I always wanted to do this. With enthusiastic consent from a patient, here's an unedited cataract case with annotations and narration with the "hand view". I'm proud to share what I've learned from my awesome mentors so far.
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Very few things are more satisfying than removing that last piece of a mature cataract. Phaco needle central, NOT chasing pieces, and being slow and deliberate is key.
@GeethaDavisMD
also emphasized not to buttonhole through ANY piece. Re-position!
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Refractive Changes of Retina Surgery and Silicone Oil or gas. Retina surgery can have significant consequences on refraction. Granted, if these procedures are happening, refraction may not be a priority but the changes are good to know.
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April IOL Cheat Sheet Update. Iโve obtained a lot more model numbers after tracking down some catalogs thanks to local reps. Thereโs a lot of change on the Clareon front. PDF on the website.
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The best way I've ever seen glaucoma organized is as presented by
@EyeDentistAAO
. This is a non-comprehensive condensed version of the "Glaucoma Family Tree" from his slides. Please check out his OKAP review slides.
#ophthalmology
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I'm so excited to announce our lOL Reference iOS App. After I catalogued nearly 10,000 lenses,
@GurpalVirdi
created a clean interface to allow users to search and browse the FDA approved IOLs. Download FREE today.
LINK:
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Itโs peak away rotation season. For the eager students or even new residents I made a very detailed narrative of one of my straightforward cases to better follow along and understand the step. Full PDF at .
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The Van Herick technique is a way to quickly gauge the depth of the anterior chamber based on corneal thickness near the limbus. There is NO substitute for gonsioscopy though and it must be performed on all angle closure suspects.
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Big update to "The Eye Guide" draft available on the website under "Educational Resources" in time for incoming residents & rotating students. Also get a preview of upcoming twitter content.
Download here:
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I did my best to summarize a very dense topic. Diabetic retinopathy is due to basement membrane thickening and loss of pericytes leading to capillary occlusion and retinal nonperfusion. Diabetic Macular Edema can occur at any stage.
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Glaucomatous visual field damage is progressive and predictable. It's called the "silent thief of sight" for a reason. Bjerrum's Area refers to the central 25ยฐ where 90% of glaucomatous damage typically occurs.
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Today was a big day. I bet every surgeon remembers their first โsoloโ case where even though the attending is nearby theyโre scrubbed in alone. Iโm so excited about my progress and to keep learning and improving.
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I'm loving the "hand view". Identifying motions outside the eye can be improved is extremely helpful. The goal whenever I operate is that EVERY single movement moves the case forward.
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Ophthalmology Eponym of the Week: The Spiral of Tillaux refers to the location of the rectus muscle insertion onto the globe. Here are the BCSC numbers.
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I've learned a great benefit of "folding" the rhexis flap back over itself before regrasping keeps the flap material central where it's controlled and provides an easy edge to regrasp.
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I absolutely stole this concept from the amazing
@EyeDentistAAO
. I hate white dot syndromes and Dr. Flynn's way of organizing it made it stick. I adapted it below with a few more BCSC facts and pics. Please check out his OKAP slides.
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There are thankfully man lens options but it can be hard to keep track of them. Here is my best attempt at a summary of the major lens options. Stay tuned for an overview of the AC and phakic IOLs!
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For refractive surgeries (including cataract surgery) we must be very aware of how the eye is naturally "aligned." If there is misalignment between the optical elements and the fovea there could be big implications for refractive outcome.
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Ophthalmology Eponym of the Week: The Goldberg theory of accomodation posits that synchronized movement by the ciliary body, zonules, and anterior hyaloid results in anterior lenticular curvature change and increased refractive power.
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It looks like what? We give a lot of creative names to things that we'll explore for the next few weeks. Sometimes they require imagination but at least we don't call everything "ground glass" (possible shots fired at radiology).
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Ophthalmology Eponym of the Week: Bjerrum's Area refers to the central 25ยฐ of the visual field where the Dutch scientist observed 90% of glaucomatous change takes place. Bjerrum Scotoma is the arcuate lesion starting at the blind spot.
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Since children cannot reliable tell you if "one" or "two" is better, a clever workaround is Streak Retinoscopy. This can also be done at the phoropter.
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Exciting news: The "Eye Guide" I've been putting together on the website is getting too big so I'm separating it into parts. Anatomy and Optics will be available as a paperback through Amazon soon and ALWAYS free on the website as a PDF.
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Glaucoma staging is now well-defined and based on ONH changes and perimetry. Anatomically narrow angles is now called "Primary Angle-Closure Suspect"
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Aqueous misdirection AKA Malignant Glaucoma AKA Aqueous Misdirection AKA Vitreous Block is a confusing topic (partly because there's so many names). The true mechanism isn't known, what is known is an abnormal lens/ciliary/vitreous relationship.
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I don't think I've ever posted this but this is my "Eye by Numbers" graphic that shows the normal measurements for ocular structures. It was a handy, high-yield resource from back in the day.
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May Update to the "IOL Cheat Sheet"; now with a second page of the remaining FDA and Catalog-Marketed approved IOLs. I find websites like iolcon or iolseu too bloated. If I'm missing any current FDA approved options please let me know! Thanks!
The FLACS method Iโm learning at PNV is to core out the center, split the lens, and take the hemis if possible. Canโt argue with the results.
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(kind of) Thematic Ophthalmology Eponym of the Week: A "Christmas Tree Cataract" is multi-colored, reflective deep cortical cataract associated with Myotonic Dystrophy and hypoparathyroidism.
#MerryChristmas
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Hering's Law and Sherrington's Law can be hard. Just remember Hering's Law refers to EOMs of different eyes so they work together (like Herring swimming together) and Sherrington's Law refers to EOMs of the SAME eye (Sharing and eye).
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The aqeous humor is produced by the inner, non-pigmented (remember this because the aqueous is clear) epithelium of the pars plicata portion of the ciliary body at a rate of 2-3 ยตL/min. It's completely turned over about every 100 mintues.
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Sarcoid can appear in the eye in many ways. The old Step 1 basics still apply and the simple Chest X-Ray is your best diagnostic tool. The iris nodules can be hard to remember but they go in alphabetical order from angle to margin.
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Myopia is an epidemic expected to affect 50% of the world's population. Thankfully there is ongoing research into treatment options in children but time outdoors certainly is good for everybody.
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PCO is the most common complication of cataract surgery. YAG is a safe way to address this secondary cataract. Do you prefer cruciate, circular, or spiraling?
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Ophthalmology Eponym of the Week: A Drance Disc Hemorrhage refers to a flame-shaped hemorrhage perpendicular to the disc and should make you think of low-pressure glaucoma.
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Presumed Ocular Histoplasmosis Syndrome is "presumed" because causality has never been demonstrated. It consists of a triad of punched out histo pots, peripapillary atrophy, and disciform scars. Treat the active CNVM.
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My newest thing is recording my hands during surgery (thankful that my residency offers this tech). It's allowing me to identify inefficient movements and further optimize surgery and make every motion more intentional. Cool videos to come.
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One of my favorite ways to get students and brand new residents involved in the OR is lens loading. It's a great way to practice dexterity and a great first first step. See my guide below and on the website.
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Trouble remembering retina layers? Memorize the "vertical pathway of light" (photoreceptors โ bipolar cells โ ganglion cells), that they all have axons connecting them, and never forget the layers! "inner" = closer to middle of globe.
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Here's EOMs by the numbers. The Spiral of Tillaux follows the MILS pattern. The Superior Oblique has the longest tendon and the vertical recti muscles insert at a 23ยฐ angle to the visual axis.
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Fuchs Uveitis Syndrome (or The Disease Formerly Known as Fuchs Heterochromic Iridocyclitis per the BCSC) features stellate KP, heterochromia, and unilateral cataract/glacuaoma. The prognosis of TDFKAFHI is good.
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Ophthalmology Eponym of the Week: Henle's Layer is refers to the axonal component (of photoreceptors) of the retinal outer plexiform layer where fluid commonly accumulates in Cystic Macular Edema.
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This rhexis really demonstrates how it will follow the "lay of the flap." This way is so controlled and nicely predicts the future shape of the rhexis. Again, cataract surgery is so rewarding and so very fun.
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Ophthalmology Eponym of the Week: Urrets-Zavalia Syndrome refers to a fixed and dilated pupil following penetrating keratoplasty for keratoconus in the setting of mydriatic use. It is thought to be secondary to iris ischemia.
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Ophthalmology Eponym of the Week: The Bruckner Test is a method of strabismus screening. The red reflex will be duller in the strabismic eye.
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Ophthalmology Eponym of the Week: Brown McLean Syndrome refers to peripheral corneal edema after cataract surgery that starts inferiorly and spreads circumferentially sparing the center.
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Ophthalmology has the coolest toys. LASERS are used every day from the front of the eye (refractive surgery with the excimer laser) to the back (PRP with argon) and there's some wavelengths that should be committed to memory.
#ophthalmology
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Ophthalmology Eponym of the Week: The van Lint Block targets the peripheral branches of facial nerve above the eyebrow and below the inferior orbital margin. This is great for the aggressive blinkers during cataract surgery.
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Ophthalmology Eponym of the Week: The Pelli-Robson (PR) chart is among the most consistent and standardized ways to test contrast sensitivity.
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Here is the high-yield take on the anatomy of (specifically my) macula. Because ophthalmologists are bursting with creativity this area has three names: Macula Lutea, Area Centralis, Posterior Pole.
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Ophthalmology Eponym of the Week: Erdheim-Chester Disease is a devastating and systemic xanthogranulomatous disease that features significant fibrosclerosis of the orbit, long bones, and internal organs.
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Ophthalmology Eponym of the Week: Wessely rings are corneal intrastromal sterile infiltrates (immune complex formation) in response to infectious or noninfectious entities like HSV, HZV, acanthamoeba, or contact lens use.
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This is either an unholy monstrosity or a high yield schematic of eyelid anatomy, you decide. The lower eyelid has a bunch of off-brand counterparts to the upper eyelid and it's worth understanding how they compare.
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Ophthalmology Eponym of the Week: Collier's Sign refers to the lid retraction that accompanies Parinaud Syndrome aka Dorsal Midbrain Syndrome aka Pretectal Midbrain Syndrome
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Ophthalmology Eponym of the Week: Speaking of tilted discs, Fuch's Coloboma (tilted disc syndrome) refers to a tilted insertion of the optic nerve that often results in a bitemporal hemianopia. Don't mistake for chiasmal lesions!
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Descemet what now? The new corneal transplant surgeries have become less invasive but also a little confusing. The names are self explanatory but easy to mix up. Don't forget K-Pro also which is usually reserved for multiple PKP failures
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OVDs or ophthalmic viscosurgical devices have made cataract surgery much safer since 1979. Like lenses, there are a lot of options and it's easy to become lost. Here's a quick guide to help you keep them straight.
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Senior year has been all about getting more comfortable in the eye. I'm so grateful to have such awesome mentors who help me achieve things like a 30 second rhexis. Cataract surgery is one of the most fun things I've ever had the opportunity to do.
#ophthalmology
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It looks like what? We'll close out our run of creative descriptors with corneal pathology. The refractive folks are extra creative. "Sand" probably would have sufficed but "Sands of Sahara" takes it to the next level.
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Ophthalmology Eponym of the Week: Arlt's Triangle refers to a triangular area with its apex at the center of the cornea where endothelial keratic precipitates form. It suggests a granulomatous condition like sarcoidosis, TB, VKH, or SO.
#ophthalmology
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Now for the stromal corneal dystrophies. These are all about location and pattern recognition. Macular is part of the "Marilyn Monroe Always..." mnemonic.
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Phakic IOLs are artificial lenses in an eye that still has its natural crystalline lens. They are used when the degree of correction is too much for LASIK/PRK/SMILE or the corneal based surgeries would result in significant abberation.
#ophthalmology
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These terms were extremely confusing to me at first. Uveal effusion vs. choroidal effusion vs. suprachoroidal... Many of these terms refer to the gathering of serous fluid in the suprachoirodal space. "hemorrhage" of course means blood.
#ophthalmology
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Ophthalmology Eponym of the Week: Sugiuraโs Sign, or perilimbal vitiligo, is seen in up to 85% of Japanese Vogt-Koyanagi-Harada Syndrome patients but rarely seen in Caucasians.
#ophthalmology
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One of the most important tools in glaucoma is gonioscopy, the visualization of the angle using a lens. Many disease processes appear in the angle so identification of the structures and when abnormalities are present are critical.
#ophthalmology
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Ophthlamology Eponym of the Week: A Bitot spot is a manifestation of Vitamin A deficiency usually temporal to the cornea. They're mixtures of keratin and Corynebacterium xerosis. Vitamin A is necessary for normal epithelial development.
#ophthalmology
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Ophthalmology Eponym of the Week: Terson Syndrome refers to sub-ILM, sub-hyaloid, or intra-vitreal hemorrhage secondary to abrupt intracranial hemorrhage.
#ophthalmology
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The optic nerve extends ~ 1 mm into the orbit and a normal optic disc is ~ 1.50 - 1.92 mm in dimeter. Thanks to
@EyeDentistAAO
for the tables that summarize the optic nerve length and blood supply. Here is my attempt at a high yield figure.
#ophthalmology
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Here is a quick summary of far points and focal points. You can always think of + and - lenses "pushing" and "pulling" the image onto the retina but a more elegant view is lenses correcting vision by placing the secondary focal point on the eye's far point.
#ophthalmology
Interesting case of torsional nystagmus this weekend. It looks like SO myokymia but the fast phase is excyclotorsion OD and incyclotorsion OS
#ophthalmology
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Follicular vs. Papillary Conjunctivitis can be challenging. For follicles, think Toxins, Viruses, and Chlamydia. For papillae, think everything else including pABillae (allergies and bacteria).
#ophthalmology
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Ophthalmology Eponym of the Week: Schlaegel Lines are streaks of pigmented curvilinear scars in the retinal periphery seen in multifocal choroiditis. This condition resembles POHS but look for vitritis to distinguish them.
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LASIK has a rich and fascinating history from its FDA approval in 1999. The Excimer Laser (193 nm) has consistently shown safety and efficacy in the treatment of refractive error. Here is a history through the various types of LASIK.
#ophthalmology
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Ophthalmology Eponym of the Week: A Hruby Lens is a -55 D lens attached to the slit lamp that produces a high magnification, upright image of the fundus.
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The "grab 'n go" method to start a rhexis flap saves a trip in and out of the eye and a few moments. I'm not the fastest now but I'm excited to be learning these efficiency tips early.
#ophthalmology
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Beware the young patient with unilateral glaucoma and ask about history of trauma! Also don't forget the angle after hyphema/trauma. Angle damage and glaucoma are common complications.
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Ophthalmology Eponym of the Week: "The Little capsulorhexis tear-out rescue" is a technique to save a rehxis that is starting to run out. Fill with an OVD and apply force backwards in the plane of the capsule.
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Ophthalmology Eponym of the Week: Kestenbaum's rule is that the reading add should equal the inverse of the visual acuity for patients with low vision. E.g., 20/200 = 200/20 = +10.00 ADD.
#ophthalmology
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First time really chopping. I think I love it because it probably can be faster than divide and conquer and my CDE was 0.50. Still need to get used to force vectors and aspirating non-debulked quadrants. Learning new skills is one of the most fun parts of the job!
#ophthalmology
Here's a closer look at the four epithelial and subepithelial dystrophies the BCSC covers in detail. A big secret to the dystrophies is pattern recognition.
#ophthalmology
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#MELive2022
featured great talks about the IOL options. It's easy for students/new residents to get lost. I took my "IOL cheat sheet" to the next level and will keep updating on the website. Download the PDF at:
#ophthalmology
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Hydroxychloroquine received a lot of press in 2022. This disease modifying rheumatologic drug can have irreversible effects on the retina.
#ophthalmology
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Ophthalmology Eponym of the Week: The Styles Crawford Effect has two kinds.
1. Light through the central pupil appears brighter than light entering near the border
2. The perceived color of monochramatic light is different for central vs. border rays
#ophthalmology
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The glands of the eye can be tricky. Picture a WOLF(fring) stalking the border of the tarsus, KRAUching in the fornix, and a sweaty Moll and you'll be halfway there!
#ophthalmology
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Asteroid hyalosis is a common entity of lipids, calcium, and phosphorus deposits suspended in the vitreous resembling an asteroid field. It's associated with DM and differenced from synchysis scintillans where the deposits float freely in the vitreous and settle.
#ophthalmology