Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
When should you consider referral to neuro-ophthalmology or neurology for ocular migraines?
"Ocular" migraine is really a misnomer. Scintillating scotoma/teichopsia (which leads the patient to seek medical attention) has a cortical, not ocular, origin with the possible exception of the rara avis of retinal migraine. If the patient identifies "build-up" of classic teichopsia (Airy 1870), in...
How do you decide when to give or defer intracameral antibiotics for endophthalmitis prophylaxis during routine cataract surgery?
I give intracameral antibiotics at the conclusion of all my cataract surgeries, and this practice is heavily supported by evidence.In particular, I use non-diluted moxifloxacin 0.05-0.1 cc, from a Vigamox brand bottle or a bottle of generic moxifloxacin from a few select manufacturers that are known...
How do you disinfect reusable Goldmann applanation tonometer tips?
We use a dilute bleach solution to store the tips. We have a culture plate with a lid that has holes to support the tips while they soak. The tip is rinsed well with water prior to use. We do not use them in patients with active infection; instead, we use disposable products like the iCare tonometer...
How do you counsel patients on the use of AREDS 3 vitamins (developed by B&L) without the support of clinical trials?
I make it clear that there are currently no prospective clinical trial data that demonstrate increased efficacy of the commercial AREDS3 formulation compared to AREDS2. I further explain that AREDS3 includes all of the AREDS2 components (but with a smaller dose of zinc) plus the addition of several ...
What factors influence the decision between anti-VEGF injections and surgical displacement with tPA for treating submacular hemorrhage in AMD patients?
The size, thickness, and location of the heme are factors to consider between anti-VEGF monotherapy and a displacement procedure. If there is sufficient thickness to the heme and it is subfoveal, then I perform an in-office displacement. I usually inject anti-VEGF + intravitreal gas on day 0, and th...
In what cases do you consider mannitol for cataract surgery?
I have found IV mannitol VERY helpful for dehydrating vitreous for short axial length, especially around 20.5 or less. Otherwise, in short eyes, there is less working space and a greater tendency for the iris to want to prolapse out, even in the absence of typical IFIS-type medications. I’ve typical...
Do you consider the vitrectomy performance of a phaco-only machine adequate for anterior vitrectomy during complicated cataract surgery?
There are no head-to-head comparative studies. However, older phaco machines with a slow cut rate and an inability to adjust the function cut/IA vs. IA cut are likely less efficient and have a higher risk of pulling on the retina. With the newer phaco machines like Centurion, they have better contro...
Do you still obtain Tensilon (edrophonium) testing for myasthenia gravis, and what do you feel is the added value over serum testing?
Edrophonium has not been available commercially for years. Neostigmine can be used intramuscularly instead, given with atropine, and the effect assessed 30-45 minutes later. Some seronegative patients will have a positive test, so it can be helpful when you still suspect myasthenia and want further ...
What has been your impression of the clinical outcomes for photobiomodulation for dry AMD?
I’m not impressed by a 2.4-letter improvement over placebo after 27 treatments. It sounds like noise and can be compared to a drop of preservative-free artificial tears. It’s not like we have tons of clinic availability to spend our time on such trivial improvements. We need a better assay to find t...
How do you treat idiopathic acute anterior uveitis that recurs immediately after a course of topical corticosteroids?
Anterior uveitis has many known causes that include HLA-B27-associated (often with ankylosing spondylitis); viral such as herpes simplex, CMV, or zoster; or as part of a syndrome that includes interstitial nephritis; or as a manifestation of juvenile arthritis. Labeling it acute means that it starts...