Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
Do you incorporate diurnal or nocturnal IOP measurements in your management of progression despite seemingly adequate daytime control?
The advent of home-based tonometry can make diurnal or nocturnal IOP measurements more convenient to obtain, though the cost of renting or buying these devices may be prohibitive for some patients. Glaucoma specialists sometimes use diurnal or nocturnal IOP measurements to identify whether there are...
In patients with end-stage glaucoma requiring surgery (cataract or incisional glaucoma surgery), how do you approach discussion of possible "snuff" and how does this factor in your decision to proceed with surgery?
I have operated on hundreds, if not thousands, of patients with end-stage glaucoma over my career. Many CAT IOL + bleb surgery or Cat IOL alone. I cannot remember a snuff directly related to surgery. Judicious use of ER acetazolamide immediately postoperatively goes a long way. If cat IOL alone and ...
What is your approach to antiviral treatment of HSV acute retinal necrosis?
Acute Retinal Necrosis (ARN) is a rapidly progressive syndrome usually caused by varicella-zoster virus (VZV)and herpes simplex virus 1 or 2 (HSV). The syndrome is rapidly progressive in the absence of antiviral treatment. PCR performed on aqueous or vitreous sampling is highly sensitive and strongl...
Do you routinely recommend IV systemic antibiotic therapy in additional to intravitreal antibiotic therapy for exogenous bacterial endophthalmitis?
Post-surgical (exogenous) endophthalmitis is an uncommon complication with the incidence ranging from 0.04%-0.3%, 0.019%- 0.54%, and 0.11% - 0.03% following cataract surgery, intravitreal injection, and vitrectomy, respectively (Soliman et al., PMID 32467482). Initial management of exogenous endopht...
In pediatric RRDs associated with high myopia or Stickler syndrome, how do you decide between scleral buckle alone versus combined vitrectomy and buckle?
Most of the time, a buckle works great. If there is posterior PVR that will not relax with a buckle or there is a GRT, then a vitrectomy will be necessary.
In patients with glaucoma who are not ideal candidates for goniotomy, angle stenting, tubes, or trabeculectomy, does the use of AlloFlo provide safe and predictable IOP control compared to other surgical options?
I have used it on one patient with severe glaucoma and a poor filtration bleb candidate. Bilateral implants. Pre-surgery IOP mid 20’s 4 meds. Now on latanoprost OU, IOP 15 OU. Now PO 3-4 months. Alloflo literature I believe shows a 40% reduction in IOP with a 40% reduction in medications at the 2-3 ...
What is an effective technique for obtaining tissue for pathological analysis from a broad-based luminal punctal/canalicular mass?
If there is enough representative tissue outside of the punctum/canaliculus proper, then it can be incised sharply like any other marginal lesion (I prefer a 15-blade and Westcott scissors). If the pathology is limited to the lumen, then a modified punctoplasty could be considered. Dilate the punctu...
What treatment strategies do you use to reduce the risk of post-herpetic neuralgia after herpes zoster ophthalmicus?
For prevention, our best tool is the VZV vaccine (Shingrix). I recommend that all patients over age 50 consider receiving it. However, if an individual develops VZO and has persistent pain, I begin with antiviral therapy to assess whether subclinical viral activation is contributing to the pain (dur...
What is your perspective on using AI with OCTA to assess optic nerve blood flow in glaucoma management?
OCTA provides quick, reliable 3D scans that reveal both structural (NFLA, ON rim, cupping, GCC thickness, FAZ) and vascular (VD retina and ONH) information. Thus, it fulfills the requirements of both the mechanical and vascular theories. However, the busy ophthalmologist must scan through over 30 va...
How do you determine the appropriate toric IOL when there is a discrepancy in axis or cylinder power between optical biometry and corneal tomography during preoperative evaluation?
Always difficult. Always re-measure when discrepancies occur. For axis discrepancies, Auto Ks, topography, biometry, and past refraction. Past refraction is where the patient lived their entire life before their cataract surgery. Which of these tests aligns the most? Past refraction, especially pre-...