Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you manage cystoid macular edema (CME) unresponsive to topical treatments in steroid responders?
Management depends on the underlying etiology of the CME. If the cause is primarily vascular, anti-VEGF therapy is typically the first-line treatment. If the CME is inflammatory in nature and continued steroid therapy is desired, I collaborate closely with a glaucoma specialist to determine if IOP c...
How do you decide on a steroid sparing agent for idiopathic orbital inflammation partially responsive to steroids?
Idiopathic orbital inflammation is a diagnosis of exclusion which is usually supported by orbital imaging and/or biopsy. It is important to exclude other causes of orbital inflammation which include thyroid eye disease, ANCA-associated vasculitis, sarcoidosis, histiocytosis, infection, or metastatic...
How do you manage periocular reconstructive surgery in patients with advanced orbital fractures and concurrent soft tissue injuries?
Assuming the patient is neurologically and hemodynamically stable, soft tissue injuries of the globe must be addressed first. Removal of orbital and intraocular foreign bodies, profuse irrigation, and globe repair, always precedes repair of the orbital fractures. When the fractures warrant repair, i...
How do you approach a patient who has anterior uveitis and is referred for evaluation of ocular TB with a positive Quantiferon gold (as part of their workup) in countries with low TB incidence?
It is a frustrating problem and is expected to increase without solid evidence. Until then, management should involve an interdisciplinary collaborative approach and a shared decision-making process.I see the following issues. I feel ophthalmologists follow the diagnostic criteria for TB uveitis us...
Do you combine anti-VEGF with PDT for polypoidal choroidal vasculopathy upfront or reserve PDT for refractory cases?
Having considered EVEREST, EVEREST II, and PLANET, I tend to start with monthly aflibercept, with a low threshold for applying PDT during the first 3 months, before the vessel complex is too established to undergo regression.In practice, I only uncommonly encounter PCV early in its clinical course; ...
When should delayed removal of an intraocular foreign body be considered?
If you are deciding whether to close the globe first and then remove the IOFB with a later surgery, then first consider the type of IOFB and its potential to incite infection or inflammation. No matter what type of IOFB it is, the team repairing the ruptured globe should inject intravitreal broad-sp...
How do you decide between initiating systemic immunotherapy versus local treatment for uveitis with associated HLA-B27 and spondyloarthropathy?
I find that most, but not all, HLA-B27 iritis can be controlled with topical therapies. To do so requires eliminating other causes of inflammation. Many patients have GI inflammation due to gluten and dairy, despite not having classic celiac disease or lactose intolerance. Reducing their intake, mod...
How do you decide whether or not to excise a pterygium prior to cataract surgery?
I'll remove a pterygium prior to cataract surgery if I suspect the pterygium will need removal at some point in the future. This could mean: 1.) I have seen evidence of pterygium progression in the recent past (either physical growth onto the cornea as compared to historical measurements/photos, or ...
If a patient is legally blind and on hydroxychloroquine, do you still recommend follow up with ophthalmology to monitor for hydroxychloroquine retinal toxicity?
A patient who is legally blind but taking hydroxychloroquine absolutely needs to be monitored by an ophthalmologist. The usual definition of legal blindness in the United States is vision no better than 20/200 in the better-seeing eye. But 20/200 is far better than say counting fingers (the ability ...
How do you counsel patients interested in LAL monovision about the possibility of reduced glasses dependence?
One of the main advantages of the LAL is the ability to fine-tune monovision after surgery, allowing patients to experience and adjust their visual balance between distance and near before final lock-in. I explain that this flexibility greatly increases satisfaction and can significantly reduce glas...