Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
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...
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 ...
How do you manage a situation where the lens optic shifts in front of the iris after a Yamane technique?
This issue typically occurs in myopic eyes with "floppy" iris characteristics and has less to do with the optic shifting anteriorly, but more with the iris shifting posteriorly. Reverse optic capture of the IOL optic by the iris can best be prevented by performing a peripheral iridotomy at the time ...
How do you approach the management of indeterminate orbital lesions in asymptomatic patients with inconclusive imaging findings?
I feel like there is a specific case here. If so, I’d love to hear the details. That said, I’d return to the differential diagnosis of orbital masses/issues with the popular VEIN mnemonic - vascular, endocrine (thyroid), inflammatory, and neoplastic. While inflammatory lesions are commonly painful, ...
How do you approach the timing of vitrectomy in non-clearing vitreous hemorrhage secondary to proliferative diabetic retinopathy?
In patients with regressed PDR following complete PRP, the timing of vitrectomy for non-clearing vitreous hemorrhage depends on the patient's overall visual needs, fellow eye status, etc. In such patients, assuming the ultrasound shows the retina to be attached, I consider the vitrectomy to be a non...
How do you manage cystoid macular edema (CME) unresponsive to topical treatments in steroid responders?
Management depends on the underlying etiology of the CME. If the cause is primarily vascular, anti-VEGF therapy is typically the first-line treatment. If the CME is inflammatory in nature and continued steroid therapy is desired, I collaborate closely with a glaucoma specialist to determine if IOP c...
How do you decide on a steroid sparing agent for idiopathic orbital inflammation partially responsive to steroids?
Idiopathic orbital inflammation is a diagnosis of exclusion which is usually supported by orbital imaging and/or biopsy. It is important to exclude other causes of orbital inflammation which include thyroid eye disease, ANCA-associated vasculitis, sarcoidosis, histiocytosis, infection, or metastatic...
How do you manage periocular reconstructive surgery in patients with advanced orbital fractures and concurrent soft tissue injuries?
First and foremost is triage - increased intracranial pressure from intracranial bleeding and other life-threatening injuries must first be ruled out, and the patient stabilized. Next, open globe injuries need to be ruled out with a thorough ophthalmic exam, including dilation. Entrapped extraocular...