Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
Have you found a successful treatment option for fixed Descemet's folds following prolonged hypotony (after hypotony has been treated/resolved) or Descemet's striae from a surgical incision?
These are difficult situations. The best success I have had is doing DSEKs and suturing the graft in 4 quadrants with 10-0 nylon to prevent detachment. It takes longer to clear but prevents detachment, and the sutures can be removed once the edema is clear. The lifespan of these transplants is inher...
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...
How do you determine when to discontinue anti-complement therapy in patients with geographic atrophy who already have center-involving disease given the minimal likelihood of central vision improvement but the potential for more rapid scotoma expansion if treatment is withdrawn?
Since these drugs have a significant risk and a marginal benefit, not to mention the significant treatment burden and their outrageous cost, it begs the question of how often they should be used altogether.
What are some methods to deal with IOP elevations with intravitreal injections in a patient without glaucomatous damage that does not want to have AC taps with each injection?
In this situation, depending on the elevated IOP, use the standard medical approach: Iopidine1%, Cosopt, Alphagan 0.2%, and in some cases, Diamox 250 mg. Wait for half an hour and repeat if necessary, or send the patient home with one or more drugs. Of course, make sure of drug selective contraindic...
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 myopic traction maculopathy, what clinical and imaging thresholds prompt you to intervene surgically rather than continue observation?
Given the risk of surgery, I typically follow patients conservatively as long as they feel the involved eye (when the other eye is covered) has visual function sufficient for important daily visual tasks such as reading, driving, working, etc. Many eyes continue to have functional vision even with v...
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 ...
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 intralesional steroid injection for chalazia (in terms of dosage, approach, timing)?
I offer the option of intralesional steroid to all patients with chalazia, particularly if there is significant inflammation present. I give up to 1 cc of a 10 mg/mL solution of dexamethasone. I have approached this by both transconjunctival as well as transcutaneous. I think transconjunctival hurts...
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...