Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In patients with myopic traction maculopathy, what clinical and imaging thresholds prompt you to intervene surgically rather than continue observation?
Given the risk of surgery, I typically follow patients conservatively as long as they feel the involved eye (when the other eye is covered) has visual function sufficient for important daily visual tasks such as reading, driving, working, etc. Many eyes continue to have functional vision even with v...
How do you utilize Diamox in patients with cerebral venous sinus thrombosis and vision symptoms who do not undergo thrombectomy/recanalization?
Diamox (acetazolamide) is often used to treat papilledema with associated visual loss in cases of CVST. While there is a theoretical risk of dehydration from acetazolamide with potential worsening of the thrombosis, 1) acetazolamide is a weak diuretic and 2) the risk of blinding visual loss usually ...
How do visual outcomes differ among scleral lenses, refractive surgery, and phakic IOLs in keratoconus patients with irregular astigmatism following cross-linking?
These are three distinct avenues of treatment for KC. The visual disability in keratoconus is secondary to perturbation of the corneal optics. This manifests itself in changes in sphere, cylinder, and optical aberrations. Scleral contact lenses, for the most part, correct all three and often give ex...
How do you approach cases of transient monocular vision loss when initial carotid imaging and cardiac workup are unrevealing?
As you eluded, it is essential to rule out amaurosis fugax in a case of TMVL, and carotid Doppler and cardiac echo are two essential tests to evaluate the two potential sources of embolization in this setting. I would also recommend an MRI of the brain (to check for possible evidence of other ischem...
In patients with progressive AZOOR who demonstrate enlarging zones of outer retinal loss despite corticosteroid therapy, how do you determine when to escalate to steroid-sparing immunomodulatory agents?
We should first be sure this is not a "masquerade" syndrome such as vitreoretinal lymphoma, infectious uveitis, or IRD. If these are considered unlikely, then at this point in the course, where there is documented progression of a presumed inflammatory process, systemic IMT should be considered. Som...
How do you decide between a combined phacovitrectomy approach versus a staged procedure for patients with a retinal detachment and dense cataract?
A primary buckle might be a consideration here to avoid the issue of the cataract altogether. But if planning to add a buckle (with vitrectomy) during these cases, it is impossible to preoperatively perform lens measurements (i.e., axial length), which would be a relative contraindication to perform...
How would you manage a patient who develops a 1 mm abscess at the internal os of the paracentesis tract following an AC tap after an Izervay injection with eye pain but no vitreous cell or retinal involvement?
It sounds like a very specific question! Never having seen a paracentesis ulcer after 30 years of surgeries with paracenteses from iris hooks, and >10s of thousands of injections (albeit mostly without paracenteses), I'd have to say this is rarer than endophthalmitis. Treat it like a corneal ulcer. ...
Who is your ideal candidate for a XEN over other filtering procedures such as trabs or tubes?
I typically reserve the Xen Gel Stent for elderly, Caucasian patients, especially women, with moderate open-angle glaucoma who need better pressure control but don’t require single-digit IOPs. These patients tend to have thinner, less fibrotic Tenon’s capsules and a lower risk of scarring, which all...
What is your preferred surgical approach for revision of an over-filtering bleb?
Hypotony after trabeculectomy is not uncommon, and I generally inform my patients prior to surgery that the risk of hypotony is roughly 10-20%. But, as is well known, not all patients develop hypotony maculopathy or detrimental effects from low IOP, and some patients can do well with IOP in the hypo...
For patients with neovascular glaucoma and uncontrolled IOP, do you ever consider a glaucoma drainage device (GDD) combined with ECP as opposed to just a standalone GDD?
I've never performed those two surgeries together, and I don't know of any papers that looked at that. Many NVG patients who get tubes in my practice are phakic, which makes ECP a non-starter. For the pseudophakic ones, I usually do a tube alone, combined with anti-VEGF and PRP. I would consider ECP...