New Macular Hole Technique: ILM Repositioning
Yoshihiro Yonekawa, MD Mass Eye and Ear / Boston Children's Hospital Editor, RETINA Roundup We hope everyone is having an enjoyable Thanksgiving weekend! This is the first article of a series on how to keep referring ophthalmologists happy. To start off the series, we interviewed two cornea surgeons in different practice settings, and asked about their perspectives on working with retina specialists. Duna Raoof, MD, is a cornea, cataract, and refractive surgeon in private practice with Harvard Eye Associates in Laguna Hills, CA. Hajirah Saeed, MD, is an adult and pediatric cornea and refractive surgeon in an academic practice at Mass Eye and Ear and Boston Children's Hospital, of Harvard Medical School (my partner in crime for complex pediatric co-management). Duna Raoof (Left) and Hajirah Saeed (Right) Thanks for joining us on RETINA Roundup Duna and Haji. First, what are the most common diagnoses that you co-manage with retina colleagues? Raoof: As a corneal specialist in a busy private practice, I see a fair amount of patients with multiple ocular comorbities that I co-manage with my retinal colleagues. The most common diagnoses include neovascular age-related macular degeneration, visually significant epiretinal membranes, and diabetic retinopathy requiring treatment. I, of course, also refer out retinal tears and detachments. Saeed: In a high volume, pathology-rich academic cornea practice, retina specialists are our best friends! In my practice, the most common referrals or opportunities for co-management include patients with aphakia undergoing secondary IOL placement requiring vitrectomy, aphakic Boston keratoprosthesis patients also requiring vitrectomy, and patients whose epiretinal membranes become apparent after addressing the corneal pathology that precluded previous visualization. I also refer patients with high myopia, who may be at greater risk for ocular complications with any intraocular manipulation or surgery, for preoperative consultation. When your patients undergo procedures with retina surgeons, what are your pet peeves that we may do? Raoof: Patients that undergo any ocular surgery are often on multiple eye drops, and I often notice that the ocular surface doesn't get the attention that it requires. Factors that impair the ocular surface post surgery include: extended use of preserved eye drops resulting in toxicity (most commonly from bezalkonium chloride) and neglecting pre-existing eyelid margin disease. Saeed: Despite our jokes about retina specialists scraping away the cornea epithelium at whim, that doesn't bother most of us! Sometimes using viscoeslatic on the ocular surface is enough for visualization but we want you to do what you need to in order to perform the safest surgery possible, including removing the corneal epithelium for visualization. However, putting patients on eye drops that impede healing corneal healing can be a hindrance to optimal corneal health. Topical NSAIDs in particular can be toxic to the corneal surface and are also associated with corneal melting with long-term use. A short course postoperatively is ok, and sometimes needed, but I try to emphasize limiting or stopping use in patients with corneal pathology or corneal transplant if they don't have a specific indication for use. Sometimes corneal and/or scleral incisions are necessary by our retina colleagues (e.g. removing a dislocated IOL). If the patient has any corneal graft (PKP, DALK, DSAEK, DMEK, etc) try to avoid making an incision that goes into the graft and stay as peripheral as possible. Scleral wounds are best because they induce the least astigmatism and seal really well! How about in clinic? Anything in particular that would be good for retina surgeons to be more cognizant of? Saeed: When seeing your complex patients keep an eye on the corneal endothelium, which can decompensate after multiple surgeries. Feel free to send the patient to us for an evaluation, even if the patient doesn't need surgery yet. Once dense fibrosis and scarring set in, a more invasive surgery like PKP may need to be done instead of a DSAEK; with early referral we can keep an eye on the endothelium and act sooner rather than later. What's the mode of communication that you prefer we use to touch base with you about shared patients? Email? Electronic health records (EHR)? Phone? Fax? Mail? Raoof: I think that fax is the most secure and efficient way to send us a non-urgent update about our patients. In my clinic when we receive a fax from another practice, it gets immediately uploaded into the patient's EHR chart and I receive a task to review it in my inbox. This is nice because the patient's question is already linked and makes it easier for me to look up that specific patient. For urgent matters, a phone call is best. Saeed: In a large academic practice with dozens of offices and fax numbers to which records can go, I find personal communication either via email or EHR (if a shared system) best. That way I can email my assistant the records directly and get them scanned into the chart. We've all had the experience of seeing a patient with complex pathology for the first time and not having any records or history-- it's a clinic stopper! I also like email/EHR because if I have a question about the patient or want to give a quick update I have a direct way of contacting the referring provider. Any other pearls that you can give us when we share patients? Raoof: Don't ignore the ocular surface! You would be surprised how much surface TLC (artificial tears and lid hygiene) can impact outcomes. In addition, bridging the communication gap is essential. So whether is it a quick call or fax to let us know your impression and plan, it is extremely helpful in our continuous learning and providing future care. Saeed: It would be great to know what the potential for vision is from the retina standpoint when referring a surgical patient. If the retina is limiting vision significantly, the likelihood of improved vision from a corneal procedure may be low and the patient can be saved from going through an unnecessary procedure and its associated risks. Of course we also do cornea surgery for non-visual purposes (uncontrolled pain or infection) but for surgeries intended to improve vision, having an idea of the potential is paramount. Also sometimes after combined retina and anterior segment surgery, postoperative visits can be split between providers, so coordinating that can be helpful in saving patients and providers time. Duna and Haji, thank you both for your insights!