Individualizing the Surgical Consultation Without Sacrificing Efficiency

George O. Waring IV, MD FACS; and Alexandra Dean

Eyetube

What does it take to make every surgical consultation feel individualized amid increasing pressure for efficiency? George O. Waring IV, MD, speaks with Alexandra Dean, Director of Practice Development at Waring Vision Institute, about building a counseling continuum that starts before the patient arrives and uses intake forms, previsit outreach, and cohesive handoffs to connect clinical recommendations with individual goals. Dean also shares practical guidance on training nonclinical counselors, using technology without losing the human touch, and creating an experience patients remember for how it made them feel. Related article: “Individualization at Every Touchpoint,” in Cataract & Refractive Surgery Today, June 2026

Enigmatically Ultrathin, Steep Corneas

Surgeons consider how to manage this pediatric patient.

Suphi Taneri, MD, PhD, FEBOS-CR; Claus Cursiefen, FEBO, FARVO; Farhad Hafezi, MD, PhD, FARVO; George Kymionis, MD, PhD

Cataract and Refractive Surgery Today

Can OCTA Help Predict DR Progression?

Quantitative biomarkers may add a new dimension to the assessment and risk stratification of diabetic retinopathy.

Kallista Zhuang, BA; Shinji Kakihara, MD, PhD; and Amani A. Fawzi, MD

Retina Today

KEY TAKEAWAYS Geometric perfusion deficit (GPD) on OCT angiography (OCTA) defines nonperfused retinal tissue based on the distance threshold from the nearest perfused capillary. In a prospective study, GPD in the deep capillary plexus was the only OCTA metric to detect significant microvascular changes in eyes with referable diabetic retinopathy (DR) at 6 months, ahead of other metrics that became significant only at 12 months. Higher baseline deep capillary plexus GPD predicted earlier onset of DR complications. OCTA-derived GPD-deep capillary plexus may complement conventional DR grading. The current staging framework for diabetic retinopathy (DR) triages patients to broad severity categories; however, within a given severity category, the framework does not necessarily identify eyes with greater risk of progression to vision-threatening complications.1,2 Retinal ischemia is central to DR pathophysiology, with ischemic burden being an important key in defining risk of progression in diabetic eyes.3 Classically, ultra-widefield fluorescein angiography (UWF-FA) is used to document the extent of retinal nonperfusion, but this dye-based tool does not lend itself to routine or frequent imaging.1,4 In contrast, OCT angiography (OCTA) enables noninvasive, depth-resolved quantification of retinal capillary perfusion at the microvascular level, without impedance related to dye or leakage artifacts. Although OCTA images may capture only a portion of the total retinal area accessible to UWF-FA, the technology is rapidly evolving in speed and precision, allowing clinicians to image wider areas of the retina. Furthermore, emerging evidence suggests that OCTA biomarkers may complement conventional DR staging in terms of the retinal ischemic burden.5 QUANTIFYING ISCHEMIA WITH OCTA OCTA has the advantage of enabling layer-specific evaluation of retinal capillary perfusion. Its depth-resolved capability is particularly relevant, as diabetic capillary damage may not occur uniformly across retinal layers.6 Quantitative metrics of OCTA-based capillary perfusion have emerged as a useful approach to characterize diabetic retinal ischemia.7,8 One such metric is geometric perfusion deficit (GPD), which defines the proportion of ischemic retinal tissue farther than 30 µm from the nearest perfused capillary (Figure 1), or the theoretical oxygen diffusion limit (excluding the physiologic foveal avascular zone).9,10 By using this threshold-based approach at the different retinal capillary plexuses, GPD provides a physiologically grounded estimate of layer-specific ischemic burden. Cross-sectional studies from our group have shown that GPD in the deep capillary plexus (GPD-DCP) captures clinically meaningful ischemic burden in DR. Among several OCTA-derived metrics, GPD-DCP provided the strongest discrimination of referable DR.11 It also has been associated with vision function, where greater perfusion deficits correlated with worse BCVA, even after accounting for other clinical and ischemic parameters.12 Importantly, macular GPD-DCP may also provide information about ischemic burden beyond the macula.