Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
What is the appropriate interval before safely performing cataract surgery after plaque radiation therapy for iris melanoma?
Great question, but one that requires a nuanced answer. Often, patients with iris melanomas have some degree of lens opacity, and following brachytherapy, the cataract will surely progress. I recommend carefully following up on the iris melanoma after radiation to ensure the lesion is regressing pro...
What is your approach to patients with biopsy proven giant cell arteritis that continue to have symptoms after initiation of high dose glucocorticoid therapy?
First, let's define and discuss “high-dose” steroids. Oral therapy is typically 60-100 mg of prednisone daily, and IV is 500-1000 mg of methylprednisolone daily for three days, followed by oral prednisone. There has been no difference in long-term outcomes for vision loss or diplopia. The complicati...
What factors influence your decision to pursue surgical management in cases of infectious keratitis caused by multidrug-resistant pathogens?
I would consider operating sooner rather than later for a keratitis that’s headed in the wrong direction. It’s important to intervene prior to the development of extensive CNV or limbal involvement or corneal perforation for a more controlled, straightforward operation. The exception may be fungal k...
How do you manage corneal ectasia after refractive surgery?
Corneal cross-linking should be the first step to halt progression. I would then typically encourage patients to try hard contacts, which help improve the vision in the most conservative way. There are a variety of surgical interventions that can be considered depending on how advanced the ectasia i...
In cases of congenital ptosis with poor levator function, how do outcomes of frontalis flap suspension compare to silicone rod frontalis sling?
A frontalis flap procedure offers superior cosmesis in that only a lid crease incision is made, and no incisions are made above the brow. However, it does take significant additional operative time to dissect the flap from a single inferior incision. There is the thought that it might be less adjust...
How do you decide to use MIGS versus traditional surgical options like trabeculectomy or tube shunt placement in the management of glaucoma?
Current IOP and your IOP goal are key. Angle MIGS will typically reduce IOP from the low to mid-20s to the mid to upper teens. I consider Xen a MIBS procedure. I’ve been able to use Xen as my bleb surgery of choice, even in patients who have had multiple prior ocular surgeries, including PPV, tube s...
When would you consider discontinuing immunosuppressive treatment in a quiescent uveitis patient without systemic manifestations of inflammation?
I typically monitor patients on immunosuppressive therapy for at least 2 years before considering stopping or weaning off such therapy. There could be exceptions to this, including patients who insist on being taken off their meds (side effects, trying to conceive, etc.), in which case I can try aft...
In a bedridden, medically fragile patient with a symptomatic conjunctival cyst superior to the limbus, what is the optimal management approach?
I would first attempt medical management with lubricants, ketorolac, olopatadine, and naphazoline. If those failed, then I would use the following drops: topical anesthetic, a vasoconstrictor, and ketorolac twice over a five-minute period, then insert a lid speculum, and unroof the cyst by grasping ...
What is your preferred surgical intervention for children with congenital nystagmus?
Eye-muscle surgery in patients with INS improves their beat-to-beat nystagmus, thus they receive more useful vision per unit time. The common clinical misperception is that eye-muscle surgery only serves to improve "letter" acuity, centralize the INS null position, or reposition the eye(s) in the or...
How do you manage the severe adverse drug reaction of central serous retinopathy with MEK inhibitors?
Fortunately, the ICSC-like association of subretinal fluid with MEK inhibitor exposure is usually reversible after cessation of the drug. When working with this class of medications, it is important to coordinate care with the treating oncologist. If a patient presents with subretinal fluid and is o...