Ophthalmology
Expert insights on ocular conditions, surgical techniques, retinal disease, and vision-related management.
Recent Discussions
In an elderly patient with limited transportation issues, is there a hypofractionated regimen you have found acceptable for a localized squamous cell carcinomas of the eyelid?
I am fortunate to work with a “XRT for skin cancer” guru, Dr. W.H. Morrison, and sought his counsel to answer this question, as largely with the conversion of skin cancers from a radiation-treatable disease to a surgical disease with the advances in Mohs surgery and oculoplastics, at MDA we rarely s...
What are the pros and cons of Multifocal IOLs vs. EDOF IOLs?
Multifocal IOLs provide excellent near, intermediate, and distance vision with high spectacle independence, making them attractive for patients who prioritize reading and near tasks, but they achieve this via light-splitting diffractive optics that reduce contrast sensitivity and can cause significa...
What factors do you take into consideration when deciding between enucleation and evisceration?
Almost always I perform an eviceration unless there’s a suspected or known tumor. Endophthalomitis is variable. If at surgery there’s no posterior involvement I’ll still do an eviceration. Typically most endophthalmitis has been aggressively treated and gives one the option of doing the procedure wi...
What is the most appropriate next step for a patient experiencing prolonged hypotony following Ahmed glaucoma valve implantation and unsuccessful medical management?
To reduce aqueous flow through the tube, a less invasive approach involves occluding the tube lumen using a 2-0 or 3-0 Prolene suture via an ab interno technique. For complete occlusion, a Supramid suture may be used instead of Prolene. The ab interno approach minimizes conjunctival disruption. Alte...
In quiescent patients with history of herpetic keratouveitis with uncontrolled IOP on topicals, do you prescribe PGAs?
The evidence on prostaglandin analogues (PGAs) in the setting of herpetic anterior uveitis is nuanced. Traditionally, we have been taught to avoid PGAs in the setting of herpetic disease, given the theoretical concerns that these drugs could compromise the host's interferon defense system. But, more...
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 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...
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...
What operative techniques do you use to minimize the risk of postoperative ectropion in a patient with pre-existing lower eyelid laxity undergoing lower eyelid blepharoplasty?
I favor a transconjunctival approach for the fat excision or transposition, combined with either pinch skin excision or CO2 laser resurfacing, and horizontal tightening either by canthopexy (in milder laxity patients) or a full tarsal strip procedure in severe laxity or frankly ectropic patients.
For bilateral cataract surgery, what first-eye events trigger aborting the second-eye surgery that day?
For my immediate sequential bilateral cataract surgeries (ISBCS), any event that could increase the risk of second-eye intraoperative or postoperative complications will trigger the aborting of the second-eye surgery. Additionally, any situation that would require a breach of ISBCS protocol leads to...