Category: Uncategorized

Research Methods Rigor

Minas, Clive, et al

First of all, I’d like to congratulate Minas on finding an article I had published in Arch Ophth over 20 years ago, that I myself had forgotten about. It does speak to the point that I’ve both performed “real hard” research myself (eg as a PI for the FDA trial for the first solid-state excimer laser), had training that was heavily biased towards a career in academic medicine, and was in academics for a few years before I left because I couldn’t hack the “politics” involved (you may have noticed my abhorrence for “political correctness”) as well as the lack of support and unreasonable constraints (eg on advertising) on me creating a strong refractive practice–back in the days where refractive surgery was not considered a “real” subspecialty (sadly still the case to some extent today)

To be clear, I’m not “against” performing hard studies, as my background and publications should make clear. I just would like to speak out against the mindset (as I have several times on this forum) that controlled trials in peer-reviewed publications are “real” and everything else is anecdotal BS

This attitude is both wrong and unnecessarily restrictive. With this attitude, all scientific research until 1950 would have to be considered “fake”, and if this “rule” had existed back then, it would mean that nothing would be discoverable–not penicillin, not any advance in any surgical technique, nor any new medication. 

There are many ways to seek out truth besides a controlled clinical trial. Think about Einstein’s great “thought experiments.” He didn’t happen to have billions of dollars, plus a time machine that would enable him to build a cyclotron. What he did have was the intellectual capacity to build thought experiments, that when gone through, would yield results that were both insightful and valid in their own way (and show the path towards later “hard” research)

Think about all the problems our profession has had with the best drugs to use before, during, and after cataract surgery, and even the best way to prep before surgery. Since many of the adverse outcomes are very rare (eg endophthalmitis), we cannot enroll enough patients to have an n that is powerful enough to assess outcomes rigorously. So then we are left with secondary metrics, like measuring bacterial loads as a metric after x antibiotic schedule preop and/or y prepping schedule. Please recall that most of the antibiotics we use for surgical prophylaxis were never actually approved by FDA (or rigorously studied) for that purpose, but for some “easy/cheap to study purpose” like bacterial conjunctivitis.

Regarding some members telling other members to “stop this avenue of discussion” I think that is quite presumptuous of them. I had to tolerate about 30 emails over 10 days several months ago about what to do to prevent one’s fingertips from bleeding after guitar playing, which had zero to do with ophthalmology. I’m sure there are some people who thought there were too many joking emails about the use of sunglasses indoors (although I found that thread quite funny). Shouldn’t we agree that only the moderator (MM) has the right to tell others to cut it out (ie to end threads that seem to be useless or taking on a non-collegial tone?

While on that topic, I would like to point out that some members have occasionally resorted to ad hominem arguments to “win” their point, or to “silence” another member with whom they disagree. This is really one of the lowest common denominators of debate, and anti-intellectual. Having someone unfairly malign me by saying basically, “Now we all know whom to refer pregnant women to if they want LASIK so he can perform more procedures” combined with the basic message of “please shut up” is not in the spirit of “free discourse” that Keranet was founded, and should really not be tolerated.

Finally, I have been contacted by several knet readers (who wish to remain anonymous) that the reason they do not actively participate and reply to posts is that they are afraid of being attacked by a few frequent posters who they feel act like a kind of “Knet mafia” (their words, not mine). By this, they mean that a handful of posters seem to feel that, because of their seniority in ophthalmology or this group, that their views should not be “overly challenged.” I have felt this myself, which is really bad, because I, myself am one of those senior members (having joined within the first few years of Knet’s founding). So I am just putting this out there, as is my wont, to open up this avenue of discussion. Please understand that I am one of the least “politically correct” eye MDs you will meet, and remember that I sometimes wish to act as a provocateur to spur discussion/thought — so try not to get “offended” or become “defensive” (I was also born in Manhattan, so sometimes my natural language is blunt and challenging and profane;))

On a parting note, while it’s nice to celebrate 1,000 participants on Knet, let’s all acknowledge that of these 1k members, about 900 ONLY read and NEVER post, another 50 rarely post, another 25 sometimes post, and ONLY ABOUT 20 MDs and 5 ODs frequently post. If we can all name 10 doctors who post 80% of all content, certainly that tells you something. Not ALL of the 900 who NEVER post are only “too busy” or “not motivated enough.” Again, I know a handful who have told me that they are too intimidated to post–which is really a very bad thing.

So if we can all agree (which I think we can) that having more members actively participate and post instead of just reading is a good thing, as it adds more diversity of opinion, then the question becomes: “What can we do to improve the experience so more members participate?”

I would like to end by posting the following questions:

1. What can we do to make it easier/more inviting/less intimidating for members to participate?

2. What can we do to form a hard code of ethics to prevent uncivil exchanges? MM is a GREAT moderator, but I’m sure everyone would agree it would be even better if we could monitor ourselves better, which would seem to necessitate some actual rules (eg, no ad hominem attacks, only the real MM saying when to close off a topic, having a maximum number of replies to a thread (?10?) that has nothing to do with eye stuff)

To tell you the truth, I was going to go back into “silent” (read only) mode a few times over the past year, when I felt that it was not worth my time to “share” while feeling attacked, but a few other members contacted me privately to say they wanted me to stay, as they thought worthwhile my: a) contributions re ASA, b) function to “stir the pot” and c) ability to “stand up to the powers that be” (again their terms, not mine). Of course, I know of at least 2 others who would love to see me leave, and have told me privately where to go;)

In summary, I have learned a LOT on Knet, but could clearly have a more positive ROI on my time if I only read most of the time, and rarely posted. Everyone who frequently posts is really doing so not just to spout out, prove how smart they are, and burnish their reputation, but because they really care about education, and are trying to share their expertise. It would just be preferable if these people (myself included) could do so in a way that was slightly less “bossy” and intimidating, and slightly more civil, so as not to discourage others from posting, and certainly not trying to silence those who do choose to post.

Let’s see what your response to this thread is–I’m eagerly awaiting the replies:)

Yours respectfully,

Emil “Dr LASEK” (like on my vanity plate)  Chynn;)

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

1st eye surgeon in NY to get LASIK himself (1999)

Performed 5,000 LASIKs from 1996-2002

Switched to non-invasive LASEK in 2003

Have performed more LASEKs than any MD in US

Nursing and LASIK

Q:

I think a lot of this can be simply answered by asking ourselves the following question:

If your wife/sister/daughter were pregnant and wanted refractive surgery, would any of us do it? Or wait till post delivery and post nursing?

No need for further studies, IMHO.

Kamran

A by Emil W. Chynn MD:

Kamran

While your question is certainly valid if the question is would you recommend getting refractive surgery during pregnancy or waiting until afterwards (I don’t think any of us would say we wouldn’t make the patient wait until afterwards)

Another question is much more valid if the question is about the true medical safety of refractive surgery on the fetus (not “theoretical/liability” concerns), and if pregnancy actually commonly causes refractive changes:

If we performed refractive surgery on a female loved one, and a week out she found out she was pregnant, would any of us be really concerned, or would we just plug, Punctal occlude, minimize drops, and tell her “don’t worry, I’m not worried, because there’s a 99.9% chance that your laser regime won’t affect your pregnancy, and a 99.9% chance that your pregnancy won’t have ANY SHORT OR LONG TERM EFFECT ON YOUR REFRACTIVE RESULT”

That’s what I (and I think most eye MDs) would say

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

1st eye surgeon in NY to get LASIK himself (1999)

Performed 5,000 LASIKs from 1996-2002

Switched to non-invasive LASEK in 2003

Have performed more LASEKs than any MD in US

ASA retreat

Dear David et al

Sorry for my delay in responding. I’m visiting my girlfriend’s family in a rural part of Bulgaria wo internet – can you believe that?;)

It’s important to always search very carefully for the cause of over and under-corrections, or you won’t really get at the root problem, and might then just be trying to shoot for plano, wo any real understanding of what went wrong

I don’t even let my fellows present cases for enhancement until they can convince me why the over or under correction occurred 

An exhaustive breakdown here would take hours and more properly be the basis for a chapter in a book about refractive surgery. Briefly outlined the possible causes are as follows:

1. Not properly taking into account standard regression with your nomogram (which should slightly overcorrect all myopes and more overcorrect all hyperopes bc they regress more). Regression happens early, so you can figure this out by examining the early postop notes for early refractive status

2. Not properly accounting for myopic progression given age in myopes less than 30 yrs old. I just posted on this extensively a week ago so won’t repost. Did want to ask fellow keranauts if and how they’re accounting for this huge factor themselves?

3. Undershoot in retrospect. Choosing a too low number. Sometimes associated w errors like not adjusting CL power upwards properly to be in the spectacle/laser plane. Much more common in hyperopes bc ignored wet MR/AR which revealed the true full plus Rx!!!

4. Overshoot. Often caused by over minusing young myopes in the refraction by not telling them to not choose smaller than darker, not allowing them to say “the same”, not red/greening them, not making them “earn” the next -.25 by actually proving it makes them see better by going down 1 line on the chart, not performing (I think this wild be legally negligent) or ignoring the wet MR/AR. Also not telling them to look far away in the AR and WaveScan to prevent accommodation! 

90% of my fellows can’t properly manifest patients and over minus 90% of young myopes. Admittedly, by the time I properly don’t over-minus them, then add minus to account for progression, we are often at a similar number. This is probably why the general ophthalmologist actually gets good long term results in younger myopes!;) But being the stickler I am, especially as a fellowship preceptor, I insist on getting to the right answer the right way!

5. Scarring or haze causing undercorrections

6. A fellow improperly panicking when seeing an Overcorrected Hyperope in the early postop period, switching from steroids to NSAIDs instead of just waiting for regression, and causing an undercorrection (this is another example of a “trial” Jim). Fortunately this only rarely happens

7. Under/over responders. Right #/wrong result. Lazy people ignore the work necessary to eliminate 1-6 above and lump everyone in this category:( These are just people who don’t regress “properly” according to the meaty part of the bell curve we incorporate into our Nomograms. They either under or over hyperplase their epithelium compared to normals. Then you MUST ADJUST YOUR NOMOGRAM the 2nd time to account for this or you’ll bounce around and never hit Plano!!! Because if they underheal/underhyperplase/overrespond the first time, they’ll do so after enhancement too!

8. Unknown. This is the worst category, and freaks me out, since then I have no logical reason to be confident my enhancement will work out. I refer these cases (1% at most) for second opinions. Half of the time someone smarter than me like Eric Donnenfeld and other super-experts who unfortunately don’t have much time to post on knet will figure out a zebra (like not fully covering the ablated cornea w a sponge containing MMC and causing a ring scar in a myope not a hyperope) 

But in summary since it’s not your case and you can’t get all the records, I agree with Ronal’s advice (and thanks for the attribution Ronal):

Why not try Voltaren QID x 1-3 months? Although this technique is more effective in the early postop period, since you’re trying to promote normal regression/epithelial hyperplasia 

Hope this helps?

PS I’m ccing my fellows so pls save this in the sever under the name “Analysis Before Enhancements” in the folder “Non-OR Protocols” and don’t forget to go over TWO protocols w each other and me EVERY th and Friday!!!;)

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

1st eye surgeon in NY to get LASIK himself (1999)

Performed 5,000 LASIKs from 1996-2002

Switched to non-invasive LASEK in 2003

Have performed more LASEKs than any MD in US

The power of CXL + PRK

James wrote to Dr. Chynn (dr. Chynn’s answers are bold):

Emil,

What brands and doses do you use for the topical and oral NSAIDs and the topical and oral steroids?

The brand of oral NSAID matters not. It’s just for pain relief BC systemic anti-inflammatory. Use generic ibuprofen 800 mg w every meal to prevent GI upset for 5 days postop

I use a Medrol DosePak postop BC it’s EZ for pts to follow the taper. But when it was unavailable we just used a generic pill w the same approx dose n it worked fine. Also helps prevent pain again BC it’s anti inflammatory 

I previously posted a list of NSAIDs. Voltaren regresses best. Nevanac doesn’t work at all. I’ve tried all. Could post a list in order of efficacy but can’t tolerate James then asking me to prove it w a 10-armed placebo-controlled trial?

Do you also prescribe Vitamin C?

Yes. I’ve said this before. For extreme myope a past -9 it’s very important in sunny climes to use 1000mg Vit C for 9 months n UV protect w good shades for the same amt of time or you’ll risk scarring!

Thanks. 

You’re very welcome Jim. Glad to share my experience w you and the group. Let me/us know if the NSAID regression also works for your PRKs. But don’t publish that ahead of me ok?!?;)

Jim

PRK for corneal scars

Dr. Chynn wrote in bold to a question from another doctor:

Emil/KeraNetters

Tangent from the December discussion on PTK in corneal scarring:

I have a 24yo with history of traumatic recurrent erosion in the left eye. Had anterior micropuncture performed by another surgeon this past December but has started to re-erode. He wants to have PTK/EpiLASIK to reduce erosions and dependence on glasses. Has been in soft bcl changed q2weeks x 2 months.

His ASP is in a cluster at 6 o’clock paracentral – just outside the visual axis. 

Historical refractions in that eye (OS) are: 

2008: -5.00-0.50×153

2010: -5.25-0.50×153

2014: -6.75-0.50×70 (this is after erosion; before ASP)

This seems like an outlier so I’d ignore it

Current MRX OS:

-5.25 – 0.75 x 115 (1 week out of SCL)

-5.75 – 0.50 x 90   (2 weeks out of scl)

You must ALWAYS also do a wet MR or AR to check for accommodation in young pts

Current CRX OS:

5.25 -1.00 x 120 (1 week out of scl)

Any advice on refractive target here and how to adjust for age and epithelial healing in area of asp?

Topo currently shows steepening over that area.

Need to send us images to r/o other abnormalities

Planning to use MMC per treatment nomogram and h/o prior corneal surgery.

The pt is clearly progressing his myopia

Get older Rxs for better data on progression

What’s his profession?

Will need to overshoot for this reason

A few ASPs aren’t going to affect anything

Agree safer to use MMC

Why is one out of BCL x only 1 wk?

Might as well wait another week

Let us know the other data pls

Thank you,

Michael

Fayetteville AR

SMILE

Q:

I will put my $0.02 here for what it’s worth.

In theory the structural integrity from SMILE should be better but independent in vivo research is needed. Dan Reinstein is a consultant for Zeiss.

SMILE has a lot of attractive features but sadly my evaluation from peers who used it and abandoned it is that outcomes are less predictable and take much longer to stabilise. The visumax laser is also not a good flap maker. It has been available outside the US for some years now but is not gaining traction.

Certainly the CEO of a large European refractive surgery company does not believe it has realistic potential. They tried hard to integrate it into their practice but failed and returned the machine.

I’d be interested to hear from those who have had a positive experience with the Visumax versus Alcon FS or Abbott iFS.

Suheb 

Melbourne

Australia

Answer by Emil Chynn:

I’ve done SMILE a few times in Europe

What’s the real benefit of a procedure that’s

Incisional

Doesn’t correct astigmatism

Doesn’t correct hyperopia

Can’t correct CK?

That makes it’s effective parameters low myopia.

There are MDs in Europe performing smile and then a LASEK or PRK on top to get rid of cyl or HOA. Sounds nuts to me

From my POV it’s greatest asset is a good marketing name?

Or am I missing something here?

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

1st eye surgeon in NY to get LASIK himself (1999)

Performed 5,000 LASIKs from 1996-2002

Switched to non-invasive LASEK in 2003

Have performed more LASEKs than any MD in US

 

Re: Myopic (Over)Correction in Younger Patients

Hi Kamran

Pls see below

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

1st eye surgeon in NY to get LASIK himself (1999)

Performed 5,000 LASIKs from 1996-2002

Switched to non-invasive LASEK in 2003

Have performed more LASEKs than any MD in US

www.ParkAvenueLASEK.com

102 E. 25th St. (& Park Avenue South)

(212) 741-8628    (212) 741-2390-fax

Sent from my EyePhone so pls excuse abbrev?

On Jun 13, 2015, at 11:17 AM, Kamran  wrote:

Hi Emil

I hope you are doing well. I wanted to ask you a question in regards to a comment that you had made about slightly overcorrecting younger myopic patients who undergo refractive surgery (regardless of ASA/PRK, LASIK, etc). You had mentioned that it’s preferable to make them slightly hyperopic, thus as they get older and develop some regression as they get older, they’ll end up back closer to plano. I think it’s a good idea, and have heard very few people talk about it. No one in fellowship (I finished my fellowship in 2013) mentioned this, and logically, it has a lot of merit

I’ve been running my own SF Match fellowship for over a decade, and also have had many “open access” surgeons use my facility. One of the first things they need to get used to is the concept of overshooting young myopes. You can’t get your long-term (ie if your patient EVER needs and enhancement, not only within 1 yr) down as much as possible unless you overshoot

A couple of questions: 

1. Do you have a nomogram that you use for this? For example, do you do more over-treatment for a patient who is 22 years old vs someone who is 28 years old? What range of targeted hyperopia do you use accounting for the age of the patient?

Yes. It’s based on several factors:

Age (and years until age 30)

Past myopic progression

Amount of near work:

Profession

If they plan on going to graduate school

How “smart/studious” they are

If they “like to read”

How much they’re on a computer/tablet

Myopic progression is typically asymptotic and flattens out at age 30. So you have to graph out a curve

It’s vital to get old Rxs. Yesterday I delayed surgery because my fellow accepted a 1 year history of eyeglass Rxs. That’s not a history. We make all our patients give us all of their old Rxs. A Rx from 3-5 years ago is more useful than one from 1-2 yrs ago

For example 2 -3.75 myopes age 23 come for LASIK. Both have glasses 1 year old that read -3.50. What would you shoot?

Most surgeons would shoot -3.75 and call it a day. Maybe -4.00. I tell my fellows that’s like “pissing in the wind” (an American idiom about something you shouldn’t do because the force of nature will overwhelm your puny efforts to go in some direction)

Let’s say that patient is a landscaper, says he doesn’t like to read and is rarely on computers, and you obtain an old Rx that’s 5 years old and -3.25. You can see he’s progressing very slowly, only .25D/5yr, and as you graph out a myopic progression line that’s asymptotic at age 30, so overshooting his current -3.50 by -.25 is appropriate

What about a girl with the same age and current Rx, who had an old Rx that’s 5 years old, but -2.75, and is Asian, both parents are myopes, her older siblings are all high myopes, who’s a graphic designer and planning on going to graduate school in the fall? Graph it out, asymptotic at age 30. You’d have to shoot at least a -4.25 to have any hope of accounting for all or at least most of her myopic progression. Otherwise you’re guaranteeing she needs an enhancement or is back in glasses by age 30

2. I know you mainly do ASA… does your targeted hyperopia only work for ASA or would it apply to LASIK as well? (I would think it would, but figured I would ask) 

I was doing this from 1997-2003 when I did 5,000 LASIKs. Having a better Nomogram that factors in myopic progression on young myopes is better for all types of procedures. The eye is obviously still going to progress at the same rate as if you didn’t laser the patient 

I started to investigate this when I was a cornea and refractive fellow under George Waring, Doyle Stulting, Keith Thompson, and David Palay in 1996-7. This was back when every other cornea fellowship was 99% cornea and 1% laser, but I was mostly interested in laser,which is why I chose them

They had an “age factor” in their Nomograms (as was common back then) that they were just in the process of removing, so one of my attendings (probably George) assigned me to look at how age affects results. I found that age doesn’t affect achieved ablation depth or REGRESSION, but does affect PROGRESSION. Only after my chart review of 100 charts with years of follow-up did it become clear that PROGRESSION was often a much larger contributor to the need for an eventual enhancement years down the line than REGRESSION. So it must be included in surgical planning to get enhancement rates down as low as possible 

3. Does your choice of excimer laser affect how much you would aim for hyperopia? Meaning that since the older lasers had more chance of causing regression, would you aim for more hyperopia if you were using an older laser? I currently have access to both a VISX S4 and an Allegretto laser. I much rather prefer the Allegretto, but depending on patient geographical preference of laser center, I use what’s available. 

It’s not REGRESSION it’s PROGRESSION! Accurate Nomograms must account for both!

Regression happens in the first few weeks after myopic LASIK, months after myopic surface ablations and Hyperopic LASIKs, and many months after hyperopic surface ablations. It’s due to asymmetrical epithelial hyperplasia, where the eye tries to revert to its original curvature by filling in part of the ablated depression with epithelium

In surface ablations you should retard regression by doing a long steroid taper on the higher Rxs (which also prevents scarring)

In overcorrected surface ablation pts, you can promote regression and epithelial hyperplasia by switching from a steroid to a NSAID so you can avoid an enhancement. The switch must be made by 1 month Postop and you need to dose the NSAID QID  for 1-3 months. You don’t need to use a BCL. In hundreds of applications I’ve seen zero melts. I’ve said before on this forum I think that concern is based on flawed data involving an isolated genetic NSAID that was removed from the market

4. At what age range would you NOT aim for targeted hyperopia?

It’s not just an age thing. Once your data of old and new Rxs show no more progression, and/or the patient is 30 or over, they’re not progressing anymore, so you don’t need to overshoot to account for profession 

I find it amazing that most doctors performing laser vision correction are only taught to think about the more minor regression, and not the more major progression when creating shoots. Of course, you can just tell patients to wait until they’re 30, but then they’ll just get lasered by someone else who also probably doesn’t factor in myopic progression

So initially you make the young 20 yo myope something like +.75, so he’s 20/15 and as symptomatic ecstatic BC of accommodation, let’s say in 5 years he’s plano, and then in 10 years he’s -.50 and still 20/25 and happy and doesn’t need an enhancement and has low myopia to help read when he’s 50??

Without overshooting this same patient would be -1.25 at age 30, pissed, and tell 100 people “LASIK isn’t permanent”??

No wonder LASIK hasn’t taken off like it should!?

Thanks!

KMR

 

Re: Would you submit this 42yo woman to refractive surgery? – See more at: http://parkavenuelasek.com/re-would-you-submit-this-42yo-woman-to-refractive-surgery/#sthash.Ip4nr9Ru.dpuf

Q:

Dear Kerafriends,

Jim is right (as always) – I’m really not feeling safe in offering LASIK, as besides the skewed axis seen on axial curvature maps and the PTA quite near 40%, her Pentacam shows some suspect parameters, mainly: ART max < 386 and BAD-D > 1,22 – Sandra, you can find some interesting data on this field on reference (1).

I like the ICL option too! By the other hand, I’m worried about this small irido-corneal angle (32,9/32,5). How smaller would it become after an ICL implantation? These small irido-corneal angles are also an issue in case of Artisan lenses, as there’s a big chance it’s not possible to keep the 1.5mm safety distance between the lens and the endothelium.

I also like the surface ablation option! By the other hand, RELEX Smile is now available here. As this leaves (almost) intact the Epithelium, the Bowmann membrane and, also, the strongest anterior stromal portion of the cornea, it seems to me it has many interesting advantages over surface ablation – don’t you think so?.

I was wondering if anyone in this group (besides me) minds about the irido-corneal angle when planning an ICL implantation?

Thank you all again!

Regards,

Daniel

A By Emil Chynn

Correct me if I’m wrong, but I know of no published evidence that shows that the structural integrity of the cornea is stronger after SMILE vs ASA/LASEK/epiLASEK/PRK

In contrast, I’d think that any incisional or lamellar procedure would be inherently more destabilizing vs a surface ablation (advanced or otherwise)

Does anyone have any data about the strength of the cornea post-SMILE vs post-ASA/PRK?

Emil William Chynn, MD, FACS, MBA

 

 

Re: Mitomycin-C OTA — published in June Ophthalmology

Q:

Dear All,

I would highly recommend the above EXCELLENT review article (link below). Many of our colleagues worked very hard to produce and excellent summary of the “state of the art”.

Randy

Highland Park, IL 

A:

dear randy, parag, roy, and everyone else

i just read this article in the blue journal, it agree it was very good and long overdue

it did say “we are not sure what the minimum effective dose in terms of concentration and time is” or something like that

i did a poster w my MD PhD fellow last year 

where we compared 0.01% MMC for 10 sec in 1 eye vs proportional to Rx/ablation time in the other eye

and found the shorter time to be equally effective in preventing scarring, ie no dose-response curve

maybe bc, as others have found, the effect of MMC is so rapid/strong you get a full effect at a very low %/time

we submitted this for publication, i think to AJO or JCRS or something like that, but got rejected

we are planning on resubmitting to an easier journal, bc our study is clearly not exactly groundbreaking

but it would help answer the question of “how low can you go” as we were at 1/2 the concentration of the common %

and at the lowest time commonly reported

can i have some suggestions on which lesser journal to submit to, as i do think it’s worth publishing

and i don’t want to go through the pain of submitting and getting rejected from a top 5 journal

so something ranked 6-10 in ophtho for impact factor would probably be more appropriate

thanks in advance for your kind help; pls reply to all (maybe taking off the knet group)

as my 2 co-authors dr b and an intern in DO school are ccd

yours

emil

———————————————————————————————–

*Emil William Chynn, MD, FACS, MBA*

 

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

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