Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How would you approach a symptomatic patient with with a history of whole brain RT with new bilateral MRI enhancing lesions within the optic nerves?
The differential would be optic neuritis from immunotherapy or leptomeningeal disease. Is there any visual deficit? It appears there is a lesion as described above rather than enhancement which would favor disease. One would need to know the disease status outside brain and if there is any other sus...
What would you recommend for a patient with bilateral conjunctival MALT (without systemic disease)?
While technically this patient is stage IVAE (>1 extranodal site is categorized as stage IV), these patients do as well as those with unilateral conjunctival MALT NHL. Bilaterality is not unusual in this disease. This is a situation where definitive treatment (24 Gy in 12) is appropriate for stage I...
Should regular screening brain MRIs be done for children with germline RB1 mutation in addition to eye exams?
Yes, baseline brain MRI and routine screening approximately every 6 months until the age of 5 years is recommended in any heritable RB patient, including those with bilateral disease or unilateral disease with a family history of the disease (to account for those individuals who may not have an "ide...
Do you extrapolate from uveitis treatment pathways when managing other inflammatory eye conditions such as atypical serpiginous choroiditis?
I do tend to apply these principles. So these entities like serpiginous, relentless placoid, etc., I would consider posterior uveitis. While we definitely do not fully understand the full pathophysiology of all these diseases, there is good evidence of inflammatory activity, hence response to steroi...
What do you use to treat uveitis refractory to conventional synthetic DMARDs and TNF inhibitors?
I would add support to a trial of intravenous tocilizumab, particularly if macular edema is a feature of the uveitis. The STOP-Uveitis trial demonstrated reasonable efficacy in intermediate, posterior, and panuveitis (STOP-Uveitis) and I have used this within my own practice with success in patients...
Is there a role for radiation therapy in the treatment of a lymphoproliferative disorder involving the orbit?
When I don't have pathology/flow/PCR reports diagnostic of malignancy, I have treated patients with "lymphoid atypia", "atypical lymphoid infiltrate", or "lymphoproliferative disorder" with symptomatic disease to 4 Gy in 2 fractions. I have a collection of such patients (about a dozen), almost all o...
How long do you continue steroid-sparing agents such as tocilizumab for GCA once the disease is in remission off steroids?
This is an excellent question and one we confront regularly. This is another of what I call “happy problems” because it is a consequence of increasing options for effective therapy for our patients.Tocilizumab is clearly an effective agent for some patients with giant cell arteritis (GCA), and patie...
How do you manage MEK inhibitor induced ocular adverse events?
MEK inhibitor associated ocular adverse events may range from subretinal fluid, which does not typically require medication cessation to uveitis, which is treated according to the level of inflammation. In one report of optical coherence tomography scan evaluations to image retinal structures follow...
Are there any situations in which you would consider starting steroid-sparing agents at the outset for patients with scleritis without any evidence of systemic rheumatic disease?
The average duration of scleritis is 7 years. The duration distribution is a bell-shaped curve, meaning that some patients have shorter disease duration but others have longer disease duration. Unless the ANCA is positive or an obvious systemic disease is present, it is very hard to know who will ha...
What are the benefits of sending HLA B27 genotype over HLA B27 antigen when evaluating for spondyloarthritis?
HLA-B27 is strongly associated with ankylosing spondylitis (AS) which is an inflammatory rheumatic disease that affects the spine, the sacroilliac joints, and peripheral joints. It is also associated with other diseases like acute anterior uveitis, inflammatory bowel disease, or psoriasis. HLA-B27 t...