Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
Do you modify your cataract surgery (i.e., biometry, phaco parameters, post-operative regimen) in any way for patients with prior glaucoma surgeries and/or severe glaucoma?
I generally do not modify my cataract surgery settings or pre-op planning. For patients with filtering blebs, I review the risks that cataract surgery could cause increased IOP and in some cases, bleb failure. For patients with filtering blebs who might be on one or more drops, I might consider bleb...
What follow-up monitoring would you recommend for an adult with self-resolved idiopathic acute pupil-sparing third nerve palsy?
Pupil-sparing third nerve palsy is a relatively common presentation for neuro-ophthalmologists. They typically resolve completely by 12 weeks, and I will typically follow them until they are fully resolved, watching them once a month. The most common are microvascular and associated with a variety o...
What is your approach to treatment for recalcitrant MGD?
Recalcitrant MGD is a frequently seen clinical problem, especially in older patients. Standard treatment encompasses warm compresses and lid hygiene. The latter can be performed with over-the-counter lid wipes or simply with baby shampoo. Tropical antibiotics such as Polytrim drops and bacitracin/po...
What is the best time frame to intervene surgically for the management of traumatic macular hole, and what techniques should one consider?
Traumatic macular holes differ from idiopathic holes as a moderate proportion may close spontaneously, particularly in younger patients and with smaller holes. Studies have quoted approximately 40+% spontaneous closure in traumatic macular holes compared to 5% for idiopathic macular holes. For this ...
How do you approach the use of Cequa in eyes with severe corneal thinning from a prior, healed corneal ulcer?
The use of Cequa or other cyclosporins has not been associated with an increased risk of thinning. Cequa prescribing information lists no contraindications and reports instillation site pain and conjunctival hyperemia as the main adverse reactions. Corneal thinning, impaired healing, and perforation...
How do you approach IOL exchange in a patient who is unhappy after cataract surgery with a premium IOL?
The first step is determining why they are unhappy, is it a quality of vision issue? Something else, like diplopia or eye pain? Assuming it's a visual quality issue, the next step is assessing the reason: a careful evaluation of corneal surface (dry eye, ABMD, Salzmann's nodules), evaluating for len...
Do you feel there are medical advantages to FLACS and if so, what are they and how often are you offering FLACS to patients?
That's a question that's sure to trigger contentious responses!Personally, I think the capability of making toric marks on the cornea or lens capsule to line up toric lenses (and using iris registration to do so), as well as the ability to do LRIs, does offer some advantage for accuracy in astigmati...
In what clinical scenarios do you incorporate topical insulin drops to treat persistent epithelial defects?
I often use topical insulin drops in lieu of Oxervate for persistent epithelial defects and neurotrophic cornea. It works well and is much more affordable.
For very low cylinder that does not qualify for a toric lens and no access to femto, do you ever consider LRIs or slightly adjusting your main wound placement (if possible)?
I personally don't do manual LRIs as they can be somewhat unpredictable. Adjusting the main wound to the steep axis can treat 0.1 to 0.3 D due to SIA, so that might be the safest plan if femto is not available. B&L's Envista toric does treat as low as 1.25D, so that may also be an option.
In primary angle closure suspects without cataracts, how do you approach the discussion about LPIs, given the relatively low risk of an acute angle closure attack?
In primary angle closure suspects without cataracts, I will have a discussion about aqueous humor dynamics and outflow mechanisms of the eye, and how that relates to risk stratification in the patient's case. We are fortunate in glaucoma to have a fair bit of evidence to guide us in our clinical dec...