Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In a patient with prior cataract surgery in one eye with an unknown monofocal lens, how do you approach selection of a monofocal in the second eye?
The choice is completely dependent on the patient and the physician's discretion and discussion. No one choice for everyone.
Which MIGS do you feel has the most durable IOP lowering effect?
There is a lack of high-quality comparative efficacy data for the wide variety of MIGS available. The HORIZON randomized clinical trial demonstrates that the Hydrus Microstent can have IOP-lowering effects and medication reduction benefits in some patients at 5 years after surgery. Proponents of can...
How do you manage a twice-recurrent mucinous adenocarcinoma of the lower eyelid with direct involvement of the lateral rectus muscle and lacrimal duct?
These are difficult cases. In the past, I have successfully treated a couple of these tumors with neoadjuvant immunotherapy, which allows for reduction in tumor volume to allow for an eye-sparing surgery. Because the orbit is involved, radiation should not be given due to the profound complications ...
How effective is weight loss in improving visual function in IIH and how much weight loss/what strategies (i.e., formal exercise program, weight loss medications) do you recommend/counsel patients on?
Weight loss is a cornerstone of IIH management because it lowers intracranial pressure (ICP), which in turn improves papilledema and visual function. It works but should not be used alone for cases with moderate or progressive visual loss. In the IIH Weight Trial,[1] the magnitude of weight loss cor...
How do you optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...
When eyelid tissue loss is substantial, when is staged reconstruction preferred over primary closure?
Tissue is rarely actually missing, but more often rolled up or difficult to identify. If tissue is truly missing (most often from a dog bite more than any other type of trauma, in my experience), this question would need to be addressed on a case-by-case basis. There are a number of factors to consi...
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 approach cases of zonular dehisence/weakness noticed intra-op?
For dehiscence of less than 90 degrees, placing CTR seems the safest and easiest way. Published studies suggest CTR use in zonular dialysis or weak zonules can improve postoperative visual or refractive outcomes in many cases. For 180 degrees of zonular loss, I try to preserve the anatomy if possibl...
Do you feel there is a role for capsulectomy for failed Ahmed implants and what is your preferred surgical approach?
There can be a role for capsulectomy after a failed Ahmed implant. In situations where a needling/5FU is insufficient, a capsulectomy provides a higher chance of success. Typically, I would dissect from the limbus backwards to the plate, excise as much capsule as possible, then close after ensuring ...
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...