists all saw the dress as White and Gold and the engineers all saw Blue and Black.

There have been reports that the split is from 70% white and gold to 50/50 in on each side.  It is possible that there may be genetic tendency to view the dress as one color or the other due to either retinal differences (the retina lines the back of the eye like film in a camera and the center of the retina is responsible for color vision) or due to differences in the brain or both.  Another interesting fact is that for some people the dress changes from white and gold to blue and black which indicates some adaptation in the brain’s interpretation of the images that are formed on the retina.  How Your Eyes Trick Your Mind shows a number of different optical illusions and explains some of the science behind them.  In some cases MRI images will show the involvement of specific parts of the brain when people are viewing an optical illusion.  The White/Gold/Blue/Black dress is a bit different than classic optical illusions in that it involves color.

In many ways we ultimately do see with our brains.  For example it is well established that people can adapt to glasses that turn everything upside down.  This is called perceptual adaptation. Another well known phenomenon is inattention blindness. This is an effect where when attention is focused on a specific detail a person will not see things that may be right in front of them.  There is likely to be continued debate about why this particular photograph of what should be referred to simply as the “striped dress” for now creates such a large difference between viewers.  For now it is nice to know that these perceptual differences are a normal part of the visual system (and whether you see it Blue&Black or White&Gold you are not right or wrong – just different).

If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.

 

Exercise & Eye Health

By | LASIK, Ophthalmologist, Ophthalmology, PRK, Refractive Surgery | No Comments

A long term study of thousands of adults shows that regular exercise lowers risk of vision loss over 20 years.  The Beaver Dam Eye Study started in 1987 and continued to follow approximately 5,000 adults over 20 years.  Vision loss was reported in 5.4% of the population overall.

People who were physically active had a 58% lower risk of vision loss according to this study.  Heart healthy practices like exercise, not smoking, healthy weight, and regular check-ups to monitor blood pressure have been shown to reduce the risk of eye diseases like macular degeneration and glaucoma.

Whether you are considering laser vision correction like LASIK or PRK or not, a heart healthy lifestyle including exercise can keep help to keep your vision safe.  Regular eye health checks with your optometrist or ophthalmologist are also very important to find and treat eye conditions.  For many eye problems early treatment is important in preventing serious vision loss and can often be found before you have symptoms.

If you have questions about laser vision correction or wish to book a complimentary evaluation with Dr. Anderson Penno, contact Western Laser Eye Associates.