Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you approach the use of tPA in patients undergoing PPV for endophthalmitis when dense fibrin or membranes are present preoperatively?
I have never used it if planning to go to the OR for endophthalmitis. I remove any anterior segment membranes surgically with forceps or the cutter to facilitate my view of the posterior segment. I do know some retina specialists who use it in non-surgical endophthalmitis patients to accelerate the ...
How do you decide where to place the LPI for angle-closure glaucoma?
For narrow angles, I place it somewhere in the inferotemporal iris in a crypt. I do not use an Argon laser. With the YAG laser at 7 mJ (though different lasers may be more or less). Offset at +250 and only one burst, I can typically get through with 2-4 shots in most irides unless there is absolutel...
How do you manage a situation where the lens optic shifts in front of the iris after a Yamane technique?
This issue typically occurs in myopic eyes with "floppy" iris characteristics and has less to do with the optic shifting anteriorly, but more with the iris shifting posteriorly. Reverse optic capture of the IOL optic by the iris can best be prevented by performing a peripheral iridotomy at the time ...
How do you approach the management of indeterminate orbital lesions in asymptomatic patients with inconclusive imaging findings?
I feel like there is a specific case here. If so, I’d love to hear the details. That said, I’d return to the differential diagnosis of orbital masses/issues with the popular VEIN mnemonic - vascular, endocrine (thyroid), inflammatory, and neoplastic. While inflammatory lesions are commonly painful, ...
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.
How do you approach management of GLP-1 receptor agonist therapy in patients who develop NAION?
Short answer is I recommend stopping the GLP-1 agonist if one eye has already developed NAION, for the sake of protecting the fellow eye. The fact is, our knowledge is still growing in this matter. While some studies indicate links between GLP-1 agonists and NAION, there are so many discussions arou...
How do you approach the timing of vitrectomy in non-clearing vitreous hemorrhage secondary to proliferative diabetic retinopathy?
In patients with regressed PDR following complete PRP, the timing of vitrectomy for non-clearing vitreous hemorrhage depends on the patient's overall visual needs, fellow eye status, etc. In such patients, assuming the ultrasound shows the retina to be attached, I consider the vitrectomy to be a non...
How do you manage cystoid macular edema (CME) unresponsive to topical treatments in steroid responders?
Management depends on the underlying etiology of the CME. If the cause is primarily vascular, anti-VEGF therapy is typically the first-line treatment. If the CME is inflammatory in nature and continued steroid therapy is desired, I collaborate closely with a glaucoma specialist to determine if IOP c...
How do you decide on a steroid sparing agent for idiopathic orbital inflammation partially responsive to steroids?
Idiopathic orbital inflammation is a diagnosis of exclusion which is usually supported by orbital imaging and/or biopsy. It is important to exclude other causes of orbital inflammation which include thyroid eye disease, ANCA-associated vasculitis, sarcoidosis, histiocytosis, infection, or metastatic...
How do you manage periocular reconstructive surgery in patients with advanced orbital fractures and concurrent soft tissue injuries?
Assuming the patient is neurologically and hemodynamically stable, soft tissue injuries of the globe must be addressed first. Removal of orbital and intraocular foreign bodies, profuse irrigation, and globe repair, always precedes repair of the orbital fractures. When the fractures warrant repair, i...