Tuesday, December 30, 2014

What Causes Dry Eye Syndrome? What is Dry Eye Syndrome?

Problematic dry eyes are one of the most common problems reported to eye doctors. Dry eyes can result from either a decrease in the amount of tear production or the quality or composition of the tears produced.

According to Dr. David Karp, M.D. of Koby Karp Doctors Eye Institute in Louisville, Kentucky, "Common causes may include advancing age, allergies, poor diet, heating/cooling environmental circumstances, hormonal changes, health status such as diabetes, arthritis, lupus, thyroid dysfunction, chemotherapy or radiation treatments and acne, rosacea, contact lens use, computer use and patients that have a history of LASIK or refractive surgery."

In addition, certain medications can contribute to dry eye symptoms such as antidepressants, antihistamines, decongestants, acne treatments, diuretics and some blood pressure medications.

Common symptoms of dry eyes may include blurred or variable vision, sensitivity to light, dryness, burning, stinging, gritty or foreign body sensations. Occasionally, the dry eye patient may experience a paradoxical excess or "reflex" tearing caused by the underlying eye surface irritation.

If you'll click here, you can use our Dry Eye Questionnaire.

Treatment of this condition may include artificial tears, gels and/or lubricating ointments at bedtime, daily eyelid hygiene scrub procedures, a prescribed medication regimen, omega-3 nutritional supplements (fish and flaxseed oil), and punctal (tear drainage) occlusion of the eyelid to retain moisture.
As you can see the causes and possible treatments are complex. Your eye doctor can formulate and individual treatment plan for you based on severity and known causes. Here are some helpful tips:
  • Wear sunglasses outdoors to reduce glare and block the drying wind effect
  • Stay hydrated by drinking plenty of water and fluids
  • Add a humidifier in the bedroom and turn off fans
  • Aim vents in cars away from your face · Take frequent "blink breaks" when using a computer
  • If taking hormone replacement therapy be sure your doctor knows about your tear problem.
Use over-the-counter lubricants such as SYSTANE ULTRA Lubricant Eye drops as needed for extra relief.
  • Supplements such as flaxseed oil and omega-3 could provide extra benefits
  • Avoid excessive caffeine
  • Smoking aggravates this problem
  • Environmental factors can add to your discomfort (smoke, fumes, dust)
  • Airline travel can increase symptoms
  • Taking antihistamines for allergy can increase symptoms
Call us to set up an appointment in our Center for Dry Eye Excellence - (502)897-1604

Wednesday, December 17, 2014

Snow Blindness Is Real.

Is there such a thing as snow blindness? Yes, there truly is.

In fact, in the world of ophthalmology, it is known as Photokeratitis. It also may be referred to by several other terms including arc eye, welder's flash, bake eyes, corneal flash, niphablepsia,  or (if you don't like that one, how about)  keratoconjunctivitis photoelectrica. Say that next time you're hanging out with your friends and really impress them.
Now, while we're on the subject of snow blindness, are you one of those folks who can't wear plain old store-bought sunglasses because you need prescription eyewear? Then this would be the perfect time for you to visit our Optical Department and check out the special lenses we offer that can protect your eyes from  good ol' Photokeratitis.


http://www.drivewearlens.com/effect.php
DriveWear Lens-click to learn more
Transition® Lenses  automatically darken in sunlight or high bright light conditions allowing you the convenience of having one pair of glasses for indoors and out no matter the weather.
DriveWear® Lenses are the first changeable polarized outdoor lens. They darken outside as well as behind a windshield. This lens reacts to all different outdoor weather and light conditions.
Xperio® Polarized Lenses eliminate all indirect reflection such as from water or snow, allowing greater depth perception and visual acuity. That's why sports enthusiasts like skiers and boaters absolutely love them.
We carry those super cool RayBan® and Panama Jack® sunglasses, too!
Come in to our Optical Department at Koby Karp Doctors Eye Institute and get the best for your eyes. You can also call for more info (502)893-0187.
 

Thursday, December 11, 2014

Can Astigmatism be corrected with Limbal Relaxing Incision?

Astigmatism is an irregularity in the shape of the cornea. There are degrees of astigmatism that may cause blurred vision even after the cataract surgery has been performed. Low to moderate astigmatism may be corrected by Limbal Relaxing Incisions (LRI) or a Toric IOL.

In LRI, incisions are made at the opposite edges of the cornea, following the curve of the iris, allowing the cornea to become more rounded when it heals. Because the incisions are outside of the field of view, they do not cause glare and other visual effects that result from other corneal surgeries like Radial Keratotomy.

LRIs are often combined with other surgical and laser vision correction procedures and cataract surgery.

It is possible that with LRI astigmatism may remain, requiring glasses for clearest vision. As with any incision, there is a small risk of infection or hemorrhage, which rarely could affect the vision. If there is full thickness incision, it may be necessary to place a suture to achieve a safe closure. Other risks of cataract surgery remain the same. As with any change of your eye's focus, there will be a period of adjustment to new vision and you may still wish to wear glasses or contacts to achieve your best vision.

(At this time most insurances do not cover the cost of LRI and you will be responsible for this additional cost. A toric IntraOcular lens contains both spherical and astigmatic correction. Your surgeon will advise you as to the best form of astigmatic correction for your situation.)

Thursday, December 4, 2014

How to give LASIK for Christmas

So you think you know someone who would love to have LASIK but you haven't thought about actually giving this procedure to someone else as a Christmas gift!

Well, it just so happens that at Koby Karp Doctors Eye Institute we offer "LASIK for Christmas" in one neat package that includes everything - the preoperative consultation, the procedure itself and all medications and post operative follow-up visits. It's truly a complete LASIK package.

And that's not all - you can use our 20% off coupon available on our website along with one of our no-interest finance plans for 12, 18 or 24 months. And it only requires 10% down. Actually, the monthly payments would be as low as $105 per month. We also accept all major credit cards. One more thing - Koby Karp has even come up with a gift certificate and a nifty Holiday gift bag & card that you can put under the Christmas tree!

Sound interesting? Perhaps you may want to talk it over with the person to whom you would like to give the gift of LASIK and even like them to have a free, no-obligation consultation with one of our ophthalmologists to be sure that they are a good candidate for the procedure. That's easy to arrange. No cost involved.

Simply call (502) 897-1604 for more information or to make an appointment for a free LASIK consultation.

By the way, you may want to know that LASIK is now so precise that it is approved by NASA for their astronauts and by the Navy for their “Top Gun” fighter pilots.

Our gift suggestion is LASIK for Christmas from Koby Karp Doctors Eye Institute and it may be exactly the gift you've been looking for!

Wednesday, November 19, 2014

Good Candidate for LASIK

Are you tired of wearing contact lenses? Have you been thinking about LASIK and wondering if you are a suitable candidate for LASIK surgery? Perhaps you want to get rid of your contact lenses and/or glasses. You're not sure you want to talk with an eye doctor just yet, but you have some questions about LASIK. Well, here's a simple test you can take in only a couple of minutes. And you don't have to give any personal contact info. It's simple and it's free. Simply click the link below to find out more.
http://www.allaboutvision.com/visionsurgery/am-i-a-lasik-candidate.htm
http://www.allaboutvision.com/visionsurgery/am-i-a-lasik-candidate.htm
After you have taken the test you're welcome to call us to set up a free, no-obligation LASIK consultation appointment. (502) 897-1604 or 1 (800) 777- 4393.

Wednesday, November 5, 2014

November is Diabetes Awareness Month

This is a good opportunity to emphasize some important points about Diabetes Mellitus and eye health.  In our country, diabetes is the leading cause of visual impairment in working-age individuals.  Many of you may already know this.  Moreover, 60 percent of adults also realize that diabetes may be detectable through a comprehensive eye exam.

Among people who don’t wear optical corrections, like contact lenses or glasses, only about one-third of adults get regular comprehensive eye exams.  A third of the 21 million Americans with Diabetes don’t know it, as they have not had regular medical exams with their primary doctors.  Often during our comprehensive eye examination we uncover some suspicious symptoms or physical findings that lead to the initial diagnosis of diabetes.  Certain symptoms such as intermittent focus difficulties which vary throughout the day, glare at night, distorted or blurred vision and sudden floaters can all point to diabetes. 

We recommend annual eye exams, even with healthy eyes, in all patients over 60 years, all patients with diabetes, patients who use contact lenses and anyone with a significant family history of glaucoma.  It is not unusual to discover diabetes during these examinations.  It is particularly important to check yearly with pupil dilation for those patients who do have a diagnosis of diabetes.  Diabetic Retinopathy can develop in the eyes very gradually and without any noticeable symptoms.  Untreated this can lead to visual impairment or blindness, and it is much more successful with earlier treatment. 

If you have diabetes, or haven’t had an eye exam in a while, consider calling us today to schedule an appointment.  The doctors of Koby Karp Doctors Eye Institute are available to see new patients.  We specialize in comprehensive eye care.  Call Doctors Eye Institute at (502) 897-1604.

Go to our website to learn more about diabetice Eye Disease treament.
 
- R. Scott Hoffman, MD

 

Thursday, October 30, 2014

How Diabetes can be deteced in eye exams.

Christopher Stroud,OD

November is Diabetes Awareness Month

I see patients every day for diabetic eye exams. It is great that they are coming in for these exams, but I find that most of them don’t understand WHY they need yearly eye exams.

High blood sugar weakens the smallest blood vessels in our body (capillaries) by weakening the wall structure. When the wall structure weakens it causes very small breaks or leaks. Although these changes happen all over the body, I can actually look in the back of the eye and see these changes.If these are seen it usually means that the blood sugar has been running a little high for a few months at a minimum. These small leaks can usually resolve on their own if the blood sugar control is improved.

If blood sugar is uncontrolled, or poorly controlled, the probability of complications continues to go up as time passes. Some of these problems include death of retinal tissue, hemorrhage into the eye, and retinal detachments. All of these more serious problems require some sort of surgical intervention or treatment and can cause permanent loss of vision in the effected eye. 

The take home point is that taking care of high blood sugar levels associated with Diabetes helps to avoid complications. The sooner this is done, the better the visual outcome is long term.

Wednesday, October 22, 2014

How to give LASIK for Christmas


Lots of people think that the most fun about Christmas presents is the surprise element. That's the whole reason we wrap them, shake them, try to guess what's in them.
 
So if you'd like to really surprise a special someone on  your list, we have a suggestion for a gift that can give them pleasure for a lifetime!
 
This Christmas give someone you love the gift of LASIK. We offer a LASIK gift certificate that includes a Holiday gift bag and card that's ready to put under the Christmas Tree!
 
We make it easy for gift givers with three special no-interest finance plans that make giving LASIK for Christmas affordable for you. And here's another Christmas bonus - we have a 20% discount coupon on our website that you can use for you LASIK Christmas gift! 
 
Call (502) 897-1604 or come in for complete details from one of our Santa's helpers.
 
 
Angie received the gift of LASIK for Christmas. She says having LASIK at Koby Karp Doctors Eye Institute is one of the best things she has ever done! Listen to her story about how she received LASIK for Christmas.

 
 
 

 
If you want to know more about LASIK at Koby Karp, click here.

Monday, October 20, 2014

Louisville area LASIK testimonials

Thinking about LASIK? Perhaps seeing some video testimonials of others who have had LASIK will help you decide. Some of our patients had different visual problems and conditions before they had the procedure. One of them may be similar to your situation. 

Click on the photo above to watch Chris tell of his LASIK experience and his rewarding outcome. You can also visit our Koby Karp LASIK Page and view more testimonials that detail other patients' individual situations. It can help you decided whether having LASIK at Koby Karp Doctors Eye Institute is the right choice for you.

Wednesday, October 8, 2014

LASIK Questions Answered


David W. Karp, MD
Alber E. Smolyar, MD
Koby Karp Doctors Eye Institute is the leader in LASIK and laser vision correction in the Louisville area.  And due to advances in equipment technology as well as improvements in the procedural techniques LASIK has become even more popular as it continues to allow patients to become glasses-free.  Doctors David Karp and Albert Smolyar of Doctors Eye Institute have been performing LASIK for years and are known for delivering excellent visual outcomes.

If you’re considering LASIK for safe and effective vision correction, you probably have questions about the recovery process. It will likely take a few days or so for your vision to stabilize after LASIK surgery, but you will likely notice almost immediate improvement.

Visual acuity improves dramatically within the first 24 hours in most cases.  In fact,  the day following the procedure the majority of our patients can drive without glasses when they return the next day to see the LASIK surgeon for a postoperative check of vision and healing progress!

The complete post-LASIK healing process typically takes several weeks. During this time it is not unusual to experience a degree of sensitivity to light,  fluctuating vision, glare or halos around light. Also, most people experience some degree of dry eye condition immediately after LASIK. This common side effect can last several weeks or even months after vision correction surgery. 

General guidelines immediately after LASIK include:
  • Do not rub your eyes.
  • Do not wear eye makeup or apply skin lotions near your eyes.
  • Do not swim or use a hot tub.
  • Avoid strenuous activity or contact sports.
  • Contact your eye doctor immediately if you develop new, unusual or worsening symptoms.
  • Use all prescription medicines and artificial tears as directed.
In the video below, Dr. Karp explains the entire LASIK procedure and answers many questions on the topic.
 

If you are interested in LASIK in Louisville please call Koby Karp Doctors Eye Institute at (502) 897-1604. You can also reach us by using the “Contact Us” button on our website main page.

 

Tuesday, October 7, 2014

Best Ophthalmologist in Louisvillle

When people search the internet, they often use the word "best" in whatever category they are interested.

Web searchers might type in "best ophthalmologist in Louisville", "best LASIK in Louisville" or "best Cataract surgery in Louisville".
The question is: can any ophthalmologist, LASIK surgeon or cataract surgeon rightfully claim to be the best?

Fortunately the Louisville area is blessed to have several outstanding ophthalmology practices featuring some of this area's most accomplished Doctors of Ophthalmology.
  
So where does Koby Karp Doctors Eye Institute rank in the standings?
 
We have been pioneers in eye care in the Louisville area for over 40 years. As one of the first to offer refractive surgery and the first to insert intraocular lenses following cataract surgery, we continue to be in the forefront of Ophthalmic technology. Our doctors offer our exceptional expertise in comprehensive eye care, the treatment of eye diseases and outpatient eye procedures.In fact, our own Dr. Scott Hoffman, was voted by his peers to be one of the Top Ten Ophthalmologists in the August 2014 issue of Louisville Magazine. And Dr. Albert Smolyar recently received a Vitals Award Top Ten Doctor Award from vitals.com based on collective patient ratings and reviews of their doctors.
 
It's not a matter of us being the best, it is a matter of you getting the best eye care for your eyes. And that is precisely what we believe we continue to deliver.

So, if we say that you get the best eye care from us, that would simply mean that it is our opinion that "nobody does it better".  And we do have a right to our opinion.
 
At Koby Karp Doctors Eye Institute our goal is to help you see the best you can possibly see. To learn more about us click here.

Friday, September 5, 2014

Are there contact lenses that replace reading glasses?

I have a lot of patients ask me if they could get contacts that would let them get rid of their reading glasses. For most people the answer is yes! Lenses like the Purevision Multifocal and the Air Optix Multifocal offer great vision in a very healthy lens material.

And here's another suggestion: some patients who naturally have good distance vision use just one contact lens for near vision. The result is what we call mono-vision.  One eye sees near and  one eye sees far. What actually happens is that the brain tells the eyes which eye should take over as it learns to use the distance focused eye for distance viewing and the near focused eye for near viewing. The majority of patients who use this method adapt to it in a very short time. It is an amazing example how the eyes and the brain work together.
 
When you use a daily disposable with no lens solution to fool with and you can just toss it whenever you want wherever you are,  it's even more convenient.  You may only wear these lenses occasionally but it’s still a great idea.
 
People often use this "one contact lens" method because they may not want to fumble with reading glasses when they go to a restaurant or shopping. They may want to be glasses free when attending an entertainment venue or sporting event where they might want to read a program or other printed items.  So, they pop in a contact lens and off they go. And when you go on vacation and don't have to chase reading glasses around makes it even more appealing. 


Of course when you set up a fitting with me, I will go over all of the options that are best for you personally. Call to set up an appointment (502) 897-1604
 
- Christoper Stroud, O.D.

 

Monday, August 18, 2014

What is pink eye?

Pink eye (conjunctivitis) is an inflammation or infection of conjunctiva – a transparent membrane that covers the white part of your eyeball. When small blood vessels in the conjunctiva become inflamed, they're more visible. This is what causes the whites of your eyes to appear reddish or pink. This is a very common condition and at Koby Karp Doctors Eye Institute we treat patients with conjunctivitis on daily basis.

Albert E. Smolyar, MD
Pink eye is commonly caused by a bacterial or viral infection or an allergic reaction.

Though pink eye can be irritating, it rarely affects your vision. Treatments can help ease the discomfort of pink eye. Because pink eye can be contagious, early diagnosis and treatment can help limit its spread.
The most common pink eye symptoms include:
• Redness in one or both eyes
• Itchiness in one or both eyes
• A gritty feeling in one or both eyes
• A discharge in one or both eyes that forms a crust during the night that may prevent your eye or eyes from opening in the morning
• Tearing
 
When to see a doctor
Keep in mind that there are other serious eye conditions that can cause eye redness. Typically, these conditions will also cause pain and blurred vision. If you experience these symptoms, seek urgent care.
People who wear contact lenses need to stop wearing their contacts as soon as pink eye symptoms begin. If your symptoms don't start to get better within 12 to 24 hours, make an appointment with your eye doctor to make sure you don't have a more serious eye infection related to contact lens use.
 
If you notice any signs or symptoms you think might be pink eye, make an appointment by calling Koby Karp Doctors Eye Institute at (502) 897-1604. Pink eye can be highly contagious and early diagnosis and treatment can protect people around you from getting pink eye too.
Albert E. Smolyar, MD

Friday, July 11, 2014

Online ads offering $299 LASIK. Is it really bait and switch?

Have you recently seen online ads offering $299 LASIK? Or $695 LASIK? Are you wondering if it is bait and switch?

The answer is yes. It absolutely is bait and switch!

You've heard the adage, "If it seems too good to be true, it probably is." Here is what those come-on ads REALLY mean.

First of all, the $299 (or $695) offer is applicable for one eye and on the condition that the eye needs only one diopter of correction. That would mean that you have almost perfect vision in that eye! So why would you even have LASIK?
Furthermore, if you are wearing glasses or contact lenses, you will likely need a lot more than one diopter of correction. So you can forget the $299. Forget the $695. The surgery for both eyes will cost you a lot more than that.
Actual Pricing

This is how the pricing actually works. For each diopter of correction that is needed, the price goes up (see chart below).  And remember, this pricing is for each eye.
Here's a chart of the charges similar to the ones that many LASIK discounters use. But beware, these prices are specifically for a LASIK procedure using outdated, low tech equipment. It is neither bladeless LASIK, nor the latest Wavefront technology.  That procedure costs a lot extra.


Price range
Prescription Range
$299-$695
Up to 1.0
$695-$849
1.25-2.0
$699-$999
2.25-3.0
$999 and up
Over 3.25
$999 and up
+ Farsighted
 
In fact, if you want the latest, most accurate, high-tech LASIK procedure, the price can be as much as $1049-$1249 per eye added to the prices on the chart. The total amount can be much as 60% higher than what you would pay at Koby Karp Doctors Eye Institute.
Additional Charges

Yes, there can be even more charges. Some cheapie clinics require a non-refundable $100 deposit or a similar charge. In addtion, almost all discount clinics charge extra for follow-up care. That can increase the cost by hundreds of dollars. Some clinics will high pressure potential patients to buy expensive lifetime assurance programs that are not needed. And post operative drugs are almost never included.
After knowing all this, if you decide you still want to visit a discount clinic, we recommend that you get their total price before you agree to the surgery or sign any contract. Then, contact us for a totally free, no-obligation LASIK evaluation. (502) 897-1604 or 1 (800) 777-4393.  

Wednesday, June 25, 2014

Sunglasses not just for looking cool.


Besides making you look super cool, can sunglasses really make a difference in both your vision and your eye health? The answer can depend on what kind of lenses are in the sunglasses you wear. If the lenses offer maximum protection from dangerous Ultra violet rays, then the answer is yes!.

But let's examine the situation more closely. First there are two types of ultra-violet rays: UV-A and UV-B.  Both types of ultraviolet rays are types of radiation.

Just as the sun's radiation can do damage to your skin, it can also do damage to your eyes.

Using the UV index is a great way to rate the effectiveness of the lenses in sunglasses to find out whether or not you're getting the maximum protection that your eyes actually need to guard against the harmful rays of the sun. So you can keep your eyes safe and look cool at the same time.

At Koby Karp Doctors Eye Institute the brands we carry in our Optical Department offer the absolute maximum protection. And we can provide prescription sunglasses that for you that give you maximum protect in your exact prescription. Come see us today! Or give us a call at (502) 893-0187.

 

Wednesday, May 28, 2014

Best options for cataract surgery in Louisville



June is Cataract Awareness Month, so now is a good time to present your options clearly explained.

Intraocular lenses, or IOLs, are implantable devices that replace the natural lens in the human eye, typically after the natural lens has developed cataracts. Cataracts are an irreversible progressive condition that diminishes vision quality.
When cataract surgery is performed the natural lens you were born with is removed.  The new lens we replace it with will determine how you see and what you clearly see. If we use standard Intraocular lenses, the ones that Medicare and many insurance companies pay for, you will have three options:

David W. Karp, MD, F.A.C.S. 
  • Distance option - Both lenses give you distant vision only
  • Close-up option - Both lenses give you close up vision only
  • Mono-vision - One lens gives you close up vision/one lens gives you distance vision.
Premium intraocular lenses, on the other hand, can allow you to see near, mid distance and far distance.

The premium IOL we recommend is the AcrySof® ReSTOR® lens. It was designed to provide quality near, mid-range and distance vision by combining the strengths of what are know as apodized diffractive and refractive technologies. That may sound confusing so let's try to simplify those terms because that apodization is what makes these lenses so special and effective.

First, please understand that similar technology has been used for years in microscopes and telescopes to improve image quality, and has now been patented for use in intraocular lenses by Alcon.

Apodization is the gradual tapering of the diffractive steps from the center to the outside edge of a lens to create a smooth transition of light between the distance, intermediate and near focal points. Diffraction involves the bending or spreading of light to multiple focal points as it passes through the lens. On the AcrySof® ReSTOR® IOL, the center of the lens surface consists of an apodized diffractive optic. This means that the series of tiny steps in that center area work together to focus light for near through distance vision.

Basically, that's about it. It takes more than just bending light to make a multifocal intraocular lens effective and efficient. The lens also has to let in as much light as possible where it is needed and that is precisely what apodization does. Simply put, that's what makes the AcrySof®ReSTOR® IOL the best of its kind on the market today.

If you want to see the best you can possible see with the one and only pair of eyes you have, then we recommend the  AcrySof® ReSTOR® lenses as your smartest option.

The  AcrySof® ReSTOR® IOL, just one more way "We Customize Your Eyes".

Call us to set up a comprehensive eye examination so we can help you choose the best option for you. (502) 897-1604.

Wednesday, May 21, 2014

How Glaucoma Eye Drops Can Grow Eyelashes


Glaucoma is a disorder of the eye in which patients can lose vision due to gradual optic nerve deterioration. The way ophthalmologists treat this is by lowering the eye pressure or intraocular pressure (IOP).

Over the past decade, the most commonly used class of eyedrops for glaucoma has been the daily-use prostaglandin analogues. The currently available medicines are latanoprost (name brand Xalatan and its generic equivalents), bimatoprost (Lumigan), travoprost (Travatan), and most recently tafluprost (Zioptan). These work on a cellular level to reduce production of fluid within the eye and increase the outflow, thereby lowering the IOP. All of these have been found to have some minor side effects, including eyelid darkening, eye redness which is often temporary, iris darkening, eye irritation and eyelash growth. Women who use these drops are often pleased by the thicker, fuller eyelashes that can result. The makers of Lumigan have created the product Latisse, which is basically the same medication packaged with a brush for placement on the eyelid skin near the lashes.

In 2008, Latisse was approved by the FDA for the treatment for eyelash hypotrichosis, meaning inadequate, sparse or insufficient eyelashes. This condition can occur as eyelashes are pulled off from repeated wearing of false eyelashes or simply breaking off. When Latisse is applied once daily to the base of the eyelashes, growth of lashes can be seen within 8 to 16 weeks, which represents the hair cycle of the eyelash.

Daily use of these glaucoma medicines has a similar effect on eyelashes; in fact, this is how it was discovered. Other adverse side-effects include eye inflammation, swelling in the retina which could affect vision, and darkening of the iris, which is not reversible. These occur very rarely, whereas eyelash growth is so common, it is expected. So here is a circumstance where one “side effect” or “adverse reaction” has yielded positive results for many women seeking to grow longer and thicker eyelashes.

- R. Scott Hoffman, M.D.