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Yearly Archives: 2011

Happy New Year!

Dear Friends,

This is my favorite week of the year.

I love that my older two are back from school, we have no hockey scheduled, I take a few days off, etc.  It’s a nice break from the routine.

I wish you all a very Happy New Year!

Stay well.


Silicone Oil for Retinal Detachments

Silicone oil is used for recurrent retinal detachments or complicated retinal detachments including PVR (proliferative vitreoretinopathy).  It can be a valuable tool to prevent blindness.

Most retinal detachments are caused by a retinal tear, or hole, in the retina.  In either case, this allows for communication between the vitreous cavity and the potential space underneath the retina.  Fluid may leave the vitreous and accumulate underneath the retina, causing a rhegmatogenous retinal detachment (rhegma = with a hole).

A vitrectomy with gas with or without a scleral buckle are common ways to surgically repair retinal detachments.

Recurrent Retinal Detachments

Occasionally, a retina can redetach and usually shortly after the first surgery.  Common reasons include an additional retinal tear, or, it is conceivable that an extra tear(s) was overlooked and not treated.

Options include repeating the vitrectomy with gas and possibly adding a scleral buckle if one is not present.  This usually does the trick.

Recurrent Detachments and PVR

Repeated retinal detachments due to additional tears usually persuades me to consider using silicone oil to fix the detachment.  In addition, a condition called proliferative vitreoretinopathy (PVR) often requires using silicone oil.

PVR can cause retinal detachments as membranes (scar tissue) form on the surface of the retina and start to pull.  This pulling can cause multiple retinal tears.

How Intraocular Gas Fixes Retinal Detachments

Intraocular gas works by “plugging” the retinal tears or retinal holes.  The gas bubble, when properly positioned against the tear/hole, prevents fluid from getting underneath the retina causing a recurrent detachment. As the gas is absorbed, the bubble will become so small that any untreated or new hole will be uncovered.  Thus, the retina can detach again.

How Silicone Oil Repairs Retinal Detachments

Think of silicone oil as a non-absorbable gas bubble.  Since the silicone oil is not absorbed, it stays large enough to always cover the holes.  This makes it highly unlikely that a redetachment can occur.

Is Intraocular Gas Better than Silicone Oil

Normally, intraocular gas is preferred as it eventually absorbs after reattaching the retina.  A separate procedure is not required to remove the gas.

Silicone oil does require removal and the vision is usually poor with the oil in the eye, however, when warranted, the oil is likely to prevent re-detachment.

What Does This Mean?

Silicone oil is a great tool to repair retinal detachments.  Repeated operations can be mentally straining and can be a hardship on the patient and family.  Also, with each new detachment, the likelihood of permanent vision loss increases, thus, the fewer detachments the better.

Too many retinal physicians, using silicone oil is a last resort to keeping the retina attached.  Often doctors wait until the retina has detached 3-4 times before considering oil (in fairness, I used to be one of them).

My belief is that oil should be used earlier to stop the vicious cycle of re-detachment and re-operation.  By preventing recurrent detachments, the vision can be better preserved in these complicated cases.

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Retinal Tears and Vitreous Hemorrhage

Vitrectomy for Retinal Tear to Remove Vitreous HemorrhageA vitreous hemorrhage may be caused by a retinal tear.  Sometimes there is so much blood in the eye that direct examination is impossible and we can only guess at the most likely cause.  It is the most difficult situation for me to handle as a doctor.

Patients lose significant vision as the blood in the middle of the eye physically blocks all light from hitting the retina.  While this is usually not permanent visual loss, the blood makes it difficult to make a definitive diagnosis as it can be impossible to see the retina.

Normally, without blood in the eye, a retinal tear may be easily diagnosed and treated with laser.

While there are other causes of vitreous hemorrhage, such as diabetic retinopathy, retinal vascular disease and others.  Still, a retinal tear causing the vitreous bleeding is quite likely.

Retinal Tears Cause Retinal Detachments

A retinal tear can cause a retinal detachment.  A retinal detachment is potentially blinding.

In cases of vitreous hemorrhage, the patient cant’ see “out” and I can’t see “in.”  My ability to examine the eye is hindered.

Options at this point are to observe (i.e. do nothing).  Observing the eye is okay as the blood is doing no harm.  But what if there is a retinal tear?  A retinal detachment could occur if there is an undiagnosed retinal tear.

Other tests, such as an ultrasound can often detect a large tear, but it is not as good as directly examining the eye.  Operating to remove the blood to facilitate proper examination is an option, too.

What Does This Mean?

I am getting older, more aggressive, but smarter.

As I have aged, i.e. gained more experience, I have become more comfortable operating in these cases.  When I was younger, I would often hesitate because I was uncomfortable offering surgery in a situation where surgery might not be necessary, but I’ve learned (through experience) that watching a waiting can be more problematic.

Most of the time I recommend operating to at least remove the blood and confirm a diagnosis.  The risks of modern vitrectomy are quite low, while the risk of a retinal detachment occurring while we are waiting is quite possible.

Vitrectomy surgery is usually performed as an outpatient.  If a tear is indeed present, it can be treated simultaneously.

At the very least, a diagnosis can be made and a potentially blinding condition avoided.

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Eylea As Good As Lucentis

Last month, the FDA approved Eylea (VEGF-Trap, aflibercept) for the treatment of wet macular degeneration.  The new drug does not need to be injected as often as Lucentis, yet it seems that the visual improvement is the same; that is, fewer injections yield similar improvement in vision…for the first year of therapy.

Keep in mind that we are always interested in a drug’s ability to improve vision, and sustain these improvements.

Eylea Improves Vision and is Sustained

This week, results from patients receiving these eye injections for a second year were reported.  It was disclosed that little benefit was seen between the two drugs for the second year of treatment, i.e. the visual results were sustained and comparable.

During the second year of treatment, both drugs were given “as needed” in contrast to the first year with regimented dosing;  monthly injections for Lucentis and bimonthly for Eylea.

Stock Drops After News

Regeneron’s stock (Regeneron manufactures Eylea/aflibercept) apparently plummeted after the news.  Wall Street seems disappointed that the the new drug may not be as cost effective nor as convenient as initially hoped.

What Does This Mean?

I think this validates the new drug.  The study confirms that visual improvement is indeed achieved with Eylea and is also maintained.

Clearly, I expect that Eylea will yield the same visual results over the first year of treatment, yet requiring fewer injections.  This means fewer trips to the doctors, fewer diagnostic texts, fewer rides from family and friends.

The data recently presented only confirms that Eylea works.  Remember, few drugs, including Lucentis, are actually used in the same fashion as when they were FDA approved, that is, we should be happy that Eylea improves vision for the 2nd year…nothing more.

More convenience, equal results, cost savings (from fewer office visits) can be translated into improved compliance (patients willing to continue treatment) and that also means MORE patients may be willing to undertake treatment!

This is exciting!

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Happy Thanksgiving

I wish all of you (almost 10,00o uniques!) a very happy Thanksgiving!

For our international readers, I’m including you, too 🙂

Please enjoy your time with friends and family.


EYLEA (aflibercept): New Treatment for Wet ARMD Approved!

Eylea Approved for Wet Macular Degeneration


On Friday (11/20), the FDA approved Eylea for the treatment of wet macular degeneration.  Eylea is another anti-VEGF based treatment designed for intraocular injection.

Eylea has several names.  Eylea is also known as VEGF Trap-Eye.  The generic name is aflibercept.

Eylea = VEGF Trap-Eye = aflibercept

VEGF Trap-Eye Works With Fewer Injections

Several pivotal studies suggest Eylea and Lucentis to be equally effective in treating wet macular degeneration.  Of note, however, is that Eylea may require fewer injections to save the same amount of vision compared to its largest competitor, Lucentis.

Recommended dosing for VEGF Trap-Eye is an injection every 8 weeks following 3 initial monthly injections.  This is compared to Lucentis which was FDA approved for monthly injections.

Delivered by Eye Injection

As with the other macular degeneration treatments, Lucentis and Avastin, Eylea will also be delivered as an intraocular injection.  The most common side effects include:  subconjunctival hemorrhage (benign, but scary looking, bleeding outside the eye), eye pain, cataract, posterior vitreous detachment, vitreous floaters and increased intraocular pressure.

What Does This Mean? Not sure.  We have to wait and see.

Submitting a new drug to the FDA seems to involve some gamesmanship.  It seems that smart companies, such as Regeneron, apply for approval of drugs that offer a new advantage over already approved medicines.

Thus, Eylea’s major advantage seems to be that fewer injections are required to gain the same effect as Lucentis (and possibly Avastin).  Think of the convenience and cost savings!

At the very least, if true, fewer treatments means better compliance!

For the very acute readers, you noticed that I compared Eylea dosing to Lucentis dosing at every four weeks.  If you have followed the actual usage of Lucentis over the last few years, Lucentis is not always given every four weeks although Lucentis was FDA approved at every 4 week dosing.

In fact, the regimen seems to have diverged in some areas of the country from every four weeks to development of an “induction” period (mandatory series of shots) and then a “treat as needed” period.

The point is that once FDA approved, the way we use a drug may change as we learn through clinical “practice” what seems to work best.

So.  Let’s see what happens with the Eylea claim of 8 week dosing.  It would be a tremendous advantage to have a product that yields the same result, but requires fewer injections, that is, fewer trips to the office!

Fingers crossed.  I wonder if it will be twice the price of Lucentis?


Still No Iluvien

FDA Denies Alimera Sciences' Iluvien for Treatment of Diabetic Macular Edema


Alimera Sciences fails to get FDA approval for Iluvien.  Iluvien is a sustained release drug delivery system that releases a steroid into the eye for the treatment of diabetic macular edema.  Alimera received the denial late last week in a letter from the FDA.

Implant Too Risky

In short, the FDA still has concerns about the safety of the new drug.  Original concerns about cataract formation and IOP (intraocular pressure) still remain despite additional safety data submission.  The FDA has stipulated additional clinical trials must be performed to answer the risk/benefit concerns.

Iluvien was anticipated to be the second sustained release drug for the treatment of a retinal disease.  The first drug, Ozurdex, was approved by the FDA for treatment of retinal vascular occlusions (e.g. CRVO, BRVO).  Ozurdex received FDA approval in 2009.

Docs Need Options for DME

Iluvien was to be indicated for the treatment of diabetic macular edema, a very common complication of patients with diabetic retinopathy.  Typically, patients receive laser treatment as a first line treatment, but alternative treatments have been long needed as laser can not be performed in everyone.

Intraocular injections of steroid or anti-VEGF medications such as Avastin or Lucentis, have also been used to treat diabetic macular edema over the past several years, but the use of these agents is “off label.”

The sustained release device is injected into the eye and will release a steroid, fluocinolone, for up to 36 months.  Shorter acting steroid injections have demonstrated favorable results and it was anticipated that a sustained release system might offer a realistic benefit of better drug levels and little need for reinjection.

What Does This Mean? Certainly, I am not in a position to remark about the FDA decision. There are many patients in whom laser is not an appropriate treatment.  There is no FDA approved alternative.  Ophthalmologists, including myself, have been using short acting steroids and anti-VEGF injections to treat these “no laser” patients.

Moreover, Iluvien would have validated sustained release drug delivery systems.  Ozurdex was first and Iluvien would have been the second delivery system designed for injection into the vitreous.

A second approved product, regardless of indication, would have been a significant endorsement for injectable sustained release systems.  Sustained release devices for macular degeneration (sustained release drug delivery of anti-VEGF), post-operative medications and glaucoma seem logical.



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Back from the AAO

Amy and I got back from Orlando, last week.  We attended the American Academy of Ophthalmology annual meeting, the world’s largest gathering of ophthalmologists and those associated with our “industry.”  It’s our huge trade show.  For us, we got some national exposure for our new company.

Telling a Story

You may remember that we received a nice endorsement from the AAO earlier in the year.  The endorsement came in the form of acceptance of our lectures (4) and and invitation to address young doctors about marketing.

In short, we told everyone about what we are doing here at

We told the story of how we started, how it has benefited my practice (patients arrive internationally and nationally), how we use the site to educate patients (real and virtual) and it has become a valuable tool in developing relationships with my patients and my “tribe” (those that follow this site…um, that means you!).

Teaching More than SEO and Social Media

While the courses topics ranged from choosing a URL to implementing social media via a blog, we were advocating some very simple points;

1.  If You Have No Website, You Don’t Exist: Patients have become empowered by the Internet.  Long gone are the days where a patient will blindly take the “referral” of one physician from another.  Today, patients want to select their doctors based on their own criteria.  The easiest way to search is to use Google, but you (my readers) know this.  If a doctor has been recommended, but a website can not be found (or is old and stale), patients will never call to make an appointment.

2.  Doctors need Transparency: There are two types of transparency that physicians must display, personal and business.  Personal transparency means that a doctor must display some attributes of being human.  This personal transparency means that doctors should share a bit about their personal side to which patients (as other humans) can relate.  Patients want to relate to their doctors.

As an example, a doctor listing his/her hobbies is much more engaging than listing the elite academic achievements to which noone else can relate (even other doctors).

Every other business in every other industry, except medicine, opens itself to public criticism and evaluation.  Movies, books, restaurants all go under review of the public.  Doctors must get used to the notion of operating this type of transparent business.

3.  Serving the Public Good. The only way a medical practice can use a website as an effective marketing tool is to publish credible health information.  While over 80% of the public turns to the Internet first for health related questions, there is a paucity of reliable information (you know this, too!).

If every doctor were to publish/write on their own sites, they would get the rankings they want …and the public would get the answers they need.  Best of all, this means that the quality of health information available to the public improves.

What Does This Mean? We got validated.  We met so many doctors trying to learn how to engage the Internet, to make their websites useful and to learn how to build relationships.  We were appreciated and really became to feel that we are leading a movement…..maybe we are.








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October is the AAO Meeting

We are leaving for Orlando, FL in a few days to attend the American Academy of Ophthalmology meeting.  It is our industry’s largest meeting of the year…worldwide.

The meeting has become so large that only a certain cities can host the event;  Atlanta, Dallas, Chicago, San Francisco, Las Vegas, New Orleans and Orlando.  Literally tens of thousands of people will attend;  doctors, administrators, technicians, vendors, etc.

This will be the largest collection of eye related people anywhere in the world.

New scientific discoveries will be announced, new products for patients will be displayed, advanced technology will be highlighted, and hundreds of courses will offered. It’s a huge showcase for anyone related to “eyes.”

We, too, are going to launch MME.

Iluvien Has New Data for the FDA

It is anticipated that Alimera will announce successful completion and submission of some long-awaited data to the FDA.

Alimera Sciences has been trying to obtain FDA approval for a sustained intraocular drug delivery system called Iluvien.  This is similar to Ozurdex (Ozurdex is used for the treatment of retinal swelling due to vein occlusions).

Iluvien will release steroids inside the eye for a period of months to control diabetic macular edema.  It is anticipated that this last bit of data will satisfy the FDA and prove that it is indeed safe and effective.

Stay tuned.

Treatment of Macular Degeneration

I don’t think there will be any earth shattering news in this field. VEGF-Trap Eye is probably going to get some press as this is another drug that promises to be quite effective in the treatment of wet macular degeneration.

VEGF-Trap Eye, or afilbercept, is a compound similar to Avastin and Lucentis, but may need to be injected less often than the aforementioned.

Medical Marketing Enterprises

This is our baby.  Amy and I are very excited.  We will be teaching no fewer than 4 courses on medical marketing using websites, blogs, SEO and social media.  There are only about 10 courses offered in total!

I have been invited to address the “Young Ophthalmologists” about marketing.  This group is comprised of young doctors who are still in training (aka residents, fellows) or those who have been in medical practice fewer than five years.

What Does this Mean? I’ll be wearing several hats this time.  I’ll be wandering the floors and attending lectures to learn more about being a retinal specialist.

On the other hand (or under another hat), Amy and I’ll be teaching other doctors how they, too, should create websites such as this to enhance patient education, improve the Internet, and provide marketing solutions.


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Floater Only Vitrectomy: No Different than Cataract Surgery

Vitrectomy eye surgery can remove floaters.  So-called “floater only vitrectomy,” or “FOV” is a comparatively simple procedure compared to other operations a retinal surgeon can perform.

Floaters Can Reduce Vision

While these are common, most people are able to tolerate them over time.  There are, however, patients that have floaters so large and dense that the vision is reduced.  (Remember, the acute onset of floaters needs to be checked out to ensure that you don’t have a retinal tear!)

A vitrectomy is part of most surgery performed by a retinal specialist.  Usually, however, the vitrectomy is performed to allow repair of a macular hole, removal of an epiretinal membrane (video of vitrectomy and then removal of ERM) or to fix a retinal detachment.  The purpose the operation is to remove the vitreous, thus allowing surgery to be performed on the retina.

Floaters reside within the vitreous.  Thus, with FOV, these offending “spots” or “cob webs” are removed as the vitreous is removed.  The operation is then complete!

Vitrectomy for Floaters is Safe

Many physicians do not recommend this surgery, but would recommend cataract surgery.  This makes little sense.  The reasons include hesitation to operate on an otherwise healthy and normal eye, but for some reason this same reasoning does not apply to cataract surgery.

Risks of vitrectomy surgery include blindness from infection or retinal detachment.  These risks, however, are the same as having cataract surgery or any other eye surgery.  In fact, the risk of infection with this retinal operation is lower than cataract surgery.

Indications for Vitrectomy are the Same As Cataract

Patients interested in cataract surgery choose to do so when the vision is decreased and it interferes with their daily activities and hobbies.  Cataract surgery is performed to remove the cloudy lens and restore the vision.

Patients who have decreased vision from floaters can also have their vision restored, when they, too, experience decreased vision and understand the risks of surgery.

Alternatives to Vitrectomy

In my view, the only alternative is observation, that is, do nothing.  There are a few doctors who advertise the use of a laser to break up floaters, but it is usually not covered by insurance, nor are the performing doctors retina specialists.

What Does This Mean? There is hope for those who have decreased vision from floaters.

Most patients have been told, over and over again, that they just have to “live with it.”  As long as patients understand the possible complications and are sure that we are dealing with true floaters, the procedure is a possibility.  This summer alone I have had several patients travel from around the country seeking help.

For doctors that don’t agree with me, the decision to perform a “floater only vitrectomy” is no different that making the decision to perform cataract surgery.  Complications are few and can happen in either case, yet in both instances, the patient sees better.

So why suffer?



Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different's a different arrangement, but it allows more continuous care with many eye specialists. In addition, I am very accessible via the web. To schedule your own appointment, call any of the numbers below.

Virginia Lasik | Office of Anh Nguyen, M.D.
Randall V. Wong, M.D.
Contact: Layla

A: 431 Park Avenue, Suite 103 • Falls Church, Virginia 22046
Ph: 703.534. 4393
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Dressler Ophthalmology Associates, PLC
Randall V. Wong, M.D.
Contact: Ashley (Surgery/Web)
Chrissy Megargee (Web)

A: 3930 Pender Drive, Suite 10 • Fairfax, Virginia 22030
Ph: 703.273.2398
F: 703.273.0239
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