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Tag Archives: Retina

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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Implantable Telescope is Available!

CentraSight Now Available, CMS to reimburse for implantable telescope to treat macular degeneration

CentraSight, the implantable telescope for macular degeneration, is now available! CMS (Centers for Medicare and Medicaid Services) has approved the telescope for those patients with macular degeneration meeting the eligibility criteria for the surgical procedure.

Medicare/Medicaid will cover the cost of the implant and the surgery in certain patients as October 1, 2011! For now, the procedure has a designation of a transitional pass-through payment, that is, CMS will approve the procedure for 2-3 years until enough payment data can be collected.

The Telescope Improves Vision

To achieve this milestone, Visioncare, the parent company, needed to show that the implantable telescope for macular degeneration met several criteria;

  • FDA Approval
  • CMS deems reasonable and necessary
  • Device offers Substantial Clinical Improvement

FDA Approval: VisionCare received FDA approval for their telescope last August.

Substantial Clinical Improvement may be difficult to attain as the device must surpass some steep challenges.  In order to achieve this status, one of the following situations must be true;

  1. the new device must be better than other available treatments
  2. the device improves the ability to diagnose a condition
  3. the device significantly improves the patient (i.e. clinical outcomes)

Availability of the CentraSight Telescope

For now, according to my contact at VisionCare, CentraSight will be offered at the locations where the original clinical trials were performed.  This has been their plan all along.  With time, as more physicians become trained, the availability will widen.

What Does This Mean? This is the first real step to helping patients with significant visual loss in both eyes.  The surgery to insert the “telesope” is similar to cataract implantation, yet the CentraSight will modify the images so more of the retina surrounding the macula is utilized for vision.

While patients with either form of the disease might be candidates, this is the first FDA sanctioned “therapy” for patients with severe loss of vision from dry ARMD.

This is not a cure or a “fix” for loss of central vision, however, the telescope does improve function for those that have no central vision from the disease and can lead to am improvement in the quality of life.

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Vitrectomy Eye Surgery for Macular Pucker

This is my first patient education video.  I uploaded this last evening to YouTube.  It is one of the best I’ve seen for a super niche like eye surgery.

Vitrectomy Surgery

As I state in the video, vitrectomy surgery is performed by retina specialists.  I completed extra training to specialize and to perform retinal surgery.

A vitrectomy is the core operation for many of the surgical diseases we treat.  For instance, a vitrectomy is used to remove an epiretinal membrane (ERM), fix a macular hole or repair a retinal detachment.  A vitrectomy can remove floaters.

It is very similar to arthroscopic surgery or laparoscopic surgery in that all the systems are “closed.”

Patient is Awake and Comfortable

Most of my procedures are performed while the patient is awake.  Before surgery, the patient receives a sedative, putting them to sleep for a few minutes while the entire eye is numbed.

This “IV sedation” or “twilight” form of anesthesia is quite popular in most outpatient surgical settings.  It avoids the rigors of general anesthesia.

By the way, the operation is completely painless!  I am usually able to talk to my patients while operating.

25 Gauge Instrumentation:  No Stitches!

The instruments used have revolutionized vitrectomy surgery.  The instruments are so thin, that we no longer have to take time to stitch the eye.  This improves efficiency (shortens operating times), but also causes less tissue damage and greatly speeds up healing time (fewer office visits).

What Does This Mean?

You’ve probably noticed that you see more and more video.  It’s a great medium, it captures your attention via audio and video, the costs of equipment are miniscule and the video quality is exeptional.

I produced this entire video at home using iMovie (Apple).  The operation took about 16 minutes in real time.  Many thanks to Meredith Maclauchlan for her skill in adding the special effects and background!

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Double Vision After Retinal Detachment Surgery

Double Vision Can Follow Retinal Detachment

Decreased vision and double vision (aka diplopia) after retinal detachment surgery may occur, yet is not common.  The perception of “double” is more common than actually seeing two of everything.  There are several causes for really seeing two images following retinal detachment surgery.

Scleral Buckle May Cause Diplopia

A common method to fix a retinal detachment involves the use of a “scleral buckle.” This involves placing an element, usually silicone rubber, on the outside of the eye and underneath the eye muscles.  The visual effect of a scleral buckle is an increase in myopia (nearsightedness) and/or astigmatism.

Scleral Buckle for Repair of Retinal Detachment

At times, manipulation of the eye muscles can cause true double vision.  The muscles may get injured or impaired such that the eye does not move in coordinated fashion with the other eye.  Diplopia can occur with this muscle imbalance.

The prescription for glasses will change after scleral buckle surgery.  Large differences between the two eyes leads to a condition called anisometropia.  Basically, this occurs when the prescription change between the two eyes is so large the brain actually does see double.

Why?  Inherent to large changes in prescription is a change in the actual size of the image that we see.  Thus, with large changes, the brain actually sees two images of different sizes.

With anisometropic double vision, one see double because the images are too different for the brain to make into one (this is, in part, why we get depth perception, the two eyes gives us slightly different views of the same image).

This is probably the most common cause of “double vision” after retinal detachment surgery.

Cataracts Can Cause Diplopia

Gas is commonly used to repair a retinal detachment.  A common side effect of intraocular gas is the hastened formation of a cataract.  This, too, can change the prescription of the eye pretty dramatically.  “Double vision ” can result from cataract formation by causing a strong shift in the prescription and by physically altering the light as it comes into the eye.

What Does This Mean? True double vision, where the eyes are misaligned after surgery is quite uncommon after retinal detachment surgery.  There are many causes of decreased vision following retinal detachment surgery and many are described as “double vision.”

Many cases are actually caused by changes in the prescription, either due to physical changes of the due to the scleral buckle, or, due to advancing cataract.

Happily, most cases can be fixed.  If the retina is functioning well enough for the double vision to be “seen,” then it’s likely corrective measures can be taken.

Specifically, eye muscle surgery can help if there are true muscle problems, whereas cataract surgery or correction with a stronger contact lens may be helpful, too.

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Macular Degeneration Declining in the U.S.

Rate of AMRD is Decreasing

The prevalence of macular degeneration may be decreasing in the United States!  A study just released indicates that the rate of this blinding eye disease has decreased by about 15-20% compared to 20 years ago.

Survey Says….

The results of the National Health and Nutrition Examination Survey (NHANES) included data collected from over 5500 individuals, age 40 and older.  Each person received an eye examination including retinal photographs.  Examiners looked for signs of geographic atrophy, exudative AMD, early AMD and advanced disease.

The NHANES study was performed between 2005-2008 and compared to the findings of a similar study completed from 1988-1994 (Third National Health and Nutrition Examination Survey).

Prevalence of AMD is Now 6.5%

The NHANES (2005-2008) analysis revealed a prevalence of AMD of 6.5% compared to the previous rate of 9.4% (1988-1994).  There was a lower rate of macular degeneration found in blacks in both studies.

The authors conclude that the decrease in macular degeneration may be due to a decrease in smoking and changes in diet.

What Does This Mean?

The results of the survey are indeed encouraging and support the notion that smoking and diet may have some influence on the development of macular degeneration.

Keep in mind that the NHANES is a survey and not a longitudinal study.  These were surveys that measured only the prevalence of a disease.  This does NOT indicate the risk , or incidence, of developing macular degeneration.

The success of public health measures are difficult to assess and take large numbers of patients and years to assess.  Smoking cessation and changes in diet are two examples of how our behavior may have changed over the past 20 years.  It is possible that these habits have influenced the rate of developing macular degeneration.

On the other hand, it is possible that the methods of collecting the data are flawed, and thus, the analysis is biased, or, put simply, the conclusions are wrong.  For instance, I am not sure if macular degeneration can be diagnosed in a patient 40 years old.  Perhaps there was a bias towards too many 40 years olds in the recent study compared to the earlier study.

While different ethnic groups were studied in the recent survey, it is difficult to accurately compare this groups habits with each other and with the previous study.

On a positive note…perhaps we are doing something better!  But in the meantime, make sure you get a regular eye exam.

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Update on Implantable CentraSight Telescope

VisionCare’s implantable telescope for patients with advanced macular degeneration was FDA approved in August.  Since then, little information has been available, but I received an update from the company last week.

Telescope is Not Being Shipped

Though FDA approval has been received, VisionCare, the parent company, has not started shipping this implantable device.  The company is quite small and is gearing up for market release.  Reading between the lines, this may occur in the next 6 months.

Medicare Reimbursement

In simplest terms, Medicare has yet to approve this device for insurance coverage, that is, they haven’t agreed to pay for it yet.  The parent company must submit an application based upon the FDA approval and the fact that this is a brand new type of medical device.

Obviously, VisionCare isn’t going to ship the Centrasight telescope if it isn’t going to be covered by insurance.

Training Centers for Eye Doctors

If you read my last article regarding the CentraSight, the implantation of the telescope involves a team approach and, thus, training for all the eye professionals involved.  Training will be required for the surgeons, eye doctors, nurses, technicians, etc.

The company is hopeful to start the initial “launch” at the centers involved in the clinical trials.  Additional sites and doctors will be added as time goes on.  My own practice is hopeful to be one of the first to train.

Information for Patients

Additional information has been provided on the CentraSite web page.

What Does This Mean?  At the very least, the telescope will have limited availability for the first half of the year.  Without Medicare approval, the device simply won’t be marketed.  The development of other centers for the device to be implanted will depend upon the initial revenues and popularity of the device.  This is not unlike cell phone coverage. 

The CentraSight telescope is also a good example of how the FDA and Medicare together to bring devices to market.  FDA approval doesn’t mean Medicare’s endorsement as the two operate independently.

Overall, there are many variables to watch;  the speed or rate in which new centers are developed and new doctors trained and the fiscal issue of insurance payment.   Be patient.

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10 Facts About Diabetic Retinopathy

I will be speaking to a local patient group regarding the implications of diabetic retinopathy later this week.  These are my “Top Ten” factoids about the eye disease.

Patients With Diabetes Need Annual Eye Exams

Without exception and at a minimum, both the AAO and AOA recommend that every patient with diabetes receive an annual eye exam.  The pupils must be dilated to allow proper examination of the retina.

It doesn’t matter if you take insulin or not.  The disease has no bias.

Diabetes Mellitus Affects the Retina

The retina is the light sensitive tissue that lines the inside of the eye.  It is the principle tissue in the eye targeted by diabetes.  Without a healthy retina, you can not see.  It is perhaps the most important structure of the eye.

Diabetic Retinopathy May be Asymptomatic

Diabetic retinopathy is a slowly progressive disease.  The key to saving vision is early diagnosis and before there are any symptoms of blurred or decreased vision.  Don’t let good vision fool you into thinking there is nothing wrong with your eyes!

Good Sugar Control Does NOT Prevent the Disease

There is nothing to prevent the development of diabetic retinopathy.  While sugar control may slow the development of the disease, there is no proof that it will actually prevent the disease.  Most doctors and patients are unaware of this one fact.

Diabetic Retinopathy Can Cause Blindness

While diabetic retinopathy can cause a spectrum of vision loss, true blindness is quite rare.  In fact, fewer than 1% of patients with diabetes will sustain “significant” vision loss in their lifetime.

In other words, blindness may be prevented most of the time, but early detection and treatment is essential.

Ophthalmologist or Optometrist Doesn’t Matter

In my opinion, not shared by many of my colleagues, I don’t think it matters if you are examined by an ophthalmologist (M.D.) or optometrist (O.D.).  In my experience, most eye doctors are able to identify/recognize diabetic retinopathy.  You should then be referred to a retinal specialist.

Diabetic retinopathy has a characteristic appearance that can be recognized easily.

Retinal Specialists Treat Retinal Disease

Okay, no kidding, but my point is that there are many ways to treat diabetic retinopathy.  While you may not be examined regularly by a retina specialist, you should evaluated by a retinal specialist once the disease is diagnosed.

There are so many treatments available to you at this time to improve or stabilize your condition.

Every Patient With Diabetes Will Develop the Disease

I have seen very few patients with diabetes over 30 years that are lucky enough not to have developed the disease.  I think it is safe to say that most will develop the disease and I tell all my patients to expect the diabetic retinopathy to develop.

Why?  If you expect the disease to develop, you are most likely going to have regular exams.  If you expect the disease to develop, then you get rid of the “denial” and seek proper medical treatment.  Also, by expecting to develop the disease, you won’t feel disappointed in yourself for failing to take better care of your health.

Macular Edema and Proliferative Diabetic Retinopathy

There are only two “stages” that require treatment.  Swelling in the macular area is called macular edema.  Macular edema causes blurry vision.  Most diabetic patients get this form.

Proliferative diabetic retinopathy (PDR) affects fewer patients, but can lead to blindness if not treated.

Both macular edema and PDR may occur simultaneously.

anti-VEGF, Laser, Steroids and Vitrectomy for Diabetic Retinopathy

We now have an array of treatments depending on the stage and severity.  Regardless of the treatment, early detection gives you the best prognosis for maintaining your vision!

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Parents' Weekend and Your Eye Exams

Your eye exams and parents’ visits to college are similar.  Both are necessary types of checkups, even when you don’t suspect a problem. 

I have two kids in college and had simultaneous parents’ weekends.  We drove to southern Maryland (SMCM) on Saturday and I went to Pennsylvania (DelVal) solo on Sunday (our pee wee hockey players had games on Sunday).  Parents’ weekends are part of every college fall schedule.  It is routine…and extremely important for the student and family.

Freshmen Need  Parents’ Weekend

I was once told by a psychiatrist friend that the reason for so many holidays and breaks (e.g. Homecoming, Parents’/Family Weekend, Fall Break, Columbus Day, Thanksgiving, etc.) was really to make the freshmen transition to college easier.  It  allows the freshmen to breakaway from home more gradually.

Now, with a sophomore and freshman in college, I think he’s right.

I Needed to Check Up

I like to think that I am pretty close to both college kids.  I talk, email and text with them several times a week.  I’d seen both of them both since school started, once for my birthday and once since then.  I didn’t speak, email or text about any obvious problems, but I still needed to see them.

So why did I go?  I needed to check on them.  I needed the reassurance of  seeing them in their school environment.   I wanted to visually examine them at school.  I gave them the chance to show us off to their friends and also let them boast about their school (and new life!).  It is my way of gauging their happiness and integration.  Happily, I wasn’t disappointed.  Both seemed pretty happy and have a nice group of friends.

Your Eye Exam

Just as with Parents’ Weekend, regular eye exams are important.  Even if you see well and don’t suspect any problems a routine visit with your doctor is probably warranted.  It may not have to be an annual event, but it should be regular and routine.  Ask  your eye doctor about his opinion based on your own history.

Regular Eye Exams and Eye Disease

If you have a condition such as diabetes, at the very least, you’ll need an annual eye exam for diabetic retinopathy.  I shared my opinion about regular examination for macular degeneration before.  Basically, if you don’t have a change in symptoms, you are probably okay, whereas in cases of diabetic retinopathy, the absence of symptoms means nothing.  To say another way, macular degeneration is a disease that requires self-monitoring where diabetic retinopathy is not.

Regular eye exams are also needed to check for other developing problems that may be “silent.”  Glaucoma and cataracts are both relatively “silent” eye problems as they are very slow to progress.

What Does This Mean? Just as with your college kids, regular exams are important…even if you don’t suspect a problem.  Early diagnosis, just like an unhappy kid at school, is much easier to deal with than letting a problem grow and fester.

Certain eye disease require routine evaluation.  Not every eye disease has obvious symptoms.  Subtle signs of disease can only be detected with a proper eye examination.

Regardless, don’t let the lack of problems and your “good” vision mislead you to think your eyes are healthy.

Go ahead and get checked.

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Decreased Vision Following Retinal Detachment

There are many reasons why your sight may be poor following retinal detachment surgery.  Obviously, it is possible that the disease actually led to loss of vision as retinal detachments can lead to blindness.   There are, however, other less serious reasons for loss of vision following retinal detachment surgery.

Scleral Buckle for Retinal Detachment Repair

A scleral buckle is common method to fix a detached retina.  In most cases, a band is passed around the circumference of the eye.  This is similar to donning a corset around your mid-section, except in the case of the eye, the eye elongates.

The lengthening of the eye causes a change in your refraction, or, the strength of glasses needed to correct your vision.  A scleral buckle causes an increase in nearsightedness.

Other surgeons may elect to place a buckle only a small portion of the eye, but the result is the same; a scleral buckle changes the refraction of the eye.

Cataract Formation

This is a very common cause of decreased vision after successful retinal detachment surgery.  Intraocular gas is often injected into the eye to help repair the detached retina.  While the gas is very helpful in reattaching the retina, it is not so good for the natural lens and hastens the development of a cataract.

Epiretinal Membrane Formation

An epiretinal membrane can form on the surface of the retina and cause decreased vision and/or distortion.  These are also called “macular pucker” or “cellophane maculopathy.”  While these membranes may form in eyes that never had a retinal detachment, they are commonly associated with retinal detachments.

Recurrent Retinal Detachment

Of course, it is also possible that the retina simply came off again.  This may be due to additional retinal tears or to a disease termed “proliferative vitreoretinopathy” or PVR.

What Does This Mean? Retinal surgeons are usually pretty successful at reattaching a retina.  The whole process of recovery; however, can extend months beyond the actual surgery date.  None of the causes listed above can be self diagnosed and it is imperative you stay close to your doctor, preferably the retinal surgeon.

Contrary to what you may believe, retinal detachment surgery often, not always, leads to improved vision.  Thus, decreased vision after surgery should be evaluated by your doctor.

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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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