A break is a tear or hole in the retina. The retina is a thin layer of 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. Because the retina is very thin, breaks may develop and cause retinal detachment with loss of vision. There are two kinds of retinal breaks: holes and tears. Retinal tears cause retinal detachments more often than retinal holes.
Horseshoe-shaped retinal tear as seen in an eye with retinal detachment (Click on image to enlarge)
What are the causes and symptoms?
Retinal breaks are fairly common in near-sighted eyes because near-sightedness is usually due to an elongation of the eye. As the eye enlarges deep in the eye socket, the retina has to stretch over a larger area. This stretching causes the retina to become thinner and may result in tiny round holes. These holes may cause no symptoms and may not cause retinal detachment.
In any eye, near-sighted or not, tears can occur from abnormal pulling on the retina by the vitreous (a clear gel that fills the eye and normally helps to hold the retina in place). Usually due to degeneration from aging, the vitreous gel condenses inside the eye and pulls on the retina. When this happens, patients usually notice the sudden onset of floating spots or “cobwebs”. Sometimes, brief lightning-like flashes of light occur in the side vision. About 10-15% of the time, new floaters and flashes mean a retinal tear has developed. This event places the eye at high risk of blindness from retinal detachment.
How is a retinal break treated?
Not all retinal breaks require treatment. The doctor may recommend observation alone. If a retinal break threatens to cause retinal detachment, the break is usually treated by laser or a freezing probe (cryopexy) to seal the retina to the eye wall at the site of the break. Treatment is NOT aimed at eliminating the flashes and floaters. Flashes usually disappear over a few weeks or months. The floaters gradually fade over many months, but they rarely disappear completely.
Treatment does not always prevent retinal detachment, so the patient should always report the new onset of more floaters or, more importantly, any progressive loss of side-vision or “curtain across the vision.”
Rarely, the central vision may become blurred and distorted due to scar tissue formation from the retinal break. This problem cannot be prevented with laser or cryopexy, though the scar tissue can be removed by surgery if it interferes with vision.
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Hypertensive retinopathy is the medical name for damage to the retina from high blood pressure. 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. Normally, these blood vessels carry oxygen and nutrients, but do not leak fluid into the retina.
How does blood pressure damage the retina?
High blood pressure puts stress on the walls of blood vessels. In the short-term, high blood pressure weakens the inner lining (endothelium) of the retinal blood vessels causing them to leak serum or blood into the retina. In the long-term high blood pressure may cause permanent blood vessel damage (hardening) leading to retinal vein occlusion or arteriolar macroaneurym.
What are the symptoms of hypertensive retinopathy?
Symptoms may occur early or late in the course of hypertensive retinopathy. Blurring of vision may occur if excess fluid (edema) leaks into the retina. Rarely, blind spots or sudden new floaters may occur. Damage to the retina may occur without symptoms.
What treatment is available?
The key to treating hypertensive retinopathy is to control blood pressure. Lowering blood pressure is associated with lower risk of loss of vision. If complications occur, laser or injections (Avastin, Lucentis, Eylea, Triesence, Ozurdex) may improve the vision by sealing leaky blood vessels. There may be some permanent damage to the retina from high blood pressure. Your doctor is going to order appropriate tests and recommend the best course of action to take at this time. See your internist to keep your blood pressure under good control.
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.
There are many different kinds of lasers used to treat eye problems and many different ways lasers can be used to help the eye function. For example, the most common type of laser performed after cataract surgery is YAG capsulotomy. In this procedure the YAG laser is designed to open up a foggy window that develops behind the lens implant. It is a very brief, painless laser that usually gives a rapid improvement in vision. Other uses for lasers include treatment for glaucoma, droopy eyelids, and near-sightedness. Lasers with specific properties are chosen for a specific purpose. This blog discusses the photocoagulating laser used to treat retinal problems.
What is the retina?
The retina is a thin layer of delicate nerve tissue, which 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. The retina has two main areas. The macula is the central area that gives you sharp, central vision and color vision. The peripheral retina is the part of the retina that gives you side vision and night vision.
Most retinal lasers work by producing a carefully measured amount of heat to the retina in very small spot sizes. This heat may help to cauterize leaking blood vessels as in diabetes or macular degeneration. Alternatively, laser may simply seal down the retina to help keep it from detaching from the inside wall of the eye in cases of retinal tears and limited retinal detachments.
What are the risks of retinal laser treatment?
While laser is generally safe and effective, there is always some risk of adverse effects. Depending on the purpose of the laser, risks include blind spots in the vision that may be permanent, loss of central vision, loss of color vision, loss of night vision, and distortion of vision.
What is it like to experience a laser treatment?
Laser treatment is performed in the office in a matter of a several minutes. To avoid pain and discomfort, the ophthalmologist anesthetizes the eye with eye drops. An injection of anesthetic around the eye is rarely required. You sit in the examining chair with your chin in the chin-rest and forehead against the supporting bar. A contact lens is placed on the eye to hold the eyelids open. You may blink normally during the laser. Try not to squeeze your eyes together, because it may push the contact lens off the eye. You may be asked to look in a specific direction or follow a small light in order to keep the eye in position for treatment. It is important to follow instructions carefully to avoid side effects of laser treatment, which may include seeing blind spots in the vision afterwards. During treatment, it is normal to see bright flashes of light. Sometimes, you may feel a pulsing sensation with the flash. If it becomes painful, please notify the doctor. The treatment may last one to fifteen minutes depending on how much retinal damage is present.
What can you expect after a laser treatment?
Immediately after the contact lens is removed, your vision may be temporarily tinted red or blue. The vision is usually blurred for a few hours because of the dilating drops. Temporary blurring from laser sometimes lasts a week or more, but is usually mild. If your laser treatment was for macular degeneration, you may see a new permanent blind spot in the vision where abnormal blood vessels were cauterized. If you had laser for retinal break, it is normal for you to see floating specks in your vision and occasional flashes of light off to the side after laser. There are usually no restrictions to your activities. You may read, watch TV, stoop, bend, and lift objects just as before your treatment. No special eye drops are required after laser treatment, but be sure to continue any eye drops you were using before the treatment. You may use sunglasses for comfort, but they are not required. If you were told that laser is being used to improve your vision, it usually takes weeks or months to see the improvement. Sometimes, more than one treatment is required. Your doctor will give you an appointment to assess the results and determine whether any more treatment is needed.
What warning signs should I report after treatment?
Although it is normal to have blurred vision right after laser, the following symptoms are important to report to your Eye 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.
A retinal macroaneurysm is an abnormal out-pouching in a retinal blood vessel (arteriole) where the arteriolar wall has been weakened. It looks like a tiny balloon in the blood vessel. 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. Retinal arterioles are blood vessels that bring blood to the retina.
Retinal Arteriolar Macroaneursym
Fluorescein angiogram of macroaneursym
OCT scan of retinal macroaneurysm
Who is at risk for a retinal macroaneurysm?
Retinal macroaneurysms are more common in older people who have high blood pressure or hardening of the arteries. These conditions appear to weaken the blood vessels in the eye causing a ballooning of the vessel wall. Retinal macroaneurysms are NOT related to aneurysms in the brain.
What are the symptoms of a retinal macroaneurysm?
Blurring of vision may occur if excess fluid (edema) leaks from the macroaneurysm. Bleeding (vitreous hemorrhage) from a macroaneurysm causes floaters that can look like tiny dots or cobwebs moving about in your vision. Sometimes, bleeding under the retina causes the sudden onset of a large blind spot in the vision.
What treatment is available?
Laser may improve the vision by sealing the macroaneurysm to keep it from bleeding and leaking fluid, but the vision rarely returns completely to normal. There may be some permanent damage to the retina from the macroaneurysm. In some cases the macroaneurysm may be observed without laser to see if it will heal on its own. In other cases, medication injections may be used to improve vision. Your doctor is going to order appropriate tests and recommend the best course of action to take at this time. The retinal macroaneurysm will not be worsened by your daily activities or by using your eyes. See your internist to keep your blood pressure under good control.
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.
One week prior to surgery: Unless your internist feels that stopping blood thinners unacceptably increases the risk of blood clots (stroke/heart attack), do not take aspirin-containing products, Effient, or Brilinta for one week prior to surgery. Coumadin may be stopped four days prior to surgery. Pradaxa, Xarelto, and Eliquis may be stopped two days prior to surgery. Your EyeMD will schedule an appointment with your primary care doctor if evaluation is needed prior to surgery. Please inform your doctor of any chest pain/pressure, fever, productive cough, shortness of breath, or bleeding tendencies.
The morning of surgery: Take no medications for diabetes unless instructed differently by your doctor. Please do take all of your other medications with a sip of water and you may use any prescribed eye drops as usual. Otherwise, do not eat or drink anything on the morning of the scheduled surgery. Report promptly to the hospital as scheduled, but expect to wait while the nurses prepare you for the operating room. Bring a complete list of your medicines with dosages. Do not wear make-up. Arrange for someone to drive you to and from the hospital.
What type of anesthesia is available?
With local anesthesia the patient is sedated with IV medication so there is no memory of the anesthetic injection around the eye. Surgical drapes are placed over the face leaving plenty of breathing room. During surgery the patient is awake, but there is usually no pain. It is important to lie still on the operating room table so that there is no movement of the head during surgery. The main advantage of local anesthesia is that the patient can leave the hospital more quickly than after general anesthesia.
With general anesthesia the patient is asleep throughout the surgery and remembers nothing of the surgery. The anesthesiologist places a tube down the throat into the trachea to breathe for the patient. After surgery the throat may be sore. Which type of anesthesia is best for a patient may be determined by the health of the patient. Otherwise, if a person cannot lie still for the surgery or if claustrophobia is a problem, general anesthesia is preferred.
What are the risks of surgery?
Although uncommon, problems such as bleeding and infection may arise from any surgery. Retinal detachment or abnormal scar tissue formation may require additional surgery. Rarely, there may be loss of vision, double vision, glaucoma, or loss of the eye. The most common problem following vitrectomy surgery is progression of cataract requiring cataract surgery at a later date.
Although serious problems are not encountered often, the risks and benefits must be weighed for each individual to arrive at a decision for surgery. For many eye problems, surgery is the only hope for improvement in vision or prevention of blindness.
What can I expect after surgery?
A soft eye patch and a hard eye shield are placed on the eye at the end of surgery. Leave these in place until your exam on the day after surgery. Tylenol (no more than 4,000 mg per day; caution with liver disease) or Ibuprofen (no more than 2,400 mg per day; caution with kidney disease) may be used if there is pain. Call the doctor for a prescription if your pain is not relieved. It is not common to have severe pain after vitrectomy surgery. A scratchy feeling is due to sutures on the white of the eye. These sutures dissolve in about three weeks and you may use a lubricating ointment (Lacrilube is available without a prescription from the drugstore) as needed for comfort. At your exam after surgery, you will be given eye drops and/or an ointment to keep the eye comfortable, to prevent infection, and to promote healing. Wearing the eye patch is optional after you are seen in the office, but wear the hard protective shield at night for at least two weeks.
The vision usually returns slowly over days to weeks after surgery, but may take many months for final recovery. Use caution while walking as your depth perception may be altered until your vision returns after surgery. You may experience light flashes, floaters, and temporary double vision for days to weeks after the surgery. Do not be alarmed, but feel free to notify the doctor of any concerns that you may have. The swelling and redness slowly disappear over two or three months. There are no restrictions to using the eyes to read, watch TV, or bathe. Ask the doctor when you may resume driving. You may shower after the patch has been removed in the office. Avoid heavy lifting and straining for one week after surgery. You may resume taking all your medications after the surgery; however, blood thinners should be withheld until after the first visit in the office one day after the surgery.
Depending upon the reason for your surgery, it may be very important to lie face down or on either side after your surgery. Be sure you understand any positioning requirements given by your surgeon. Additionally, if a gas bubble is placed in your eye at the time of surgery, you may not fly on a plane until it has dissolved or you could risk severe pain and blindness. Similarly, nitrous oxide should not be used if any other surgery is required while you are healing from your eye surgery. Be sure to wear a wristband for six weeks after eye surgery to notify health care providers that you have a gas bubble in the eye. Remove the wristband only when your doctor has notified you that the gas bubble is gone.
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 mainstay of treatment of wet-type age-related macular degeneration (AMD) requires the intraocular injection of medication (e.g. Avastin, Lucentis, Eylea, Beovu, and Vabysmo) to prevent loss of vision. Although effective, this treatment entails some degree of risk. For example, infection may occur at a rate of about one in one thousand to one in five thousand injections. Moreover, there may be a low increased risk of stroke.
Although some studies do not show increase risk (Campbell), other large studies have demonstrated an increased risk of stroke. In one study the increased risk of stroke appeared to be 1 in 127 patients within one year after starting treatment for AMD (Schlenker). These studies were unable to prove that the medication itself was responsible for the increased risk of stroke. For example, it may be that people with new-onset wet AMD are at a higher risk of stroke than others. In 2019 a population-based study demonstrated no increased risk of stroke and heart attack related to AMD treatment (see reference). Additional research in ongoing.
Given this information what are the options? Certainly, a patient may decide not to treat macular degeneration and risk loss of vision in an effort to decrease the risk of stroke. Another option may be to minimize the frequency of injections. That is, if the macular degeneration remains stable after several monthly injections, consider extending the time interval between injections. In this manner there is less exposure to the drug. Furthermore, if the wet-AMD appears to have reached end-stage with significant loss of vision, the injections might be stopped altogether. If done carefully, one may reduce the risk of a sudden recurrence of wet-AMD with further loss of vision while off treatment.
The type of medication used for injection has not been proven to make a difference in the risk of stroke. Although Martin et al found a slight increase in stroke risk with Avastin compared with Lucentis, these findings were not supported by Chakravarthy and Schlenker. More research is needed to better define risk of stroke and how we may minimize the risk. A recent meta-analysis of current data as of 2022 (Reibaldi) supports Lucentis over the other agents as being safer from a systemic risk of heart attack and stroke. Please refer to my blog on medication choices for treating retinal problems.
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.
Color photo and auto fluorescent fundus image of Stargardt disease
What is Stargardt disease?
Stargardt disease is an inherited problem of the retina. 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. Stargardt’s disease mainly affects the central part of the retina that normally provides sharp, central, reading vision and color vision.
What causes Stargardt disease?
Stargardt disease is usually inherited in a recessive pattern, which means it may skip many generations. An individual usually inherits the affected gene from both parents who carry the gene in order to have symptoms of the condition. Individuals who have inherited the gene from only one parent usually do not exhibit symptoms and are called “carriers”. If both parents carry the gene, then one in four children will have symptoms of Stargardt disease. If a person with Stargardt disease has children with someone who does not carry the gene, none of their children will have Stargardt disease, but half of their children will carry the gene. The gene variants that cause Stargardt disease are very common; they are present in about one in twenty people.
What are the symptoms of Stargardt disease?
Stargardt disease may cause no symptoms in the early stages. It may cause symptoms early or late in life. With time, symptoms may include the following:
Photophobia—unusual sensitivity to light.
Hemeralopia—difficulty seeing well in bright light.
Decreased color vision.
Blurring of central vision, sometimes with distortion or blind spots.
If Stargardt disease progresses over many years, it may cause a loss of vision to the point of legal blindness. In such cases, the loss of central vision interferes with the ability to read and drive, but the side-vision usually remains good. Sometimes it progresses very slowly and never causes significant visual loss. The rate of visual loss can be predicted by identifying others in the same family who also have Stargardt disease, as the pattern is often similar among family members. The visual symptoms may be monitored with the Amsler grid test.
How is Stargardt disease diagnosed?
The symptoms listed above may be the first clue to the diagnosis. A routine dilated eye examination can detect the retinal changes of Stargardt disease. In most cases a fluorescein angiogram is helpful. In this procedure the ophthalmologist injects a dye into the vein of the arm and photographs are taken of the retina, which show specific changes in the retina to make the diagnosis. A free genetic test can be ordered by my office and mailed to you. It involves a painless swab of the lining of the mouth. It is very reliable to detect the gene that causes Stargardt disease.
How is Stargardt disease treated?
There is no proven treatment for Stargardt disease, but studies are underway to find a treatment to slow the loss of vision. Researchers recommend avoiding excessive exposure to sunlight and avoid taking vitamin A supplements. It may also be helpful to avoid excessive dietary intake of foods that contain vitamin A, such as carrots and liver.
If significant loss of vision does occur, there are programs and devices that focus on helping a person find ways to cope with the visual impairment. Various low-vision optical devices such as magnifying devices, closed-circuit televisions, and large-print reading material can help to minimize the effects of visual impairment. Your ophthalmologist can prescribe optical devices or refer you to a low-vision specialist. Because side vision is less commonly affected, the remaining sight can be very useful.
A wide range of support services, rehabilitation programs, and devices are available to help people with cone dystrophy continue with many of their favorite activities. The Lighthouse for the Blind and the Pinellas Center for the Visually Impaired have classes and specialists in providing prescription lenses to magnify printed material. The Division of Blind Services provides rehabilitation services and financial aid for eye care in selected cases. Your doctor can give free access to the “talking book” library to make “books on tape” available. A form is available from your doctor that establishes legal blindness to be used for property tax and income tax deductions. As always, if you have any questions please do not hesitate to contact your doctor for more information.
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.
There is currently no proven treatment for Stargardt disease (SD), an inherited eye condition that affects the retina and causes a slow loss of central vision over years. It affects about one in 10,000 people and may begin to cause symptoms early or late in life.
In Stardardt disease there is an abnormal protein that is involved with transporting vitamin A. In normal eyes Rim protein transports vitamin A from the retina to cells that recycle it for continued use. The retina requires vitamin A to process light for functional vision. Eyes with Stargardt disease have a defective Rim protein. As a result, vitamin A that has been used by the retina tends to accumulate in the retina in the form of toxic byproducts called vitamin A dimers (pronounced, “DYE-mer”). Vitamin A dimers are thought to contribute to permanent retinal damage over time.
Alkeus is a company that is researching the use of a drug that may slow the loss of vision in Stargardt disease. This pill (ALK-001) is taken by mouth once a day. In laboratory studies it appears to slow the formation of vitamin A dimers. It has been studied in the laboratory and now has been cleared by the FDA for study in humans. The study will compare the effect of ALK-001 to placebo (sugar pills) to determine the effectiveness and safety. Eligible patients are healthy individuals between 12 and 60 years of age. Candidates must undergo genetic testing to confirm the diagnosis. The study will last for 24months. If this and other studies prove the usefulness of ALK-001 it will likely be approved by the FDA for general use by ophthalmologists outside of clinical trials in the future.
UPDATE OCT 2022: The TEASE 1 Study reported very favorable results at the American Academy of Ophthalmology meeting in Chicago this month. There was slowing of the rate of vision loss and no prominent safety issues.
For further information and to find the study sites see: Clinical Trials
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.
There is substantial evidence that fenofibrate is beneficial in the treatment of diabetic retinopathy. The retina in a thin layer of nerve tissue that is sensitive to light and acts like the film in a camera. The retina “takes a picture” of what your eyes focus on. The fine blood vessels in the retina are especially sensitive to high blood sugar levels, which cause the vessels to leak and eventually become blocked. This damage is called diabetic retinopathy.
Fenofibrate is a medication commonly used to control blood lipid levels. Abnormal serum levels of lipid have been shown to increase the risk of hardening of the arteries (atherosclerosis), which may lead to stroke and heart attack. While the goal of controlling lipids in diabetes is important in itself, fenofibrate appears to offer an independent benefit to small blood vessels (capillaries) in the retina. Two large studies (ACCORD and FIELD) demonstrated that fewer laser treatments were needed in a group of patients on fenofibrate compared with other patients who were randomized not to receive treatment with this medication for abnormal serum lipid levels. Fenofibrate may be used along side other medications used for lipid control (such as statins). However, patients with severe kidney damage should not use fenofibrate. A common dose of fenofibrate is 160mg per day. However, fenofibrate 54mg is recommended for patients with glomerular filtration rate (GFR) between 30 and 50. No fenofibrate is recommended if the GFR is less than 30.
There are established treatments for diabetic retinopathy. The mainstay of treatment of vision-threatening diabetic retinopathy remains laser and anti-VEGF injections (Avastin, Lucentis, Vabysmo, and Eylea). In severe cases of diabetic retinal damage, vitrectomy surgery is needed to restore vision or prevent blindness. However, there are patients with diabetes who lose vision despite treatment and those who develop side-effects of treatment. Therefore, fenofibrate is a welcome addition to the medical treatment regimen.
Prevention of diabetic eye damage is far superior to treatment of diabetic retinopathy. Therefore, it is best to prevent diabetic damage to the eyes and other organs in the body through proper management of blood sugar, blood pressure, and blood lipids with the help of a medical doctor. In difficult cases of diabetes, the help of an endocrinologist is necessary. Finally, annual dilated eye exams with an eye doctor skilled in the management of diabetic retinopathy is key to identify retinal damage before vision is lost.
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.
Cystoid macular edema (CME) is an accumulation of fluid in the center of the retina. The fluid is clear like water and comes from abnormal leakage of the blood vessels in the retina. The retina is a thin layer of delicate nerve tissue which 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” of objects you look at and sends the message to the brain. The macula is the central area of the retina that gives you sharp central vision and color vision. CME frequently causes a blurring of vision described as fuzzy, hazy, or cloudy. Cystoid macular edema is NOT related in anyway to macular degeneration.
What causes cystoid macular edema?
Although the exact causes of CME are unknown, it may accompany blood vessel problems or inflammation. It most commonly occurs after cataract surgery and may be seen in as many as 3% of eyes undergoing surgery.
How is cystoid macular edema treated?
Since many factors may lead to CME, many different types of treatment are available. Usually weeks to months are required to improve the vision. Sometimes more than one type of treatment is needed for best results. Rarely, vision cannot be restored.
Treatment may include eye drops (steroid, and non-steroid) instilled into the eye several times a day. Sometimes, pills are used to decrease inflammation. Occasionally, medication is injected next to the eye under the eyelid. Anesthetic eye drops help to make the injections painless. Sometimes, surgery is needed to look for infection or remove abnormal scar tissue from inside the eye. With treatment most cases of CME can be managed successfully with improvement in vision. For more information visit www.retinavitreous.com
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.
Ozurdex is a very small tube-like implant that contains steroid medication that is slowly released into the eye for up to 3-6 months. The Ozurdex implant is injected into the eye in the office setting in order to decrease inflammation, swelling, or leaky blood vessels inside the eye. It has been shown to improve vision in eyes with retinal vein occlusion, diabetic macular edema, and inflammation in the eye. The Ozurdex implant completely dissolves in the eye. Repeated injections may be necessary for continued improvement in vision.
How is an Ozurdex injection performed?
Anesthetics are used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation is often felt as the implant is injected into the eye with a very thin, short needle. The procedure is very brief.
What are the side effects of Ozurdex?
Although possible, it is rare to see the Ozurdex implant floating in the vision. In about 30-40% of patients, the pressure inside the eye increases and requires eye drops. About 1% of patients require glaucoma surgery to prevent loss of vision. Most eyes develop cataract and eventually require surgery. Rare risks of steroid injection include bleeding, infection, retinal detachment, and loss of vision/loss of the eye. The risk of infection is about one in 1,000 injections. Please report any severe loss of vision to the doctor without delay.
How do I care for the eye?
You may be given eye drops and instructions on how to use them. Physical activity is not limited after Ozurdex injection. Tylenol or Ibuprofen may be used if there is discomfort, 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. If you have any questions or concerns, please call the office. Additional information is available at www.ozurdex.com.
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.
PUES is an abnormal leakage of clear fluid under the retina, which causes symptoms of blurred vision, sometimes with distortion of straight lines. It is also call the peripapillary pachychoroid syndrome. This condition frequently presents as central serous retinopathy. The retina is a thin layer of delicate tissue in the back of your eye, which lines the inside wall like the film in a camera. The retina “takes the picture” of objects you look at and sends the message to the brain.
What causes PUES?
PUES appears to be due to an abnormal leakage of serum (clear fluid) from blood vessels in the choroid. The choroid is a layer of tissue with many blood vessels lying under the retina. When the choroid is thick, it may abnormally leak fluid into the retina (Figure A-D) causing visual symptoms. Thick choroid is seen more commonly in far-sighted eyes than near-sighted eyes.
Thickened choroid leads to leakage of fluid into the retina
What is the treatment of PUES?
If the leakage is mild, observation may be all that is needed. If symptoms of blurred vision become significant, treatment may include eye drops or pills taken by mouth (Figure E-F). In rare cases, laser treatment or surgery in the operating room may be required to control the leakage. An attempt is made to eliminate aggravating factors such as ocular inflammation and, rarely, medications.
What will happen to my vision?
With prompt treatment the vision usually remains stable. In some cases, there may be a degree of permanent damage to the retina affecting the vision from past leakage that cannot heal. Treatment needs to be continued as a return of leakage may occur is medications is stopped (Figure G-H).
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.
Cataract is a foggy lens inside the eye (click image to enlarge)
Opacity of the posterior capsule after cataract surgery (Click to enlarge)
What is posterior capsular opacity (PCO)?
Posterior capsular opacity is a common condition in which the posterior capsule becomes hazy after cataract surgery. The posterior capsule is the clear layer of tissue that supports the intraocular lens, which is implanted into the eye at the time of cataract surgery. Over time after cataract surgery, the posterior capsule may lose its clarity.
What causes posterior capsular opacity?
The posterior capsule becomes opaque because of an abnormal growth of hazy tissue, like scar tissue, grows over the clear posterior capsule. These cells are remnants of cells from the cataract. Research is underway to determine what might be done to prevent PCO from developing.
What are the symptoms of posterior capsular opacity?
The symptoms of PCO are very similar to symptoms from cataract: blurred, cloudy, hazy vision with or without glare from oncoming lights, especially at night. These symptoms usually develop slowly, although sometimes the problem is discovered suddenly if the other eye is a clear seeing eye. In these cases, the clear eye is covered and the cloudy vision is discovered in the eye with PCO.
How is posterior capsular opacity treated?
If the vision is good and the symptoms are mild, no treatment is needed and the PCO will not harm the eye. If improvement in vision is needed, YAG laser can be performed in a brief, pain-free treatment to open the posterior capsule to allow for improvement in vision. If the vision does not improve after YAG laser, a change in glasses may be needed or further examination of the eye may disclose other problems limiting visual return.
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.
Glaucoma is a condition in which the pressure inside the eye damages the cells of the optic nerve. The optic nerve transmits information from the eye to the brain to provide vision. Glaucoma affects two million Americans and is the second leading cause of blindness in the United States.
What causes glaucoma?
There are many different types of glaucoma, but most types of glaucoma have in common an abnormally high pressure inside the eye. The pressure in the eye is not directly related to blood pressure. The normal range of pressure in the eye is between 8-21 units of measurement. There is a tissue inside the eye that pumps a clear fluid (aqueous) into the eye keeping the eye from collapsing. Another tissue called the trabecular meshwork normally drains the aqueous from the eye preventing the pressure from building up. In most types of glaucoma, the drain becomes clogged or blocked resulting in an increase of the pressure inside the eye. High pressure inside the eye damages the cells of the optic nerve. In an uncommon type of glaucoma (normal tension glaucoma), the pressure measurements are within the normal range, but the optic nerve is unusually sensitive and will become damaged if the pressure is not lowered even further.
Who is at risk for having glaucoma?
About two or three percent of Americans develop glaucoma. It may occur at any age, but usually occurs after the age of forty. It appears to be hereditary and, therefore, is more common in people who have family members with glaucoma. Diabetes increases the risk of glaucoma. African-Americans develop glaucoma fifteen times more frequently than European-Americans. Another risk factor for glaucoma is uveitis and trauma…especially, blunt injury to the eye. Steroid eyedrops and injections (triamcinolone and Ozurdex) may bring out glaucoma in eyes that are predisposed.
What are the symptoms of glaucoma?
The most common type of glaucoma is “open angle” glaucoma. In its early stages, glaucoma causes no obvious symptoms. However, driving vision can be impaired early on. Moreover, if it is not detected and treated early, glaucoma eventually may cause a gradual, severe, permanent loss of vision. Rarely, visual hallucinations may occur.
A less common type of glaucoma called “angle closure” glaucoma may cause sudden pain, redness, and blurred vision. It is more often seen in far-sighted eyes. In some cases, the tendency for an acute attack of glaucoma can be predicted on examination. In such cases laser treatment and/or cataract surgery may help to “open” the angle to prevent a future attack of angle closure glaucoma.
How is glaucoma diagnosed?
The most common test for glaucoma in an eye examination is tonometry. Tonometry measures the pressure inside the eye. Most people are first suspected to have glaucoma because high pressure is found on a routine exam. Another way to diagnose glaucoma is by examination of the optic nerve inside the eye. A nerve damaged by glaucoma has an abnormal appearance called “cupping,” which may provide a clue to the diagnosis. Additionally, a formal measurement of the peripheral vision (side vision) by a visual field test usually confirms the loss of vision that may not otherwise be noticeable. A visual field test is not part of a standard exam, but is performed if glaucoma is suspected. Repeated visual field tests help to determine whether treatment has been adequate to prevent loss of vision. Finally, sophisticated computerized tests (optical coherence tomography) are available to measure the thickness of optic nerve fibers to help in the diagnosis and assess the treatment of glaucoma.
What treatment is available?
Treatment of glaucoma is directed at lowering the pressure in the eye. The first line of treatment in most cases includes prescription eye drops. There are a number of very effective eye drops that work by either opening the drain or by slowing down the pump to lower the pressure. These drops are powerful medicines that should be used exactly as prescribed to prevent blindness from glaucoma and minimize side effects from the eye drops. Side effects are not common, but may include burning, itching, redness, dry mouth, and worsening of bronchitis or asthma. It is very important to take the eye drops exactly as prescribed to prevent blindness. If eye drops fail to control the pressure, laser surgery may help. Finally, surgery performed in the operating room (trabeculectomy) may create an artificial drain to lower the pressure. After trabeculectomy patients are warned to notify the doctor urgently if the eye becomes red or appears to be infected, because infection may enter the eye after trabeculectomy and result in severe damage or blindness. In general, patients with glaucoma may require regular examinations every three to four months to preserve vision.
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 Iluvien implant is shaped like a small thin tube so that it can be injected into the eye in the office with a needle attached to an injector. The tube contains a corticosteroid medicine that is released into the eye slowly for up to 2-3 years. Repeated injections may be performed. When the tube-like implant is empty it remains in the eye and usually causes no problems.
What is the Iluvien implant used for?
The Iluvien implant decreases inflammation, leaky vessels and swelling inside the eye. It has been approved to treat diabetic macular edema. It helps keep the vision from worsening and may improve vision over time.
How is an Iluvien implant inserted into the eye?
Anesthetic solutions are used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation may be felt as the implant is injected into the eye with a very thin, short needle. The procedure is very brief.
What are the possible side-effects?
It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. It is rare to see the tube floating in the vision. Most eyes require cataract surgery several months after injection of the implant. About 30-40% of eyes experience a pressure increase (glaucoma) in the eye. Although the pressure is not usually painful, it may require eye drops to prevent permanent loss of vision. In 1-5% of eyes, glaucoma surgery is needed. Rare risks of injection include bleeding, infection, retinal detachment, and loss of vision/loss of the eye. Please report any severe loss of vision to the doctor without delay.
How do I care for the eye?
You may be given eye drops and instructions on how to use them. Physical activity is not limited. Tylenol or Ibuprofen may be used if there is discomfort, but severe pain should be reported to your doctor without delay. If you have any questions or concerns, please call the office.
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.
Clear vitreous gel fills the eye (click on image to enlarge)
Why is an intravitreal steroid injection performed?
An intravitreal steroid injection (ISI) is a painless office procedure performed to decrease inflammation, swelling, or leaky blood vessels inside the eye. Conditions that may require ISI include diabetic macular edema, retinal vein occlusion, uveitis, macular degeneration, and other causes of swelling and/or inflammation. The steroid medicine acts to decrease inflammation and leakage from blood vessels from a variety of causes, thereby offering the chance for improvement in vision. The effect of ISI lasts for several months after which repeated injection may be considered if necessary.
How is an intravitreal steroid injection performed?
Anesthetic solutions are used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation is often felt as the steroid is injected into the eye with a very thin, short needle. The procedure is very brief.
Intra-vitreal injection
What medications are injected?
Triamcinolone is a steroid that has been used for many years in the eye. The most common preparation contains preservatives that may be decanted from the preparation to avoid ocular inflammation. Triesence® is a form of triamcinolone for the eye that lacks preservatives, but is more expensive. These steroids usually provide anti-inflammatory effect for several months.
Dexamethasone may be injected into the eye in a slow-release implant, called Ozurdex®. The effect of Ozurdex® may last up to 3-6 months.
Iluvien® is a steroid implant (2014) approved for the treatment of diabetic macular edema. It may last up to 2-3 years.
Yutiq® is a steroid implant approved for the treatment of uveitis. It may last up to 2-3 years.
Intraocular steroid preparations
Will an intravitreal steroid injection affect my vision?
It is normal to see the steroid medication after the injection as many floating particles (triamcinolone) or a single large fiber (Ozurdex®, Iluvien®, Yutiq®), which slowly disappear over several weeks to months in the case of triamcinolone and Ozurdex. The anticipated improvement in vision occurs slowly during this time. Commonly, the pressure inside the eye increases and may require eye drops for several months. Sometimes the high pressure results in optic nerve damage (glaucoma) and rarely requires surgery in 1-4% of cases. There is also an increased rate of cataract formation. For these reasons ISI is best performed in eyes that have already had cataract surgery and are not at high risk of glaucoma damage. Rare risks of steroid injection include bleeding, infection, retinal detachment, and loss of vision or loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections. The risk of infection is about one in 1,000 injections. Please report pain or any severe loss of vision after injection to the doctor without delay.
How do I care for the eye?
You may be given eye drops and instructions on how to use them. Artificial tears may be used hourly until the eye feels less irritated from the iodine solution, which is used to prevent infection. Physical activity is not limited after ISI. 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. If you have any questions or concerns, please call your doctor.
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 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 is called a retinal artery occlusion.
What causes a retinal artery occlusion?
Usually a blockage occurs from a piece of hardened artery in the neck (carotid artery) which breaks away and flows “down stream” to lodge in a small retinal artery. Hardening of the arteries is due to aging, obesity, high cholesterol, high blood pressure, diabetes, and tobacco use. Therefor, patients with retinal artery occlusion are at risk of other complications of hardening of the arteries (e.g. heart attack and stroke).
Abnormal tissue from a heart valve may also be the source of blockage. Rarely, an occlusion may result from blood disorders or inflammation such as giant cell arteritis. Fibromuscular dysplasia is suspected in young patients with retinal artery occlusion. Trauma may cause retinal artery occlusion by dissection of the carotid artery, often associated with neck pain.
What are the symptoms of a retinal artery occlusion?
A sudden, painless loss of vision is common. There may be loss of only the central vision, the side vision, or there may be a dark bar or band above or below the center of vision. The loss of vision may be temporary or permanent.
What treatment is available?
If the blockage is mild, some or all of the vision may return with time. Sometimes it is necessary to help relieve the blockage with eye drops, pills, or an office procedure to lower the pressure in the eye. The blockage may be overcome and the blood flow may resume if the pressure in the eye is decreased quickly. This treatment may bring back some or all of the vision, but sometimes no treatment can bring back any vision. If an underlying medical problem is found, it must be treated.
Your doctor is going to order appropriate tests and recommend the best course of action to take at this time. The retinal artery occlusion will not be worsened by your daily activities or by using your eyes. If you have any questions, please feel free to ask.
What general health issues are there?
Retina artery occlusion usually indicates the need for an urgent general medical evaluation for increased risk of stroke. About 10% to 15% of people who experience retinal artery occlusion will suffer from a stroke within three months. Half of those individuals will have a stroke within 48 hours of having eye symptoms. Those people who survive this initial high-risk period must still be monitored because there is a 40% risk of stroke or heart attack within ten years from the time of retinal artery occlusion. This important health issues are why it is important to undergo regular general medical evaluations and work to minimize factors that worsen hardening of the arteries. Such factors include physical inactivity, overweight, tobacco use, high blood pressure, high cholesterol, and diabetes.
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.
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.
Cataract is a foggy lens inside the eye (click image to enlarge)
What is a cataract?
A cataract is a foggy lens inside the eye. The lens is positioned behind the iris to focus light that passes through the pupil (see drawing above). The lens inside the eye works like a lens in a camera. The normal lens is clear, but it may lose its clarity over time. When the lens loses its clarity, it causes hazy and cloudy vision, often with glare from on-coming lights. The distance vision is often affected more than the near vision.
What causes cataract?
Cataract is common with age. The older a person becomes, the more likely cataracts will form. Other causes include heredity (family history of cataract), inflammation, blunt injury to the eye, sun exposure, tobacco, high blood pressure, diabetes, and medications (such as corticosteroids (prednisone) and some anti-depressants known as SSRI inhibitors).
How is cataract treated?
The only treatment of cataract is surgery in the operating room, with or without the assistance of laser. There is no way to remove a cataract with vitamins, pills, or eye drops. However, a change in glasses may minimize the blurred vision caused by cataract in the early stages. There is no emergency to treat a cataract. It will not harm the eye to hold-off from having surgery except in extremely severe cases. At the time of cataract surgery, a lens implant will be placed inside the eye to improve the ability of the eye to focus.
When is surgery needed?
Surgery is needed when the haziness in the vision from cataract has become bad enough to require improvement in vision that cannot be achieved with glasses. This is a decision made by the patient with help from the doctor.
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.
Hemoglobin A1C is a blood test that measures the average blood sugar level in the blood over the past two or three months. Specifically, this test measures the amount of sugar that permanently attaches to hemoglobin, a protein in red blood cells. Because red blood cells live for about three months, this test shows the average blood sugar level during that time. This test gives some of the information that you could get if you measured your blood sugar every day continuously throughout the day and night.
Why is hemoglobin A1C important?
We know high blood sugar damages blood vessels and may cause blindness, kidney failure, nerve damage, amputation, heart attack, stroke, and premature death. Managing blood sugar dramatically reduces the risk of these complications. The hemoglobin A1C test helps to determine whether your blood sugar control has been adequate to minimize damage from diabetes.
Do I need both hemoglobin A1C and standard blood sugar testing?
Yes. Each test gives different information about blood sugar control. For example, your fasting blood sugar may be normal, but if your hemoglobin A1C is high, then you know there are times in the day that the blood sugars are too high and you are still at risk of having complications from diabetes. On the other hand, if your hemoglobin A1C is high, you need spot checks of the blood sugar level to know specifically what part of the day in which you may need to manage differently.
How do results from hemoglobin A1C compare with blood sugar levels?
The hemoglobin A1C test measures the percent of hemoglobin that is chemically bound to sugar. The normal range of hemoglobin A1C is 4-6%, which corresponds to an average blood sugar level of 60-120 mg/dl. Your doctor will help determine what level is best for you, but generally a hemoglobin A1C greater than 7% (average blood sugar equal to 140 mg/dl) means that measures must be taken to achieve better management.
The hemoglobin A1C test results may be inaccurate in certain conditions. The test results may be falsely low in the following situations: the use of dapsone, certain types of anemia, mechanical heart valves, recent blood transfusion, enlarged spleen, treatment with erythropoietin, severely elevated triglycerides, high-dose vitamin C or E.
Conversely, test results may be falsely elevated in the following situations: untreated hypothyroidism, after surgical removal of the spleen, Iron deficiency, vitamin B12 deficiency, reduced red blood cell production by the bone marrow, chronic alcoholism, chronic kidney disease.
If there is a question about the reliability of the test results, other means of testing may be considered, such as the fructosamine test.
Hemoglobin A1c
Blood Sugar
A1c
(mg/dL)
4%
60
5%
90
6%
120
7%
150
8%
180
9%
210
10%
240
11%
270
12%
300
13%
330
What can I do if my hemoglobin A1C results are high?
While it is important to keep blood sugar levels from being too high, it is also important not to risk frequent or severe episodes of dangerously low blood sugar levels. You and your doctor will evaluate your situation to determine which of the following factors may be playing a role:
Too little exercise
Inadequate medication type or dosing
Too much food
Wrong types of food
Increased stress
Infection
The hemoglobin A1C test provides you with more information to maintain good management of your diabetes. Better control means a longer, healthier life. And any positive change in your care, no matter how small, makes a difference. For example, each 1% decrease in the hemoglobin A1C reduces the risk of eye and kidney damage by 37% and reduces the risk of diabetes-related death by 21%. The more you are involved with your health care, the greater the likelihood of living a longer and healthier life.
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.
Ocular toxoplasmosis is an inflammation of the eye caused by an infection of the retina by a parasite called Toxoplasma gondii. 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” of objects you look at and sends the image to the brain.
What causes ocular toxoplasmosis?
Toxoplasma gondii infects humans and animals throughout the world. Twenty to fifty percent of adults in the United States test positive for exposure, but few people experience symptoms. The most common presentation resembles mononucleosis with symptoms of fever, fatigue, and swollen lymph glands. Because the toxoplasma organism can become inactive and form a protective microscopic cyst within human cells, it can cause relapses of infection and spread to new areas of the body months to years after the initial infection. If the parasite spreads through the blood stream to the eye, ocular toxoplasmosis may threaten blindness.
How is toxoplasmosis contracted?
The most common ways to contract infection are as follows: 1.) Hand-to-mouth transmission of the toxoplasma organism in cat feces e.g. cleaning the litter box. 2.) Eating undercooked meat, chicken, or eggs from infected animals. 3.) Eating unwashed fruits and vegetables that are contaminated by animal feces. 4.) Hand-to-mouth transmission from handling infected raw meat or animal products. 5.) Transmission from infected mother to child through the placenta during pregnancy. 6.) Rarely, Toxoplasma infection may acquired through contaminated drinking water or dust in the air.
Toxoplasma gondii completes its life cycle by producing millions of oocysts (eggs) in the intestines of the cat. These infectious eggs leave the cat in the feces and may lie dormant in the ground for up to two years. These eggs may infect an animal that may eat from the ground or a human who eats unwashed, contaminated fruits and vegetables from the ground. Once inside a human or animal, the eggs “hatch”, multiply, and spread throughout the body. When the immune system attacks the parasite, it becomes dormant and “hibernates” inside cells throughout the body. In months or years in the future, it may become active to cause infection again.
What are the symptoms of ocular toxoplasmosis?
If toxoplasma reaches the eye, early symptoms include seeing new tiny floating spots (floaters), pain, redness, tearing, light sensitivity, and blurred vision. Late symptoms include permanent blind spots in the vision and, rarely, blindness. These symptoms are not specific for ocular toxoplasmosis, but they are especially important to recognize in people with known toxoplasma scars in the retina. If such symptoms are promptly reported to the doctor, treatment may minimize permanent damage to the eye.
What treatment is available?
Sulfa antibiotics (Septra or Bactrim) are frequently used for several weeks to treat active infection. In some cases of toxoplasmosis, another antibiotic called clindamycin is used. This medicine may rarely cause a severe bloody diarrhea, which should be reported to the doctor immediately for effective treatment. Prednisone pills and similar eyedrops may be used to decrease inflammation. Rarely, antibiotics may be injected into the eye. Often, the pupil of the eye is dilated with eyedrops during the active infection to prevent scarring and to relieve pain.
It is not uncommon for untreated ocular toxoplasmosis to result in loss of vision. It is rare to experience serious side effects from medication used to treat toxoplasmosis. Armed with the knowledge to report side effects promptly to the doctor, you can minimize the chance of suffering from any permanent ill-effects from treatment.
Finally, notify your doctor if you had a toxoplasma infection in the past as it may be important to avoid intraocular steroid injections to prevent a return of infection.
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.
Pneumatic retinopexy is a surgical procedure to repair retinal detachment, close macular holes, treat vitreomacular traction, and displace blood from beneath the center of the retina as occurs in some cases of wet type age-related macular degeneration. A gas bubble that is injected into the eye is used to gently push against the retina to hold it in position. Strict positioning of the head is essential for success.
How is pneumatic retinopexy performed?
Pneumatic retinopexy can be performed in the office or in the operating room of a hospital. An injection of anesthetic around the eye is used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection. If there is a retinal break, cryopexy is used to seal the break. Cryopexy is performed by holding a pencil-like probe with a freezing tip against the white of the eye. It may cause a pressure sensation of coldness. Sometimes, laser is also used to seal retinal breaks. In preparation of the gas injection, fluid is removed from the eye with a small needle to make room for the gas bubble. After the gas injection, the eye is patched.
Will I be able to see the gas bubble?
It is normal to see the gas bubble while looking out of the eye. It appears as a black curved line across the vision, a single black ball in the bottom of the visual field, or as many black “fish eggs.” The gas bubble will move in the vision with head and eye movements. Usually, there is very little vision when looking through the gas bubble when it is large. The vision slowly improves as the gas bubble disappears by dissolving in the fluids of the eye over four to six weeks.
How does pneumatic retinopexy work?
Image of retinal detachment (top) and pneumatic retinopexy (bottom).
The gas bubble in the eye floats upward and gently holds the retina in position. Depending on what part of the retina needs support, the head must be kept in proper position. For example, if there is a break in the part of the retina that corresponds to the twelve O’clock position on a clock, then the head must remain upright so that the bubble floats up against the superior part of the retina. Otherwise, the bubble will not provide proper support and the retina will not heal properly and more surgery may be needed.
A retinal detachment is present in the top left-hand side of the photograph.
Intra-ocular gas bubble seen on photograph following pneumatic retinopexy.
How long do I need to stay in position?
You may need to stay in position from a few days to two weeks depending on your surgeon’s recommendations. It is best to attempt to remain in the recommended head position for 90% of the day and night. While in position, you may use your eyes to read or watch TV. A special pillow may be purchased to sleep in a face down position, which is recommended to close a macular hole. For five or ten minutes of every hour or two, you may stop the positioning to rise, stretch, and quietly move about the house to use the bathroom or eat. Until the gas bubble is gone, you should not fly in an airplane or undergo anesthesia using nitrous oxide, as doing so may result in blindness. Keep a MedicAlert band on your wrist until the gas bubble is gone.
How well does pneumatic retinopexy work for retinal detachment?
The PIVOT study compared the results of pneumatic retinopexy versus vitrectomy in the repair of retinal detachment. On average, pneumatic retinopexy resulted in less distortion and an additional line of visual improvement on the eye chart compared with vitrectomy. However, strict positioning is needed for success with pneumatic retinopexy; therefore, the success rate of reattaching the retina with a single procedure was 81% for pneumatic retinopexy compared to 93% with vitrectomy. Additional surgery, when necessary, usually results in successful reattachment.
What are the risks of pneumatic retinopexy?
Although generally a safe procedure, pneumatic retinopexy is not without risks. Adverse effects include pain, bleeding, infection, scarring, glaucoma, cataract, loss of vision, deformity, blindness, and loss of the eye. When pneumatic retinopexy is recommended, the benefits outweigh the risks of surgery.
How do I care for the eye?
Keep the patch on and use no eye drops in the operated eye until the patch has been removed in the office on the first day after surgery. After the office visit you may shower and shampoo your hair being careful not to bump or rub the eye. The eye can be gently dried by patting it with a clean, dry towel. You may be given eye drops and instructions on how to use them. Tylenol (no more than 4,000 mg per day) or Ibuprofen (no more than 2,400 mg per day) may be used if there is pain. Patients with liver disease should be cautious about taking Tylenol, and patients with kidney disease should be cautious about taking ibuprofen. Prescription pain medication is available if needed. It is normal to have some discomfort, but severe pain should be reported to your doctor. It is normal to experience eyelid swelling and bruising. The eye will be red and watery. Sometimes, there is a sensation resembling an eyelash in the eye. After the patch has been removed, this discomfort is best managed with Lacrilube (available in the pharmacy without a prescription), which may be used in the eye as often as needed. After the first office visit following the surgery, an eye patch is not necessary. However, at night a hard shield may be used to cover the eye to protect it from trauma. If you have any questions or concerns, please call the office.
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.
Although Plaquenil is of proven benefit for a number of medical problems, very rarely it can cause damage to the eyes (1-2% at 10 years and 3-20% at 20 years). Early symptoms may be subtle. Small blind spots may develop just above or around the center of vision. Sometimes they progress to form a doughnut-shaped blind area around the central vision. If not detected early, the central vision itself may be lost. When this occurs, color vision is usually affected. These symptoms, however, are not specific to Plaquenil damage. The Eye MD must use special tests to determine whether any eye changes are due to Plaquenil or not. Ocular side effects appear to be dose related, so the risk increases with increased daily dosage. Individuals less than 5’3” to 5’7” in height regardless of weight should take less than 400mg of Plaquenil per day. Additionally, a person who weighs less than 135 pounds should take less than 400mg of Plaquenil per day according to current recommendations. Other factors that may increase the risk of ocular damage include age over 60 years, kidney disease, liver disease, and use of Tamoxifen.
Plaquenil 200mg tablets
Recommended maximum dosage based on height and weight:
Plaquenil is an effective medication with fewer side effects than other medicines used for the same purpose. However, it is important to monitor your eyes for side effects that might indicate the need to stop taking Plaquenil. The Amsler grid chart (below) 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.
While focusing on center of grid, make sure the whole grid is seen…no missing areas (click on image to enlarge)
What happens if you develop retinal changes from Plaquenil?
Retinal damage from Plaquenil is extremely rare. If early retinal changes are found, Plaquenil may be discontinued. By discontinuing Plaquenil at an early stage, vision can be saved. Continued examination is important to monitor the eyes for further changes.
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 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.
Horseshoe-shaped retinal tear as seen in an eye with retinal detachment (Click on image for enlargement)
What causes retinal detachment?
Retinal breaks (holes and tears in the retina) cause retinal detachment. These retinal breaks are usually caused by a degeneration of the vitreous (the clear gel that fills the eye and normally helps to hold the retina in place). Vitreous degeneration is common in aging and near-sightedness, but may also follow a direct blow to the eye, hemorrhage, infection, or inflammation inside the eye. When the vitreous degenerates and condenses, it pulls on the retina and may cause retinal tears, which often lead to retinal detachment.
What are the symptoms of retinal detachment?
Prior to retinal detachment, most people notice warning signs such as new floating spots or “cobwebs” in the vision. Sometimes, brief lightning-like flashes of light are seen in the side vision. These are the symptoms of vitreous degeneration and retinal breaks. The retinal detachment that follows usually causes a dark “curtain” or “shadow” to form in the side-vision. The “shadow” often comes from below and on the side near the nose. If it is not treated, the shadow gradually covers all of the vision resulting in blindness. There is generally no pain with retinal detachment.
How is retinal detachment treated?
The treatment of most retinal detachments requires surgery. Your doctor is skilled in a number of techniques to prevent blindness. Which type of surgery is recommended depends on the precise findings on examination. Surgery is not usually aimed at eliminating flashes and floaters. Flashes usually disappear in a few weeks or months. The floaters gradually fade over many months, but rarely disappear completely. Some retinal detachments that do not cause symptoms may be observed without initial surgery.
Laser/Cryopexy demarcation: Small areas of the retinal detachment (especially before any side vision has been lost) can sometimes be treated with laser or cryopexy to “seal down” the retinal along the edges of the detachment in an effort to prevent it from extending further. This surgery is performed in the office. If it is not successful in stopping the detachment, more extensive surgery is required.
Pneumatic retinopexy: Many retinal detachments can be repaired by this surgery performed in the office by anesthetizing the eye, sealing the break(s) with laser or a freezing probe (cryopexy), and pushing the retina into proper position with a gas bubble which is injected into the eye. Although this procedure is successful most of the time, it requires the strict cooperation of the patient to remain in proper head position for about five days. If this procedure fails, more extensive surgery in the hospital operating room is sometimes needed.
Scleral buckle surgery: Some retinal detachments require the placement of a permanent plastic supporting belt around the eye to create a “ledge of support” for the retina. This is a major surgery in which a belt is placed around the eye in the hospital operating room. The eye is often rendered more near sighted by this procedure. Rarely, permanent side effects include double vision. If this surgery is not successful, vitrectomy surgery may be recommended. Scleral buckle surgery is preferred over other methods of surgery if the retinal breaks are located in the inferior (bottom portion) of the retina, where gas bubbles may not be effective in holding the retinal in position. Scleral buckle is also preferred over vitrectomy in eyes with a clear lens, because vitrectomy surgery usually results in cataract formation. Scleral buckle surgery is often used when other attempts at surgery have failed.
The video below demonstrates scleral buckle surgery. If you are uncomfortable watching surgery, please do not click on this video:
Vitrectomy surgery: Performed in the hospital operating room as a major eye surgery, vitrectomy surgery involves making small incisions into the eye to remove floaters, dissect scar tissue, remove fluid from under the retina, apply laser, and place a gas bubble or silicone oil into the eye to hold the retina in place. Specific head positioning is sometimes needed. Sometimes a cataract or lens implant must be removed to adequately repair the retina. This surgery may be repeated if necessary to prevent blindness.
The video below demonstrates vitrectomy surgery. If you are uncomfortable watching surgery, please do not click on this video:
With one or more surgeries most retinal detachments can be repaired keeping useful vision. Vision may not return to normal, as there may be some permanent damage from the retinal detachment resulting in blurred or distorted vision. In some cases additional surgery is needed to removed scar tissue that forms after retinal reattachment surgery. There are always risks to surgery including hemorrhage, infection, scarring, glaucoma, cataract, double vision, deformity, loss of vision/loss of the eye. Sometimes despite all efforts with surgery, all vision may be lost. Surgery is recommended for retinal detachments because blindness usually results if treatment is withheld. If you have questions, please do not hesitate to ask your doctor.
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 macula is the center of the retina (in box). The bottom image is an optical coherence tomogram of the macula. (Click to enlarge)
What is macular telangiectasia (MacTel)?
Macular telangiectasia is a disorder of retinal cells and tiny blood vessels located in the center of the retina. It has also been called juxtafoveal telangiectasis. 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 macula is the central portion of the retina that is responsible for sharp reading vision. In MacTel the macula undergoes slow degeneration, and tiny foveal blood vessels become irregular and dilated for unknown reasons. They rarely leak blood or clear fluid in the fovea. MacTel may resemble changes in the retina from drugs that are used to treat breast cancer (Tamoxifen).
Who is at risk for developing macular telangiectasia?
Macular telangiectasia is usually found in males and females during their 5th to 8th decade of life. It may occur in as many as one in every 1,000 persons. MacTel is associated with diabetes, high blood pressure, and tobacco use, but the exact cause has not been determined. Hereditary factors appear significant. Low serum levels of an amino acid called L-serine may play a role, but there are no clear recommendations for supplementation to date.
What are the symptoms of macular telangiectasia?
Blurring of vision is the most common symptom. Distortion of vision may also make reading or seeing small details difficult. Distortion is when straight lines appear wavy or crooked. It may be monitored with the Amsler grid test. Symptoms and clarity of vision may change from day to day. If sudden loss of vision or increased distortion occurs, your doctor should be notified without delay (within a week) as treatment may be needed.
What treatment is available?
There is no cure, but treatment may improve vision or keep the vision from worsening in certain instances. No specific treatment may be recommended if the symptoms are mild. Supplements containing the amino acid L-serine are being investigated. Laser and medicine injections help selected patients. Treatment usually does not return the vision to normal.
Your doctor is going to order appropriate tests and recommend the best course of action to take at this time. Physical activity and use of your eyes will not worsen macular telangiectasia. Magnification may help with reading. If you have any questions, please feel free to ask. If you would like to participate in research, contact www.mactelresearch.com.
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.
To the USF residents: I enjoyed meeting you for the lecture on infectious diseases. I hope this link to a movie version of the lecture is helpful to review the topics discussed on 12-19-13. Please give me feedback on how I may improve the presentation.
