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Tag Archives: Eye Disorders

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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Sometimes the Disease Wins

I have a patient, already blind in his right eye, who just suffered his third retinal detachment in the last 2 months in his remaining, left eye.  I am operating, again, to try and prevent his going totally blind.

I trained with a world famous and world class mentor, Steve Charles, M.D. of Memphis, TN.  My fellowship lasted a year, where I learned my specialty, and some lessons, that will last a lifetime.  Among the lessons learned…”sometimes the disease wins.”

Retinal Disease Often Means Lost Vision

Retinal disease often leads to permanent loss of vision.  Sometimes mild, yet often, significant loss of vision.  As a young physician I remember tending to believe that I might just be the one “super hero doc” who was better than most.  I remember thinking that maybe my surgical results would be better than any others.

As a practicing physician of 18 years, I know, and have witnessed, so many times that outcomes are not what we had hoped…despite perfect surgery and treatment.  I have learned to respect eye disease.  Doctors don’t always “win” as there is no such thing as a “perfect surgical outcomes.”

Poor Outcomes are Disappointing

Poor surgical outcomes may be defined as results that are less than perfect.  In my case, I often perform surgeries that were technically perfect, yet the visual results are disappointing.  Nothing went wrong, but it is just the nature of the disease.

Doctors Are Still Not Perfect

In this highly technological age, with advances such as Avastin, laser surgery, Ozurdex, etc., it’s hard to tell patients that we are not perfect and results can not be guaranteed.  In fact, it’s hard to tell patients that despite our best efforts and intentions, outcomes may be disappointing.

Medical care, especially surgery, gives us the opportunity to alter the natural course of a disease.  For instance, the natural course of a retinal detachment is blindness.  The success rate of retinal detachment surgery is about 95%.  This means that 95% of the time we are able to reattach the retina and prevent blindness.  This does NOT mean that 95% of the time patients we well.

The eye disease still wins 5% of the time.

What Does This Mean? What Dr. Charles taught me, was that I shouldn’t (and physicians as a whole) take poor outcomes on a personal level.  This is easier said than done.

With time, I learned how to do this.  Perhaps this is manifest in my “explanations” that highlight the potential pitfalls of a particular disease.  Through education, I hope to convey my expectations and hope they are aligned with my patients, because I have learned that “sometimes the disease wins.”

With my particular patient above, I saw him Saturday morning.  While his retina is now reattached, it must remain this way for before we can have some hope.  Right now, his eye disease is winning.

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How to Diagnose Macular Degeneration

Unlike the diagnosis of diabetic retinopathy, a patient with macular degeneration must have symptoms of the disease for the diagnosis to be made.  In most cases, the retina should have characteristic “damage,” and, most importantly, the patient must be having symptoms, i.e. decreased vision and/or distortion.

In Whom We Make the Diagnosis

Patients afflicted with macular degeneration are almost always greater than 55 years old, show signs of the disease, often of northern European ancestry and have decreased vision and/or distortion.

The disease is progressive and, in most cases, affects both eyes.

Symptoms of Macular Degeneration

As I wrote last week, a patient with diabetic retinopathy may not have anything wrong with their vision, that is, they may not  have symptoms.

A patient with macular degeneration must have visual symptoms.

What are Drusen?

Some of the hallmarks of macular degeneration include the presence or absence of pigmentary changes, fluid, blood and drusen.

Drusen are creamy white spots within the layers of the retina.  There are two types, hard and soft, but both can be associated with macular degeneration.  They are not diagnostic of the disease, but many non-retina physicians know this.

Drusen may be present in the retina without other evidence of degeneration.  Drusen may be normal.

Fluorescein Angiography is Diagnostic

As with any retinal disease, a good dilated pupil exam is necessary to look at the retina.  If there are no signs of the disease, the vision is good, no further testing is needed.

If there are signs of the disease, then a fluorescein angiogram should be performed.  This test involves injection of a dye into your arm.  The dye travels to the retina and pictures are taken.  A fluorescein angiogram is a great test for showing just how healthy, or unhealthy, the retina can be.

A fluorescein angiogram can diagnose macular degeneration.

What Does This Mean? In contrast to diabetes, where patients must be examined routinely due to the potential of a lack of symptoms, macular degeneration patients don’t benefit from routine examination if they have no symptoms.  (I am not saying don’t get an eye exam as many people are unaware of having vision loss!)

By definition, macular degeneration damages the macula.  Therefore, if present, there should be changes in the vision.

In cases of suspected macular degeneration, diagnostic tests are available.  At times, patients can look like they have ARMD, yet have normal vision.  As this is a progressive disease, those that are suspected of developing the disease should be followed regularly in years to come.

A normal fluorescein angiogram can also determine if drusen are normal, or associated with the disease.

As always, see your eye doctor if you develop any persistent decreased vision or distortion (symptoms continuously present for more than one day).

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How To Diagnose Diabetic Retinopathy

The retina is the only part of the eye affected by diabetes.  The only way to diagnose diabetic retinopathy is by direct visualization of the retina.  Your eye doctor should be able to dilate your eyes and, by simply looking at your retina, diagnose the disease.  That’s all.

No Symptoms of the Eye Disease

Symptoms are the effects of a disease.  These are what a patient feels, not what a doctor sees.  Complaints of blurry vision, pain, shortness of breath, nervousness…all are types of symptoms.

The disease, diabetic retinopathy, can cause mild blurriness to complete blindness, or nothing at all.  Many patients see perfectly, yet have the disease.  They just don’t know it.

This is the danger of diabetic retinopathy.  Just like high blood pressure, it may cause absolutely no symptoms.

No Diagnostic “Tests”

A normal eye exam does not always include dilation of the pupils.  Every diabetic patient must have the pupils dilated at least annually.  These are the recommendations of the American Academy of Ophthalmology and the American Optometric Association.

Why?  A dilated exam is the only way to examine the retina.  A dilated exam is the only way your doctor  can “see” the characteristic changes of diabetic retinopathy.  There are no diagnostic tests for diabetic retinopathy.

In the absence of symptoms, the diabetic retinopathy can still be diagnosed.  Early detection means preventing loss of vision.

Fluorescein angiography and OCT (optical coherence tomography) are used commonly to study some of the aspects of your retina (i.e. is there retinal swelling?), but neither are necessary for the diagnosis.

The only way to diagnose diabetic retinopathy is for somone to “see” it.

What Does This Mean? Diabetic eye disease can be “silent.” Many people believe that the absence of symptoms means the absence of disease.  Obviously not true.

The patients with whom I have had the most trouble (i.e. they go blind despite my intervention) have had either no symptoms or ignored themselves for an extended period.  Certainly, they never had an eye exam until it was too late.

Sadly, in almost all cases, the blindness could have been prevented if someone had just “looked.”

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Your Eye Treatments

Eye drops are the most common form of medication for your eyes.  There are also ointments (aka salves), pills and injectable medicines.  The eye is unique in the many ways.  It can be treated directly with medicines.  Eye drops and ointments are the most common.  Medications given by mouth or intravenous usually don’t get into the eye well, due to the blood brain barrier.  Direct injection of medicine into the eye is probably the best for treating problems inside the eye (e.g. the retina).

Eye Drops

The skin is the only other organ in the body where the medication is placed directly upon it.  We use lotions and creams to treat ailments and diseases of the skin.

Eye drops, too, are placed right where we want them.  These drops commonly treat infections, fight glaucoma, lubricate, reduce inflammation, etc.  Eye drops are best suited for problems that develop outside, that is, on the surface, of the eye.  They aren’t so useful for treating diseases in side the eye as the drops do not penetrate the eye very well.

Each eye drop has a volume of about 32 microliters.  The volume of the surface of the eye is about 28 microliters.  These are approximations, but my point is that for most eye drop medications, the volume of one drop exceeds the amount of liquid that can be “held” by the surface of the eye.

This means that whatever the medication, never use more than one drop, or, the excess will roll down your cheek…it is a waste.  I have always recommended that if the directions recommend the use of more than one drop at a time, don’t buy it.  The manufacturer knowingly advises you waste a portion of the product.

A  more practical view?  Often patients are directed to use more than one different type of eye drop.  Separate the drops by a minute or two to prevent the first being washed away (and down your cheek) by the second drop.  Give the first drop time to be absorbed.


There are fewer medications available in ointment form.  The advantage of an ointment, or salve, is the effects may last a bit longer.  Once applied, the ointment heats up.  As it nears body temperature, the ointment melts and releases the medicine over the ocular surface.

Ointments; however, are somewhat greasy, difficult to apply and, most of all, generally blur the vision.  Patients don’t like to use them, they are messy and they can’t see.

Eye ointments are great for eye lid problems and for cases where lubricating the eye requires more than just drops (e.g. just before you go to bed).

Intravenous Medications

Rarely used in the office setting, intravenous medications can be used when there are eye and systemic complications that need to be treated.  Beyond the scope of this article, intravenous medications may be used to treat certain infections, bacterial and viral, that are out of control (e.g. herpes, CMV, syphilis).  Still not much drug finds its way into the eye even whe given I.V.  The “blood-brain-barrier” prevents many drugs from getting inside the eye.  This is a unique problem of the eye and the brain.


Tablets and pills are sometimes used to treat certain types of inflammation, occasionally eye pressure and only a few types of infections.  This route, too, fails to get large quantities of medicine inside the eye, again, due to the blood brain barrier.

Intravitreal Eye  Injections

Most of the advances in treatment for macular degeneration and diabetic retinopathy involve intravitreal injections.  Injecting anti-VEGF medications and steroids have given us new ways to treat these two common retinal diseases.  This circumvents the the “blood brain barrier.”

Sustained Release Drug Delivery

This category is really a subset of intravitreal injections.  These devices will be injected into the eye and release drug over many months (bypasses the blood brain barrier).  Right now, Ozurdex, is the only FDA approved system.  It releases steroid for the treatment of retinal vascular occlusions.  Other sustained release systems are in the pipeline.

What Does This Mean?

Depending on the malady, topical eye drops and ointments are probably best suited to treat disease outside the eye.  They have the advantage of being applied directly to the target tissue.

Similarly, by directly injecting medicine into the eye to treat retinal disease, intravitreal injections share the same advantage; namely, directly applying the medication to the target.

While the main thrust of this web site focuses on retinal disease, don’t forget that eye drops were really the first time we could apply medicine directly to the eye.  History has taught us that this is a very effective method.  This makes for an exciting future for the treatment of retinal disease.

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Iluvien Treatment for Diabetic Macular Edema

Iluvien gets closer to FDA approval for treatment of diabetic macular edema.  Earlier this week, I wrote about emerging treatments for diabetic retinopathy.  Of the group, Iluvien is now the most likely to be available.

Alimera Sciences has filed for NDA (New Drug Application) for Iluvien.  In March, the company announced the favorable results in their clinical trials for the FDA.  The NDA is the last step for FDA approval.

Iluvien Releases Steroid

Iluvien is a sustained release drug delivery system.   Similar to Ozurdex, the delivery system will release steroid after injection into the eye.   (Ozurdex is presently FDA approved for retinal vein occlusions, not diabetic retinopathy.  The makers of Ozurdex are hopeful that it may be used for diabetes.)

The steroid released by Iluvien, fluocinolone, will last for 24 months after injection.  The vehicle will remain in the eye after the drug is released.

Alternative to Present Treatments

The present treatment for diabetic macular edema involves laser treatment, anti-VEGF injections and/or steroid injections.  The laser treatment has limited applications, that is, it can’t be used in all patients and also doesn’t work as well as any of the injections.

The injections, on the other hand, don’t last long and need to be repeated.

Iluvien may obviate the need for repeated treatments and offer significant improvement in vision compared to the standard laser therapy.  With fewer injections, there is less chance of infection.

What Does This Mean? Ozurdex was FDA approved about one year ago.  The significance of Iluvien’s NDA is the validation of the advantages of intraocular sustained release drug systems.

All emerging treatments for diabetic macular edema involve injections.  All seem to offer superior treatment compared to the standard of care, laser photocoagulation.  A sustained release system for diabetic retinopathy will change the way we treat this very common eye disease.

The introduction of Iluvien is estimated to be towards the end of the year according to this week’s press release.

I can’t wait.

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When To Stop Your Eye Treatment

The decision to stop your eye treatment for wet macular degeneration should be easy…and guilt free.  The anti-VEGF injections (treatment for wet macular degeneration) require multiple injections and many trips to the office.  Injections are often recommended for over a year.  It can be a real hassle and becomes a hardship for the friends and family… and sometimes the goals of the therapy seem “blurry.”

Recommended Treatment for Wet Macular Degeneration

Whether the treatment entails Avastin, Lucentis or Macugen, the present recommendations are about the same.  All are recommended to be given as a series of injections, every 4-6 weeks for at least a year.

Instead, I usually recommend that a patient, and their family, consider making a commitment to an initial set of 3 injections and then consider additional treatment.  At my practice, this means 3 trips to the office spaced 6 weeks apart over 12 weeks.

After the 3rd injection, I recommend re-evaluation 6 weeks later.  Two things can happen; the patient has improved or the patient has not improved.

Patients Who Have Better Vision

Patients who have improved are now highly motivated to continue the injections.  The success speaks for itself, the patient is aware of the benefits (i.e. improved vision) and we continue with the intraocular injections.   If the leakage has stopped, we monitor for recurrence. 

In general, the better the vision, the more vigilant we are about monitoring and the more aggressive we are about the injections.

It is an easy decision to continue treatment.

Patients Who Don’t Get Better Vision

Patients who don’t get better vision may have some tough decisions to make.  Should treatment continue?

Often, the patients that have not improved after the initial injections consider dropping the injections.  After 3 injections the vision should have improved and/or I can tell if the treatment is working.  Why continue treatments if it isn’t working after 3 injections?

I am likely to agree with stopping especially if the vision is much worse than the other, non-treated, eye.  In these situations where one eye is always going to be worse, regardless of additional treatment, is there value to more shots?

Practical Concerns

Regardless of the age of my patient, I like to have someone else drive them to the office on “injection day.”  I don’t want my patients driving after receiving an injection into their eye.  It may be too distracting while they drive.

Often this means a family member must take time off from work.  Doctors are not always mindful of the burden these treatments may put on a family.

Doctors Support Patient’s Decision

Doctors should clearly state that continued treatment is unlikely to improve the vision.  This should relieve the guilt of not continuing treatment.  A doctor’s job is to educate well enough so that a patient is able to make qualified, and informed,  decision.

What Does This Mean?  Treatments for wet macular degeneration are great.  The anti-VEGF medications work really well, but there is a down side.

The treatments requires many office visits and can last more than a year and requires a lot of support/help from family and friends.  They also don’t work in every case.

So many patients feel obligated to their doctor to continue their treatment.  The solution would be easier to the make, if , many times, the doctor would remove the guilt. 

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Sudden Vision Loss is Painless

True sudden vision loss can occur from a variety of reasons and are considered emergencies.  Most commonly retinal disease is the culprit.  Almost all causes of are painless.  While both macular degeneration and diabetic retinopathy can lead to blindness, they both usually do so slowly.  There are exceptions.

Vision Loss from Diabetes

Vision lost from diabetic retinopathy is usually due to macular edema and is very slowly progressive.  Diabetic retinal detachments can also blind, but these, too, occur slowly.

A vitreous hemorrhage can occur in minutes although the sight is only temporarily affected.

Wet Macular Degeneration

Compared to the dry form of the disease, wet macular degeneration is rapid, but does not usually cause abrupt loss of sight.  The vision loss can be rapid, say over a period of days or weeks.

Sometimes, the neovascular membrane (the “wet” abnormal blood vessels) can bleed within the retinal tissue and cause sudden loss of vision.

Vitreous Hemorrhage

One cause of bleeding into the vitreous is diabetic retinopathy as stated above.  Other causes can include a retinal tear.  There are a few other causes, but are very uncommon.

By the way, patients on blood thinners generally do NOT develop a vitreous hemorrhage.

Vascular Occlusions

Both retinal vein occlusions and retinal artery occlusions can cause instant loss of vision.

Retinal Detachments

Usually rapid loss of vision, but not sudden.  A retinal detachment can cause rather quick progressive loss of vision starting with the peripheral vision moving centrally.  This can occur over a day or two, but not minutes.

Corneal Abrasions

This may be the only exception to the painless statement.  The surface of the cornea is responsible for about 2/3 of the focusing power of the (that’s why laser vision correction is performed on the cornea).  If you scratch the cornea, you get sudden loss of vision and…pain!

Other Causes Related to the Brain

Injury to the optic nerve and stroke can also cause sudden loss of vision.  There are certain situations with the optie nerve where pain may be involved.  Strokes are usually painless, but other neurologic conditions may be associated.

What Does This Mean?  It is impossible to diagnose sudden vision loss over the phone.  We treat sudden vision loss as an emergency at our office.  Happily, most of the time there really is no emergency because every one’s definition of “sudden” and “vision loss” are different, but how would we know?

In an eye doctor’s office, these unscheduled visits can kill an office schedule.  It happens quite often, as you can imagine, to a retinal specialist.

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Radiation and Lucentis Combined to Treat Macular Degeneration

External beam radiation and Lucentis may be combined to treat wet macular degeneration.    The results showed the treatment may be very safe and, when combined with anti-VEGF injections such as Lucentis, may decrease the need for frequently repeated injections.

Neovascularization, the growth of abnormal blood vessels, underneath the macular defines “wet macular degeneration.”

Radiation Kills Cells

Radiation treatments have been used in and around the eye to treat tumors.  Radiation, in this case, halts the replication of cells.  In the case of tumors, the lesions can no longer grow.  So too, with neovascularization, new growth is inhibited.  This is not the first study that has investigated the use of radiation for wet macular degeneration, but this is one of first trials combining external beam radiation with Lucentis.

Side Effects of Radiation to the Eye

Radiation can be toxic to the eye.  It can cause cataracts, damage to the optic nerve and retina.  It may also damage the lacrimal (produces tears to the eye) system and cause dry eye.

The investigators were able to dose and administer the radiation safely, seemingly able to avoid the usual complications of external beam radiation.

Treatment Required Fewer Injections of Lucentis

The gold standard for treating wet macular degeneration is now injections with either Lucentis or Avastin.  The injections, however, need to be repeated as often as monthly.  While highly successful, the need for repeated treatment requires a lot of trips to the office and can be expensive.

The study combined the use of the popular anti-VEGF agent, Lucentis (ranibizumab).  The design of the trial required 2 initial injections during the first month of treatment.

52% of patients did not require additional injections for the 12 month study period (they only had 2!).

Also noteworthy, most patients stabilized and actually improved their vision.

What Does This Mean? This is not an approved treatment.  It is in no way a true “study,” but this small trial still has some merits.  It provides us with a small amount of evidence that alternative treatments using radiation may be useful.

First, recall that anti-VEGF injections, such as Lucentis or Avastin, now standard therapy for wet macular degeneration, were developed for chemotherapy against several types of cancers.  The discovery that this improved patients with macular degeneration was coincidental.

For instance, patients receiving chemotherapy for colon cancer started noting improvement in their vision.  Evidently, these patients had both cancer and wet macular degeneration.

External beam radiation has long been used for many types of cancer treatments.

In both cases, agents that halt rapidly dividing (i.e. growing) tissues should be effective in both the cancer treatment and the eye disease.  The radiation stymies cell replication and the Lucentis (anti-VEGF) inhibits grow of new blood vessels.  In the case of cancer, a tumor can not enlarge without blood supply.

So, it makes sense that this may work.

Lastly, this really underscores the need for treatments that do not need to be repeated so frequently, such is the case with Lucentis and Avastin.  Right now, most doctors inject as frequently as every 4-6 weeks!  Drug delivery systems designed to release drug over an extended period may aid this as well.

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Eye Surgery Removes Floaters

Persistent floaters that decrease vision can be removed.  A vitrectomy, a retinal eye operation, can be used to successfully remove the vitreous and the “floaters” located within this gel-like tissue.

Most Floaters are From a PVD

Most new “spots” or “cob-webs” are due a posterior vitreous detachment (PVD).  A vitreous detachment increases the risk of a retinal tear and/or retinal detachment.  As we have discussed previously, a PVD is a common occurrence (especially as we get older).  Patients should be examined when the symptoms of a PVD first appear and then 6 weeks after the symptoms started.

From a medical point of view, if a retinal tear has not occurred at the 6 week point, the patient may not need to return for another exam.

These Spots Can Be Annoying

Sometimes, the floaters are so numerous or so large that they are annoying, prevent normal function and may decrease vision.  There is hope and there is help.

A Vitrectomy is the Only Solution

A vitrectomy can remove most of the vitreous, and thus, remove the vitreous opacities.  The vision returns to “normal.”

Vitrectomy eye surgery is routinely performed by retinal specialists.  The operation is usually performed for other reasons rather than just opacification or cloudiness of the vitreous.  It can be used to repair retinal detachments, macular holes or remove epiretinal membranes, for instance.

Of course, there are risks of vitrectomy surgery.  Though very rare, the biggest risks are blindness from infection or retinal detachment.

Some doctors advocate the use of a special laser (YAG laser) to reposition the vitreous within the eye.  I personally don’t feel this is a wise choice as there is a chance of causing retinal tears, and possibly, retinal detachment.

What Does This Mean? It is true that most people learn to tolerate small changes in vision.  In my practice, I rarely performed a vitrectomy for just floaters while I was in Baltimore.  I operate on floaters much more often at my present locations.

Perhaps our tolerance for visual changes is different here.

The point is that, if needed, the surgery can be helpful.  It is not a fancy operation, but rather a routine procedure and does not involve new technology.

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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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