Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
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 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...
In eyes with chronic DME despite frequent anti-VEGF, what is your threshold to add or switch to intravitreal steroid therapy?
I’m quick to add steroids to anti-VEGF treatment. If there is little to no response to 3 anti-VEGF injections, adding a dexamethasone implant (Ozurdex) can help a lot. I will usually do that before switching in class. I usually switch to a different anti-VEGF if there is good but incomplete response...
How does a history of malignant glaucoma in one eye influence your surgical approach to the fellow eye, particularly regarding prophylactic/intra-operative measures (i.e., iridotomy, IZH)?
Although this is not a common occurrence, a history of malignant glaucoma in one eye will affect my surgical planning in the fellow eye. I have performed a prophylactic IZH in the fellow eye during cataract surgery. Additionally, I make sure that when appropriate, all fellow eyes have received a las...
What surgical strategies do you recommend for managing isolated skew deviation after stroke?
Skew deviation is a tough matter to diagnose and treat, but as a general fact the most cases of skew deviations occur along with an acute stroke or as a consequence of demyelinating disorders. Thankfully, most of them tend to disappear after a few weeks and rarely require treatment. Between the chro...
In cases of failed endothelial keratoplasty with concurrent cataract, do you favor repeat keratoplasty plus lens extraction in the same setting or sequential surgeries?
I tend to favor combining the two into one surgery. If the view is not clear enough or the patient is interested in a more accurate refractive outcome, the surgery can, of course, be staged with the endothelial keratoplasty first, followed by cataract surgery about 3 months or so later. With the use...
What is the value of resection in high risk (but small or early stage) skin cancers at the medial canthus?
The value of resection of a high risk small or early stage skin cancer at the medial canthus is potential assurance of complete removal of the skin cancer by confirmation of negative margins. Depending on the extent of disease and surgical approach, this may or may not be straightforward. There are ...
In phacomorphic glaucoma with limited view, how do you approach surgical management (i.e., staged or combined surgery, temporize with LPI)?
In true phacomorphic glaucoma, the definitive treatment is cataract extraction. I first focus on medically lowering the IOP, and if the cornea is hazy, I do everything possible to clear it to obtain a safe surgical view. If the view remains limited, I’m comfortable using the biometry from the fellow...
How do you balance empiric therapy and diagnostic testing in severe pediatric conjunctivitis presentations?
It depends on the meaning of "severe pediatric conjunctivitis." There are 3 main types of pediatric conjunctivitis that being bacterial, viral, and allergic. Viral needs to be broken down into viral and herpes viral, in the way they are treated. For routine pediatric conjunctivitis, which does not i...