Category: Video

Total Retinal Detachment Repaired with 25 gauge Vitrectomy

Post author By Randall Wong, M.D.
Post date February 13, 2019

Retina Specialist | Retinal Detachment | Northern Virginia | Washington DC

Vitrectomy for Retinal Detachment

Vitrectomy alone has become very popular for repairing a retinal detachment. Other choices include pneumatic retinopexy (an in-office procedure), scleral buckle, or vitrectomy with scleral buckle.

Retina specialists differ in their own preference for certain techniques. I often choose vitrectomy alone or vitrectomy with scleral buckle. These are the two most successful methods. Remember, retinal detachments aren’t always fixed the first time and are sometimes not fixable.

The vitrectomy requires installation of 3 ports or trocars. Two ports are reserved for each hand and the 3rd port is hooked up to a tube which keeps the eye pumped with either saline or air.

With 25 gauge vitrectomy systems, as in this case, the blue trocars are simply pushed into the eye. The holes are so small that they are regarded as self-sealing. Sutures are not required at the end of surgery and healing is much faster.

The first step of the vitrectomy is to remove the vitreous. You can note a PVD, complete detachment of the retina, two holes/tears and detachment of the macula. The patient barely has a cataract and has not had cataract surgery. As I move around the eye, I am also examining the retina looking for all possible tears or holes which led to this “rhegmatogenous” retinal detachment.

Rhegmatogenous retinal detachment are the most common and are caused by holes, or “rhegma,”

Macular Detachment

At the start of the operation, note how difficult it is to see the macula. As the retina becomes “less detached” the typical brown/yellow appearance of the macula becomes more apparent. The macula is the functional center of the retina and provides the capability of us to see 20/20. The remaining portions of our retina provide peripheral vision.

Macular detachment can alter the visual outcome of surgery.

Fluid-Air Exchange

After I have identified the two tears and marked them with cautery (turning the tissue white), I also created a 3rd hole called a retinotomy.

Drainage of the sub-retinal fluid occurs through the 3rd hole (retinotomy). Sometimes if a hole or tear is more conveniently located, I can skip the part of a retinotomy. At the end of the fluid-air exchange, the retina is completely attached.

The gas will be absorbed slowly over the next two weeks. Retina specialists vary as to the type of gas and mixture (concentration) used. I commonly use 16% SF6. Other gases/mixtures can take longer.

As the gas is absorbed, there is always a concern of the retina detaching again.

Laser Treatment

Having identified and marked all the tears, I can easily see where to use/aim the laser. When the fluid-air exchange is completed, unmarked retinal holes can become invisible.

The idea of laser is to induce scar formation to the layer underneath. This prevents redetachment from the same tears as the gas is absorbed by the eye.

The key to successful retinal detachment surgery is identifying all the tears and treating them all successfully.

Air-Gas Exchange

The very last step of the operation involves replacement of the air with a special inert gas.

The gas will be absorbed slowly over the next two weeks. Retina specialists vary as to the type of gas and mixture (concentration) used. I commonly use 16% SF6. Other gases/mixtures can take longer.

As the gas is absorbed, there is always a concern of the retina detaching again.

Tags Retinal detachment, Video, Woodburn Surgery Center

Surgery Uncategorized Video

Asteroid Hyalosis | Common Floaters of the Vitreous

Post author By Randall Wong, M.D.
Post date May 10, 2017
No Comments on 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).

Tags asteroid hyalosis, Posterior vitreous detachment, Vitreous

Video

How I Became a Retina Specialist

Post author By Randall Wong, M.D.
Post date August 22, 2016
1 Comment on How I Became a Retina Specialist

I’m Randy Wong. I’m a Retina Specialist, located in Fairfax, Virginia. Today, I’d like to tell you how I became a Retina Specialist and discuss a little bit about what a Retina Specialist does as an eye doctor.

To become a Retina Specialist, I had to first go to college and medical school and do an internship and then a residency and then, finally, I did training to sub-specialize. So, let’s break it down.

Haverford College

After High School, I went to Haverford College and I got a BA in biology; that took four years. Right after college, I went to medical school.

Specifically, I went to Jefferson Medical College, located in Philadelphia. That was a four-year program, and when I graduated from Jefferson, I was now an M.D. with no specialization.

Bryn Mawr Hospital | Internship

Right after Medical School, I went to the Bryn Mawr Hospital outside of Philadelphia. For one year, I was an intern in their Internal Medicine department; it has nothing to do with ophthalmology, but my internship served as a pre-requisite, so that I could get an ophthalmology residency.

After my internship at the Bryn Mawr Hospital, I then became an ophthalmology Resident at Georgetown University, and this was a three-year program. At the end of that Residency, I was finally a general ophthalmologist.

Fellowship for Retina Specialist

It was pretty clear to me during my ophthalmology residency that I was going to subspecialize – or, I wanted to subspecialize – in diseases of the retina. I wanted to become a retina specialist.

So, after I finished residency at Georgetown University, I then took a Fellowship. This is additional subspecialty training, and I went to Memphis, Tennessee so I could be a Retina Specialist under the tutelage of Steven Charles and Maurice Landers.

After completing my Retina Fellowship, I was now a Retina Specialist. After that, I just had one more test to take and that was to become Board Certified.

Board Certified Ophthalmologist

I am a Board Certified ophthalmologist which means I am Board Certified in General Ophthalmology, not Retina. There is no board certification for a retina specialist, at least at this time. So, after my Fellowship, I had to take a test, and passed, to test my knowledge on all general ophthalmology. Once I did pass that, that allowed me to say that I was a Board Certified Ophthalmologist.

In conclusion, I’m Randy Wong. I am a Retina Specialist in Fairfax, Virginia. Actually, I am a Board Certified Ophthalmologist and a Retina Specialist, in Fairfax, Virginia.

I hope this was helpful. See you next time.

Tags retina specialist

Retinal Detachments Video

Retinal Detachment | Signs, Symptoms and Treatment

Post author By Randall Wong, M.D.
Post date April 28, 2016
1 Comment on Retinal Detachment | Signs, Symptoms and Treatment

Welcome! I’m Randy Wong. Thank you very much for watching this video. Today we are going to talk about retinal detachments.

We are going to talk about;

The definition of a retinal detachment
What it can cause – the signs and symptoms
Surgery to fix a retinal detachment
Timing – when is the best time for surgery?

I hope you enjoy this.

Rhegmatogenous Retinal Detachment

Today we are going to talk about 1 of 2 types of retinal detachments. We are going talk about rhegmatogenous retinal detachments and, by definition, that means the detachment is caused either by a retinal hole or retinal tear.

The hole or tear allows the fluid from the middle of the eye to communicate to a space underneath the retina. So therefore if fluid accumulates underneath the retina through this hole or tear, the retina detaches.

Keep in mind a retinal detachment is potentially blinding. So as we will talk about later, there is some urgency, or sometimes it’s an emergency, to fix a retinal detachment.

Symptoms of a Retinal Detachment

Symptoms of a retinal detachment include loss of your peripheral vision and usually the peripheral, or side vision, is involved first and the loss of vision moves centrally.

Flashes and floaters are also commonly associated with a retinal detachment because those are usually signs of a retinal tear that you may have sustained.

So, the recommendations are that new flashes and new floaters should be examined by your doctor and your doctor ought to be looking for a retinal tear because it is our job to try and prevent you from getting a retinal detachment if we can diagnose a retinal tear.

Again, symptoms of a retinal detachment include; loss of peripheral vision, especially if the vision loss is moving centrally, new flashes and new floaters.

What Do You Do? (When to call your eye doctor)

What should you do if you think you are having a retinal detachment? Maybe you’ve noticed an increase in flashes, an increase in the number of floaters or you are losing your peripheral vision.

My suggestion would be to let your own eye doctor know that you are having these new symptoms.

Once you arrive at your eye doctor’s office you need to get your pupils dilated. By dilating your pupils your doctor can directly examine your retina and if he diagnoses, or she diagnoses, you with a retinal detachment, you are going to need surgery.

Unfortunately, there are not any drops or medicines to fix a retinal detachment.

Retinal Detachment | Surgery

There are three ways or three methods to fix a retinal detachment. The first is called a pneumatic retinopexy. The second is an operation called a scleral buckle and the third is an operation called a vitrectomy.

Pneumatic Retinopexy

A pneumatic retinopexy involves injection of gas into your eye. The gas is used as a tool to help reattach your retina. With a pneumatic retinopexy, depending upon the location of the tear, you may have to hold your head in a certain position.

This is sometimes face down, this is sometimes keeping your head straight up or to the right or to the left. Again, the positioning depends upon the location of the tear.

A pneumatic retinopexy can be done in the office and can be very effective in fixing retinal detachments.

Scleral Buckle

A second way to fix a retinal detachment is with a scleral buckle. A scleral buckle involves placing a silicone band or rubber around the outside of your eye.

Don’t worry, it will be completely unnoticed once you’ve healed up. It’s intended to stay there.

A scleral buckle is a very effective way to repair a retinal detachment and has been around for several generations. It does require surgery and the most common complication of scleral buckle surgery is the increase in nearsightedness after the operation because your eye is actually made slightly longer.

Vitrectomy

A third way to fix a retinal detachment is with a vitrectomy. Remember a scleral buckle involves placing an element or a piece of rubber around the outside of your eye.

A vitrectomy involves going inside the eye to remove the vitreous and the fluid underneath the retina. Many times gas is also put into the eye at the end of the operation and just like pneumatic retinopexy you may have to hold your head in a certain position.

Vitrectomy and Scleral Buckle

So there are three ways to fix a retinal detachment: either with pneumatic a retinopexy, a scleral buckle or a vitrectomy.

Now, many times, surgeons may decide to combine both a scleral buckle and vitrectomy. This is really personal preference and all surgeons have different indications as to when to perform both.

Timing of Retinal Detachment Surgery

The timing of retinal detachment surgery is really dependant upon whether or not the macula, which is the functional center of your retina, is, what we call “threatened.”

Another way to look at it is;

“What’s the chance of you losing your central vision if we delay surgery”? If you have a retinal detachment which is not threatening your macula, therefore, it’s not threatening your central vision. Waiting a day, or longer, probably is appropriate.

Another situation is where the macula is already detached which would mean that your central vision is already lossed. Again, this is an urgent situation but not an emergent situation.

Probably the only time where retinal detachment surgery is an emergency is when you still have 20/20 vision, that is, your central vision is intact, but your doctor feels that if your retinal detachment were to enlarge your central vision might be in jeopardy.

Summary of Retinal Detachments

To summarize, we’ve talked about retinal detachments, specifically we’ve talked about rhegmatogenous retinal detachments and those are retinal detachments that involve a hole or tear in the retina.

We talked about symptoms of retinal detachments; new onset flashes, new onset floaters or loss of your peripheral vision.

We talked about surgery. The three options are pneumatic retinopexy, scleral buckle and/or vitrectomy.

We talked briefly about the timing of surgery…it’s all dependent if your central vision, or your macula is involved.

Thank you for watching!

I’m Randy Wong. I’m a retina specialist in Fairfax, Virginia. Thank you very much for watching this video. I hope you enjoyed it.

By the way, if you have any questions or comments, please leave them at the end of this video on YouTube or at the end of the article if you are reading this on one of my blogs.

We will see you again!

Tags Retinal detachment, Video, vitrectomy