Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
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 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 a patient with recurrent episodes of GCA that flare shortly after steroid tapering, how do you differentiate between steroid-dependent inflammatory relapse, an alternative autoimmune vasculitic process, and a paraneoplastic phenomenon?
This could certainly be worrisome for a paraneoplastic phenomenon. GCA is associated disproportionately with myeloid lineage mutations (CHIP - clonal hematopoiesis of indeterminate significance). TET2 is think is the best-studied mutation, but in my experience, any other CHIP mutations such as ASXL1...
How would you approach management of nodular scleritis in the setting of suspected GCA?
Scleritis is probably a rare but real association with GCA. The rarity is such that I would not ignore alternative causes of scleritis. For example, ANCA-associated vasculitis could mimic GCA and syphilis has also been reported as a masquerade. Scleritis is usually divided into 5 forms: nodular, dif...
How do you approach treatment of eyelid sarcoma?
I have personally not treated eyelid sarcoma but have treated SCC and adenexal carcinoma both definitively and in adjuvant settings. I have used 60 and 66 Gy in 2 Gy per fraction for adjuvant and definitive patients respectively with electrons using appropriate eye shielding.
How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?
I'm definitely not an expert in this topic, but you have many clinical tools to increase/decrease your clinical suspicion for GCA vs. cardioembolic stroke. Some things I would ask: Is this patient currently in Afib? What's their CHADSVASC? Are they anticoagulated? Can we get a TTE to check for vege...
Do you steer away from PRK when chronic pain history is present in an otherwise appropriate refractive surgery candidate?
There is not enough data to support the theory that patients with a history of pain may have more complications in PRK like slow or non-healing epithelial defects and neuropathic pain. However, I personally push patients toward femto LASIK when they qualify for both PRK and femto LASIK. The main rea...
How do you approach evaluating patients with suspected neuropathic corneal pain?
Start by taking a good history. Certain diagnoses, such as diabetes, previous cranial surgery, and/or radiation, and a history of varicella zoster keratitis should make you suspicious. If you suspect neurotrophic disease, don’t put any drops in the eye until you’ve had a chance to visually inspect t...
What is your approach to intralesional steroid injection for chalazia (in terms of dosage, approach, timing)?
I offer the option of intralesional steroid to all patients with chalazia, particularly if there is significant inflammation present. I give up to 1 cc of a 10 mg/mL solution of dexamethasone. I have approached this by both transconjunctival as well as transcutaneous. I think transconjunctival hurts...
How do you decide whether to continue hydroxychloroquine in a young patient who develops subretinal neovascularization with no other risk factors?
Hydroxychloroquine (HCQ), an anti-inflammatory and immunomodulatory agent, is used to treat autoimmune diseases (rheumatoid arthritis, lupus, Sjogren’s disease, etc.) and malarial prophylaxis. Vision problems can ensue resulting from these deleterious irreversible effects of HCQ on retina if the cum...