Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
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...
When should amblyopia treatment be initiated in patients being treated for retinoblastoma?
There is decent data (small numbers) that amblyopia therapy is beneficial in RB patients, even those with macular/foveal involvement if this is unilateral. The timing for initiation is not clear, however. Treatment initiation is probably most effective once tumor burden is under control enough to ha...
What dose would you use for a plaque brachytherapy for a melanoma involving the iris?
The following isotopes have been used for radioactive plaque therapy to treat choroidal melanomas: 125I, 103Pd, and 131Cs as low-energy seeds, and 106Ru as β emitter. The dose used for uveal melanomas is between 80-90Gy with most studies reporting doses ~85 Shields et al., PMID 10980767. In this lar...