Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you approach IOL calculations and selection in patients with keratoconus based on disease severity?
Lens selection assuming stable KCN and no plan for a transplant: Symmetrical astigmatism and they don't want to wear CL after surgery? Can consider a toric lens. Symmetrical astigmatism and they are okay with continuing RGP/sclerals? Monofocal aberration-free lens. Asymmetrical astigmatism and want...
What is your approach to audiometric monitoring for patients on Teprotumumab and how do you discuss the possibility of irreversible hearing loss with your patients?
I have set up a connection with our institution’s ENT and audiometry service to do a baseline test for any patient who is a candidate for teprotumumab. If the patient already has abnormalities in the high and ultrahigh frequencies, would not proceed to treatment. Would also repeat the test if the pa...
In patients with progressive AZOOR who demonstrate enlarging zones of outer retinal loss despite corticosteroid therapy, how do you determine when to escalate to steroid-sparing immunomodulatory agents?
We should first be sure this is not a "masquerade" syndrome such as vitreoretinal lymphoma, infectious uveitis, or IRD. If these are considered unlikely, then at this point in the course, where there is documented progression of a presumed inflammatory process, systemic IMT should be considered. Som...
How do you approach the management of a patient with psoriasis and chronic anterior uveitis who is unable to take DMARDs and has tried TNF inhibitors and IL-17 inhibitors but has ongoing bilateral anterior uveitis?
Psoriasis is so common that it is possible that this is a chance association, but published studies do support the likelihood that there is a causal association between psoriasis and uveitis and a much stronger association between psoriatic arthritis and uveitis. The choice of therapy depends to a g...
Do you feel there is a role for capsulectomy for failed Ahmed implants and what is your preferred surgical approach?
There can be a role for capsulectomy after a failed Ahmed implant. In situations where a needling/5FU is insufficient, a capsulectomy provides a higher chance of success. Typically, I would dissect from the limbus backwards to the plate, excise as much capsule as possible, then close after ensuring ...
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 ...
What is your approach to managing failed trabeculectomies with scarring but controlled IOP?
It's important to differentiate "controlled IOP" from the controlled rate of disease progression. If IOP is consistently 10-12 in the clinic and HVF and OCT are stable, close observation may be all that is needed. However if the IOP is "controlled" but the HVF shows evidence of progressive functiona...
What is your preferred surgical approach for revision of an over-filtering bleb?
Hypotony after trabeculectomy is not uncommon, and I generally inform my patients prior to surgery that the risk of hypotony is roughly 10-20%. But, as is well known, not all patients develop hypotony maculopathy or detrimental effects from low IOP, and some patients can do well with IOP in the hypo...
Do you stop netarsudil or brimonidine for patients with very injected conjunctiva prior to trabeculectomy, and what do you feel is the benefit?
I find Rhopressa helpful in lowering IOP pre-op surgery, but it can cause inflamed conjunctiva, so I stop 1 week prior to surgery and prefer brimonidine 0.15% (Alphagan P), and it may have neuroprotective value as well.
Which patients are good candidates for micropulse CPC?
Micropulse CPC is a suitable option for treating elevated IOP in a number of scenarios: advanced VF loss resulting in a small central or temporal island, intolerant to topical/oral glaucoma meds, poor general health limiting interventional surgery, no social support, and non-compliance.