WEBVTT
00:00:03.200 --> 00:00:08.560
Welcome to ASRS's Journal of Vitrial Diseases Authors Forum.
00:00:08.720 --> 00:00:09.839
I'm your host, Dr.
00:00:09.919 --> 00:00:13.519
Timothy Murray, editor-in-chief of JVRD.
00:00:13.919 --> 00:00:28.800
On each episode of the JVRD Authors Forum, I will interview innovative retinal researchers on their studies featured only in JVRD and how these studies will impact our patients' care in our clinics.
00:00:29.120 --> 00:00:38.799
Tune in to hear directly from investigators about the clinical implications of the newest and highest quality research in the field of retina.
00:00:39.679 --> 00:00:43.759
Welcome to JVRD's Author Podcast.
00:00:44.000 --> 00:00:46.640
I'm pleased to be joined tonight by Dr.
00:00:46.799 --> 00:00:51.359
Alan Ruby, Associate Retinal Consultant of Royal Oak, Michigan.
00:00:51.600 --> 00:01:01.280
We're going to discuss his paper, Outer Retinal Optical Coherence Tomography Changes Associated with Interocular Silicone Oil Administration.
00:01:01.520 --> 00:01:02.320
Welcome, Dr.
00:01:02.399 --> 00:01:03.039
Ruby.
00:01:03.359 --> 00:01:03.840
Thank you, Dr.
00:01:04.000 --> 00:01:04.239
Marie.
00:01:04.400 --> 00:01:05.280
It's a pleasure to be here.
00:01:05.599 --> 00:01:13.680
So, you know, I think all of us have had these kind of concerns of silicone oil with visual compromise over time.
00:01:14.000 --> 00:01:18.319
And it's been hard to assess what that etiology has been.
00:01:21.439 --> 00:01:22.319
So it's interesting.
00:01:22.480 --> 00:01:32.719
I have historically always done OCT on my patients right prior to removing the silicone oil because luckily you can get a pretty good idea as to what the macula looks like.
00:01:33.040 --> 00:01:37.920
There's any edema or an epiretinal membrane that you may need to address at the time of the surgery.
00:01:38.159 --> 00:01:46.000
So as we started looking at these pre-operatively, we realized we were starting to see some changes in them that we could not readily explain.
00:01:46.159 --> 00:01:49.599
And the interesting thing was a lot of them post-operatively, the changes went away.
00:01:49.680 --> 00:01:52.079
So that was sort of the impetus for the study.
00:01:52.400 --> 00:01:54.719
And so I thought you did this in a nice way.
00:01:54.799 --> 00:01:59.359
You looked at macula on and macula off eyes, thinking that there's a potential difference.
00:01:59.599 --> 00:02:06.079
You evaluated them with OCT and you looked afterwards, followed pre-visual acuity and post-visual acuity.
00:02:06.239 --> 00:02:09.199
What do you think the main take-home points for this were?
00:02:09.840 --> 00:02:18.879
It's interesting because this is one of those times where the clinical findings, the OCT findings, and the final outcomes did not necessarily match.
00:02:19.120 --> 00:02:32.479
Because one would assume that if you saw OCT findings before the oil was removed that you thought maybe contributing to the decreased vision, that those changes in OCT would portray a poorer visual outcome.
00:02:32.719 --> 00:02:42.159
But instead, what we actually found is that the majority of these changes went away after the oil was removed that did not seem to impact the final visual acuities.
00:02:42.400 --> 00:02:49.919
Very, very different than a lot of things that we see in OCT that typically will predict what final visual acuity outcomes are.
00:02:50.080 --> 00:02:51.840
So we thought that was incredibly interesting.
00:02:51.919 --> 00:03:03.919
It really had not been reported before, if for no other reason than none of the other studies had looked at OCT pre-operatively with the oil in, and then subsequently when the oil was taken out.
00:03:04.560 --> 00:03:15.439
So one of the things that we've discussed is potential fluctuations of interocular pressure during oil placement or oil direct damage to the optic nerve.
00:03:16.319 --> 00:03:21.680
It didn't seem clear to me that those had any role in what you were looking at.
00:03:22.159 --> 00:03:35.360
No, and that was really interesting because if you look back at most of the other reports that have been shown to look at OCT post-operatively, a lot of them suggested that there was some type of change in the ganglion cell layer.
00:03:35.439 --> 00:03:37.120
And we at we just did not see that.
00:03:37.280 --> 00:03:43.039
Really, with the changes that we saw with the oil in the eye were more ellipsoid zone changes.
00:03:43.199 --> 00:03:53.360
And then subsequently, when the oil was removed, some of those ellipsoid changes actually got worse in the short run, but universally in the macula-on cases, they all went away.
00:03:53.520 --> 00:03:56.800
And the majority of the macula off cases, they also went away.
00:03:56.960 --> 00:04:10.560
So I think the take-home message here is that unless you're looking at OCT findings while the oil is in the eye to see what was there before the oil was taken out, it's almost impossible to try to explain what the decrease in vision was actually from.
00:04:10.639 --> 00:04:17.839
And I think that's the big take-home message is that especially looking at ganglion cell layer, there's a little bit of subjectivity.
00:04:18.000 --> 00:04:32.480
Obviously, you can measure it objectively, but it's very hard to say necessarily that that mild change in the thickness of the ganglion cell layer was consistent with the decreased vision, which we're saying was unexplained after the oil removal.
00:04:32.879 --> 00:04:43.120
And I think you made a really key point here, which is that we have great imaging technology, and it always surprises me when people don't use that in their post op patients.
00:04:43.279 --> 00:04:54.319
I'm kind of most interested in anatomical, you know, microscopic level imagery in my post-op patients to guide some of the treatments afterwards.
00:04:55.680 --> 00:05:02.959
Yeah, I 100% agree with you because I think there really is no great data on when to take oil out.
00:05:03.279 --> 00:05:10.319
You know, we have sort of historically relied on, oh, you should keep it in for three to six months, but there's really no real data to drive that.
00:05:10.399 --> 00:05:23.600
And with the advent of OCT, it really gives us the ability to look into the eye with the oil still in and see if there are any changes in the foveal region, which may suggest there's something going on that may have an impact on our outcome.
00:05:23.839 --> 00:05:37.439
So if we do see something there, we do see thickness or we see subfoveal lucencies, which we had seen on many of these OCTs, maybe that indicates we should be thinking about taking the oil out earlier in hopes to reverse those changes.
00:05:38.000 --> 00:05:42.879
But it didn't seem to be dependent on oil duration in your study.
00:05:43.199 --> 00:05:46.240
I mean, patients did really well regardless.
00:05:46.879 --> 00:05:47.439
They did.
00:05:47.680 --> 00:05:55.839
And again, you know, one of the shortcomings of the study is simply that there were many different surgeons who contributed patients.
00:05:56.079 --> 00:06:05.439
Therefore, we don't have a way of getting into the minds of these doctors as to whether or not when they saw these changes, did that in any way influence the timing of the removal?
00:06:05.600 --> 00:06:21.040
So while the OCTs could be looked at while the oil was in, we don't have a breakdown as to when the OCT findings were actually noticed when the oil was taken out and the subsequent change in resolution of those images and the difference that was seen on OCT.
00:06:21.120 --> 00:06:22.639
So you're 100% correct.
00:06:22.800 --> 00:06:24.480
The only thing we know is they all went away.
00:06:24.720 --> 00:06:24.879
Right.
00:06:25.120 --> 00:06:33.439
Which I love, but then some of your patients had a permanent decline in vision in the macula off group, even though the OCT findings resolved.
00:06:36.560 --> 00:06:45.199
Is that was the oil in any way contributory to that decrease in vision, or was it just contributed from the macula off status of the retina?
00:06:45.360 --> 00:06:57.199
Because one of the inclusion criteria was that once your macula was off, if you had a second surgery, at that time of the second surgery, the macula had to be attached at the time of the surgery to be included in this study group.
00:06:57.600 --> 00:07:05.759
So one one of the things I wondered about is that you had 13 patients over a period of eight years.
00:07:06.079 --> 00:07:08.879
So why was that number so small?
00:07:09.040 --> 00:07:11.040
Is it just the lack of imaging?
00:07:11.600 --> 00:07:12.720
Yeah, it really was.
00:07:12.879 --> 00:07:20.959
You know, we had uh 295 patients who had had oil during the surgery at the time of the initial detachment repair.
00:07:21.120 --> 00:07:33.279
So during those eight years, almost 300 patients who had had the procedure done, but because only a limited number of physicians do OCT imaging with the oil in, that limited the number.
00:07:33.360 --> 00:07:43.600
And the other thing was we eliminated any patient that had PVR stage C or D andor adjuvant therapies, including PFO or any stain.
00:07:43.759 --> 00:07:56.720
So, as we all know, the majority of the patients in most of our practices get oil for recurrent detachments with PVR, etc., or tractional detachments, more complicated procedures that usually indicate the need for oil.
00:07:56.879 --> 00:08:13.120
We deliberately excluded all of those to try to eliminate any confounding factors and looked only at those patients who had had primary oil for maculon detachment, all of whom had a vitreous hemorrhage or the MACOF detachments that we had talked about, none of whom had PVR.
00:08:13.839 --> 00:08:27.199
So I think really the biggest take-home for me, and it's something you and I do routinely already, is image your patients with or without oil on their follow-up visits to get a better idea of what's going on in the macula.
00:08:27.360 --> 00:08:29.439
I'm surprised that that's not a routine.
00:08:29.519 --> 00:08:31.120
Does that surprise you?
00:08:31.600 --> 00:08:40.240
It totally surprises me because we all have had those patients where we go in and take the oil out, and then there's a question in your mind: is there perisilicone proliferation?
00:08:40.320 --> 00:08:41.919
Is there an epiretinal membrane?
00:08:42.080 --> 00:08:43.039
Do I need to stain?
00:08:43.120 --> 00:08:44.080
Do I need to address it?
00:08:44.240 --> 00:08:53.279
And when you have the OCT pre-operatively, it really gives you a good image and it makes you much more able to plan for that surgery.
00:08:53.440 --> 00:09:04.799
In other words, you're not needlessly trying to remove something that you're seeing a reflection of intraoperatively, when in fact, on an OCT, you would have been able to see it was just a normal interface between the retina and the oil.
00:09:04.960 --> 00:09:06.639
So I 100% agree with you.
00:09:07.120 --> 00:09:15.519
So for me, when I see my post ops, silicone oil or not, I usually get white-field imaging and OCT as a routine.
00:09:15.679 --> 00:09:21.039
I kind of feel like in this day and age, that should be the minimum standard.
00:09:21.679 --> 00:09:23.279
Yeah, no, I completely agree with you.
00:09:23.360 --> 00:09:47.279
I just think that we miss a lot on our clinical exam and in the operating room that much clearer could be delineated pre-operatively and help us plan, either, as you said, with OCT, wide field imaging, because we all know a lot of these patients, the view intra-operatively can be compromised by the cornea, by the lens, or other variables that make your ability to take care of the pathology less than ideal.
00:09:47.440 --> 00:09:57.279
And I think having the pre-operative imaging where you're able to delineate that with OCT findings, et cetera, just makes planning better and I would suspect make the outcome better.
00:09:57.679 --> 00:09:57.919
Dr.
00:09:58.080 --> 00:09:59.519
Ruby, thanks for joining us.
00:09:59.600 --> 00:10:08.720
I think this was an excellent clinically relevant study that has potential to impact patient care across the board, both in and out of the U.S.
00:10:09.039 --> 00:10:10.399
Thanks for joining us.
00:10:10.639 --> 00:10:11.440
Thank you.
00:10:11.759 --> 00:10:15.759
Thanks for tuning in to the JVRD Authors Forum.
00:10:16.000 --> 00:10:27.360
You can watch and listen to more episodes on the ASRS YouTube channel and on popular podcast directories, including Apple Podcasts and Spotify.
00:10:28.000 --> 00:10:39.279
Visit www.asrs.org forward slash JVRD forum on the ASRS website to learn more.
00:10:39.600 --> 00:10:40.879
See you soon.
00:00:03.200 --> 00:00:08.560
Welcome to ASRS's Journal of Vitrial Diseases Authors Forum.
00:00:08.720 --> 00:00:09.839
I'm your host, Dr.
00:00:09.919 --> 00:00:13.519
Timothy Murray, editor-in-chief of JVRD.
00:00:13.919 --> 00:00:28.800
On each episode of the JVRD Authors Forum, I will interview innovative retinal researchers on their studies featured only in JVRD and how these studies will impact our patients' care in our clinics.
00:00:29.120 --> 00:00:38.799
Tune in to hear directly from investigators about the clinical implications of the newest and highest quality research in the field of retina.
00:00:39.679 --> 00:00:43.759
Welcome to JVRD's Author Podcast.
00:00:44.000 --> 00:00:46.640
I'm pleased to be joined tonight by Dr.
00:00:46.799 --> 00:00:51.359
Alan Ruby, Associate Retinal Consultant of Royal Oak, Michigan.
00:00:51.600 --> 00:01:01.280
We're going to discuss his paper, Outer Retinal Optical Coherence Tomography Changes Associated with Interocular Silicone Oil Administration.
00:01:01.520 --> 00:01:02.320
Welcome, Dr.
00:01:02.399 --> 00:01:03.039
Ruby.
00:01:03.359 --> 00:01:03.840
Thank you, Dr.
00:01:04.000 --> 00:01:04.239
Marie.
00:01:04.400 --> 00:01:05.280
It's a pleasure to be here.
00:01:05.599 --> 00:01:13.680
So, you know, I think all of us have had these kind of concerns of silicone oil with visual compromise over time.
00:01:14.000 --> 00:01:18.319
And it's been hard to assess what that etiology has been.
00:01:21.439 --> 00:01:22.319
So it's interesting.
00:01:22.480 --> 00:01:32.719
I have historically always done OCT on my patients right prior to removing the silicone oil because luckily you can get a pretty good idea as to what the macula looks like.
00:01:33.040 --> 00:01:37.920
There's any edema or an epiretinal membrane that you may need to address at the time of the surgery.
00:01:38.159 --> 00:01:46.000
So as we started looking at these pre-operatively, we realized we were starting to see some changes in them that we could not readily explain.
00:01:46.159 --> 00:01:49.599
And the interesting thing was a lot of them post-operatively, the changes went away.
00:01:49.680 --> 00:01:52.079
So that was sort of the impetus for the study.
00:01:52.400 --> 00:01:54.719
And so I thought you did this in a nice way.
00:01:54.799 --> 00:01:59.359
You looked at macula on and macula off eyes, thinking that there's a potential difference.
00:01:59.599 --> 00:02:06.079
You evaluated them with OCT and you looked afterwards, followed pre-visual acuity and post-visual acuity.
00:02:06.239 --> 00:02:09.199
What do you think the main take-home points for this were?
00:02:09.840 --> 00:02:18.879
It's interesting because this is one of those times where the clinical findings, the OCT findings, and the final outcomes did not necessarily match.
00:02:19.120 --> 00:02:32.479
Because one would assume that if you saw OCT findings before the oil was removed that you thought maybe contributing to the decreased vision, that those changes in OCT would portray a poorer visual outcome.
00:02:32.719 --> 00:02:42.159
But instead, what we actually found is that the majority of these changes went away after the oil was removed that did not seem to impact the final visual acuities.
00:02:42.400 --> 00:02:49.919
Very, very different than a lot of things that we see in OCT that typically will predict what final visual acuity outcomes are.
00:02:50.080 --> 00:02:51.840
So we thought that was incredibly interesting.
00:02:51.919 --> 00:03:03.919
It really had not been reported before, if for no other reason than none of the other studies had looked at OCT pre-operatively with the oil in, and then subsequently when the oil was taken out.
00:03:04.560 --> 00:03:15.439
So one of the things that we've discussed is potential fluctuations of interocular pressure during oil placement or oil direct damage to the optic nerve.
00:03:16.319 --> 00:03:21.680
It didn't seem clear to me that those had any role in what you were looking at.
00:03:22.159 --> 00:03:35.360
No, and that was really interesting because if you look back at most of the other reports that have been shown to look at OCT post-operatively, a lot of them suggested that there was some type of change in the ganglion cell layer.
00:03:35.439 --> 00:03:37.120
And we at we just did not see that.
00:03:37.280 --> 00:03:43.039
Really, with the changes that we saw with the oil in the eye were more ellipsoid zone changes.
00:03:43.199 --> 00:03:53.360
And then subsequently, when the oil was removed, some of those ellipsoid changes actually got worse in the short run, but universally in the macula-on cases, they all went away.
00:03:53.520 --> 00:03:56.800
And the majority of the macula off cases, they also went away.
00:03:56.960 --> 00:04:10.560
So I think the take-home message here is that unless you're looking at OCT findings while the oil is in the eye to see what was there before the oil was taken out, it's almost impossible to try to explain what the decrease in vision was actually from.
00:04:10.639 --> 00:04:17.839
And I think that's the big take-home message is that especially looking at ganglion cell layer, there's a little bit of subjectivity.
00:04:18.000 --> 00:04:32.480
Obviously, you can measure it objectively, but it's very hard to say necessarily that that mild change in the thickness of the ganglion cell layer was consistent with the decreased vision, which we're saying was unexplained after the oil removal.
00:04:32.879 --> 00:04:43.120
And I think you made a really key point here, which is that we have great imaging technology, and it always surprises me when people don't use that in their post op patients.
00:04:43.279 --> 00:04:54.319
I'm kind of most interested in anatomical, you know, microscopic level imagery in my post-op patients to guide some of the treatments afterwards.
00:04:55.680 --> 00:05:02.959
Yeah, I 100% agree with you because I think there really is no great data on when to take oil out.
00:05:03.279 --> 00:05:10.319
You know, we have sort of historically relied on, oh, you should keep it in for three to six months, but there's really no real data to drive that.
00:05:10.399 --> 00:05:23.600
And with the advent of OCT, it really gives us the ability to look into the eye with the oil still in and see if there are any changes in the foveal region, which may suggest there's something going on that may have an impact on our outcome.
00:05:23.839 --> 00:05:37.439
So if we do see something there, we do see thickness or we see subfoveal lucencies, which we had seen on many of these OCTs, maybe that indicates we should be thinking about taking the oil out earlier in hopes to reverse those changes.
00:05:38.000 --> 00:05:42.879
But it didn't seem to be dependent on oil duration in your study.
00:05:43.199 --> 00:05:46.240
I mean, patients did really well regardless.
00:05:46.879 --> 00:05:47.439
They did.
00:05:47.680 --> 00:05:55.839
And again, you know, one of the shortcomings of the study is simply that there were many different surgeons who contributed patients.
00:05:56.079 --> 00:06:05.439
Therefore, we don't have a way of getting into the minds of these doctors as to whether or not when they saw these changes, did that in any way influence the timing of the removal?
00:06:05.600 --> 00:06:21.040
So while the OCTs could be looked at while the oil was in, we don't have a breakdown as to when the OCT findings were actually noticed when the oil was taken out and the subsequent change in resolution of those images and the difference that was seen on OCT.
00:06:21.120 --> 00:06:22.639
So you're 100% correct.
00:06:22.800 --> 00:06:24.480
The only thing we know is they all went away.
00:06:24.720 --> 00:06:24.879
Right.
00:06:25.120 --> 00:06:33.439
Which I love, but then some of your patients had a permanent decline in vision in the macula off group, even though the OCT findings resolved.
00:06:36.560 --> 00:06:45.199
Is that was the oil in any way contributory to that decrease in vision, or was it just contributed from the macula off status of the retina?
00:06:45.360 --> 00:06:57.199
Because one of the inclusion criteria was that once your macula was off, if you had a second surgery, at that time of the second surgery, the macula had to be attached at the time of the surgery to be included in this study group.
00:06:57.600 --> 00:07:05.759
So one one of the things I wondered about is that you had 13 patients over a period of eight years.
00:07:06.079 --> 00:07:08.879
So why was that number so small?
00:07:09.040 --> 00:07:11.040
Is it just the lack of imaging?
00:07:11.600 --> 00:07:12.720
Yeah, it really was.
00:07:12.879 --> 00:07:20.959
You know, we had uh 295 patients who had had oil during the surgery at the time of the initial detachment repair.
00:07:21.120 --> 00:07:33.279
So during those eight years, almost 300 patients who had had the procedure done, but because only a limited number of physicians do OCT imaging with the oil in, that limited the number.
00:07:33.360 --> 00:07:43.600
And the other thing was we eliminated any patient that had PVR stage C or D andor adjuvant therapies, including PFO or any stain.
00:07:43.759 --> 00:07:56.720
So, as we all know, the majority of the patients in most of our practices get oil for recurrent detachments with PVR, etc., or tractional detachments, more complicated procedures that usually indicate the need for oil.
00:07:56.879 --> 00:08:13.120
We deliberately excluded all of those to try to eliminate any confounding factors and looked only at those patients who had had primary oil for maculon detachment, all of whom had a vitreous hemorrhage or the MACOF detachments that we had talked about, none of whom had PVR.
00:08:13.839 --> 00:08:27.199
So I think really the biggest take-home for me, and it's something you and I do routinely already, is image your patients with or without oil on their follow-up visits to get a better idea of what's going on in the macula.
00:08:27.360 --> 00:08:29.439
I'm surprised that that's not a routine.
00:08:29.519 --> 00:08:31.120
Does that surprise you?
00:08:31.600 --> 00:08:40.240
It totally surprises me because we all have had those patients where we go in and take the oil out, and then there's a question in your mind: is there perisilicone proliferation?
00:08:40.320 --> 00:08:41.919
Is there an epiretinal membrane?
00:08:42.080 --> 00:08:43.039
Do I need to stain?
00:08:43.120 --> 00:08:44.080
Do I need to address it?
00:08:44.240 --> 00:08:53.279
And when you have the OCT pre-operatively, it really gives you a good image and it makes you much more able to plan for that surgery.
00:08:53.440 --> 00:09:04.799
In other words, you're not needlessly trying to remove something that you're seeing a reflection of intraoperatively, when in fact, on an OCT, you would have been able to see it was just a normal interface between the retina and the oil.
00:09:04.960 --> 00:09:06.639
So I 100% agree with you.
00:09:07.120 --> 00:09:15.519
So for me, when I see my post ops, silicone oil or not, I usually get white-field imaging and OCT as a routine.
00:09:15.679 --> 00:09:21.039
I kind of feel like in this day and age, that should be the minimum standard.
00:09:21.679 --> 00:09:23.279
Yeah, no, I completely agree with you.
00:09:23.360 --> 00:09:47.279
I just think that we miss a lot on our clinical exam and in the operating room that much clearer could be delineated pre-operatively and help us plan, either, as you said, with OCT, wide field imaging, because we all know a lot of these patients, the view intra-operatively can be compromised by the cornea, by the lens, or other variables that make your ability to take care of the pathology less than ideal.
00:09:47.440 --> 00:09:57.279
And I think having the pre-operative imaging where you're able to delineate that with OCT findings, et cetera, just makes planning better and I would suspect make the outcome better.
00:09:57.679 --> 00:09:57.919
Dr.
00:09:58.080 --> 00:09:59.519
Ruby, thanks for joining us.
00:09:59.600 --> 00:10:08.720
I think this was an excellent clinically relevant study that has potential to impact patient care across the board, both in and out of the U.S.
00:10:09.039 --> 00:10:10.399
Thanks for joining us.
00:10:10.639 --> 00:10:11.440
Thank you.
00:10:11.759 --> 00:10:15.759
Thanks for tuning in to the JVRD Authors Forum.
00:10:16.000 --> 00:10:27.360
You can watch and listen to more episodes on the ASRS YouTube channel and on popular podcast directories, including Apple Podcasts and Spotify.
00:10:28.000 --> 00:10:39.279
Visit www.asrs.org forward slash JVRD forum on the ASRS website to learn more.
00:10:39.600 --> 00:10:40.879
See you soon.
