Call Us: 703.273.2398

Tag Archives: Surgery

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!

Enhanced by Zemanta

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.

Enhanced by Zemanta

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.

Enhanced by Zemanta

Implantable Telescope Treats Macular Degeneration

A new implantable intraocular telescope is now available for patients with endstage macular degeneration.  Patients with severe, bilateral (both eyes), loss of central vision caused by macular degeneration may now benefit from this tiny visual prosthesis.  The company, VisionCare, received FDA approval for CentraSight just last week.

How Does CentraSight Work?

The CentraSight implantable telescope is designed to be placed inside only one of your eyes.  This  “telescope,” a very strong intraocular lens, will magnify your central vision and project your central vision on a larger corresponding area of your retina.  The operative eye (the eye receiving the implant) will give you central vision.

Your other eye (not receiving the implant, but has lousy central vision) will remain the same, but give you peripheral vision.  You’ll have one eye for central and the other eye for peripheral vision.

The CentraSight Program

There are four steps;  Diagnosis, Screening, Implantation and Visual Training.

Diagnosis of Macular Degeneration

You must suffer from end-stage macular degeneration.  This can be either wet  or dry.  This must be confirmed by a retina specialist.  You must be stable and are no longer treatable with any medications such as anti-VEGF.

Candidate Screening

In addition to suffering from macular degeneration, other criteria include;

  • you are legally blind from macular degeneration
  • vision improves with external telescope simulator
  • your disease is irreversible, and no longer needing drug treatment
  • you have not had cataract surgery in the eye receiving the implant
  • you meet age, vision, eye and health requirements

Surgical Implantation

Once you are determined to be an excellent candidate, surgery will be performed very similar to cataract surgery.  It will be performed as an outpatient.  There are risks of eye surgery, but none too different than other intraocular surgery.

Visual Rehabilitation

After surgery, you’ll work with eye doctors and other low vision professionals to teach you to use your new intraocular telescope.

What Does This Mean? This is not a cure for the disease, but seems to be an excellent choice for those that have profound, permanent, visual loss.  This may potentially return visual function to those suffering from permanent loss of their central vision.  This could transform disability to impairment (another topic of discussion).

This means there is hope despite a pretty bleak path for those that have suffered significant loss of vision so far.

This means we should be watchful for more news as it develops and mindful that this is brand new.

It is exciting.

Enhanced by Zemanta

When a Cataract Comes Back

While not a retinal problem, cataracts can “return” and can mimic the symptoms of the original cataract; blurred vision, glare and distortion.  This can usually be remedied by a simple painless laser procedure called a YAG capsulotomy.

Cataract Surgery with Implant

Like grey hair, everyone gets cataracts.  With time, the natural lens of the eye clouds with time.  This clouding decreases vision.  The lens is similar to an “M&M” piece of candy both in size and shape.  An M&M is a core of milk chocolate surrounded by a candy coated shell.

Cataracts Cause Decreased Vision

When cataract surgery is performed, the cataract surgeon cuts a hole in the outside candy coating.  The “chocolate”  (core of the lens) is then sucked out leaving the empty candy coated shell.  In the real eye, this shell is actually a clear tissue very similar to plastic wrap used to cover food.  This shell is called the “capsular bag.”

Once the cloudy natural lens material is removed, a clear plastic implant is used to replace the natural lens.  Vision is restored.

Plastic Wrap Gets Dirty

With time, from weeks to years, this clear plastic wrap-like material can get cloudy.  The original symptoms of blurry vision and glare return.  Decreased vision from “posterior capsule opacification” occurs in almost every cataract patient.

Using a “laser” to Restore Vision

A YAG laser is a type of laser that uses its energy to cut.  By focusing the laser beam on the back portion of the candy coating shell, just behind the implant, a small hole is created.  This removes the cloudy/hazy tissue out of the line of sight and vision is restored.

YAG Laser Used for Posterior Capsulotomy
Laser Cut Hole in Posterior Portion of Shell (Capsule)

Does the Implant Fall

Properly performed, a YAG capsulotomy will not cause the implant to move.  While it has happened (and to me!), it is unusual as the implant is usually scarred in place.

In theory, there may be a slight increased risk of a retinal tear that could lead to a retinal detachment.

What Does This Mean?

Many of my patients have had cataract surgery.  It is a relief when we find the cause of the decreased vision is only due to PCO (posterior capsule opacification) and not due to diabetic retinopathy or macular degeneration.

Many people erroneously believe (and perpetuated by some docs) that cataracts “come back.”  They don’t.

This is also why many people believe cataract surgery is performed with laser.  It isn’t, but now you know why, and how, the rumor started.

Reblog this post [with Zemanta]

Eye Patches After Surgery

Patching the eye after surgery is a matter of routine.  The eye patch is usually worn only overnight and then removed for the rest of the post-operative period.  It can offer protection, reduce discomfort, but really has no “healing” attributes.

The Lid Should be Closed Against the Eye

A properly placed eye patch, for any reason, should be a “pressure patch,” meaning that the taped patch should exert enough pressure on the eye to keep the lid closed.  This also ensures that the eye can not rub against the patch itself.

Pain Reduced

Whatever “discomfort” (doctor language for pain) there might be after the operation is decreased by blocking light.  While the eye is still able to move underneath the closed lid, there is some additional comfort created by decreased blinking.

The cornea is a very sensitive tissue.  Small abrasions can cause great sensitivity to light.  Corneal abrasions, even those unrelated to surgery, usually heal rapidly, with or without patching.


The eye is dirty, so there is no protective effect from the patch, unlike, say, a true bandage.  Remember that the eye, nose and mouth are all connected.

In the old days, when cataract surgery required a “large” incision to be made into the eye, a shield was placed on top of the patch.  This shield would offer physical protection until the incision healed and became stronger.

Special Situations

There are a few special situations where patching is important after eye surgery.  Occasionally the surgical wounds are not tightly sealed (i.e. the eye is leaking) and an additional day or two of patching is required.  If patching doesn’t suffice, then a short trip back to the operating room might be warranted.

What Does This Mean? As surgical techniques have advanced, there is less tissue damage from surgery, that is, there is less cutting that causes trauma to the eye.  Hence, there is really little discomfort after surgery.

Many cataract surgeons often have the patch removed later in the day so post-operative eye drops can be started right away.  I’ve even heard of a few surgeons that forget the patch all together.

I still prefer to patch.  I find it very useful to help limit swelling after placing a scleral buckle for retinal detachment, but I don’t find it mandatory for the reasons above.

An eye patch does serve as a reminder that an operation was performed and, I believe, are expected.

Reblog this post [with Zemanta]

Eye Drops to Help You Heal

After eye surgery, there are several eye drops to help you recuperate, and heal, quickly.  These eye drops usually include an antibiotic, anti-inflammatory, and sometimes, an eye drop to keep  you dilated for comfort.

There are many types of eye surgery; cataract, glaucoma, corneal, retina, etc.  In general, the post-operative medications/drops that we use are about the same.


These usually come packaged in a bottle with a tan colored top.  It may be used 4 times a day.  The drop is clear and may be prescribed to be used 4 times per day.

Remember that eye drops do not penetrate the eye very well, so it is probable that the antibiotics really help the outside of the eye and the actual incision (i.e. place where your surgeon “cut” into your eye) from becoming infected.

One of the unfortunate complications of any intraocular surgery is endophthalmitis, an infection of the contents of the eye.  I doubt the topical drops actually fight any infection inside the eye per se.

Anti-Inflammatory Drops

These usually come in a white or pink capped bottle.  I prefer a steroid called prednisolone acetate 1% (e.g. Pred Forte, Omni Pred).  It is milky white.  This drop must be shaken prior to instillation.  It is really a suspension, that is, the drop contains microscopic particles of drug that settle out.

Other anti-inflammatories included Xibrom or Acular.  These are not steroids and probably not as strong.

Anti-inflammatory drops help the eye keep comfortable during the healing.  If we limit the post-operative inflammation, there should be less discomfort.

Dilating Drops

Some operations and some docs require dilating drops after the operation.  These are in a bright red topped dropper.  These are very similar to what is used in the office to dilate your eyes for examination.

Occasionally, it is helpful to keep the pupil dilated during the recovery period.  I like to use these drops at the end of an operation.  The drops I use will keep the pupil dilated for a day or two, but I don’t have to wait for dilation the next day for the follow-up exam.

Certain dilating drops can also cause “cycloplegia” in addition to simple pupillary dilation.  One of muscles inside the eye, the ciliary muscle, can sometimes spasm, causing severe pain and discomfort.  “Cycloplegia” prevents this from occurring and helps keep the eye comfortable.  The ciliary muscle also helps focus, so vision become blurry.

What Does This Mean? Most of the post-operative medicines we use are topical drops.  Oral medicines usually aren’t necessary.   Most of the drops are really used to promote smooth, comfortable healing, the antibiotics being the exception.

Oral pain relievers generally are not required.  I rarely have to prescribe anything by mouth regardless of the procedures I performed.  The operation I perform requiring the most tissue manipulation is a scleral buckle.  Even with this procedure, oral pain relievers are not necessary.  (Of course, this is surgeon dependent and reflects the way I practice only.)

Reblog this post [with Zemanta]

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.

Reblog this post [with Zemanta]

Retina Surgery is "Same Day" Surgery

Retinal eye surgery, either vitrectomy or scleral buckle, is usually performed while the patient is awake and as an outpatient, allowing you to go home the “same day.”  Usually, there is absolutely no pain with retina surgery and recovery takes place in the comfort of your own home.

In most cases, operations are performed under “local sedation.”  This term varies, but at our surgical center local sedation involves giving a sedative through the intravenous (I.V.).  This puts the patient in “la la land” for a few minutes during which the eye is then numbed using an injection.  When the patient awakes, the eye is numb and can’t move.

Pain is transmitted via nerves.  The anesthetic prevents the perception of pain by blocking nerve conduction.  The nerves that control the eye muscles are also blocked, thus, the eye can not move.  Both pain and movement are controlled.

The eye remains in the eye socket during the operation.  The eye lids are held wide open with a wire clamp, or speculum, to allow maximum exposure of the eye for the surgery.

The time for surgery depends on the retinal procedure and the amount of work required, but the anesthesia will work for several hours.

Vitrectomy eye surgery involves minimal cutting on the eye.  The use of 25-gauge instruments for vitrectomy eliminates cutting tissue on the outside of the eye, thus, there isn’t much discomfort any way.  Scleral buckle surgery for retinal detachments creates the most discomfort due to increased cutting on the outside of the eye, but this method of anesthesia is still very effective.

Most of the time, my patients are completely awake…and comfortable.  We can talk and listen to music.  On occasion, patients will report they are able to see the instruments moving inside the eye!

On rare occasion general anesthesia is required.  This may be due to the age of the patient (i.e. child), anxiety, claustrophobia, etc.  We usually prefer the patient fully awake or slightly sedated.  The recovery is much faster, easier and safer without general anesthesia.

What Does This Mean? In most cases, technology has improved retina surgery to be completed much faster, and safer, than even 10 years ago.  The reduction in operating times, the time it requires to perform an operation, has allowed “local” anesthesia to become preferred by many doctors.

Along with shorter operating times, and less general anesthesia, most surgery is easily performed as an outpatient as the time it takes to recover from “anesthesia” is much shorter.

Many practices choose to operate in a surgical center, a freestanding outpatient surgical site,  – usually maximizing efficiency…and time.

Reblog this post [with Zemanta]

Optometry Student's First Retinal Surgery

Optometry students frequently rotate through our office.  One of our visiting students had the chance to watch me in the operating room.  I asked her to write about the experience…


My name is Maggie, and I’m a fourth year student at the SUNY College of Optometry in NYC. I had the opportunity to observe retinal surgeries with Dr Wong in the OR, and it was an amazing experience!

The first surgery was scheduled at 7:30am (I know, I wasn’t too excited) for a vitrectomy to repair a retinal detachment. The patient had developed a retinal detachment secondary to a retinal hole. Sub-retinal fluid can accumulate under the hole and cause the retina to detach, which then needs to be treated. The urgency of treatment depends on the location of the detachment and the condition of the macula (the central part of vision). If the macula is still attached, ie “macula-on retinal detachment”, the patient needs to be treated as soon as possible, which was the case in patient# 1.

The patient was already prepped for surgery (with pre-operative antibiotics, anesthesia etc). Retinal surgeries usually do not require general anesthesia; the patient was given retrobulbar anesthesia, which is local “blocking” of an area supplied by a specific nerve. I was very excited to be in the OR; I have observed a few surgeries before but this was my first ocular surgery! I got to sit right behind Dr Wong and see the entire thing. Dr Wong had warned me about the graphic nature of ocular surgery, but it wasn’t bad at all! There wasn’t any blood or fluid gushing out, as one would imagine. It was a relatively clean, blood-less surgery! The incision was made 5mm lateral to the limbus (where the color part of your eye meets the white part). This was like “port of entry” to get into the retina. Before performing the laser, Dr Wong performed a “vitrectomy”. Vitreous is the jelly part of the eye, between the lens and the retina. It sort of keeps the eye intact, keeps the retina attached to the choroid. However, it can also block the surgeon’s view and interfere with laser treatment, which is why it is necessary to remove it.

After the vitrectomy, Dr Wong sealed up the retinal hole with the laser and repaired the retinal detachment. The surgery went well, and the patient was discharged after being given post-op anti-biotics/anti-inflammatory.

The second patient was scheduled for a membranectomy secondary to epi-retinal membrane (ERM). An ERM is a membrane that forms over the macula. ERM can distort vision and cause traction on the macula, which is when treatment is indicated. The pre-op process is similar to the one described above; vitrectomy is also necessary in this case. After the vitrectomy, Dr Wong physically peeled off the membrane with forceps! This is a very delicate procedure since the membrane is over the macula; and a little slip up can affect the central vision! You could actually see the membrane coming off-of the macula! Again, the patient was discharged after the appropriate post-op treatment.

Both the patients are scheduled to see Dr Wong for follow up visits.

Being in the OR was an awesome experience, and I can’t wait to go back!

Reblog this post [with Zemanta]


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
View Map

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
View Map