Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you decide between a combined phacovitrectomy approach versus a staged procedure for patients with a retinal detachment and dense cataract?
A primary buckle might be a consideration here to avoid the issue of the cataract altogether. But if planning to add a buckle (with vitrectomy) during these cases, it is impossible to preoperatively perform lens measurements (i.e., axial length), which would be a relative contraindication to perform...
How would you manage a patient who develops a 1 mm abscess at the internal os of the paracentesis tract following an AC tap after an Izervay injection with eye pain but no vitreous cell or retinal involvement?
It sounds like a very specific question! Never having seen a paracentesis ulcer after 30 years of surgeries with paracenteses from iris hooks, and >10s of thousands of injections (albeit mostly without paracenteses), I'd have to say this is rarer than endophthalmitis. Treat it like a corneal ulcer. ...
In patients with myopic traction maculopathy, what clinical and imaging thresholds prompt you to intervene surgically rather than continue observation?
Given the risk of surgery, I typically follow patients conservatively as long as they feel the involved eye (when the other eye is covered) has visual function sufficient for important daily visual tasks such as reading, driving, working, etc. Many eyes continue to have functional vision even with v...
When should you seek hyperbaric oxygen therapy for patients with CRAO?
I usually pursue hyperbaric oxygen therapy within the 24-hour window from symptom onset for CRAO. This can be performed following TNK if given. In reality, though, there are multiple barriers to achieving this, including: Few centers offer hyperbaric oxygen therapy Labor intensive Difficulty with i...
What type of air/SF6 fill do you recommend following DSEAK in patients with scleral fixated IOLs? (i.e., only AC fill vs full eye fluid-gas exchange?)
For these patients I do a suture pull through technique with a prolene suture to anchor the graft at the distal edge. To keep chamber stability and prevent the bubble from moving posteriorly, I suture all wounds including the paracenteses. I use 18% SF6 or 6% C3F8 and do a full fill. C3F8 has become...
In primary angle closure suspects without cataracts, how do you approach the discussion about LPIs, given the relatively low risk of an acute angle closure attack?
In primary angle closure suspects without cataracts, I will have a discussion about aqueous humor dynamics and outflow mechanisms of the eye, and how that relates to risk stratification in the patient's case. We are fortunate in glaucoma to have a fair bit of evidence to guide us in our clinical dec...
In what cases do you consider mannitol for cataract surgery?
I have found IV mannitol VERY helpful for dehydrating vitreous for short axial length, especially around 20.5 or less. Otherwise, in short eyes, there is less working space and a greater tendency for the iris to want to prolapse out, even in the absence of typical IFIS-type medications. I’ve typical...
Who is your ideal candidate for a XEN over other filtering procedures such as trabs or tubes?
I typically reserve the Xen Gel Stent for elderly, Caucasian patients, especially women, with moderate open-angle glaucoma who need better pressure control but don’t require single-digit IOPs. These patients tend to have thinner, less fibrotic Tenon’s capsules and a lower risk of scarring, which all...
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...
Do you stop netarsudil or brimonidine for patients with very injected conjunctiva prior to trabeculectomy, and what do you feel is the benefit?
I find Rhopressa helpful in lowering IOP pre-op surgery, but it can cause inflamed conjunctiva, so I stop 1 week prior to surgery and prefer brimonidine 0.15% (Alphagan P), and it may have neuroprotective value as well.