Surgeons vs. Non-Surgeons

20 Jun Surgeons vs. Non-Surgeons

Posted at 10:15h in How I Practice, My Opinion by
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Two types of doctors; surgeons vs. non-surgeons. Similar to right brained vs. left brained.As a retina specialist, I’m a surgeon.

There are basically only two types of doctors.  I like to think of us as either “left” brained or “right brained,” but perhaps it’s more accurate to simply classify doctors as surgeons vs. non-surgeons.

The surgeons are more decision makers while the non-surgeons (PCP, family docs, internists, pediatricians, etc.) are the problem solvers (the smarter of the two groups, too!).

One major difference between the two types is our commitment to a treatment plan.  Treatment often requires surgery.  Surgery cant’ be undone.  We must always weigh the risks and benefits of surgery to the patient…and be ready for unforeseen complications.

Retinal Specialists

I am a board certified Ophthalmologist, and I am a surgical subspecialist.  Further training allows me to function as a retina specialist, an eye doctor who treats medical and surgical diseases of the retina.

Common retinal problems which require surgery include retinal detachments, epiretinal membranes, floaters, macular holes and others.

Making the decision to operate is not always easy.

I must make the decision based upon my best judgement, weighing all options and goals…and commit.

Risks vs. Benefits of Surgery

What are the potential risks of surgery versus the benefits.  Are the risks of surgery paramount to the potential benefits?  Is surgery worth it?

If there were no complications of surgery, this would not be a big deal, but in the “practice”of medicine unplanned reactions, results and complications may occur.

Sometimes the disease makes the decision simple.  For instance, a retinal detachment requires surgery.  The natural history of an untreated retinal detachment is complete blindness, that is, without successful surgery, blindness will occur.  The risk of blindness from surgery (for example, due to infection) is around 1:10,000.

In this case, not operating would be a mistake.  The risk of blindness is almost guaranteed if surgery is not considered.

Epiretinal Membranes, Floaters and Cataracts

On the other hand, epiretinal membranes, floaters, and cataracts are less clear-cut.  The decision to operate is more complex as a subjective (the patient’s perception or appreciation of a problem) evaluation is integral to making a decision over surgery.

Even though a patient may clearly have an epiretinal membrane, vitreous opacities (aka floaters) or a cataract causing blurry vision, unless the patient is worried about losing more vision, surgery may not be necessary.

Left untouched, none are potentially blinding.  Leaving them alone is okay.

Complications in these circumstances are really troubling.

What Does this Mean?

Complications of surgery are what define a surgeon’s practice.  Knowing when to operate and how to deal with the unexpected are what defines a good and healthy doctor-patient relationship.

If there were no complications in surgery, you wouldn’t need a “good” doctor.  If every surgery turned out as expected, we wouldn’t need to build relationships.

In the next week, I’ll be writing about some advances at our center to make vitrectomy surgery even safer than our current systems… further reducing the likelihood of complications.

 

Randy

Randall V. Wong, M.D.
Retina Specialist
Fairfax, Virginia 
www.RetinaEyeDoctor.com

 

 

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12 Comments
  • John
    Posted at 15:28h, 20 June Reply

    I am an overseas reader with my own personal eye history and I always enjoy reading your sober and clear-headed eye news – whereas I am saddened from time to time to hit upon certified eye doctors in the US that use their websites to promote various homeopathic, microcurrent and vitamin-based “natural” cures to improve conditions as ARMD and other serious retinal disorders as if such remedies were supported by strong science. Eye patients need the true facts, not woodoo medicine.

    Is it possible that at some point you could write a bit about retinal laser photocoaculation? Both for people with retinal tear and hole repair, retinal detachment repair, and of course for diabetic retinopaties treated with laser it might be interesting to know the long term prognosis for the laser burns and the possible scotomas caused by them within the visual field. It would be enlightening to know the long term prognosis for such scars – whether they tend to worsen with additional vision loss or whether they tend to improve perhaps with some restoration of vision within the affected area – or if they simply remain stable. I seem to have read rather divergent statements on this subject.

    Thanks.

    John
    Denmark

  • Farid Dawood
    Posted at 08:05h, 21 June Reply

    Dear dr. Wong,

    My name is Farid and im 23 years old.
    I know u r very busy, but could you please react to my e-mail that i sent u a few days ago. Im in desperate need of help.

    Also have u heard of docter marco mura? He is the best doctor for FOV in the netherlands where i live. He uses 23G instrument and always does induced PVD. Based on that would u think he is a good doctor to go for FOV?

    Greets Farid

    • Randall V. Wong, M.D.
      Posted at 18:02h, 22 June Reply

      Farid,

      Sorry for the delay, but I don’t answer the blog comments but every week or so. I’ve answered your email of 4 days ago.

      I do not know doctor Marco Mura. Sorry.

      I do not favor 23 gauge and I do NOT think inducing a PVD is wise.

      The 23 gauge “holes” are too large and hypotony occurs too often. Some, due to this, will use gas or air at the end of the operation, but this extra step has its own side effects. Also, the tip of the 23 gauge is not as small as the 25 gauge; tears are more apt to occur.

      Overall, vitrectomy is much safer than one would believe by reading on the Internet. Chance of infection is quite small and retinal tears occur 1-2%.

      Inducing a PVD, however, dramatically increases retinal tear formation. I am guessing, but perhaps 20-25% of the time.

      There is no need to induce a PVD. Everyone eventually develops a PVD, but most never notice floaters.

      Randy

      Randall V. Wong, M.D.
      Retina Specialist
      Fairfax, Virginia
      https://retinaeyedoctor.com/march2023

  • Jonathan Brickman
    Posted at 08:24h, 21 June Reply

    Randy, I think you were trying to help patients understand the fundamental difference between a surgeon and the non-surgeon so they could better understand the limits and focus of each, but I think you left us hanging without closure with all this stuff in the middle about complications, and common situations…Did you mean to tell us when to stick with the non-surgeon and when to find the surgeon? Otherwise, very helpful! Thanks, Brick

  • Scott
    Posted at 20:36h, 22 June Reply

    Dr Wong, I recently saw a local retina surgeon who is very well regarded and while he would gladly perform a FOV at a patient’s request, however he has reservations about doing it to otherwise healthy eyes and has never done it to a patient under 40. He prefers to perform induced PVD and uses 25g instruments. Although he would do a “core-only” vitrectomy, he is not convinced that it increases the safety of the operation or signifigantly reduces the chances for a retinal tear.

    Another concern expressed is that there is no data available on the long term safety of the procedure to accurately gauge complication rates. While a 1-2% retinal tear risk may be accurate within 5 years, what about when we go out 10-15 years from now? What unforeseen consquences could a patient face? Is there enough data to make an intelligent assumption? A recent article discusses the long term risk increase for open angle glacoma from vitrectomies. Is this a risk discussed enough in your opinion?

    These questions are not to pit you against any other doctor, but to compare paradigms among professionals (although I would love to have you guys discussing this at a round table).

    I believe you are operating on the hypothesis that a core only vitrecomy on otherwise healthy eyes does not have the same inherent risks as a standard vitrecomy on other eyes. Do you believe this theory has been tested enough for a patient to have accurate information?

    Thanks for your time. I was in Williamsburg last week and thought about coming to see you. I’ll get there one day soon!

    -Scott

    • Randall V. Wong, M.D.
      Posted at 12:45h, 02 July Reply

      Dear Scott,

      I think there is a 1-2% chance of retinal detachment within the first 2-3 months after surgery. After that, the risk of retinal detachment is theoretically lower. There is no study of retinal detachment after vitrectomy surgery. The chance of retinal tear is increased due to the surgery causing the tear.

      The statement in the first paragraph means to me; 1) he hasn’t done enough PVD inductions for him to realize the iatrogenic tears, or 2) there is something missing in the translation of what he said.

      There is definitely an increased risk if tear formation with inducing a PVD.

      I am not operating on a hypothesis, but rather commenting on my experience. I prefer to induce a PVD for other conditions such as macular holes and proliferative diabetic retinopathy. Causing a tear is not uncommon.

      Randy

  • Joseph Lucas
    Posted at 08:14h, 08 July Reply

    Hi Dr. Wong,
    I’m looking forward to details on the advances you made concerning vitrectomy surgery. Reducing complications is great news! I am 24 and I have suffered from a really annoying floater in my right eye for one year. I feel really depressed and I am more and more interested by a FOV. However side effects scare me a bit. Eye doctors in France told me that after a FOV I will have a cataract anyway. They also told me that a cataract surgery means a complete loss of auto-focus. Do you agree ?
    Thanks for what you do for people suffering from floaters. I really appreciate your work.
    Joseph

  • Joseph
    Posted at 16:45h, 16 July Reply

    Thanks for your answer Dr Wong!
    Are you refering to “accommodative intraocular lenses” ? I am wondering why are these lenses still so unknown. They seem to have no side-effects and allow autofocus.
    Last question now. If only one of my eye develop a cataract will it be possible to see correctly if only one eye has an artificial lens. Will the two eyes manage to autofocus in a proper manner even if one as a natural lens and the other as an artificial lens ?
    Have a good day and thanks again for your awesome work.
    Joseph

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