Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How would you approach the management of a patient presenting with bilateral central corneal perforations following treatment with Ipilimumab/Nivolumab?
I am aware of at least one case report describing this situation (Aschauer et al., PMID 36072439).Ideally, the offending medication is halted, but when dealing with life-threatening cancer, this may not be possible, especially if the treatment is working. In the acute setting, trying to stabilize th...
Is there a role for PDT in a young patient with PXE and bilateral CNVM who requires intravitreal anti-VEGF injections every 4 weeks and is beginning to develop atrophy?
I am not a fan of PDT for patients who are developing incipient atrophy. The question says anti-VEGF therapy is being given every 4 weeks, but it is not clear what agent is being used. I would try 2nd generation therapy such as faricimab, 8 mg aflibercept, or possibly brolucizumab (after discussion ...
In what scenarios do you consider using an amniotic membrane graft for macular hole closure?
Given that the success rate of closing macular holes is excellent when the hole is worth closing, and that there are no studies demonstrating the benefit to the patient of amniotic membranes for (presumably) very large and chronic holes, I can't recommend this approach. Having said that, I have no e...
How do you balance medical management versus additional glaucoma surgery in patients with advanced glaucoma who develop IOP elevation after healing from a trabeculectomy revision for bleb leak complicated by prior suprachoroidal hemorrhage?
This is a very complicated case, and I will commend you for handling such a case. I would typically start with medical management, and if the glaucoma is sufficiently controlled, then that would be sufficient. However, given the progressive and complex nature of glaucoma, the pressures may not be ad...
What strategies do you use to improve Jones tube tolerability in patients who require CPAP therapy?
I have seen infections from CPAP in a patient who has never had surgery. Lower lid punctum plugs helped considerably. I’ve not seen this in a Jones tube patient. I’m sure any patient manipulating the tube would be unsuccessful. Plugging the tube with anything physical is unlikely to be possible. The...
How do you incorporate intravitreal methotrexate injections into the management of traumatic retinal detachment repairs?
I do not use intravitreal methotrexate after ocular trauma. I assume the question is directed at the prevention and/or treatment of PVR. Multiple studies have shown this medication is not effective in the treatment or prevention of PVR.
How do you decide on when to start or continue anti-VEGF injections during pregnancy?
The safety of anti-VEGF medications in pregnant women hasn't been adequately evaluated with regard to fetal safety. If at all possible, I don't initiate anti-VEGF injections during pregnancy. If a patient is currently on anti-VEGF therapy and then becomes pregnant, I hold treatment at that point. Id...
How do you approach patient selection for starting intravitreal complement inhibitors?
Because complement inhibition seems to have only a modest effect on GA progression, no clear functional benefit in pivotal trials, and a not-insignificant risk of CNV and optic neuropathy, I tend toward a conservative view when deciding whether to recommend it to patients. A good candidate, in my v...
Do you routinely perform ILM peeling in all epiretinal membrane (ERM) cases or do you selectively peel based on OCT features and membrane characteristics?
With rare exceptions, I peel ILM in all ERM cases for two main reasons. First, it is the best way (and in some cases the only way) to ensure that the ERM is removed completely, thereby avoiding the postoperative scenario of persistent ERM causing persistent visual symptoms. Second, there is good evi...
How do you approach the use of tPA in patients undergoing PPV for endophthalmitis when dense fibrin or membranes are present preoperatively?
I have never used it if planning to go to the OR for endophthalmitis. I remove any anterior segment membranes surgically with forceps or the cutter to facilitate my view of the posterior segment. I do know some retina specialists who use it in non-surgical endophthalmitis patients to accelerate the ...