Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you determine the timing and necessity of surgical removal for retained subretinal perfluorocarbon?
Timing: Defer PFO removal until after you are convinced the retina is attached and will likely stay attached (e.g., after gas resolves or, if under oil, later than 8 weeks). Necessity: Plan for surgical removal if subretinal PFO is foveal or perifoveal. If not, then defer indefinitely unless PFO loc...
What has been your experience adopting office-based surgery and has it meaningfully improved patient access or practice efficiency?
We have demeaned and minimized what we do, and in response, Medicare and insurance companies have decreased our reimbursements. We (ophthalmologists) have advertised how easy cataract surgery is, and in general, what we do, and we are our own worst enemies.
Which MIGS do you feel has the most durable IOP lowering effect?
There is a lack of high-quality comparative efficacy data for the wide variety of MIGS available. The HORIZON randomized clinical trial demonstrates that the Hydrus Microstent can have IOP-lowering effects and medication reduction benefits in some patients at 5 years after surgery. Proponents of can...
Should teprotumumab be used in patients with active, moderate Graves thyroid eye disease in the absence of proptosis?
Teprotumumab is NOT a benign therapy with multiple serious side effects and complications. In the setting of acute TED with significant disease, it has a place. For the average patient, there are multiple other treatments and other Biologics with fewer complications.
Which patients do you routinely prescribe ketorolac for after cataract surgery?
I recommend bromfenac (not ketorolac) to all patients undergoing cataract surgery - based on work by Drs. @Dr. First Last and John Whittpen that found that starting topical NSAIDs 1-3 days preop provided. Lower risk of CME Larger pupils throughout cataract surgery Less discomfort during cataract su...
What factors guide your decision to test for or start empiric treatment for Acanthamoeba keratitis in cases of corneal ulcers?
I can't say that I've ever started empiric treatment for acanthamoeba keratitis prior to other workup/testing/culture results, although I suppose if you have a slam dunk case with a known acanthamoeba exposure, I would do so. The question of whether to test for AK is far more interesting. New-onset ...
When do you use GLP-1 receptor agonists for the management of patients with idiopathic intracranial hypertension (IIH)?
I would use GLP-1 agonists in all overweight IIH patients who did not have a contraindication if it wasn't for the cost. In the IIH treatment trial, 6% weight loss over 6 months lowered intracranial pressure by about 50 mm (acetazolamide also lowered ICP by about 50 mm, but of course, it did it much...
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
In a patient with recurrent episodes of GCA that flare shortly after steroid tapering, how do you differentiate between steroid-dependent inflammatory relapse, an alternative autoimmune vasculitic process, and a paraneoplastic phenomenon?
Paraneoplastic disease rarely behaves like GCA with ischemic manifestations. If a non-GCA vasculitis is suspected, perhaps repeat biopsy or serologic testing for other markers could be done. I'm not sure of the value of these tests, however, given that the treatment approach with immunosuppression w...
Do you feel there is value to getting endothelial cell counts in the absence of frank edema/visual significance in your management endothelial dystrophies?
I would, yes, mostly for patient understanding of their condition and following up on it objectively. There is a clinical benefit, but it is limited. Clinically, I use it to give the patients an assessment about their risks of edema post cataract surgeries or to push for early cataract surgeries in...