Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
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, ...
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...
How do you manage cystoid macular edema (CME) unresponsive to topical treatments in steroid responders?
Management depends on the underlying etiology of the CME. If the cause is primarily vascular, anti-VEGF therapy is typically the first-line treatment. If the CME is inflammatory in nature and continued steroid therapy is desired, I collaborate closely with a glaucoma specialist to determine if IOP c...
How do you decide on a steroid sparing agent for idiopathic orbital inflammation partially responsive to steroids?
Idiopathic orbital inflammation is a diagnosis of exclusion which is usually supported by orbital imaging and/or biopsy. It is important to exclude other causes of orbital inflammation which include thyroid eye disease, ANCA-associated vasculitis, sarcoidosis, histiocytosis, infection, or metastatic...
How do you manage periocular reconstructive surgery in patients with advanced orbital fractures and concurrent soft tissue injuries?
Assuming the patient is neurologically and hemodynamically stable, soft tissue injuries of the globe must be addressed first. Removal of orbital and intraocular foreign bodies, profuse irrigation, and globe repair, always precedes repair of the orbital fractures. When the fractures warrant repair, i...
How do you approach a patient who has anterior uveitis and is referred for evaluation of ocular TB with a positive Quantiferon gold (as part of their workup) in countries with low TB incidence?
It is a frustrating problem and is expected to increase without solid evidence. Until then, management should involve an interdisciplinary collaborative approach and a shared decision-making process.I see the following issues. I feel ophthalmologists follow the diagnostic criteria for TB uveitis us...
Do you combine anti-VEGF with PDT for polypoidal choroidal vasculopathy upfront or reserve PDT for refractory cases?
Having considered EVEREST, EVEREST II, and PLANET, I tend to start with monthly aflibercept, with a low threshold for applying PDT during the first 3 months, before the vessel complex is too established to undergo regression.In practice, I only uncommonly encounter PCV early in its clinical course; ...
When should delayed removal of an intraocular foreign body be considered?
If you are deciding whether to close the globe first and then remove the IOFB with a later surgery, then first consider the type of IOFB and its potential to incite infection or inflammation. No matter what type of IOFB it is, the team repairing the ruptured globe should inject intravitreal broad-sp...