Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
How do you decide when to give or defer intracameral antibiotics for endophthalmitis prophylaxis during routine cataract surgery?
I give intracameral antibiotics at the conclusion of all my cataract surgeries, and this practice is heavily supported by evidence.In particular, I use non-diluted moxifloxacin 0.05-0.1cc, from a Vigamox brand bottle or bottle of generic moxifloxacin from a few select manufacturers that are known to...
How has the ADVISE trial changed your approach to steroid sparing agents for non-infectious uveitis?
The ADVISE trial was a well-designed, multinational trial that compared adalimumab therapy for non-infectious intermediate, posterior, or panuveitis versus conventional immunosuppressive therapy or CID. Two hundred twenty-seven subjects were enrolled over four years, and a fifth year was required to...
How do you sequence IV steroids and IGF-1R blockade when inflammatory activity and proptosis coexist in a patient with active thyroid eye disease (TED)?
I don't find that steroids are actually necessary for patients who are receiving IGF1R inhibitors. The inflammation typically responds quite well to Teprotumumab (haven't tried Veligrotug yet), so steroids don't really add any benefit. These days, I only use IV steroids for patients who can't get IG...
How often do you recommend ophthalmologic screening exams for patients with sarcoidosis?
The American Academy of Ophthalmology has guidelines for routine eye exams for an asymptomatic, healthy individual (not someone with sarcoidosis). These guidelines include a complete, dilated eye exam at age 40, interim exams at the discretion of the patient and one's ophthalmologist, and an exam ev...
How do you differentiate between macular schisis vs. macular edema vs. optically empty spaces (from macular telangiectasia) on OCT?
When trying to differentiate between these identities, I begin by looking at the morphology of the intraretinal fluid-filled spaces on OCT imaging. The cystoid spaces in macular edema caused by vascular leakage or medications (e.g., niacin) are typically round in shape and increase in size toward th...
How do you approach treatment of eyelid sarcoma?
I have not personally 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.
What factors guide your decision to perform subretinal fluid drainage during primary scleral buckle surgery for a rhegmatogenous retinal detachment?
Since external drainage of subretinal fluid is the step in scleral buckle surgery associated with the greatest risk of serious complications (i.e. subretinal hemorrhage, retinal perforation, retinal incarceration), I only drain if the subretinal fluid so bullous that drainage is necessary to insure ...
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...