Month: May 2015

25g needle bending

Q:

When McLean originally published this technique (Ophthalmology, 1986), it was with a regular, non-bent 20g needle. The advantage of using such a large needle is that there is zero chance of perforating. When Peter Laibson discussed this technique at the AAO, he suggested maybe using a smaller (i.e. 25g) needle. With that, unbent, folks experience perforations. Then, one of his more brilliant fellows, Roy Rubinfeld, invented the “Rubinfeld anterior stromal puncture needle”, which was bent like a cystitome.  If they are really not available anymore I will probably go back to the original 20g needle. Sromal puncture is ESSENTIAL in cases of post-traumatic (non-EBMD related) recurrent erosions. MUCH better than simple debridement, burr polishing, etc., as it addresses the underlying pathology appropriately.

 

Randy

Highland Park, IL

A:

It’s pathetically easy to bend the tip of a 25g needle using the protective cap, so just the sharp point is bent at a right angle. No need to worry about not being able to buy a special needle

I learned this tip from Claes Dohlman at Harvard

Sill don’t know why you wouldn’t just do a LASEK if there’s any Rx (as there is 90% of the time) as it works better and gets rid of the Rx also and doesn’t cause starbursts

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

Q2:

It is easy to bend the tip, Emil.

Working with Ralph Eagle at Wills we found it was not at all easy to make the bent tip of a consistent length.

We tried hard.

Especially in erosions in the pupillary space, it mattered in our in vivo and in vitro work.

Deeper penetrations caused more scarring.

Non-standardized needle:

Standardized needle;

Both at roughly same postop point. Again NFI. -Roy

Q3:

Emil:

Completely agree that it is very easy to bend needle with protective cap as you slide it out and this is how I do it for cutting sutures and for stromal puncture.  

I do not agree that it’s a good idea though to do PRK or Lasek at the same time as treating ABMD because I often find that the epithelium on these patients is thickened and abnormal and when you remove it by doing a simple superficial keratectomy there is a significant change in the refraction when it heals.  10-15 years ago I used to combined PRK with ABMD treatment and got a lot of wacky outcomes.  Stopped doing that and now that I have OCT imaging of the epithelium I know exactly why those wacky outcomes occurred.  Epithelium on these patient is thickened, highly modeled and often irregular.

Steve

A by Dr. Chynn:

All you have to do is back off on the Rx and be conservative in what you enter into the laser to treat

By doing so I’ve been within .75D every time. No wacky outcomes or bad over corrections 

Emil William Chynn, MD, FACS, MBA

Skewed topography

Q:

27 year old woman wants Lasik.

MR

-5.75 +0.50 x 95 20/20

– 5.25+0.50 x 85 20/20

Pachs 574 OD, 599 OS

 Topographies attached.

What concerns me is the skewed topography left eye.

Would you recommend:

1. No refractive surgery

2. PRK

3. Lasik

 Thanks,

 David

Atlanta, GA

A:

Hi David

In general, if the axis of the astigmatism lines on topography/Orbscan/Pentacam up with a patient’s other refractive data, eg MR, AR, wave scans, etc, I don’t call this a skew and just attribute the pattern to the corneal topography accurately reflecting the patient’s astigmatism, which in such cases are primarily corneal in nature, rather than lenticular, for example.

I don’t work in + cylinder notation, but isn’t this the case in your case?

I’m wondering what the group’s consensus is about the use of the word “skew”? Deviating from 90/180? Or deviating from the other refractive data for cyl?

If so, then I wouldn’t be worried about anything, and I would think LASIK wouldn’t be contraindicated. She’s got plenty of tissue, manifests to 20/20, and I assume you can get old eyeglass data to confirm the degree of her astigmatism has been stable

If the Topo axis doesn’t align with her refractive axis, that in itself isn’t necessarily always that worrisome, because couldn’t she just have more lenticular than corneal cyl? But in this case I’d suggest an ASA (LASEK or epiLASEK)

The decision on whether to perform incisional vs non incisional surgery is easier for me, since as you know I’m 100% ASA

Hope you’re doing well. It’s been a long time since I’ve seen you in person–20 years!

I also have a question for you personally if you still have fellows, as I’ve got a problem situation with a current fellow I’d like your guidance on about how to deal with it

Looking forward to catching up!

Yours

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

– See more at: http://parkavenuelasek.com/skewed-topography/#sthash.1jL3v24J.dpuf

MDs Defending ODs Performing Procedures

Q:

Good thought, John, but to what would we be responding on social media?  Though it is likely a small audience, posting a response to Ophthalmology/Optometry Times is at least relevant.  A post to Twitter/FB/etc. may seem like a random rant, unless the article has also been tweeted out, in which case we can respond to that.  I just want to make sure we, as a profession, do not come off as whiny and defensive.  I think a large portion of the general public already sees us as “just” eye doctors, not on par with neurosurgeons/cardiologists/orthopedists, and often not knowing that ophthalmologists are MDs (or DOs).

I think a more consistent message would be some sort of statement put out by the AAO.  That particular idea certainly might be overkill, but I feel something similar to that appears more professional and less petulant than 200 of us commenting on an article.  In essence, it would be nice to have a larger representative organization speak on behalf of many of us in these sorts of situations.  Maybe I’m wrong.

Tough situation.  Still amazed that it was published to begin with.  An ounce of prevention…

– Nadeem

A:

nobody reads AAO announcements except we eye doctors, so once again–preaching to the choir

PLEASE TAKE IT FROM ME, look at the incredible list of media in my sig file–and that’s only half of my experience

making a separate public site on knet, while laudable, prob wont be worth the time, as nobody will go there/read it

prob w ophtho times posts are same–preaching to the choir

the only way to do this properly so we influence both the general public and congress is to:

1. reply/post/comment on whatever thread the original cited article provides, most provide some feedback

2. if no feedback is provided, email the comment to the author, as most authors these days are freelance, ie paid per article, not a salary position, particularly on internet news, so it is their financial interest to write a follow-up article and get it published, as they’d make 2x as much $ for little more effort, so if a lot of us email the author, or one of us emails him/her a really valid/interesting rebuttal, he will then go to his editor and ask for permission to do a follow-up article

3. social media is very helpful, as many people weirdly enough get the bulk of their news from sm. i’ve had many pts in their 20s say they chose me bc they know me through instagram bc my dog rhett the borzoi has 600 followers. i agree this is the most bizarre way to choose your surgeon, but i am telling you that people under 30 do stuff like this. a press release by AAO would NEVER be read by them, and if they did bumble across it, they would dismiss this as written by “THE MAN”–in contrast, social media is seen by millenials as more “authentic” and “unfiltered”

4. you can also write to your congressmen, as they all have full-time staff members who just tally letters/emails, and if a large majority say x, the elected official 99x out of 100 will support x, bc he wants to stay in office and have a job (so that is why lots of short letters are more effective than a few long ones, as they are normally just counted and the politician almost never even gets to see any individual letter

so that’s my summary on how we should be effective!:)

———————————————————————————————–

*Emil William Chynn, MD, FACS, MBA*

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