Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
Is it safe to continue azathioprine in a patient with severe bilateral panuveitis (thought to be related to sarcoidosis) and benign ethnic neutropenia, given worsening neutropenia since starting the medication, or should an alternative immunosuppressive agent be considered?
In this case, I would consider stopping azathioprine and switching to an alternative medication, such as an anti-TNF agent. Although not a large drop in the PMN, azathioprine is known to cause leukopenia, and in a patient with known neutropenia, extra precaution should be taken. In the case of uveit...
How do you manage dry eye syndrome due to lacrimal or meiobian gland dysfunction after external beam radiotherapy?
I have also found autologous serum (AS) or platelet-rich plasma (PRP) eye drops/tears to be extremely useful (provided by an ophthalmologist). Dry eye can also be exacerbated by graft vs. host disease, which I have anecdotally seen worsened within radiation fields and is characterized by a lasting m...
How do you manage Cancer-Associated Retinopathy (CAR) in a patient who doesn’t have a known cancer diagnosis, given the difficulty in finding the underlying cancer and the risks of using immunosuppressive treatments to preserve vision?
Auto-immune retinopathy, whether paraneoplastic or non-paraneoplastic, can be a very difficult condition to diagnose and manage. There are a few features that raise suspicion for a paraneoplastic cause particularly, such as rapid progression and more significant intraocular inflammation (anterior ch...
How has your evaluation of IRDs changed with advances in molecular genetics?
Comprehensive medical history and physical examination, and review of all pertinent medical records.
In which cases of post-injection endophthalmitis should early vitrectomy be considered if there is little to no improvement 48 hours after a tap and inject and there is no organism isolated?
Prompt vitrectomy should be considered in all patients with post-injection endophthalmitis (PIE) if there is no improvement 48 hrs after a tap and inject. The initial tap did not identify the organism. Non-infectious endophthalmitis can be included in the differential diagnosis of persistent inflamm...
What is the appropriate interval before safely performing cataract surgery after plaque radiation therapy for iris melanoma?
Great question, but one that requires a nuanced answer. Often, patients with iris melanomas have some degree of lens opacity, and following brachytherapy, the cataract will surely progress. I recommend carefully following up on the iris melanoma after radiation to ensure the lesion is regressing pro...
In what cases do you consider mannitol for cataract surgery?
I have found IV mannitol VERY helpful for dehydrating vitreous for short axial length, especially around 20.5 or less. Otherwise, in short eyes, there is less working space and a greater tendency for the iris to want to prolapse out, even in the absence of typical IFIS-type medications. I’ve typical...
Do you prescribe pre-operative drops prior to cataract surgery, if so which ones and why?
I do not use preoperative drops. There are no published clinical trials that have established any benefit for preoperative antibiotics or NSAIDS. The strongest evidence supports preoperative povidone-iodine drops and intracameral antibiotics such as cefuroxime or moxifloxacin. This has been validate...
What has been your experience adopting office-based surgery and has it meaningfully improved patient access or practice efficiency?
We have demeaned and minimized what we do, and in response, Medicare and insurance companies have decreased our reimbursements. We (ophthalmologists) have advertised how easy cataract surgery is, and in general, what we do, and we are our own worst enemies.
How do you counsel patients with GCA on the benefits of steroids who have already experienced vision loss?
I first tell the patient they are at considerable risk for further visual loss in the same eye or the other eye over the next 1-2 weeks. I also let them know that, even though their risk of visual loss has been reduced, their best option for preventing further visual loss is immediately starting hig...