Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In cases of failed endothelial keratoplasty with concurrent cataract, do you favor repeat keratoplasty plus lens extraction in the same setting or sequential surgeries?
I tend to favor combining the two into one surgery. If the view is not clear enough or the patient is interested in a more accurate refractive outcome, the surgery can, of course, be staged with the endothelial keratoplasty first, followed by cataract surgery about 3 months or so later. With the use...
What is the role of topical aqueous suppressants as an adjunct to intravitreal anti-VEGF therapy in patients with persistent macular edema despite optimized injection frequency depending on etiology of ME?
Interesting question: It isn't stated what the cause of the macular edema is. In the only two indications for which there is evidence that anti-VEGF injections can have value (RVO and DME), there is little evidence of aqueous suppressants being of any value. So, in my opinion, non-intersecting sets....
For bilateral cataract surgery, what first-eye events trigger aborting the second-eye surgery that day?
For my immediate sequential bilateral cataract surgeries (ISBCS), any event that could increase the risk of second-eye intraoperative or postoperative complications will trigger the aborting of the second-eye surgery. Additionally, any situation that would require a breach of ISBCS protocol leads to...
How do you counsel patients when discussing risks/benefits of ECP vs. CPC?
I don't regularly use ECP, but I have a lot of experience with micropulse CPC (referred to as MP-TLT or MPCPC) and traditional CPC. Firstly, although MPCPC involves less energy compared to traditional CPC, that does not mean that the procedure is without risk. Because of these risks, MPCPC should no...
What has been your experience with netarsudil in the management of corneal edema, particularly concerning its clinical effectiveness and insurance coverage?
I don't use netarsudil to treat corneal edema - I have discontinued it in patients who developed reticular epithelial edema (aka honeycomb edema), which is a rare but reported side effect with unclear mechanism. If elevated IOP is thought to be contributing to corneal edema, I typically use aqueous ...
What has been your experience with occluder contact lenses for intractable diplopia?
Poor, I’ve had better luck with scotch tape on one glasses lens placed in the center. It usually only needs a piece about an inch by an inch. This allows peripheral vision. Unfortunately, many don’t want to do this.
What work-up do you recommend for optic nerve edema in a patient who is immunocompromised?
Symptoms (is visual loss present or not?) and time of onset/pace help to direct the workup. For unilateral optic nerve edema with vision loss, optic neuritis and NAION are always high on the differential. In immunocompromised patients, an infectious cause such as herpes zoster, syphilis, TB, and art...
How do you differentiate between macular schisis vs. macular edema vs. optically empty spaces (from macular telangiectasia) on OCT?
When trying to differentiate between these identities, I begin by looking at the morphology of the intraretinal fluid-filled spaces on OCT imaging. The cystoid spaces in macular edema caused by vascular leakage or medications (e.g., niacin) are typically round in shape and increase in size toward th...
For those using 5% Betadine as a single-use prep, how are you handling the associated costs or aliquoting?
Very difficult legal question. Other countries make 5 or 10 cc bottles produced by Allergan and other generics for 1 dollar. They are multi-use and sterile. Not legal to import into the USA. By FDA law, for patient use, 10 percent has been used in the USA for 20 years without a significant problem. ...
How has OCT and OCT-A technology impacted your use of FA in the evaluation of retinal diseases?
Over the course of my practice, OCT Angiography (OCT-A) has become my primary daily scan, dramatically reducing my reliance on fluorescein angiography (FA). The OCT-A image is accompanied by a structural OCT image and minimal additional time is required for its acquisition. High-resolution OCT-A fre...