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Randall V. Wong, M.D. Retina Specialist September 20, 2009 Tyson’s Corner, VA Sunny and 78!
Randall V. Wong, M.D. Retina Specialist Capitol Eye Consultants Fairfax Virginia Dressler Ophthalmology Assoc. Fairfax Vir...
Agenda <ul><li>Top 10 Retinal “Emergencies” </li></ul><ul><li>Contraindications to Laser Vision Correction </li></ul><ul><...
Retina Emergencies The Top Ten <ul><li>Vitreous Hemorrhage </li></ul><ul><li>Vascular Occlusions </li></ul><ul><li>Submacu...
Apparent Temperature <ul><li>Heat Index = (Temp) x (RH) </li></ul><ul><li>Wind Chill =  (Temp) x (Wind Speed) </li></ul><u...
 
Retina Emergency Index Relative Eye Emergency Index <ul><li>Actual Emergency </li></ul><ul><li>X </li></ul><ul><li>Perceiv...
Relative Eye Emergency Index <ul><li>Not found on Google </li></ul><ul><li>This was created for fun </li></ul><ul><li>Give...
Factors Influencing Perceived Emergency <ul><li>Pain </li></ul><ul><li>Anxiety </li></ul><ul><li>Stress </li></ul><ul><li>...
Emergency Color Index <ul><li>Yellow 1-2 weeks </li></ul><ul><li>Orange < 1 week </li></ul><ul><li>Red 1-3 days </li></ul>...
#10 Vitreous Hemorrhage <ul><li>Diabetes </li></ul><ul><li>Retinal Tear </li></ul>
Vitreous Hemorrhage Management <ul><li>Is the retina attached? Is there a tear? </li></ul><ul><li>Wait as long as you want...
#9 Vascular Occlusions <ul><li>Vein Occlusions </li></ul><ul><ul><li>Observe (aka wait) </li></ul></ul><ul><ul><li>Rule ou...
Vascular Occlusions Management <ul><li>Look for signs of neovascular glaucoma </li></ul><ul><li>RON </li></ul><ul><li>Ozur...
#8 Submacular Hemorrhage <ul><li>Valsalva </li></ul><ul><li>Trauma </li></ul><ul><li>ARMD </li></ul>
 
Submacular Hemorrhage Management <ul><li>Valsalva – observe, blood is benign </li></ul><ul><li>Trauma – observe,  </li></u...
Submacular Hemorrhage <ul><li>In most cases, observation is warranted.  Even in cases of likely ARMD, there is no true eme...
#7 Wet Macular Degeneration <ul><li>Serous Detachment </li></ul><ul><li>Sometimes Blood </li></ul><ul><li>Moderate Loss of...
 
Wet ARMD Management <ul><li>Establish presence of neovascularization </li></ul><ul><li>Treat with anti-VEGF or other thera...
#6 Vitritis/Uveitis <ul><li>Decreased vision, pain and suffering </li></ul>
Vitritis/Uveits Management <ul><li>Control inflammation </li></ul><ul><li>Topical </li></ul><ul><li>Sub-tenon’s </li></ul>...
Vitritis/Uveitis <ul><li>Control pain/discomfort should take a few days </li></ul><ul><li>Vision will return slowly </li><...
#5 Retained Lens Material <ul><li>Following cataract surgery </li></ul><ul><li>Inflammation </li></ul><ul><li>Decreased Vi...
Retained Lens Material Management <ul><li>Control IOP </li></ul><ul><li>Diamox/Topicals </li></ul><ul><li>Keep cornea clea...
Retained Lens Material <ul><li>Emergency Index  :  Yellow  (1-2 weeks) </li></ul><ul><li>REEI  :  Red  (1-3 days) </li></u...
#4 Posterior Vitreous Detachment <ul><li>Assume there is a tear </li></ul><ul><li>If no tear, re-evaluate 6 weeks after sy...
#3 Retinal Tear <ul><li>Usually symptomatic (f/f) </li></ul><ul><li>Is there surrounding detachment? </li></ul><ul><li>Eme...
 
#2 Endophthalmitis <ul><li>Exogenous – usually recent intraocular surgery or history of trabeculectomy (filtering surgery)...
 
Endophthalmitis <ul><li>The second true ophthalmic emergency. </li></ul><ul><li>Emergency Index  :  Blue  (NOW!) </li></ul...
Retinal Detachment <ul><li>Is the Macula on or off? </li></ul>
Retinal Detachment Macula Attached Management <ul><li>Location, location, location </li></ul><ul><li>Superior </li></ul><u...
Macula Attached Management <ul><li>Refer for surgery. </li></ul><ul><li>Inferior/Macula ON  :  RED  </li></ul><ul><li>Nasa...
Drum Roll!!!!!!!!!!!
#1 Superior RD Macula Attached <ul><li>Perhaps one of the only true retinal emergencies </li></ul><ul><li>In theory, once ...
 
Macula Off  Retinal Detachments <ul><li>“The horse is out of the barn.” </li></ul><ul><li>Once the macula is detached, the...
Macula Off Emergency Index <ul><li>Medical Emergency – Orange </li></ul><ul><li>Patient/Doctor Emergency Index – RED/BLUE ...
Emergencies <ul><li>Endophthalmitis </li></ul><ul><li>Retinal Detachment </li></ul><ul><ul><li>Superior detachment </li></...
Relative Eye Emergencies <ul><li>Most are not true emergencies </li></ul><ul><li>REEI was created for fun </li></ul><ul><l...
Contraindications Laser Vision Correction Are there any?
Contraindications  LVC <ul><li>There may be no actual retinal contraindications to laser vision correction. </li></ul><ul>...
Extreme Myopia <ul><li>Myopic degeneration – behaves much like ARMD </li></ul><ul><li>May not have potential to reach 20/2...
Retinal Detachment LVC <ul><li>Previous retinal detachment </li></ul><ul><li>Potential for good vision </li></ul><ul><li>L...
Diabetes Refractive Surgery <ul><li>Assess macular edema, ischemia and potential for 20/20 </li></ul><ul><li>If good candi...
Retinal Detachment Laser Vision Correction <ul><li>Previous retinal detachment or retinal tear does not, in my opinion, pr...
Social Media why not?
Social Media <ul><li>d </li></ul><ul><li>Forum for disseminating information </li></ul><ul><li>Trusted sources (the old wo...
Wikipedia Definition <ul><li>Social media supports the human need for social interaction, using Internet- and web-based te...
Social Media <ul><li>Empowers both Patients and Doctors </li></ul><ul><li>Improves knowledge </li></ul><ul><li>Level playi...
Evolution of Social Media <ul><li>Computer </li></ul><ul><li>Cell Phone  </li></ul><ul><li>Email </li></ul><ul><li>Text Me...
Internet <ul><li>Largest provider of the information we share </li></ul><ul><li>People provide the content </li></ul><ul><...
 
<ul><li>“ Owns” 70% of internet traffic </li></ul><ul><li>Largest URL in the world </li></ul><ul><li>Largest advertising a...
www.RetinaEyeDoctor.com <ul><li>Blog/Web site </li></ul><ul><li>Credible resource  </li></ul><ul><li>Target audience </li>...
Goals for RetinaEyeDoctor.com <ul><li>Share information </li></ul><ul><li>Build a “virtual” community based upon the needs...
Social Media Can Build Your Practice <ul><li>First in our area to bring the medical community up to speed  </li></ul><ul><...
Already This Week <ul><li>JF  - retinal detachment, last Sunday </li></ul><ul><li>MR – concerns regarding ME and BRVO, wou...
What Can You Do? <ul><li>Visit  www.RetinaEyeDoctor.com </li></ul><ul><li>Read and subscribe </li></ul><ul><li>Tell your p...
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Retinal Emergencies

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Presentation outlining eye and retinal emergencies.

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Retinal Emergencies

  1. 1. Randall V. Wong, M.D. Retina Specialist September 20, 2009 Tyson’s Corner, VA Sunny and 78!
  2. 2. Randall V. Wong, M.D. Retina Specialist Capitol Eye Consultants Fairfax Virginia Dressler Ophthalmology Assoc. Fairfax Virginia
  3. 3. Agenda <ul><li>Top 10 Retinal “Emergencies” </li></ul><ul><li>Contraindications to Laser Vision Correction </li></ul><ul><li>Social Media……………..why not? </li></ul>
  4. 4. Retina Emergencies The Top Ten <ul><li>Vitreous Hemorrhage </li></ul><ul><li>Vascular Occlusions </li></ul><ul><li>Submacular Blood </li></ul><ul><li>Uveitis </li></ul><ul><li>Floaters </li></ul><ul><li>Retained lens </li></ul><ul><li>Dislocated IOL/Lens </li></ul><ul><li>Trauma </li></ul><ul><li>Endophthalmitis </li></ul><ul><li>Retinal Detachment </li></ul>
  5. 5. Apparent Temperature <ul><li>Heat Index = (Temp) x (RH) </li></ul><ul><li>Wind Chill = (Temp) x (Wind Speed) </li></ul><ul><li>How it Feels When Humidity or Wind is Added </li></ul>
  6. 7. Retina Emergency Index Relative Eye Emergency Index <ul><li>Actual Emergency </li></ul><ul><li>X </li></ul><ul><li>Perceived Emergency </li></ul><ul><li>= </li></ul><ul><li>Relative Eye Emergency Index </li></ul>
  7. 8. Relative Eye Emergency Index <ul><li>Not found on Google </li></ul><ul><li>This was created for fun </li></ul><ul><li>Gives you a relative scale as to how to proceed given the actual emergency and what you should do to keep your patient………………yours. </li></ul>
  8. 9. Factors Influencing Perceived Emergency <ul><li>Pain </li></ul><ul><li>Anxiety </li></ul><ul><li>Stress </li></ul><ul><li>Doctor’s Comfort Zone </li></ul>
  9. 10. Emergency Color Index <ul><li>Yellow 1-2 weeks </li></ul><ul><li>Orange < 1 week </li></ul><ul><li>Red 1-3 days </li></ul><ul><li>Blue Immediate Referral </li></ul>
  10. 11. #10 Vitreous Hemorrhage <ul><li>Diabetes </li></ul><ul><li>Retinal Tear </li></ul>
  11. 12. Vitreous Hemorrhage Management <ul><li>Is the retina attached? Is there a tear? </li></ul><ul><li>Wait as long as you want </li></ul><ul><li>Wait as long as you can (consider REEI) </li></ul><ul><li>Blood is not toxic </li></ul><ul><li>Actual Emergency = Yellow 1-2 weeks </li></ul><ul><li>REEI = RED (1-3 days) </li></ul>
  12. 13. #9 Vascular Occlusions <ul><li>Vein Occlusions </li></ul><ul><ul><li>Observe (aka wait) </li></ul></ul><ul><ul><li>Rule out neovascular glaucoma </li></ul></ul><ul><li>Artery Occlusions </li></ul><ul><ul><li>Theoretic Emergency </li></ul></ul><ul><ul><li>Rule out neovascular glaucoma </li></ul></ul>
  13. 14. Vascular Occlusions Management <ul><li>Look for signs of neovascular glaucoma </li></ul><ul><li>RON </li></ul><ul><li>Ozurdex </li></ul><ul><li>Observation </li></ul><ul><li>Actual Emergency: < Yellow (2-4 weeks) </li></ul><ul><li>REEI : Orange (1 week) </li></ul>
  14. 15. #8 Submacular Hemorrhage <ul><li>Valsalva </li></ul><ul><li>Trauma </li></ul><ul><li>ARMD </li></ul>
  15. 17. Submacular Hemorrhage Management <ul><li>Valsalva – observe, blood is benign </li></ul><ul><li>Trauma – observe, </li></ul><ul><li>ARMD – if CNV apparent by FA, then treatment is possible. </li></ul>
  16. 18. Submacular Hemorrhage <ul><li>In most cases, observation is warranted. Even in cases of likely ARMD, there is no true emergency </li></ul><ul><li>Emergency Index : Orange (1 week) </li></ul><ul><li>REEI : Red (1-3 days) </li></ul>
  17. 19. #7 Wet Macular Degeneration <ul><li>Serous Detachment </li></ul><ul><li>Sometimes Blood </li></ul><ul><li>Moderate Loss of Vision </li></ul><ul><li>Look for CNV </li></ul>
  18. 21. Wet ARMD Management <ul><li>Establish presence of neovascularization </li></ul><ul><li>Treat with anti-VEGF or other therapy </li></ul><ul><li>Emergency Index : Orange (1 week) </li></ul><ul><li>REEI : Red (1-3 days) </li></ul>
  19. 22. #6 Vitritis/Uveitis <ul><li>Decreased vision, pain and suffering </li></ul>
  20. 23. Vitritis/Uveits Management <ul><li>Control inflammation </li></ul><ul><li>Topical </li></ul><ul><li>Sub-tenon’s </li></ul><ul><li>Oral </li></ul>
  21. 24. Vitritis/Uveitis <ul><li>Control pain/discomfort should take a few days </li></ul><ul><li>Vision will return slowly </li></ul><ul><li>Emergency Index : Orange (1 week) </li></ul><ul><li>REEI : Red (1-3 days) </li></ul>
  22. 25. #5 Retained Lens Material <ul><li>Following cataract surgery </li></ul><ul><li>Inflammation </li></ul><ul><li>Decreased Vision </li></ul><ul><li>High IOP </li></ul><ul><li>Pain </li></ul>
  23. 26. Retained Lens Material Management <ul><li>Control IOP </li></ul><ul><li>Diamox/Topicals </li></ul><ul><li>Keep cornea clear </li></ul><ul><li>Usual post-op meds </li></ul><ul><li>Possible surgery if IOP and cornea are not controlled </li></ul>
  24. 27. Retained Lens Material <ul><li>Emergency Index : Yellow (1-2 weeks) </li></ul><ul><li>REEI : Red (1-3 days) </li></ul><ul><li>Doctor : Really Red </li></ul>
  25. 28. #4 Posterior Vitreous Detachment <ul><li>Assume there is a tear </li></ul><ul><li>If no tear, re-evaluate 6 weeks after symptoms initially started </li></ul><ul><li>If there is a tear, or not sure, refer as if tear. </li></ul><ul><li>Timely referral: 1-3 days or 6 weeks </li></ul><ul><li>Emergency Index : Orange (1 week) </li></ul><ul><li>REEI : Red (1-3 days) </li></ul>
  26. 29. #3 Retinal Tear <ul><li>Usually symptomatic (f/f) </li></ul><ul><li>Is there surrounding detachment? </li></ul><ul><li>Emergency Index : Red (1-3 days) </li></ul><ul><li>REEI : Red (1-3 days) </li></ul>
  27. 31. #2 Endophthalmitis <ul><li>Exogenous – usually recent intraocular surgery or history of trabeculectomy (filtering surgery) </li></ul><ul><li>Endogenous – very rarely seen in office based practice. </li></ul>
  28. 33. Endophthalmitis <ul><li>The second true ophthalmic emergency. </li></ul><ul><li>Emergency Index : Blue (NOW!) </li></ul><ul><li>REEI : Blue (Yesterday!) </li></ul><ul><li>Timely referral: Immediate! And not to the emergency room. Hours count. </li></ul>
  29. 34. Retinal Detachment <ul><li>Is the Macula on or off? </li></ul>
  30. 35. Retinal Detachment Macula Attached Management <ul><li>Location, location, location </li></ul><ul><li>Superior </li></ul><ul><li>Inferior </li></ul><ul><li>Other </li></ul>
  31. 36. Macula Attached Management <ul><li>Refer for surgery. </li></ul><ul><li>Inferior/Macula ON : RED </li></ul><ul><li>Nasal/Temporal, Macula ON : RED </li></ul><ul><li>Superior/Macula ON : BLUE </li></ul>
  32. 37. Drum Roll!!!!!!!!!!!
  33. 38. #1 Superior RD Macula Attached <ul><li>Perhaps one of the only true retinal emergencies </li></ul><ul><li>In theory, once the macula is detached, reattachment does not ensure return to normal vision. </li></ul><ul><li>Relative Eye Emergency Index : BLUE </li></ul>
  34. 40. Macula Off Retinal Detachments <ul><li>“The horse is out of the barn.” </li></ul><ul><li>Once the macula is detached, there is no statistical difference between operating immediately or anytime within the next 2 weeks. </li></ul>
  35. 41. Macula Off Emergency Index <ul><li>Medical Emergency – Orange </li></ul><ul><li>Patient/Doctor Emergency Index – RED/BLUE </li></ul><ul><li>Recommendation – stay calm, make contact to referring doctor. Reassure patient that contact within the next few days is appropriate </li></ul>
  36. 42. Emergencies <ul><li>Endophthalmitis </li></ul><ul><li>Retinal Detachment </li></ul><ul><ul><li>Superior detachment </li></ul></ul><ul><ul><li>Macula is on </li></ul></ul><ul><ul><li>SAME DAY REFERRAL </li></ul></ul>
  37. 43. Relative Eye Emergencies <ul><li>Most are not true emergencies </li></ul><ul><li>REEI was created for fun </li></ul><ul><li>But, reminds us to take into account the patient’s feelings and perceptions (right or wrong) </li></ul><ul><li>Timely Referral : RED (1-3 days) </li></ul>
  38. 44. Contraindications Laser Vision Correction Are there any?
  39. 45. Contraindications LVC <ul><li>There may be no actual retinal contraindications to laser vision correction. </li></ul><ul><li>There may be several “ perceived ” retinal contraindications to laser vision correction. </li></ul>
  40. 46. Extreme Myopia <ul><li>Myopic degeneration – behaves much like ARMD </li></ul><ul><li>May not have potential to reach 20/20 </li></ul><ul><li>Up to the refractive surgeon </li></ul>
  41. 47. Retinal Detachment LVC <ul><li>Previous retinal detachment </li></ul><ul><li>Potential for good vision </li></ul><ul><li>LVC is probably a good choice, buckles used to increase myopia </li></ul><ul><li>Refractive surgeon needs to be aware of previous buckle or RD surgery. Carefully assess axial length. </li></ul>
  42. 48. Diabetes Refractive Surgery <ul><li>Assess macular edema, ischemia and potential for 20/20 </li></ul><ul><li>If good candidate, then make sure sugars are well controlled. </li></ul><ul><li>Screen more than once </li></ul>
  43. 49. Retinal Detachment Laser Vision Correction <ul><li>Previous retinal detachment or retinal tear does not, in my opinion, present an absolute contraindication for surgery </li></ul><ul><li>It would be wise that the refractive surgeon be aware of the presence of a scleral buckle as the axial length is now abnormal. </li></ul>
  44. 50. Social Media why not?
  45. 51. Social Media <ul><li>d </li></ul><ul><li>Forum for disseminating information </li></ul><ul><li>Trusted sources (the old world of mouth) </li></ul><ul><li>Small or large audience </li></ul><ul><li>Real time </li></ul>
  46. 52. Wikipedia Definition <ul><li>Social media supports the human need for social interaction, using Internet- and web-based technologies to transform broadcast media monologues (one to many) into social media dialogues (many to many). It supports the democratization of knowledge and information, transforming people from content consumers into content producers. </li></ul>
  47. 53. Social Media <ul><li>Empowers both Patients and Doctors </li></ul><ul><li>Improves knowledge </li></ul><ul><li>Level playing field, no more “ivory tower.” </li></ul><ul><li>Sy Syms “an educated consumer is our best customer.” </li></ul><ul><li>How to integrate into your practice? </li></ul>
  48. 54. Evolution of Social Media <ul><li>Computer </li></ul><ul><li>Cell Phone </li></ul><ul><li>Email </li></ul><ul><li>Text Messaging </li></ul><ul><li>Social Media </li></ul><ul><li>Mobile Devices </li></ul><ul><li>We have been accustomed to sharing and obtaining information in real time </li></ul>
  49. 55. Internet <ul><li>Largest provider of the information we share </li></ul><ul><li>People provide the content </li></ul><ul><li>Who monitors the content? </li></ul>
  50. 57. <ul><li>“ Owns” 70% of internet traffic </li></ul><ul><li>Largest URL in the world </li></ul><ul><li>Largest advertising agency </li></ul><ul><li>“ Relevance” </li></ul><ul><li>Our patients need credible sources of information </li></ul><ul><li>We need credible/relavant sources of information </li></ul>
  51. 58. www.RetinaEyeDoctor.com <ul><li>Blog/Web site </li></ul><ul><li>Credible resource </li></ul><ul><li>Target audience </li></ul><ul><li>Patients with ARMD/DR </li></ul><ul><li>Doctors </li></ul><ul><li>Informational site regarding my practice of retinal disease </li></ul>
  52. 59. Goals for RetinaEyeDoctor.com <ul><li>Share information </li></ul><ul><li>Build a “virtual” community based upon the needs of our patients and our own interests </li></ul><ul><li>Use social media to improve communication between doctors and patients, and between doctors based upon credible/relevant information </li></ul><ul><li>Enhance our “real” community </li></ul>
  53. 60. Social Media Can Build Your Practice <ul><li>First in our area to bring the medical community up to speed </li></ul><ul><li>Follow me on Twitter </li></ul><ul><li>Linked In </li></ul><ul><li>Facebook </li></ul><ul><li>Email : R Wong@ R etina E ye D octor.com </li></ul>
  54. 61. Already This Week <ul><li>JF - retinal detachment, last Sunday </li></ul><ul><li>MR – concerns regarding ME and BRVO, would like to postpone treatment, worried. </li></ul><ul><li>M – responded to post on Vitamins that save sight. </li></ul><ul><li>These types of examples will only continue to increase as more and more people embrace the internet and social media. </li></ul>
  55. 62. What Can You Do? <ul><li>Visit www.RetinaEyeDoctor.com </li></ul><ul><li>Read and subscribe </li></ul><ul><li>Tell your patients </li></ul><ul><li>Tell your colleagues </li></ul><ul><li>Tell me what you need </li></ul>

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