Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How does corneal sensation testing play into your evaluation of a patient presenting with a chronic or recurrent epithelial defect of uncertain etiology?
Decreased corneal sensation may indicate the presence of neurotrophic keratitis (NK). The differential for NK is large but common causes are viruses such as HSV/VZV, DES, or diabetic keratopathy. Prior to topical anesthetic, I use a tissue folded to a point and touch the cornea at various locations ...
Do you routinely recommend IV systemic antibiotic therapy in additional to intravitreal antibiotic therapy for exogenous bacterial endophthalmitis?
Post-surgical (exogenous) endophthalmitis is an uncommon complication with the incidence ranging from 0.04%-0.3%, 0.019%- 0.54%, and 0.11% - 0.03% following cataract surgery, intravitreal injection, and vitrectomy, respectively (Soliman et al., PMID 32467482). Initial management of exogenous endopht...
How do you approach tube shunt placement in very high myopes with thin sclera?
Due to decreased scleral rigidity in highly myopic eyes, there is a higher risk of hypotony and hypotony maculopathy with filtering surgeries, including tube shunts. In choosing the type of tube shunts, I would favor a valved tube shunt in high myopes. For surgical technique, I take great care when ...
How do you manage uncontrolled glaucoma in patients in their mid 90s and beyond?
This truly depends on their lifestyle, activity level, and mental status. I will still consider trabeculectomy in patients who are highly functional and compliant if their glaucoma is truly uncontrolled and they are losing vision. Trabeculectomy is still a highly effective surgery, and elderly patie...
How should diabetic retinopathy surveillance be adjusted for patients starting GLP-1 agonists?
As with traditional anti-hyperglycemic medications, GLP-1 agonists may cause transient worsening of diabetic retinopathy due to the initial rapid control of blood glucose. Therefore, if a patient has existing retinopathy and is about to start GLP-1 agonist therapy, I recommend closer monitoring. For...
For patients with nAMD who are developing GA in the same eye, do you consider adding anti-complement therapy?
My personal perspective, shared by many colleagues around the country, is that the minimal anatomic and functional benefit of anti-complement therapy does not outweigh the aggregate risks and costs of perpetual treatment with these agents. I discuss these issues with my GA patients (including those ...
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 ...
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.