Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
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...
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...
How do you determine the timing of surgical intervention for traumatic cataracts in children?
When it is visually significant or blocking the view to the posterior pole.
How do you determine whether to proceed with topography-guided PRK, lamellar keratoplasty, or a full-thickness transplant in patients with irregular astigmatism and corneal scarring?
Start with a rigid gas permeable refraction. If the vision can be improved to a satisfactory level, then something like topography-guided PRK could be considered, or simply fit the patient in a RGP/Scleral lens. If the vision is still not adequate, a lamellar keratoplasty can be considered. Although...
In a patient with isolated HLA B27+ anterior uveitis, how long would you continue immunosuppressive therapy?
Although the majority of patients with Human Leukocyte Antigen B27 (HLA B27)-associated recurrent, acute anterior uveitis have some evidence of spondyloarthropathy, this disease does occur sometimes with clinical disease only in the eye. The disease is not usually chronic (i.e., lasting longer than ...
Would you consider using a JAK inhibitor for a patient with RA associated scleritis?
Yes, I have used it before with success when with limited options. I recommend speaking to the MSL from one of the JAKi developers and they can provide the data to make an informed decision or to appeal to insurance if denied.