Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you monitor glaucoma progression in highly myopic patients with unreliable visual fields and atypical RNFL scans?
Monitoring glaucoma in highly myopic eyes with unreliable tests is a well-known challenge. Careful clinical examination of the optic nerve, supported by stereo disc photos, remains essential. Myopic discs are often tilted with shallow cupping, making glaucomatous change easy to miss. However, featur...
How much with-the-rule astigmatism would you intentionally leave in patients under 40 undergoing cataract surgery, considering the expected age-related shift toward against-the-rule astigmatism?
IOL selection and expectations are hugely important in this conversation. Will leave less for a multifocal, and more with a standard IOL. A sharpshooter, I might correct all the cyl with a standard IOL, but with the expectation they will need touch-ups. A good place to start is their topo and their ...
What is your preferred approach to managing a patient with tube exposure?
I typically put the patient immediately on a topical antibiotic until I can find OR time to surgically fix. I have seen others try Prokera or amniotic membrane grafts in the clinic if patients are very opposed to surgical correction, though these haven't worked well in my experience. I find that mov...
What are your best strategies for managing intraoperative floppy iris syndrome during cataract surgery when the iris becomes incarcerated in the paracentesis immediately after anterior wound construction?
Look for sources of posterior pressure—lid speculum, patient positioning, breath holding, etc. Remake the paracentesis higher on the cornea. For the main wound, use a longer tunnel and place it higher on the cornea. Try to end the wound at or over the papillary margin. Use Omidria or epi in the bott...
How would you approach the management of HLA-B27-associated recurrent uveitis and inflammatory back pain with a recent history of melanoma?
This is a very practical question (and challenging to answer succinctly as well!). Like many scenarios seen in clinical practice, there is unfortunately less data in the literature than we would like to guide us here. While decent data exists on the risk of incident cancer following exposure to biol...
Is it safe to continue azathioprine in a patient with severe bilateral panuveitis (thought to be related to sarcoidosis) and benign ethnic neutropenia, given worsening neutropenia since starting the medication, or should an alternative immunosuppressive agent be considered?
In this case, I would consider stopping azathioprine and switching to an alternative medication, such as an anti-TNF agent. Although not a large drop in the PMN, azathioprine is known to cause leukopenia, and in a patient with known neutropenia, extra precaution should be taken. In the case of uveit...
What baseline visual testing, if any, do you recommend at diagnosis for patients with multiple sclerosis who deny visual complaints?
I do a baseline eye exam with visual acuity, OCT RNFL, and fundus photos yearly. If I see any abnormalities, then I might consider a repeat exam in six months. If all is normal and there's no history of optic neuritis, I do yearly appointments. If they are on DMTs that have eye side effects, then I ...
How do you manage macular-threatening toxoplasma chorioretinitis in pregnancy?
When contemplating treatment in a pregnant woman, it's always advisable to coordinate care with the managing OB/GYN to ensure the health of both the mother and the fetus. One could consider a treatment course of clindamycin for toxoplasma chorioretinitis, administered systemically with oral pills or...
How do you decide which secondary IOL to place in an aphakic eye?
I am a fan of scleral fixated IOLs as they can be inserted through a smaller corneal incision than ACIOLs, they present less risk when it comes to corneal decompensation and glaucoma, and have predictable refractive outcomes. I personally use a modified needle-assisted Yamane technique for my second...
How do you decide whether to continue hydroxychloroquine in a young patient who develops subretinal neovascularization with no other risk factors?
Hydroxychloroquine (HCQ), an anti-inflammatory and immunomodulatory agent, is used to treat autoimmune diseases (rheumatoid arthritis, lupus, Sjogren’s disease, etc.) and malarial prophylaxis. Vision problems can ensue resulting from these deleterious irreversible effects of HCQ on retina if the cum...