Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
In an elderly patient with limited transportation issues, is there a hypofractionated regimen you have found acceptable for a localized squamous cell carcinomas of the eyelid?
I am fortunate to work with a “XRT for skin cancer” guru, Dr. W.H. Morrison, and sought his counsel to answer this question, as largely with the conversion of skin cancers from a radiation-treatable disease to a surgical disease with the advances in Mohs surgery and oculoplastics, at MDA we rarely s...
In quiescent patients with history of herpetic keratouveitis with uncontrolled IOP on topicals, do you prescribe PGAs?
The evidence on prostaglandin analogues (PGAs) in the setting of herpetic anterior uveitis is nuanced. Traditionally, we have been taught to avoid PGAs in the setting of herpetic disease, given the theoretical concerns that these drugs could compromise the host's interferon defense system. But, more...
What brain imaging findings do you find reliable to help support a diagnosis of idiopathic intracranial hypertension?
In a study by Bidot et al., PMID 26457687, transverse venous sinus stenosis (TVSS) was the most useful sign of IIH because of its high pooled sensitivity (97%) and specificity(93%). Orbital findings, such as optic nerve head protrusion, posterior scleral flattening, optic nerve tortuosity, and diste...
Do you still obtain Tensilon (edrophonium) testing for myasthenia gravis, and what do you feel is the added value over serum testing?
Edrophonium has not been available commercially for years. Neostigmine can be used intramuscularly instead, given with atropine, and the effect assessed 30-45 minutes later. Some seronegative patients will have a positive test, so it can be helpful when you still suspect myasthenia and want further ...
In phacomorphic glaucoma with limited view, how do you approach surgical management (i.e., staged or combined surgery, temporize with LPI)?
In true phacomorphic glaucoma, the definitive treatment is cataract extraction. I first focus on medically lowering the IOP, and if the cornea is hazy, I do everything possible to clear it to obtain a safe surgical view. If the view remains limited, I’m comfortable using the biometry from the fellow...
If a patient is legally blind and on hydroxychloroquine, do you still recommend follow up with ophthalmology to monitor for hydroxychloroquine retinal toxicity?
A patient who is legally blind but taking hydroxychloroquine absolutely needs to be monitored by an ophthalmologist. The usual definition of legal blindness in the United States is vision no better than 20/200 in the better-seeing eye. But 20/200 is far better than say counting fingers (the ability ...
For a patient with orbital sarcoidosis who has achieved sustained clinical remission on adalimumab in combination with mycophenolate mofetil, how long would you recommend continuing mycophenolate before considering a gradual taper and discontinuation?
Unfortunately, there is no sarcoidosis-specific evidence or guideline that sets how long to continue mycophenolate once orbital disease is in remission. Most of this data is extrapolated from other studies that indirectly measure disease flares. Alipour et al., PMID 40316030, published a study in Re...
What factors guide your decision to test for or start empiric treatment for Acanthamoeba keratitis in cases of corneal ulcers?
I can't say that I've ever started empiric treatment for acanthamoeba keratitis prior to other workup/testing/culture results, although I suppose if you have a slam dunk case with a known acanthamoeba exposure, I would do so. The question of whether to test for AK is far more interesting. New-onset ...
How has immediate patient access to their medical records changed your documentation?
Sadly, EMR has destroyed medical records... trying to figure out what happened, etc., is like an archaeological dig.