Author Archives: Scott Pautler

DOCTOR SCOTT E. PAUTLER NAMED TO PRESTIGIOUS BEST DOCTORS IN AMERICA® LIST

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Best Doctors

Doctor Scott E. Pautler has been named one of the Best Doctors in America® for 2014. The prestigious recognition marks the seventeenth time that Doctor Pautler has earned this honor.

The highly regarded Best Doctors in America® List, assembled by Best Doctors, Inc. and audited and certified by Gallup® results from exhaustive polling of over 45,000 physicians in the United States. In a confidential review, current physician listees answer the question, “If you or a loved one needed a doctor in your specialty, to whom would you refer?”  Best Doctors, Inc. evaluates the review results, and verifies all additional information to meet detailed inclusion criteria.

Best Doctors has earned a sterling reputation for reliable, impartial results by remaining totally independent. Doctors cannot pay to be included in the Best Doctors database, nor are they paid to provide their input. The List is a product of validated peer review, in which doctors who excel in their specialties are selected by their peers in the profession.

Over the past 20 years, Best Doctors has earned global acclaim for its remarkable database of physicians, regarded as the world’s premier effort to create a validated, peer-reviewed database of excellence in medicine.  The Best Doctors methodology is rigorously impartial and strictly independent; only those doctors recognized as the top 5% of their respective specialty earn the honor of being named one of the Best Doctors in America.  The experts who are a part of the Best Doctors in America database provide the most advanced medical expertise and knowledge to patients with serious conditions – often saving lives in the process by finding the right diagnosis and right treatment.

About Best Doctors, Inc.:

Best Doctors works with the best five percent of doctors, ranked by impartial peer review, to help people get the right diagnosis and right treatment. The company’s innovative, peer-to-peer consultation service offers a convenient new way for physicians to collaborate with other physicians to ensure patients receive the best care. The global health solutions company, which has grown to over 30 million members worldwide, uses state-of-the-art technology capabilities to deliver improved health outcomes while reducing costs. Gallup® has audited and certified Best Doctors’ database of physicians, and its companion Best Doctors in America® List, as using the highest industry standards survey methodology and processes. Founded in 1989 by Harvard Medical School physicians, Best Doctors seamlessly integrates its trusted health services with Fortune 500 and Fortune 1000 employers, insurers and other groups in every major region of the world. The company also designs and implements international insurance programs that help people be sure they get the right health solutions.

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.

Central Serous Retinopathy

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central serous retinopathy
anatomy of the eye (click on image to enlarge)

 

What is central serous retinopathy (CSR)?

Central serous retinopathy (also known as central serous chorioretinopathy) is an abnormal leakage of clear fluid under the retina, which causes symptoms of blurred vision often associated with a round or oval dark spot in the central vision. 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 a picture” of objects you look at and sends the message to the brain.

What causes central serous retinopathy (CSR)?

The exact cause of CSR has not been well-defined. Classically, it occurs in middle-aged people with type-A personality and who are often under stress at home or work.  However, anyone may be affected regardless of age, personality type, and level of stress. Individuals with type-A personality are perfectionists who often feel pressured by time constraints. Research suggests that hormones released under stress can affect the blood vessels beneath the retina (in the choroid). These vessels may leak an abnormal amount of fluid, which then works its way under the center of the retina. Far-sighted eyes are more commonly affected than near-sighted eyes.  

What other things can aggravate central serous retinopathy (CSR)?

A host of factors may aggravate CSR. Sometimes, medical conditions (Cushing’s Syndrome, systemic lupus erythematosus, polycystic ovary disease, sleep apnea), medications (pseudephedrine, prednisone/cortisone/steroid by mouth/cream/injection/spray, OTC medication for the common “cold”, OTC nasal sprays, diet pills, muscle relaxants, and medications for erectile dysfunction), and other agents (testosterone, cocaine, caffeine, niacin, amphetamines, estrogen blockers, etc.) may contribute to the development of CSC. Rarely, CSC may be triggered by pregnancy, or by a viral infection or bacterial infection. Intense exercise has been implicated, as well. Indeed, anything that causes emotional or physiological stress in the body, including intense fasting, may contribute to the development of CSC.

What are non-medical treatments of CSC?

In many cases, the symptoms will disappear with time. Over a period of weeks to months, the abnormal leakage may stop with normal healing. Importantly, avoiding known triggers (listed above) may help. Other helpful measures include stress management, getting 8 hours of sleep per night, and treatment of sleep apnea.  

What are medical treatments of CSC?

The doctor can recommend the best course of action by taking special pictures of the eye called a fluorescein angiogram. The fluorescein angiogram shows where the leak is coming from and how active the leak is. Prescription medication may be helpful if fluid leakage does not go away with time alone. Patients with high blood pressure may benefit from beta-blocker medications. Thermal laser photocoagulation may be helpful if the site of leakage is not close to the center of vision. Side-effects are rare, but may include the appearance of a small, permanent blind spot in the vision. Another laser called Visudyne photodynamic therapy (PDT) may successfully avoid blind spots in the vision in eyes with areas of leakage close to the center of vision. Medicine injections may also be used to treat this condition.

What will happen to the vision?

Usually the vision returns to normal or near normal. Rarely, central serous chorioretinopathy will cause permanently limited central vision with distortion. In about a third of cases, CSC will return at a later date in the same or other eye. Repeated episodes of leakage may result in a build-up of permanent damage to the retina. Therefore, any future decrease in vision should be promptly reported to the doctor. The vision may be monitored with the Amsler grid test.

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  © 2013-2023 Designs Unlimited of Florida.  All Rights Reserved.

Tobacco and Eye Disease

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How does tobacco affect the eyes?

Tobacco use is widely known to cause lung damage, but the eyes are also affected. Bothersome irritation of the eyes is caused by smoke from tobacco especially in patients with dry eyes. However, permanent loss of vision may occur from such problems as macular degeneration, retinal vein occlusion, ocular histoplasmosis syndrome, glaucoma, cataract, Grave’s Disease (a thyroid condition that affects the eyes), uveitis (inflammation of the eye), ischemic optic neuropathy, and diabetic retinopathy. Tobacco appears to play a role in causing and/or worsening these conditions. Tobacco is known to promote hardening of the arteries, and this may harm blood flow to the eye. Tobacco also promotes the development of blood clots, which may block blood flow in the eye. Tissue damage also occurs from toxic compounds in tobacco that cause a chemical reaction called oxidation. More research is needed to fully understand the role of tobacco in causing loss of vision.

What resources are available to help stop tobacco use?

Because most people cannot stop tobacco “cold turkey,” many resources are available to help quit the habit. Counseling may provide much needed support in the process of stopping tobacco use. For free classes and one-month’s supply of nicotine replacement therapy, your doctor can refer you to the Area Health Education Center. Alternatively, you may call 1-877-848-6696. The class schedule may be viewed at www.ahectobacco.com/calendar.  If you are interested in talking to informed support staff, please call 1-800-QUIT-NOW. Nicotine replacement therapy plays an important role and several preparations are available over-the-counter. These non-prescription forms of nicotine include gum, lozenges, and patches. Medicare and most insurance companies now cover the costs of prescription medications to help stop tobacco use. These include nicotine nasal sprays, nicotine inhalers, as well as pills (Zyban and Chantix). With the help of counseling, nicotine replacement, and prescription medication, you can live a longer and healthier life without tobacco. For more information please visit www.smokefree.gov.

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  © 2013-2022 Designs Unlimited of Florida.  All Rights Reserved.

Posterior Vitreous Detachment (PVD)

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What is posterior vitreous detachment?

A posterior vitreous detachment (PVD) occurs when the vitreous gel inside the eye condenses and pulls away from the retina.  The vitreous is a thick, clear gel with invisible fibers that fills the inside of the eye.  From birth the vitreous gel is attached to the retina and helps to support it.  The retina is a thin layer of tissue that lines the inside of the eye like film in a camera.  Just like film, the retina serves to “take the picture” of objects you look at.  The primary cause of PVD is a degeneration of the vitreous, in which the tiny fibers clump together causing the vitreous to pull away from the retina.

vitreous gel
Clear vitreous gel fills the eye (click on image to enlarge)

 

PVD
A. Vitreous gel fills the eye at birth. B. Vitreous fibers begin to pull away from retina. C. Further separation of vitreous fibers that remain attached to the optic disc. D. Complete separation of vitreous fibers from the posterior retina.

 

What symptoms does posterior vitreous detachment cause?

The most common symptoms of PVD are floaters and flashes.   Floaters are specks, fibers, or veils that appear to move in front of your eye.  Floaters are actually tiny clumps of gel or cellular debris within the vitreous.  PVD sometimes causes bleeding inside the eye.  Blood in the vitreous appears as floaters described as hair-like strands or tiny round dots.  Over time floaters may appear like a cloud or veil that moves across the vision.  Flashes are brief streaks of light that are usually seen off to the side, especially at night, when you turn your head or eyes.  Flashes are caused by vitreous gel tugging on the retina with eye movement.  Although the sudden onset of new floaters is reported by almost everyone with PVD, flashes are only seen by half of all people with PVD.

Why is it important to be seen for these symptoms?

Although many people have occasional floaters or flashes of light, the sudden onset of many new floaters, with or without flashes, is an important symptom to report to your eye doctor.  In about 10-20% of people with these symptoms, the vitreous pulls on and tears the retina.  A retinal tear by itself causes no pain or visual problems.  However, if a retinal tear is not detected and treated, it may go on to cause blindness from retinal detachment.  A retinal detachment is when the retina stops functioning because it is pulled away from the inner eye wall and floats freely inside the eye.  A retinal detachment causes a progressive loss of vision appearing like a curtain or shadow that slowly moves across the vision from the side.

What causes posterior vitreous detachment?

PVD is usually due to degeneration of the vitreous gel from aging.  Over time, the thick vitreous gel tends to become liquefied and the microscopic fibers in the gel tend to condense together becoming visible and causing traction on the retina.  The following conditions tend to accelerate the degeneration and cause PVD to occur earlier in life:  trauma, inflammation, diabetes, and myopia (near-sightedness).

How is posterior vitreous detachment managed?

The most important step is to have a thorough, dilated eye examination.  The eye doctor will check for the presence of a tear in the retina.  If a tear is found, laser or cryopexy is usually recommended to decrease the chances of blindness from retinal detachment.  If a retinal detachment is found, more extensive surgery is required in an attempt to repair it.  If there is no retinal tear or retinal detachment found at the initial exam, another exam several weeks later may be performed to be certain that a delayed tear has not occurred.  Generally, there are no restrictions to your activities.

What happens to the floaters and flashes?

There is no treatment to make the floaters and flashes go away even though they may be quite annoying.  The flashes gradually subside and disappear over days to weeks without treatment.  However, the floaters rarely completely disappear.  They will gradually fade and become less obvious over weeks to many months.  For the first few days or weeks, many people find that the floaters are less annoying if they wear sunglasses when out of doors and turn the lights down when indoors.

What to be on the lookout for?

After examination or treatment, any new floaters or loss of side vision should be reported to the doctor without delay.  Sometimes, new tears or a retinal detachment can occur after the eye examination.  In fact, 7% of eyes with PVD will develop a retinal break sometime after the initial eye exam; about half occur more than one year after PVD.  This is more likely to occur in near-sighted eyes and eyes with lattice degeneration.

PVD may stimulate the formation of macular pucker, which may cause symptoms of distortion of vision. Treatment of a retinal tear does not prevent macular pucker.

When one eye develops a PVD, the fellow eye will usually do so at a future date.  Whether the floaters and flashes are more or less severe in the second eye, they should be promptly reported to the eye doctor.  If the first eye develops a torn retina, the second eye runs about a 20% chance of developing a tear as well.  But even if the first eye does not have a torn retina, the second eye may still develop a tear when a PVD occurs.

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 2014-2023 Designs Unlimited of Florida. All Rights Reserved.

Retinal Vein Occlusion

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What is a retinal vein occlusion (RVO)?

Retinal vein occlusion means blockage of a vein in the retina.  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 veins are blood vessels that drain blood out of the retina. An abnormal blood clot in a retinal vein causes a blockage (occlusion) of the blood flowing out of the retina.  Depending on the location of the occlusion, vein occlusions are divided into branch retinal vein occlusion and central retinal vein occlusion.

retinal vein occlusion
anatomy of the eye (click on image to enlarge)

Who is at risk for a retinal vein occlusion?

Retinal vein occlusions occur in 1-2% of people over 40 years of age. Retinal vein occlusions are more common in people who are overweight, use tobacco or estrogen, or have hardening of the arteries, diabetes, high blood pressure, sleep apnea, glaucoma, or blood disorders.

What are the symptoms of a retinal vein occlusion?

Blurring of vision may occur if excess fluid (edema) leaks from the veins into the center of the retina.  Floaters can look like tiny dots or cobwebs moving about in your vision.  They may be due to bleeding from the retina into the central gel of the eye.  Pain is rare and may be due to high pressure in the eye (neovascular glaucoma).

What treatment is available?

There is no cure, but treatment may improve vision or keep the vision from worsening.  Your doctor may allow time for the vein to heal.  Sometimes eye drops or pills may be prescribed.  Medicine injections (Avastin, Lucentis, Eylea, steroids) may help recover vision and may be applied without pain in most cases. Injections may be required for the long-term; about half of eyes with central retinal vein occlusion require injections for at least three years. Injections for retinal vein occlusion are safe in regard to risks of problems outside the eye. However, there appears to be a low risk of stroke (intracranial hemorrhage) of <4/1000 every year of treatment.

Laser may stabilize or improve the vision.  The vision may not return to normal following treatment as there may be some permanent damage to the retina from the occlusion.  In some cases when treatment cannot improve the vision, laser is used to prevent severe pain and complete blindness.

Your doctor is going to order appropriate tests and recommend the best course of action to take at this time.  The retinal vein occlusion will not be worsened by your daily activities or by using your eyes. You may monitor the vision with the Amsler grid test.  It is important to be seen by your primary care doctor to treat risk factors of hardening of the arteries to prevent stroke and heart attack.

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.

recent BRVO
blood spots and white exudates in retina from recent brach retinal vein occlusion (click on image to enlarge)
healing BRVO
Fewer blood spots as vein occlusion heals with Avastin (click on image to enlarge)
CRVO
Recent-onset central retinal vein occlusion of left eye

Copyright  © 2013-2023 Designs Unlimited of Florida.  All Rights Reserved.

Confusion between PreserVision AREDS-2 and “New” PreserVision AREDS-2

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There is confusion between PreserVision AREDS-2 and “new” PreserVision AREDS-2.   In September 2013 Bausch and Lomb changed the contents of PreserVision AREDS-2 and renamed the new vitamin, “New” PreserVision AREDS-2. The color of the box and the label on the bottle remain the same. The difference between the old and new vitamins is the “new” formulation lacks omega-3 fatty acids. They were removed because the AREDS study group was unable to demonstrate a benefit in patients with age-related macular degeneration (AMD). Other smaller studies have suggested a benefit and additional studies are needed to confirm or refute the value of omega-3 fatty acids in AMD.

Why is the difference important to me?

The importance in the difference for patients lies with the dosage. The recommended dosage for the older PreserVision AREDS-2 was two softgels twice a day. The recommended dosage for the “New” PreserVision AREDS-2 is one softgel twice a day. To avoid an error in dosing, patients need to be aware of which of the two similar vitamins they are taking.

Is there a cheaper version of AREDS-2 vitamins?

Yes.  As the patent expired on the ARED-2 formula, there are less expensive options now available.  The least expensive AREDS-2 vitamin that I am aware of at the time I write this blog is Equate Advanced Eye Health Complex by Walmart.  This vitamin is equivalent to the “New” PreserVision AREDS-2, but much less expensive. It is taken one pill twice-a-day.

By Scott E. Pautler, MD

 

PreserVision AREDS 2
PreserVision AREDS 2 (click to enlarge)
New PreserVision AREDS2
New PreserVision AREDS 2 (click to enlarge)

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  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Sub-Tenon’s Steroid Injection

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Why is a sub-Tenon’s steroid injection performed?

A sub-Tenon’s steroid injection (STS) is an office procedure performed to decrease inflammation, swelling, or leaky blood vessels inside the eye. The steroid medicine acts to decrease inflammation and leakage from blood vessels from a variety of causes, thereby offering the opportunity for improvement in vision. The effect of STS lasts for several months after which repeated injection may be considered if necessary.

How is a sub-Tenon’s steroid injection performed?

Anesthetic solutions are used to make the procedure pain-free. A pressure sensation is often felt as the steroid is injected next to the eye with a very thin, short needle. The procedure is brief.

Periocular steroid injeciton
Sub-Tenon’s Steroid Injection (click on image to enlarge)

Will the injection affect my vision?

The vision may be slightly blurred immediately after an injection. The anticipated improvement in vision occurs slowly over a period of weeks to months. Sometimes, the pressure inside the eye increases and may require eye drops for several months. There may also be an increased rate of cataract formation. It is common for the upper lid to droop slightly; this improves over several months.  Rare risks of steroid injection include bleeding, infection, retinal detachment, glaucoma, and loss of vision. Please report any severe loss of vision to the doctor without delay.

How do I care for the eye after injection?

If a patch is placed on the eye, keep it on as directed by the doctor, usually 2-3 hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after STS. 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 the office.

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  © 2013-2022 Designs Unlimited of Florida.  All Rights Reserved.

Lucentis (ranibizumab) Therapy

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vial of Lucentis
Lucentis vial

 

What is Lucentis therapy?

Lucentis therapy is a treatment for wet-type macular degeneration, diabetic retinopathy, myopic macular degeneration, and retinal vein occlusion.  It involves painless injections of medication into the eye to stop abnormal, leaky blood vessels. It is also used in the treatment of other retinal disorders.

How effective is Lucentis therapy?

Lucentis was proven in extensive studies to be very effective. In wet-type macular degeneration, a large study showed that monthly injections of Lucentis over a two-year period offered a 90% chance of stable or improved vision. Similar benefits are seen in other retinal conditions as well. Currently, therapy often starts with monthly injections until maximal vision is restored. Afterwards, the injections may be given less frequently to maintain stable vision. In some cases, the medication may be stopped and the eye kept under careful observation for reactivation. There are several medications in this class; the best choice of medications depends on the underlying diagnosis.

What are the risks of Lucentis therapy?

Severe complications are very rare, but risks of Lucentis injection include bleeding, infection, glaucoma, retinal detachment, cataract, and loss of vision/loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor.  There may be an increased risk of difficultly with future cataract surgery estimated to be about 1% of cases. In these cases the fibers (zonules) that hold the cataract in place may become weakened from Lucentis injection. When this occurs, special techniques are required to remove the cataract and place a lens implant. Rarely, two procedures are required to accomplish the task. Studies are ongoing to determine if there may be an increased risk of stroke with AMD therapy. Currently, it appears that Lucentis places a patient at lower risk of stroke and heart attack compared with the other medications used to treat macular degeneration and diabetic retinopathy.(Reibaldi 2022)  Pregnancy should be avoided while on Lucentis therapy.

intra-ocular injection
Intra-vitreal injection

What do I expect after a Lucentis 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. 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 the office.

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  © 2013-2022 Designs Unlimited of Florida.  All Rights Reserved.

Aldactone for central serous retinopathy (spironolactone)

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What is spironolactone?

Aldactone tablets
Aldactone tablets

Spironolactone is a type of diuretic often used to treat excess fluid accumulation in the body, which may occur in cirrhosis or congestive heart failure. It also has an effect on hormone balance and therefore is sometimes used in females for the treatment of acne. It has been shown to be helpful in the treatment of central serous retinopathy, a condition of fluid leakage in the eye, which is probably mediated by hormones.

What side effects might be encountered?

While you are taking this medicine, you may experience drowsiness or a washed-out feeling. Only rarely may this medicine cause rash, stomach upset, tender or enlargement of the breasts, temporary impotence, or menstrual disorders. These side effects disappear when the medicine is stopped. Severe reactions are rare. To be safe, this medicine is avoided in pregnant or breast-feeding women.  High blood potassium levels may occur.

What other medicines might interact with spironolactone?

Other drugs may interact with spironolactone. Care should be taken in patients with known kidney disease or when using this medicine with other drugs that increase serum potassium levels (some blood pressure pills, called ACE inhibitors and related medications). Patients should avoid foods rich in potassium such as bananas, tomatoes, potatoes, and low-sodium salt replacements. In some cases, the serum potassium may be monitored.  Be sure to inform your internist that you are on spironolactone for your eye condition.

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  © 2013-2022 Designs Unlimited of Florida.  All Rights Reserved.

Migraine with or without a headache

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Migraine aura
Artistic illustration of migraine aura (click on image to enlarge)

What is migraine?

Migraine is a common cause of headache that affects 10% of the population. Migraine may also cause unusual visual symptoms that occur with or without a headache.

What causes migraine?

The cause of migraine is unknown, but heredity may play a role. Many people with migraines have family members who also have had migraine. Migraine may be caused by abnormal episodes of blood vessel constriction within the brain. A number of events may trigger a migraine (ref): emotional stress, hunger, lack of sleep, hormonal changes (puberty, menopause, and hormone pills), bright lights, loud noises, a change in altitude or weather conditions, exercise, and certain foods (including caffeine, chocolate, alcohol, and red wine). Sometimes eye problems can worsen or bring on migraine. Such problems include improper eyeglasses, eye dryness, double vision, past eye injury or eye surgery.  There is evidence that links migraine with a defect in the wall of the upper chamber of the heart (patent foramen ovale).  It has been theorized that small particles (e.g. platelet-thrombin emboli) may originate in the venous circulation and pass through the defect in the heart wall into the arterial circulation and on to the brain.  This might explain small defects in the brain sometimes seen on MRI scans in patients with migraine.   

What are the symptoms of a migraine?

Migraine is associated with a great number of symptoms. Hours or days before a migraine episode occurs, subtle symptoms may be noticed. These symptoms include depression, fluid retention, and stomach disturbances. Visual symptoms can occur before a headache or be the sole symptom of a migraine. These visual symptoms occur without warning when the vision is impaired just off to the side of central vision. A jagged light (“like cracked glass”), which appears to shimmer or repeatedly flash, borders the area of impaired vision. The jagged light causes a missing area of vision and gradually works away from the center to the peripheral vision, taking on a C shape over a period of 15 to 30 minutes. It sometimes is described as heat waves, bubbles, tunnel vision, or a kaleidoscope, and it may be silver and white or in color. Objects may appear too small or too big (This is called the Alice in Wonderland Syndrome). In middle-aged patients a brief loss of vision may occur in one eye resembling a stroke-like symptom. It usually involves both eyes but may appear more prominently in one eye. In younger patients, nausea and a throbbing headache often follow the light flashes. In older patients, the visual symptoms may occur without headaches.  Keep in mind that there are many types and causes of flashing lights.

Migraine may also cause other symptoms that do not involve the eyes. Such symptoms include tingling of the face and hands, weakness, or trouble with speech. If this occurs, it may be helpful to call a neurologist for consultation.

The headache may be described as a deep, penetrating pain or a painful stretching sensation. The headache often begins on one side of the head, but it may spread over the entire head. It may be throbbing nor non-throbbing.

aura from Migraine
Simulation of migraine aura (click on image to enlarge)

 

What treatment is available?

Making the correct diagnosis is the most important step. Light flashes may be caused by other problems such as retinal detachment. Therefore the eye doctor is often called on to make this important distinction. If migraine symptoms occur infrequently, no treatment is needed.  Establishing regular sleep, meal, and exercise programs may help. Riboflavin and magnesium supplements may be of benefit as well. Prescription medication is available if headaches are severe or frequent.  They are usually prescribed by a neurologist.  

If there is any significant change in symptoms or if permanent loss of function occurs, please contact your doctor without delay. In rare instances, a brain aneurysm or tumor may cause unusual light flashes and headache. Your doctor will decide whether further examination or testing is required.

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  © 2013-2023 Designs Unlimited of Florida.  All Rights Reserved.

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Do I need a retina scan?

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With all of the technological advances in eye care, there are many ways to visualize the eye and a retina scan is often offered during an eye examination. A retina scan is another name for a photograph of the retina. Is it really needed? Is it worth the money? The answers to these important questions depend on the circumstances of the eye exam.

Is a retina scan really needed?

For routine eye exams in which the patient has no symptoms of a retinal condition, a retina scan may not be necessary. Important symptoms of retinal problems include: straight lines looking crooked, a blind spot or missing area in the vision, a loss of peripheral vision. If these symptoms are present, a retina scan or a referral to a retinal specialist may be in order.

What types of retina scans are available?

The following are scans that may be ordered by the eye doctor:

  1. Color Fundus Photography: an image of the retina as seen by the examining eye care specialist.  It may be helpful to monitor and compare lesions from visit to visit.
  2. Fundus Autofluorescence Photography: an image of the fluorescence of the retinal layers taken with a short-wave light.  Helpful in diagnosis of many degenerative conditions such as age-related macular degeneration.
  3. Optical Coherence Tomography (OCT): a cross-sectional image of the retina (or other part of the eye).  This test is helpful to diagnose fluid leakage in or under the retina and to assess macular hole.  
  4. Fluorescein Angiography: a specialized image of the retina taken after an organic dye is injected into the vein of your arm.  It shows blood flow and sites of abnormal leakage.
  5. Indocyanine Green Angiography: similar to fluorescein angiography, but with a different dye that is used to see deeper into the eye to examine the choroid.  Useful in macular degeneration and posterior uveitis.

Is a retina scan worth the money?

An examination of the retina is included in a complete eye exam without further charge. A retina scan is sometimes used as an additional step (with additional charges) if the examining doctor is not comfortable with his/her ability to diagnose a retinal condition. The cost of a retina scan may be avoided in some cases by choosing an eye doctor who is comfortable examining the dilated eye for retinal problems without the use of a scan.

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.

Painless eye injections

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painless eye injections
Eye anatomy

Why are eye injections given?

Increasingly, medicines are injected into the eye to treat a variety of conditions including macular degeneration, diabetic retinopathy, and retinal vein occlusion. Many different medications are injected including Lucentis, Avastin, Eylea, Beovu, Vabysmo, Syfovre, Izervay, and steroids. Especially, because these medicines may require repeated injections over time, it is essential these injections cause no pain. Therefore, we go out of our way to provide painless eye injections.

What choices of anesthesia is available?

There are currently many different ways to anesthetize the eye before an injection. Most doctors use an anesthetic eye drop. Additional local anesthesia is usually given with either a pledget, a gel, or a painless injection. A pledget is a small piece of cotton or other absorbent material that is soaked in anesthetic and placed inside the lower lid to numb the eye in preparation of an injection. Rarely, an anesthetic injection is needed. While an anesthetic injection sounds worse, it causes no pain (due to the anesthetic drops) and works better in some patients to avoid pain with the intraocular injection of medicine.

What needles are used for injecting medicine?

Fine needles are used for injection to minimize discomfort. The standard needle size for injections into the eye is 30 gauge. However, most medications may be injected with much finer 33 gauge needles. There are some medications, such as Syfovre, that require larger bore needles due to viscosity.

What are other causes of pain with eye injection?

In rare instances pain may occur due to an increase in the eye pressure. When medicine is injected into the eye it takes up space. Because the eyeball does not enlarge like a balloon, the pressure inside the eye increases. Usually, this increase in pressure is well tolerated. However, in some patients the increase in pressure may cause pain. In this situation the doctor may elect to remove a small amount of fluid from the eye before injecting the medicine in order to avoid the pressure increase and the associated pain.

Measures can be taken to avoid pain with most eye injections. Another issue is pain after an eye injection. Please see link for more information.

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  © 2001-2023 Designs Unlimited of Florida.  All Rights Reserved.

How do I use my eye drops?

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How do eye drops work?

You ask, “how do I use my eye drops?” but first let’s talk about the drops. Prescription eye drops contain a calculated amount of carefully tested medication.  The medication in the eye drops is rapidly absorbed into the tissues of the eye over a period of seconds to minutes after they are placed in the eye.  For this reason it is important to administer the correct amount of drops and to prevent the drops from spilling out of the eye or passing down the back of your throat through your tear duct.

What side-effects might be encountered?

In some patients eye drops can cause stinging, redness, or irritation.  These are not allergic reactions, but should be reported to the doctor if they become bothersome.  A significant amount of itching might be due to an allergic reaction to the drops. Only rarely do severe reactions occur.  Be sure to report wheezing or shortness of breath to the emergency department.

How do I properly use this medicine?

Be sure your hands are clean.  While looking up with head tilted back, pull the lower eyelid away from the eye with one finger and place one-drop of medicine inside the lower lid onto the eye.  Continue to hold the eyelid away from the eye for about 15 seconds. Then, gently close the eye without blinking.  Keep the eye closed for a minute or two while pressing with your index finger against the side of your nose where the upper and lower eyelids come together.  Finally, dry the remainder of the medicine from your eyes with a tissue paper.  This allows the medicine to be absorbed into the eye and keeps the medicine from going down your throat minimizing side effects.  Using this routine, the next eye drop may be instilled without the need to wait. Use any ointments only after all the recommended drops have been placed in the eye.  Try to use your medication on schedule as missing an eye drop may result in damage to your eye.

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  © 2001-2023 Designs Unlimited of Florida.  All Rights Reserved.

Vitrectomy Surgery

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

 

What is vitrectomy surgery?

Vitrectomy surgery is an advanced form of eye surgery that is performed in the operating room under a microscope. It is often used to treat conditions such as retinal detachment, macular pucker, macular hole, vitreomacular traction, diabetic retinopathy, vitreous hemorrhage, dislocated cataract/lens implant, endophthalmitis, and uveitis. Vitrectomy may take thirty minutes to several hours to perform depending upon what task is being accomplished. Despite common tales, the eye is not taken out and placed on the cheek. It remains in its normal position throughout the surgery. Vitrectomy may be performed under general anesthesia to avoid pain and to avoid eye movement during surgery. During vitrectomy, tiny needle-like incisions are made to enter the white of the eye to gain access to the central core of the eye, which contains a gel called vitreous. Various instruments no larger around than needles are placed into the small incisions to perform tasks such as peeling or cutting membranes from the retinal surface, cauterizing blood vessels, removing blood or inflammatory debris from the eye, and applying laser. The surgeon views the tips of the instruments through the dilated pupil with an operating microscope. Sometimes, a gas bubble or silicone oil is placed in the eye to hold the retina in position to heal properly.

What type of anesthesia is available?

Although some surgeons and patients choose local anesthesia, general anesthesia is also 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 generally does not feel pain. It is important to lie still on the operating room table as movement during surgery may result in damage to the eye and affect the final visual result.

General anesthesia offers some advantages over local anesthesia. With general anesthesia the patient is motionless and remembers nothing of the surgery. The anesthesiologist places a tube to hold the airway open. Which type of anesthesia is best for a patient may be determined by the health of the patient, so you may wish to ask your internist for advice. If a person cannot lie still for the surgery or if claustrophobia is a problem, general anesthesia is preferred. Although there are risks with any type of anesthesia, modern techniques offer a high degree of safety for the patient.

How can I prepare for vitrectomy surgery?

Your retinal specialist may schedule an appointment with your primary care doctor if evaluation is needed prior to surgery. Please inform your doctor of any chest pain or pressure, fever, productive cough, or shortness of breath. Unless otherwise notified by your doctor, do not take aspirin-containing products or any herbal supplements for two weeks prior to surgery. Coumadin may be stopped four days prior to surgery. On the morning of surgery, take no medications for diabetes unless instructed differently by your doctor, but please do take all of your other medications with a sip of water. Otherwise, do not eat or drink anything after midnight the day before surgery. If you usually use eye drops in the morning, they may be taken on the morning of surgery. Please click on this link for further information on how to prepare for surgery.

What are the risks of vitrectomy 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/loss of the eye. The most common problem following vitrectomy surgery is progression of cataract. Although serious problems are not encountered often, the risks and benefits must be weighed for each individual prior to surgery. For many eye problems, vitrectomy surgery is the only way to improve vision or prevent blindness.

What can I expect after vitrectomy 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. You may use Tylenol or Advil for aching pain, but 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 may result from sutures on the white of the eye. These sutures dissolve in about three weeks. 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 you may wear the hard protective shield as needed to prevent trauma to the eye. 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 and feel free to ask about special pillows and equipment available to help maintain head position. If a gas bubble is placed in your eye at the time of surgery, you may not fly on a plane or undergo nitrous-oxide anesthesia until the gas has dissolved, or you could risk severe pain and blindness. You may see the gas bubble as a horizontal, dark, curved line or as a dark ball in the vision. If a gas bubble is used during surgery, please keep a MedicAlert bracelet on your wrist until the gas has disappeared. The vision usually returns slowly over days to weeks after surgery, but may take many months for final recovery. The swelling and redness slowly disappear over weeks to months.

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.

See: How to prepare for retinal surgery.

Copyright  © 2001-2022 Designs Unlimited of Florida.  All Rights Reserved.

Eylea (aflibercept) Therapy

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Eylea vial image


What is Eylea® therapy?

Eylea therapy is a treatment for diabetic retinopathy, retinal vein occlusion and wet-type macular degeneration.  It involves repeated painless injections of medication into the eye to prevent blindness by stopping abnormally leaky blood vessels that occur in the eye conditions listed above.  Other similar medications that are also used in these conditions include Avastin, Lucentis, Vabysmo, and Beovu.

How effective is Eylea therapy?

Eylea was proven in FDA-approved studies to be effective. In wet-type macular degeneration, monthly or bimonthly injections of Eylea over a one-year period offered a 95% chance of losing less than three lines on a standard eye chart. Eylea was also shown to be effective in the treatment of diabetic retinopathy and retinal vein occlusion to improve vision and prevent severe complications. The results with Eylea are similar to treatment with Lucentis, Avastin, and Beovu. Eylea therapy often starts with injections every 4-6 weeks. Afterwards, the injections may be given less frequently.  In some cases the injections may be stopped, but continued monitoring is necessary. There are several medication options apart from Eylea. The best choice of medication may depend on the underlying diagnosis. For example, patient who have glaucoma may have better pressure control while under treatment with Eylea compared with other drugs.

What are the risks of Eylea therapy?

Severe complications are very rare, but risks of Eylea injection include bleeding, inflammation, infection, retinal detachment, cataract, glaucoma, and loss of vision/loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor.  There may be an increased risk of difficultly with future cataract surgery estimated to be about 1% of cases. In these cases the fibers (zonules) that hold the cataract in place may become weaken from Eylea injection. When this occurs, special techniques are required to remove the cataract and place a lens implant. Rarely, two procedures are required to accomplish the task.  Studies are ongoing to determine if there may be an increased risk of stroke with Eylea therapy. The possible risk of stroke may be related to the older age of patients with AMD. Further investigation will provide more information. Pregnancy should be avoided while on Eylea therapy.

intra-ocular injection
Intra-vitreal injection

What do I expect after an Eylea 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. 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 the doctor’s office.

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  © 2001-2022 Designs Unlimited of Florida.  All Rights Reserved.

Avastin Therapy for Retinal Disease

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What is Avastin therapy?

Avastin therapy is a treatment for retinal conditions involving abnormal blood vessel leakage including wet-type age-related macular degeneration, myopic macular degeneration,  retinal vein occlusion, diabetic retinopathy, and cystoid macular edema. The treatment involves the painless injection of medication into the eye to stop the leakage and improve vision. The benefits of treatment last one or more months. Repeat injections are common in order to keep the leakage from returning. When the problem has stabilized, the injections may be given less often or discontinued in some conditions. Avastin has not been reviewed by the FDA for use in the eye; therefore, it is used off-label. Safety and effectiveness has been established through extensive experience with the use of Avastin in the eye for a multitude of problems since 2005. There are other similar drugs that have been FDA-approved for use in the eye including Lucentis, Eylea, Vabysmo, and Beovu. These drugs are much more expensive than Avastin. Avastin costs about $50 compared to $2,000 with the FDA-approved drugs. There may be reasons to use one medication over another depending on the diagnosis.

How effective is Avastin therapy?

Avastin has been found to be effective in the treatment of a variety of retinal disorders of blood vessel leakage. It was shown to be as effective as Lucentis in the treatment of wet-type macular degeneration in most patients. Avastin is also effective in the treatment of macular edema, retinal vein occlusion, diabetic retinopathy and other conditions of the eye.

What are the risks of Avastin therapy?

Severe complications are very rare, but risks of Avastin injection include bleeding, infection, inflammation, glaucoma, retinal detachment, cataract, and loss of vision/loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor. There may be an increased risk of difficultly with future cataract surgery estimated to be about 1%. In these cases the zonules that hold the cataract in place may become weaken from Avastin injection. When this occurs, special techniques are required to remove the cataract and place a lens implant. Rarely, two procedures are required to accomplish the task. Studies are ongoing to determine if there may be an increased risk of stroke with Avastin therapy. Further research is needed. However, pregnancy should be avoided while on Avastin therapy.

There appears to be a greater risk of high eye pressure (glaucoma) in eyes treated with Avastin compared with Lucentis and Eylea. This may be especially important in patients at increased risk of glaucoma due to past high eye pressures or positive family history of glaucoma.

Because Avastin must be measured and placed in a syringe by a compounding pharmacy after manufacture, there may be increased risk of complications with Avastin compared with other similar drugs such as Lucentis, Eylea, Beovu, and Vabysmo. There may be an increased risk of infection due to the introduction of bacteria during repackaging.  Some patients experience persistent round floaters due to silicone droplets used to lubricate the syringe from the pharmacy.  Over the years, there have been concerns over needle quality (sharpness), which can make injection more uncomfortable.

intra-ocular injection
Intra-vitreal injection

What do I expect after an Avastin injection?

If a patch is placed on the eye, keep it on as directed by the doctor, usually 3-4 hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after the 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. If you have any questions or concerns, please call the office.

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  © 2001-2022 Designs Unlimited of Florida.  All Rights Reserved.

Argus II Retinal Implant

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What is the Argus II retinal implant?

The Argus II retinal implant is an electronic instrument used to restore limited vision in patients who are blind in both eyes from retinitis pigmentosa. 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 and sends the message to the brain. Retinitis pigmentosa is a group of inherited diseases that affects the retina and may cause a profound loss of vision.

How does the Argus II retinal implant work?

The Argus II retinal implant system has several parts. There is a small video camera placed on glasses. The camera records video images and transmits the information to a video processor worn on the belt around the waist. The processor then converts the video information into a digital code that is transmitted to an implant that has been surgically inserted into the eye. The implant includes a set of diodes that are placed inside the eye on the surface of the retina and a coil that is secured to outside of the eye wall underneath the skin where it cannot be seen.

Who is eligible for the Argus II retinal implant?

In February 2013 The FDA granted approval for the use of the Argus II retinal implant only to patients with severe vision loss due to advanced retinitis pigmentosa. Eligible patients must have had good vision early in life and lost all but bare light perception or worse. Patients must also be older than 25 years of age. Researchers hope that with further research the device will be approved in the future for patients with less severe vision loss and for patients with other types of retinal disease. The implant is expected to become available in late 2013.

How much is the vision improved with the Argus II retinal implant?

The improvement in vision is very limited, but helpful in select patients. No clear image is seen. However, eligible patients with the retinal implant are able to see borders between light and dark. This allows them to function better with simple visual tasks such as walking and seeing objects with high contrast. The amount of improvement varies from patient to patient. Because there are risks to surgery, the FDA is appropriately cautious in its approval of the device only for patients with profound loss of vision.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345188/

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to RvaAdmin@rvaf.com. We accept Medicare, most insurances, and self-pay.

Copyright  © 2001-2022 Designs Unlimited of Florida.  All Rights Reserved.

Myopia (near-sightedness)

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

What is myopia?

A myopic eye is a near-sighted eye.  Without glasses the vision is usually quite good at near, but blurred at distance.  Myopia affects 25% of Americans and about 22% of the world population. High myopia (greater than -6.00 diopters) is less common, affecting about 2% of the world population and projected to rise to 10% by the year 2050.

What causes myopia?

Myopia is an inherited condition that usually develops in childhood or early adulthood.  The eye, which is round like a ball at birth, becomes oval like an egg.  The outer appearance of the eye is not usually changed, but the elongation of the eye changes the focus of the eye from distance to near. There is evidence to suggest that extensive near work (e.g. reading) may worsen myopia.

myopia
A myopic eye has elongated somewhat like an egg. Incoming images do not focus on the retina in the back of the eye.

Why is it important to know about myopia?

Although most people with myopia do not develop complications, highly near-sighted people are at increased risk of losing vision from glaucoma, cataract, macular degeneration, and retinal detachment. The higher the degree of near-sightedness (myopia greater than -6.00 diopters), the greater the risk of loss of vision.

Glaucoma is a condition in which the pressure inside the eye damages nerve tissue that helps you see.  This pressure usually causes no pain or discomfort and pressure measurements may be normal at times.  Over months to years, the pressure slowly takes away the side vision.  If undetected and untreated, it may cause total blindness.  The best way to diagnose glaucoma is to have regular eye exams each year with pressure measurements.  Treatment is effective in preventing vision loss through the use of eye drops.  Sometimes, laser or surgery is needed.

Myopic macular degeneration is an uncommon cause of vision loss from severe myopia. The macula is the central part of the retina in the back of the eye.  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.  In very near-sighted eyes, the retina becomes stretched as the eye elongates.  As a result, the central vision may become blurred or distorted even with proper glasses.  Distortion is when straight lines look wavy or crooked.  Blood vessels under the macula may bleed causing sudden blurring, blind spot, or distortion.  Any of these symptoms should be reported to the eye doctor without delay, as early treatment with medicine injections and/or laser may prevent further loss of vision.

Retinal detachment is a separation of the retina from the inside wall of the eye. 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.  Warning symptoms prior to retinal detachment may include new floaters or brief flashes of light in the side-vision.  Later, a dark curtain or shadow slowly starts off to the side and takes away the vision as the retina detaches.  Laser or surgery repairs most retinal detachments.  It is important to diagnose a retinal detachment early in order to prevent permanent damage to the retina.  Report any new floaters, flashes, or loss of side-vision to your eye doctor without delay.

How is myopia treated?

The standard treatment of myopia is to refocus the eye with eye glasses or contact lenses. LASIK and PRK surgery flatten the cornea to focus images onto the retina. Orthokeratology is a controversial method used to flatten the cornea with contacts lenses worn overnight. Lens implants are a more aggressive measure to focus light in highly near-sighted eyes. All of these methods of treatment are simply aimed to focus the vision.  They are not designed to correct the underlying problem of elongation of the eye that leads to complications and loss of vision.  Diluted atropine eye drops appear to reduce the progression of myopia in an effort to avoid complications of severe elongation of the eye.

Will LASIK surgery help prevent these complications of myopia?

Although LASIK surgery is very effective at flattening the cornea to help eliminate the need for glasses, it does not restore the spherical shape to the eye.  Therefore, it is still necessary to be aware of the warning signs of possible complications from myopia.

What are the Do’s and Don’ts?

Using your eyes to read or work at a computer will not weaken them. Avoid intensive rubbing of your eyes.  Remember to have your eyes examined once a year.  Report the following symptoms to your eye doctor without delay:

¨     Blind spot or distortion of central vision

¨     New floaters or flashes of light

¨     Loss of side-vision

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  © 2001-2022 Designs Unlimited of Florida.  All Rights Reserved.

Floaters and Flashes

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vitreous gel
Vitreous gel fills the eye (Click on image to enlarge)

 

What are floaters and flashes?

Floaters are small specks, fibers, or bug-like objects that may appear to move in front of your eye.  They appear black or gray and may be few or numerous.  At times they may appear like a veil or cloud moving in the vision even after the eye is still.  They are frequently seen when looking at a brightly lit background, like 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. Many dot-like floaters may be due to bleeding inside the eye, especially when they come on suddenly. Long-standing, numerous, dot-like floaters may represent inflammation in the eye.

Floaters image
Floaters as simulated in photograph (click on image to enlarge)

Flashes are brief streaks of light that are usually seen off to the side, especially at night when you turn your head or eyes.  They may appear curved or like a brief lightning flash and last for only a second. Flashes are caused by fibers in the vitreous gel tugging on the retina with eye movement. This type of flashing light is different from migraine.

What do these symptoms mean?

Although many people have occasional floaters or flashes of light, the sudden onset of many new floaters with or without flashes is an important sign of abnormal pulling on the retina by the vitreous.  In some instances, the retina may tear and cause blindness from detachment of the retina.

What causes floaters and flashes?

Floaters and flashes are usually due to degeneration of the vitreous gel in the eye from ageing.  Over time, the vitreous shrinks, condenses, and pulls away from the retina.  The condensation causes floaters and the pulling irritates the retina and is perceived as flashes of light. Myopia (near-sightedness) is a common cause of long-standing floaters.

What should be done about these symptoms?

The most important step is to have a thorough dilated eye examination, preferably by a retinal specialist.  The need for examination is urgent if the onset of symptoms is sudden. The eye doctor will check for the presence of a tear in the retina.  If a tear is found, laser or cryopexy is usually recommended to decrease the chances of blindness from retinal detachment.  If a retinal detachment is found, more extensive surgery is required in attempt to repair it.

Once an exam has demonstrated no retinal damage, he symptoms of flashes and floaters do not require specific treatment.  The flashes usually occur less frequently over time.  It may take days or weeks for the flashes to subside. Rarely, flashes will continue over many years.  Likewise, floaters subside with time, but take weeks to months to become less noticeable.  It is best not to concentrate on following floaters by moving your eyes as it may make them more bothersome. Depression and stress may worsen the degree in which floaters interfere with daily visual activities.

Many people have long-standing floaters that are not bothersome. In these cases, no treatment is needed after an examination to insure good eye health. Very rarely floaters will persist and interfere with vision. In these unusual cases, vitrectomy surgery may be considered. There are options to consider.

What should you be on the lookout for?

After examination or treatment, any significant new floaters (especially, many new dot-like floaters) or any loss of side vision should be reported to the doctor without delay.  An occasional flash of light in itself is not usually indicative of damage to the retina.  Sometimes, new tears or a retinal detachment can occur at a later date after the initial examination.

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  © 2014-2022 Designs Unlimited of Florida.  All Rights Reserved.

Jetrea Injection (Ocriplasmin)

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vitreous gel
Clear vitreous gel fills the eye (click on image to enlarge)

What is Jetrea® injection used for?

Prior to being discontinued, Jetrea therapy was a treatment for retinal conditions involving abnormal pulling of fibers on the retina. Usually due to ageing, fibers which normally lie on the surface of the retina begin to pull on the retina causing a loss of vision. The treatment involved the injection of medication into the eye to cause of release of traction (pulling) on the retina. It may take weeks to months for Jetrea to take effect.

Jetrea

How effective is Jetrea therapy?

In vitreomacular traction syndrome about 40% of cases improve when the traction is limited. In macular hole cases, successful closure of the hole is seen within six months in as many as 60% of eyes with small holes. Please refer to separate literature on these conditions.

Jetrea VMT
Vitreomacular traction relieved by Jetrea (click to enlarge)

What are the risks of Jetrea therapy?

Severe complications are very rare, but risks of Jetrea injection include bleeding, infection, inflammation, glaucoma, dislocation of lens, retinal detachment, cataract, and loss of vision/loss of the eye. A common side effect of treatment is the appearance of new floaters in the vision. Less than one percent of injections are associated with sudden decreased vision for unknown reasons. Fortunately, the vision returns in most cases within a two week period. About 2% of eyes injected with Jetrea experience a yellow tint in the vision which usually clears with time. Currently, it does not appear that Jetrea has any significant systemic adverse effects.  However, pregnancy should be avoided while on Jetrea therapy.

What do I expect after a Jetrea injection?

If a patch is placed on the eye, keep it on as directed by the doctor, usually 3-4 hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after the 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. If Jetrea is not successful, vitrectomy surgery may be considered.

Note: Since June 30, 2020, Jetrea stopped being manufactured.

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  © 2013-2020 Designs Unlimited of Florida.  All Rights Reserved.

Macular Hole

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globe anatomy
anatomy of the eye (click on image to enlarge)
normal macular OCT
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 a macular hole?

Macular hole means there is a tiny hole in the center of the retina.  The retina is a thin layer of tissue in the back of your eye which lines the inside wall like the film inside the back of a camera.  The retina “takes a picture” of objects you look at and sends it to the brain.  The macula is the center of the retina and gives you sharp central vision for reading and seeing fine details.  When the macula is damaged, the central vision worsens.  Macular hole is not macular degeneration and does not lead to macular degeneration. Macular hole affects both eyes in only about 10% of cases.

What causes a macular hole?

A macular hole is caused when the clear gel that fills the eye (vitreous) pulls on the macula.  When you are born the vitreous gel is thick, clear, and filled with tiny, invisible fibers.  With age or trauma, the vitreous gel begins to condense and pull away from the retina.  If the attachment of the vitreous to the macula is unusually strong, the pulling may result in a macular hole.

What are the symptoms of a macular hole?

Blurring of vision is mild at first, noted especially while trying to read fine print.  It slowly worsens; often with distortion (straight lines look crooked).  Sometimes there is a small blind spot in the center of vision. The visual symptoms may be detected and monitored with the Amsler grid test.

What treatment is available?

In a small number of cases, a macular hole may heal itself. In other cases the vision improves with a medicine injection (Jetrea®). If this fails or is not possible, a surgery may be performed that releases the abnormal pulling of the vitreous on the macula.  A gas bubble (pneumatic retinopexy) is then placed in the eye to close the hole in the macula.  Strict facedown positioning is recommended for several days following surgery.  Special cushions and massage tables are available to help maintain the proper head position.  The most common side effect of surgery is cataract formation.  Cataracts develop after surgery in most eyes over several months to years.  About 5% of eyes require more than one surgery to close the macular hole.  In 2-3% of eyes, the retina may detach during or soon after surgery as a result of continued pulling on the retina by vitreous fibers.  This requires additional surgery to prevent profound loss of vision.  Unommon risks of surgery include hemorrhage, infection, blindness and loss of the eye.

Surgery to close macular hole is usually successful in improving vision, though the vision rarely returns completely to normal.  Some residual distortion and central blurring of vision is common. The vision improves very slowly after surgery over several months to years.

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  © 2001-2022 Designs Unlimited of Florida.  All Rights Reserved.

For more information please visit Retina Vitreous Associates of Florida.

Vitreomacular Traction Syndrome

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vitreous gel
Clear vitreous gel fills the eye (click on image to enlarge)
normal macular OCT
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 the vitreomacular traction syndrome?

The vitreomacular traction syndrome is a condition in which the vitreous gel, which fills the inside of the eye, pulls on the macula. The macula is the center of the retina and gives sharp central vision for reading and seeing fine details. The retina is a thin layer of tissue in the back of the eye that lines the inside wall like the film inside the back of a camera.  The retina “takes a picture” of objects you look at and sends it to the brain. When the macula is damaged, the central vision worsens.

What causes the vitreomacular traction syndrome?

The vitreomacular traction is caused when the clear gel that fills the eye (vitreous) pulls on the macula.  At birth the vitreous is a thick and perfectly clear gel.  With age or trauma the vitreous gel begins to condense and pull away from the retina.  If the attachment of the vitreous to the macula is unusually strong, the vitreous may pull the macula away from its normal position, distorting this normally smooth tissue.

normal OCT
Normal macula as seen on optical coherence tomography (click to enlarge)
VMT
Vitreomacular traction as seen on optical coherence tomography (click to enlarge)

What are the symptoms of the vitreomacular traction syndrome?

Blurring of vision is mild at first, noted especially while trying to read fine print.  It slowly worsens, often with distortion (straight lines look crooked).  Sometimes there is a vague blind spot in the center of vision. The visual symptoms may be detected and monitored with the Amsler grid test.

What treatment is available?

If the symptoms are mild, no treatment is needed.  Medicine injection (Jetrea®) or vitrectomy surgery may help if there is significant loss of vision.  In most cases the vision improves with injection or a surgery that releases the abnormal pulling of the vitreous on the macula.  A gas bubble may be placed in the eye to smooth out the macula.  Strict facedown positioning may be recommended for one week following surgery.  Special cushions and massage tables are available to help maintain the proper head position.  The surgery is usually successful in returning vision, though the vision may not return completely to normal.

The image below shows the separation of vitreous fibers from the macula after Jetrea injection:

Jetrea VMT
Vitreomacular traction relieved by Jetrea (click to enlarge)

Below is a video that reviews the anatomy of the eye, information on vitreomacular traction, and an example of vitrectomy surgery:
https://youtu.be/r-5Az8_DU3U

Below is the case of a 70-year-old woman who had mild VMT. She was observed over several years and the traction released without 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  © 2013-2022 Designs Unlimited of Florida.  All Rights Reserved.

How to find a good retina doctor?

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Why is it necessary to find a good retinal doctor?

Finding a good retinal doctor is important to receive the best level of care. Your doctor should be up-to-date on the latest treatments and be able to choose from among the many choices of treatment to determine which is the best for you as an individual. Some doctors may not keep up with new treatment options and, therefore, may not offer these choices to you as a patient. Moreover, some treatments work better for some patients, but do not work well for others. You must rely on your retinal specialist to offer the best treatment for you. To do so, your doctor must get to know your eyes and you as a person in order to choose what is best for you. The retinal specialist must then review the options and explain why he/she has chosen your treatment plan. All treatments have benefits, risks, and limitations. All of this information must be explained to you. It is helpful if the doctor gives you written information to take home to review after the visit.

How do you go about finding a good retina doctor?

This task is not easy or as obvious as it may seem. At a minimum, your retina doctor should be a medical doctor (MD or DO) and completed a residency in ophthalmology and should be board-certified by the American Board of Ophthalmology.  You can find out online if your doctor is certified. Board certification is essential, but it is only the first step in finding your retina doctor.

Be aware that some ophthalmologists call themselves retina specialists, but they have not completed a retina fellowship program. A retina fellowship is a one or two-year program of highly specialized training, which is undertaken after a general ophthalmology residency program. You may ask your doctor if he/she completed a fellowship in retinal disease and for how long (one or two years). Some information is available to you at the web site of the American Society of Retinal Specialists. You may prefer a doctor who has been trained at a highly reputable university. One source of information is Castle Connolly.

A number of additional factors may be important in the decision to choose the best retina doctor for you:

Does your doctor do research? This issue has a good side and a possible bad side. In general, research may help a doctor to stay up-to-date on diagnosis and treatment. On the other hand, intensive research may draw the doctor’s attention away from information that does not pertain to his/her research interest. In this scenario, the doctor may become an expert in a small area of research and fall behind in the general knowledge of patient care that is important to your care. Simply put, you may prefer a doctor whose primary interest is patient care, not scientific research. Having said that, there are superb retina doctors who excel at both research and patient care. When interviewing a retinal specialist, try to gain a sense as to whether the doctor is more interested in you and your eye problem or his/her research.

Who referred you to the retinal specialist? Although this may not be an important issue, it is something to consider. In years past, doctors referred their patients to other doctors primarily on the basis of their knowledge about who provided the best care. There was no incentive to refer to anyone but the best for their patients. Due in large part to considerable financial duress imposed by government regulation and the insurance industry, general eye doctors have found the need to reap financial gains by hiring retina doctors to work for them. In this setting, the referring doctor may choose a retina doctor who works in the same clinic (or a separate building owned by the same clinic) because he/she makes money from doing so. The clinic retinal doctor may well not be the best doctor available in the area for your care. When in doubt, get a second opinion outside the clinic.

Are you comfortable with your retina doctor? This is a simple, but exceedingly important question to ask yourself. If you do not feel comfortable with your doctor, you may not follow through with instructions properly. You may not ask questions and gain an understanding of your problem. Never hesitate to seek a second opinion. A good doctor is not threatened by second opinions. In fact, good doctors often offer second opinions to their patients who appear uncertain or distressed.

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.

Diabetic Retinopathy

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Diabetes mellitus is a group of conditions characterized by abnormally high blood sugar levels.  Short-term side effects include increased thirst, frequent urination, and weight changes.  Long-term complications include numbness of the hands and feet, loss of vision, kidney failure, as well as hardening of the arteries leading to amputation, heart attack, stroke, and premature death.  Diabetes affects about one million Floridians and 16 million Americans.  It is the leading cause of blindness in America among adults.  Several studies have proven that strict control of blood sugar levels dramatically decreases the risk of blindness and other complications of diabetes.  The National Eye Institute proved that laser treatment may save vision if diabetic eye damage is detected early.  The American Diabetes Association recommends annual eye examinations for all adults with diabetes to prevent blindness.

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.

What is diabetic retinopathy?

Diabetic retinopathy is a condition that occurs after many years of high blood sugar.  It consists of damage to tiny blood vessels within the retina resulting in abnormal leakage of fluid and blood inside the eye.  If not detected or treated, diabetic retinopathy may cause bleeding, scar tissue formation, retinal detachment, and blindness.

Stages of diabetic retinopathy:

Non-proliferative diabetic retinopathy: The first stage of retinal damage consisting of a weakening or blockage of tiny blood vessels, which does not require treatment with laser unless macular edema develops.

Diabetic macular edema: Swelling of the central retina (the macula) due to abnormal leakage of fluid from small blood vessels weakened by diabetes.  Blurring of central vision may advance to legal blindness.

Proliferative diabetic retinopathy: The second stage of diabetic retinopathy in which abnormal, weak blood vessels begin to grow from the retina into the clear gel (vitreous) which fills the inside of the eye.  If not treated, this serious stage often results in blindness from bleeding.  Symptoms include new “floaters” or sudden loss of vision.  Retinal detachment may occur from diabetic scar tissue, which pulls the retina off the eye wall.  Retinal detachment causes a dark shadow in the vision or total loss of vision.  Laser and vitrectomy surgery best control these problems if detected early.

How is diabetic retinopathy diagnosed?

Because no symptoms may be present until severe damage to the retina has occurred, it is essential that all adults with diabetes have a complete, dilated eye examination at least once a year.  The eye doctor can see into the eye with an ophthalmoscope to diagnose retinopathy.  If significant changes are found, photographs can be taken to record the changes. A fluorescein angiogram may be performed in the office by injecting a fluorescent dye into the vein of the arm while photographs are taken of the retina.  It supplies important information about the health of the retinal blood vessels.

How is diabetic retinopathy treated?

No treatment is needed if the vision is not threatened.  If blood vessel damage is significant, painless injections of medicine (Avastin) may be required to improve vision. Laser treatment performed in the office can often prevent severe visual loss.  Laser produces heat, which serves to cauterize the damaged retinal blood vessels.  Usually there is no pain, but if extensive laser is needed, an anesthetic injection may be given around the eye.  In severe cases of bleeding and scar tissue formation, vitrectomy surgery is performed as a one-day surgery in the hospital.  With laser and vitrectomy surgery, most people can retain useful vision. However, some people lose vision despite all efforts with treatment.

What can I do to prevent diabetic damage?

Strict control of the blood sugar has been proven to reduce the rate of progression of diabetic retinopathy by about 70%.  In addition, loss of vision can be minimized by optimal control of other health problems such as physical inactivity, obesity, hypertension (<130/<80), cholesterol (<200) and triglycerides (<150), heart failure, and kidney failure.  Tobacco use is strongly discouraged.  Daily aspirin use is recommended.

PREVENT BLINDNESS THROUGH GOOD MANAGEMENT OF DIABETES AND REGULAR DILATED EYE EXAMINATIONS.

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  © 2013 Designs Unlimited of Florida.  All Rights Reserved.