Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you decide where to place the LPI for angle-closure glaucoma?
For narrow angles, I place it somewhere in the inferotemporal iris in a crypt. I do not use an Argon laser. With the YAG laser at 7 mJ (though different lasers may be more or less). Offset at +250 and only one burst, I can typically get through with 2-4 shots in most irides unless there is absolutel...
What has been your experience with standalone canaloplasty or phaco/canaloplasty in terms of IOP lowering?
As is oftentimes the case with these procedures (the various minimally invasive glaucoma surgeries), results will vary based on surgeon and patient selection. I have found canaloplasty helpful, though I tend to combine it with some percentage of trabeculotomy (i.e., I'd do 360 canaloplasty with 180 ...
How important are retinal fluid fluctuations for long-term vision and how do you factor them in when making treatment decisions for conditions like nAMD and DME?
I think the question has been asked in a different form here. As I have commented on Mednet previously, it depends on a lot of factors, primarily: Are you treating the OCT or the patient? I'd also say the answer is very different for nARMD (or any CNVM) DME or edema from RVO. People: this is not a o...
What has been your experience with the travoprost intracameral implant (iDose)?
My experience has been positive, but I consider patient selection prior to surgical planning to be crucial. At this time, I am mostly targeting mild to moderate POAG patients who are on 1-3 glaucoma medications (at least one being a PGA). I usually perform the iDose along with cataract surgery and a...
In a patient with prior cataract surgery in one eye with an unknown monofocal lens, how do you approach selection of a monofocal in the second eye?
The choice is completely dependent on the patient and the physician's discretion and discussion. No one choice for everyone.
Which MIGS do you feel has the most durable IOP lowering effect?
There is a lack of high-quality comparative efficacy data for the wide variety of MIGS available. The HORIZON randomized clinical trial demonstrates that the Hydrus Microstent can have IOP-lowering effects and medication reduction benefits in some patients at 5 years after surgery. Proponents of can...
How do you manage a twice-recurrent mucinous adenocarcinoma of the lower eyelid with direct involvement of the lateral rectus muscle and lacrimal duct?
These are difficult cases. In the past, I have successfully treated a couple of these tumors with neoadjuvant immunotherapy, which allows for reduction in tumor volume to allow for an eye-sparing surgery. Because the orbit is involved, radiation should not be given due to the profound complications ...
How effective is weight loss in improving visual function in IIH and how much weight loss/what strategies (i.e., formal exercise program, weight loss medications) do you recommend/counsel patients on?
Weight loss is a cornerstone of IIH management because it lowers intracranial pressure (ICP), which in turn improves papilledema and visual function. It works but should not be used alone for cases with moderate or progressive visual loss. In the IIH Weight Trial,[1] the magnitude of weight loss cor...
When eyelid tissue loss is substantial, when is staged reconstruction preferred over primary closure?
Tissue is rarely actually missing, but more often rolled up or difficult to identify. If tissue is truly missing (most often from a dog bite more than any other type of trauma, in my experience), this question would need to be addressed on a case-by-case basis. There are a number of factors to consi...
How do you approach cases of zonular dehisence/weakness noticed intra-op?
For dehiscence of less than 90 degrees, placing CTR seems the safest and easiest way. Published studies suggest CTR use in zonular dialysis or weak zonules can improve postoperative visual or refractive outcomes in many cases. For 180 degrees of zonular loss, I try to preserve the anatomy if possibl...