Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
When should you seek hyperbaric oxygen therapy for patients with CRAO?
I usually pursue hyperbaric oxygen therapy within the 24-hour window from symptom onset for CRAO. This can be performed following TNK if given. In reality, though, there are multiple barriers to achieving this, including: Few centers offer hyperbaric oxygen therapy Labor intensive Difficulty with i...
How do you balance medical management versus additional glaucoma surgery in patients with advanced glaucoma who develop IOP elevation after healing from a trabeculectomy revision for bleb leak complicated by prior suprachoroidal hemorrhage?
This is a very complicated case, and I will commend you for handling such a case. I would typically start with medical management, and if the glaucoma is sufficiently controlled, then that would be sufficient. However, given the progressive and complex nature of glaucoma, the pressures may not be ad...
What is your approach to incorporating IPL therapy for meibomian gland dysfunction?
We use a protocol that treats the whole upper and lower eyelid, and periocular area that includes the brow, crows feet and lower eyelid/cheek junction. We treat the nose as well. That said, I don’t believe a study exists to support IPL/BBL for MGD control, and IPL is questionable as a treatment for ...
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...
What is your go-to multifocal lens?
As of today, the Alcon PanOptix for most patients who want a multifocal-type outcome. But more importantly, I think matching the strengths/weaknesses/side effect profile of each lens type with each patient's optical system and expectations. Well-controlled head-to-head studies regarding this would b...
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...
Is there benefit for anterior chamber washouts for the treatment of infectious keratitis extending into the anterior chamber and when do you consider utilizing it?
Regarding bacterial infections, I have never felt the need to perform an anterior chamber washout, as vancomycin and tobramycin drops have good intraocular penetration. You do not want to go do a washout on a reactive hypopyon, and many times it is hard to differentiate a reactive hypopyon from an e...
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 your experience, what factors prompt you to switch a patient with diabetic macular edema to Eylea HD?
In my practice, it isn’t switching to longer acting anti-VEGF, it is the treatment of the peripheral retinal ischemia. I often initially treat CSME with Avastin, but I use an IVFA to evaluate and treat the non-perfused retina with laser. It is the PRP that treats the VEGF production driving the diab...
What strategies do you use to improve Jones tube tolerability in patients who require CPAP therapy?
I have seen infections from CPAP in a patient who has never had surgery. Lower lid punctum plugs helped considerably. I’ve not seen this in a Jones tube patient. I’m sure any patient manipulating the tube would be unsuccessful. Plugging the tube with anything physical is unlikely to be possible. The...