Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you decide the best way to treat glaucoma in patients with ICE syndrome given their higher risk of surgical failure and corneal complications?
In general, patients with ICE syndrome have unilateral refractory disease that often requires surgical management. MIGS procedures are not typically effective given the angle anatomy and progressive nature of the disease, and I usually perform tube shunt surgery in these cases. Placing the tube deep...
In patients with a history of retinal vein occlusion, how should the risk of recurrent thromboembolic events influence the selection of osteoporosis therapies?
The FDA-approved prescribing information for raloxifene explicitly lists retinal vein thrombosis alongside deep vein thrombosis and pulmonary embolism as contraindications.
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...
In patients with treated endophthalmitis secondary to a bleb leak, how do you determine timing of revision?
There are really two separate (but related) issues to address here: The infection. This is treated in conjunction with my vitreoretinal colleagues, as it will require intravitreal antibiotics +/- vitrectomy, depending on the degree of posterior segment involvement. Of course, the bleb is also cultu...
Do you re-load with monthly doses when switching a patient with DME from aflibercept to faricimab, or do you transition directly to a treat-and-extend schedule?
When I switch from one anti-VEGF agent to another, I start with the same treatment interval I was using with the previous agent, so I can assess the comparative efficacy of the two agents. Once I have determined the new agent is more effective, I proceed immediately to a treat-and-extend dosing regi...
For those using 5% Betadine as a single-use prep, how are you handling the associated costs or aliquoting?
Very difficult legal question. Other countries make 5 or 10 cc bottles produced by Allergan and other generics for 1 dollar. They are multi-use and sterile. Not legal to import into the USA. By FDA law, for patient use, 10 percent has been used in the USA for 20 years without a significant problem. ...
What has been your experience with dSLT?
Overall positive. The procedure is quick and the interface is intuitive. We have to warn the patients that they are going to feel it, and oh man, if you look at the anterior chamber about 20 minutes after the dSLT, you are going to see a lot of cells floating around there. I have been able to perfor...
What concentration/dose of mitomycin C do you use for trabeculectomies and XENs and how do you titrate based on patient factors?
I use the mitosol kit and reconstitute at 0.2 mg/ml (0.02%). I inject the mitomycin at the end of the case, after ensuring watertight conjunctiva closure by raising a bleb via a corneal paracentesis. My standard dose then is 60 ug injected (0.3ml of 0.2 mg/ml), but I may titrate that dose/volume up ...
Do you modify your cataract surgery (i.e., biometry, phaco parameters, post-operative regimen) in any way for patients with prior glaucoma surgeries and/or severe glaucoma?
I generally do not modify my cataract surgery settings or pre-op planning. For patients with filtering blebs, I review the risks that cataract surgery could cause increased IOP and in some cases, bleb failure. For patients with filtering blebs who might be on one or more drops, I might consider bleb...
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.