Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How would you approach the management of a patient presenting with bilateral central corneal perforations following treatment with Ipilimumab/Nivolumab?
I am aware of at least one case report describing this situation (Aschauer et al., PMID 36072439).Ideally, the offending medication is halted, but when dealing with life-threatening cancer, this may not be possible, especially if the treatment is working. In the acute setting, trying to stabilize th...
Is there a role for PDT in a young patient with PXE and bilateral CNVM who requires intravitreal anti-VEGF injections every 4 weeks and is beginning to develop atrophy?
I am not a fan of PDT for patients who are developing incipient atrophy. The question says anti-VEGF therapy is being given every 4 weeks, but it is not clear what agent is being used. I would try 2nd generation therapy such as faricimab, 8 mg aflibercept, or possibly brolucizumab (after discussion ...
How do you approach recommending ocular exams for asymptomatic candidemic patients considering the discordance between the IDSA and American Academy of Ophthalmology guidelines?
Endogenous endophthalmitis due to Candida sp. occurs in <1% of patients with candidemia. The IDSA 2016 guidelines for management of candidiasis outline evaluation and treatment of patients with endophthalmitis, with recommendations to perform a dilated ophthalmologic exam on all patients with candid...
In what scenarios do you consider using an amniotic membrane graft for macular hole closure?
Given that the success rate of closing macular holes is excellent when the hole is worth closing, and that there are no studies demonstrating the benefit to the patient of amniotic membranes for (presumably) very large and chronic holes, I can't recommend this approach. Having said that, I have no e...
How do you decide between repeat surgical correction vs. botulinum toxin injections for recurrent intermittent exotropia after previous surgery?
If the lateral rectus muscle has been recessed, it would be very challenging to get Botox accurately administered. Bilateral medial rectus resection would be easier and is very effective.
How do you balance medical management versus additional glaucoma surgery in patients with advanced glaucoma who develop IOP elevation after healing from a trabeculectomy revision for bleb leak complicated by prior suprachoroidal hemorrhage?
This is a very complicated case, and I will commend you for handling such a case. I would typically start with medical management, and if the glaucoma is sufficiently controlled, then that would be sufficient. However, given the progressive and complex nature of glaucoma, the pressures may not be ad...
Is there benefit for anterior chamber washouts for the treatment of infectious keratitis extending into the anterior chamber and when do you consider utilizing it?
Regarding bacterial infections, I have never felt the need to perform an anterior chamber washout, as vancomycin and tobramycin drops have good intraocular penetration. You do not want to go do a washout on a reactive hypopyon, and many times it is hard to differentiate a reactive hypopyon from an e...
What strategies do you use to improve Jones tube tolerability in patients who require CPAP therapy?
I have seen infections from CPAP in a patient who has never had surgery. Lower lid punctum plugs helped considerably. I’ve not seen this in a Jones tube patient. I’m sure any patient manipulating the tube would be unsuccessful. Plugging the tube with anything physical is unlikely to be possible. The...
How do you incorporate intravitreal methotrexate injections into the management of traumatic retinal detachment repairs?
I do not use intravitreal methotrexate after ocular trauma. I assume the question is directed at the prevention and/or treatment of PVR. Multiple studies have shown this medication is not effective in the treatment or prevention of PVR.
In cases where placing an IOL in the bag/sulcus is not possible, how do you decide between leaving a patient aphakic for a scleral-fixated IOL (assuming this can't be done immediately) vs. placing an ACIOL?
In 2 situations, I would leave a patient aphakic even without an IOL: highly myopic patients where the actual IOL power is minimal +\- 3 D, in that case, glasses can correct residual refraction, supposing that the patient does not develop anisometropia monocular patients with up to 5 D residual ref...