Author Archives: Scott Pautler

Serine and MacTel

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What is MacTel?

MacTel (Macular Telangiectasia) is a degeneration of the center of the retina (called the macula) that affects central vision. The macula is a type of nerve tissue that works to give sharp central vision to read and see fine details. There is evidence that an amino acid called serine plays a role in the cause MacTel.1

How does serine relate to MacTel?

Serine is an amino acid that is used by the body to build proteins and lipids. If this building block is not used properly by the body, abnormal nerve lipids (deoxysphingolipids) may accumulate and damage nerve cells.

 In an inherited condition (hereditary sensory and autonomic neuropathy type 1) an abnormal enzyme causes abnormal nerve lipids in the body and can cause nerve damage. Peripheral nerve damage may cause numbness and tingling of the hands and feet. Autonomic nerve damage may interfere with internal organ function (e.g. intestines, bladder, heart). In addition, these patients frequently develop MacTel.  

Even without this inherited condition of neuropathy, patients with MacTel often have low blood levels of serine that result in high blood levels of abnormal nerve lipids. These abnormal nerve lipids have been shown to damage retinal cells and likely play a role in loss of vision in MacTel.

 What can be done with this information?

At present (1-2020) the authors of the research paper advise against starting treatment based on their paper. They caution that more research is needed. However, the FDA found that over-the-counter L-serine supplements to be generally safe. One study found the use of L-serine (400mg/kg/day) safely lowered the abnormal nerve lipids in a case of hereditary sensory and autonomic neuropathy.2 Side effects of taking L-serine include stomach discomfort, diarrhea, constipation, and frequent urination. Most supplements come in the form of capsules containing L-serine 500mg. It is unknown what dosage might be most effective for MacTel. A patient may wish to take the dosage recommended on the bottle by the manufacturers.

Check for current prices of L-serine on Amazon.

Another option is the use of fenofibrate, a prescription medication that can lower the abnormal nerve lipid levels. This option may be especially useful in patients with MacTel who have abnormal cholesterol and/or triglycerides because fenofibrate has already been approved for use in the treatment of these conditions apart from potential benefit for MacTel. 

In general, patients with MacTel who also have symptoms of sensory or autonomic neuropathy should notify their retinal specialist and internist for additional testing and consider treatment.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

References:

1. Gantner, et al. Serine and lipid metabolism in macular disease and peripheral neuropathy. N Eng J Med 2019;10:1422-1433.

2. Auranen et al. Clinical and metabolic consequences of L-serine supplementation in hereditary sensory and autonomic neuropathy type 1C. Cold Spring Herb Case Stud 2017;3:6.

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Step Therapy

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What is Step Therapy?

In August 2018 the Centers for Medicare and Medicaid Services (CMS) introduced “step therapy” to Medicare Advantage plans.  CMS is the federal government agency that administers the Medicare program.  Step therapy is concept in which doctors are required to use inexpensive medications before they use more expensive medications without regard to how well the medications work and what side effects might be caused by the medications.  Medicare Advantage is a type of medical insurance provided by Medicare with the primary goal of reducing the costs of medical care.  Private insurance companies have followed the Medicare Advantage lead in implementing step therapy in 2019.

What eye medications are affected by step therapy?

The most common effect step therapy has had on eye care is in the use of antiVEGF medications. AntiVEGF medications are a group of drugs that have in common the ability to stop abnormal blood vessels from growing and leaking in the eye.  They help control abnormal blood vessels that can lead to blindness from a number of diseases including macular degeneration (caused by age, near-sightedness, and other conditions) macular edema, retinal vein occlusion, and diabetic eye disease.  

Why are antiVEGF medications targeted?

There is a large price difference among antiVEGF drugs.  The most commonly used antiVEGF drugs include Avastin, Lucentis, Eylea, Beovu, and Vabysmo. While a dose of Avastin costs about $50, the price of Lucentis, Eylea, and Beovu is about $2,000 per dose.  Due to an unexpected fluke, Avastin was found to be very effective in the treatment of eye disease AFTER it had been approved by the FDA and priced by the drug company for the treatment of colon cancer.  Because only a fraction of a vial of Avastin is used in the eye, the cost to treat eye disease is fairly low.  Lucentis and Eylea underwent lengthy study to gain approval by the FDA for the treatment of eye disease.  As a result, the drug companies were allowed under current law to set a higher price. 

Are the antiVEGF drugs equal in safety and effectiveness?

Although there are no major differences in safety and effectiveness in most patients, there are some differences among the antiVEGF drugs that might be important in individual patients.  Silicone oil droplets from the syringe may cause bothersome, persistent floaters.  This appears to be more common with Avastin.  Also, Avastin may place an eye at increased risk of infection and blindness because it must be packaged twice.  The potency of the drugs appears to be less with Avastin than Lucentis, which appears to be less potent than Eylea.  This difference in effectiveness may be important in certain patients.  The ophthalmologist (fellowship-trained retinal specialist) is in the best position to make recommendations for the patient. 

What can a patient do?

If step therapy is deemed not desirable by a patient, he or she may consider avoiding medical insurance coverage that mandates step therapy, such as Medicare Advantage.  If step therapy is required by an existing insurer, the doctor may be forced to use Avastin for initial treatment.  Often, the choice of medication may be changed after three or more injections if the treatment effect can be shown to be ineffective to the satisfaction of the insurance company.  

How might the government have handled this issue better?

A better solution to the problem of controlling the costs of medications is competition.  Competition fosters efficiency.  Current federal laws inhibit competition by not allowing Medicare to negotiate prices of medications.  Other laws require excessively expensive and inefficient processes to develop new drugs.  The unintended consequence of these laws was that drug companies lost incentive to develop better drugs.  To compensate drug companies for the laws that cause the high costs required to bring new drugs to market, the government passed more laws that barred competition and allowed drug companies to charge high prices for their drugs.  This was supposed to help drug companies recoup the costs of drug development.  However, the price of lack of competition and high drug costs is born by the patient.    

The government can lower drug costs by increasing competition.  Although Europe is not efficient by any stretch of the imagination, even they have more efficient systems in place for drug development compared with the United States.  The FDA attempts to manage new drug development, but its regulations and processes need to be streamlined.  Patent laws that prevent competition need to be reviewed.  The government can provide a platform to open price negotiation with drug companies.  Doctors should be allowed back into the scene as advocates for their patients instead being gagged by insurance companies due to government regulations.  Patients should be given a transparent view of the process of drug efficacy and pricing. 

By Scott E. Pautler, MD  

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Stem Cell Therapy for Macular Degeneration

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globe anatomy
anatomy of the eye (click on image to enlarge)

What is stem cell therapy?

            Although there is on-going research to refine the use of stem cells to treat conditions like macular degeneration with the hope of halting or recovering lost vision, there is currently no proven therapy available in the United States. Unfortunately, private clinics have started promoting potentially blinding “cell therapy” for numerous problems including macular degeneration. The concept is that cells will be harvested from a number of sites (usually fat) and then injected into the eye. The promise is that this treatment will help treat eye disease.

What is the danger of stem cell therapy given in this fashion?

            Stem cell therapy provided in these clinics has resulted in blindness/loss of the eye. Injections given into the eye have caused bleeding, scarring, and retinal detachment with loss of vision. The reason for the loss of vison may include the types of cells that are injected and the method of injection. There does not appear to be any uniformity of cell type that is used. In addition, the method of injection appears to be into the vitreous gel of the eye. This may create inflammation in the vitreous that results in scar tissue and traction on the retina. Inflammation and scar tissue formation in the vitreous may result in blindness from retinal detachment.

What is a patient to do?

            It is very frustrating to lose vision from macular degeneration. Currently, FDA-approved treatments help many patients, but fall short of a cure. It is understandable for a desperate patient to seek care where hope is offered. However, current “cell therapy clinics” are not the answer. Seek the advice of your trusted ophthalmologist and utilize low vision care with magnification. Await the results of FDA-sponsored clinical trials to find safe and effective treatments for macular degeneration. 

By Scott E. Pautler, MD

Copyright  © 2019 Designs Unlimited of Florida.  All Rights Reserved.

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Uveitis Diagnosis by Subtype

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Anterior Uveitis

Mimics: leukemia, lymphoma, RBCs, pigment dispersion, foreign body

Granulomatous:Non-Granulomatous:
SarcoidosisHLA B27
TBHerpes Group (esp unilateral)
Herpes groupTINU (esp acute/bilateral)
ToxoplasmosisFuch’s Uveitis (heterochromia)
SO/VKHJIA
Blau Syndrome (child)Spirochetes (Syphilis, Lyme)
Bactrim etcBehcet 
Moxifloxacin (iris transillumination)Post-infectious/reactive 
Spirochetes (Syphilis, Lyme)Other: Posner Schlossman or drug-related
MS associated uveitis 
Lens induced 

Intermediate uveitis 

(Primary vitreous involvement +/-retinal vascular sheathing, CME, disc edema)

Infectious:       Non-Infectious:
SyphilisMultiple Sclerosis
TBSarcoidosis
Lyme DiseaseInflammatory bowel dz (Crohns, UC)
Bartonellosis (cat scratch) 
Toxocara (unilateral) 
HTLV-1 (joint/CNS findings) 
Whipple’s Disease (bowel and neuro dz) 
?Toxoplasmosis 

Retinitis (chorioretinitis)

(Mimics: lymphoma, leukemia, met carcinoma, focal ischemia) Rule Out Infection!

Note: multimodal imaging is especially helpful in white dot syndromes

Infectious:    Non-Infectious:
Toxoplasmosis (most common focal)White dot syndromes (e.g. APMPPE)
Herpes group (HSV/VZV/CMV)Acute macular neuroretinitis (AMN)
SyphilisBehcet Disease
Bartonella (cat scratch) 
DUSN 
Toxocara 
Lyme Disease 
Endogenous fungus or bacteria 
Emerging (Dengue, Yellow fever, West Nile) 

Choroiditis:

(mimics: benign and malignant tumors, Leukemic/lymphoproliferative infiltrates, scleritis)

Infectious:Non-Infectious:
SyphilisSarcoidosis
Lyme DiseaseAPMMPE
TB (including Serpiginous-like)Multifocal Choroiditis (+/- panuveitis)
Endogenous fungal/bacterialPunctate Inner Choroiditis (PIC)
Cryptococcus (rare)Ocular Histoplasmosis Syndrome
Coccidiodomycosis (rare)Birdshot Choroiditis
Emerging dz (West Nile Virus)Serpiginous and Relentless Placoid 
 Blau Syndrome (AD, sarcoid-like)

Panuveitis:

Infectious:Non-Infectious:
SyphilisSarcoidosis
TBMultifocal Choroiditis with Panuveitis
ToxoplasmosisVKH
ARN/PORNSympathetic Ophthalmia
Endogenous fungal/bacterial 
Lyme Disease 
Onchocerciasis (outside US) 

Retinal Vasculitis:

Infectious:Non-Infectious:
SyphilisSarcoidosis
Herpes group (Frosted branch)Eales Disease (?TB)
para-viral syndromeSLE, PAN, Churg Strauss, Wegener
HIVBirdshot (before choroiditis)
ToxoplasmosisMultiple Sclerosis
 Behcet Disease
Primary Artery:Primary Vein:Arteries and Veins:
SyphilisSarcoidosisMS
Herpes GroupEales DiseaseBehcet Disease
SLE, PAN, Churg Strausspara-viral syndromesWegener
Frosted Branch AngiitisHIVFrosted Branch Angiitis
 Toxoplasmosis 
 Birdshot (before choroiditis) 

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2019-2022 Designs Unlimited of Florida.  All Rights Reserved.

Beovu for Macular Degeneration

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globe anatomy
anatomy of the eye (click on image to enlarge)

What is Beovu therapy?

            Beovu (pronounced “BEE oh view”) therapy is a treatment for wet-type macular degeneration (AMD).  It was approved by the FDA in the United States in 2019. It involves repeated injections of medication into the eye to stop abnormally leaky blood vessels. Other similar medications include Avastin, Lucentis, Eylea, and Vabysmo.

How effective is Beovu therapy?      

            Beovu was proven in FDA-approved studies to be as effective as Eylea. In wet-type macular degeneration, injections of Beovu over a one-year period offered a 95% chance of losing less than three lines on a standard eye chart. The results with Beovu were similar to treatment with Eylea; however, Beovu appeared to stop leakage in wet AMD more often than Eylea. Beovu therapy often starts with injections every 4-6 weeks. Afterwards, the injections may be given every two or three months to maintain vision. Half of eyes treated in a large study could be managed with injections every three months. At this time, it is not known whether Beovu is more effective than Eylea due to limitations in the studies to date.   

What are the risks of Beovu therapy? 

            Severe complications are very rare, but risks of Beovu injection include inflammation (~10%), artery occlusion (~3.4%), bleeding, infection, retinal detachment, glaucoma, cataract, and loss of vision/loss of the eye. When inflammation occurs, it may affect the blood flow to the retina with an overall risk of ~3.4% in Beovu-treated eyes. This complication may result in permanent and profound loss of vision. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor. In initial studies there appeared to be a low risk of stroke with Beovu therapy. The risk of stroke may be related to the older age of patients in which it is used. Further investigation will provide more information. Pregnancy should be avoided while on Beovu therapy. Currently, caution is used in recommending Beovu due to the risk of inflammation and loss of vision, which appears greater than other available medications. In 2022, a new medication, Vabysmo, was approved by the FDA. Vabysmo may offer the advantage of less frequent injections like Beovu, but with a lower risk of inflammation.        

What do I expect after a Beovu injection?

Be careful not to rub the eye after the injection because the eye may remain anesthetized for several hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after the injection. On the day of injection, Tylenol or Ibuprofen may be used if there is discomfort after the injection, but severe pain should be reported to your doctor without delay. It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. After the day of injection, if you develop new floating dots, new pain, and/or loss of vision, contact your doctor.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright ©2019-2022 Designs Unlimited of Florida.  All Rights Reserved.

Pentosan (Elmiron) and Your Eyes

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See Anatomy of the Eye

What side effects can pentosan polysulfate have on my eyes?

Although pentosan polysulfate (PPS) is of proven benefit for interstitial cystitis, it may cause damage to the eyes.  Early symptoms may be subtle.  Blurred vision, especially with reading, is common.  Straight lines may appear wavy or distorted.  There may be a slow adaptation from light to dark environments.  Blind spots or missing areas may occur in the central vision.  These symptoms are due to retinal damage; however, they are not specific to pentosan polysulfate damage.  The Eye MD (retina specialist) must use special tests to determine whether vision symptoms are due to pentosan polysulfate or other types of retinal conditions such as macular degeneration.    

Who is at risk of losing vision?

Ocular side effects appear to be related to a build-up of medicine in the body over years.  The longer a person has been on PPS, the greater the chances of developing retinal damage.  Although the average duration of use at the time of diagnosis is 15 years, some patients develop symptoms as early as three years after starting the medication.  With continued use of PPS, additional permanent damage occurs that may result in loss of vision.

What can I do to protect myself?

Pentosan polysulfate is an effective medication for control of pain with interstitial cystitis.  However, it is important to monitor your eyes for side effects that might indicate the need to stop the medication.  The Amsler grid chart should be checked at least once a week testing each eye separately, using glasses if needed.  Look for a missing part of the grid either above or below the central dot while looking only at the center of the grid.  Additionally, your Eye MD should examine your eyes every year with specific testing to look for early signs of retinal changes.  It may be useful to see a retinal specialist who has training in this area.

What happens if I develop retinal changes from pentosan polysulfate?

If early retinal changes are found, pentosan polysulfate may be discontinued.  By discontinuing pentosan polysulfate at an early stage, vision may be saved.  Continued examination is important to monitor the eyes for further changes.  There is no specific treatment for retinal toxicity from pentosan polysulfate. However, if blood vessels grow under the retina, treatment may be helpful as with wet macular degeneration.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2019-2022 Designs Unlimited of Florida. All Rights Reserved.

AAO 2019 Cases with a Point Handouts

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We thank senior instructor David J. Browning, MD, PhD for organizing this course and we thank the attendees for their participation and input for improvement. The following are the handouts from the individual cases that may be downloaded for review. The files are listed in alphabetical order by instructor’s last name followed by case number and subject of the talk.

Browning Case Asymmetric Retinitis PigmentosaDownload
Browning Case Management of Proliferative Diabetic RetinopathyDownload
Browning Case Asymmetric Retinitis PigmentosaDownload
Browning Case Patchy Ischemic Retinal WhiteningDownload
Browning CaseThe Nonadherent Patient with Diabetic Macular EdemaDownload
Agarwal CasesDownload
Kokame Case 1 Endo CNVDownload
Kokame Case 2 Macular hole CMEDownload
Kokame Case 3 PCVDownload
Kokame Case 4 macular edemaDownload
Pautler Case 1 disc collateralsDownload
Pautler Case 2 AEPVMDownload
Pautler Case 3 SNIFRDownload
Wong Case 1 CRAO HandoutDownload
Wong Case 2 antiVEGF half-life HandoutDownload
Wong Case 3 HandoutDownload

Treatment of Floaters

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What are floaters?

Floaters are small specks, fibers, or bug-shaped objects that may appear to move in front of your eye.  At times they may appear like a veil or cloud moving in the vision.  Floaters differ from blind spots in the vision in that floaters have some degree of independent movement.  Blind spots are missing areas in the vision that move precisely with eye movement.  Although floaters do follow the movement of the eye, there is usually some degree of continued movement after the eye stops moving.  They are frequently seen when looking at a blank wall or blue sky. Floaters are actually tiny clumps of fiber or cellular debris within the jelly-like fluid (vitreous) that fills the inside of the eye.

What does this symptom mean?

Although many people have occasional floaters, the sudden onset of many new floaters with or without flashes is an important sign of abnormal pulling on the retina by the vitreous.  Sometimes, the retina tears and may cause loss of vision from detachment of the retina. At other times, floaters may persist and chronically interfere with vision.

What causes floaters?

Floaters are usually due to degeneration of the vitreous gel in the eye from aging.  Over time, the vitreous shrinks, condenses, and pulls away from the retina.  The condensation causes fibers and cellular clumps to pull away from the retina and float freely inside the eye. The shadow of these opacities is what we see as floaters. Other causes of floaters include trauma, bleeding, retinal breaks and detachment, eye surgery, inflammation, and cancer (very rarely). 

vitreous floaters and haze
Vitreous floaters and haze interfering with vision after repair of retinal detachment. The vitreous opacities appear as fibers and haze in this photo. They interfere with a clear view of the retina when looking into the eye and they interfere with the vision when looking out through the haze.

What can be done about floaters?

It is important to have a thorough dilated eye examination to determine the cause of floaters.  Treatment is dictated by the cause of the floaters.  If there is no serious underlying cause (retinal break, retinal detachment, etc.), no treatment may be needed. New floaters often fade without treatment.  It can be helpful to avoid tracking or following floaters to allow your brain to ignore them. Floaters are less obvious in a darker environment, so wearing sunglasses outdoors may help minimize symptoms of floaters. Stress and depression appear to aggravate the symptoms of floaters and may be treated separately. 

YAG Laser Treatment:  A special laser may be useful in some cases of persistent floaters. It is an office treatment in which the laser in used to break the floating fibers and clumps into smaller fragments in the vitreous of the eye.  Although it may help, YAG laser does not eliminate floaters.  Repeat treatments are frequently necessary. Complications may include bleeding, increased floaters, retinal breaks and retinal detachment, which may require surgery to prevent blindness.  There is limited evidence on the safety and effectiveness of YAG laser for floaters and it may not be covered by insurance. YAG laser may result in loss of vision/loss of the eye.

Vitrectomy Surgery: Vitrectomy is a surgery performed in the operating room. It is commonly used to treat serious problems of the vitreous and retina.  It is very effective at reducing or eliminating floaters.  However, complications include bleeding, infection, retinal break and retinal detachment, which may require surgery to prevent blindness.  Serious complications occur in 1-2% of eyes reported in most studies, although some reports suggest the risk of complications may be as high as 10%.  The most common problem with vitrectomy is cataract formation.  After vitrectomy, cataract may develop over months to years and often requires cataract surgery.  Glaucoma has been reported years after vitrectomy, but the exact incidence is not known.  Vitrectomy surgery may result in loss of vision/loss of the eye.

For most patients the best course of action is observation of floaters without treatment at first.  If symptoms persist and significantly interfere with vision despite 6-12 months of observation, treatment may be helpful.  Most patients report good results with vitrectomy, but the possibility of complications must be carefully considered and accepted prior to embarking on surgery.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright 2019-2022 Designs Unlimited of Florida. All Rights Reserved.

Amaurosis Fugax: A black-out of vision in one eye

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Anatomy of the eye

What is amaurosis fugax?

            The retina in your eye is like the film inside a camera. The retina “takes the picture” of objects you look at and sends the message to the brain. The retina is a living tissue, which requires blood supplied by tiny vessels called arteries. If a retinal artery becomes blocked, it causes a sudden black-out of vision in one eye that may last minutes to hours. This symptom is called amaurosis fugax (pronounced, “am-a-ro-sis fyoo-jacks”).

What causes amaurosis fugax?

            Amaurosis fugax (AF) is usually caused by a temporary blockage of blood flow to the eye from a piece of hardened artery in the neck (carotid artery) that breaks away and flows “down stream” to lodge in a small retinal artery. Abnormal tissue from a heart valve may also be the source of retinal artery blockage. Rarely, an interruption of blood flow to the eye may result from blood disorders or inflammation.

What is to be done?

            First and foremost, a prompt eye exam is required to make an accurate diagnosis. Sometimes, intra-ocular hemorrhage, migraine, or retinal artery vasospasm may simulate amaurosis fugax. These other diagnoses are managed differently. If amaurosis fugax is confirmed, then evaluation is undertaken to find the cause of the blocked blood supply to the eye (retina or optic nerve). If the loss of vision is recent, the need for testing may be an emergency.

            The reason for laboratory and x-ray testing is to identify treatable conditions that might cause stroke or permanent loss of vision if left untreated. 

Where do I go for urgent care?

            An urgent MRI brain scan (diffusion-weighted imaging) may be performed at a stroke center such as those available through the emergency room at Adventist Hospital, St. Joseph’s Hospital, or Tampa General Hospital. The brain scan can identify strokes that may be present without symptoms. Such strokes need to be treated in the hospital to prevent complications of paralysis and death. 

Other important studies may also be performed to identify underlying treatable conditions. Blood tests may identify giant cell arteritis, a treatable inflammation of the arteries. A carotid sonogram studies the circulation of major arteries in the neck that lead to the brain and eyes. An ECHO cardiogram may identify an abnormal heart valve or a blood clot in the heart. These findings may be treatable to reduce the risk of future stroke.

Adventist Hospital Emergency Department

3100 East Fletcher Avenue

Tampa, FL 33613

(813) 971-6000

St. Joseph’s Hospital Emergency Department

3001 W Dr Martin Luther King Jr Blvd

Tampa, FL 33607

(813) 870-4000

Tampa General Hospital Emergency Department

1 Tampa General Circle

Tampa, FL 33606

(813) 844-7000

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2019-2022 Designs Unlimited of Florida.  All Rights Reserved.

Retinoschisis

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See Anatomy of the Eye

What is the retina?

            The retina is a “tissue-paper” thin layer of nerve tissue, which lines the inside of the eye like the film in a camera.  In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.  The retina has many layers of cells and fibers that normally adhere together for the retina to work properly.

What is retinoschisis (pronounced “retino-SKEE-sis”)?

            In Retinoschisis the retina splits into two layers that separate from each other.  The outer layer of the retina usually remains attached to the inside of the eye wall.  The inner layer of the retina floats inside the eye as fluid fills the space between the two layers.  It is similar to what happens to multi-ply tissue paper in a sink.  The layers of tissue paper may float apart from each other.   

What causes retinoschisis?

            Retinoschisis is caused by a weakness of the cells that normally hold the layers of the retina together.  Retinoschisis is more common in people who are far-sighted.  This tendency may be hereditary.    

What are the symptoms of retinoschisis?

            Retinoschisis usually causes no symptoms.  It is usually found on a routine dilated eye exam and becomes an important issue because it resembles retinal detachment.  

How is retinoschisis treated?

            Retinoschisis does not usually require treatment because it rarely causes any visual symptoms or problems.  However, retinal detachment may be caused by retinoschisis. Therefore, it is important to report any loss of side vision, like a curtain or shadow.  These symptoms may be a sign of retinal detachment, which does require treatment to prevent blindness. 

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2019-2022 Designs Unlimited of Florida.  All Rights Reserved.

Diabetic Retinopathy: laser or injection?

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What is diabetic retinopathy?

            The retina is a “tissue-paper” thin layer of nerve tissue, which lines the inside of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. After many years of high blood sugar, diabetes causes damage to blood vessels in the retina (diabetic retinopathy). Damaged blood vessels may leak clear fluid (edema) into the retina causing blurred vision and legal blindness. Also, new retinal blood vessels (neovascularization) may grow inside the eye abnormally. These new blood vessels tend to bleed causing floaters in the vision. In severe cases, they produce scar tissue, retinal detachment, glaucoma, and blindness or loss of the eye. 

What treatment options are available?

            To prevent progressive damage from diabetes, optimal diabetes management includes controlling blood sugar, blood pressure, and serum lipids (cholesterol and triglycerides), as well as weight control (diet and exercise), and avoiding tobacco. However, once diabetic damage occurs in the retinal blood vessels, laser treatment and/or medicine injections may be required. Medicine injections take effect quicker than laser, but the benefits of laser last longer than injections.

How does laser work and what are the side effects?

            The laser used to treat diabetic retinopathy coagulates damaged retina and seals leaky retinal blood vessels. Laser treatment may be given in the office or the operating room and is usually well tolerated with minimal discomfort. Side effects may include difficulty with night vision, side vision, and, rarely, central blind spots. Many of the same side effects appear from diabetes over time as blood vessel blockage occurs from high blood sugar levels. Laser provides long-lasting protection from blindness.

How do injections work and what are their side effects?

Injections of medicines are divided into steroid medicines and non-steroid (anti-VEGF) medications. With any injection, there is a low risk of serious infection that may blind the eye. Non-steroid (anti-VEGF) medications work by blocking chemical messages between retinal cells that cause leakage and bleeding in diabetes. Anti-VEGF medications include Avastin, Lucentis, Eylea, and Vabysmo. These medications take effect fairly quickly and are very effective, but the effect does not last very long (unlike laser). Anti-VEGF injections must be given every 4-6 weeks at first. Over months to years, fewer injections are usually needed. There appears to be an increased risk of death from stroke and heart attack among patients who undergo repeated antiVEGF injections for up to 2 years. The risk is about 17% (range: 2% to 33%) higher in diabetics undergoing injections than other diabetic patients not undergoing injections.

Steroid medicines are effective, but are generally considered a second-choice medication because of side effects. They are given by repeated injection. Side effects include a very high chance of cataract over a period of months to years. Steroids may cause the pressure in the eye to rise and this may result in glaucoma, which requires eye drops and may require surgery.

When to use injections and when to use laser?

The two main reasons to undergo treatment for diabetic retinopathy are 1.) swelling of the retina (macular edema) and 2.) the growth of abnormal new blood vessels (neovascularization) that threaten to bleed into the eye. Macular edema occurs when diabetes causes a breakdown of the normal water-tight barrier in the walls of blood vessels in the retina. If edema is located in the center of the macula, injections have been shown to be superior to laser. However, supplemental laser treatment may help to seal leaks after the injections begin to take effect. If macular edema is not located in the center of the retina, laser alone may protect against loss of vision. Injections may be added later if edema extends into the center of the retina at a future date.

Neovascularization (NV) is the new growth of abnormal blood vessels on the surface of the retina. The growth of these blood vessels indicates an advance degree of damage to the retina from diabetes. This stage of diabetes damage is called proliferative diabetic retinopathy. NV causes loss of vision from bleeding (hemorrhage), scarring, and retinal detachment. NV may be treated with laser and/or anti-VEGF injections. If center-involved macular edema is present along with NV, anti-VEGF injections are usually preferred at the start of treatment. However, anti-VEGF injections may be used alone in the treatment of NV in the absence of macular edema, as well. But the injections must be given monthly at first, and the eye must be rigorously monitored. If there is a gap in treatment, the result may be disastrous. 

Laser has been used successfully for long-term control of NV since the 1970’s. Laser is performed in the office or the operating room and is well-tolerated. Usually, one to three treatments offer long-term control of NV. Laser is currently considered a standard treatment for NV in the absence of center-involved macular edema. However, anti-VEGF injections remain an option, as well. The advantages and disadvantages of each form of treatment must be weighted in a given case. In some instances, a combination of injections and laser may be preferred. Unfortunately, despite these treatments surgery in the operating room may be needed. Although vision is usually preserved with treatment, diabetes remains the leading cause of blindness in the United States. The best results of treatment are seen in patients who have regular eye exams and manage their blood sugars well.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2019-2022 Designs Unlimited of Florida.  All Rights Reserved.

Silicone Oil for Repair of Retinal Detachment

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See Anatomy of the Eye

What is the retina?

The retina is a “tissue-paper” thin layer of nerve tissue, which lines the inside of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.

What is retinal detachment?

When the retina detaches, it is no longer in proper position inside the eye. Instead, it is like film that has unrolled inside a camera. When this occurs, a camera cannot take a picture. Similarly, when the retina detaches the eye loses vision.

How is silicone oil used to repair retinal detachment?

Silicone oil is injected into the eye during vitrectomy surgery to hold the retina in place against the eye wall. It works by pushing and holding the retina in position from the inside. This is different from scleral buckle surgery in which the eye wall in indented to push it against the retina from the outside. Depending on the characteristics of a retinal detachment, during vitrectomy surgery silicone oil or gas may be used to hold the retina in place.

What are the advantages and disadvantages of silicone vs. gas to repair retinal detachment?

Various gas bubbles (air, SF6, or C3F8) are most frequently used hold the retina in position for healing after vitrectomy for retinal detachment repair. However, the effect of gas bubbles is temporary. Silicone oil may be used instead of a gas bubble (pneumatic retinopexy) for longer duration of action. Although gas has a higher surface tension with better ability to close retinal breaks, gas bubbles dissolve in the fluids of the eye and disappear over a period of days (air) to weeks (SF6 and C3F8). Silicone oil remains in the eye until it is removed with surgery in the operating room; it does not dissolve in the fluids of the eye. The long duration of effect with silicone oil makes it helpful when treating retinal detachments with inferior retinal breaks and with proliferative vitreoretinopathy. Silicone oil may also be used when a patient cannot stay in proper position, as is often required after retinal detachment surgery for proper healing with pneumatic retinopexy (gas injection). Head positioning is much less critical for success with silicone oil as compared to gas tamponade. Air travel is another reason silicone oil may be used over gas tamponade; there are no restrictions on air travel with silicone oil as there are with gas. As long as gas or silicone is in the eye, the vision is poor. The only way to remove silicone oil is with surgery in the operating room.

How long is silicone oil left in the eye?

Silicone oil may be left inside the eye for weeks, months, or years after surgical repair of retinal detachment. How long before surgical removal of silicone largely depends on the nature of the retinal detachment. The average duration of silicone oil retention in the eye is 3-4 months; however, some surgeons prefer to leave silicone in place for one year after repair of retinal detachment associated with scar tissue (proliferative vitreoretinopathy). In severe cases of retinal detachment, the only way to keep the retina attached is by leaving silicone oil in the eye permanently. Although this situation is not desirable, it may be necessary to retain silicone oil in the eye to preserve limited vision and keep the eye from shrinking and becoming deformed and/or painful from advanced scar tissue formation. When silicone oil is retained long-term inside the eye, periodic evaluation is needed to identify and treat late complications.

What complications are associated with silicone oil?

Although silicone oil may be the only way to successfully repair difficult retinal detachments, complications may occur. The most common side-effect with silicone oil is cataract formation. If a silicone lens implant is in the eye, the silicone oil may adhere to the lens implant and impair vision. Rarely, silicone oil may cause glaucoma (high pressure in the eye that can result in loss of vision if left untreated). This may be treated with eye drops, laser, or glaucoma surgery. Sometimes, it is necessary to remove and/or replace the silicone oil. In exceedingly rare cases, glaucoma may drive silicone oil from the eye through the optic nerve into the brain.  

After many months to years, silicone oil may emulsify (break into tiny bubbles). These bubbles may then travel into the front of the eye and cause the cornea (the clear front window of the eye) to fog over. This may require removal/replacement of silicone and, rarely, corneal transplantation.

Severe complications from silicone oil are rare. The use of silicone oil may be the only hope of retaining vision and the eye in some cases. With routine exams and follow-up care, complications may be prevented or detected early, and managed appropriately. 

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2019-2022 Designs Unlimited of Florida.  All Rights Reserved.

Fluorescein Angiography

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Anatomy of the Eye (click on image to enlarge)

What is fluorescein angiography?

Fluorescein angiography is a photographic test using a special camera to take pictures of the retina inside the eye.  A dye is injected into a vein in the arm.  As the dye courses through the retina, many photographs are taken.  These photographs reveal exquisite details of the retina. In patients whose veins are difficult to access, oral fluorescein angiography may be considered.

Why is fluorescein angiography ordered?

After a complete examination of your eyes, the Eye MD may recommend fluorescein angiography to help establish a diagnosis or help to monitor results of treatment.  Very often a fluorescein angiogram helps in choosing the best treatment for a particular condition.  For example, if the Eye MD sees a leakage of fluid in the retina, the fluorescein angiogram will help determine the source of leakage, so that treatment can be directed appropriately.  Similarly, the end of treatment may be determined by repeating the fluorescein angiogram to see if the leakage has been stopped.    

What are the side effects of fluorescein angiography?

Usually after fluorescein angiography the skin turns yellowish for several hours from the dye.  Because the dye leaves the body through the kidneys, the urine will turn dark orange for a day or so.  Alternatively, if you are on kidney dialysis, mention the orange color to the dialysis technician so as to avoid unnecessary concern.  Some people feel nauseated during the procedure.  This symptom passes quickly, and may be avoided next time by injecting a smaller dose of dye more slowly.  If the dye escapes from the vein, you may feel a burning pain at the injection site.  Relief is obtained with an ice-cold compress for several hours.  Notify the doctor if pain occurs or persists at the injection site after twenty-four hours.  Allergic reactions to fluorescein are rare and are usually limited to skin rash and itching, which responds to Benadryl.  Even more rarely, severe allergic reactions can occur at the time of injection and may be life threatening.  This is treated as an emergency in the doctor’s office where equipment is available. Finally, some blood test results are altered by fluorescein if blood is drawn within a day or so after angiography, so you may wish to notify the laboratory.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2019-2022 Designs Unlimited of Florida.  All Rights Reserved

Myopic Macular Degeneration

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Anatomy of the Eye (click on image to enlarge)

What is myopic macular degeneration?

Myopic macular degeneration (MMD) is a degeneration of the center of the retina seen in some people who are myopic (near-sighted). MMD is not the same as age-related macular degeneration. The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision.  The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera.  In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.  Although macular degeneration affects the central vision, it does not affect peripheral vision— the ability to see objects off to the side when looking straight ahead.  This means that macular degeneration alone does not result in total blindness.  

What causes myopic macular degeneration?

Changes in the shape of the near-sighted eye cause myopic macular degeneration.  The normal shape of the eye is round like a ball. As an eye becomes myopic, the eye elongates and looks more like the shape of an egg. The elongation of the eye means that the retina becomes stretched and thin. This causes macular degeneration in some eyes over time. The higher the amount near-sightedness (the thicker your glasses), the greater the chances of myopic macular degeneration. Two forms of MMD are “dry” and “wet”.  However, the wet type may become “dry” and the dry type may become “wet” over  time:

  • Dry macular degeneration is the most common type and involves the disintegration of the light-sensitive tissues in the macula.  Loss of vision is usually gradual in dry macular degeneration.  
  • Wet macular degeneration occurs in a small group of eyes with MMD.  It occurs when abnormal blood vessels grow under the macula and cause fluid leakage, bleeding, and scarring of the macula.  Vision loss may be rapid and severe. An important, but under-recognized form of wet MMD is dome-shaped maculopathy.

What are the symptoms of myopic macular degeneration?

Macular degeneration may cause no symptoms in its early stages.  Over time, symptoms may include the need for more light while reading and blurring of central vision, often with distortion or a blind spot. Although macular degeneration is usually present in both eyes, it may cause visual symptoms in only one eye. Rarely, severe loss of vision occurs in both eyes, and render a person legally blind. However, total blindness is extremely rare in myopic macular degeneration.

How is myopic macular degeneration diagnosed?

A dilated eye examination can detect myopic macular degeneration before visual loss occurs.  The hallmark of myopic macular degeneration is a thinning of the macula due to stretching of the retina and the underlying blood vessel layer that gives nutrition to the retina.  After the diagnosis is made, a fluorescein angiogram is often helpful.  In this procedure the ophthalmologist injects an organic dye into the vein of the arm.  Photographs of the retina are taken to reveal the presence and location of the leaking blood vessels marked by the organic dye.

How is dry myopic macular degeneration treated?

No specific treatment is required for eyes with MMD and no symptoms. However, it may be helpful to avoid eye rubbing. If the eyes feel tired at the end of the day, warm compresses are safer than rubbing the eyes. A Bruder mask may be purchased at the drug store or online. It may be heated in the microwave for 10 seconds and placed on the eyes after testing the temperature. It provides warm moist heat that soothes the eyes. 

How is wet myopic macular degeneration treated?

Medication injections (Avastin or Lucentis) performed in the office often help preserve vision in wet MMD.  Treatment rarely returns vision to normal, but may limit the amount of vision loss from blood vessel growth and leakage. Frequent office visits and photographs are needed to monitor for activity and determine the need for treatment. The Amsler grid test is used at home to help monitor the vision. If the grid test shows new or progressive distortion in the vision, notify the eye doctor within a few days.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Please note: As an Amazon Associate I may earn from qualifying purchases.  You pay no additional fees by accessing the link provided.  These funds help defray the costs of maintaining this website.  Thank you for your support.

Copyright  © 2019-2023 Designs Unlimited of Florida.  All Rights Reserved.

The Best Vitamins for Macular Degeneration

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What are vitamins?

Before discussion about the best vitamins for macular degeneration, just what are vitamins? Vitamins are organic compounds that are needed by your body to function, but cannot be made by your body. Therefore, they must be consumed to promote good health. Vitamin and nutritional supplements are not regulated or tested by the Food and Drug Administration. Claims by manufacturers that these supplements improve health must be scientifically proven. 

Should I take vitamins?

Doctors and nutritionists are limited in their ability to make firm recommendations in many situations because nutrition research is still in its infancy. Beware of authors and marketers who make grand claims as to the effectiveness of vitamins and herbs. Most healthy individuals who eat a well-rounded diet do not need to take supplemental vitamins, although there are some situations in which supplements have been shown to be beneficial. In general, vitamins are useful in the following situations: advanced age, age-related macular degeneration, food fads, gastrointestinal absorption abnormalities, and hemodialysis.

Vitamins and nutritional supplements—the more the better?

Although vitamin deficiency causes illness, excess vitamin intake may result in toxicity. Toxic effects are especially seen with the fat-soluble vitamins (Vitamins A, E, D, and K). However, even dosages of vitamin B6 exceeding 500mg per day may cause light sensitivity, and vitamin C may cause nausea and diarrhea in large doses of 2 grams per day. Vitamin A may cause liver damage, visual changes, and birth defects in dosages as low as 15,000 IU per day and long-term use of vitamin A may cause osteoporosis and increased risk of bone fracture. Beta carotene may cause smokers and former smokers/asbestos workers to be at increased risk of lung cancer. Vitamin E appears safe up to 400 IU, but daily dosages exceeding 800 IU may cause abnormal bleeding and dosages exceeding 1200 IU may cause headache, fatigue, nausea, diarrhea, cramping, weakness, blurred vision, and gonadal dysfunction. Vitamin D may cause abnormal calcium deposits in soft tissues when taken during kidney failure or in doses greater than 2,000 IU. 

So what are the best vitamins for age-related macular degeneration (AMD)?

The AREDS2 formula is the most carefully studied vitamin combination proven to reduce the risk of vision loss in AMD. There are many companies that manufacture the AREDS2 formula, but the most economical source (to the best of my knowledge) is Equate Advanced Eye Care Complex from Walmart. Another more expensive brand is Preservision AREDS2. There is NO vitamin A or beta carotene in AREDS2. Be aware that mineral supplements such as zinc in the AREDS2 formula may interfere with the absorption of prescription medications such as thyroid pills. Therefore, take AREDS2 vitamins 4 hours apart from prescription medications to minimize their interactions. Iron supplements may worsen macular degeneration and should be avoided unless prescribed by a physician.

Click here to check updated prices of Preservision AREDS2 on Amazon.

Preservision AREDS 2
Preservision AREDS 2 (click to enlarge)

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Please note: As an Amazon Associate I may earn from qualifying purchases.  You pay no additional fees by accessing the link.  These funds help defray the costs of maintaining this website. Thank you for your support.

Copyright  © 2021-2023 Designs Unlimited of Florida.  All Rights Reserved.

Optic Disc Drusen

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What are optic disc drusen?

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Anatomy of the Eye (click on image to enlarge)

The optic nerve is the nerve that connects the eye to the brain. It sends the “picture” taken by the eye to the brain. The optic disc is the part of optic nerve that can be directly seen by the eye doctor on an examination. Optic disc drusen are calcified deposits in the optic disc that may be detected directly on exam or by testing with cameras or ultrasound.  They are present in about 2% of the population. 

ON drusen image
Top color image shows optic disc as round structure without clearly seen drusen.
Bottom fundus autofluorescence image shows the optic disc drusen as bright white spots in optic disc..

What causes optic disc drusen and why are they important?

Optic disk drusen are present from birth, but often go undetected until later in life. Usually they cause no problem, but they may crowd the nerve fibers in the optic nerve. The crowded optic nerve may be predisposed to blood vessel blockage later in life, especially with hardening of the arteries. The condition of blocked blood supply to the optic nerve is called ischemic optic neuropathy (ION). Sleep apnea may play a role in some patients and SSRI anti-depressants may be a risk factor for ION.

Sometimes, optic disc drusen can cause loss of side vision as in glaucoma. In this case, eye drops are sometimes prescribed. Rarely, bleeding under the retina may occur due to blood vessel growth (similar to wet macular degeneration). In that instance, medicine injections or laser may be used.

Finally, optic disc drusen may be buried in the optic disc and the appearance may resemble optic disc edema (papilledema). True papilledema is caused by elevated pressure in the brain. It is, therefore, important to make a correct diagnosis. Although a number of tests may be used, optical coherence tomography (OCT) is the single most reliable test for diagnosis.

How are optic disc drusen managed?

Most cases of optic disc drusen cause no problems and require no treatment. There is no accepted method to remove them. The usual recommendations to prevent hardening of the arteries may be helpful to avoid ION (avoid tobacco and control weight, blood pressure, cholesterol and blood sugar). In order to detect early changes in the vision, it may be helpful to monitor the vision each week with an Amsler grid test. If a sudden blind spot or distortion (straight lines look wavy or crooked) is detected, contact the eye doctor within 2-3 days for evaluation and management.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

 

Copyright  © 2019-2023 Designs Unlimited of Florida.  All Rights Reserved.

Intermediate Uveitis

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Vitreous is the gel that fills the eye (click on image to enlarge)

See Anatomy of the Eye

What is intermediate uveitis?

Uveitis (pronounced, “you-vee-EYE-tis”) is a general term used to describe inflammation inside the eye.  The uvea is the name given to the layer of tissue in the eye that has a brown color (melanin pigment) and blood vessels, which serve to provide blood supply and protect the eye from excessive light.  The uvea can be divided into separate parts, which perform different functions in the eye: the iris, the ciliary body, the pars plana, and the choroid. The part of the uvea in the front of the eye is called the iris (the round, blue or brown part of the eye that you can see in the mirror).  Behind the iris is the ciliary body, which produces the fluid that fills the eye. The pars plana serves as the boundary between the ciliary body and the choroid.  The back part of the uvea that lies under the retina (the “film” in the eye that “takes the picture”) is called the choroid.  Therefore, in any one patient uveitis is usually given a more specific name depending on where most of the inflammation is located in the eye. In intermediate uveitis the inflammation is primarily located in the vitreous gel that fills the eye, which is located in an intermediate position between the front and the back of the eye. It is sometimes referred to as vitritis or pars planitis.  

What causes intermediate uveitis?

Uveitis may be caused by an infection, an injury from trauma, a disease in the body outside the eye, or sometimes for unknown reasons.  Infection by a virus, bacteria, fungus, or other parasite may cause uveitis. Infections may be limited to the eye or may involve other organs as well. In intermediate uveitis, infection may be caused by syphilis, tuberculosis, Lyme disease, cat scratch disease, Whipple’s disease, toxocariasis, human lymphotrophic virus (HTLV-1), or toxoplasmosis.

In other situations, uveitis is caused by inflammation without infection.  For example, multiple sclerosis, sarcoidosis, HLA-B27, and inflammatory bowel disease may cause intermediate uveitis. Pars planitis is a sub-type of intermediate uveitis that often starts early in life during childhood. Its cause is unknown.

Uveitis commonly occurs following an injury to the eye.  Very rarely, cancer or cancer-fighting drugs may cause intermediate uveitis. In some cases, no underlying cause can be found to be the cause of uveitis.  Tobacco may be an aggravating factor and should be discontinued.     

What are the symptoms of intermediate uveitis?

The most common symptoms include tiny floating spots which move or “float” in the vision. They are usually numerous and may cause a veil-like appearance in the vision.  Sometimes blind spots, blurred vision, distortion, or loss of side vision occurs. The eye may be painful, red, tearing, and light sensitive if other parts of the eye are also inflamed.  Symptoms may be mild or they may be severe and disabling.

How is intermediate uveitis managed?

To effectively treat intermediate uveitis, it is important to find the underlying cause whenever possible.  Take some time to carefully review and report to your doctor any unusual or unexplained symptoms such as rashes, back and joint problems.  Tell your doctor if you travel abroad, spend time in rural settings, or may be exposed to animals or infections.  Heredity may also play a role. You should tell your doctor about any family members with inflammatory disorders anywhere in the body. Also, review and report your ancestry (for example, Asian, Mediterranean, or American Indian ancestry).  When the doctor diagnoses uveitis, laboratory tests may be ordered to help determine its cause.  Occasionally, a surgical biopsy is needed for diagnosis.   If infection is found, antibiotics are prescribed.  To limit the damage from inflammation, intermediate uveitis is treated with anti-inflammatory medication in the form of eye drops, injections, or pills.  When pills are used, the eye doctor frequently coordinates medical care with the expert assistance of a rheumatologist.  Rarely, surgery is required to treat uveitis.  In some cases, intermediate uveitis may be long-lasting. In these cases, years of therapy are needed to preserve vision.  Intermediate uveitis is a serious eye problem and may result in loss of vision or blindness.  However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized.

In some cases, intermediate uveitis may go away, but return at a future date.  Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact your doctor. Preliminary evidence suggests that tobacco use may be an aggravating factor in some cases of uveitis.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2018-2022 Designs Unlimited of Florida.  All Rights Reserved.

Retinal Rejuvenation

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Retinal rejuvenation is a name given by the company that sells a new-generation laser machine to ophthalmologists. The laser is used to treat the retina with the hope of delaying loss of vision from age-related macular degeneration (ARMD). Although the laser company calls this treatment “retinal rejuvenation,” this name may be overstating the true effects of this new laser.

The scientific basis for the use of the laser for macular degeneration is the LEAD study. This study evaluated 292 patients with ARMD over a three-year period. Half of the eyes were treated with the new micro-pulse laser and the remainder received sham treatment for comparison. Overall, the treatment was not shown to be of benefit in slowing the loss of vision from macular degeneration. However, when looking at subsets of eyes with certain types of macular degeneration (no reticular pseudodrusen), there was a trend toward a benefit. These results, however, had a weak fragility index (meaning that more research is needed). Conversely, eyes with reticular pseudodrusen (subretinal drusenoid deposits) lost vision at a greater rate after undergoing retinal rejuvenation than those eyes that were not treated.

“Retinal rejuvenation” needs more study before it is implemented on a wide scale basis. It is currently (2018) not approved for this use in the United States. More research is needed to better establish its helpfulness in reducing the risk of vision loss from age-related macular degeneration and to identify potential risks involved with its use.

I do not recommend the “retinal rejuvenation” treatment for age-related macular degeneration by the new micro-pulse laser at this time. I look forward to more high-quality research in the future to better establish the potential role of this laser for my patients with ARMD.

By Scott E. Pautler, MD

Copyright  © 2018 Scott E Pautler MD. All rights reserved.

On-Time Doctor Award

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On-Time Award

Being on-time is an important issue for me, as waiting in the doctor’s office can seem like an eternity. I know your time is important. As such, I strive to train my staff to work with me to make your visit as pleasant and efficient as possible. When you approach the front desk, you are promptly greeted by our receptionist, not ignored as though you are invisible. Within short order a technician brings you back to the examination area of the office designed for optimal preparation for the doctor. You wait only long enough for the eye drops to dilate your eyes for retinal examination. I seek to spend time directing my attention to you and your eye problem, so I have my technicians take notes on the computer while I examine the retina. At this time, I use technical language that sound strange, but I soon translate the findings of my exam into everyday language. Because it is easy to forget what you hear in a doctor’s office, I encourage you to bring a family member or friend with you. Also, I supply information sheets for most retinal conditions and maintain an active blog site to help inform you about your condition.

Sometimes, the day does not go as planned. If an emergency patient is sent directly to see me for urgent care, I do fall behind. Nonetheless, I usually do not remain behind schedule for long because I allow extra time in my schedule for unforeseen delays in my schedule. Despite our best effort, first-time patients usually take extra time. Many forms are required by the government and the insurance company. An extensive history at the first visit is required to help identify the problem. Photographic testing can be time consuming. In complicated cases, we place a telephone call after the visit to communicate the results of exam and testing.

Regardless of how busy we are, I aim to treat you with courtesy and compassion. Wherever possible, I will minimize waiting. I am humbled and honored to have been awarded the “On-Time Doctor Award” by Vitals for 2018-2019. And I thank you for your patience on those days I am unable to meet my goal of “no wait.”

With sincerest regards,

Scott E. Pautler, MD, FACS

On-Time Award

Visudyne Photodynamic Therapy

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Anatomy of the Eye (click on image to enlarge)

What is photodynamic therapy?

Photodynamic therapy (PDT) is a treatment for retinal conditions in which leaky blood vessels threaten to cause permanent loss of vision. PDT involves the injection of a light-sensitive dye into the vein of the arm. The dye, called Visudyne, concentrates in the abnormal blood vessels that leak fluid and/or blood under the retina. A diode laser then activates the Visudyne, which seals the leaky blood vessels without the use of cauterizing lasers. By avoiding the use of cautery, PDT is able to treat abnormal leaking vessels with a much lower chance of causing a blind spot in the vision from the treatment. For this reason PDT is sometimes called the “cold laser.” PDT has largely replaced the cauterizing (hot) laser in the treatment of age-related macular degeneration and central serous chorioretinopathy.

What do I expect after photodynamic therapy?

For 48 hours you should avoid direct sunlight, which could activate some of the dye in your system before it is eliminated from the body. Sunlight or Halogen light may cause a severe light reaction and should be avoided during this time. For this reason it is advisable to come to the office for treatment wearing a long-sleeved shirt, gloves, long pants, socks, closed shoes, and a hat. Make arrangements for someone else to drive, so you may remain shielded from light in the back seat of the car on the way home from the office. After PDT, there are no limitations in physical activity or visual activity. Some doctors recommend against straining or heavy work for one week after the treatment to avoid putting too much pressure on the blood vessels in the eye. Although some blurring of vision is common immediately after treatment, severe changes in the vision should be reported to the doctor. It may take months for the treatment to take effect. Repeated treatments with PDT may be used as needed in difficult cases.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2018-2022 Designs Unlimited of Florida.  All Rights Reserved.

Lens Implant Options

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Cataract
Cataract is a foggy lens inside the eye (click image to enlarge).
Image courtesy of Caitlin Albritton.

See Eye Anatomy

Why are lenses implanted during cataract surgery?

Cataract is the name given to the natural lens inside your eye when it becomes cloudy. When cataract interferes with vision, surgery is performed to remove the cloudy lens. In order to replace the focusing power of your natural lens, a synthetic lens implant is placed inside the eye at the time of cataract surgery.

What lens implant power options are available?

The patient may choose to have the power of the lens implant adjusted to focus the eye at various distances. The power calculations are not perfect and often glasses still must be worn by many patients. Most people choose to have the lens implant focused mainly for distance. Rarely, near-sighted patients prefer to keep the primary focus at near. Standard lens implants are fixed-focus lenses. That is, they do not focus at distance and near. For example, an eye with a standard lens implant focused for distance must use reading glasses for near work.

How can we decrease our dependence on glasses after cataract surgery?

In order to decrease the need for glasses, there are options to consider, each with advantages and disadvantages. Options include bifocal contact lenses, mono-vision lens implant correction, and multifocal lens implants.

Bifocal Contact lenses: This option may be good for patients who already use bifocal contact lenses. The contacts lenses help focus at near and may refine distance vision as needed.

Mono-vision Lens Implants: In this option one eye is focused mainly at distance and one eye is focused mainly for near. Not everyone can adapt to this situation and there is slight loss of depth perception with mono-vision correction. This option is best for those who already have adapted to mono-vision contact lenses.

Multifocal Lens Implants: This is a new option offered by premium lens implants that cost more for the patient. Basically, these implants offer improved range of focus for both distance and near. Many brands are available. The choice of lens depends on how much help with distance and near vision is desired. However, the greater the range of focus a given lens offers, the greater the side effects of the multifocal lens. Side effects include decreased contrast sensitivity and glare/halos from light especially at night. Loss of contrast sensitivity makes it more difficult to see gray print on white paper. Glare and halos bother some patients more than others.

A combination of strategies may be used. For example, a low-range-of-focus multifocal lensimplant (Symfony) may be used with mild mono-visionfocusing to minimize the downsides compared with each method when used alone.

Examples of multifocal lens implants include Symfony, Restor 2.5, and Restor 3.0. There are many others. Below is a chart to demonstrate the trade-offs among these lenses.

Lens Implant Styles: Benefits and Limitations    
Style Distance vision Intermediate vision Near vision Need for reading glasses Contrast sensitivity Glare/Halos
Standard IOL (monofocal) Excellent Fair Poor Most of the time Excellent Rare
Symfony IOL Very good Good Fair Much of the time Good Mild
Restor 2.5 IOL Fairly good Good Good Some of the time Poor Moderate
Restor 3.0 IOL Fairly good Fair Good Rarely needed Poor > Moderate

If you have strong preferences, be sure to communicate with your doctor to be given the best lens implant for your situation. Keep in mind that the eye changes over time and the need for glasses may change over months to years after cataract surgery.

By Scott E. Pautler, MD

Copyright © 2018 Designs Unlimited of Florida.  All Rights Reserved.

Over-the-Counter Pain Medications

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What are over-the-counter pain medications?

Over-the-counter (OTC) pain medications are pills that can be purchased without a prescription. There are a number of brands available. Examples include ibuprofen (Motrin) and acetaminophen (Tylenol). As ibuprofen and acetaminophen work via different pathways, they can be used together for improved pain control.

What side effects might be expected?

Most drugs have many possible side-effects. The major concern with acetaminophen is liver damage especially seen in patients with known liver disease. The major concern with ibuprofen is kidney damage in patients with known kidney disorders. Also, ibuprofen may irritate the stomach and increase the risk of stomach ulcers. This is especially seen in patients over the age of 65, history of stomach ulcers, or taking medications such as aspirin, steroids, or warfarin (Coumadin). Ibuprofen thins the blood and, therefore, may increase the tendency to bleed by slowing the ability of the blood to clot. The risk of stomach problems with ibuprofen may be reduced by using Zantac or Pepcid, which are available over-the-counter.

How can OTC pain medications be optimally used to control post-operative pain?

Because pain from surgery is short-lived, drug dependence is not a significant issue. The best strategy is to stay ahead of severe pain rather than trying to catch up due a lapse in medication. The optimal use of OTC medication may reduce the need for prescription narcotic pain medication. Prescription narcotic pain medications have side-effects such as sedation, constipation, nausea, and vomiting. With the proper use of OTC pain medications, the need for narcotics can be minimized.

As most narcotic pain medication is combined with acetaminophen, the dosage of OTC acetaminophen (Tylenol) must be decreased so as to avoid exceeding the maximal daily dosage (3,000mg per day).

Copyright © 2018 Designs Unlimited of Florida.  All Rights Reserved.

Maximal Use of OTC Pain Medication for Pain Control after Surgery
Dosing Schedule: 8AM 2PM 8PM 2AM Daily Maximum
Ipubrofen 800mg 800mg 800mg 800mg 3200mg
Dosing Schedule: 11AM 5PM 11PM Daily Maximum
Tylenol Extra-Strength 1000mg 1000mg 1000mg 3,000mg
Note: This schedule may need to be altered if you have kidney or liver disease.
This schedule is designed not to exceed maximum dosages of these medications.
Decrease the dosage as the pain improves after surgery.
Do not take additional medications that contain ibuprofen or acetaminophen without
adjusting the OTC medication dosage so as not to exceed the maximal daily dosages.
Consult with your doctor prior to using this medication schedule.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

The Amsler Grid Test

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What is the Amsler grid?

The Amsler grid is a test used to detect and monitor macular disease (see Anatomy of the Eye). The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision.  The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera.  In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.

How is the Amsler grid used?

The grid is observed one eye art a time with reading glasses if needed for proper focusing at normal reading distance. The patient is asked to fixate on the center of the grid while using “side vision” to see if there are any missing areas. The lines on the grid should appear straight and uniform. If any abnormalities are noted, an ophthalmologist (retinal specialist) may be consulted to determine the cause of the problem.

Below is a link to download or print an Amsler grid chart for use at home.

Amsler grid RVAF

Some patients prefer a more sensitive (and more expensive) test to monitor the vision called the Foresee Home Monitoring Program.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright © 2018-2022 Designs Unlimited of Florida.  All Rights Reserved.

Distortion
Distortion of lines on Amsler Grid (click on image to enlarge)

Steroid Eye Drops

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What are Steroid Eye Drops?

Steroid eye drops are prescription medications used to reduce pain, swelling and inflammation. This class of medication is separated from non-steroids by mechanism of action, effectiveness, and side effects. There are a number of steroid eye drop brands available. Examples include prednisolone (Pred Forte, AK-Pred), fluorometholone (FML, FML Forte, Flarex), dexamethasone (Ocu-dex), loteprednol (Lotemax, Alrex), difluprednate (Durezol), rimexolone (Vexol).

How do steroid eye drops work?

Steroid eye drops work by inhibiting a wide variety of biochemicals in the body that promote inflammation. Steroid eye drops are usually more effective that non-steorid eye drops (NSAID eye drops) when used alone, but these two classes of anti-inflammatory drops often work best when used together.

There are advantages and disadvantages to the various brands of steroid eye drops. To varying degrees, all steroid drops reduce inflammation and they all have side effects. The most important side effects include cataract formation and elevation of Intraocular pressure (glaucoma). Prednisolone acetate has been the gold standard for treating ocular inflammation. Dexamethasone generally is not as effective and it has comparable side effects. Difluprednate (Durezol®) is as effective as prednisolone and can be used less often, but it is much more expensive. Loteprednol (Lotemax®) and rimexolone (Vexol®) are less likely to cause glaucoma, but they are expensive. Low concentrations of fluorometholone (FML®) is not likely to cause cataract or glaucoma, but it is not as strong as prednisolone and are mainly used for treating inflammation outside the eye, as in cases of blepharitis (inflammation of the eyelids) and keratitis (inflammation of the cornea).

How does the doctor choose which steroid drop to use?

In some cases the doctor has had good experience with a specific agent for a given situation. In other cases the choice may be guided by convenience and cost. For convenience the costlier difluprednate may be used twice a day compared to 4 times a day for prednisolone. Patients with a tendency for glaucoma, may require more expensive medication such as rimexolone or loteprednol.

If you have strong preferences, be sure to communicate with your doctor to be given the best steroid eye drops for your situation. Always use your eye drops exactly as prescribed and keep all appointments as scheduled in order to monitor for effectiveness and safety.

Ophthalmic Steroid Prices6/25/18 
    
GenericTradeCostSource
PrednisolonePred Forte $            27GoodRx
FluorometholoneFML Forte $            35GoodRx
DexamethasoneDecadron $            60CVS
RimexoloneVexol $            93GoodRx
DifluprednateDurezol $          180GoodRx
LoteprednolLotemax $          230GoodRx

By Scott E. Pautler, MD

What is the Amsler grid?

The Amsler grid is a test used to detect and monitor macular disease (see Anatomy of the Eye). The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision.  The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera.  In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.

How is the Amsler grid used?

The grid is observed one eye art a time with reading glasses if needed for proper focusing at normal reading distance. The patient is asked to fixate on the center of the grid while using “side vision” to see if there are any missing areas. The lines on the grid should appear straight and uniform. If any abnormalities are noted, an ophthalmologist (retinal specialist) may be consulted to determine the cause of the problem.

Below is a link to download or print an Amsler grid chart for use at home.

Amsler grid RVAF

Some patients prefer a more sensitive (and more expensive) test to monitor the vision called the Foresee Home Monitoring Program.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright © 2018-2022 Designs Unlimited of Florida.  All Rights Reserved.

Pain in and Around the Eye

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globe anatomy
anatomy of the eye (click on image to enlarge)

Pain is a symptom that often warns of serious problems. The nature of the pain may help to determine the origin of the pain and, sometimes, the cause. The following are types of pain and their causes:

Severe, sharp, jabbing pain in the eye: If persistent and associated with a sensation like sand in the eye, this pain often suggests a problem in the cornea. The cornea is the clear front window at the front of the eye. It is replete with very sensitive nerve endings that may be irritated by any disruption of the “skin” on the surface like a corneal abrasion. Treatment is important to relieve pain and prevent infection or scarring of the cornea as this may result in a loss of vision.

A very brief isolated episode of a jab in the eye: May be due to a benign blockage of an oil gland in the eyelid margin (blepharitis). It may also be a symptom of a type of migraine called an “ice pick” headache.

A burning, tingling pain over the forehead: May indicate the onset of shingles (Herpes Zoster). The pain often precedes the onset of a painful rash composed of small vesicles (blisters) on the forehead. It is important to start antiviral medication and evaluate the eye to determine if there is direct eye involvement.

Deep, boring pain: May be seen with sinus pathology alone and may be present in varying severity. However, this type of pain may also be due to problems in the brain such as aneurysm or brain tumor. This pain may also be caused by high pressure in the eye (acute glaucoma) or serious inflammation inside the eye (uveitis). Rarely, poor blood flow to the eye from the carotid artery may cause a deep pain around the eye; atherosclerosis or giant cell arteritis may be the cause.

Pain may be caused by dry eye syndrome. It is usually associated with dryness, burning, and foreign body syndrome.

This monograph does not cover all types or causes of eye pain. Any significant, persistent pain in the eye warrants evaluation. In many cases the more severe the pain, the more urgent the need for evaluation.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright  © 2018-2022 Designs Unlimited of Florida. All rights reserved.