Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In a patient with recurrent episodes of GCA that flare shortly after steroid tapering, how do you differentiate between steroid-dependent inflammatory relapse, an alternative autoimmune vasculitic process, and a paraneoplastic phenomenon?
Paraneoplastic disease rarely behaves like GCA with ischemic manifestations. If a non-GCA vasculitis is suspected, perhaps repeat biopsy or serologic testing for other markers could be done. I'm not sure of the value of these tests, however, given that the treatment approach with immunosuppression w...
How do you determine the timing and necessity of surgical removal for retained subretinal perfluorocarbon?
Timing: Defer PFO removal until after you are convinced the retina is attached and will likely stay attached (e.g., after gas resolves or, if under oil, later than 8 weeks). Necessity: Plan for surgical removal if subretinal PFO is foveal or perifoveal. If not, then defer indefinitely unless PFO loc...
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...
Should teprotumumab be used in patients with active, moderate Graves thyroid eye disease in the absence of proptosis?
Proptosis is not the only manifestation of TED. Diplopia and lid retraction are a big deal, and Tepezza can help with this.
When do you use GLP-1 receptor agonists for the management of patients with idiopathic intracranial hypertension (IIH)?
I would use GLP-1 agonists in all overweight IIH patients who did not have a contraindication if it wasn't for the cost. In the IIH treatment trial, 6% weight loss over 6 months lowered intracranial pressure by about 50 mm (acetazolamide also lowered ICP by about 50 mm, but of course, it did it much...
In an elderly patient with limited transportation issues, is there a hypofractionated regimen you have found acceptable for a localized squamous cell carcinomas of the eyelid?
I am fortunate to work with a “XRT for skin cancer” guru, Dr. W.H. Morrison, and sought his counsel to answer this question, as largely with the conversion of skin cancers from a radiation-treatable disease to a surgical disease with the advances in Mohs surgery and oculoplastics, at MDA we rarely s...
When should methotrexate injections be initiated for proliferative vitreoretinopathy?
This is an excellent question with a nuanced answer. Currently, we lack substantial level 1 evidence to guide precise treatment strategies for off-label use of methotrexate (MTX) in the treatment or proliferative vitreoretinopathy (PVR). Based on animal and human clinical retrospective studies, the ...
How do you decide to use MIGS versus traditional surgical options like trabeculectomy or tube shunt placement in the management of glaucoma?
Current IOP and your IOP goal are key. Angle MIGS will typically reduce IOP from the low to mid-20s to the mid to upper teens. I consider Xen a MIBS procedure. I’ve been able to use Xen as my bleb surgery of choice, even in patients who have had multiple prior ocular surgeries, including PPV, tube s...
When have you found benefit combining different MIGS procedures?
The data regarding combining different MIGS procedures are primarily retrospective, non-comparative, subject to selection bias and other biases, and performed in widely varying patient populations that make direct comparison difficult. From a mechanistic standpoint, combining MIGS makes sense, such ...
What should be the first line treatment for metastatic uveal melanoma?
There is no consensus for frontline treatment of metastatic uveal melanoma. A clinical trial would be recommended for all patients if possible. If the disease is only within the liver, consideration of liver directed therapy would be reasonable. For metastatic disease beyond the liver checkpoint imm...