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This beautiful optical coherence tomography of a vitelliform lesion allows us to demonstrate how the physics of laser absorption translate into our clinical images. In addition, it highlights how we need to interpret the images as a dynamic representation of biological tissue rather than a simple photograph of our patient eyes. After working on the recent post on adult vitelliform I couldn’t let this aspect of the image go to waste. #physics #medicalimaging #cool #totalgeek (at Deep Blue Retina) https://www.instagram.com/p/B81L19iBc51/?igshid=1o7k0yyj3nmqn

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Adult vitelliform dystrophy: The accumulation of yellow material in the subfoveal space in adults is the hallmark of this condition, which can be easily confused with age related macular degeneration. Optical coherence tomography demonstrates the homogeneous isointense material between the retina and the pigment epithelium. This material has a bright signal on autofluorescence imaging, as seen in the images in this post. Although similar in appearance to Best’s disease, which occurs in younger patients, there is no clear genetic background and the electrooculogram is usually normal. Patients have a better visual prognosis than typical age related macular degeneration, although the vitelliform material can often reabsorb leaving a central area of foveal atrophy, with loss of central vision. — The issue that draws my attention when I see patients like the one in this post, is the constant struggle that we encounter in medicine between “splitters” and “lumpers” in clinical diagnosis. Too many patients are diagnosed as having macular degeneration when they have less common conditions. Similar things happen in every field of medicine. But beyond the academic discussion of correct specific diagnoses, we find ourselves simultaneously pushing Precision Medicine, based on individual patient characteristics that may impart different response to therapies, and Massive Lumping medicine (term I just concocted), where patients with related but different conditions are grouped together to attempt to achieve statistical -and financial- value for new medicines. Ultimately, we find ourselves with patients that present with findings that are not classic for any specific condition, and yet we are forced by the billing and coding machine to stamp them with one final diagnosis, even when we know that the most logical approach would be to avoid defining any specifics and allow time to hand us the clues that we need to reach that elusive diagnosis. The coding machine is impatient. #diagnosticmedicine #modernmedicine #ophthalmology #retina #eye #medicine https://www.instagram.com/p/B8wLRQ1hEIt/?igshid=19ytjezyt8aij

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Angioid streaks are breaks in the layer underlying the retina, called Bruch’s membrane. Certain conditions that lead to brittleness of Bruch’s can develop to these linear cracks, mostly around the optic nerve and posterior aspects of the globe. Bruch’s membrane serves as a physical barrier between the retina and the underlying blood vessels of the choroid, while allowing the diffusion of oxygen and small molecules to nourish the outer retina. I often explain to my patients that Bruch’s membrane is like a layer of concrete on the pavement, that when cracked allows the underlying grass and vegetation to come through it. In the case of the eye, instead of blades of grass, it is blood vessels that creep through the fissures, creating subretinal choroidal neovascularizations. The patient in this post has a condition called pseudoxanthoma elasticum and has abundant angioid streaks in both eyes. Unfortunately, the patient developed choroidal neovascularization under both maculas, and has fibrotic scars with severe central vision loss in both eyes. The angioid streaks are more noticeable under autofluorescent imaging, where I have attempted to highlight them in yellow. The skin in the back of the neck of the patient has the classic “peau d’orange” changes of pseudoxanthoma elasticum. -- It has been four months since our new practice, Deep Blue Retina opened its doors. I am so thankful for my patients and the community for their support. We have been getting busier every week, but we are making every effort to maintain the personal connection that our patients require. We have been refining the work of our imaging department (which shows in the quality of the photography that we can present in this medium). Our electrophysiology and ultrasonography department is building its technical expertise. The team is growing, and we will announce the additions to our programs in the coming weeks. #goodthingstocome #lookingforwardto2020 #ophthalmology #retina #optometry #clinicalresearch #medicaleducation (at Memphis Tennese) https://www.instagram.com/p/B4snF4LhmKy/?igshid=qkazgvowfh1p

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Adult vitelliform dystrophy is a condition that can often be confused with various forms of macular degeneration. To make it even more complicated, some patients with macular degeneration can present with secondary vitelliform changes. The most important distinction, though, is with the presence of choroidal neovascularization, since the elevated subretinal lesion can be inaccurately interpreted as such. Most patients have relatively good central vision until the vitelliform lesion resolves, leaving behind a discrete patch of atrophy. The photos in this post show the eyes of a patient with this condition. The right eye has the typical vitelliform changes, while the left eye has the atrophic vestiges of prior vitelliform. -- I hope everyone is enjoying a good weekend. I have enjoyed not travelling and working and mostly staying in to read and listen to music. We all need these days to recharge! -- #ophthalmology #retina #maculardegeneration #visionloss (at Memphis, Tennessee) https://www.instagram.com/p/B4aSpkmBayk/?igshid=uu4cgue5003u

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Retinal burns from high-power laser pointer: Absorption of light energy by the retina and retinal pigment epithelium is a well recognized phenomenon. We utilize it for therapeutic purposes when we perform laser therapy in diseases like diabetic retinopathy. Unfortunately, it can also be harmful in certain situations, like viewing solar eclipses without proper eye protection. Whereas most readily available laser pointers do not generate energy to create laser burns, certain high-power laser pointers, available on the internet, can produce laser burns. These are the same products that unscrupulous individuals have shined on aircraft cockpits flying overhead. The photos in this post show what happens to a retina when these high intensity lasers are shone to the eyes. The initial injury demonstrates retinal whitening and thickening of the outer retina and interdigitated pigment epithelium complex. After a few weeks the edema resolves with residual atrophy and localized functional loss. With a foveal burn, vision can drop to 20/100 or worse levels. #ophthalmology #retina #thisshouldberegulated #boyswillbeboys https://www.instagram.com/p/B3sDaKOhj9L/?igshid=is1lac0mr9ix

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Elevated pressure of the eye, glaucoma, can occur from multiple causes. Any mechanical process that blocks the normal flow of aqueous can lead to elevated eye pressures. Some of these processes are not often well explained in the glaucoma textbooks, since they are relatively uncommon. The patient in the post had previous surgery for a retinal detachment with proliferative vitreoretinopathy (scarring on the retinal surface), which required filling the vitreous cavity with silicone oil. In the last surgery, the oil was removed as well as a cataract. In these complex cases, where I remove the lens from the posterior approach, I usually leave a rim of anterior lens capsule for possible future secondary intraocular lens implantation. In addition, fluid-air exchange is performed to attempt to remove the majority of silicone oil droplets. This patient presented a couple of days after surgery with severe eye pain and markedly elevated eye pressure. The mechanism of the glaucoma was migration of a small bubble of air into the anterior chamber that in turn blocked the flow of aqueous by sealing the anterior capsulotomy. Understanding the mechanism allows us to formulate a rational treatment plan. Most acute angle closure glaucomas can be treated with a laser iridotomy, which in this case would have not worked, since the blockage did not occur by pupillary block. If a procedure needed to be performed, the best approach for this patient would have been a superior paracentesis with removal of a portion of the air bubble (superior since the bubble rises to the top and facilitates the drainage). We were able to treat the condition by positioning the head of the patient in a way that moved the bubble away from the capsular opening. Since air is reabsorbed quickly, a few hours were sufficient to decrease the size of the bubble and allow normal flow of aqueous. The photo in this post was taken the day after the attack and shows where the aqueous is flowing just below the bottom edge of the bubble. #glaucoma #retina #retinasurgery #eyesurgery #ophthalmology (at Memphis, Tennessee) https://www.instagram.com/p/B1CH9dlBEal/?igshid=1h9yqut4svnye

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Neovascular glaucoma is the end stage process that occurs in eyes with severe ischemic retinal diseases. Pathological elevation of VEGF levels stimulate the growth of abnormal vessels (neovascularization) on the iris and trabecular meshwork. Initially, the intraocular pressure rises due to blockage of the meshwork by the neovascular tissue and by increasing the viscosity of the aqueous fluid. Ultimately, the neovascularization fibroses and contracts, scarring the meshwork and creating permanent Peripheral Anterior Synechiae or PAS. The intraocular pressure can rise to levels above sixty millimeters of mercury, damaging the optic nerve and sometimes causing severe eye pain. When this condition is identified before the cicatricial phase, the use of anti-VEGF medications can often reverse the process. Here are some clinical tips to manage this condition: 1. Always perform gonioscopy when suspecting neovascular glaucoma. As I pointed above, this not only serves for diagnosis but also allows us to predict if medical treatment with anti-VEGF will suffice or if the patient will need immediate glaucoma surgery. 2. Treat severe ischemic retinopathies regardless of their visual potential. The one thing worse than being blind in one eye is to have severe intractable pain in that eye. This is the proverbial “adding insult to injury”. 3. Follow retinal vein occlusions closely when diagnosed acutely. Our ophthalmic predecessors talked about the “ninety day glaucoma”, since neovascular glaucoma takes about that timeframe to develop. 4. Chronic retinal detachments can also cause neovascular glaucoma. Fix the retinal detachment. 5. My nightmare scenario: neovascular glaucoma in aphakic eyes that have chronic silicone oil fill and relatively good vision. Those of us that choose to manage bad diseases will face this problem every so often. The photo in this post shows ectropion uveae, which is also a cicatricial development in neovascular glaucoma. As the iris neovascularization contracts, it pulls the posterior iris surface over the pupillary margin into the front surface of the iris. (at Memphis, Tennessee) https://www.instagram.com/p/B0Mg7JtBNaP/?igshid=lkuqvnaod7u8

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Surgical Leadership Workshop by Harvard Medical School: Spent an amazing week in London learning about business development, entrepreneurship and psychology of leadership. Not only was the program enlightening, but it provided the opportunity to meet and interact with a small group of high achieving surgeons from all over the world. Healthcare systems may be different in Spain, Germany, South Africa, Indonesia, Brazil and the US, but we all have things in common: We all have to manage people, we all have to create financial budgets and strategic plans and we are all focused on improving our surgical outcomes. Looking forward to graduation in Boston later this year! #leadership #surgery #surgeon #lifeofasurgeon #professionalgrowth #futureplans @harvardhbs @harvardmed @imperialcollege @londonschoolofeconomics @theroyalsociety (at The Royal Society) https://www.instagram.com/p/Bv4I5wpgWN8/?utm_source=ig_tumblr_share&igshid=1owiofdmnoklc

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Dear Followers, I am entering an exciting new phase. I want to rebrand, reengage and take on new topics from medicine and ophthalmology to surgery, as well as healthcare in general. This may take me a few months. If you have any suggestions about subjects or perspectives that you want me to explore, please feel free to forward them to me. I have learned so much from the interactions with all the doctors from across the world that message me regularly. I want to take these experiences and channel them into this account in a more organized and cohesive fashion. We live in the most connected period in history. Information and discussions now can flow freely and instantly across all geographic and political barriers. For all the negative attributes that can be associated with social media, I believe that this is a wonderful platform for physicians, researchers, intellectuals and patients to come together and collaborate to improve our medical and scientific world. Please continue following this page in the meantime! Big things are on the way! https://www.instagram.com/p/BurHYX1gdZk/?utm_source=ig_tumblr_share&igshid=17fe914lctzpz

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Knowing when to stop in surgery: Understanding the limits of your own physical abilities in the operating room is the most important lesson for every surgeon. The patient in this post presented with a severe traction retinal detachment form diabetes. During surgery the dissection was extremely difficult, dur to the way the thick fibrovascular membranes were attached to thin atrophic ischemic retina. While I regularly attempt to fully lift the posterior hyaloid to the vitreous base and eliminate all epiretinal membranes, the bigger issue here was stopping the dissection once the central retina had been liberated, but before complications like retinal tears started occurring. I teach the simple mantra of "always leave the eye better than what you started". Which means stop before you create trouble. The vision 6 weeks post-op was 20/30. I think I can live with that outcome

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Knowing when to stop in surgery: Understanding the limits of your own physical abilities in the operating room is the most important lesson for every surgeon. The patient in this post presented with a severe traction retinal detachment from diabetes. During surgery the dissection was extremely difficult, due to the way the thick fibrovascular membranes were attached to thin atrophic ischemic retina. While I regularly attempt to fully lift the posterior hyaloid to the vitreous base and eliminate all epiretinal membranes, the bigger issue here was stopping the dissection once the central retina had been liberated, but before complications like retinal tears started occurring. I teach the simple mantra of “always leave the eye better than what you started”. Which means stop before you create trouble. The vision 6 weeks after surgery was 20/30. I think I can live with that outcome. #surgery #surgicaltraining #surgicaleducation #ophthalmology #medicine #medicina #cirugia #retinasurgery #retina (at Memphis, Tennessee) https://www.instagram.com/p/Bto2n49AOlP/?utm_source=ig_tumblr_share&igshid=1wfovs5dgp6gp

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3D view of an anomalous optic nerve: As a medical student, learning about the retina and optic nerve, it's difficult to understand the volumetric features of these anatomical parts using flat photography. It is a surprise for students as they learn to perform stereo biomicroscopy and see the optic nerve and retina as three dimensional structures. These are beautiful organs that have elevations and crevices, that are accentuated in diseased states. The video above shows a nerve with a congenital malformation that has a deep excavation in the optic nerve cup. While not a typical coloboma or optic nerve pit, this condition is within that spectrum. This patient has an exudative macular detachment and has undergone prior surgeries and lasers, documented by the pigmentary changes around the nerve. Without a true 3D viewing system on Tumblr, the quick alternation of left and right stereo pair images can provide a sense of depth to the nerve structure. #ophthalmology #optometry #eyeexamination #opticnerve #neurology #neuroscience #visualneuroscience #medicine

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Featured on last month's issue of Memphis Magazine. It was a pleasure to sit down with Michael Finger and discuss current therapies to address vision loss, and my hopes for the future. To read the full article, head over to http://memphismagazine.com! #901surgery #901health #901medicine #ophthalmology #internationalmedicine #internationalsurgery #diabeticretinopathy #retinopathyofprematurity #medicine #internationalhealth

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3D view of an anomalous optic nerve: As a medical student, learning about the retina and optic nerve, it's difficult to understand the volumetric features of these anatomical parts using flat photography. It is a surprise for students as they learn to perform stereo biomicroscopy and see the optic nerve and retina as three dimensional structures. These are beautiful organs that have elevations and crevices, that are accentuated in diseased states. The video above shows a nerve with a congenital malformation that has a deep excavation in the optic nerve cup. While not a typical coloboma or optic nerve pit, this condition is along that spectrum, and this patient has an exudative macular detachment and prior surgeries and laser, documented by the pigmentary changes around the nerve. Without a true 3D viewing system on Instagram, the quick alternation of left and right stereo pair images can provide a sense of depth to demonstrate the depth of these nerve structures. #ophthalmology #optometry #eyeexamination #opticnerve #neurology #neuroscience #visualneuroscience #medicine (at Charles Retina Institute) https://www.instagram.com/p/BsyijDCgNsS/?utm_source=ig_tumblr_share&igshid=1cdq6b665euzp

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Featured on this month’s issue of @memphismagazine. It was a pleasure to sit down with Michael Finger and discuss current therapies to address vision loss, and my hopes for the future. They found interest in this Instagram page and made a special profile on it. To read the full article, head over to memphismagazine.com! #901health #901medicine #901surgery #ophthalmology #internationalmedicine #internationalsurgery #diabeticretinopathy #retinopathyofprematurity #medicine #internationalhealth (at Memphis, Tennessee) https://www.instagram.com/p/Bsq5EPSAfKa/?utm_source=ig_tumblr_share&igshid=14r849uk0huir

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The process of scar formation is critical in most surgical specialties. In retina surgery, scar tissue over the retinal surface is called proliferative vitreoretinopathy, and is dominated by contraction of displaced retinal pigment epithelium cells and muller cells. When these cells contract they pull on the retina and lift it from the curvature of the globe, causing a retinal detachment. The images in this post are from a young child with Marfan’s syndrome that has redetached in this recently operated eye (he lost all the vision in the other eye from a previous retinal detachment). The folds of the retina are caused by epicenters of traction called “starfolds”. Surgical intervention with removal of the retinal traction can reattach the retina. Unfortunately the biological process of scarring is not stopped with surgery and contraction can recur. We have no medical treatment that can treat the scar cells from contracting that doesn’t cause damage to the normal retinal cells. This is clear “unmet need” in our specialty. #ophthalmology #retina #surgery #pvr (at Memphis, Tennessee) https://www.instagram.com/p/Br26KC-gc8X/?utm_source=ig_tumblr_share&igshid=1l5065pclkwvg

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Retinal detachments can present as a complication of various congenital malformations. The patient in this post had a macular coloboma, which is caused by a failure of closure of the optic fissure during embryological development. The retina over the coloboma is extremely thin and can develop holes that lead to the retinal detachments. This adult patient did not notice the worsening vision in this eye, due to having poor vision since birth. He presented with a cataract (which made the view into the eye difficult) and had scarring on the retina from the chronic detachment. In surgery we had to remove the cataract, remove the proliferative scar tissue over the retina, drain the retinal detachment fluid and fill the eye with silicone oil. — In my last post I received good support from the followers on posting my old video format and simultaneously posting the individual images from the video. I will try to keep this new system going forward. Thanks to Dr. Rafieetary for reminding me of this patient for the post. #ophthalmology #microsurgery #medicine #surgery #thisisnotsurgeryonagrape (at Charles Retina Institute) https://www.instagram.com/p/BrWAGADlzK1/?utm_source=ig_tumblr_share&igshid=f2qrr4z89y5v