RetinaLink’s Following the Fellows highlights Yasha Modi, MD, who is a second year Vitreoretinal Fellow at Cleveland Clinic, Cole Eye Institute, in Cleveland, Ohio.
Dr. Modi’s Attending, Dr. Aleksandra Rachitskaya, said “Dr. Yasha Modi is an outstanding vitreoretinal fellow. His knowledge of all things retina is impressive and he always stays abreast new developments. His enthusiasm about complex medical and surgical cases is contagious and he has proven himself to be a superb teacher to his junior colleagues. I look forward to seeing Dr. Modi succeed in his career as a vitreoretinal specialist and to his contributions to the field of retina.”
Where did you go to Medical school?
Y. MODI, MD: I attended Yale School of Medicine in New Haven, Connecticut.
Why did you choose Retina versus another subspecialty?
Y. MODI, MD: I thought it was a field where my intellectual curiosity best aligned with my clinical and surgical interests. Since medical school, I have been in awe of the rapid evolution of diagnostic imaging modalities employed within retina to evaluate disease and the targeted pharmacotherapy that has revolutionized treatment. Additionally, the field comes with several “unknowns” that reassured me that I would never be bored or complacent as a retina specialist. What sealed the deal for me was watching my first macular hole surgery as a resident and then seeing the closed hole under gas (via OCT) on the first postoperative day. I knew at the moment, that vitreoretinal surgery would be a whole lot of fun. I haven’t been disappointed since.
What was the biggest surprise in your first year of Fellowship?
Y. MODI, MD: There were no major surprises in the transition between residency and fellowship. However, the largest adjustment required was managing the increased clinical volume of fellowship. This required a swift recalibration in the efficiency in which I evaluated patients, while working diligently to not compromise quality of care.
What’s your favorite small gauge platform? And why?
Y. MODI, MD: I have been fortunate to try 23-, 25-, and 27-gauge platforms in my fellowship and my favorite platform is currently 25-gauge vitrectomy. This platform, in my hands, yields a fantastic compromise of minimizing sphere of influence while not compromising efficiency or maneuverability within the eye. Additionally, for complex diabetic cases including posterior hyaloid traction with dense plaques and tractional detachments, using the 25-gauge vitrector as a horizontal or vertical scissors has simplified some of the more challenging maneuvers I have encountered.
I suspect that as I become more facile as a surgeon and instrumentation improves, I will migrate to 27-gauge vitrectomy on a more regular basis.
What is your favorite hand-held instrument and why?
Y. MODI, MD: When I started “pinch-and-peeling” for macular cases with an end-gripping ILM forceps, my attending, Dr. Peter Kaiser, asked me “Why don’t you pinch and pray instead?” He was referencing the fact that the angle in which I was grasping the tissue precluded visualization of the ILM upon closing the forceps. Since then, I have switched to the 25-gauge Tano Asymmetric forceps (currently my favorite instrument), which allows for direct visualization of the tissue being grabbed both in the open and closed configuration. I have started using this forceps also for PVR cases and have not been disappointed.
Is that different than what your Attending Physicians use during surgery?
Y. MODI, MD: The majority of my mentors use the end-grasping forceps. Two Attendings, however, use the Asymmetric forceps, and it was in their OR that I first realized the advantages of this instrument. As a whole, I learn from all of my mentors and then try to implement the surgical approach that seems most logical to me, and works best in my hands. The freedom to experiment with a variety of techniques and instruments has been an incredibly valuable experience of my fellowship, and I cannot thank my mentors enough for that leeway.
When treating a new patient with AMD, what is your preferred anti-VEGF treatment regimen?
Y. MODI, MD: My preferred treatment for patients with neovascular AMD is intravitreal bevacizumab. There are plenty of studies demonstrating similar efficacy and safety data of bevacizumab and ranibizumab in monthly, PRN, and treat-and-extend protocols. Additionally, while some clinicians have espoused the superior efficacy of aflibercept over other anti-VEGF treatments in the setting of patients with large fibrovascular PEDs, this finding is not consistently borne out in the literature. Finally, I believe our generation of physicians has a responsibility to provide cost-effective care, and thus starting with a non-inferior, equally safe, and cheaper medication makes a lot of sense to me.
Do you change your anti-VEGF treatment regimen, if your patient is not responding to your first line of treatment?
Y. MODI, MD: This question is a bit trickier than the last because there is no established definition of a “non-responder”. As such, the decision for me to alter therapy is largely based on the assessment of clinical benefit rather than OCT-guided responsiveness. I recognize the subjectivity and potential flaws in this logic but perhaps an example may clarify my thought process. If a patient with an occult CNV, 20/30 vision, and minimal metamorphopsia doesn’t resolve her subretinal fluid after three injections of bevacizumab, I will likely continue her on the current treatment course. However, if the same patient presents with worsening vision, worsening complaints of metamorphopsia, or an OCT demonstrating worsening intraretinal or subretinal fluid, I will switch to aflibercept after three treatments with bevacizumab. I switch to aflibercept next because it has a different mechanism of VEGF inhibition and a higher binding affinity, which translates into a longer treatment effect than bevacizumab and ranibizumab.
What is your favorite place to vacation when you have a few days off?
Y. MODI, MD: My favorite long-weekend trip is to Miami, Florida. I spent three years there for my residency at Bascom Palmer Eye Institute and nothing beats a 70-degree evening in January when it’s five degrees and snowing in Cleveland.
What’s your advice for incoming Fellows in July?
Y. MODI, MD: Travel internationally and spend time observing other surgeons. I was fortunate to visit LV Prasad Eye Hospital in Visakhapatnam, India and learned small-incision cataract surgery from some true cataract masters. Additionally, I worked with a fantastic vitreoretinal surgeon and uveitis specialist (Dr. Avinash Pathengay) whose clinical exam was so good, he reliably diagnosed CME on indirect exam. (I even challenged him with a few OCT confirmation tests). Through this experience, I became a better observer, surgeon, and clinician.
Dr. Modi can be reached via e-mail at firstname.lastname@example.org