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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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How To Diagnose Diabetic Retinopathy

The retina is the only part of the eye affected by diabetes.  The only way to diagnose diabetic retinopathy is by direct visualization of the retina.  Your eye doctor should be able to dilate your eyes and, by simply looking at your retina, diagnose the disease.  That’s all.

No Symptoms of the Eye Disease

Symptoms are the effects of a disease.  These are what a patient feels, not what a doctor sees.  Complaints of blurry vision, pain, shortness of breath, nervousness…all are types of symptoms.

The disease, diabetic retinopathy, can cause mild blurriness to complete blindness, or nothing at all.  Many patients see perfectly, yet have the disease.  They just don’t know it.

This is the danger of diabetic retinopathy.  Just like high blood pressure, it may cause absolutely no symptoms.

No Diagnostic “Tests”

A normal eye exam does not always include dilation of the pupils.  Every diabetic patient must have the pupils dilated at least annually.  These are the recommendations of the American Academy of Ophthalmology and the American Optometric Association.

Why?  A dilated exam is the only way to examine the retina.  A dilated exam is the only way your doctor  can “see” the characteristic changes of diabetic retinopathy.  There are no diagnostic tests for diabetic retinopathy.

In the absence of symptoms, the diabetic retinopathy can still be diagnosed.  Early detection means preventing loss of vision.

Fluorescein angiography and OCT (optical coherence tomography) are used commonly to study some of the aspects of your retina (i.e. is there retinal swelling?), but neither are necessary for the diagnosis.

The only way to diagnose diabetic retinopathy is for somone to “see” it.

What Does This Mean? Diabetic eye disease can be “silent.” Many people believe that the absence of symptoms means the absence of disease.  Obviously not true.

The patients with whom I have had the most trouble (i.e. they go blind despite my intervention) have had either no symptoms or ignored themselves for an extended period.  Certainly, they never had an eye exam until it was too late.

Sadly, in almost all cases, the blindness could have been prevented if someone had just “looked.”

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Iluvien Treatment for Diabetic Macular Edema

Iluvien gets closer to FDA approval for treatment of diabetic macular edema.  Earlier this week, I wrote about emerging treatments for diabetic retinopathy.  Of the group, Iluvien is now the most likely to be available.

Alimera Sciences has filed for NDA (New Drug Application) for Iluvien.  In March, the company announced the favorable results in their clinical trials for the FDA.  The NDA is the last step for FDA approval.

Iluvien Releases Steroid

Iluvien is a sustained release drug delivery system.   Similar to Ozurdex, the delivery system will release steroid after injection into the eye.   (Ozurdex is presently FDA approved for retinal vein occlusions, not diabetic retinopathy.  The makers of Ozurdex are hopeful that it may be used for diabetes.)

The steroid released by Iluvien, fluocinolone, will last for 24 months after injection.  The vehicle will remain in the eye after the drug is released.

Alternative to Present Treatments

The present treatment for diabetic macular edema involves laser treatment, anti-VEGF injections and/or steroid injections.  The laser treatment has limited applications, that is, it can’t be used in all patients and also doesn’t work as well as any of the injections.

The injections, on the other hand, don’t last long and need to be repeated.

Iluvien may obviate the need for repeated treatments and offer significant improvement in vision compared to the standard laser therapy.  With fewer injections, there is less chance of infection.

What Does This Mean? Ozurdex was FDA approved about one year ago.  The significance of Iluvien’s NDA is the validation of the advantages of intraocular sustained release drug systems.

All emerging treatments for diabetic macular edema involve injections.  All seem to offer superior treatment compared to the standard of care, laser photocoagulation.  A sustained release system for diabetic retinopathy will change the way we treat this very common eye disease.

The introduction of Iluvien is estimated to be towards the end of the year according to this week’s press release.

I can’t wait.

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Gas Injection for Retinal Detachments

Injecting gas into the eye, called pneumatic retinopexy, is the fourth way to fix retinal detachments.  Other methods include

Gas Injection

This procedure is performed in the office.  Similar to other intraocular injections, except gas is introduced into the eye instead of anti-VEGF medications or steroids.

The gas is usually injected at 100% concentration and will expand a bit over the first day or so.  This allows us to inject a small amount of gas that will enlarge and cover more retinal surface area.

Gases used are usually SF6 (sulfur hexafluoride), C2F6 (hexafluoroethane) and C3F8 (octafluoropropane).  These are large molecules, are inert (don’t react with tissue) and can expand at given concentrations.

Their large size means that they will be slowly absorbed after injection, giving us plenty of time to use them as a tool.  In comparison, air, if injected into the eye, does not expand and will be absorbed within 24 hours.

Advantages of Gas Injection

No “operation” is the biggest advantage.  The procedure can be completed within hours of diagnosis.  There are no issues with scheduling an operation at the hospital, pre-operative clearance and coordinating schedules.

Quick Healing – no actual cutting, so tissue healing is very quick.

No Change in Glasses – as the eye remains the same shape (in contrast to scleral buckle), there is no change in glasses prescription.

Disadvantages to Pneumatic Retinopexy

Lower Success Rate – not all retinal detachments can be treated with gas injection.  The forces within the vitreous are NOT changed.

After gas is injected, the head must be positioned so that the gas abuts the retinal tear.  For instance, if the tear is at the “12 o’clock” position of the eye, the head must be held upright, or erect.  Similaryly, if the retinal tear is located at “9 o’clock” as you are looking at the patient, the head must be tilted over to the left to position the gas “bubble” appropriately.

Retinal Detachments and Retinal Tear
A Retinal Tear Can Lead to a Retinal Detachment

For example, in the illustration above, the tear is located at 10 o’clock.  The head should be tilted to the patient’s left, so the gas, as it rises in the eye, will abut the retinal tear.

Usually, only retinal detachments with tears from 8-4 o’clock can be treated with gas.  It is not possible to treat tears occurring at 6 o’clock.

In both scleral buckle surgery and vitrectomy eye surgery, forces are reduced in the vitreous.  This does not occur with pneumatic retinopexy (gas injection).  Therefore, redetachment occurs more often.  The success rate is lower, perhaps around 85% for this procedure.  Scleral buckle and/or vitrectomy procedures are slightly more successful.

Whenever gas is used, there is a higher rate of cataract formation after the operation.  As with any procedure, there is a chance of infection that can cause blindness.

How the Gas Bubble Works

Basically, the gas, when positioned properly, blocks the transmission of fluid through the retinal tear or retinal hole.  The retina reattaches.  By using either laser or freezing (cryotherapy), the tear is treated to induce scarring that will eventually “seal” the retina and prevent re-detachment.  It does NOT “push” the retina back per se.

What Does This Mean? Depending upon the circumstances, there are a variety of ways to operate to fix a retinal detachment.  Gas injection has many advantages, and is a successful way to proceed.

My personal feeling is that gas injection used to be a great time saver, however, the success rate is lower.  As technology as advanced (e.g. 25  gauge vitrectomy), operating room procedures have become easier, and quicker, to perform.  The advantages to pneumatic retinopexy, or gas injection, have become…well, er, “blurry.”

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Vitrectomy Surgery for Retinal Detachments

Vitrectomy eye surgery for repair of a retinal detachment can be an alternative or adjunct to scleral buckle.  Vitrectomy surgery involves the removal of the vitreous from the eye.  This procedure was introduced (i.e. invented) in the mid-1970’s and enhanced our ability to treat retinal detachments.

Retinal Tears Cause Retinal Detachments

Remember that the culprit in “rhegmatogenous” retinal detachments is the formation of a hole or retinal tear in the retina.  The vitreous can exert “pulling,” or traction, on the retina and cause a retinal tear. 

Using a scleral buckle surgery, we introduced “slack” in the vitreous to release some of the traction.

Vitrectomy surgery, too, is focused (no pun intended) on relieving stress in the vitreous.  By cutting and removing the vitreous, the vitreous can no longer “pull” on the retina and cause additional tears and keep the detached retina elevated.

Remove the Vitreous, Replace with Gas

After removing the vitreous, the next step usually involves exchanging the vitreous and fluid with intraocular gas.  The purpose of the gas is to stop the migration of fluid to the space underneath the retina (by definition, a retinal detachment). 

Many people are told (incorrectly) that the purpose of the gas is to “push” the retina back into position, but this is not so.  The surface tension of the gas bubble actually acts as a cork, stopping migration of fluid from the vitreous cavity to the subretinal space.

A Vitrectomy Can Fix a Retinal Detachment
A Vitrectomy to Repair Retinal Detachment

In this way, the retina is reattached, and kept attached, until significant scarring takes place to keep the retina attached by itself.

The gas will absorb, but the length of time required depends upon the type and concentration of the gas (I use 16% SF6, sulfahexafluoride).  It does not stay in the eye as long as the gas others use as I believe this to minimize the amount of post-operative complications.

During the time gas is actually in the eye, patients are warned against experiencing large changes in atmospheric pressure.  Going to the mountains or airplane travel is usually prohibited as the decreased atmospheric pressure can cause a rapid increase in the volume of the intraocular gas.  This could cause the pressure in the eye to increase too fast.

In short, the gas is used as a tool to help reattach the retina.  Depending upon the location of the tear in the retina, a patient may be required to keep his/her head in a certain position following surgery.  This positioning is as crucial as the operation itself. 

For instance, if the tear is located at the top of the eye, the patient may need to sit up in a chair for days following surgery.  If the thear is located at the bottom of the retina, face-down positioning may be needed.

Advantages of Vitrectomy

There are a few advantages to vitrectomy for repair of a retinal detachment.  There is no worry about becoming more near-sighted as there is no scleral buckle placed.  Similarly, there is no chance of causing double vision as there is no manipulation of the eye muscles as in the case of a scleral buckle.

Basically, for the patient, there is less operating outside the eye.  Discomfort (“doctor-speak” for pain) is minimized.

There is, however, the chance of infection, as there is with any intraocular surgery, that can lead to blindness.  “Endophthalmitis,” the fancy clinical term for this type of infection, is less common in retinal surgery than cataract surgery.  The chance of infection occurring is small, somewhere around 1:5,000-10,000.

Vitrectomy with Scleral Buckle

Many times both a scleral buckle and a vitrectomy are utilized for a retinal detachment.  There are no clearcut reasons when to use vitrectomy or scleral buckle or both.  As I said last post, placing a scleral buckle can be time consuming in certain instances…thus affecting the decision.

What Does This Mean?  There are several ways to fix a retinal detachment.  Vitrectomy surgery fixes the retinal detachment from the inside, requires less tissue manipulation (i.e. operating) and is more comfortable than a scleral buckle. 

Using both modalities, in the right situation, can lead to a higher success rate as we are fixing a retinal detachment from both the inside (vitrectomy) and the outside of the eye (scleral buckle).

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Scleral Buckle Surgery for Retinal Detachment

A scleral buckle is one of several ways to “fix” a retinal detachment. Other ways include vitrectomy eye surgery as well as a combination of scleral buckle and vitrectomy.  An office procedure, called pneumatic retinopexy, is sometimes used as well.

Scleral Buckles are “Oldies But Goodies”

The scleral buckle has been employed for about 75 years.  The principle behind a scleral buckle is to cause the shell of the eye, or sclera (the white “wall” of the eyeball) to indent, or “buckle.”  The most common way to achieve “buckling” is by oversewing a thick piece of silicone rubber or sponge around the eye or encircling the eye with a silicone band and pulling it tight (same as a belt “buckle”).

The longevity of the scleral buckle implies, at least to me, that it is inherently very good surgery.  It corrects the principal problem – relieving “pulling” on the retina.

A Scleral Buckle is Placed to Repair a Retinal Detachment
The Scleral Buckle Reduces the Diameter of the Eye (Yellow Arrows)

Pretend You Are Sitting inside Your Eye

The result of any scleral buckle  is to reduce the internal diameter of the eye.  In doing so, the vitreous can no longer pull on the retina.  The cause of a retinal detachment is a retinal tear (or retinal hole).

For example, suppose the room in which you are sitting is the eye and you are the vitreous.  The wallpaper of the room is the retina.  Stretch your arms apart and pretend you can reach from one wall to the other.  Your fingertips are glued to the wallpaper.  This is how the vitreous adheres to the retina.

If you move to the left, your right arm now pulls on the wallpaper (or the retina) and you cause a tear on the right side.  Similarly, if you move to the right, you create pulling, or traction, on the left wall and cause a tear.

By placing a scleral buckle around the eye, the internal diameter is reduced.  This would be the same as moving the walls of the room closer and, as a result, your arms would bend and create slack in the “vitreous.”  You could move left or right with less pulling on the wallpaper, and less likely to cause a retinal tear.

Same with the retina!

“Side Effects” of a Scleral Buckle

Side effects, or possible complications, of scleral buckle surgery include;

  • increased myopia (you will be more nearsighted) – due to the increased length of the eye.  There may also be a large change in the refraction due to astigmatism.
  • double vision – uncommon, but the buckle is placed outside of the eye and underneath the eye muscles.  By manipulating the eye muscles, double vision is possible.
  • pain – usually not an issue and is usually (in my experience) amenable to Tylenol/Advil.

Fun Facts About Scleral Buckles

  1. The eye is not taken out.  We wouldn’t be able to put it back in.
  2. The “buckle” is usually made of silicone rubber (different than silicone oil) and has no known systemic side effects.  It can also be made of a silicone sponge material.  These, too, are safe.
  3. The “buckle” is intended to be permanent.  At times, it may extrude, but it is very uncommon.  The buckle only really needs to be in place for a couple of months, but we usually never plan on removing them.
  4. Some surgeons use metal clips to help fasten the buckle around the eye.  This can be a problem if future MRI’s are needed.

What Does This Mean?

Though “old,” scleral buckles are not obsolete.

There has been a shift in practice patterns among retina surgeons over the past 15 years.  About 15 – 20 years ago, pneumatic retinopexy was first described (aka invented).  Scleral buckles with vitrectomy became popular in certain areas of the country and, more recently, vitrectomy alone has  become popular.

As I’ll explain in the next few posts, vitrectomy surgery has become instrumental for the repair of retinal detachment, but there is still a role for scleral buckling.

I believe it to be a very valuable tool for retinal detachment surgery, but their use is sometimes based upon the length of time a surgeon takes to perform that part of the operation.  It can take a matter of minutes…to hours.

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Sustained Release; Ozurdex Now Treats Diabetic Macular Edema?

Ozurdex, a sustained release drug delivery system,  may soon be used to treat diabetic macular edema. The sustained release intravitreal implant has been tested, with favorable results, for possible use in treating the common retinal swelling caused by diabetes. Results were published recently in the March issue of the Archives of Ophthalmology.

Ozurdex was FDA approved for the treatment of retinal vein occlusions last year. It was the first sustained release drug delivery system for the eye. It releases dexamethasone, a well studied (i.e. old) steroid.

Diabetic macular edema is a common complication of diabetic retinopathy and is the most common cause of lost vision due to diabetes. The most common treatment for DME has been laser photocoagulation.

Over the past years, small anecdotal studies have implicated the favorable use of intraocular injections of either steroid or anti-VEGF medications as an alternative method for treating diabetic macular edema.

It is not uncommon for retinal specialists to turn to intraocular injections as a means to help control the retinal swelling as a first line of therapy or to augment the laser treatment.

The small study involved 171 patients and tested two strengths of Ozurdex along with placebo (i.e. nothing). Both strengths of the Ozurdex group showed improvement, and more importantly, improvement that was sustained for at least 6 months compared to the sham (placebo) group.

What Does This Mean? The results are expected. It is not surprising that a sustained release system shows improvement when the intraocular injections (shorter acting) showed improvement, too.

What is significant is the that the technology continues to move forward and that newer “treatments” continue to emerge based upon this sustained release technology.

Whether or not Ozurdex is going to be used for diabetic macular edema depends upon Medicare. If Medicare is going to reimburse (that is, pay) for Ozurdex in diabetes then docs may start using it routinely.

“Off-label” indications are really not the issue in this case, but the cost of Ozurdex is the issue.  The cost of Ozurdex is about $1300.

If insurance companies do not reimburse Ozurdex, it is too expensive for patients to be willing to cover the expense out of their pocket.

Keep your eye out for news on Iluvien (pSivida/Alimera Sciences). Iluvien is expected to be presented to the FDA for approval for …treatment of diabetic macular edema. Iluvien is a sustained release drug delivery system that releases fluocinolone…a steroid.

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Why Glasses Won't Help You See

“Will glasses help?”  We often wonder if “correction” will help decreased vision in the presence of retinal disease such as macular degeneration and diabetic retinopathy.  Spectacles can only help so much yet won’t “reverse” the loss of vision from the disease.  This is opposite to those people who claim they are “blind,” yet with glasses see quite well.

How do Glasses Work?

The goal of corrective lenses is to focus an image, sharply, on the surface of your retina (technically the macula).  If you are nearsighted (myopic), the image of what you see falls short, or in front, of the macula.

Nearsighted Image is "TOO SHORT" and Falls in Front of Retina

Glasses are used to refocus the image on the retina.  This is exactly like a projector focusing on a movie screen.

If you are farsighted (hyperopic), the image actually is focused behind, or past, the macular surface and glasses are used to move the image forward onto the retina.

Farsighted Image is "TOO FAR" and Falls Behind the Macula

What is the Macula?

The macula is the functional center of the retina.  It measures only about 1.5 mm X 1.5 mm, yet it gives us all of the attributes of our “sight.”  It provides us our best color vision, central sight for reading and watching TV and is the only part of the retina sensitive enough to “see” 20/20.

"JUST RIGHT" - Image Falls ON the Retina

Will Glasses Work?

If there is macular disease, such as diabetic retinopathy or macular degeneration, even properly measured glasses won’t work.

The vision is decreased due to the macular disease.  It simply isn’t capable of “seeing” 20/20.  The disease is preventing the retina from working to its full potential.

When glasses are working, the image is properly focused on the retina, but the retina is not working well.

Low Vision Aids

It may now make sense why “low vision” aids don’t simply correct for the disease.  Low vision aids may be useful by enlarging the image focused on the retina.  It may make the image easier to “see,” but the disease is still present.  Sometimes, images can be focused to the side of the diseased macula, but these “para-macular” areas are not as sensitive as the macula itself.

In all cases, vision is compromised.

What Does This Mean?

When we speak of decreased vision, implicit in our discussion is the assumption that the proper glasses, or contacts, are being used.  The eye is a pretty remarkable optical system, and in most cases, it is pretty routine to find the right lens to help correct myopia, hyperopia and astigmatism.

The optical system can’t correct for disease.  while the unit may be functioning properly, that is, focusing an image precisely on the retina, the disease will always win.

This is true of macular disease, glaucoma and some cataract.

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You Look All Bent Out of Shape

Distortion, also known as metamorphopsia, is a symptom of many macular diseases.   Anything that affects the macula can cause distortion; epiretinal membranes, macular holes, macular edema, diabetic retinopathy and macular degeneration.  The macula is a place in the retina, the functional center.  Thus, the term “macular” becomes an adjective when describing retinal disease located in the center of the retina.

OCT scan of a retina at 800nm with an axial re...
Image via Wikipedia

The macula is a small area of the retina measuring about 1.5 x 1.5 mm.  It is very sensitive and allows us our best color vision and the ability to see 20/20.  A normal macula (fovea) is smooth and slightly concave (see OCT).  Light falls on the normal macula giving us vision.  This is very similar to a projector focusing images onto a movie screen.  If there is a physical change to the macula or disease, central vision is usually affected.

Macular Pucker or Epiretinal Membranes

Epiretinal membranes are, as the name implies, membranes that develop on the surface of the retina and cause the underlying retina to wrinkle, or “pucker.”  This physical wrinkling of the macula causes decreased vision and distortion.

Surgically removing the membrane usually improves the distortion and can improve the vision, too.

Macular Holes

If you were to poke a pin through a piece of ballon and then stretch out the rubber, you’d create a nice round hole.  A macular hole is actually a stretch hole in the center of the macula.  Images that fall within this hole are not seen as there literally is no retina in the center of the macula.

Symptoms include decreased vision, distortion and sometimes, scotomas, which are the fancy name for blindspots.

Macular Edema

Swelling of the macula can occur from a variety of causes.  The two most common causes germaine to this web site are diabetic retinopathy (more specificially, diabetic macular edema) and swelling secondary to choroidal neovascularization in cases of wet macular degeneration.

Other causes, however, include central serous retinopathy, central and branch vein occlusions, cystoid macular edema from cataract surgery (uncommon these days) and from cases of intraocular inflammation (aka uveitis).

Macular Degeneration Causes Distortion 3 Different Ways

As above, choroidal neovascularization can physically distort the retina and cause distortion.  These abnormal blood vessels can develop in between the layers of the retina causing physical disruption of the retina.  The analogy here is exactly like the “Princess and the Pea.”

Wet macular degeneration can also cause macular edema as we discussed above.

Dry macular degeneration can also cause symptoms of distortion.  One of the layers of the retina, called the RPE, becomes diseased and degenerates.  This loss of one of the principle layers of the retina can cause distortion.

What Does This Mean? Distortion, or metamorphopsia, can be a symptom of a variety of retinal or macular disorders, not just macular degeneration.  The key for saving your sight is early detection and diagnosis.  Usually this may require consultation with a retina specialist to discuss the various treatments.

A fluorescein angiogram and/or an OCT (Optical Coherence Tomography) may be very helpful to your doctor, but this can vary.

Other causes of metamorphopsia, not related to the retina, could include large amounts of astigmatism or a decentered lens.

While most causes are indeed retina related, it is also important to note that most have a treatment with the exception of dry macular degeneration.  There is some rumbling; however, that there may be some promising treatments for dry macular degeneration in the near future.

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Doctors Improve the Internet!

Doctors can improve the Internet.  Doctors could be creating more web sites that provide good, credible health information, or content, to educate the public.  There is a paucity of reliable “experts” writing on health.  The timing is perfect for docs to become more involved.

Stop Playing Doctor

Too few doctors really use the Internet to engage patients.  There is the mistaken belief that by doing so we may breach patient confidentiality or that we may be liable for advice we give.

So stop playing doctor.  Use the Internet to inform, to educate.  Leave the advice and treatment plans in the office; where it belongs.

Creating a Primary Resource

We all know that good, reliable health information is hard to find on the Internet.  There are lots of web pages out there, but most are written by “perceived” experts.  Perceived experts are those that have taken the time to create content, but it isn’t necessarily good content.  Many times perceived experts are actually trying to sell a product; vitamins and diet plans are good examples.

Doctors, however, are the authority figures.  They are the experts and along with “authority” comes credibility.  Docs use this authority in the office everyday seeing patients.  This same authority could be used on the Internet to create more accurate and relevant health content.

If docs are able to serve as primary resources of information, the health information on the web gets better.

“Just the Facts, Maam” (Sgt. Joe Friday, “Dragnet”)

What am I talking about?  I am not talking about offering medical advice over the Internet.  I am not talking about forming a relationship with a patient online via email or FaceBook.  That would take too much time and would be wrong.

I am; however, interested in getting more docs to publish information about health – for the sole purpose of educating.  For instance, on this web site I educate about two retinal diseases; diabetic retinopathy and macular degeneration.  I have written quite a few articles about the diseases and provide information so others can learn.  I have chosen to share my knowledge.  In contrast, I am NOT offering medical advice nor offering treatments or recommendations per se.

As they used to say on Dragnet, ” Just the facts, maam.”

What Does This Mean? A doctor’s expertise is broken into several parts.  One part of expertise is knowledge and I am advocating that more docs share their knowledge.

Docs like to participate in speaking engagements all the time.  There is not much difference between giving a lecture and preparing content for the web.  In fact, content for the web can be in many formats; including Power Point.

My point is that docs to this same sort of “soft” marketing and lecturing already.  There really is no difference between giving a lecture and preparing content for the web.  It’s stuff we know and are sharing.

Another facet of “expertise” is experience.  Doctors distinguish themselves by their experience, not necessarily their knowledge.  Knowledge without experience is useless.  A doctor can NOT use his experience over the Internet.

A doctor’s experience does not exist on the web, but his knowledge certainly could.

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offices

Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different practices.....it'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
F:703.992.8158
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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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