Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In primary angle closure suspects without cataracts, how do you approach the discussion about LPIs, given the relatively low risk of an acute angle closure attack?
In primary angle closure suspects without cataracts, I will have a discussion about aqueous humor dynamics and outflow mechanisms of the eye, and how that relates to risk stratification in the patient's case. We are fortunate in glaucoma to have a fair bit of evidence to guide us in our clinical dec...
What is the best next surgical approach to manage severe inferior oblique overaction and superior oblique underaction after inferior oblique myectomy?
Persistent superior oblique (SO) muscle underaction after inferior oblique (IO) myectomy usually indicates an abnormal, loose, and floppy superior oblique tendon. At surgery, the first thing to do is traction testing of both oblique muscles to detect tightness or laxity. Videos of the "exaggerated t...
How do you monitor and manage visual development and amblyopia in children with glaucoma who require multiple surgeries during critical periods of visual maturation?
There is nothing special about managing visual development and amblyopia in children with glaucoma. They must be followed by a pediatric ophthalmologist and a cycloplegic refraction performed at least yearly (more frequent if a change is expected based on changes in vision or axial length) and glass...
What is the role of topical aqueous suppressants as an adjunct to intravitreal anti-VEGF therapy in patients with persistent macular edema despite optimized injection frequency depending on etiology of ME?
Interesting question: It isn't stated what the cause of the macular edema is. In the only two indications for which there is evidence that anti-VEGF injections can have value (RVO and DME), there is little evidence of aqueous suppressants being of any value. So, in my opinion, non-intersecting sets....
What techniques do you use to minimize the risk of buckle extrusion or infection, especially in younger or highly myopic patients?
No different techniques. Make sure you soak the elements in saline with an antibiotic. Do not touch the buckle with your hands. Do not use instruments that can damage the silicone. Extrusions and infections are not common. Kids have a healthy Tenon that will keep buckles from extruding. Also, buckle...
How do you determine the duration and taper of systemic corticosteroids when you add them alongside antibiotics for orbital cellulitis?
There is no 'standard of care' answer for this. My personal preference is the following: Pediatric patients -- 0.25 to 0.5 mg/kg dexamethasone daily (given in AM) for up to 3 days, starting the day after source control/cultures from surgery. Higher dose/longer duration if very inflamed, and lower d...
How do you approach offering multifocal IOLs to patients with prior retinal pathology and surgery (i.e., mac-off RD) who have had relatively good recovery of vision?
As a retina specialist, I have seen a significant increase, over recent years, in patients doing badly because someone inserted a multifocal IOL in the context of prior or impending retinal disease. In most of these cases, the patients seemed naive to the implications, reporting that they were told ...
What has been your experience incorporating the Port Delivery System (PDS) into clinical practice?
My initial exposure was as a study surgeon, and the first patient I saw in the study had had the port system placed 9 months before. When I saw her, the port injection surface had become exposed with breakdown of the surrounding conjunctiva and tenons. This required urgent surgery and a conjunctival...
What type of air/SF6 fill do you recommend following DSEAK in patients with scleral fixated IOLs? (i.e., only AC fill vs full eye fluid-gas exchange?)
For these patients, I do a suture pull-through technique with a Prolene suture to anchor the graft at the distal edge. To keep chamber stability and prevent the bubble from moving posteriorly, I suture all wounds, including the paracenteses. I use 18% SF6 or 6% C3F8 and do a full fill. C3F8 has beco...
In cases of severe ocular trauma with NLP vision, under what circumstances do you consider proceeding with pars plana vitrectomy?
I don’t. Often, it is time to have a difficult discussion with the patient about the timing of eviseration or enucleation, if the eye presents as an open globe. The risk of endophthalmitis, worsening ptysis and pain, as well as the small risk of sympathetic ophthalmia, are sound reasons to consider ...