Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
Is there benefit for anterior chamber washouts for the treatment of infectious keratitis extending into the anterior chamber and when do you consider utilizing it?
When it comes to corneal infections, there is no evidence that an 'anterior chamber washout' and putting antibiotics in the AC does anything. In ophthalmology, we can 'carpet bomb' the cornea with antibiotics. Fungal infections and acanthamoeba are much harder to treat, but still not clear than doin...
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, ...
What is the role of bilateral same-day cataract surgery in your practice?
Like many things in medicine, sometimes there are mental hurdles to jump over that are more challenging than operational or evidence-based hurdles. We perform many invasive procedures, bilateral same day: laser vision correction, intravitreal injections, phakic IOLs, etc. Yet many of us, myself incl...
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....
In eyes with lamellar macular holes, what clinical or OCT features push you toward recommending surgery versus continued observation?
Most published papers and my personal surgical experience suggest that surgery on eyes with a lamellar hole alone (i.e., without a significant associated ERM) RARELY yields visual improvement. For this reason, I generally discuss the surgical option only in patients with progressive expansion of lam...
How do you decide on treatment modality for ocular surface squamous neoplasia?
For primary OSSN, my initial treatment modality will either be wide surgical excision with cryotherapy and amniotic membrane graft or medical treatment with 5-Fluorouracil drops QID x7 days, followed by a 3-week drop holiday. I find that there is little to no downside to trying 5-FU first, given tha...
What is your approach for treating allergic conjunctivitis in a patient who has failed ketotifen and olopatadine?
Agree with Dr. @Dr. First Last - and for in-office treatments, I've been increasingly impressed with Rinsada irrigation in some cases (rinse out the fornix, which seems to trap some allergens there), as well as mitigation and desensitization therapy if the allergist can find specific allergens to fo...
How do you approach patient selection for starting intravitreal complement inhibitors?
Because complement inhibition seems to have only a modest effect on GA progression, no clear functional benefit in pivotal trials, and a not-insignificant risk of CNV and optic neuropathy, I tend toward a conservative view when deciding whether to recommend it to patients. A good candidate, in my v...
For patients with evidence of prior bilateral uveitis (PS, pupillary membranes, inactive KP, no view posteriorly) who reports no prior symptoms and who has had negative lab work-up, when do you consider repeat work-up and which labs would you repeat?
This is a difficult question to answer succinctly, as so much information is missing to provide a complete response. However, it does raise some important points that are worth mentioning:There is a prevailing tenet, which I was taught as a resident and hear often from residents today, that 1st epis...
When should you consider referral to neuro-ophthalmology or neurology for ocular migraines?
"Ocular" migraine is really a misnomer. Scintillating scotoma/teichopsia (which leads the patient to seek medical attention) has a cortical, not ocular, origin with the possible exception of the rara avis of retinal migraine. If the patient identifies "build-up" of classic teichopsia (Airy 1870), in...