Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
Which patients do you routinely prescribe ketorolac for after cataract surgery?
I recommend bromfenac (not ketorolac) to all patients undergoing cataract surgery - based on work by Drs. @Dr. First Last and John Whittpen that found that starting topical NSAIDs 1-3 days preop provided. Lower risk of CME Larger pupils throughout cataract surgery Less discomfort during cataract su...
What has been your impression of the clinical outcomes for photobiomodulation for dry AMD?
I’m not impressed by a 2.4-letter improvement over placebo after 27 treatments. It sounds like noise and can be compared to a drop of preservative-free artificial tears. It’s not like we have tons of clinic availability to spend our time on such trivial improvements. We need a better assay to find t...
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...
How do you counsel patients with GCA on the benefits of steroids who have already experienced vision loss?
I first tell the patient they are at considerable risk for further visual loss in the same eye or the other eye over the next 1-2 weeks. I also let them know that, even though their risk of visual loss has been reduced, their best option for preventing further visual loss is immediately starting hig...
In bilateral sequential NAION, do you expect any progressive worsening of OCT/VF years from the ischemic event and when would you have these patients evaluated for another progressive optic neuropathy?
One should not see progressive loss of vision years after the initial insult with NAION. One may see variability in the automated field testing, but it should not be steady progression. OCT should be at its lowest nadir for both rNFL and GCL by 6 months, without further loss beyond age-appropriate c...
Has adopting a 3D heads-up digital visualization system changed your approach to anterior segment surgical teaching of residents or fellows?
We have been using NGENUITY to teach our cornea fellows, residents, and med students for the last 3-4 years. It has been a tremendous addition because it allows multiple people to have a real-world view, not just one surgical assistant. In addition, visiting students who may not be approved to scrub...
Do you feel there is value to getting endothelial cell counts in the absence of frank edema/visual significance in your management endothelial dystrophies?
I would, yes, mostly for patient understanding of their condition and following up on it objectively. There is a clinical benefit, but it is limited. Clinically, I use it to give the patients an assessment about their risks of edema post cataract surgeries or to push for early cataract surgeries in...
How do you manage Cancer-Associated Retinopathy (CAR) in a patient who doesn’t have a known cancer diagnosis, given the difficulty in finding the underlying cancer and the risks of using immunosuppressive treatments to preserve vision?
Auto-immune retinopathy, whether paraneoplastic or non-paraneoplastic, can be a very difficult condition to diagnose and manage. There are a few features that raise suspicion for a paraneoplastic cause particularly, such as rapid progression and more significant intraocular inflammation (anterior ch...
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 ...
What has been your experience adopting office-based surgery and has it meaningfully improved patient access or practice efficiency?
We have demeaned and minimized what we do, and in response, Medicare and insurance companies have decreased our reimbursements. We (ophthalmologists) have advertised how easy cataract surgery is, and in general, what we do, and we are our own worst enemies.