Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
For patients with neovascular glaucoma and uncontrolled IOP, do you ever consider a glaucoma drainage device (GDD) combined with ECP as opposed to just a standalone GDD?
I've never performed those two surgeries together, and I don't know of any papers that looked at that. Many NVG patients who get tubes in my practice are phakic, which makes ECP a non-starter. For the pseudophakic ones, I usually do a tube alone, combined with anti-VEGF and PRP. I would consider ECP...
How do you approach surgical repair of a 6-clock-hour retinal dialysis with posteriorly folded retina, and what strategies do you use to minimize retinal slippage?
First of all, make sure it’s a dialysis and not a GRT. For dialysis, I would definitely start with a buckle.
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...
What techniques do you use to minimize the risk of buckle extrusion or infection, especially in younger or highly myopic patients?
No different techniques. Make sure you soak the elements in saline with an antibiotic. Do not touch the buckle with your hands. Do not use instruments that can damage the silicone. Extrusions and infections are not common. Kids have a healthy Tenon that will keep buckles from extruding. Also, buckle...
How would you approach choosing a MIGS procedure for a patient with mild glaucoma with progressively worsening PAS undergoing cataract surgery?
In a patient with mild glaucoma and progressive PAS undergoing cataract surgery, I first assess whether the mechanism is primary or secondary angle closure, such as from uveitis. Context is important here. Given that the angle is at least partially compromised, I generally avoid angle-based MIGS at ...
In which cases of post-injection endophthalmitis should early vitrectomy be considered if there is little to no improvement 48 hours after a tap and inject and there is no organism isolated?
Prompt vitrectomy should be considered in all patients with post-injection endophthalmitis (PIE) if there is no improvement 48 hrs after a tap and inject. The initial tap did not identify the organism. Non-infectious endophthalmitis can be included in the differential diagnosis of persistent inflamm...
What are the clinical indications for performing a second laser peripheral iridotomy (LPI) instead of proceeding directly with cataract surgery?
The only reason for a second LPI in CACGL or occludable angle is if sector iris bombe develops due to posterior synechiae formation. Otherwise, one LPI will normalize the pressures between the posterior and anterior chambers. If you still see progressive angle closure after LPI, you are dealing with...
In eyes with lamellar macular holes, what clinical or OCT features push you toward recommending surgery versus continued observation?
Most published papers and my personal surgical experience suggest that surgery on eyes with a lamellar hole alone (i.e., without a significant associated ERM) RARELY yields visual improvement. For this reason, I generally discuss the surgical option only in patients with progressive expansion of lam...
How has your use of SLT changed given the 6-year results of the LiGHT trial?
I offer primary SLT to almost all of my treatment-naive patients with OHTN or POAG, and most patients with mild-moderate disease who have never received SLT. I counsel patients that with primary SLT, they are less likely to show disease progression at 6 years and less likely to require incisional gl...
In clinical practice, how can AMD imaging biomarkers guide risk stratification and shape discussions with patients regarding prognosis and monitoring?
When I see a patient with intermediate AMD, if I see biomarkers on OCT such as hyperreflective foci (HRF), drusen that have hyporeflective cores, lots of drusenoid deposits, acquired vitelliform lesions, or areas of thick basal laminar deposit, I realize that patient is at higher risk for progressio...