Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
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 the decision to escalate from conservative medical therapy to surgical intervention in a patient with EBMD-related recurrent corneal erosions who has not responded to several months of nighttime lubricating ointment?
In the case of recurrent erosion in the setting of EBMD, we first attempt to optimize the conditions for a pristine and smooth ocular surface. This includes non-preserved lubricants, hypertonic saline to avoid swelling and sloughing at night, and treatment of any dry eye and meibomian gland dysfunct...
How do you decide to use MIGS versus traditional surgical options like trabeculectomy or tube shunt placement in the management of glaucoma?
Current IOP and your IOP goal are key. Angle MIGS will typically reduce IOP from the low to mid-20s to the mid to upper teens. I consider Xen a MIBS procedure. I’ve been able to use Xen as my bleb surgery of choice, even in patients who have had multiple prior ocular surgeries, including PPV, tube s...
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, ...
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...
How do you manage uncontrolled glaucoma in patients in their mid 90s and beyond?
This truly depends on their lifestyle, activity level, and mental status. I will still consider trabeculectomy in patients who are highly functional and compliant if their glaucoma is truly uncontrolled and they are losing vision. Trabeculectomy is still a highly effective surgery and elderly patien...
How should diabetic retinopathy surveillance be adjusted for patients starting GLP-1 agonists?
As with traditional anti-hyperglycemic medications, GLP-1 agonists may cause transient worsening of diabetic retinopathy due to the initial rapid control of blood glucose. Therefore, if a patient has existing retinopathy and is about to start GLP-1 agonist therapy, I recommend closer monitoring. For...
When do you consider adding steroids alongside intravenous antibiotics for patients with orbital cellulitis?
If the orbital cellulitis is infectious, I never add steroids. There is no literature or proof that they do anything, and decreasing immunity, in my opinion, is simply a bad idea. If it is inflammatory, then absolutely. Most infectious orbital cellulitis is from the sinuses and is more common in chi...
How do you approach a patient with idiopathic anterior uveitis who has ongoing disease despite adalimumab every two weeks?
This is a style question, I think. I thought it would be useful to note the choice here might depend on testing for anti-adalimumab antibodies as there is some suggestion that changing to once weekly adalimumab in the presence of anti-adalimumab antibodies might not be efficacious. (Ismayilova et al...
For patients with nAMD who are developing GA in the same eye, do you consider adding anti-complement therapy?
My personal perspective, shared by many colleagues around the country, is that the minimal anatomic and functional benefit of anti-complement therapy does not outweigh the aggregate risks and costs of perpetual treatment with these agents. I discuss these issues with my GA patients (including those ...