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Dr. Chynn bicycle riding for a good cause

Dr. Chynn was a part of Benz Lisbon bicycle event. Watch the video below for more information.

LASEK Testimonials

LASEK is the most advanced version of laser vision correction that is possible with modern medicine today. LASIK is 10x as risky, reduces the structural integrity of your eyes, can worsen glares, halos, and dry eyes, may not get you to your best vision possible. There are also issues of flap complications before and after surgery that may cause a LASIK patient to have poor vision or even go blind after treatment.

Read patient testimonials here.

The power of CXL + PRK

James wrote to Dr. Chynn (dr. Chynn’s answers are bold):

Emil,

What brands and doses do you use for the topical and oral NSAIDs and the topical and oral steroids?

The brand of oral NSAID matters not. It’s just for pain relief BC systemic anti-inflammatory. Use generic ibuprofen 800 mg w every meal to prevent GI upset for 5 days postop

I use a Medrol DosePak postop BC it’s EZ for pts to follow the taper. But when it was unavailable we just used a generic pill w the same approx dose n it worked fine. Also helps prevent pain again BC it’s anti inflammatory

I previously posted a list of NSAIDs. Voltaren regresses best. Nevanac doesn’t work at all. I’ve tried all. Could post a list in order of efficacy but can’t tolerate James then asking me to prove it w a 10-armed placebo-controlled trial?

Do you also prescribe Vitamin C?

Yes. I’ve said this before. For extreme myope a past -9 it’s very important in sunny climes to use 1000mg Vit C for 9 months n UV protect w good shades for the same amt of time or you’ll risk scarring!

Thanks.

You’re very welcome Jim. Glad to share my experience w you and the group. Let me/us know if the NSAID regression also works for your PRKs. But don’t publish that ahead of me ok?!?;)

Jim

ASA Retreat

Dear David et al

Sorry for my delay in responding. I’m visiting my girlfriend’s family in a rural part of Bulgaria wo internet – can you believe that?;)

It’s important to always search very carefully for the cause of over and under-corrections, or you won’t really get at the root problem, and might then just be trying to shoot for plano, wo any real understanding of what went wrong

I don’t even let my fellows present cases for enhancement until they can convince me why the over or under correction occurred

An exhaustive breakdown here would take hours and more properly be the basis for a chapter in a book about refractive surgery. Briefly outlined the possible causes are as follows:

1. Not properly taking into account standard regression with your nomogram (which should slightly overcorrect all myopes and more overcorrect all hyperopes bc they regress more). Regression happens early, so you can figure this out by examining the early postop notes for early refractive status

2. Not properly accounting for myopic progression given age in myopes less than 30 yrs old. I just posted on this extensively a week ago so won’t repost. Did want to ask fellow keranauts if and how they’re accounting for this huge factor themselves?

3. Undershoot in retrospect. Choosing a too low number. Sometimes associated w errors like not adjusting CL power upwards properly to be in the spectacle/laser plane. Much more common in hyperopes bc ignored wet MR/AR which revealed the true full plus Rx!!!

4. Overshoot. Often caused by over minusing young myopes in the refraction by not telling them to not choose smaller than darker, not allowing them to say “the same”, not red/greening them, not making them “earn” the next -.25 by actually proving it makes them see better by going down 1 line on the chart, not performing (I think this wild be legally negligent) or ignoring the wet MR/AR. Also not telling them to look far away in the AR and WaveScan to prevent accommodation!

90% of my fellows can’t properly manifest patients and over minus 90% of young myopes. Admittedly, by the time I properly don’t over-minus them, then add minus to account for progression, we are often at a similar number. This is probably why the general ophthalmologist actually gets good long term results in younger myopes!;) But being the stickler I am, especially as a fellowship preceptor, I insist on getting to the right answer the right way!

5. Scarring or haze causing undercorrections

6. A fellow improperly panicking when seeing an Overcorrected Hyperope in the early postop period, switching from steroids to NSAIDs instead of just waiting for regression, and causing an undercorrection (this is another example of a “trial” Jim). Fortunately this only rarely happens

7. Under/over responders. Right #/wrong result. Lazy people ignore the work necessary to eliminate 1-6 above and lump everyone in this category:( These are just people who don’t regress “properly” according to the meaty part of the bell curve we incorporate into our Nomograms. They either under or over hyperplase their epithelium compared to normals. Then you MUST ADJUST YOUR NOMOGRAM the 2nd time to account for this or you’ll bounce around and never hit Plano!!! Because if they underheal/underhyperplase/overrespond the first time, they’ll do so after enhancement too!

8. Unknown. This is the worst category, and freaks me out, since then I have no logical reason to be confident my enhancement will work out. I refer these cases (1% at most) for second opinions. Half of the time someone smarter than me like Eric Donnenfeld and other super-experts who unfortunately don’t have much time to post on knet will figure out a zebra (like not fully covering the ablated cornea w a sponge containing MMC and causing a ring scar in a myope not a hyperope)

But in summary since it’s not your case and you can’t get all the records, I agree with Ronal’s advice (and thanks for the attribution Ronal):

Why not try Voltaren QID x 1-3 months? Although this technique is more effective in the early postop period, since you’re trying to promote normal regression/epithelial hyperplasia

Hope this helps?

PS I’m ccing my fellows so pls save this in the sever under the name “Analysis Before Enhancements” in the folder “Non-OR Protocols” and don’t forget to go over TWO protocols w each other and me EVERY th and Friday!!!;)

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

1st eye surgeon in NY to get LASIK himself (1999)

Performed 5,000 LASIKs from 1996-2002

Switched to non-invasive LASEK in 2003

Have performed more LASEKs than any MD in US

Research Methods Rigor

Minas, Clive, et al

First of all, I’d like to congratulate Minas on finding an article I had published in Arch Ophth over 20 years ago, that I myself had forgotten about. It does speak to the point that I’ve both performed “real hard” research myself (eg as a PI for the FDA trial for the first solid-state excimer laser), had training that was heavily biased towards a career in academic medicine, and was in academics for a few years before I left because I couldn’t hack the “politics” involved (you may have noticed my abhorrence for “political correctness”) as well as the lack of support and unreasonable constraints (eg on advertising) on me creating a strong refractive practice–back in the days where refractive surgery was not considered a “real” subspecialty (sadly still the case to some extent today)

To be clear, I’m not “against” performing hard studies, as my background and publications should make clear. I just would like to speak out against the mindset (as I have several times on this forum) that controlled trials in peer-reviewed publications are “real” and everything else is anecdotal BS

This attitude is both wrong and unnecessarily restrictive. With this attitude, all scientific research until 1950 would have to be considered “fake”, and if this “rule” had existed back then, it would mean that nothing would be discoverable–not penicillin, not any advance in any surgical technique, nor any new medication.

There are many ways to seek out truth besides a controlled clinical trial. Think about Einstein’s great “thought experiments.” He didn’t happen to have billions of dollars, plus a time machine that would enable him to build a cyclotron. What he did have was the intellectual capacity to build thought experiments, that when gone through, would yield results that were both insightful and valid in their own way (and show the path towards later “hard” research)

Think about all the problems our profession has had with the best drugs to use before, during, and after cataract surgery, and even the best way to prep before surgery. Since many of the adverse outcomes are very rare (eg endophthalmitis), we cannot enroll enough patients to have an n that is powerful enough to assess outcomes rigorously. So then we are left with secondary metrics, like measuring bacterial loads as a metric after x antibiotic schedule preop and/or y prepping schedule. Please recall that most of the antibiotics we use for surgical prophylaxis were never actually approved by FDA (or rigorously studied) for that purpose, but for some “easy/cheap to study purpose” like bacterial conjunctivitis.

Regarding some members telling other members to “stop this avenue of discussion” I think that is quite presumptuous of them. I had to tolerate about 30 emails over 10 days several months ago about what to do to prevent one’s fingertips from bleeding after guitar playing, which had zero to do with ophthalmology. I’m sure there are some people who thought there were too many joking emails about the use of sunglasses indoors (although I found that thread quite funny). Shouldn’t we agree that only the moderator (MM) has the right to tell others to cut it out (ie to end threads that seem to be useless or taking on a non-collegial tone?

While on that topic, I would like to point out that some members have occasionally resorted to ad hominem arguments to “win” their point, or to “silence” another member with whom they disagree. This is really one of the lowest common denominators of debate, and anti-intellectual. Having someone unfairly malign me by saying basically, “Now we all know whom to refer pregnant women to if they want LASIK so he can perform more procedures” combined with the basic message of “please shut up” is not in the spirit of “free discourse” that Keranet was founded, and should really not be tolerated.

Finally, I have been contacted by several knet readers (who wish to remain anonymous) that the reason they do not actively participate and reply to posts is that they are afraid of being attacked by a few frequent posters who they feel act like a kind of “Knet mafia” (their words, not mine). By this, they mean that a handful of posters seem to feel that, because of their seniority in ophthalmology or this group, that their views should not be “overly challenged.” I have felt this myself, which is really bad, because I, myself am one of those senior members (having joined within the first few years of Knet’s founding). So I am just putting this out there, as is my wont, to open up this avenue of discussion. Please understand that I am one of the least “politically correct” eye MDs you will meet, and remember that I sometimes wish to act as a provocateur to spur discussion/thought — so try not to get “offended” or become “defensive” (I was also born in Manhattan, so sometimes my natural language is blunt and challenging and profane;))

On a parting note, while it’s nice to celebrate 1,000 participants on Knet, let’s all acknowledge that of these 1k members, about 900 ONLY read and NEVER post, another 50 rarely post, another 25 sometimes post, and ONLY ABOUT 20 MDs and 5 ODs frequently post. If we can all name 10 doctors who post 80% of all content, certainly that tells you something. Not ALL of the 900 who NEVER post are only “too busy” or “not motivated enough.” Again, I know a handful who have told me that they are too intimidated to post–which is really a very bad thing.

So if we can all agree (which I think we can) that having more members actively participate and post instead of just reading is a good thing, as it adds more diversity of opinion, then the question becomes: “What can we do to improve the experience so more members participate?”

I would like to end by posting the following questions:

1. What can we do to make it easier/more inviting/less intimidating for members to participate?

2. What can we do to form a hard code of ethics to prevent uncivil exchanges? MM is a GREAT moderator, but I’m sure everyone would agree it would be even better if we could monitor ourselves better, which would seem to necessitate some actual rules (eg, no ad hominem attacks, only the real MM saying when to close off a topic, having a maximum number of replies to a thread (?10?) that has nothing to do with eye stuff)

To tell you the truth, I was going to go back into “silent” (read only) mode a few times over the past year, when I felt that it was not worth my time to “share” while feeling attacked, but a few other members contacted me privately to say they wanted me to stay, as they thought worthwhile my: a) contributions re ASA, b) function to “stir the pot” and c) ability to “stand up to the powers that be” (again their terms, not mine). Of course, I know of at least 2 others who would love to see me leave, and have told me privately where to go;)

In summary, I have learned a LOT on Knet, but could clearly have a more positive ROI on my time if I only read most of the time, and rarely posted. Everyone who frequently posts is really doing so not just to spout out, prove how smart they are, and burnish their reputation, but because they really care about education, and are trying to share their expertise. It would just be preferable if these people (myself included) could do so in a way that was slightly less “bossy” and intimidating, and slightly more civil, so as not to discourage others from posting, and certainly not trying to silence those who do choose to post.

Let’s see what your response to this thread is–I’m eagerly awaiting the replies:)

Yours respectfully,

Emil “Dr LASEK” (like on my vanity plate) Chynn;)

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

1st eye surgeon in NY to get LASIK himself (1999)

Performed 5,000 LASIKs from 1996-2002

Switched to non-invasive LASEK in 2003

Have performed more LASEKs than any MD in US

Nursing and LASIK

Q:

I think a lot of this can be simply answered by asking ourselves the following question:

If your wife/sister/daughter were pregnant and wanted refractive surgery, would any of us do it? Or wait till post delivery and post nursing?

No need for further studies, IMHO.

Kamran

A by Emil W. Chynn MD:

Kamran

While your question is certainly valid if the question is would you recommend getting refractive surgery during pregnancy or waiting until afterwards (I don’t think any of us would say we wouldn’t make the patient wait until afterwards)

Another question is much more valid if the question is about the true medical safety of refractive surgery on the fetus (not “theoretical/liability” concerns), and if pregnancy actually commonly causes refractive changes:

If we performed refractive surgery on a female loved one, and a week out she found out she was pregnant, would any of us be really concerned, or would we just plug, Punctal occlude, minimize drops, and tell her “don’t worry, I’m not worried, because there’s a 99.9% chance that your laser regime won’t affect your pregnancy, and a 99.9% chance that your pregnancy won’t have ANY SHORT OR LONG TERM EFFECT ON YOUR REFRACTIVE RESULT”

That’s what I (and I think most eye MDs) would say

Emil William Chynn, MD, FACS, MBA

Harvard/Columbia/Dartmouth/NYU/Emory-trained

1st eye surgeon in NY to get LASIK himself (1999)

Performed 5,000 LASIKs from 1996-2002

Switched to non-invasive LASEK in 2003

Have performed more LASEKs than any MD in US

Dr. Elghobaier, former fellow

Working with Dr. Chynn as a refractive fellow at PAL is a great experience I will never forget. It’s very hard to summarise all what I gained in such few words. At PAL all staff are multifunction, well trained and continuously educated. Any mistake is analysed in front of all so nothing there is kept for chance.

As a doctor I learned a lot of paramedical and nonmedical stuff such as marketing, administration, dealing with hightech software and hardware and doing simple maintainance of medical machines. One will never find all of this at any other private practice. So I think PAL is the best center to learn any fellow how to manage a private practice in USA particularly Dr. Chynn has no work secrets in front of his fellows and every thing is a subject of extended discussion.Away from working hours, Dr. Chynn is not that kind of stiff managers but he is a very nice guy. He is a real New Yorker. He told me about many things in the big city. I still remember our walking from his home to the practice with his nice dog Rhett , we made ice balls and used high trees as targets . He won by the way.

Dr. Mohamed Gamal Elghobaier, medical director of Oyoun Masr Center for Refractive and ophthalmic surgeries, Sohag, Egypt

A doctor had post-LASIK complications, here is Dr. Chynn’s answer

Q:

I would be most thankful if you could give me your precious input in this case. The 35 yo patient had a LASIK in both eyes 8 months ago, in her 1st post op day, she had both eyes dislocated flaps and epithelial ingrowth after that.

However, the bilateral weird lesions were found in addition to the epithelial ingrowth. There is no eye inflamation, no complaints at all, no soreness and even the V/A is 6/5 with prescription. Is this an infections crystalline keratopathy (ICK)?There is an indolent course and in stereoscopic view, looks like a cyst under the flaps with some cristal like shape material inside.Please, find the picture from both eyes attached. I look forward to receiving your opinion!Thank you.A by Emil Chynn, MD:

i would do this myself:

1. lift up flap very atraumatically2. scrape very aggressively, both the bed and undersurface of the flap, need a lot of pressure or won’t remove the tissue3. when you scrape the underside of the flap it helps to put something underneath or the flap will slide around and you will unintentionally debride all the epithelium which would again predispose to epi ingrowth4. apply alcohol afterwards to kill off the many epi cells you aren’t going to be able to scrape off5. may need to apply hypotonic saline to swell up the flap as a good scraping takes several minutes, during which time the flap dehydrates, and if that happens too much you’ll get a mismatch between flap and bed, which would again predispose to epi ingrowth. an additional benefit is the hypotonic saline will remove any striae that might be present (which is common)6. stretch flap out so you don’t have flap/bed size mismatch7. put in sutures where the epi ingrowth was, don’t tie too tight or will induce a lot of astigmatism, but tight enough that it secures the edge to prevent recurrance, what i like to do is tie them a bit tight to induce a tiny bit of cyl, which then mostly goes away when you later cut the sutures, i usually use interrrupted bc that is a LOT easier than running, but i have seen excellent and possibly more astimatically-neutral running sutures by surgeons who might be more dextrous than myself;)and, my final plug for my sub-sub-specialty:EPITHELIAL INGROWTH IS IMPOSSIBLE AFTER LASEK!:)hope this helps and good luck

Dr. Chynn on SMILE procedure

A college of Dr. Chynn inquired about the new SMILE ReLEX procedure

Q:

I have a friend in London with myopia (-1.75 & -2.75, Aet ~ 40 & female) considering refractive surgery.

Is it time for SMILE (1,2) or if it were your family member would you do LASIK … or PRK?

Any recommendations re surgeon – please contact me directly.Is there really less dry eye (3)?

A by Emil Chynn, MD:

My humble yet informed opinion as the 1st eye MD in NYC to get LASIK and having switched from incisional to non incisional surgery years ago:

at such a low rx, she should have LASEK, as there is 0 risk of making her see worse in well-trained hands, and there is no need to cut a flap for such a low Rx, and her chance of haze at such a low Rx is also 0, and she will heal quickly if it is a true LASEK not a PRK (defined as en bloc removal of epithelium, not whether you put it back or not, i suggest not after 20,000 surface ablations), and he chance of dry eyes or night glare will be lower than after any incisional surgery, and i don’t know why smile is all the rage except for marketing, having seen many and done 1 while in europe last year, and you cannot treat HOA or even cyl very well with smile, so isn’t it really a glorified ALK?

Commenting on an article by another doctor

Q:

Gurus

I have been asked to defend the ophthalmic surgeons request to use multidose eye drops for dilating patients in pre op prior to ophthalmic surgery

Our pharmacy and risk management leaders are against this despite the recent and seemingly never ending shortage and high cost of single use dropsPlease see article enclosed

What are your thoughts ?

Is there such an overwhelming risk by using mydriacyl phenylephrine and cyclogyl in a standard 5 ml bottle used just for the one day ?Meeting is at 6 tomorrow morning

Many thanks

A by Dr. Emil W. Chynn:

It’s a bad paper for many reasons:

The eye and skin aren’t sterile

The bugs they grew out are normal flora

You put the drops in before prepping

They failed to show any transmission

They failed to show any disease causation

In 90% of countries they use multi dose drops preop wo problems. Usually over many days

So using multi dose within a day then discarding is perfectly reasonable n logical

 

 

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