Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
What is an effective technique for obtaining tissue for pathological analysis from a broad-based luminal punctal/canalicular mass?
If there is enough representative tissue outside of the punctum/canaliculus proper, then it can be incised sharply like any other marginal lesion (I prefer a 15-blade and Westcott scissors). If the pathology is limited to the lumen, then a modified punctoplasty could be considered. Dilate the punctu...
How do you approach the management of epithelial ingrowth in a patient who underwent LASIK 20 years ago and developed epithelial ingrowth following recent cataract surgery?
If it’s a small area in the periphery, not causing any issue, then it would be reasonable to monitor it as it may not progress. If it is progressing or starting to cause issues, you can either try YAG, which may take more than one round, or simply lift the flap and scrape both the bed and underside ...
How do you decide the best way to treat glaucoma in patients with ICE syndrome given their higher risk of surgical failure and corneal complications?
In general, patients with ICE syndrome have unilateral refractory disease that often requires surgical management. MIGS procedures are not typically effective given the angle anatomy and progressive nature of the disease, and I usually perform tube shunt surgery in these cases. Placing the tube deep...
Do you re-load with monthly doses when switching a patient with DME from aflibercept to faricimab, or do you transition directly to a treat-and-extend schedule?
When I switch from one anti-VEGF agent to another, I start with the same treatment interval I was using with the previous agent, so I can assess the comparative efficacy of the two agents. Once I have determined the new agent is more effective, I proceed immediately to a treat-and-extend dosing regi...
What concentration/dose of mitomycin C do you use for trabeculectomies and XENs and how do you titrate based on patient factors?
I use the mitosol kit and reconstitute at 0.2 mg/ml (0.02%). I inject the mitomycin at the end of the case, after ensuring watertight conjunctiva closure by raising a bleb via a corneal paracentesis. My standard dose then is 60 ug injected (0.3ml of 0.2 mg/ml), but I may titrate that dose/volume up ...
Do you modify your cataract surgery (i.e., biometry, phaco parameters, post-operative regimen) in any way for patients with prior glaucoma surgeries and/or severe glaucoma?
I generally do not modify my cataract surgery settings or pre-op planning. For patients with filtering blebs, I review the risks that cataract surgery could cause increased IOP and in some cases, bleb failure. For patients with filtering blebs who might be on one or more drops, I might consider bleb...
What is the best time frame to intervene surgically for the management of traumatic macular hole, and what techniques should one consider?
How do you approach IOL exchange in a patient who is unhappy after cataract surgery with a premium IOL?
The first step is determining why they are unhappy, is it a quality of vision issue? Something else, like diplopia or eye pain? Assuming it's a visual quality issue, the next step is assessing the reason: a careful evaluation of corneal surface (dry eye, ABMD, Salzmann's nodules), evaluating for len...
In what clinical scenarios do you incorporate topical insulin drops to treat persistent epithelial defects?
I often use topical insulin drops in lieu of Oxervate for persistent epithelial defects and neurotrophic cornea. It works well and is much more affordable.
For very low cylinder that does not qualify for a toric lens and no access to femto, do you ever consider LRIs or slightly adjusting your main wound placement (if possible)?
I personally don't do manual LRIs as they can be somewhat unpredictable. Adjusting the main wound to the steep axis can treat 0.1 to 0.3 D due to SIA, so that might be the safest plan if femto is not available. B&L's Envista toric does treat as low as 1.25D, so that may also be an option.