Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
What type of air/SF6 fill do you recommend following DSEAK in patients with scleral fixated IOLs? (i.e., only AC fill vs full eye fluid-gas exchange?)
For these patients, I do a suture pull-through technique with a Prolene suture to anchor the graft at the distal edge. To keep chamber stability and prevent the bubble from moving posteriorly, I suture all wounds, including the paracenteses. I use 18% SF6 or 6% C3F8 and do a full fill. C3F8 has beco...
In patients with progressive AZOOR who demonstrate enlarging zones of outer retinal loss despite corticosteroid therapy, how do you determine when to escalate to steroid-sparing immunomodulatory agents?
We should first be sure this is not a "masquerade" syndrome such as vitreoretinal lymphoma, infectious uveitis, or IRD. If these are considered unlikely, then at this point in the course, where there is documented progression of a presumed inflammatory process, systemic IMT should be considered. Som...
How do you decide between a combined phacovitrectomy approach versus a staged procedure for patients with a retinal detachment and dense cataract?
A primary buckle might be a consideration here to avoid the issue of the cataract altogether. But if planning to add a buckle (with vitrectomy) during these cases, it is impossible to preoperatively perform lens measurements (i.e., axial length), which would be a relative contraindication to perform...
How would you manage a patient who develops a 1 mm abscess at the internal os of the paracentesis tract following an AC tap after an Izervay injection with eye pain but no vitreous cell or retinal involvement?
It sounds like a very specific question! Never having seen a paracentesis ulcer after 30 years of surgeries with paracenteses from iris hooks, and >10s of thousands of injections (albeit mostly without paracenteses), I'd have to say this is rarer than endophthalmitis. Treat it like a corneal ulcer. ...
Who is your ideal candidate for a XEN over other filtering procedures such as trabs or tubes?
I typically reserve the Xen Gel Stent for elderly, Caucasian patients, especially women, with moderate open-angle glaucoma who need better pressure control but don’t require single-digit IOPs. These patients tend to have thinner, less fibrotic Tenon’s capsules and a lower risk of scarring, which all...
What is your preferred surgical approach for revision of an over-filtering bleb?
Hypotony after trabeculectomy is not uncommon, and I generally inform my patients prior to surgery that the risk of hypotony is roughly 10-20%. But, as is well known, not all patients develop hypotony maculopathy or detrimental effects from low IOP, and some patients can do well with IOP in the hypo...
For patients with neovascular glaucoma and uncontrolled IOP, do you ever consider a glaucoma drainage device (GDD) combined with ECP as opposed to just a standalone GDD?
I've never performed those two surgeries together, and I don't know of any papers that looked at that. Many NVG patients who get tubes in my practice are phakic, which makes ECP a non-starter. For the pseudophakic ones, I usually do a tube alone, combined with anti-VEGF and PRP. I would consider ECP...
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...
How do you decide the best way to treat glaucoma in patients with ICE syndrome given their higher risk of surgical failure and corneal complications?
In general, patients with ICE syndrome have unilateral refractory disease that often requires surgical management. MIGS procedures are not typically effective given the angle anatomy and progressive nature of the disease, and I usually perform tube shunt surgery in these cases. Placing the tube deep...
How long should you wait after superficial keratectomy for accurate IOL measurements?
I wait at a minimum of 4 weeks and reassess the topography to see if it stabilizes. If not stable, I will repeat every 4 weeks until stable (usually no more than 3 months needed).