Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In cases where placing an IOL in the bag/sulcus is not possible, how do you decide between leaving a patient aphakic for a scleral-fixated IOL (assuming this can't be done immediately) vs. placing an ACIOL?
In 2 situations, I would leave a patient aphakic even without an IOL: highly myopic patients where the actual IOL power is minimal +\- 3 D, in that case, glasses can correct residual refraction, supposing that the patient does not develop anisometropia monocular patients with up to 5 D residual ref...
How do you decide on when to start or continue anti-VEGF injections during pregnancy?
The safety of anti-VEGF medications in pregnant women hasn't been adequately evaluated with regard to fetal safety. If at all possible, I don't initiate anti-VEGF injections during pregnancy. If a patient is currently on anti-VEGF therapy and then becomes pregnant, I hold treatment at that point. Id...
How do you approach patient selection for starting intravitreal complement inhibitors?
Because complement inhibition seems to have only a modest effect on GA progression, no clear functional benefit in pivotal trials, and a not-insignificant risk of CNV and optic neuropathy, I tend toward a conservative view when deciding whether to recommend it to patients. A good candidate, in my v...
Do you routinely perform ILM peeling in all epiretinal membrane (ERM) cases or do you selectively peel based on OCT features and membrane characteristics?
With rare exceptions, I peel ILM in all ERM cases for two main reasons. First, it is the best way (and in some cases the only way) to ensure that the ERM is removed completely, thereby avoiding the postoperative scenario of persistent ERM causing persistent visual symptoms. Second, there is good evi...
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 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...