Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
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!
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...
What is your approach to long-term suppressive therapy of valganciclovir for a patient with a history of CMV anterior uveitis?
Once I confirm a diagnosis of CMV anterior uveitis (+ PCR), I treat patients with valganciclovir 900 mg PO twice daily for 21 days and then switch to prophylactic dosing of 900 mg daily for 6 months to 1 year. That being said, many patients have recurrences even on prophylactic dosing and need, in m...
What strategies do you use to manage refractory cystoid macular edema in uveitis patients who have already received ocular steroids and systemic immunosuppression?
For this clinical situation, especially if the CME is bilateral, systemic peg-interferon alpha is an excellent option. Commence with peg-interferon 180 mcg injected subcutaneously weekly. Check baseline CBC/diff and complete metabolic panel prior to starting treatment and at least weekly initially (...
When should you seek hyperbaric oxygen therapy for patients with CRAO?
I usually pursue hyperbaric oxygen therapy within the 24-hour window from symptom onset for CRAO. This can be performed following TNK if given. In reality, though, there are multiple barriers to achieving this, including: Few centers offer hyperbaric oxygen therapy Labor intensive Difficulty with i...
Which patients do you routinely prescribe ketorolac for after cataract surgery?
I recommend bromfenac (not ketorolac) to all patients undergoing cataract surgery - based on work by Drs. @Dr. First Last and John Whittpen that found that starting topical NSAIDs 1-3 days preop provided. Lower risk of CME Larger pupils throughout cataract surgery Less discomfort during cataract su...
What treatment strategies do you use to reduce the risk of post-herpetic neuralgia after herpes zoster ophthalmicus?
For prevention, our best tool is the VZV vaccine (Shingrix). I recommend that all patients over age 50 consider receiving it. However, if an individual develops VZO and has persistent pain, I begin with antiviral therapy to assess whether subclinical viral activation is contributing to the pain (dur...
For LALs, after lock-in, when does a residual refractive shift justify corneal enhancement rather than continued observation?
I would wait at least 4 weeks. There could be some residual diffusion occurring in the LAL after the monomers have been locked. In theory, if some of the monomers were not polymerized during the lock-in, they can diffuse within the LAL. Water then follows to equilibrate, and you can get a change in ...
How do you decide between repeat surgical correction vs. botulinum toxin injections for recurrent intermittent exotropia after previous surgery?
If the lateral rectus muscle has been recessed, it would be very challenging to get Botox accurately administered. Bilateral medial rectus resection would be easier and is very effective.
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...