Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
When should methotrexate injections be initiated for proliferative vitreoretinopathy?
This is an excellent question with a nuanced answer. Currently, we lack substantial level 1 evidence to guide precise treatment strategies for off-label use of methotrexate (MTX) in the treatment or proliferative vitreoretinopathy (PVR). Based on animal and human clinical retrospective studies, the ...
How do you decide to use MIGS versus traditional surgical options like trabeculectomy or tube shunt placement in the management of glaucoma?
Current IOP and your IOP goal are key. Angle MIGS will typically reduce IOP from the low to mid-20s to the mid to upper teens. I consider Xen a MIBS procedure. I’ve been able to use Xen as my bleb surgery of choice, even in patients who have had multiple prior ocular surgeries, including PPV, tube s...
When have you found benefit combining different MIGS procedures?
The data regarding combining different MIGS procedures are primarily retrospective, non-comparative, subject to selection bias and other biases, and performed in widely varying patient populations that make direct comparison difficult. From a mechanistic standpoint, combining MIGS makes sense, such ...
What should be the first line treatment for metastatic uveal melanoma?
There is no consensus for frontline treatment of metastatic uveal melanoma. A clinical trial would be recommended for all patients if possible. If the disease is only within the liver, consideration of liver directed therapy would be reasonable. For metastatic disease beyond the liver checkpoint imm...
How do you decide when to stop anti-VEGF injections for patients with exudative AMD?
The ongoing anti-VEGF injections are usually withdrawn when the clinical status of nAMD stabilizes with the absence of clinical activity for an extended period of time or, rarely, when the visual acuity improves to 20/20. I usually use the treat and extend protocol for the treatment of exudative AMD...
In non-visually significant hypotony maculopathy after trabeculectomy, how do you approach timing and decision to revise the trab?
Hypotony after filtering surgery is not uncommon, with IOP less than 6 on 2 or more post op visits occurring in 28.6% of patients in a recent retrospective review by Khaliliyeh et al., PMID 41692420. However, most (79.9%) of these patients did not show any clinical sequelae. In this review, 10% of p...
In pediatric RRDs associated with high myopia or Stickler syndrome, how do you decide between scleral buckle alone versus combined vitrectomy and buckle?
Most of the time, a buckle works great. If there is posterior PVR that will not relax with a buckle or there is a GRT, then a vitrectomy will be necessary.
What alternative treatments do you recommend trying for patients struggling with persistent, chronic ocular surface pain following refractive surgery unresponsive to traditional methods (i.e., lubrication, topical cyclosporine, punctal plugs)?
The first step is to identify the underlying cause of pain. If nociceptive: Target the visible source of pain. If peripheral neuropathic (e.g., due to corneal nerve abnormalities): Consider topical therapies that modulate nerve function, such as autologous blood-derived products (PRGF, AST, PRP) or...
What factors will most influence your decision to offer ENCELTO to patients with macular telangiectasia type 2?
Yet another (presumably very expensive) surgical treatment for a chronic macular disease was approved on the basis of OCT measurements without demonstrating visual benefit to the patient in a disease with a slow, variable course. Show me quality of life studies and visual benefit justifying surgical...
How should ectasia risk be triaged using RSB, PTA, and tomography?
Randleman ectasia risk score is very helpful in assessing the risks. It takes into consideration RSB PTA topography, CT, and age. Randleman Ectasia Risk Factor Score System