Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In eyes with lamellar macular holes, what clinical or OCT features push you toward recommending surgery versus continued observation?
Most published papers and my personal surgical experience suggest that surgery on eyes with a lamellar hole alone (i.e., without a significant associated ERM) RARELY yields visual improvement. For this reason, I generally discuss the surgical option only in patients with progressive expansion of lam...
How has your use of SLT changed given the 6-year results of the LiGHT trial?
I offer primary SLT to almost all of my treatment-naive patients with OHTN or POAG, and most patients with mild-moderate disease who have never received SLT. I counsel patients that with primary SLT, they are less likely to show disease progression at 6 years and less likely to require incisional gl...
In clinical practice, how can AMD imaging biomarkers guide risk stratification and shape discussions with patients regarding prognosis and monitoring?
When I see a patient with intermediate AMD, if I see biomarkers on OCT such as hyperreflective foci (HRF), drusen that have hyporeflective cores, lots of drusenoid deposits, acquired vitelliform lesions, or areas of thick basal laminar deposit, I realize that patient is at higher risk for progressio...
What is your preferred regimen for treating recalcitrant and recurrent macula-threatening ocular toxoplasmosis?
Treatment options for ocular toxoplasmosis include: Trimethoprim/sulfamethoxazole (Bactrim) Azithromycin Pyrimethamine + sulfadiazine + folinic acid Atovaquone Oral clindamycin Intravitreal clindamycin I usually start with Bactrim DS PO BID. If a patient is sulfa allergic or pregnant, I start with a...
What alternative treatment strategies can be considered for pediatric patients with idiopathic choroidal neovascularization (CNVM) who require q4 week intravitreal anti-VEGF injections?
My experience in children with CNVM is that they do not need continuous injections. Always add an STK at the time of intravitreal injections. AND most importantly, many kids will let you inject them awake just like adults. Something that needs to be discussed with the patients themselves. If a kid s...
How do you manage checkpoint inhibitor-associated Vogt-Koyanagi-Harada (VKH) disease in patients who have poorly controlled diabetes?
Management of ocular inflammation secondary to immune checkpoint inhibitors (ICPIs) is a balance between managing ocular disease and not negatively impacting treatment of the underlying malignancy. If there is ICPI-associated VKH disease with serous retinal detachment, use of corticosteroids is unav...
What intra-op and post-op strategies maximize the longevity of a functional bleb in younger patients?
Great question, and one which I hope others will chime in on. Intraoperatively, I really want to ensure a broad dissection of Tenon's capsule from the underlying sclera to allow diffuse flow of aqueous into the subconjunctival space. I inject MMC (0.2mg/ml) rather than use sponges, so I like to ensu...
How would you approach the management of posterior uveitis caused by Toxoplasma gondii in immunocompromised patients, considering the potential for atypical presentations and treatment resistance?
There are no established studies to confirm the best medications and duration for the treatment of toxoplasmosis retinitis. The recommendations are based on experience and consensus. Further, I am not sure how you established resistance since one rarely has the organism to test, and there is no rout...
What is the role of bilateral same-day cataract surgery in your practice?
Like many things in medicine, sometimes there are mental hurdles to jump over that are more challenging than operational or evidence-based hurdles. We perform many invasive procedures, bilateral same day: laser vision correction, intravitreal injections, phakic IOLs, etc. Yet many of us, myself incl...
How do you determine the timing and necessity of surgical removal for retained subretinal perfluorocarbon?
Timing: Defer PFO removal until after you are convinced the retina is attached and will likely stay attached (e.g., after gas resolves or, if under oil, later than 8 weeks). Necessity: Plan for surgical removal if subretinal PFO is foveal or perifoveal. If not, then defer indefinitely unless PFO loc...