Category Archives: Retinal Disorders

Myopic Macular Degeneration

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myopic-macular-degeneration
Anatomy of the Eye (click on image to enlarge)

What is myopic macular degeneration?

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

What causes myopic macular degeneration?

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

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

What are the symptoms of myopic macular degeneration?

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

How is myopic macular degeneration diagnosed?

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

How is dry myopic macular degeneration treated?

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

How is wet myopic macular degeneration treated?

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

By Scott E. Pautler, MD

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

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

Intermediate Uveitis

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

See Anatomy of the Eye

What is intermediate uveitis?

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

What causes intermediate uveitis?

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

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

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

What are the symptoms of intermediate uveitis?

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

How is intermediate uveitis managed?

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

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

By Scott E. Pautler, MD

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

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

Proliferative Vitreoretinopathy (PVR)

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

See Anatomy of the Eye

What is PVR?

The retina is a “tissue-paper” thin layer of nerve tissue that lines the inside of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. Proliferative vitreoretinopathy is a condition in which sheets of scar tissue grow on the surface of the retina. It usually occurs after retinal detachment as a part of the healing process. Unfortunately, the PVR scar tissue pulls on the retinal and is the most common cause of failure of attempted repair of retinal detachment. There is evidence of PVR in about 10% of eyes that present with retinal detachment.

What is retinal detachment?

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

What causes PVR?

Proliferative vitreoretinopathy is caused by the excessive formation of scar tissue. Scar tissue is a common healing mechanism in the body. For example, if the skin is cut, scar tissue closes the laceration. In the eye scar tissue develops in response to retinal detachment and surgical repair. If it becomes excessive, the scar tissue causes the retina to detach again. The abnormal production of scar tissue in the eye is called PVR. Tobacco use may increase the risk of PVR.

How is PVR treated?

The treatment of PVR requires one or more surgeries. Your doctor is skilled in a number of techniques to prevent blindness. Which type of surgery is recommended depends on the precise findings on examination.

Scleral buckle surgery:  Some retinal detachments require the placement of a permanent plastic supporting belt around the eye to create a “ledge of support” for the retina. This belt is placed in the hospital operating room in a major surgery. The eye is often rendered more near sighted by this procedure. Rarely, side effects include double vision.

Vitrectomy surgery:  Performed in the hospital operating room as a major eye surgery, vitrectomy surgery involves making small incisions into the eye to remove floaters, dissect scar tissue, remove fluid from under the retina, apply laser, and place a gas bubble or silicone oil into the eye to hold the retina in place. Specific head positioning is sometimes needed.  Sometimes a cataract or lens implant must be removed to adequately repair the retina. After surgery, it may be necessary to lie in a specified position for several days for success. This surgery may be repeated if necessary to prevent blindness.

With one or more surgeries most retinal detachments with PVR can be repaired keeping useful vision. The vision usually does not return to normal. It is frequently blurred or distorted. There are always risks to surgery including hemorrhage, infection, scarring, glaucoma, cataract, and double vision. Sometimes despite all efforts with surgery, all vision may be lost. Surgery is recommended for retinal detachments with PVR because blindness usually results if treatment is withheld. If you have questions, please do not hesitate to ask your doctor.

By Scott E. Pautler, MD

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

Copyright  © 2017-2023 Designs Unlimited of Florida.  All Rights Reserved.

The Ocular Histoplasmosis Syndrome

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

What is the ocular histoplasmosis syndrome (OHS)?

OHS is a condition where abnormal blood vessels may grow under the retina causing blurred, distorted vision. The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” of objects you look at and sends the image to the brain.

What causes the ocular histoplasmosis syndrome?

Most cases of OHS occur as a result of an infection by the fungus Histoplasma capsulatum. This organism is found in bird and bat dropping and is most common in the Ohio and Mississippi river valley areas. High-risk activities include farmers, pest control workers, poultry keepers, construction workers, roofers, landscapers, and cave explorers. When soil is disturbed by wind or human activity, the fungal spores become airborne. After the spores are inhaled, they may cause a brief “flu-like” infection or may cause no symptoms at all in a healthy individual. In infants, the elderly, and those with compromised immune systems severe complications may include acute respiratory distress syndrome (ARDS), pericarditis, adrenal insufficiency, and meningitis.

Usually there are no visual symptoms at the time of active infection. However, after the infection is gone, scars are left in the body. These scars may be seen on x-rays of the lung, liver, and other parts of the body. Many years after the initial active infection, scars under the retina may cause loss of vision from the growth of abnormal blood vessels. At this stage, there is no active infection and a person with OHS cannot transmit an infection to someone else. The risk of loss of vision from OHS appears greater in those who smoke tobacco.

What are the symptoms of the ocular histoplasmosis syndrome?

Decreased central vision is common. It may be most notable at near and is usually associated with distortion, which means straight lines appear wavy or crooked. These symptoms come from active leakage of fluid and blood under the retina from abnormal blood vessels associated with OHS scars. Without treatment more scare tissue forms under the retina and a permanent blind spot develops in the center of vision.

What treatment is available?

There are a number of treatments for OHS and it is important to start treatment as soon as possible after the start of symptoms. The main treatment for the abnormal leaking blood vessels involves medication injection in the office. Medicine injections may be given painlessly in the office with anesthetics. Repeat injections may be required if leakage from the abnormal blood vessels returns. Most people respond well with an improvement in vision. The eye should be monitored because new areas of leakage may occur at a future date. An Amsler grid chart should be used at home on a regular basis to detect recurrent activity at a future date.

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 © 2017-2022 Designs Unlimited of Florida. All Rights Reserved

Uveitis Questionnaire

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Below is a downloadable form to fill out and bring to your doctor. This questionnaire may help identify the underlying cause and help with treatment of uveitis.  

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.

Uveitis-Questionnaire-v20220204Download

Slow Myopic Progression

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

Although most people with myopia (near-sightedness) do not suffer from complications, highly near-sighted eyes (greater than 6 diopters) are at risk of vision loss. Myopia is fairly prevalent, affecting about 25-35% of adults in the United States. Extensive visual tasks focused at near may be increasing the risk of myopia. Highly myopic eyes are at increased risk of myopic macular degeneration, cataract, glaucoma, and retinal detachment. Therefore, treatment to reduce the progression of myopia is important to prevent loss of vision.

The simple act of spending time away from near work appears to offer help in reducing the onset of myopia. In one study the incidence of myopia was decreased by 10% by spending 40 minutes per day outdoors.

Recent studies support the use of dilute atropine eye drops to slow the progression of myopia. Atropine 0.01% must be prepared by a pharmacy with a doctor’s prescription. The cost is about $20-30 per month. The drop is used once per day. This low-concentration eye drop had minimal effects on the eye. A dilated pupil and difficulty focusing at near are rarely encountered. Therefore, light sensitivity is minimized. Very rare side effects of atropine including rapid heart rate, dry mouth, and urinary retention, constipation, and flushing of the skin are not generally reported with diluted atropine used to treat myopia. Allergic reactions with redness and itching are rare with low-concentration atropine, as well.

Eligible patients include children (aged 5-15) with progressively worsening myopia (1 diopter of more in one year).   However, there are no hard and fast rules; a strong family history of high myopia may play into the decision to treat a child with myopia to slow its progression. Treatment may continue until age 18 years. More studies are needed to better define the best time to start treatment and the optimal duration of treatment. For now, however, it appears that atropine may be the safest and most effective pharmacological treatment to slow the progression of myopia.

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 © 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

Multiple Sclerosis and Your Eyes

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

What is multiple sclerosis?

Multiple Sclerosis is a condition of the brain and spinal cord in which there is a loss of the insulating coat of the nerve cells (demyelination). The cause is unknown, but viral and auto-immune causes are suspected along with genetic predisposition. Because the brain controls movement and sensation, multiple sclerosis may cause a variety of symptoms. The symptoms may occur from time to time with normal periods in between (relapsing form). Alternatively, the symptoms may slowly progress and persist over time (progressive form).

How does multiple sclerosis affect the eyes?

Multiple sclerosis may disrupt the nerves that affect the vision or the movement of the eyes. It may also cause inflammation inside the eye. The following are well-recognized problems involving the eyes:

Optic Neuritis: Inflammation of the optic nerve may cause a sudden loss of vision. Often, there is pain in or behind the eye made worse with eye movement.

Internuclear Ophthalmoplegia (INO): An interruption of the nerve fibers that coordinate movement of the two eyes may cause a loss of alignment. If the two eyes are not pointing in the same direction, double vision occurs.

Intermediate Uveitis: A low-grade inflammation inside the eye (vitritis) may cause the slow-onset of fine floating specks in the vision. Over time, the vision may become blurred due to the accumulation of specks, as well as swelling of the retina.

How is multiple sclerosis diagnosed?

When visual symptoms occur, the ophthalmologist may undertake a number of tests in the office to diagnose multiple sclerosis. The optical coherent tomogram (OCT) can identify defects in the optic nerve and diagnose macular edema. Usually, an MRI scan is needed to identify degenerative plaques seen in the brain due to multiple sclerosis. Ultimately, a neurologist is consulted to confirm the diagnosis.

How is multiple sclerosis treated?

A neurologist orchestrates the treatment of multiple sclerosis. Medication and physical therapy help to manage symptoms. There is no cure. The clinical course of multiple sclerosis is variable. The least long-term disability is usually seen in women, those with onset of symptoms early in life, and those with few intermittent symptoms at onset.

The ophthalmologist manages the ocular symptoms. Loss of vision usually returns over time and may be accelerated with the use of IV steroids. Double vision may also improve over time and may be managed by patching one eye.

Intermediate uveitis usually requires medication to prevent progressive permanent loss of vision. Although mild cases may be carefully observed, treatment is needed if floaters interfere with vision or if macular edema (retinal swelling) is present. Steroid medications may be used by pills or by injection. They are best used for short-term management of flare-ups of inflammation. Other non-steroid medications help to suppress the inflammation over the long-term. These medications often require the assistance of a rheumatologist who watches for side effects while the ophthalmologist monitors the inflammation.

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 © 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

Uveitis

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

What is uveitis?

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

What causes uveitis?

Uveitis may be caused by infection, injury from trauma, disease in the body outside the eye, or sometimes for unknown reasons. Infection by a virus, bacteria, fungus, or other parasite may cause uveitis. Infections may be limited to the eye or may involve other organs as well. In other cases uveitis is caused by inflammation without infection. For example, arthritis, multiple sclerosis, lupus, and inflammatory bowel disease may cause uveitis. Uveitis commonly occurs following an injury to the eye. In some cases, no underlying cause can be found to be the cause of uveitis. Very rarely, cancer may cause uveitis. Tobacco may be an aggravating factor and should be discontinued.

What are the symptoms of uveitis?

Various symptoms may be experienced depending on where is uvea is most inflamed. Symptoms may be mild or they may be severe and disabling. The eye may be painful, red, tearing, and light sensitive. Tiny floating spots which move or “float” may be seen. Sometimes blind spots, blurred vision, distortion, or loss of side vision occurs.

How is uveitis managed?

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

In some cases, uveitis can return at a future date. Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact your doctor.

By Scott E. Pautler, MD

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

Copyright © 2016-2023 Designs Unlimited of Florida. All Rights Reserved.

Eye Injuries from Fireworks on the 4th of July

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Although we all love to celebrate the 4th of July, it is important to take action to avoid blindness from accidents involving the use of fireworks.

I will never forget the sorrow I felt for the family of a beautiful 2-year old girl who lost her vision from an accident many years ago on the 4th of July. Her family had earnestly wanted to share the joy of the holiday with their toddler. They purchased some bottle rockets and placed the child far away from where her father lit the rockets. Unfortunately, one of the rockets fell to the side and spun around and around the family. It finally exploded in front the young child before her parents could offer protection. The particles from the casing fractured from the explosion and flew in all directions. Several of the red plastic chards struck the child in her eyes. I was called on to care for her in the emergency room. As the family watched fearfully, I examined the child and determined that she needed to be treated in the operating room as an emergency. I operated for many hours, removing pieces of shrapnel from both eyes. Eventually, I was able to suture the eye lacerations closed. Several additional surgeries were required. Although I was able to save her from total loss of vision, she was legally blind. Permanently. For the rest of her life.

This sad experience prompts me to write this blog prior to the festivities on the 4th of July. To minimize the risk of injury, I ask that parents take their families to see professional displays of fireworks rather than putting on their own shows. Even sparklers can cause severe skin and eye burns due to the high temperatures at which they burn. If you suffer an injury, please report without delay to the emergency room of your local hospital for care.

Please keep the family celebrations fun and safe this year.

By Scott E. Pautler, MD

See also:

http://www.aao.org/eye-health/news/teen-nearly-loses-vision-to-fireworks

http://www.aao.org/eye-health/tips-prevention/injuries-fireworks-eye-safety

Macular Pucker

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

What is the Macula?

The macula is a special area of the retina that gives you fine, central, reading vision. The retina is a thin layer of tissue that lines the back of the eye. It acts like the film in a camera. The retina “takes a picture” of objects you look at and sends it to the brain.

What is Macular Pucker?

Macular pucker occurs when abnormal scar tissue grows like a sheet of cellophane on the macula and causes wrinkling. Macular pucker is present in about one in twenty eyes and is more common later in life. It may occur from aging of the gel inside the eye (vitreous separation), from a torn or detached retina, or from inflammation. Macular pucker is also called cellophane maculopathy, and “wrinkled retina.”  Macular pucker is not the same problem as macular degeneration. Macular pucker does not lead to macular degeneration

What are the Symptoms?

The presence and severity of symptoms vary widely with macular pucker. Symptoms include distortion and blurred vision. Distortion means that straight lines look crooked or wavy. It is readily detected and monitored with the Amsler grid test. Many patients have few or no symptoms and the macular pucker remains stable without worsening.

What is the Treatment?

If symptoms are mild and well-tolerated, no treatment is needed. The macular pucker may not progress and the vision may not worsen further. New glasses will not restore the vision to normal. There is no role for vitamins, exercises, eye drops, pills, or laser in the treatment of macular pucker. This problem usually affects one eye, although occasionally both eyes are involved. When the symptoms of macular pucker interfere with daily activities, vitrectomy surgery can improve vision by removing the abnormal tissue that wrinkles the retina. The amount of visual improvement depends upon the health of the retina under the scar tissue. Usually, there is a significant improvement in vision with much less distortion. Rarely, does the vision return completely to normal. Improvement in vision after surgery takes month to years. The most common side effect from vitrectomy is progression of cataract.

Below is a time-lapse video of a retina scan (OCT) of a 64 year-old woman with longstanding blurred vision and distortion in her right eye with 20/100 vision. After surgery her thickened retina gradually thinned (although it did not return to normal). Her vision returned to 20/25 over time.

For more information please visit Retina Vitreous Associates of Florida.

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 © 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

The Retinal Break: Holes and Tears

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

What is a retinal break?

A break is a tear or hole in the retina. The retina is a thin layer of nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. Because the retina is very thin, breaks may develop and cause retinal detachment with loss of vision. There are two kinds of retinal breaks: holes and tears. Retinal tears cause retinal detachments more often than retinal holes.

Retinal break
Horseshoe-shaped retinal tear as seen in an eye with retinal detachment (Click on image to enlarge)

What are the causes and symptoms?

Retinal breaks are fairly common in near-sighted eyes because near-sightedness is usually due to an elongation of the eye. As the eye enlarges deep in the eye socket, the retina has to stretch over a larger area. This stretching causes the retina to become thinner and may result in tiny round holes. These holes may cause no symptoms and may not cause retinal detachment.

In any eye, near-sighted or not, tears can occur from abnormal pulling on the retina by the vitreous (a clear gel that fills the eye and normally helps to hold the retina in place). Usually due to degeneration from aging, the vitreous gel condenses inside the eye and pulls on the retina. When this happens, patients usually notice the sudden onset of floating spots or “cobwebs”. Sometimes, brief lightning-like flashes of light occur in the side vision. About 10-15% of the time, new floaters and flashes mean a retinal tear has developed. This event places the eye at high risk of blindness from retinal detachment.

How is a retinal break treated?

Not all retinal breaks require treatment. The doctor may recommend observation alone. If a retinal break threatens to cause retinal detachment, the break is usually treated by laser or a freezing probe (cryopexy) to seal the retina to the eye wall at the site of the break. Treatment is NOT aimed at eliminating the flashes and floaters. Flashes usually disappear over a few weeks or months. The floaters gradually fade over many months, but they rarely disappear completely.

Treatment does not always prevent retinal detachment, so the patient should always report the new onset of more floaters or, more importantly, any progressive loss of side-vision or “curtain across the vision.”

Rarely, the central vision may become blurred and distorted due to scar tissue formation from the retinal break. This problem cannot be prevented with laser or cryopexy, though the scar tissue can be removed by surgery if it interferes with vision.

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 © 2022 Designs Unlimited of Florida. All Rights Reserved.

Hypertensive Retinopathy

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anatomy of the eye (click on image to enlarge)

What is hypertensive retinopathy?

Hypertensive retinopathy is the medical name for damage to the retina from high blood pressure. The retina in your eye is like the film inside a camera. The retina “takes the picture” of objects you look at and sends the message to the brain. The retina is a living tissue, which requires blood supplied by tiny vessels. Normally, these blood vessels carry oxygen and nutrients, but do not leak fluid into the retina.

How does blood pressure damage the retina?

High blood pressure puts stress on the walls of blood vessels. In the short-term, high blood pressure weakens the inner lining (endothelium) of the retinal blood vessels causing them to leak serum or blood into the retina. In the long-term high blood pressure may cause permanent blood vessel damage (hardening) leading to retinal vein occlusion or arteriolar macroaneurym.

What are the symptoms of hypertensive retinopathy?

Symptoms may occur early or late in the course of hypertensive retinopathy. Blurring of vision may occur if excess fluid (edema) leaks into the retina. Rarely, blind spots or sudden new floaters may occur. Damage to the retina may occur without symptoms.

What treatment is available?

The key to treating hypertensive retinopathy is to control blood pressure. Lowering blood pressure is associated with lower risk of loss of vision. If complications occur, laser or injections (Avastin, Lucentis, Eylea, Triesence, Ozurdex) may improve the vision by sealing leaky blood vessels. There may be some permanent damage to the retina from high blood pressure. Your doctor is going to order appropriate tests and recommend the best course of action to take at this time. See your internist to keep your blood pressure under good control.

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 © 2016-2023 Designs Unlimited of Florida. All Rights Reserved.

Stargardt Disease

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Stargardt disease image
Color photo and auto fluorescent fundus image of Stargardt disease

What is Stargardt disease?

Stargardt disease is an inherited problem of the retina. The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. Stargardt’s disease mainly affects the central part of the retina that normally provides sharp, central, reading vision and color vision.

What causes Stargardt disease?

Stargardt disease is usually inherited in a recessive pattern, which means it may skip many generations. An individual usually inherits the affected gene from both parents who carry the gene in order to have symptoms of the condition. Individuals who have inherited the gene from only one parent usually do not exhibit symptoms and are called “carriers”. If both parents carry the gene, then one in four children will have symptoms of Stargardt disease. If a person with Stargardt disease has children with someone who does not carry the gene, none of their children will have Stargardt disease, but half of their children will carry the gene. The gene variants that cause Stargardt disease are very common; they are present in about one in twenty people.

What are the symptoms of Stargardt disease?

Stargardt disease may cause no symptoms in the early stages. It may cause symptoms early or late in life. With time, symptoms may include the following:

  1. Photophobia—unusual sensitivity to light.
  2. Hemeralopia—difficulty seeing well in bright light.
  3. Decreased color vision.
  4. Blurring of central vision, sometimes with distortion or blind spots.

If Stargardt disease progresses over many years, it may cause a loss of vision to the point of legal blindness. In such cases, the loss of central vision interferes with the ability to read and drive, but the side-vision usually remains good. Sometimes it progresses very slowly and never causes significant visual loss. The rate of visual loss can be predicted by identifying others in the same family who also have Stargardt disease, as the pattern is often similar among family members. The visual symptoms may be monitored with the Amsler grid test.

How is Stargardt disease diagnosed?

The symptoms listed above may be the first clue to the diagnosis. A routine dilated eye examination can detect the retinal changes of Stargardt disease. In most cases a fluorescein angiogram is helpful. In this procedure the ophthalmologist injects a dye into the vein of the arm and photographs are taken of the retina, which show specific changes in the retina to make the diagnosis. A free genetic test can be ordered by my office and mailed to you.  It involves a painless swab of the lining of the mouth.  It is very reliable to detect the gene that causes Stargardt disease.

How is Stargardt disease treated?

There is no proven treatment for Stargardt disease, but studies are underway to find a treatment to slow the loss of vision. Researchers recommend avoiding excessive exposure to sunlight and avoid taking vitamin A supplements. It may also be helpful to avoid excessive dietary intake of foods that contain vitamin A, such as carrots and liver.

If significant loss of vision does occur, there are programs and devices that focus on helping a person find ways to cope with the visual impairment. Various low-vision optical devices such as magnifying devices, closed-circuit televisions, and large-print reading material can help to minimize the effects of visual impairment. Your ophthalmologist can prescribe optical devices or refer you to a low-vision specialist. Because side vision is less commonly affected, the remaining sight can be very useful.

A wide range of support services, rehabilitation programs, and devices are available to help people with cone dystrophy continue with many of their favorite activities. The Lighthouse for the Blind and the Pinellas Center for the Visually Impaired have classes and specialists in providing prescription lenses to magnify printed material. The Division of Blind Services provides rehabilitation services and financial aid for eye care in selected cases. Your doctor can give free access to the “talking book” library to make “books on tape” available. A form is available from your doctor that establishes legal blindness to be used for property tax and income tax deductions. As always, if you have any questions please do not hesitate to contact your doctor for more information.

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 © 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

Fenofibrate for Diabetic Retinopathy

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There is substantial evidence that fenofibrate is beneficial in the treatment of diabetic retinopathy. The retina in a thin layer of nerve tissue that is sensitive to light and acts like the film in a camera. The retina “takes a picture” of what your eyes focus on. The fine blood vessels in the retina are especially sensitive to high blood sugar levels, which cause the vessels to leak and eventually become blocked. This damage is called diabetic retinopathy.

Fenofibrate is a medication commonly used to control blood lipid levels. Abnormal serum levels of lipid have been shown to increase the risk of hardening of the arteries (atherosclerosis), which may lead to stroke and heart attack. While the goal of controlling lipids in diabetes is important in itself, fenofibrate appears to offer an independent benefit to small blood vessels (capillaries) in the retina. Two large studies (ACCORD and FIELD) demonstrated that fewer laser treatments were needed in a group of patients on fenofibrate compared with other patients who were randomized not to receive treatment with this medication for abnormal serum lipid levels. Fenofibrate may be used along side other medications used for lipid control (such as statins). However, patients with severe kidney damage should not use fenofibrate. A common dose of fenofibrate is 160mg per day. However, fenofibrate 54mg is recommended for patients with glomerular filtration rate (GFR) between 30 and 50. No fenofibrate is recommended if the GFR is less than 30.

There are established treatments for diabetic retinopathy. The mainstay of treatment of vision-threatening diabetic retinopathy remains laser and anti-VEGF injections (Avastin, Lucentis, Vabysmo, and  Eylea). In severe cases of diabetic retinal damage, vitrectomy surgery is needed to restore vision or prevent blindness. However, there are patients with diabetes who lose vision despite treatment and those who develop side-effects of treatment. Therefore, fenofibrate is a welcome addition to the medical treatment regimen.

Prevention of diabetic eye damage is far superior to treatment of diabetic retinopathy. Therefore, it is best to prevent diabetic damage to the eyes and other organs in the body through proper management of blood sugar, blood pressure, and blood lipids with the help of a medical doctor. In difficult cases of diabetes, the help of an endocrinologist is necessary. Finally, annual dilated eye exams with an eye doctor skilled in the management of diabetic retinopathy is key to identify retinal damage before vision is lost.

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 © 2015-2022 Designs Unlimited of Florida. All Rights Reserved.

Cystoid Macular Edema (CME)

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

What is cystoid macular edema?

Cystoid macular edema (CME) is an accumulation of fluid in the center of the retina. The fluid is clear like water and comes from abnormal leakage of the blood vessels in the retina. The retina is a thin layer of delicate nerve tissue which lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina which “takes the picture” of objects you look at and sends the message to the brain. The macula is the central area of the retina that gives you sharp central vision and color vision. CME frequently causes a blurring of vision described as fuzzy, hazy, or cloudy. Cystoid macular edema is NOT related in anyway to macular degeneration.

What causes cystoid macular edema?

Although the exact causes of CME are unknown, it may accompany blood vessel problems or inflammation. It most commonly occurs after cataract surgery and may be seen in as many as 3% of eyes undergoing surgery.

How is cystoid macular edema treated?

Since many factors may lead to CME, many different types of treatment are available. Usually weeks to months are required to improve the vision. Sometimes more than one type of treatment is needed for best results. Rarely, vision cannot be restored.

Treatment may include eye drops (steroid, and non-steroid) instilled into the eye several times a day. Sometimes, pills are used to decrease inflammation. Occasionally, medication is injected next to the eye under the eyelid. Anesthetic eye drops help to make the injections painless. Sometimes, surgery is needed to look for infection or remove abnormal scar tissue from inside the eye. With treatment most cases of CME can be managed successfully with improvement in vision. For more information visit www.retinavitreous.com

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 © 2015-2022 Designs Unlimited of Florida. All Rights Reserved.

Posterior Uveal Effusion

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anatomy of the eye (click on image to enlarge)

What is posterior uveal effusion syndrome (PUES)?

PUES is an abnormal leakage of clear fluid under the retina, which causes symptoms of blurred vision, sometimes with distortion of straight lines. It is also call the peripapillary pachychoroid syndrome. This condition frequently presents as central serous retinopathy. The retina is a thin layer of delicate tissue in the back of your eye, which lines the inside wall like the film in a camera. The retina “takes the picture” of objects you look at and sends the message to the brain.

What causes PUES?

PUES appears to be due to an abnormal leakage of serum (clear fluid) from blood vessels in the choroid. The choroid is a layer of tissue with many blood vessels lying under the retina. When the choroid is thick, it may abnormally leak fluid into the retina (Figure A-D) causing visual symptoms. Thick choroid is seen more commonly in far-sighted eyes than near-sighted eyes.

PUES
Thickened choroid leads to leakage of fluid into the retina

What is the treatment of PUES?

If the leakage is mild, observation may be all that is needed. If symptoms of blurred vision become significant, treatment may include eye drops or pills taken by mouth (Figure E-F). In rare cases, laser treatment or surgery in the operating room may be required to control the leakage. An attempt is made to eliminate aggravating factors such as ocular inflammation and, rarely, medications.

What will happen to my vision?

With prompt treatment the vision usually remains stable. In some cases, there may be a degree of permanent damage to the retina affecting the vision from past leakage that cannot heal. Treatment needs to be continued as a return of leakage may occur is medications is stopped (Figure G-H).

For more information see: Isolated Posterior Uveal Effusion: expanding the spectrum of the uveal effusion syndrome.

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 © 2015-2022 Designs Unlimited of Florida. All Rights Reserved.

Retinal Artery Occlusion

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anatomy of the eye (click on image to enlarge)

What is a retinal artery occlusion?

The retina in your eye is like the film inside a camera. The retina “takes the picture” of objects you look at and sends the message to the brain. The retina is a living tissue, which requires blood supplied by tiny vessels called arteries. If a retinal artery becomes blocked, it is called a retinal artery occlusion.

What causes a retinal artery occlusion?

Usually a blockage occurs from a piece of hardened artery in the neck (carotid artery) which breaks away and flows “down stream” to lodge in a small retinal artery. Hardening of the arteries is due to aging, obesity, high cholesterol, high blood pressure, diabetes, and tobacco use. Therefor, patients with retinal artery occlusion are at risk of other complications of hardening of the arteries (e.g. heart attack and stroke).

Abnormal tissue from a heart valve may also be the source of blockage. Rarely, an occlusion may result from blood disorders or inflammation such as giant cell arteritis. Fibromuscular dysplasia is suspected in young patients with retinal artery occlusion.  Trauma may cause retinal artery occlusion by dissection of the carotid artery, often associated with neck pain.

What are the symptoms of a retinal artery occlusion?

A sudden, painless loss of vision is common. There may be loss of only the central vision, the side vision, or there may be a dark bar or band above or below the center of vision. The loss of vision may be temporary or permanent.

What treatment is available?

If the blockage is mild, some or all of the vision may return with time. Sometimes it is necessary to help relieve the blockage with eye drops, pills, or an office procedure to lower the pressure in the eye. The blockage may be overcome and the blood flow may resume if the pressure in the eye is decreased quickly. This treatment may bring back some or all of the vision, but sometimes no treatment can bring back any vision. If an underlying medical problem is found, it must be treated.

Your doctor is going to order appropriate tests and recommend the best course of action to take at this time. The retinal artery occlusion will not be worsened by your daily activities or by using your eyes. If you have any questions, please feel free to ask.

What general health issues are there?

Retina artery occlusion usually indicates the need for an urgent general medical evaluation for increased risk of stroke. About 10% to 15% of people who experience retinal artery occlusion will suffer from a stroke within three months. Half of those individuals will have a stroke within 48 hours of having eye symptoms. Those people who survive this initial high-risk period must still be monitored because there is a 40% risk of stroke or heart attack within ten years from the time of retinal artery occlusion. This important health issues are why it is important to undergo regular general medical evaluations and work to minimize factors that worsen hardening of the arteries. Such factors include physical inactivity, overweight, tobacco use, high blood pressure, high cholesterol, and diabetes.

Where do I go for urgent care?

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

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

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.

Tampa Stroke Centers:

Adventist Hospital Emergency Department

3100 East Fletcher Avenue

Tampa, FL 33613

(813) 971-6000

St. Joseph’s Hospital Emergency Department

3001 W Dr Martin Luther King Jr Blvd

Tampa, FL 33607

(813) 870-4000

Tampa General Hospital Emergency Department

1 Tampa General Circle

Tampa, FL 33606

(813) 844-7000

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

Ocular Toxoplasmosis

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

What is ocular toxoplasmosis?

Ocular toxoplasmosis is an inflammation of the eye caused by an infection of the retina by a parasite called Toxoplasma gondii. The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” of objects you look at and sends the image to the brain.

What causes ocular toxoplasmosis?

Toxoplasma gondii infects humans and animals throughout the world. Twenty to fifty percent of adults in the United States test positive for exposure, but few people experience symptoms. The most common presentation resembles mononucleosis with symptoms of fever, fatigue, and swollen lymph glands. Because the toxoplasma organism can become inactive and form a protective microscopic cyst within human cells, it can cause relapses of infection and spread to new areas of the body months to years after the initial infection. If the parasite spreads through the blood stream to the eye, ocular toxoplasmosis may threaten blindness.

How is toxoplasmosis contracted?

The most common ways to contract infection are as follows: 1.) Hand-to-mouth transmission of the toxoplasma organism in cat feces e.g. cleaning the litter box. 2.) Eating undercooked meat, chicken, or eggs from infected animals. 3.) Eating unwashed fruits and vegetables that are contaminated by animal feces. 4.) Hand-to-mouth transmission from handling infected raw meat or animal products. 5.) Transmission from infected mother to child through the placenta during pregnancy. 6.) Rarely, Toxoplasma infection may acquired through contaminated drinking water or dust in the air.

Toxoplasma gondii completes its life cycle by producing millions of oocysts (eggs) in the intestines of the cat. These infectious eggs leave the cat in the feces and may lie dormant in the ground for up to two years. These eggs may infect an animal that may eat from the ground or a human who eats unwashed, contaminated fruits and vegetables from the ground. Once inside a human or animal, the eggs “hatch”, multiply, and spread throughout the body. When the immune system attacks the parasite, it becomes dormant and “hibernates” inside cells throughout the body. In months or years in the future, it may become active to cause infection again.

What are the symptoms of ocular toxoplasmosis?

If toxoplasma reaches the eye, early symptoms include seeing new tiny floating spots (floaters), pain, redness, tearing, light sensitivity, and blurred vision. Late symptoms include permanent blind spots in the vision and, rarely, blindness. These symptoms are not specific for ocular toxoplasmosis, but they are especially important to recognize in people with known toxoplasma scars in the retina. If such symptoms are promptly reported to the doctor, treatment may minimize permanent damage to the eye.

What treatment is available?

Sulfa antibiotics (Septra or Bactrim) are frequently used for several weeks to treat active infection. In some cases of toxoplasmosis, another antibiotic called clindamycin is used. This medicine may rarely cause a severe bloody diarrhea, which should be reported to the doctor immediately for effective treatment. Prednisone pills and similar eyedrops may be used to decrease inflammation. Rarely, antibiotics may be injected into the eye.  Often, the pupil of the eye is dilated with eyedrops during the active infection to prevent scarring and to relieve pain.

It is not uncommon for untreated ocular toxoplasmosis to result in loss of vision. It is rare to experience serious side effects from medication used to treat toxoplasmosis. Armed with the knowledge to report side effects promptly to the doctor, you can minimize the chance of suffering from any permanent ill-effects from treatment.

Finally, notify your doctor if you had a toxoplasma infection in the past as it may be important to avoid intraocular steroid injections to prevent a return of infection.

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.

Hydroxychloroquine (Plaquenil) and your eyes

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What side effects can Plaquenil have in the eye?

Although Plaquenil is of proven benefit for a number of medical problems, very rarely it can cause damage to the eyes (1-2% at 10 years and 3-20% at 20 years).  Early symptoms may be subtle.  Small blind spots may develop just above or around the center of vision.  Sometimes they progress to form a doughnut-shaped blind area around the central vision.   If not detected early, the central vision itself may be lost.  When this occurs, color vision is usually affected.  These symptoms, however, are not specific to Plaquenil damage.  The Eye MD must use special tests to determine whether any eye changes are due to Plaquenil or not.  Ocular side effects appear to be dose related, so the risk increases with increased daily dosage.  Individuals less than 5’3” to 5’7” in height regardless of weight should take less than 400mg of Plaquenil per day.  Additionally, a person who weighs less than 135 pounds should take less than 400mg of Plaquenil per day according to current recommendations.  Other factors that may increase the risk of ocular damage include age over 60 years, kidney disease, liver disease, and use of Tamoxifen.

Plaquenil 200mg tablets
Recommended maximum dosage based on height and weight:
Weight (lbs):Height:Maximum dosage:
68-774’0″ – 4’1″One table per day
78-864’2″ – 4’3″One per day except Sunday take two a day
87-964’4″ – 4’5″One per day except M-F take two a day
97-1064’6″ – 4’8″One per day except M-W-F two a day
107-1164’9″ – 4’10”One per day except M-W-F-S two a day
117-1254’11” – 5’0″Two per day except weekend take one a day
126-1345’1″ – 5′ 2″Two per day except Sunday take one a day
≥1355’3″ or tallerTwo per day

*** See updated dosing schedule based on 2017 American Academy of Ophthalmology Guidelines.

What can you do to protect yourself?

Plaquenil is an effective medication with fewer side effects than other medicines used for the same purpose.  However, it is important to monitor your eyes for side effects that might indicate the need to stop taking Plaquenil.  The Amsler grid chart (below) should be checked at least once a week testing each eye separately, using glasses if needed.  Look for a missing part of the grid either above or below the central dot while looking only at the center of the grid.  Additionally, your Eye MD should examine your eyes every year with specific testing to look for early signs of retinal changes.

Blue Yellow Amsler Grid
While focusing on center of grid, make sure the whole grid is seen…no missing areas (click on image to enlarge)

What happens if you develop retinal changes from Plaquenil?

Retinal damage from Plaquenil is extremely rare. If early retinal changes are found, Plaquenil may be discontinued.  By discontinuing Plaquenil at an early stage, vision can be saved.  Continued examination is important to monitor the eyes for further changes.

By Scott E. Pautler, MD

Reference: Article on early detection

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.

Retinal Detachment

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anatomy of the eye (click on image to enlarge)

What is the retina?

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

What is retinal detachment?

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

Retinal break
Horseshoe-shaped retinal tear as seen in an eye with retinal detachment (Click on image for enlargement)

What causes retinal detachment?

Retinal breaks (holes and tears in the retina) cause retinal detachment. These retinal breaks are usually caused by a degeneration of the vitreous (the clear gel that fills the eye and normally helps to hold the retina in place). Vitreous degeneration is common in aging and near-sightedness, but may also follow a direct blow to the eye, hemorrhage, infection, or inflammation inside the eye. When the vitreous degenerates and condenses, it pulls on the retina and may cause retinal tears, which often lead to retinal detachment.

What are the symptoms of retinal detachment?

Prior to retinal detachment, most people notice warning signs such as new floating spots or “cobwebs” in the vision. Sometimes, brief lightning-like flashes of light are seen in the side vision. These are the symptoms of vitreous degeneration and retinal breaks. The retinal detachment that follows usually causes a dark “curtain” or “shadow” to form in the side-vision. The “shadow” often comes from below and on the side near the nose.  If it is not treated, the shadow gradually covers all of the vision resulting in blindness. There is generally no pain with retinal detachment.

How is retinal detachment treated?

The treatment of most retinal detachments requires surgery. Your doctor is skilled in a number of techniques to prevent blindness. Which type of surgery is recommended depends on the precise findings on examination. Surgery is not usually aimed at eliminating flashes and floaters. Flashes usually disappear in a few weeks or months. The floaters gradually fade over many months, but rarely disappear completely.  Some retinal detachments that do not cause symptoms may be observed without initial surgery.

Laser/Cryopexy demarcation:  Small areas of the retinal detachment (especially before any side vision has been lost) can sometimes be treated with laser or cryopexy to “seal down” the retinal along the edges of the detachment in an effort to prevent it from extending further.  This surgery is performed in the office. If it is not successful in stopping the detachment, more extensive surgery is required.

Pneumatic retinopexy:  Many retinal detachments can be repaired by this surgery performed in the office by anesthetizing the eye, sealing the break(s) with laser or a freezing probe (cryopexy), and pushing the retina into proper position with a gas bubble which is injected into the eye. Although this procedure is successful most of the time, it requires the strict cooperation of the patient to remain in proper head position for about five days. If this procedure fails, more extensive surgery in the hospital operating room is sometimes needed.

Scleral buckle surgery:  Some retinal detachments require the placement of a permanent plastic supporting belt around the eye to create a “ledge of support” for the retina. This is a major surgery in which a belt is placed around the eye in the hospital operating room. The eye is often rendered more near sighted by this procedure. Rarely, permanent side effects include double vision. If this surgery is not successful, vitrectomy surgery may be recommended. Scleral buckle surgery is preferred over other methods of surgery if the retinal breaks are located in the inferior (bottom portion) of the retina, where gas bubbles may not be effective in holding the retinal in position. Scleral buckle is also preferred over vitrectomy in eyes with a clear lens, because vitrectomy surgery usually results in cataract formation. Scleral buckle surgery is often used when other attempts at surgery have failed.

The video below demonstrates scleral buckle surgery. If you are uncomfortable watching surgery, please do not click on this video:

Vitrectomy surgery:  Performed in the hospital operating room as a major eye surgery, vitrectomy surgery involves making small incisions into the eye to remove floaters, dissect scar tissue, remove fluid from under the retina, apply laser, and place a gas bubble or silicone oil into the eye to hold the retina in place. Specific head positioning is sometimes needed. Sometimes a cataract or lens implant must be removed to adequately repair the retina. This surgery may be repeated if necessary to prevent blindness.

The video below demonstrates vitrectomy surgery. If you are uncomfortable watching surgery, please do not click on this video:

With one or more surgeries most retinal detachments can be repaired keeping useful vision. Vision may not return to normal, as there may be some permanent damage from the retinal detachment resulting in blurred or distorted vision. In some cases additional surgery is needed to removed scar tissue that forms after retinal reattachment surgery.  There are always risks to surgery including hemorrhage, infection, scarring, glaucoma, cataract, double vision, deformity, loss of vision/loss of the eye. Sometimes despite all efforts with surgery, all vision may be lost. Surgery is recommended for retinal detachments because blindness usually results if treatment is withheld. If you have questions, please do not hesitate to ask your doctor.

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.

Macular Telangiectasia

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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 macular telangiectasia (MacTel)?

Macular telangiectasia is a disorder of retinal cells and tiny blood vessels located in the center of the retina. It has also been called juxtafoveal telangiectasis. The retina in your eye is like the film inside a camera. The retina “takes the picture” of objects you look at and sends the message to the brain. The macula is the central portion of the retina that is responsible for sharp reading vision. In MacTel the macula undergoes slow degeneration, and tiny foveal blood vessels become irregular and dilated for unknown reasons. They rarely leak blood or clear fluid in the fovea. MacTel may resemble changes in the retina from drugs that are used to treat breast cancer (Tamoxifen).

Who is at risk for developing macular telangiectasia?

Macular telangiectasia is usually found in males and females during their 5th to 8th decade of life. It may occur in as many as one in every 1,000 persons. MacTel is associated with diabetes, high blood pressure, and tobacco use, but the exact cause has not been determined. Hereditary factors appear significant. Low serum levels of an amino acid called L-serine may play a role, but there are no clear recommendations for supplementation to date.

What are the symptoms of macular telangiectasia?

Blurring of vision is the most common symptom. Distortion of vision may also make reading or seeing small details difficult. Distortion is when straight lines appear wavy or crooked. It may be monitored with the Amsler grid test. Symptoms and clarity of vision may change from day to day. If sudden loss of vision or increased distortion occurs, your doctor should be notified without delay (within a week) as treatment may be needed.

What treatment is available?

There is no cure, but treatment may improve vision or keep the vision from worsening in certain instances. No specific treatment may be recommended if the symptoms are mild. Supplements containing the amino acid L-serine are being investigated. Laser and medicine injections help selected patients. Treatment usually does not return the vision to normal.

Your doctor is going to order appropriate tests and recommend the best course of action to take at this time. Physical activity and use of your eyes will not worsen macular telangiectasia. Magnification may help with reading. If you have any questions, please feel free to ask. If you would like to participate in research, contact www.mactelresearch.com.

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.

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.

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.