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Main Topics and Key Points:
1. Difficulties and Value of Scientific Publishing in Latin America:
- Dr. David and the interviewer highlight the challenges of publishing research in Latin America, including bureaucratic hurdles in government institutions and the costs associated with open access journals.
- Appointment: Dr. David's father told him: "Publishing in Latin America is twice as difficult because it is twice as difficult.«.
- Despite these difficulties, Dr. David emphasizes the value of publishing, not only to share knowledge, but also as an example to follow and to promote scientific advancement in the region.
2. Eyesite Academy: Sharing Practical Knowledge in Ophthalmology:
- Dr. David describes the Eyesite Academy as a project that seeks to share practical knowledge and advice ("on a par with apples") with young ophthalmologists and fellows, bridging the gap between textbook theory and the real-life challenges of surgical practice.
- The aim is to go beyond the "recital" of books, offering practical guides on specific procedures, such as the placement of intravitreal gas or the management of intraoperative complications.
- Appointment: "The intention of starting this project was really to share what one is learning in practice, that is, literally, and to explain it to those who are just starting out."
- The project aims to grow with the collaboration of other professionals to create a practical manual accompanied by images and videos, covering various areas of ophthalmology.
- The difficulty of maintaining the project individually is recognized, and an invitation is extended to others to collaborate.
3. The Importance of Feedback and Evolution in Medical Communication:
- Dr. David reflects on the importance of recording and listening to himself to improve his communication of medical concepts, noting a positive evolution in his confidence and self-expression since his first videos.
- It highlights how practicing these types of formats allows us to break out of the "comfort zone" of traditional medical communication, which is often perceived as overly serious and protocol-based.
- Being open to constructive criticism is considered essential for professional growth and continuous improvement.
4. Breaking Patterns and Re-evaluating Medical Practices:
- The need to question established practices and consider evidence-based alternatives, even if they are not the norm, is discussed.
- Appointment: "There are times when you have to break the mold, and sometimes by breaking the mold you find things that were written, but what you mention or more or less what you want to talk about becomes obsolete."
- Dr. David presents his article as an example of how a less invasive, non-traditional technique (pneumatic vitreolysis) can be a valid option in selected cases of macular hole.
- This idea is related to the current trend toward minimally invasive surgery in other areas, such as glaucoma.
5. Pneumatic Vitreolysis for the Treatment of Macular Hole:
- Dr. David presents his article on pneumatic vitreolysis as an alternative to pars plana vitrectomy with internal limiting membrane peeling and long-acting gas tamponade, the standard treatment for macular hole.
- Pneumatic vitreolysis is based on the idea of releasing vitreomacular traction, the main cause of many macular holes, by injecting intravitreal gas.
- Studies from 1995 onwards are mentioned that reported the closure of small macular holes with vitreomacular traction using this technique.
- Dr. David shares three clinical cases from his private practice:
- Case A: Recent macular hole with vitreomacular traction that closed successfully with pneumatic vitreolysis, achieving excellent visual recovery (20/25) and complete anatomical restoration of the retina.
- Case B: More chronic macular hole without evident vitreomacular traction that did not respond to pneumatic vitreolysis, but had a good anatomical and visual result (20/30) after subsequent vitrectomy with membrane peel.
- A third case (not detailed in the briefing but mentioned in the discussion) of a macular hole with traction that also closed with pneumatic vitreolysis.
- The importance of proper patient selection is emphasized, with those with medium-sized macular holes and active vitreomacular traction, without peripheral retinal lesions, being more likely to achieve success.
- The head-down position for the first week is considered crucial for the success of pneumatic vitreolysis.
- The technique of gas injection and paracentesis is discussed, sharing Dr. David's personal preference for injecting the gas first and performing the paracentesis afterward to avoid anterior chamber collapse in eyes with low pressure.
- The fear of complications such as gas-associated rhegmatogenous retinal detachment is addressed, arguing that with good patient selection and close monitoring, the risk is low.
6. Considerations in Pseudophakic Patients:
- The question arises about the application of pneumatic vitreolysis in pseudophakic patients, recognizing the greater theoretical risk of retinal detachment due to decreased vitreous adhesion.
- Although Dr. David has not treated cases of macular hole with pneumatic vitreolysis in pseudophakic patients, he believes it could be attempted if there is no complete posterior vitreous detachment and peripheral traction is not significant, always informing the patient thoroughly about the risks and benefits.
7. Importance of Honesty and Shared Decision-Making with the Patient:
- The ethical imperative to fully inform patients about the various treatment options, including non-traditional alternatives, their success rates, and potential risks is emphasized.
- The final decision should be made by the patient, respecting their preference even if they opt for standard treatment.
- In the case of pneumatic vitreolysis, it is crucial to explain that if it does not work, the probability of success of subsequent surgery remains similar to if it had been performed from the beginning.
Conclusions:
Dr. David's podcast episode and article highlight the importance of perseverance in research and scientific publication in Latin America, the need to share practical knowledge among healthcare professionals, and the validity of exploring therapeutic alternatives based on evidence and clinical experience. Pneumatic vitreolysis is presented as a potentially beneficial and less invasive option for the treatment of macular holes in carefully selected patients, emphasizing the need for an open and honest discussion with the patient about the risks and benefits of each approach. The Eyesite Academy project stands as a valuable initiative to democratize practical knowledge in ophthalmology and foster collaboration among colleagues.
Next Steps/Points to Consider:
- Stay tuned for the full open-access publication of Dr. David's article for a more in-depth analysis of the methodology and results.
- Please consider Dr. David's invitation to collaborate with Eyesite Academy for those interested in sharing their knowledge and experience.
- Reflect on your own clinical practices and be open to considering evidence-based alternatives, always prioritizing patient well-being.
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