Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you approach the management of patients with one clinical demyelinating event and MOG+ antibody status?
I do not always treat a MOG+ single event (isolated optic neuritis, isolated transverse myelitis, or ADEM-like presentation) as it is possible that it might be a one-time-only event (as might occur after a viral illness or vaccination). If there has been "dissemination in time", then I would conside...
How do you diagnose and treat patients who develop uveitis while on bisphosphonate therapy for osteoporosis?
Ocular inflammation, usually anterior uveitis, can occur as a consequence of bisphosphonate therapy. Virtually always, the bisphosphonate is one that is given intravenously and the ocular inflammation begins a day or two after the treatment. Furthermore, the inflammation is generally self-limited; i...
What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?
If at all possible, I continue to use tocilizumab as a glucocorticoid sparing agent for patients with giant cell arteritis. Given the results of the GIACTA trial, the Villiger trial, and lots of observational data, it is clear that tocilizumab provides efficacy in terms of reducing risk of relapse a...
How do you approach the management of acute attacks of MOGAD-associated optic neuritis?
If vision loss is severe and has not improved after corticosteroids/IVIG, I would consider plasma exchange (PLEX). Although we do not have controlled studies of PLEX in MOGAD, it is often used for cases of fulminant demyelination in other neuroinflammatory disorders.
Would you consider use of belimumab in a patient with SLE with recurrent anterior uveitis who failed other treatment options?
First, uveitis in SLE certainly happens, but it is rare, occurring in less than .5% of patients. So, we have scant evidence on how to treat it beyond case reports (to my knowledge). I have had SLE patients with uveitis (including anterior uveitis), but all responded fortunately to hydroxychloroquine...
What is your approach to evaluation of underlying autoimmune disease in patients with bilateral scleromalacia?
Scleromalacia perforans is an uncommon form of scleritis wherein there is scleral melt in an otherwise white/quiet appearing eye. The most common systemic association for scleromalacia perforans is with long standing rheumatoid arthritis. Other etiologies of scleritis should also be considered: syst...
Would you recommend medical therapy for asymptomatic idiopathic intracranial hypertension with completely normal visual field testing?
If this patient has asymptomatic papilledema from idiopathic intracranial hypertension, then I might focus on weight loss first, which can be curative. I would follow her visual fields closely, however, and would have a low threshold to start acetazolamide if any change in her visual fields is noted...
How do you evaluate asymptomatic patients referred for benign intracranial hypertension?
"Benign intracranial hypertension" is not really the preferred term for pseudotumor cerebri or idiopathic intracranial hypertension (IIH) anymore, as the phenomenon can lead to permanent vision loss and thus cannot be considered truly benign. Having said that, if the patient has no symptoms (no blur...
How do you evaluate patients who have panuveitis without any systemic symptoms?
Although many patients with panuveitis or another anatomic subset of uveitis might have a systemic disease such as sarcoidosis, Behcet's disease, ankylosing spondylitis, or inflammatory bowel disease, often a systemic disease is not diagnosable. A thorough history is the best way to suspect a system...
What is your approach to management of ongoing scleritis in SLE despite mycophenolate?
Around 1 out of every 50 SLE patients will develop scleritis. It is essential that the rheumatologist work closely with the ophthalmologist. We (rheumatologists) are important due to our knowledge and experience with immunosuppressants, while the ophthalmologist is essential in assessing disease act...