Video interview with Ophthalmologist & Retina specialist, Aryeh Pollack, M.D.

Hi, it's Doctor Robert Seicherd with another episode of Doctor Podcasts. And I'm currently on the Twitter platform, which is rapidly becoming the most prominent video platform on the Internet. Today, I am pleased and honored to have a guest who's one of the top Retina Doctors in all of New York City and the New York City metropolitan area. It's Doctor Ari Pollock. Doctor Pollock is a retina specialist. He's a clinical assistant professor of ophthalmology at the NYU Grossman School of Medicine and also at the Mount Sinai School of Medicine and also at the New York Eye and Ear Infirmary, all here in New York City.

Doctor Holic is a workaholic. I know because he's always available to see patients 24/7 and he's always able to help other doctors with patients who have retina problems. So I'm really pleased to have him here, take some time to spend with us and talk about retina. Today. Retina is a part of the eye, which we'll discuss in a moment. The retina is a very important part of the eye, which basically sends messages to the brain. But unfortunately retina can have problems. So today we're going to discuss things like macular degeneration, how diabetes affects the retina, something called diabetic retinopathy and things like retinal detachment and and other things.

So, Dr. Pollack, thanks very much for taking the time today to well of. Course the pleasure is all mine and I think we're gonna have a great time here today. Absolutely. And the audience? We got rave reviews on our first. I saw the first, the first episode. It was awesome. It was outstanding. Yeah. I'm very honored to be the 2nd guest. Yeah, so it's. I feel like a trailblazer. Absolutely. Absolutely. So let's talk about the retina. Could you tell us what the retina is and what part of the eye it's in?

And sure, we have actually a model of the. So that's a good place to start. We can start both here today. That's great. So just gonna open this up here. Well, there's our lens, right? This is actually a surgery that we do. This is actually a drop nucleus, right? Sometimes the cataract doctors make mistakes and the nucleus falls down and we then we have to go and we have to then go and Fakal emuls and retrieve it. Well, remember retrieve it, we use the Fakal Fragmentome and we emulsify it and we take it out basically.

So essentially this is the retina's really the posterior or the back portion of the eye? So here, right over here, is the optic nerve, and what the retina is, is a very special neurosensory layer of tissue that produces A photochemical response. Really. A neurochemical response in response to light transmits this message to the brain through the optic nerve, and the brain then registers this as an image or a little bit like a series of pixels. So people can better understand it's essentially essentially most like the digital chip in a camera, right.

So in the old days for the. Audience or film or the film of a camera in the audience, right? For the audience that remembers film and camera, the retina is like the film in the old fashioned cameras. It gets the message and then it sends it to the brain. But it's very sophisticated. Interestingly, a large part of the brain is devoted to vision. That's of course, absolutely true. The whole occipital lobe. There's occipital lobe just the way that the optic nerve eventually transmits the message through the thalamus up to the through the occipital lobes.

It is crucial, really. But the source of all that vision is the retina, right? And you only get one of them. Right now, at this point, one in each. Eye One. In each eye, you can get as many lenses as you want. You can get as many corneas as you want, but you only get one retina, right? The retina is actually neural tissue, like the brain, so if there's any damage to the retina. Which is why these diseases that we're gonna discuss are so important, right? So many of my patients ask me, what is the macula?

They sometimes confuse macular with a disease. Can you explain what the macula? Is so the Mac, the anatomic macula on this diagram here is really the points, the area in between the arcades which are the blood vessels that emanates from the optic nerve. But what's really significant about the macula is the macula is the part of the retina that is the central part of the retina, which is then even the fovea that is very cone dense. And because it is so cone dense, this is the part of the retina that we use to read, to recognize faces, to watch television.

So if there's something wrong with the macula, then the patient's central vision is going to be horribly impaired, right? So the macula is the most important. Part, and that's the most important part of the retina that's in the center. That's in the center of. That's correct, right. Without that, you can't drive. You can't watch TV. That's right, you can't go to Twitter. And see that you can't do. It can't do any of that. Can't do any of that. All right. Interestingly, you've spent many years learning how to be a physician.

You went to medical school, you did a residency and ophthalmology, and then you became a retina specialist. Can you tell us how much training is required to become a retina specialist? Well, you have to go through the normative 4 years of medical school, one year of internship, 3 years of ophthalmology residency, and another two years of fellowship. That's a lot of training. And during the fellowship you learned surgery as you learn. My fellowship actually was fairly extensive and we did both medical retina and surgical retina.

I was actually the only fellow for two years. Really. Yeah. So we were really very busy and I learned an incredible amount during my fellowship. But we did both surgery and surgical retina. And medical retina in my fellowship, Yeah, you have pretty amazing credentials. I should mention that Doctor Powell went to Harvard Medical School, which is the top medical school in the USA if it's not the whole world. So his credentials are amazing. And now he's a clinical assistant professor at two major medical schools in in New York City.

So it's quite an accomplishment. Tell us So go back a little further. Why did you decide to be a doctor in the first place? Well, I'll tell you, my dad was an ophthalmologist and my mom, my mom is a professor and I really had no choice. If I didn't go into medicine, I would have slept in the garage. That was the choice either either either sleep in your bed or go to the garage. That was it. So I really didn't. I don't know that I really had a conscious. Decision necessarily. But I do know though that really from the time that of my earliest memories, I was going to medical school.

So it was never. But yet obviously I went to college and still had to decide what to do. And medicine really appealed to me because I thought that it was just a great way to spend your life. Taking the apex of technology and fusing that with really helping people and really synthesizing science, science and in some ways humanity or the humanities and into one profession, and I just thought that would be a pretty cool way. To spend my life sounds like an easy decision to me. It was either Garage or Harvard, but.

That was it. Those are the two. Yeah. I would have picked Harvard as well, but obviously you have to be brilliant to get into there. That's quite an accomplishment. Speaking of the retina and macula, one of the most common diseases that we see now and senior citizens is something called macular degeneration, which talked about a lot. Can you tell us what macular degeneration is? Well, that's that's that's a great question. There's there's there's billions of dollars of research that I think has been spent on defining exactly what causes macular degeneration and why it happens.

But generally speaking there are two kinds of macular degeneration. There's the dry kind of macular degeneration and the wet kind of macular degeneration and the dry kind of macular degeneration essentially for some reason as we get older. Just the cells kind of just atrophy and wither in the wet kind of macular degeneration. New blood vessels grow under the retina. These blood vessels then leak and bleed and scar. Bad, bad thing, but it occurs mostly in senior citizens though, right? Absolutely.

So the incidence, if you take a look at the overall incidence of macular degeneration. Say of it actually can happen in younger patients as well, but often in younger patients there could be some form of genetic disease that causes some form of macular degeneration, but that's a little bit different. But even still, a cross-sectional prevalence of macular degeneration throughout the country is probably about 12%. So even people above age 65. No, no, no. Above age 65 is much worse, much worse. It's 12% above about 40-5.

Really. Yeah, Above 45, it's 12%. Above 85, for example, it approaches 50% and it's above 45. I would say that there's an increase in incidence of 1 to 2% per year. Wow. Yeah, so what's the current theory? Is it vascular? Lack of blood supply? Some. Other issues, the dry and the wet are probably a bit different. The dry macro degeneration right now, it's a multifactorial entity right now. Overaction of complement seems to be the complement cascade seems to be what drug manufacturers are going to target.

For the dry, the wet is some form of ischemia that produces A molecule called VEGF which is very popular in the press. And this is how it really relates to treatments that the treatment for wet consists of injections of an anti VEGF, a molecule that blocks VEGF that makes the bleeding go away. That's interesting. What's the treatment for the dry type of macular degeneration? Well, as we're learning more, actually some of the classifications are even being revised really even as we speak. And the treatment has always been really since 2000, vitamins where vitamin C, vitamin E, zinc, gluten, Z, xanthine, leafy green vegetables.

These really do help. They they do provide some benefits perhaps up to depending on on the on the study and depending upon whether it was the the study was called a Reds age-related eye diseases. There was a Reds one and there was a Reds two and a Reds two. They they they put it. They they replaced beta carotene with with. With lutein and zinc actually, so with the Arads 2, they actually did get a little bit better, better protection. So with the Arads one overall there was about a 7% protection with the vitamins of absolute benefit, of relative benefit, it could have gone as high as up to 20%, right.

And a lot of my elderly patients take that. If you don't have macular degeneration, but you have a parent or a sibling that has macular degeneration, is there any benefit in taking the A Reds two vitamin? No, the dosage is far too high. If the criteria really to take an A Reds two vitamin are really drusen which are? Waste products, essentially protein, cholesterol that get deposited largely under the retinal pigment epithelium which is this very special layer of skin under the retina and they have to be essentially a certain number and a certain size where would really benefit, where the patient would really benefit.

But if somebody just has risk factors, the A Reds vitamins are the the dosage is way too high and it'll it'll burn a hole through your stomach eventually with time, especially in the young. In a young patient so, but I would tell them to just take a regular vitamin to take a regular multivitamin and they could supplement with lutein, which is pretty much pretty much harmless of five to 10 milligrams and eat a lot of leafy green vegetables, things like spinach. Spinach. Broccoli. Exactly. Anything that's green.

If it's green, it's good and cigarette smoking. Cigarette smoking is a disaster, right? Cigarette smoking makes it worse. Actually, I would tell them actually to control their lipids too control their cholesterol. High cholesterol also makes it worse, as well as hypertension. Hypertension also makes dry macular degeneration worse. Does diabetes make macular degeneration worse? No. No. So it's most of the aging diseases kind of clump together and make each other worse, right? And how do you treat the wet macular degeneration?

So the wet macular degeneration has been around for many years. You mentioned the injection. It's already 20 years already, but there's some form of anti VEGF. There've been many on the market. They really extend from Lucentis or Eilea Avastin. These have been the the really the famous How often do patients need to? Have well that's that's an excellent question. So the focus really right now is trying to get patients. To have as few injections a year as possible. So there are newer medications that came out that are all over television.

This Babaizmo that according to their according to the studies, allows patients to get out, allows about 50 to 60% of patients to get out to at least to at least four months. And some can even get out to six months, that's pretty good because I remember when the injections. First started they were monthly, the new monthly, but even still even with the visible, you have to load them with an injection every three months and then you can extend. I understand there's a form of dry degeneration called geographic atrophy and there's a new drug for that.

Is that? Right, That is correct. There are two new drugs coming out on the market for geographic atrophy. They both target complements. One targets C31, targets C51 is called Syphovre and the other is called Tamura. So these agents should be out pretty soon. But what these agents really do though is they really slow the slope of progression for the most part. So I mean the numbers are. It's by no means a cure, but it gives more area under the curve. Where vision where vision is preserved. But the the point though is, is that the best patients for this are patients where the zones of atrophy or or wasting away are close to the center of the vision and are not have not involved the center of the vision.

Because once the center of the vision is involved it's too late. But if these zones are close to the fovea, then there may be some benefits towards, you know, towards not not A. Terribly statistically significant benefit, but there is some benefit, there is some benefit to it. Bottom line, if you have macular degeneration or if you have a close family member has it see a retina specialist like Dr. Pollack and make sure you're monitoring that very carefully. And we also mentioned that you're a New York Eye and Ear Infirmary in Mount Sinai and you're part of the trauma service at New York Eye and Ear Infirmary here in Manhattan.

Can you explain what that is? Sure. So it's a really a few very, very talented surgeons for the most part really take for the most part, take their own time and really devote it to the hospital. And and really to the city and to the and This is why the Infirmary is really such an important place where essentially all the trauma that happens in the in the greater New York area is, is, is is really referred to New York on your Infirmary. And we do things like take out foreign bodies. There's like metal on metal injuries where shards of nails get gets basically perforates the globe and lodges.

In the vitreous cavity or lodges in the retina, and these have to be removed. These also cause retinal detachments, they cause massive vitreous hemorrhages. They cause choroidal hemorrhages. And these patients are very, very skillfully dealt with in New York Eye near Infirmary. So you're there in the middle of the night, 4th of July at night, treating patients who've had firecracker injuries or who are hammering a nail and part of the nail broke and went into their eye or were using a power tool and a piece of metal.

Fluid that's that's essentially what happens. Yeah, right. That's why I said he's a workaholic. Dr. Cuz you can always find him on the holidays in the hospital helping patients out. That's a sign of dedication. That's fantastic. I wanna move on to another thing that many of my patients have and has talked about commonly and recently. We've heard there's a diabetes epidemic in the USA and around the world, right? And many patients develop something called diabetic retinopathy. Can you explain what that is?

Of course. So as we know, diabetes is both a endocrine disease, a blood sugar disease and it's also a vascular disease, right. This is the reason why patients with diabetes. Have a higher incidence of heart attacks. They have a higher incidence of stroke. They have their feet get amputated, They have kidney disease is because there's small vessel disease that that's the blood vessels get occluded. So this happens in the retina and what happened to the retina is very small blood vessels and these blood vessels get occluded.

And when they get occluded, new blood vessels grow and these new blood vessels unfortunately bleed and form scar tissue. And when they bleed and form scar tissue, they can pull on the retina and they can detach the retina. And this is a would produce a classic traction retinal detachment in response to diabetes as well the blood vessels of the inner lining of the blood vessels, the endothelium, becomes porous and proteins leak. Serum and proteins leak out into the interstitial space of the of the macula.

And produce macular edema so patients with diabetes can lose vision from both of these processes. How often should a patient's been diagnosed with diabetes or pre diabetes? See their ophthalmologists. So it depends on the extent of retinopathy. Essentially, if they really have no retinopathy then they can really just need to be seen once a year. If they have minor retinopathy then they can be seen every three months, but if they begin to have. Like at least moderates nonproliferative diabetic retinopathy, then they need to be seen every three months.

So at a minimum, if you have diabetes or you're prediabetic or your A1C blood test levels are elevated, see an ophthalmologist. And if you have diabetic retinopathy, you should see a retina specialist like you, right? Happy to treat them right. So it makes a large part of my practice. Now you also treat with lasers, right? Well, we treat with lasers, we treat with lasers and we treat as well with the same injections that we treat with macular degeneration because the VEG F molecule is really the molecule that gets produced in response was one of the many molecules.

But right now conceptually the major molecule that gets produced in response to ischemia and the the same injections that work for macular degeneration work for diabetes as well. So, so it's an excellent question that you asked before the injections became prevalent 20 years ago, we laser was a was a very laser was the only treatment that we had. So for macular edema, we would treat the areas of thick and macula with very fine points of laser also attempting to close the micro aneurysms and we would also place something called panretinal photocoagulation which are larger retinal spots that would essentially alter the circulation.

It's a complex process but it would reduce the ischemia and it would reduce the new blood vessels. I still think that there's that there's still a role for both actually and the IT certainly cuts laser in my opinion certainly does cut down on the number of injections and the frequency of injections and if done properly laser can work very well. I have some patients that are very squeamish and don't want injections and there are certain techniques with micro pulse laser but not quite using the micro pulse laser as the micro pulse laser.

Really you just using very short bursts of laser that barely make a spot in my experience helps tremendously to control the diabetic macular edema and the injection also lets us put in less heavy laser. So it's really so many of the complications that existed with the heavy laser over the years are really avoided because you don't have to put in such heavy laser as we used to as there's really a synergy between between the two. So there's a fusion between the two in a synergy. You mentioned the word ischemia a few times.

That means a reduced blood supply, reduced oxygen to the retina and then the retina suffers consequences. What benefit is there of controlling your blood sugar or keeping your A1C blood tests low to prevent the diabetic complications? So that's crucial. That's completely crucial. If you again, if you take a look at the classic studies, 66% of the of the whole treatment of diabetics depends on the patient's good blood sugar control with the hemoglobin A1C of of 6.4 or less and and in fact for every one for for every 1% of hemoglobin A1C that's above 7.

OK, so let's say somebody presents with a hemoglobin A1C of 8 their chance of running into trouble over the years even perhaps even goes up to as high as 50%, right? And the. Trouble could be the trouble could be total loss of it. Trouble could be vitreous hemorrhage, retinal detachment. Trouble could be serious problems. So it's really crucial for

diabetics to control the sugar. I remember one of my mentors in fellowship used to explain to the patients that that we can when we didn't even have the the VEGF drugs. Laser was the only entity. And he used to tell them that that that if you don't control your sugar, it's kind of like like swimming against the tide where eventually the tide is just gonna catch you. We can put in laser to control the tide, but if the sugar is not controlled, eventually the tide's gonna come back and the bleeding's gonna start again and we're gonna have to put in more laser or do surgery or do something more aggressive.

Right, very important. Now, these days there's a lot of news about new drugs, Ozempic, Regovy, Moon, Jarro. These are drugs that control the blood sugar. They also cause very significant weight loss and have some beneficial cardiac cardiovascular effect. What's the effect on the eye and patients with diabetic retinopathy? So that's. Ozempic. I'm sorry. So that's a great question. That's an awesome question because as you said, it's really very, very, very popular right now. So in the long run, the likelihood of better blood sugar control would likely be that there, that the retina's more stable and that the diabetic retinopathy would regress.

But in the short run, as we know from patients with bariatric surgery as well as with patients that have had pancreas transplants where all of a sudden they're getting intensive blood sugar control, and this happens over a relatively short period of time. Paradoxically, the retinopathy actually gets worse over a short period of time. So if. It drops too rapidly. If it drops too rapidly, the patients could experience fairly significant progression, which is more so correlated with patients who have a long term history of diabetes as well as patients who have poor control and have hemoglobin A1C of 9.4% or more.

So it's really important to be monitored carefully the last two weeks. I had one patient last week who lost. 90 pounds in six months? Yeah. Yeah. I've seen many of these patients. Yeah. I couldn't even recognize it, I know. And I had another patient a week before. Lost 40 pounds. Yeah, in six months, right, right. So they one of them was diabetic, right? I didn't see any retinopathy. The other one is not diabetic but used it for weight loss. So anyone who's losing a lot of weight with Ozempic or the other drugs with Govi munjaro should be followed by their ophthalmologist, especially if you've had dramatic weight loss and also dramatic drop in the A1C blood test.

Could you explain what the A1C blood test is, since we've mentioned it several times? Several. Sure. Yes. So the A1C blood test is essentially what happens in diabetes is that the the red blood cell when it gets glycosylated by high sugar is not quite the same red blood cell as a regular red blood cell. So what happens is there's a certain percentage, so to speak of, of a ones of of glycosylated, of glycosylated blood cells that are detected that the lab is basically able to detect and produce that as a function of control of of diabetes, of diabetic retinopathy.

So ideally diabetics should be below 6.46 point 4 should 6.4 should be the number, yeah? Right. All right. That's great. Good to know. Tell us, you know, doing retinal surgery, I do eye surgery, but I'm always amazed by retinal surgery. Even more, I don't do retinal surgery. I'm not a retina specialist because you're dealing with an extremely sensitive, very thin. Part of the eye that's incredibly sensitive to any touch or manipulation. Tell us about the surgical skills that you need to do surgery on the retina.

Well, I think that the most important surgical skill is outstanding judgment that has to be employed within often split second decisions. That's I think that's the most important thing. The actual manual surgical skill is very difficult too. It takes a while to really be able to peel membranes and to really fix retinas the right way and to fix macular holes and to get good ILM peels you're talking about. These are things that are microns in size, and it does take some time to be able to really become facile at it and to be able to do it effectively and quickly.

But that part always comes. I think the technical part always comes. It's always, it's the judgment, being able to read the defenses so to speak that I believe is really the most critical part of being an outstanding retina surgeon. You were telling me about the football and Allen, that's right. To doing retina surge right. I thought that was fascinating. So tell me about. So, I mean, once you get to a certain level, like for example in the NFL, I think there's every guy who plays quarterback, Every quarterback can put the ball where they have to put it.

Otherwise they never would have gotten through high school. They never would have gotten through college. But it's being able to read complex defenses and being able to pick them apart that really makes the great, that really makes the great quarterback. Not to throw interceptions. That's really what really makes SO the great retina assertion. So basically, you're like the Tom Brady of ophthalmology. Is that? Listen, hey, I won't refuse the analogy, but.

That's that's a great point. Judgment, but judgment, yeah, but also right? Absolutely. Judgment is the most most important. Thing Yeah, I've trained many residents in eye surgery, not retina, but in cataract surgery, coronal transplants, etc. Some of them have very excellent hand skills and are really good, but they get to a point where what do I do now? They don't know what to do and that's where my judgment comes in. I tell them, OK, here's what you do next to. Do the surgery right and get a good result.

With time, they eventually learn that most of them. But don't get me wrong, I mean, it's kind of like a bit. The analogy that the program directors have classically used was really more that it's flying. It's like flying an F16 airplane because really what you are doing, you're using both your feet as well, right? You're using 1 foot to control the microscope and you're really trying to focus in and out of where you are and you know the other foot is controlling the tracks me machine. So you're you're basically engaging vitreous and tissue at different speeds and you you sort of have to get into certain planes and things do happen fairly quickly and you have to be effective at at delaminating or segmenting tissue without really making breaks or making tears and and causing problems.

So you gotta do all this all at the same time and with all this it's always or you always have to be thinking 5 steps ahead of well, if this is gonna happen what am I gonna do? If that's gonna happen what do we do? That's the that's that's kind of like I believe the the most important part of. F16 fighter not so right. What you're saying is you're like Tom Brady and Tom Cruise all in one, all in one.

That's right. That's right. That's pretty amazing. Now, the retina is extremely thin. It's like paper thin. I think it's about 1/4 of a millimeter thin. That's correct thinest point. So we're talking about something that's paper thin, looking under a microscope, which magnifies it about 10:15 times, and you're peeling apart layers of a piece of paper under the microscope, correct? Right. So. Everything has to be exact, but the most important point is understanding which plane you're in, right? That's the most important point, right?

Is being in the correct understanding the plane and being exactly where you need to be. So in the plane, in the in the certain plane, That's right. Same deal. Same deal. Yeah. Good. Wow, that's pretty amazing. Yeah. Some of my patients occasionally come in out of the blue and have a retinal detachment. They have no previous problems. They just kind of wake up one morning and they can't see out of an eye. Can you tell us what a retinal detachment is? Sure. So there's the gel in the back of the eyes.

Cool the vitreous gel. If we go back to our model. This is really what takes up the whole about 4/5 of the eye essentially. And what happens is, is that as we get old, when we're born, this gel is 90% gel and 10% liquid. As we get older, it becomes 50% gel and 50% liquid. And when the gel liquefies, it pulls on the retina and when it pulls on the retina, it can make a tear. The liquefied gel can then go through the tear and that can then detach the retina. So that's a classic regmatogenous, what we call a regmatogenous attachment.

There's also you can get a retinal detachment from diabetes too, as we discussed also is that the scar tissue from diabetics, it contracts and it pulls and when it pulls the retina, the retina as well can detach it's. Kind of like a rubber band attached to the retina and a little bit it kind of like makes a table top and it's, you know. So why do young people, Let's say you're 30 years old. Why does a 30 year old get a retinal detachment out of the blue? Well sometimes 30 year olds they they could be myopic.

We're very nearsighted and the the just the characterization of the protein to collagen ratio is different in myops than it is in in non myops and people who who are emotropic or don't need glasses and the gel liquefies at an earlier rate in these patients. Now sometimes also these patients what happens is they they can have predisposing lesions called lattice degeneration and or and or retinal holes. And their pathology sometimes when they detach is a bit different where sometimes the vitreous gel percolates through these retinal holes and through the lattice degeneration and they actually detach without the gel being pulled off.

And it is a bit of a difference in how you treat the two. Right now you can treat certain retinal tears or detachments of laser and others require actual surgery, right? Right. So if there's just a retinal tear, the the retina will be is still adherent to the choroid, the layer under the retina. And you can basically seal this detachment closed with this tear closed with laser. If fluid gets under the retina, then some form of surgical procedure has to be performed and sometimes we can't fix this in the office.

If it's very if, it's if, if, depending on the geography of the tear, on on how high up it is on the eye, so to speak, how many tears there are. Sometimes we can treat this with a with a gas bubble in the office where the gas bubble expands against the tear, the retinal pigment of the wind pumps out the fluid and the retina reattaches and then we put in laser at a later date. Sometimes we that that can happen. Most of the time though we do wind up going to the operating room to perform a procedural called the vitrectomy with or without a bands that we sew around the eye called the Sclerobacle where we take out the gel from the back of the eye and we reattach the retina, drain the fluid either using heavy liquids actually air conditioning fluid to to to to squeegee the fluids from behind the retina or we make a drink, we just make a retinotomy, make a drainage retinotomy.

We just aspirate the fluid from under the retina and then we put in laser and then we put in a gas bubble. Interesting. I've been seeing more and more patients who have something called macular holes and they wind up having macular surgery, which is relatively new. Can you tell us about that? Well, the macular hole surgery has been, has been around for a while. Macular hole surgery is in its modern state, has really been in existence for about 20 years. But as time has gone on, the results are better, basically because the instrumentation is better.

We use small incision surgery. The small the instruments from the four steps are in many ways better than the older four steps were. There are dyes that we use now to sustain the internal limiting membrane of the retina and which is the crucial point of closing a macular hole. Essentially what happens? The question really then becomes, well why does somebody get a macular hole? There are, you know, two or three theories as far as how someone gets a macular hole. It's either the vitreous gel that we discussed pulls and makes a macular hole.

Sometimes membranes on the surface of the macula have a tangential pull and this causes swelling around the fovea and hydraulic force of the swelling pops the hole open and sometimes even just the internal limiting membrane in the retina which is a normal part of the retina. As time goes on this as well causes the same effect of causing the centripetal forest that that pops the hole open. So often just peeling the terminal limiting membrane in the retina effectively and accurately is the most important part of closing the macula.

Is this really the most important part is removing the vitreous gel. If you even if you just remove the vitreous gel, perhaps 90% of holes can close even from just that alone. But the difficult ones, removing the internal limiting memory in the retina is really the the key and and the basically the dyes that are in use today do make an instrumentation do make it somewhat easier than it was even 10 years ago. Yeah, I see patients now who've had macular holes. They had great. They look great. They look great.

Their visions, their visions restored. Yeah, 1520 years ago. So they were, yeah. It wasn't that you got good closure. The visions are definitely better, I think, today, than they were, than they were years ago, right? So technology once again in medicine and definitely advances and absolutely helps us. Tell you're busy guys. I mentioned earlier you're always helping out your colleagues and patients. Tell us what your average week is like. What do you do with ophthalmology and your retina practice?

I just work all day. I just see patients all day and I operate. That's essentially what I do. It's very simple. That's it. That's my week. You. Know that that's great that you're doing that. I've seen many of your patients who have other eye issues and they're all. Very happy and have fantastic results. So I'd like to thank you very much. All right today for for coming for this interview. You've shed a lot of light and information about. Thank you very much. It's a pleasure to be here. Yeah, and the retina.

And thank you in the audience for listening and watching this on Twitter. We're going to have some more doctor podcasts in the very near future. Although I start out with two ophthalmology subjects, I am moving on to other specialties such as gastroenterology. Cardiology and other specialties, so please stay tuned. Thank you.

In this episode