Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In a bedridden, medically fragile patient with a symptomatic conjunctival cyst superior to the limbus, what is the optimal management approach?
I would first attempt medical management with lubricants, ketorolac, olopatadine, and naphazoline. If those failed, then I would use the following drops: topical anesthetic, a vasoconstrictor, and ketorolac twice over a five-minute period, then insert a lid speculum, and unroof the cyst by grasping ...
In quiescent patients with history of herpetic keratouveitis with uncontrolled IOP on topicals, do you prescribe PGAs?
The evidence on prostaglandin analogues (PGAs) in the setting of herpetic anterior uveitis is nuanced. Traditionally, we have been taught to avoid PGAs in the setting of herpetic disease, given the theoretical concerns that these drugs could compromise the host's interferon defense system. But, more...
What do you feel are some of the advantages and disadvantages of dropless cataract surgery and what are your preferred agents?
A clear advantage of dropless surgery is that the patient no longer needs to use post-op drops. This may not necessarily present as an advantage to the surgeon, as any additional techniques will add time and cost to the cataract surgery, especially if a particular technique is not covered by insuran...
What are some special considerations for treatment of glaucoma and IOP lowering in patients with optic disc drusen?
Optic disc drusens (ODDs) in patients with glaucoma provide unique challenges for clinicians. ODDs on the surface of the optic disc are easy to spot; deeper (buried) DDs are difficult to diagnose. They require deeper B-scan cuts or require extended depth (ED) options. One must be cautious not to ove...
In patients with glaucoma who are not ideal candidates for goniotomy, angle stenting, tubes, or trabeculectomy, does the use of AlloFlo provide safe and predictable IOP control compared to other surgical options?
I am cautiously optimistic in this situation, one in which we frequently find ourselves in tertiary care glaucoma practices. I will say that it is helpful to have another option that seems (so far) to be safe, even in severe glaucoma cases. Unfortunately, we are not really going to know about the pr...
How do you approach the treatment of "normal tension glaucoma" and how do you discuss this with patients?
It highlights that glaucoma is probably not an eye pressure disease, but rather a vascular disease. As noted above, there is a genetic component clearly, but vasculopaths (DM, Sleep apnea, CVD, etc.) increase that risk with the same IOP.
How do you decide between initiating systemic immunotherapy versus local treatment for uveitis with associated HLA-B27 and spondyloarthropathy?
I find that most, but not all, HLA-B27 iritis can be controlled with topical therapies. To do so requires eliminating other causes of inflammation. Many patients have GI inflammation due to gluten and dairy, despite not having classic celiac disease or lactose intolerance. Reducing their intake, mod...
How would you treat corneal melt (in the absence of peripheral arthritis) in rheumatoid arthritis?
Corneal melt is a rare, but serious complication of rheumatoid arthritis. It usually occurs in patients who are sero-positive with active joint disease. A viral infection such as herpes simplex could cause a corneal ulcer that would mimic an immune-mediated melt. It is critical to communicate with t...
How do you decide on treatment modality for ocular surface squamous neoplasia?
For primary OSSN, my initial treatment modality will either be wide surgical excision with cryotherapy and amniotic membrane graft or medical treatment with 5-Fluorouracil drops QID x7 days, followed by a 3-week drop holiday. I find that there is little to no downside to trying 5-FU first, given tha...
How do you determine when to discontinue anti-complement therapy in patients with geographic atrophy who already have center-involving disease given the minimal likelihood of central vision improvement but the potential for more rapid scotoma expansion if treatment is withdrawn?
Since these drugs have a significant risk and a marginal benefit, not to mention the significant treatment burden and their outrageous cost, it begs the question of how often they should be used altogether.