This is the full verbatim transcription (not edited very well, though I added subtitles for navigation and place marking) of the webinar produced in October 2015 “FOV | Frequently Asked Questions” where we also had two guests (patients) who have had the procedure.
Breaking up the video and producing in different parts is simply too time intensive.
This is Dr. Randall Wong. Welcome to my webinar. I am a retinal specialist in Fairfax, VA. We are going to talk about the treatment of floaters and frequently asked questions. However, tonight we have two very special guests so what I would like to do tonight is go over the more frequent questions before surgery which are usually my questions and then after surgery which are actually your questions.
Then we will have John and Mark introduce themselves to tell a little bit about themselves and a little bit about their story and then open up the floor to questions from the attendees. If everyone thinks that is okay I would like to keep this to about an hour.
Sound Check for Webinar
I just want to double check that people can hear me. For the attendees, I can talk to the panelists but cannot talk to the attendees. Type in the chat box and we can get started shortly. Thanks John. Thank you Chrissy. I am going to try something really daring. I am going to turn my web camera on.
Can you guys see me? I can see you at nine o’clock position on the screen. I can’t see you so I am going to turn it off and add it when I record this. You cannot see me any longer? John, can you see me? No I can’t see you anymore. Okay thanks for coming. We are going to get started. I am going to have a very short, short slide series and then “frequently asked questions.”
NB: This turned out to be a huge mistake. I had intended to record a video of myself and then mix in later, but whatever I did, froze the webcam recording me. Will try again next time.
Agenda for Webinar
Again I am Randall Wong, M.D., and you can check out my website at www.retinaeyedoctor.com. Let’s get started. As I said I am a retinal specialist in Fairfax, VA. Fairfax is just outside Washington, D.C. My website specifically for patients with floaters is www.vitrectomyforfloaters.com. What I would like to do tonight is talk about getting an appointment, getting a vitrectomy and what we do afterwards.
We will talk about frequently asked questions before surgery and then frequently asked questions after surgery. Because I was able to get two special guests tonight and would like them to tell their story and then open up the floor to any specific questions you may have for the guests or what you may have for me.
Making an Appointment
The process is pretty simple. At some point you have followed me or seen our materials or visited our website and you want to schedule an initial consultation. The easiest way to do that is to just go through Chrissy. Chrissy has been handling all my digital appointments for the last several years. Here is her email: email@example.com.
If and when you are ready and there is no hurry to come see me just reach out to her and she will have all the logistics in finding out whether or not your insurance is going to work and then help figure out what weeks would be great for an appointment, etc., etc. Surgery is done as an outpatient same day surgery. Typically it is done on a Friday.
Often you will come to see me Wednesday or Thursday or that Friday. If we decide to proceed with surgery you will have surgery on that following Friday morning. It is done as an outpatient. You go home within a couple of hours and then I will see you on Saturday to take off the patch and start the drops.
Please Make Sure to Have a Ride Home After FOV
Something has come up that is new. We need to make sure that you have a ride, not a taxi, to take you home from the surgical center. This is beyond my control and I apologize. You will go home with a patch and do not need to do anything that day but the hospital is insisting that you have someone known to you to help you get home.
Basically the next day we will take off the patch and start drops. When I see you there are all kinds of questions from me. A lot of you have done your research. A lot of you have been listening to this Webinar to learn more about the process of vitrectomy to remove your floaters.
On the first day or the first encounter I actually have the most questions. The biggest question is do the floaters move or are they fixed? And it is very important because they should swish back and forth or up and down with eye movement. They should not be fixed because if they are then they are actually in the vitreous.
The vitreous is a kind of fluid and it has been described as a gel so they need to move back and forth or move with eye movement. There needs to be some lag and if so I know that whatever you are seeing has got to be in the vitreous and therefore the vitrectomy is going to help you. When I see you in the office I am very interested to see whether you have any evidence of other eye disease.
Floaters from PVD or Other Cause?
Remember floaters can come from a PVD, which is the most common cause, but there can also be floaters from blood or inflammation. So, floaters from blood might be from a disease such as diabetic retinopathy or something else that is wrong with the retina. So, I have to make sure that whatever you are seeing is not from a vascular problem such as diabetes that is affecting the retina.
On fewer occasions a small percentage of people have floaters from inflammation or uveitis. Most people know they have a history of this but just in case you don’t I need to make sure to me that the eye looks very healthy. I need to establish whether there is a PVD because if there is a PVD and we decide to proceed with surgery a PVD is the easiest scenario for me to perform surgery to remove your floaters and the reason is I don’t have to create a PVD.
We have one guest tonight who had a PVD induced and we have a second guest tonight who already came to me with a PVD. There will be some subtle nuances as to what the differences are.
Is There a Cataract?
The next question I have is: Is there a cataract? The whole question of cataracts on the Internet is very kind of disturbing because I think they are overplayed. In my experience and my statement about cataracts is the following: Cataracts can happen but they are unlikely.
I am not so sure why there is the sentiment on the Internet experience and my observations it is just not true. So my parting line for cataracts is yes they can happen and yes they can be accelerated by vitrectomy but it is unlikely. So I am very curious during our initial consultation to establish whether or not you have a cataract so we can talk a little bit about that.
Can I see the Floaters?
Another common question that I get as a doctor is: Can I see the floaters? And for those of you who have been through this or actually read my website I actually don’t care to look for your floaters and the reason is that your own vitreous is supposed to be 100% clear to you whereas I as your doctor should be able to see your entire vitreous. So it doesn’t really matter or makes it impossible for me to see exactly what you are seeing.
The most important thing to me is for you to establish or confirm whatever you are seeing moves back and forth with eye movement because then I know it can only be in the vitreous. The last thing we need to talk about is whether we need to put stitches in 25-gauge.
Over the last few years I have decided with my young patients that it is probably easiest if we put stitches in at the end of the operation even though it is 25-gauge because this just takes away some of the potential problems although temporary and although benign it just reduces the problems after surgery.
Questions After Vitrectomy
Questions after surgery usually come from the patient: How come my vision is so poor? What about pain, activity? Warning signs? How do I take my drops? What about these stitches? And then follow-up. So let’s go down the list. So why is vision poor?
As John and Mark will attest, the day after surgery the patch comes off and I do not waste my time trying to get you to read the smallest line on the eye chart and the reason is that there are so many reasons that your vision should be poor the day following surgery.
I expect your vision to be poor.
#1: You have had a patch
#2: You have just had an operation
#3: You may have had a PVD induced
I only need to establish that you are able to see light.
Sometimes people have double vision and that is from the anesthesia or from the local block that we give. But all that is temporary and usually turns around in the first 24-48 hours.
Having said that when you take the patch off sometimes you even see floaters. But it is the usual case that when I take the patch off that is the worst your vision is going to be and from there on there is going to be continued improvement and clearer sailing.
There is almost never any pain. I don’t think I have ever had to prescribe any medicines for pain control after a vitrectomy. Usually whatever you would take for a headache: Tylenol, Advil, aspirin is sufficient if you were to have some discomfort but I don’t expect you to have any discomfort.
You may resume full activity within 24-48 hours. I insist actually that you don’t reduce your activity. There are two times when I want you to call me or let me know that there is a problem. And that is pain that does not go away with your normal headache medicine or if you feel that your vision is actually getting worse.
There is a difference between your vision getting worse and not improving as fast as you would like. However, if your vision were to go backwards I really want to know about that. There are two reasons for this: This could be signs of infection or a retinal detachment.
I make this really easy. There is only a tan top and a white top. The white top is a steroid and the tan top is an antibiotic. Use it four times a day one drop each until you follow-up with me or your doctor at home.
Stitches generally don’t hurt. You can usually feel that there is a foreign body sensation or something is in your eye but most people cannot feel them the last four to six weeks because they will dissolve. But for the first day or two before they get soft with absorbing your tears you might be able to feel them.
As far as follow-up is concerned I really want you to come to the office to see me knowing that you have got your own doctor appointment in seven to ten days because that is when I would normally see you when you would stick around to see me. If you want to see me you are absolutely welcome to.
I certainly have had patients who have returned and actually stayed so that I can see them in follow-up. It doesn’t mean that is their last follow-up. Certainly the first appointment after surgery is a critical period.
What I would like to do at this time is to welcome John and Mark. They are both patients of mine. They have both have had an FOV; John already having had a PVD and Mark needed to have an induced PVD.
John, I am going to ask you to go first to tell your story and then Mark and then we will open up the Webinar to questions. So John, tell us a little bit about who you are, what you have been through, and whatever you want to share.
John: Thank you very much. My history of floaters goes back almost 40 years. I was 12 when I first noticed them. I have talked with optometrists and ophthalmologists over the years and the general consensus was that you just live with them.
They talked about the only treatment was vitrectomy and any doctor I talked about when they talked about vitrectomy is: “You don’t want to do that. It is very scary.” I even tried about ten years ago. There was a doctor in Falls Church who was doing Yag laser treatment for floaters. I tried that. It broke them up and dispersed them a little bit for a day or so but they came back.
The floaters have never been that terrible for me. I would have squiggle lines that would float throughout my vision. I was able to do all the normal things I needed to do during the day. That changed about 2013. Since seeing Dr. Wong this is my second procedure. The first one was on my right eye in 2013.
Randy: You can call me Randy.
John: Thank you Randy. In 2013 my vision got progressively worse with a diagnosis of vitreal detachment at that time but I had one floater that kept getting in my right eye right in the middle of my vision and it made it difficult for driving etc. I have been doing research every six months.
I would go on the web and try to find different treatments for floaters. That is how I found the laser and I found Dr. Randy’s website. The way he presented things with the information plus his background and training I knew that this was the person I needed to talk to because I had considered cold calling some of the ophthalmologists at some of the bigger eye centers in our area to see what we could do about this and vitrectomy. I called Dr. Wong, had the visit.
In a couple of weeks I had my first procedure. It did not take very long. It was in the morning. The whole procedure, the vitrectomy, took about ten minutes and as I was waking up they brought me back to recovery. From the time the procedure started to when I went out the door was about an hour. There was no pain involved with it and no discomfort at all. I followed up the next morning and got the patch off. On my right eye my vision was blurry and had a little red tinge but that cleared within a day or so but my eye was dilated but it got better so that was good.
About 5-6 months later my vision had started to decrease in my right eye. I wound up developing a cataract. There was no problem with it. I just had to get my glasses and vision adjusted.
Randy: John, I am sorry. What eye did we operate on first?
John: The right eye was my first one, the one that you just did was my left eye. So I went into one of the other ophthalmologists into his office and he specializes in cataracts. They did a cataract replacement. Same thing. One day a patient with no pain and I am very pleased with it because I have worn glasses all my life. They put a corrective cataract in and the vision in my right eye is perfect at 20/15. No floaters.
Randy: Let me interject for all of your listening. John is older than most of the patients. He had a PVD and because he has had a PVD and is a little bit older and he had established early cataracts that is usually the norm whereas we will hear from Mark which is a little bit different. I know everybody is listening that you just said it doesn’t cause cataracts. What I am trying to stipulate is that because there is a preexisting cataract you know that months later it can happen. It is not the end of the world as John will tell you. Sorry to interrupt John.
John: I definitely don’t want to discourage anybody. You were mentioning the concern about cataracts. My whole point is that if you do happen to get one it is not the end of the world. The left eye was a worse situation a couple of months ago. In April my vision got markedly worse with squiggles much like smudged eyeglasses all the time.
I went to see Dr. Wong again and that is when he found out I had a PVD. The same thing. We scheduled for the procedure. I just had my 7-day checkup. Very similar. Went in. They put me to sleep with light anesthesia but it did not last very long. Got up and the time from when the procedure started to the time that I was headed out to the car with my driver was about an hour.
No pain at any time. I still have no pain. Vision is great and I am very pleased. That’s it.
Randy: Thank you John. I really, really appreciate it. Now I would like Mark to tell his story and then we will open this up to questions.
Mark: Thanks Dr. Wong. My story is very similar to John’s. I had floaters for about ten years. They never really bothered me and I was able to go on with my daily life. How old are you, Mark? I just turned 38. I thought you were 24. That is my wife although I appreciate that. I saw the floaters and was told like John to live with them. ____ out of the windshield the first doctor told me and I did that for the better part of ten years, maybe 15 years and then.
For the last year or so they got really, really bad. The blurry vision, flashing of lights making sports nearly impossible, very difficult and unenjoyable. So like John, I went on the internet and started researching and found Dr. Wong. I saw some of his old Webinar and signed up for one that he had a week or two later and got as much education as I could and decided at that point that it was time to fly out and see Dr. Wong.
Randy: You have to call me Randy also.
Mark: Okay I will. I will try. So I went out and saw Randy and basically he said in a calm voice that I can help you and we went forward from there just like John. The surgery was running smoothly.
His office and his OR staff are amazing and very friendly and made you feel comfortable about something that seems very, very scary considering how many eye doctors tell you not to do it but that everybody has them.
I think I am now 12 weeks out from my right eye and it is unbelievable. The vision is perfect and I could not be happier with the results in my right eye. Everybody helps you, the staff, in finding hotels which I can make some recommendations as well.
FAQs: Frequently Asked Questions
That is terrific. Thank you both again for attending and participating and telling your story. I am going to open up the Webinar to questions.
I already have the first question from JB:
Q: How long should I wait before having cataract surgery after FOV? What if my poor vision from the FOV and from accelerated cataract is debilitating?
A: Well, if this were to happen there is no reason why you can’t get cataract surgery. Having a vitrectomy does not obviate the need or the ability to have cataract surgery.
Any other questions from anybody? Just type it in the questions area.
Q: MK is going to ask with an induced PVD vitrectomy how often is there a retinal detachment?
A: MK: I think I got an email from you this morning. I would say we get a retinal detachment probably 1-2% of the time. And the retinal detachment, if it were to happen, does not happen immediately. It usually occurs within the first couple of weeks after surgery however.
The idea of inducing a PVD is to get rid of most of the vitreous. Unfortunately, it basically requires you to tug on the vitreous which is attached to the retina so there is the possibility that you tear that. I think that our techniques over the last couple of years have improved so we have been able to reduce that but full disclosure about 1-2% of the time when you are inducing a PVD you could create a tear and not all those will turn into retinal detachments but I think you need to be generous in thinking and it is probably around 2-3% most of the time at most.
Randy: You are welcome JB. As we wait for more questions I am going to ask John that I don’t recall that I used stitches in you. How many days was it after surgery that you felt your eyes to be normal?
John: You are correct. With the procedure you did not use stitches and my eyes except for the dilation and blurry vision from that were normal the next day. There was no irritation and nothing to bother me in a day or so. How long would you guess, just estimate, when did your vision return back to normal?
Let’s see. I had it on Friday. I think it was sometime on Sunday. I would say about two days afterwards.
Randy: All right. Mark, what would you say?
Mark: The same. I had the stitches. I had the sensation that there was something there. It was not bothersome. I felt that it went away a few days to a week.
Great. And the vision when I was flying home I was feeling very confident about the vision a couple of hours after you took the patch off.
Randy: And that is a good point. Most patients are able to leave the following day and as I said earlier you can expect to return to physical activity within 24-48 hours. Taking a train or flying home doesn’t really matter . Taking the patch off. That is a good point. Most patients are able to leave the following day and as I said earlier you can expect to return to full physical activity within 24-48 hours. There seems to be some question as to whether or not you can fly but there is no reason for us to put gas in the eye after the FOV and that would be the only reason you couldn’t fly.
Most patients come in early in the week. We operate on Friday and they are out of town and going back home on Saturday. It is really pretty remarkable.
Q: JB asks how long should I give myself to recover from FOV and cataract surgery before going back to school work?
A: I really think it depends on how comfortable you are to going back and working. As far as I am concerned as I just said within a day or two you should be able to resume pretty much all your activities including studies and school work.
John: Randy, if you don’t mind, for myself I was back to work on Monday so after my FOV and then for the right eye and after cataract surgery there were no restrictions so I had them done at the end of the week and I was back at work without any difficulties. That’s terrific.
Randy: Mark, why don’t you share with everybody what you do for a living?
Mark: I am a PE teacher so I actually went back with a little bit of hesitancy worrying about being hit but the moment I went back I kept hearing your voice, “no restraints” and within an hour I was doing what I do and never turned back so that was about it. I got back right away.
Q: JB also wants to know for John how long did you wait after FOV to get cataract surgery.
John: The vision didn’t change on me. I had it in October and November I think it was the first time. I noticed over several months that I would go in and get my glasses adjusted and my prescription adjusted because I have worn glasses most of my life. My vision changed and I noticed, we noticed, my doctor and I that over time my prescription was 5.25 and now it was 6.25.
He noticed that over visits and he took a closer look and said that I think you may have a cataract.. I did not notice and always thought of cataracts as a white out and hard to see, etc. It wasn’t what I had so I went in and saw the ophthalmologist. He did a couple of tests and confirmed the cataracts. It was probably five or six months of slow progression.
It wasn’t debilitating but just that I noticed it and it was aggravating especially for distance vision. It wasn’t quite as clear as I would have liked it. That is when we picked up the cataract and when it was scheduled it wasn’t that I had to get in and get this done because I couldn’t see anything. It wasn’t that bad.
Randy: Terrific. Mark, anything you want to add?
Mark: I did not have any problems with the cataracts.
Q: Anyway, MK, new floaters. Is this a common issue? New floaters.
A: Do you mean after surgery or just new floaters in general? If you have new floaters in general or anytime you have new floaters you always have to worry about a retinal tear. Recommendations are to get examined in 24-72 hours after the new floaters because you can’t distinguish between floaters from a PVD, floaters from your vitreous, or floaters, floaters from blood, or a retinal tear which could lead to a retinal detachment.
The recommendation for new floaters is to get examined to make sure you don’t have a tear in your retina. Once you establish that then you can pick and choose what you want to do about the floaters. Floaters after the operation are common. When we take the patch off the first day it is very common to have some floaters. You will notice by the way they move or the size and shape are all different because these floaters are just from the inflammation from surgery. There could be a little bit of blood. There could be Kenalog that is floating around in there, etc. etc. If there are new floaters, the bottom line for new floaters is to get examined. Floaters after the operation generally don’t worry because chances are you just saw me. We are almost always worried about the integrity of your retina.
Q: Another, JB, for your FOV patients who already had cataract surgery do you routinely open the posterior capsule during the FOV even if the capsule is clear to obviate future laser posterior capsule surgery?
A: Never had this question before. Very insightful. What JB is alluding to or asking is that the cataract is just like an M & M. When the cataract surgery is performed on the candy coating and then we use an instrument to suck out the chocolate which is the cataract.
The candy coating that is left is usually clear as saran wrap and we use that as a sac to place the clear plastic implant. That candy coating that is clear as saran wrap at the end of the operation almost always gets cloudy after surgery. The chances of it getting cloudy is about 100% by ten years. This can cause recurrent blurring of vision. A common procedure to clear this up is to use a laser in the office and to poke a hole in this candy coating. So that is known as a Yag capsulotomy.
Q: What JB is asking me is that since I am operating inside the eye do I routinely make a hole in the candy coating so you don’t need laser in the future.
A: The answer is: No I do not. I will tell you that if there is clouding that I notice preoperatively or clouding during the operation I will do it but I don’t routinely do it regardless of the clarity. If it is cloudy, I will consider doing it. We will talk about it. Certainly I will do it and it is a very good question.
Q: Another JB. Wow, there are a lot tonight. Can you establish that a full PVD has taken place at consultation or do you determine this during surgery and at what age does a PVD typically happen?
A: I don’t think there is anything called a partial PVD. I read lots of times that doctors tell patients they have a partial PVD. A PVD usually occurs over several days to a couple of weeks but the end result is a complete PVD meaning the posterior vitreous is completely separated from the retina probably out to what we call the equator or halfway towards the front.
I can usually see this during the preoperative operation but it is kind of a moot point because it is more important for me to just establish there is some PVD at the consultation so that I know I don’t have to induce one or talk about inducing a PVD.
Q: What is the best answer to give to friends and relatives who ask me why I need to travel so far to have my eyes fixed than getting it done here in Atlanta? Saying that most doctors won’t do it because they say it is unnecessary leads to more questions and I am unable to answer why most doctors won’t do this. Is there a simple answer to this? Sorry if this question is worded strangely. I think you kind of hit the nail on the head.
Mark: Try this one. I feel your pain. For whatever reason I think Randy said it best. There is a lot of misinformation about FOV surgery and for whatever reason looking at an otherwise healthy eye and they are trying to normalize it as much as they can. They are not actually taking into account what is truly bothersome to your daily life and when you have a doctor as compassionate as Randy it is too bad not more doctors are helping out in the way that Randy is.
I can’t really explain why they do that but I understand what you are asking. It is hard when you start to talk to family members who don’t get it but there are those of us who have gone through it and get it. That is what I am saying. Dr. Wong is one of those people who gets it. And if that makes sense that is the best answer that I can give you.
Randy: John, anything to add?
John: Yes actually. My thought on it is that there are lots of doctors in the area when I was researching this. I might be able to find another ophthalmologist who would be willing to do this but the reason I was looking to Randy and why I liked going to him is that especially having been there twice is his experience.
That counts a lot to me in terms of my comfort level. If you see another ophthalmologist; I don’t know but I am just going to guess, he/she may do a vitrectomy occasionally. They don’t do it consistently. The two times I have done this we have had four or five patients at a time for the follow-up for the next day.
Randy does this consistently. Frequently, his experience, it counts a lot to me so that would be why I would travel to go to somebody who knows what they are doing and who does this frequently and who knows what to look for follow-up and questions. Those are my thoughts on the experience.
Randy: What I want to add is that I couldn’t do this if I hadn’t done it for a long time. It takes me a little bit to put myself on line. This is what I am worried about but overall this is no more scarier or difficult than cataract surgery. Had I been in the beginning of my career I am not so sure I would have the confidence to do this but after 24 years of doing tons of vitrectomies I know what the real risks are and what the issues are.
Probably, as all of you know is that vitrectomy or FOV is certainly safer than cataract surgery in terms of endophthalmitis. The chance of endophthalmitis in cataract surgery is 1 chance in 2000. This is not my statistic and I do not even do cataract surgery. Getting endophthalmitis, that same blinding infection with vitrectomy is at most 1 in 10,000.
Again, not my statistics so right there much safer in terms of infection. I think the chance of getting a tear and retinal detachment from cataract surgery is very similar to having vitrectomy. Vitrectomy with induced PVD may be increasing your risk a little bit. I really don’t know. It just doesn’t happen that often. If you read most of the stuff I have online I am your advocate and am here because I understand that just because you don’t have cataracts you are still having problems with your vision and there is a cure. As far as I am concerned if you understand the risks and accept them then we as adults can move forward and come to a solution.
Now to get back to your real question, JB, is why do most people not say this. Vitrectomy was invented and widely available starting in the 1980s give or take a couple of years. Up until then, patients with retinal detachment was due to diabetes and that is the most common cause. They had no alternative until vitrectomy was invented. So now patients with likely to go blind disease could now undergo a vitrectomy.
Unfortunately for probably the first generation these patients who had no hope had vitrectomy and there were not enough people who knew this procedure and they went blind. This was only in the 1980’s.
There are plenty of doctors who are still in practice who remember the 1980s and so the association is blindness. I don’t blame them for this. It is just that things have changed so much since the 1980s and celebrating the 30th anniversary. In that time period the technology has changed so much that the complications have not really approached that of cataract surgery in the world. But that fact escapes most eye doctors whether it is general ophthalmologists or optometrists. Any non-retinal specialist isn’t going to understand that.
In addition, 25-gauge has really made this safer as far as I am concerned. That is a new nuance that many people haven’t recognized. Believe it or not, not all retinal specialists in the United States even use 25-gauge. To me that is kind of a statement as to how varied your experience with different doctors is going to be.
I don’t want to say that I am better because I do not feel I am better than anybody but I think that is why your experience JD is so difficult to explain. In a word, I think it just comes down to inexperience or unknowing. I am sorry that is your plight and that it is so difficult. Everybody I see has been discounted for years or told to get used to this or it is crazy, etc., etc.
For all the people who do not understand what you have been going through it is hard to explain why you have to go all the way to Fairfax. I get that.
Q: JB says, “Thank you John.” “Am I going to relocate?”
A: I don’t know if I will. Just stay tuned. Nothing has been official. Tough question.
MK: Do you often see any tear in the retina during the surgery and do you repair it? Does the repair cause loss of vision? Would gas help prevent a detachment? Would it be worth it to prevent this from happening even at 1-2%?
A: I see most tears during the operation. In fact, if you look at some of the videos one of the things that I do at the end of the vitrectomy right before I close is I indent or depress from the outside of the eye to make sure I can see every bit of the retina. I would say that 98% of tears are visible. 98% of the time I can find a tear. If I find a tear, I am going to fix it right there.
I usually use laser or I can use freezing and that treatment because the tear always happens in the front of the eye you are never going to know it ever happened. It will have absolutely no impact on your vision.
Q: Dr. Wong: Even with a PVD don’t you still have to remove vitreous off of the retina and other sections of the eye? If so, isn’t that just as risky as a non-PVD vitrectomy? Can’t there still be a tear in the sections where the vitreous is still attached? Not quite clear what you mean.
A: My goal is to remove vitreous off the back of the retina all the way up to the equator and as much as I can see anterior realizing that it is impossible to separate the vitreous and the retina from the anterior or the front of the eye. It can easily be done in the posterior; can’t do it in the anterior part.
I am pretty sure that I did not answer your question but I don’t know what else to say.
Q: JB: If you do get an infection in the eye can it be treated effectively if caught in time?
A: The answer is yes. As a retinal specialist I am tasked with treating endophthalmitis or infections inside the eye from cataract surgery. There is certainly a correlation that the sooner you get to it the better the results.
From a liability issue I just need to inform you that a blinding infection can happen and the results are always in-between. A direct answer to your question is that often with timely treatment you can get pretty good results but sometimes not.
Q: JB asked if floaters tend to be non-existent in the anterior vitreous.
A: I am going to tell you that in patients with PVD large opacities collapse or move forward. In younger patients where I can’t see the opacities but I know they are there I assume that they are evenly dispersed front to back.
Again, I want to highlight that I don’t make it an issue to see what you are seeing. As long as they swish back and forth I know that moving the vitreous is important. This brings up the question so what do I do about the anterior vitreous and protection of the lens? I don’t think that is an issue. I know others online think that is important. I just don’t agree.
Q: JB asked because in your videos in one of your FOVs you started the vitrectomy in a section where there was already a PVD but that as you are cutting and sucking out the vitreous aren’t you sucking out the posterior vitreous from the rest of the retina?
A: Not necessarily. I am just separating the vitreous that I can see in the operation but the posterior hyaloid is probably still attached but it is so far out it doesn’t matter.
Q: JB: What is the difference between the 23-gauge and the 25-gauge?
A: The biggest difference is the size of the hole or the size of the sclerotomy. The smaller the number the bigger the hole. The initial vitrectomy system was a 20-gauge and then we moved to 23 and then 25-gauge. There is now also 27-gauge on the market and that is the smallest.
In my opinion, the biggest difference between the 23-gauge and the 25-gauge is that there is a greater chance of hypotony after surgery. That is may why you read that certain surgeons put gas in every time. I never put gas and we are not having this Webinar about retinal detachments. It is not expected for me to put gas in. I think the biggest issue is the chance of having no pressure the next morning.
I have tried 23-gauge. I don’t like it. I have used 25-gauge almost exclusively for the last 5,6, 7 years. I am waiting for 27-gauge to be delivered. However, it is not available in case of those who were wondering. It is just not available for purchase yet. I have done it and will be doing some more this week kind of as a favor to me by Alcon but it is not widely available yet.
Q: JB: My local retinal doctor says 23 is better.
A: I do not know why he would say that. The only other difference that I can think of is that the instruments that you put in the eye because the holes are bigger can be a little thicker and may be a little bit more rigid but once you adapt with the 25-gauge system I don’t think there is any advantage at all to the 23-gauge. It could be an issue of “tomato, tomato.”
Q: JB says does an existing PVD induce other risks besides retinal detachment?
A: The only other risk would be endophthalmitis. The answer to that is no as far as I know. I think there is a correlation between the longer time it takes to operate the more complications. 25-gauge with a preexisting PVD is a pretty quick straightforward operation so in that regard it is kind of safer. I am not sure that it is actually safer in any other regard however. So JB, as I said before the remaining floaters after the operation may be from blood, inflammation from the surgery, or it could be from Kenalog. All of this should go away in a couple of weeks. Some people say they see some clear lines and black specks. Our perception of floaters and everybody is a little bit different but I can say in the usual sense or in the usual case floaters after surgery are not from the floaters in the vitreous. Basically at the end of the operation all the vitreous that you can see should be gone.
Q: MK: Do I think 27-gauge will further minimize retinal detachment.
A: I don’t know. I haven’t done enough of them. In theory, that may be possible because a 27-gauge instrument will have a smaller hole in which to aspirate the vitreous but it is really going to be difficult to prove statistically that 25 versus 27 is better or worse.
It is one of those events that if something doesn’t happen very often it is very difficult from a statistical point of view to prove something is better or worse.
Q: JB says do I still do core vitrectomy?
A: Only after discussion I try not to. It is not an issue with older patients with a PVD. It can be an issue with younger patients and it is basically case by case.
Q: Do I have floaters? No. Do I need an FOV to remove them? Depends on how much they bothered me. Our tolerance for floaters varies. Our tolerance for blurry vision varies. Our tolerance for pain all varies.
I don’t have floaters so I really cannot honestly answer that question. I know that if and when I need cataract surgery because everyone is going to need cataract surgery if they live long enough and I would have cataract surgery. I know statistically that the chances of complications are fewer or the same with vitrectomy so you can probably read in-between the lines. If it would bother me then I would certainly consider it.
Closing Remarks About FOV
Randy: Mark and John, I think we should wrap it up. It has been about an hour. How about a last word or two from each of you. John, since I had Mark go first would you like to say anything in closing?
John: Your Webinars are very insightful. I know that is what helped me take the next step at least with the initial consultation. So once again if you are sitting in the same position I am sitting in you owe it to yourself to (1) sit in on the Webinar that you have done; and (2) fly out and actually meet Randy in person to sit and talk about your options. I am so thankful I did and not a day goes by that I don’t think about what a great move it was.
Randy: I congratulate you in taking that step. I also congratulate John. John, do you have anything to say in closing?
Mark: I am very grateful and that I had the opportunity and feel fortunate that I live a little bit closer than other folks but I would have made the trip having been there now. It has made a big difference and I am a big advocate. As I told you, anything that I can do to help get the word out and let people know it is a good alternative and that I recommend it.
Randy: I want to thank everyone for coming and want to specifically thank John and Mark for taking their time tonight to share their experiences with the rest of you. For the other attendees who have been following us for a long time.
At some point, maybe I can meet you. I hope this is helpful. The easiest way for you to keep in contact with us is to follow us at www.retinadoctor.com or www.vitrectomyforfloaters.com.
If you need to get in touch with Chrissy here is her email: firstname.lastname@example.org. I would like to acknowledge Mark Erickson who has provided us with these excellent illustrations at www.Jirehdesign.com.
Thank you everyone for joining. We will see you soon.