Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How would you approach a patient with vitreoretinal lymphoma without CNS or systemic involvement?
The optimal treatment approach for primary intraocular lymphoma is debated. This is a rare disease with only small retrospective series guiding therapy. There is no clear superior treatment approach in the literature. In clinical practice, younger patients are often treated initially with high-dose ...
How do you go about assessing a patient that has had refractive surprise following cataract surgery when determining the cause for surprise and in preparation for the other eye?
Pretty simple, if at the visit at 1 week BEFORE the second eye is done, if the vision is NOT good and they are refracted and there is a surprise, then look again. If necessary, DON'T do the 2nd eye until you know what is going on with the first surgery!
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...
How do you approach IOL calculations and selection in patients with keratoconus based on disease severity?
Lens selection assuming stable KCN and no plan for a transplant: Symmetrical astigmatism and they don't want to wear CL after surgery? Can consider a toric lens. Symmetrical astigmatism and they are okay with continuing RGP/sclerals? Monofocal aberration-free lens. Asymmetrical astigmatism and want...
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...
When do you consider adding steroids alongside intravenous antibiotics for patients with orbital cellulitis?
If the orbital cellulitis is infectious, I never add steroids. There is no literature or proof that they do anything, and decreasing immunity, in my opinion, is simply a bad idea. If it is inflammatory, then absolutely. Most infectious orbital cellulitis is from the sinuses and is more common in chi...
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 ...
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, ...
What recommendations do you provide to patients who develop ocular side effects with Dupixent?
I would start with over-the-counter artificial tears without preservative and then refer to an ophthalmologist, ideally a corneal specialist who is experienced in the nuances of treating this condition. I have also had success switching from Dupixent to Adbry, although JAK inhibitors are a better o...
What are some methods to deal with IOP elevations with intravitreal injections in a patient without glaucomatous damage that does not want to have AC taps with each injection?
In this situation, depending on the elevated IOP, use the standard medical approach: Iopidine1%, Cosopt, Alphagan 0.2%, and in some cases, Diamox 250 mg. Wait for half an hour and repeat if necessary, or send the patient home with one or more drugs. Of course, make sure of drug selective contraindic...