Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
What is the most appropriate next step for a patient experiencing prolonged hypotony following Ahmed glaucoma valve implantation and unsuccessful medical management?
To reduce aqueous flow through the tube, a less invasive approach involves occluding the tube lumen using a 2-0 or 3-0 Prolene suture via an ab interno technique. For complete occlusion, a Supramid suture may be used instead of Prolene. The ab interno approach minimizes conjunctival disruption. Alte...
What has been your experience with Durysta (bimatoprost implant) for glaucoma management?
Excellent option for glaucoma patients. I have been offering routinely for about a year now. Topicals are also an option, but compliance, insurance coverage, side effects (ocular surface), and monthly cost all affect quality of life and efficacy of treatment. I prefer SLT + Durysta over topical trea...
What is the appropriate interval before safely performing cataract surgery after plaque radiation therapy for iris melanoma?
Great question, but one that requires a nuanced answer. Often, patients with iris melanomas have some degree of lens opacity, and following brachytherapy, the cataract will surely progress. I recommend carefully following up on the iris melanoma after radiation to ensure the lesion is regressing pro...
What is your approach to patients with biopsy proven giant cell arteritis that continue to have symptoms after initiation of high dose glucocorticoid therapy?
First, let's define and discuss “high-dose” steroids. Oral therapy is typically 60-100 mg of prednisone daily, and IV is 500-1000 mg of methylprednisolone daily for three days, followed by oral prednisone. There has been no difference in long-term outcomes for vision loss or diplopia. The complicati...
What factors influence your decision to pursue surgical management in cases of infectious keratitis caused by multidrug-resistant pathogens?
I would consider operating sooner rather than later for a keratitis that’s headed in the wrong direction. It’s important to intervene prior to the development of extensive CNV or limbal involvement or corneal perforation for a more controlled, straightforward operation. The exception may be fungal k...
In cases of congenital ptosis with poor levator function, how do outcomes of frontalis flap suspension compare to silicone rod frontalis sling?
A frontalis flap procedure offers superior cosmesis in that only a lid crease incision is made, and no incisions are made above the brow. However, it does take significant additional operative time to dissect the flap from a single inferior incision. There is the thought that it might be less adjust...
When would you consider discontinuing immunosuppressive treatment in a quiescent uveitis patient without systemic manifestations of inflammation?
I typically monitor patients on immunosuppressive therapy for at least 2 years before considering stopping or weaning off such therapy. There could be exceptions to this, including patients who insist on being taken off their meds (side effects, trying to conceive, etc.), in which case I can try aft...
What is your preferred surgical intervention for children with congenital nystagmus?
Eye-muscle surgery in patients with INS improves their beat-to-beat nystagmus, thus they receive more useful vision per unit time. The common clinical misperception is that eye-muscle surgery only serves to improve "letter" acuity, centralize the INS null position, or reposition the eye(s) in the or...
Which MIGS procedure do you believe provides the most sustainable IOP reduction when performed alongside cataract surgery?
There is no single consensus on this question. There are several MIGS options available in the market, and most glaucoma specialists use only a subset of these options. If you ask five ophthalmologists, you might hear six different answers. I prefer to categorize MIGS into two types: non-filtering a...
What’s your threshold for initiating treatment in patients with optic nerve cupping but normal IOP, normal visual fields, and borderline OCT findings?
My answer relies on the appearance of the OCT findings, the patient's and family history, and the progression over time. A Borderline OCT finding is broad. Patients who have a myopic fundus, or just a displacement of the retinal vessels near the optic nerve, do not worry me, and I choose to wait. If...