How I Practice Surgery Uncategorized

Virginia to Resume Elective Surgery

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Elective surgery may resume in Virginia.  I practice in northern Virginia and have only operated on emergencies for the last month.  My patients with non-emergent surgical problems had to cancel or reschedule surgery due to the pandemic.

As recommended by the American Academy of Ophthalmology and the Centers for Disease Control and Prevention, we have not been performing elective eye surgery since the beginning of March due to the pandemic.  Cancellation of elective surgery of all kinds was enforced to spare hospital resources and limit uninfected patients’ and staffs’ exposure to the virus.

Late last week, Virginia Governor Northam announced that elective surgical cases could start again May 1, 2020.  While the ban was originally set to expire April 24, 2020, Northam extended the ban an additional week citing the need to carefully assess each hospital’s ability to care for non-COVID-19 patients and to provide sufficient PPE (personal protective equipment) for patients and healthcare workers.

What Are Elective Cases?

Elective surgery is not to be confused with “optional” surgery.  Cosmetic surgery (face lift, breast augmentation) can be considered both optional and elective.

Elective surgery should be renamed “non-emergency” surgery, where the surgery is necessary, but can be scheduled in advance.  Cataract surgery is a great example of elective surgery.

As a retina specialist, I do not perform cataract surgery, but there are still elective eye surgeries.  Elective retina surgery includes:

Emergency surgery, on the other hand, might include surgery to repair a retinal detachment, that is, if we wait too long, the prognosis gets worse.

Redistribution of Resources

In Virginia, the actual patients needing critical care and hospitalization, according to the state authorities, has started to level off though local infection numbers continue to rise.

Hospitals with ample resources (staff and PPE) may start to schedule elective cases.  If we are able to successfully take care of these additional patients without compromising our capabilities, we will continue to expand our services.

What Does this Mean?

Restarting elective procedures does NOT mean we have returned to normal.   Social distancing and other mitigation must continue as we are increasing exposure and person to person contact by providing elective surgical care.

Taking care of patients who need elective surgery, for example, cataract surgery and hip replacement surgery, is just the first step to slowly redistribute our healthcare resources and is a tiny step towards “normal.”  It’s a test of each hospital’s infrastructure.

Scheduling elective surgery also means that our offices will be soon opening…our patients considering elective surgery need pre-operative and post-operative care.

If you are anticipating elective surgery, call your doctor.  This is not a national mandate, but the return to elective surgery will be decided by each state, or in some cases, by the city mayor.

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Cataract Cataract Surgery Surgery Treatments Vision Correction

Lasers Used in Ophthalmology

Lasers Used in Ophthalmology

Lasers used in ophthalmologyLaser eye surgery can mean many more things than laser vision correction.  Lasers are used in almost all parts of the eye to treat eye disease such as glaucoma, refractive eye surgery and many diseases of the retina.

The following is a short review discussing the many different lasers and how we use them in ophthalmology.

Laser Vision Correction

Laser vision correction is a very common laser eye surgery.  PRK and LASIK are often advertised to reduce a patient’s need and dependance upon glasses (or contact lenses).

Both the femtosecond and excimer lasers are used to perform laser vision correction.  The lasers reshape the corneal curvature which heavily influences the refraction of your eye.

Laser vision correction reduces the need for glasses in patients who have nearsightedness (myopia), farsightedness (hyperopia) and astigmatism.  Certain corneal scars can also be removed with the laser.

Laser Cataract Surgery

Modern cataract surgery now involve the accuracy and dependability of the femtosecond laser.  The laser can be used in crucial parts of the cataract removal process:

  • creating a corneal incision (the first step)
  • creating the capsulorhexis (the opening of the lens capsule)
  • liquefying the cataract
  • treating astigmatism, if needed

The cataract can be compared to an M & M candy.  A candy coating surrounding a chocolate center.  In this analogy, the cataract is enclosed by the lens capsule:  the cataract is the chocolate center and the lens capsule is the outside candy coating.  During cataract surgery, the “capsulorhexis” is the opening created in the front side of the cataract, the candy coating, which allow access to the cataract (chocolate) held within.  Once the chocolate is removed, the IOL is placed within the candy coating, lens capsule, keeping the IOL in place.

After Cataract – Posterior Capsular Opacification

During cataract surgery, the intraocular implant is placed inside a clear tissue called the lens capsule.  Just like “Saran Wrap,” this tissue is crystal clear.  With time, the tissue often becomes cloudy and blurs the vision.  This “after cataract” mimics the same symptoms of the original cataract, but vision can be restored with Nd:YAG laser which clears the cloudy lens capsule.


Several different lasers can be used to treat different types of glaucoma.

Open angle glaucoma, the most common form of glaucoma in the United States, is usually treated with eye drops to lower the eye pressure.  When the eye drops fail to work, ALT (Argon Laser Trabeculoplasty), SLT (Selective Laser Trabeculoplasty) or MLT (Minipulse Laser Trabeculoplasty) can be used to treat patients with open angle glaucoma.

These lasers treat the drainage part of the eye, called the trabecular meshwork, to increase the absorption of internal fluid (aqueous humor) and decrease the pressure of the eye.

The laser procedures are similar and differ by the types of laser used:  Argon or diode laser, Nd:YAG laser or the minipulse laser.

Laser can also be used to reduce the production of aqueous humor by treating the ciliary body.  The ciliary body is located behind the iris and can be treated with argon or diode laser to reduce the production of fluid, thereby reducing eye pressure.  This form of treatment is often done in conjunction with cataract surgery.

Narrow angle glaucoma is common in asians and patients with hyperopia.  In this scenario, fluid is blocked from migrating through the pupil to the anterior chamber to

Retina and Vitreous

The argon laser, diode laser and minipulse laser are used to treat patients with diabetic retinopathy, swelling from various retinal vascular disorders and others.  Tears in the retina are usually treated with the argon or diode laser.

Nd:YAG vitreolysis is performed for certain opacities within the vitreous.


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Surgery Uncategorized Video

Asteroid Hyalosis | Common Floaters of the Vitreous

Asteroid hyalosis is a common finding of the vitreous.   As you can see in beginning of the video, the “asteroid bodies” are creamy white flecks suspended in the vitreous.

Asteroid Hyalosis is Benign

The exact cause of asteroid hyalosis is not known and does not appear to be associated with any particular systemic disease though there may be an association with aging.


My experience has been that asteroid hyalosis is a benign finding and not associated with either systemic or eye disease.  As you are able to see in this video, the flecks really move around as they are suspended in the vitreous.

Curiously, in most cases, patients with asteroid hyalosis are completely unaware of the condition, that is, the flecks, or asteroid bodies, do not cause any problems with vision.  Patients usually do NOT complain of floaters.

Asteroid and Floaters

I included this video really to demonstrate the appearance of asteroid hyalosis.  If you listen and watch the video, this patient has been complaining of floaters for many years.  There is no real way to determine if what he is seeing is the asteroid hyalosis or “normal” floaters.

Regardless of what the cause, the floaters had been bothering him for quite a while.  Anything which moves back and forth with eye movement has to be related to the vitreous, hence, a vitrectomy should remove the opacities, aka “floaters.”

Induce PVD

Toward the end of the video, I “induce” or cause a posterior vitreous detachment (PVD).  I inject Kenalog to help me see remaining vitreous.  Unfortunately, the Kenalog is a suspension and is the same color as the asteroid hyalosis.

Though a bit difficult to see, the posterior portion of the vitreous lifts up toward the front of the eye when the PVD is successfully created.

In conclusion, I operated on this patient who had been complaining of longstanding floaters and, as an incidental finding, had floaters (not necessarily from the asteroid).



Blurry Vision Following Vitrectomy

blurry vision following vitrectomyHere are some causes of blurry vision following vitrectomy eye surgery.  These are temporary causes and should resolve in a short time.

There are other reasons that may blur your vision, but those reasons may be related to the particular eye disease for which we are operating.

An Eye Patch Causes Blurry Vision

After every vitrectomy, an eye patch is placed to keep the eyelids closed against the eye.  There really no medicinal use of a patch other than comfort.

The pressure required to keep the eyelid closed is also enough to temporarily change the shape of your cornea.  In a sense, we are artificially creating astigmatism.

Any alteration to the smoothness of the cornea or its shape can cause significant changes in your vision.

Blurriness from the patch usually resolves the same day.

Dilating Drops Cause Blurry Vision

Dilating drops are a very common cause of blurry vision.  The drops dilate the pupil allowing me to see inside your eye and perform the operation.

The same drops also paralyze the muscles used to help you focus.

We usually use dilating drops which are slightly stronger than those used routinely in the office, hence, the dilation lasts longer.

Blurry vision is caused for two reasons.  First, more light is allowed into the eye.  Most of the this extra light needs to be focused.

Second, your eye can not focus normally because the focusing muscles (ciliary muscles) are paralyzed.

Blurry vision from the drops can take a few days to reverse.

Scleral Stitches

Sometimes I elect to close the small entry wounds, called sclerotomies, with absorbable stitches (aka sutures).  The wounds are adjacent to the cornea, but close enough to cause some warping or bending of the cornea if pulled too tightly.

This should all reverse when the sutures fall out by themselves.

Most vitrectomies these days are sutureless, so this has become less of an issue.

Any questions or comments?  Please feel free to add them below!


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