Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
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 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the minimal likelihood of central vision improvement but the potential for more rapid scotoma expansion if treatment is withdrawn?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.
In extensive basal cell carcinoma involving both upper and lower eyelids and the lacrimal gland, is radiotherapy poorly tolerated (especially to doses up to 50-60 Gy) and/or is orbital exenteration preferred?
For advanced basal cell carcinoma with orbital invasion, I would treat with hedgehog inhibitors. If there is an inadequate clinical response, exenteration is usually recommended. Radiation is not particularly effective for BCC and can have significant ocular side effects.
What specific exam findings or test changes prompt escalation of care when evaluating pediatric patients with optic disc drusen for possible increased intracranial pressure?
Both pediatric and adult patients with optic disc drusen can develop increased intracranial pressure, including IIH, like normal individuals. This is important to remember, especially if the symptoms and risk factors suggest elevated intracranial hypertension. In the pediatric group, especially youn...
How do you incorporate OCT and OCT-A in conjunction with FA in your evaluation of retinal diseases?
There are no clinical or diagnostic factors that predict who will benefit from an intervention for vitreous floaters. Symptomatology from vitreous floaters is subjective. Patient-reported outcome measures after floaterectomy are also subjective. The improvement in symptoms following vitrectomy (I do...
What is your algorithm for transitioning a patient with chronic noninfectious posterior uveitis from corticosteroids to immunosuppressive therapy?
There are some forms of noninfectious posterior/panuveitis where it is known from the time of uveitis diagnosis that steroid-sparing immunosuppression (IMT) will be needed. For example, in birdshot retinochoroiditis or serpiginous choroidopathy, IMT is often initiated in concert with oral corticoste...
How do you decide the threshold and duration of subretinal fluid that can be safely tolerated in exudative AMD when adjusting treat-and-extend intervals?
There are so many other factors at play here. The very nature of this question begs the question of whether you are treating the patient or the OCT. Sadly, it appears the preponderance of patients I have seen are treated at fixed intervals of 1-2 months and no treat and extend, even from physicians ...
How do you approach offering multifocal IOLs to patients with prior retinal pathology and surgery (i.e., mac-off RD) who have had relatively good recovery of vision?
As a retina specialist, I have seen a significant increase, over recent years, in patients doing badly because someone inserted a multifocal IOL in the context of prior or impending retinal disease. In most of these cases, the patients seemed naive to the implications, reporting that they were told ...
In patients with treated endophthalmitis secondary to a bleb leak, how do you determine timing of revision?
There are really two separate (but related) issues to address here: The infection. This is treated in conjunction with my vitreoretinal colleagues, as it will require intravitreal antibiotics +/- vitrectomy, depending on the degree of posterior segment involvement. Of course, the bleb is also cultu...