The eyes have it

Major technological advances in eye surgery make many procedures as quick as a visit to the dentist.

Dr levinger 298.88 (photo credit: Judy Siegel-Itzkovich)
Dr levinger 298.88
(photo credit: Judy Siegel-Itzkovich)
Not so long ago, eye surgery required a hospital stay of at least a night and up to a week. Today, inpatient beds in ophthalmology wards are rare, and reserved for patients with very complicated conditions. And you can now get a cataract removed or have your eyeballs "shaved" to get rid of glasses on a lunch break, with less time or pain than a root-canal. There are constant advances in refractive, cataract and oculoplastic surgery, and it is difficult for eye doctors, especially ophthalmological surgeons, to keep up. For this reason, an international conference on these three specialties was held recently in Jerusalem's Inbal Hotel, attracting 85 doctors from around the world and 250 Israelis. What was most unusual is that the four-day conference wasn't organized by an ophthalmology society or a hospital, but by Enaim, a private chain of eye surgery clinics. It included not only multimedia lectures, but also live surgery from Enaim's Jerusalem clinic and Meir Medical Center in Kfar Saba. Despite the fact that the organizer is a commercial entity, participants were full of praise for the high quality of the conference. It was Enaim's fourth biennial conference, with previous ones held at the Dead Sea. ENAIM WAS established in 1999 by Dr. Shmuel Levinger, a 1974 graduate of the Hebrew University-Hadassah Medical School who learned his specialty at the Hadassah University Medical Center on Jerusalem's Mount Scopus and for years ran its cornea unit. He established and managed Hadassah's laser surgery institute, set up an ophthalmology hospital in Uzbekistan, and operated the eye department at a hospital in Malawi (in Africa) for three years. He is also a senior ophthalmology adviser to the capital's Bikur Holim Hospital (where he volunteers to examine the eyes of newborns) and Israel's representative in the European Ophthalmological Surgery Society. He even competed to purchase Bikur Holim but lost out, apparently to Russian-born billionaire Arkadi Gaydamak. Levinger, who runs the chain of clinics - in Jerusalem, Tel Aviv, Haifa and Beersheba, with three optics centers in Tel Aviv and Jerusalem - with his dentist wife Dr. Ronit Levinger - is a controversial figure. The controversy is based mostly on the fact that he left a senior post in one of the country's leading public medical centers and was the first in his profession to establish a for-profit chain of clinics. Some colleagues who remain in the public sector, says Levinger in an interview with The Jerusalem Post during his conference, are "probably jealous. In Jerusalem, our clinic in Shaare Ha'ir does the same number of eye procedures as that of a middle-sized hospital's ophthalmology department; we do more than Shaare Zedek Medical Center. People who say we are solely interested in profits have to check if it is true. They have to look at the level of medical expertise, at the results. You can't fool the patients; they know what is good for them. The news about satisfaction passes by word of mouth. We do very little advertising." "I don't have a single bad word to say about my colleagues at Hadassah; the doctors in the laser institute are wonderful people, and I still have excellent relations with them. So why did I leave, when I was king of laser eye surgery at Hadassah? I wanted to buy the best laser surgery equipment for the institute and went to Prof. Avi Yisraeli [then director-general of the Hadassah Medical Organization and now director-general of the Health Ministry]. He promised me he would find the funds, but was unable to do it. I decided to leave - to go into the wilderness, despite my tenured position. I knew the service was in demand, because I did more Sharap [private medical services] in the eye department than anyone else." TODAY, ENAIM clinics perform 60 percent of all refractive surgery (aimed at seeing without eyeglasses) in the country. Its physicians - all independent and not salaried - also perform cataract, glaucoma, corneal, retinal and other surgery, as well as oculoplasty, which is plastic surgery related to the eyes such as eyelid tuck and the removal of bags under the eyes. Levinger, who has performed over 100,000 eye operations in his long career, has had many famous patients, from Prime Minister Ehud Olmert on down. "But our patients are not only the rich." Although several cabinet members and other well-known public figures have suddenly appeared without their glasses after having refractive surgery, tens of thousands of ordinary people have as well. Some of the health funds, especially Kupat Holim Meuhedet, have agreements with Enaim on operations, especially those such as cataract removal that are included in the basket of health services, but with reductions on vision-improving refractive and esthetic surgery. Levinger and other Enaim doctors charge NIS 10,000 for refractive surgery, which is not included in the basket provided by health insurers. Although the actual procedure takes seconds, Levinger says the price is justified by their experience and the high cost of equipment. He adds that Enaim quietly provides cataract and other urgent surgery free for very needy patients. "We tried to set up a voluntary organization to help the poor, but the Income Tax Authority didn't approve it on the grounds that it constituted a 'conflict of interest,'" Levinger maintains. An increasing number of patients are young haredim, despite the community's long-time discouragement of esthetic surgery. Even the most rigid rabbis have been persuaded that removing one's glasses improves the chance of finding a good shidduch (match). "We have no queues. Patients don't have to wait for months to have a cataract removed. We buy the most expensive equipment in the world," he insists. "We also have very good results." Dr. Joseph Douieb, who came to Enaim from Hadassah with Dr. Levinger, is now responsible for Enaim's Jerusalem clinic. Born and trained in Paris, he came on aliya in 1995 with his family, which now includes five children. "Although most operations are performed with anesthesia in the form of eye drops, in Jerusalem we always have a trained anesthesiologist in the operating room," he says, "and people always go home soon after surgery." The clinic doesn't handle the most complicated cases, such as those involving elderly people with cardiac insufficiency, as a hospital is best suited for them, but it does operate on diabetics, for example. About 80% of procedures are aimed at getting rid of eyeglasses, while the rest is for pathological conditions such as cataracts or esthetic surgery such as lid tucks. "We don't accept everybody for refractive surgery; only about 70% of those who request it are suitable." Refractive surgery can be performed even on patients who suffer from keratoconus, a progressive eye disease often appearing in the teens or early 20s in which the normally round cornea thins and begins to bulge into a cone-like shape that deflects light as it enters the eye. This results in distorted vision and may be accompanied by nearsightedness and astigmatism (irregular curvature of parts of the eye, usually the cornea). In the mildest form of keratoconus, eyeglasses or soft contact lenses may help. But as keratoconus - which was widely discussed in the conference lectures - progresses and the cornea thins, these are no longer enough. Rigid gas-permeable contact lenses may be the answer, and there are also plastic corneal inserts which are intracorneal rings (known as Intacs) placed just under the eye's surface to help produce a flatter cornea, leading to clearer vision. However, Intacs are not included in the basket of health services. Douieb says the Jerusalem clinic also performs cornea transplants, with corneas provided by TBI, a commercial organ bank in the US. As for his move from a public medical center to a commercial clinic, he says: "It is not shameful to make money. We work on a very high level and have published many articles in medical journals. Enaim is the only private medical clinic chain that organizes international conferences. We also organize International Vision Eye to raise awareness about vision, and perform free eye checks for drivers. We examine residents in battered women's shelters and donate hundreds of glasses to the needy," says the French-born surgeon, who is an adviser to the Israel Defense Forces on keratoconus and previously headed the IDF's keratoconus clinic. One foreign participant at the conference was Dr. Leon Grupenmacher, an ophthalmological surgeon from Curitiba, Brazil, who heads the ophthalmology department at the city's Catholic University Medical Center and also runs a private practice. Grupenmacher, a Jew who has already been to Israel three times, performs 400 to 500 operations a month, including treatment of keratonocus, cataracts and corneal transplants. His private practice is largely packed with rich patients who can afford refractive laser surgery. Israel offers the most modern technology, unlike Brazil, where medical institutions that serve the poor are not so well equipped, says Grupenmacher, the fifth ophthalmologist in his immediate family - who wears no glasses not because he had refractive surgery but because "I don't need them." But he did perform such surgery on his wife and did lid tucks on his 67-year-old father. Untreated cataracts are the main cause of blindness among his country's 200 million residents, followed by diabetes. He predicts that in the next decade, the use of glasses will continue to decline, while the safety of surgery will continue to rise. There will eventually be artificial lenses with liquid inside to allow them to change shape according to distance. Dr. Vladimir Feingold, who is not a physician, came to the conference from Switzerland to represent his company, Biovision, which developed the Invue system for the correction of presbyopia (a reduced ability to focus on near objects caused by a loss of elasticity of the lens after age 45). The system uses a blade cartridge to implant an extremely thin lens in a corneal pocket using a precise lens guide. An engineer and scientist, Feingold has the rights to 40 different patents related to medicine, especially ophthalmology. "Just two weeks ago, I received a patent for my intracorneal implants." He lectured at the conference and gave a course. "There is a giant world market for the treatment of presbyopia because of aging baby boomers," he notes. It takes 15 seconds to insert the lens and just five minutes for the whole procedure. "Well-off people undergo Botox injections and have plastic surgery, and then they go to a restaurant and can't read the menu. So they come to us."