Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In extensive basal cell carcinoma involving both upper and lower eyelids and the lacrimal gland, is radiotherapy poorly tolerated (especially to doses up to 50-60 Gy) and/or is orbital exenteration preferred?
For advanced basal cell carcinoma with orbital invasion, I would treat with hedgehog inhibitors. If there is an inadequate clinical response, exenteration is usually recommended. Radiation is not particularly effective for BCC and can have significant ocular side effects.
What specific exam findings or test changes prompt escalation of care when evaluating pediatric patients with optic disc drusen for possible increased intracranial pressure?
Both pediatric and adult patients with optic disc drusen can develop increased intracranial pressure, including IIH, like normal individuals. This is important to remember, especially if the symptoms and risk factors suggest elevated intracranial hypertension. In the pediatric group, especially youn...
How do you counsel patients with GCA on the benefits of steroids who have already experienced vision loss?
I first tell the patient they are at considerable risk for further visual loss in the same eye or the other eye over the next 1-2 weeks. I also let them know that, even though their risk of visual loss has been reduced, their best option for preventing further visual loss is immediately starting hig...
What is your approach to audiometric monitoring for patients on teprotumumab and how do you discuss the possibility of irreversible hearing loss with your patients?
I have set up a connection with our institution’s ENT and audiometry service to do a baseline test for any patient who is a candidate for teprotumumab. If the patient already has abnormalities in the high and ultrahigh frequencies, would not proceed to treatment. Would also repeat the test if the pa...
How do you incorporate OCT and OCT-A in conjunction with FA in your evaluation of retinal diseases?
There are no clinical or diagnostic factors that predict who will benefit from an intervention for vitreous floaters. Symptomatology from vitreous floaters is subjective. Patient-reported outcome measures after floaterectomy are also subjective. The improvement in symptoms following vitrectomy (I do...
How do you determine when to discontinue anti-complement therapy in patients with geographic atrophy who already have center-involving disease given the minimal likelihood of central vision improvement but the potential for more rapid scotoma expansion if treatment is withdrawn?
Since these drugs have a significant risk and a marginal benefit, not to mention the significant treatment burden and their outrageous cost, it begs the question of how often they should be used altogether.
What is the standard of care for timing of a mac-off retinal detachment repair?
The literature on this topic is mixed and at times contradictory. My own synthesis of the literature, which I believe coincides with the consensus standard of care, suggests that repair of macula-involving rhegmatogenous retinal detachment is relatively time sensitive: urgent but not emergent. The c...
How do you manage the severe adverse drug reaction of central serous retinopathy with MEK inhibitors?
Fortunately, the ICSC-like association of subretinal fluid with MEK inhibitor exposure is usually reversible after cessation of the drug. When working with this class of medications, it is important to coordinate care with the treating oncologist. If a patient presents with subretinal fluid and is o...
What is your algorithm for transitioning a patient with chronic noninfectious posterior uveitis from corticosteroids to immunosuppressive therapy?
There are some forms of noninfectious posterior/panuveitis where it is known from the time of uveitis diagnosis that steroid-sparing immunosuppression (IMT) will be needed. For example, in birdshot retinochoroiditis or serpiginous choroidopathy, IMT is often initiated in concert with oral corticoste...
How do you decide the threshold and duration of subretinal fluid that can be safely tolerated in exudative AMD when adjusting treat-and-extend intervals?
There are so many other factors at play here. The very nature of this question begs the question of whether you are treating the patient or the OCT. Sadly, it appears the preponderance of patients I have seen are treated at fixed intervals of 1-2 months and no treat and extend, even from physicians ...