Category Archives: Retinal Treatments

Eye Care by Internet & Phone

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Questions?

Do you need eye care, but are fearful of COVID-19?

Do you need a second opinion on your eye problem?

Do you need an accurate diagnosis?

Do you need to know the best treatment options?

How can we help?

Now you can obtain high quality information on the phone, on videoconference (Facetime, Skype, etc), and by e-visit on a confidential computer portal.  

We offer assessments and treatment recommendations.  We review your history directly, examine your eyes with a video device, and review photos and charts from past exams.  If you live near Tampa, we are available to see you in the office.  If you are distant, we can put you in contact with superb physicians closer to you.  

What does it cost?

There is no charge to you with Medicare and most insurances.  If you have no insurance, the cost is $35 for the first visit.  Additional fees may apply if there is a need for review of photos and medical records. 

Does it matter where I live?

Although it is best if you live near Tampa, we may be able to help even if you live afar.  If you are local, we are available to examine your eyes directly if needed. If you live distant from Tampa, we can refer you to a reputable eye-care specialist in your area if you need an examination.

How do I make contact?

Call 1-888-622-8521.  Ask the receptionist for a virtual appointment with Scott E. Pautler, MD.  They will establish a patient account and arrange for a call-back within 24 hours.  

Send a secure email to Dr Pautler: spautler@retinavitreous.intellechartdirect.net 

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.

Indicate your interest in a virtual exam and briefly state your eye problem.  We will return your email or contact you by phone at your preference.

Serine and MacTel

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What is MacTel?

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

How does serine relate to MacTel?

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

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

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

 What can be done with this information?

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

Check for current prices of L-serine on Amazon.

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

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

By Scott E. Pautler, MD

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

References:

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

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

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Step Therapy

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What is Step Therapy?

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

What eye medications are affected by step therapy?

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

Why are antiVEGF medications targeted?

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

Are the antiVEGF drugs equal in safety and effectiveness?

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

What can a patient do?

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

How might the government have handled this issue better?

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

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

By Scott E. Pautler, MD  

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

Stem Cell Therapy for Macular Degeneration

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

What is stem cell therapy?

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

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

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

What is a patient to do?

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

By Scott E. Pautler, MD

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

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

Beovu for Macular Degeneration

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

What is Beovu therapy?

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

How effective is Beovu therapy?      

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

What are the risks of Beovu therapy? 

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

What do I expect after a Beovu injection?

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

By Scott E. Pautler, MD

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

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

Treatment of Floaters

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What are floaters?

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

What does this symptom mean?

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

What causes floaters?

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

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

What can be done about floaters?

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

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

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

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

By Scott E. Pautler, MD

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

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

Diabetic Retinopathy: laser or injection?

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What is diabetic retinopathy?

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

What treatment options are available?

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

How does laser work and what are the side effects?

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

How do injections work and what are their side effects?

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

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

When to use injections and when to use laser?

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

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

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

By Scott E. Pautler, MD

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

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

Silicone Oil for Repair of Retinal Detachment

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See Anatomy of the Eye

What is the retina?

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

What is retinal detachment?

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

How is silicone oil used to repair retinal detachment?

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

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

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

How long is silicone oil left in the eye?

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

What complications are associated with silicone oil?

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

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

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

By Scott E. Pautler, MD

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

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

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.

Retinal Rejuvenation

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

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

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

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

By Scott E. Pautler, MD

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

Visudyne Photodynamic Therapy

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globe anatomy
Anatomy of the Eye (click on image to enlarge)

What is photodynamic therapy?

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

What do I expect after photodynamic therapy?

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

By Scott E. Pautler, MD

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

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

Over-the-Counter Pain Medications

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What are over-the-counter pain medications?

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

What side effects might be expected?

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

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

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

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

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

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

By Scott E. Pautler, MD

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

Steroid Eye Drops

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What are Steroid Eye Drops?

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

How do steroid eye drops work?

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

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

How does the doctor choose which steroid drop to use?

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

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

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

By Scott E. Pautler, MD

What is the Amsler grid?

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

How is the Amsler grid used?

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

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

Amsler grid RVAF

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

By Scott E. Pautler, MD

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

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

NSAID Eye Drops

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What are NSAID Eye Drops?

NSAID eye drops are prescription medications used to treat macular edema or reduce pain and inflammation. NSAID stands for Non-Steroidal Anti-Inflammatory Drug. This class of medication is separated from steroids by mechanism of action, effectiveness, and side effects. There are a number of NSAID eye drop brands available. Examples include Ketorolac, Acular, Acuvail, Voltaren, Nevanac, Ilevro, Xibrom, Bromday, Prolenza, Ocufen, and Bromsite.

How do NSAIDS work?

NSAIDS work by inhibiting the COX enzyme that produces specific prostaglandins, which promote inflammation. Prostaglandins are a major class of inflammatory mediators in the body. There are other mediators of inflammation that sometimes need to be controlled, so steroid eye drops are often used in addition to NSAIDS.

There is conflicting evidence as to whether one NSAID drug is better than another. Some believe that Nevanac and Ilevro are better for pain control. Others believe that Voltaren is better to control signs of inflammation inside the eye.

How does the doctor choose which NSAID to use?

In some cases the doctor has had good experience with a specific agent for a given situation. In other cases the choice may be guided by convenience and cost. For convenience some drops may be used once or twice a day (e.g. Ilevro, Xibrom, Bromday, Prolenza, and Bromsite). Although their prices vary, they tend to be expensive in comparison to generic drugs.

As an alternative, other NSAIDS are used more frequently, but cost less. Acular and Voltaren are available in generic formulations that cost under $20. These drops are frequently used four times a day. They are less expensive even though more eye drops are used per day. They may cause eye irritation in some patients.

If you have strong preferences, be sure to communicate with your doctor to be given the best NSAID eye drops for your situation. Be sure to use your eye drops exactly as prescribed and keep all appointments as scheduled in order to determine the effect of the medication and to look for side effects.

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

Treatment of Uveitis

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

How is Uveitis treated?

The key to treating uveitis is to identify the underlying cause. However, the specific cause may not always be found. Therefore, it is helpful to place a given case of uveitis into various classifications in order to treat most effectively. In some cases there is an infection that requires treatment with antibiotics. In other cases there is an underlying inflammation in the body outside the eye that is not associated with infection. In such cases the treatment of the systemic condition is required to settle the eye. Finally, there are inflammatory conditions not associated with infection that only affect the eyes. In these cases treatment may be directed to the eye alone. Such treatment often starts with eye drops.

What infections cause uveitis?

A large variety of organisms may infect the eye: bacteria, viruses, fungi, worms, insect larvae, protozoa, and other parasites. Some infect the eye alone. Others infectious agents affect other parts of the body as well. Infectious agents may enter the eye from a cut or opening into the eye from an eye injury. This is called endophthalmitis. Urgent antibiotic treatment is required as the risk of permanent loss of vision is high.

In other types of infection, the organism enters the eye through the blood stream. An infectious agent may enter the body through a cut in the skin, through the gastro-intestinal tract, the uro-genital tract or through the lungs. Once it is in the body the organism may enter the blood vessels and travel to the eye. For example, toxoplasmosis is a parasite found in contaminated food that enters the gastro-intestinal tract. It then spreads to the eye through the blood stream and infects the retina.

Because a large variety of infectious agents may enter the eye, the patient must inform the doctor of possible exposure to infection and carefully complete a uveitis questionnaire. Sometimes, a medical specialist in infectious disease is consulted.

What systemic inflammatory conditions can affect the eye?

Many autoimmune conditions cause inflammation without infection. The immune system abnormally identifies the body as being “foreign.” The resultant inflammation may affect various organs of the body. For example, rheumatoid arthritis in an autoimmune condition that affect the joints and sometimes causes inflammation of the sclera (the white outer coat of the eye).

In order to identify an autoimmune disease, the doctor will ask many questions about inflammation outside the eye (uveitis questionnaire) and order appropriate tests.

What are inflammatory conditions that affect the eye alone?

Sometimes, the immune system attacks the eye without affecting other organs in the body. The underlying trigger or cause of inflammation cannot usually be found. These conditions are placed into categories that help plan treatment strategies. For example, anterior uveitis (inflammation of the front of the eye) is initially treated with anti-inflammatory eye drops. On the other hand, Birdshot Chorioretinitis (BSCR) is an inflammation of the back part of the eye that usually requires long-term systemic treatment (pills or injections in the skin). There are many different ocular inflammatory conditions, which are identified by tests ordered by the doctor.

What medications are used for uveitis?

The type of treatment depends on the cause and category of inflammation. Antibiotics are used if an infection is suspected. The doctor prescribes antibiotics by pill or IV (intravenous) if the infection affects organs outside the eye. The doctor prescribes eye drops, pills, and/or injections if the infection affects only the eye.

The eye doctor may consult a rheumatologist to help monitor treatment with a systemic anti-inflammatory medication (pills and/or injections) if an inflammation affects organs outside the eye. Sometimes, an inflammation only affecting the eye requires the use of systemic medication, too. The ophthalmologist may also use eye drops and painless eye injections to control the inflammation.

Anti-inflammatory eye drops include steroid eye drops and non-steroid eye drops. They may be used separately or together depending on the type of inflammation. Steroid eye drops may cause the intra-ocular pressure to rise and must be monitored. Non-steroid eye drops may irritate the cornea (the front window of the eye). Dilating drops are often used to minimize pain from inflammation and help prevent harmful scar tissue from damaging the iris (the brown or blue part on the front of the eye).

Steroid injections may be given next to the eye (subtenon’s injection) or into the eye (intravitreal injection). Anesthetics help prevent pain with injection. Steroid implant injections (Ozurdex and Iluvien) offer longer duration of effect. Steroid injections may be especially useful in the treatment of macular edema (swelling of the retina) in patients with uveitis.

Steroid pills are often used at the beginning of treatment to control severe inflammation. Prednisone is the most common medication used to treat uveitis. It is usually used at high starting doses and then is slowly tapered down to an acceptable dose for long-term use or is completely discontinued. Prednisone has unacceptable side effects if used in high doses for many months to years.

Non-steroidal anti-inflammatory drugs (NSAIDS) given as pills may provide steroid-free treatment for some cases of uveitis. Some are available over-the-counter. Others are available by prescription. They may adversely affect the stomach and kidney.

Immune system suppressants help to quell uveits. Methotrexate, azathioprine, mycophenolate mofetil, cyclosporin are often used safely and effectively. Routine blood tests help detect side effect before permanent damage occurs. Although there was concern of an increased risk of skin cancer and lymphoma due to immune suppression, the SITE extension study showed that cancer risk is not increased. Very strong medications are used in very severe inflammation that threatens life or blindness (cyclophosphamide and chlorambucil). Pregnancy is avoided while on immune suppressants.

Biologic medications are new and very effective in the treatment of uveitis. Humira is given at home as an injection under the skin every two weeks. Long-term effects are being studied.

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.

Prednisone for Eye Inflammation

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What is prednisone?

Prednisone is a very powerful medication related to a hormone produced by your body. Prednisone is very effective at decreasing inflammation. Inflammation in the eye can result from infection, injury, systemic diseases like arthritis, and sometimes from unknown causes. If left untreated, inflammation may cause permanent damage to the eye and loss of vision.

How is prednisone used?

A form of prednisone can be used as eye drops to control inflammation in the front of the eye. Often these drops must be used frequently for best results. If stronger dosages or deeper penetration of medication is required, another medicine like prednisone may be injected next to the eye. This injection is given with little discomfort by using anesthetic eye drops before the injection. If severe, vision-threatening inflammation is present, prednisone pills are prescribed.

What side effects might be encountered?

As prednisone is powerful, many side effects may occur. More frequent and severe side effects are seen the longer the medication is used. Fairly mild, common side effects include temporary mood swings, appetite changes, fluid retention, acne-like rash, trouble sleeping, and difficulty controlling diabetes. More serious side effects usually seen with prolonged treatment include reactivation of TB, stomach ulcer, brittle bones and hip fracture. Any worrisome symptom is reason to contact your doctor. It is important to report all other medication you are taking because interactions between drugs can occur. Finally, serious side effects can occur if prednisone is discontinued too rapidly. Follow the instructions of your doctor carefully.

Your doctor has identified a serious, vision-threatening eye problem that warrants the use of prednisone, a very powerful medicine that should be used with care. Be sure to inform your general medical doctor that you are going to start taking prednisone. Additional tests or medications may be needed to protect you against the side effects of prednisone.

How to take prednisone and protect against side-effects?

To protect yourself against bone loss and fractures, take calcium 1,500 mg (Tums EX) and vitamin D 800 Units every day. Also, make sure your internist approves before starting prednisone. Notify your doctor if you have had a positive TB test or have been exposed to TB (tuberculosis).

Take prednisone after breakfast in the morning. You may use antacids such as Maalox to prevent upset stomach. It is very important for your health to discontinue prednisone by gradually decreasing the dosage as recommended.

Follow a tapering schedule of dosing to avoid serious reactions. Your doctor will make recommendations based on your situation.

AS YOU LOWER THE DOSE OF PREDNISONE, BE SURE TO REPORT TO YOUR DOCTOR ANY SIGNIFICANT WEAKNESS, TIREDNESS, DIZZINESS, OR LOW BLOOD PRESSURE. THESE SYMPTOMS MAY REPRESENT A SERIOUS SIDE-EFFECT OF PREDNISONE WITHDRAWAL.

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

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.

Scleral Buckle Surgery

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

What is scleral buckle surgery?

Scleral buckle surgery is an advanced form of eye surgery for the repair of retinal detachment that is performed in the operating room under a microscope. Scleral buckle surgery 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. During scleral buckle surgery a silicone band or sponge is sutured to the external eye wall (the sclera) behind the eye muscles and hidden by the covering of the eye (the conjunctiva). The surgery creates an indentation (buckle) in the sclera that offers a ledge of support for the retina inside the eye and offsets traction on the retina from the vitreous gel (a major cause of retinal break and retinal detachment).

SBP image
Artistic rendition of scleral indentation (click on image to enlarge)

Below is an example of scleral buckle surgery. If you are uncomfortable watching surgery, please do not click on this video.

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 scleral buckle surgery?

Your EyeMD will schedule an appointment with your primary care doctor if evaluation is needed prior to surgery. Please inform your doctor of any chest pain/pressure, fever, productive cough, 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 should 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 scleral buckle 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 from surgery. Although serious problems are not encountered often, the risks and benefits must be weighed for each individual prior to surgery. In retinal detachment, surgery is the only way to improve vision and prevent blindness.

What can I expect after scleral buckle 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.

Over-The-Counter Pain Medication Schedule for Maximum Effect
Dosing Schedule:8AM2PM8PM2AMMaximum
Ipubrofen800mg800mg800mg800mg3200mg
(200mg tablets)4 tablets4 tablets4 tablets4 tablets 
      
Dosing Schedule:11AM5PM11PM Maximum
Tylenol Extra-Strength1000mg1000mg1000mg 3,000mg
(500mg acetaminophen)2 caplets2 caplets2 caplets  
      
Note: This schedule may need to be altered if you have kidney or liver disease.
This schedule is designed not to exceed maximum dosages of these medications.
Do not take addiitonal medications that also contain ibuprofen or acetaminophen.

It is common to have moderate discomfort after scleral buckle surgery. A scratchy feeling may result from sutures on the white of the eye. These sutures dissolve in about a month. 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. 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 swelling and redness slowly disappear over weeks to months. The vision usually returns slowly after surgery and may take months to years for final recovery. Sometimes, the vision does not recover completely to normal. If the center of the retina was detached, there is usually some degree of permanent blurring of vision or distortion.

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.

Retinal Cryopexy

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

What is retinal cryopexy?

Retinal cryopexy is a procedure performed in the office or operating room designed to treat retinal problems. The name, cryo, comes from a Greek word meaning icy cold. This procedure utilizes the freezing effect to treat damaged retina.

cryo probe
Cryopexy Probe

How is retinal cryopexy performed?

After the eye has been anesthetized, a pencil-like probe is gently pressed against the eye. The cryo machine, activated by a foot pedal, cools the tip of the cryo probe. The freezing effect is conducted through the eye wall to the retina. The procedure takes several minutes to perform.

What conditions may require retinal cryopexy?

Retinal cryopexy is used to treat abnormal or damaged retinal tissue. The most common condition requiring retinal cryopexy is a retinal tear. Retinal tears threaten loss of vision from retinal detachment. Retinal cryopexy is used to make the retinal tear adhere to the inner eye wall. Retinal cryopexy is preferred over laser to treat retinal tears in attached retina when cataract or vitreous hemorrhage obscures the view of the retina and blocks the path of laser light.

Other conditions that are occasionally treated with cryopexy include diabetic retinopathy, retinal vein occlusion, Coats disease, neovascular glaucoma, pars planitis, retinopathy of prematurity, tumors, and familial exudative vitreoretinopathy (FEVR).

What are the risks of retinal cryopexy?

While cryopexy is generally safe, there are risks to consider. The most common adverse effects include redness, swelling, bruising, tearing, and pain after the procedure. Sometimes, cryopexy does not prevent retinal detachment, and more surgery is needed at a future date. Severe complications are rare and include infection, bleeding, scarring, deformity, blindness, deformity, and loss of the eye. When cryopexy is recommended, the benefits of treatment outweigh the risks.

What is expected after retinal cryopexy?

An eye patch may be placed over the eye after the procedure and prescription eye drops may soothe the eye after the patch has been removed. For several days after retinal cryopexy, the eyelids may appear swollen. Tearing and achiness is common for several days. The white of the eye may be red for a week or two. Over-the-counter pain medications often help improve comfort. Cryopexy will not prevent distortion of vision due to macular pucker that sometimes develops after retinal tears.

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.

Laser Surgery and the Retina

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Laser
Laser treatment (click to on image to enlarge)

There are many different kinds of lasers used to treat eye problems and many different ways lasers can be used to help the eye function. For example, the most common type of laser performed after cataract surgery is YAG capsulotomy. In this procedure the YAG laser is designed to open up a foggy window that develops behind the lens implant. It is a very brief, painless laser that usually gives a rapid improvement in vision. Other uses for lasers include treatment for glaucoma, droopy eyelids, and near-sightedness. Lasers with specific properties are chosen for a specific purpose. This blog discusses the photocoagulating laser used to treat retinal problems.

What is the retina?

The retina is a thin layer of delicate nerve tissue, which lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. The retina has two main areas. The macula is the central area that gives you sharp, central vision and color vision. The peripheral retina is the part of the retina that gives you side vision and night vision.

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

What types of problems affect the retina?

The most common problems for which laser is used to treat the retina include diabetes, retinal vein occlusion, macular degeneration, retinal macroaneurysm, and retinal tears.

How does the laser help?

Most retinal lasers work by producing a carefully measured amount of heat to the retina in very small spot sizes. This heat may help to cauterize leaking blood vessels as in diabetes or macular degeneration. Alternatively, laser may simply seal down the retina to help keep it from detaching from the inside wall of the eye in cases of retinal tears and limited retinal detachments.

What are the risks of retinal laser treatment?

While laser is generally safe and effective, there is always some risk of adverse effects. Depending on the purpose of the laser, risks include blind spots in the vision that may be permanent, loss of central vision, loss of color vision, loss of night vision, and distortion of vision.

What is it like to experience a laser treatment?

Laser treatment is performed in the office in a matter of a several minutes. To avoid pain and discomfort, the ophthalmologist anesthetizes the eye with eye drops. An injection of anesthetic around the eye is rarely required. You sit in the examining chair with your chin in the chin-rest and forehead against the supporting bar. A contact lens is placed on the eye to hold the eyelids open. You may blink normally during the laser. Try not to squeeze your eyes together, because it may push the contact lens off the eye. You may be asked to look in a specific direction or follow a small light in order to keep the eye in position for treatment. It is important to follow instructions carefully to avoid side effects of laser treatment, which may include seeing blind spots in the vision afterwards. During treatment, it is normal to see bright flashes of light. Sometimes, you may feel a pulsing sensation with the flash. If it becomes painful, please notify the doctor. The treatment may last one to fifteen minutes depending on how much retinal damage is present.

What can you expect after a laser treatment?

Immediately after the contact lens is removed, your vision may be temporarily tinted red or blue. The vision is usually blurred for a few hours because of the dilating drops. Temporary blurring from laser sometimes lasts a week or more, but is usually mild. If your laser treatment was for macular degeneration, you may see a new permanent blind spot in the vision where abnormal blood vessels were cauterized. If you had laser for retinal break, it is normal for you to see floating specks in your vision and occasional flashes of light off to the side after laser. There are usually no restrictions to your activities. You may read, watch TV, stoop, bend, and lift objects just as before your treatment. No special eye drops are required after laser treatment, but be sure to continue any eye drops you were using before the treatment. You may use sunglasses for comfort, but they are not required. If you were told that laser is being used to improve your vision, it usually takes weeks or months to see the improvement. Sometimes, more than one treatment is required. Your doctor will give you an appointment to assess the results and determine whether any more treatment is needed.

What warning signs should I report after treatment?

Although it is normal to have blurred vision right after laser, the following symptoms are important to report to your Eye MD:

  • Pain
  • Severe loss of vision
  • Dark curtain or shadow across 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 © 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

Preparing for Retinal Surgery

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How can I prepare for surgery?

One week prior to surgery: Unless your internist feels that stopping blood thinners unacceptably increases the risk of blood clots (stroke/heart attack), do not take aspirin-containing products, Effient, or Brilinta for one week prior to surgery. Coumadin may be stopped four days prior to surgery. Pradaxa, Xarelto, and Eliquis may be stopped two days prior to surgery. Your EyeMD will schedule an appointment with your primary care doctor if evaluation is needed prior to surgery. Please inform your doctor of any chest pain/pressure, fever, productive cough, shortness of breath, or bleeding tendencies.

The morning of surgery: Take no medications for diabetes unless instructed differently by your doctor. Please do take all of your other medications with a sip of water and you may use any prescribed eye drops as usual. Otherwise, do not eat or drink anything on the morning of the scheduled surgery. Report promptly to the hospital as scheduled, but expect to wait while the nurses prepare you for the operating room. Bring a complete list of your medicines with dosages. Do not wear make-up. Arrange for someone to drive you to and from the hospital.

What type of anesthesia is available?

With local anesthesia the patient is sedated with IV medication so there is no memory of the anesthetic injection around the eye. Surgical drapes are placed over the face leaving plenty of breathing room. During surgery the patient is awake, but there is usually no pain. It is important to lie still on the operating room table so that there is no movement of the head during surgery. The main advantage of local anesthesia is that the patient can leave the hospital more quickly than after general anesthesia.

With general anesthesia the patient is asleep throughout the surgery and remembers nothing of the surgery. The anesthesiologist places a tube down the throat into the trachea to breathe for the patient. After surgery the throat may be sore. Which type of anesthesia is best for a patient may be determined by the health of the patient. Otherwise, if a person cannot lie still for the surgery or if claustrophobia is a problem, general anesthesia is preferred.

What are the risks of surgery?

Although uncommon, problems such as bleeding and infection may arise from any surgery. Retinal detachment or abnormal scar tissue formation may require additional surgery. Rarely, there may be loss of vision, double vision, glaucoma, or loss of the eye. The most common problem following vitrectomy surgery is progression of cataract requiring cataract surgery at a later date.

Although serious problems are not encountered often, the risks and benefits must be weighed for each individual to arrive at a decision for surgery. For many eye problems, surgery is the only hope for improvement in vision or prevention of blindness.

What can I expect after surgery?

A soft eye patch and a hard eye shield are placed on the eye at the end of surgery. Leave these in place until your exam on the day after surgery. Tylenol (no more than 4,000 mg per day; caution with liver disease) or Ibuprofen (no more than 2,400 mg per day; caution with kidney disease) may be used if there is pain. Call the doctor for a prescription if your pain is not relieved. It is not common to have severe pain after vitrectomy surgery. A scratchy feeling is due to sutures on the white of the eye. These sutures dissolve in about three weeks and you may use a lubricating ointment (Lacrilube is available without a prescription from the drugstore) as needed for comfort. At your exam after surgery, you will be given eye drops and/or an ointment to keep the eye comfortable, to prevent infection, and to promote healing. Wearing the eye patch is optional after you are seen in the office, but wear the hard protective shield at night for at least two weeks.

The vision usually returns slowly over days to weeks after surgery, but may take many months for final recovery. Use caution while walking as your depth perception may be altered until your vision returns after surgery. You may experience light flashes, floaters, and temporary double vision for days to weeks after the surgery. Do not be alarmed, but feel free to notify the doctor of any concerns that you may have. The swelling and redness slowly disappear over two or three months. There are no restrictions to using the eyes to read, watch TV, or bathe. Ask the doctor when you may resume driving. You may shower after the patch has been removed in the office. Avoid heavy lifting and straining for one week after surgery. You may resume taking all your medications after the surgery; however, blood thinners should be withheld until after the first visit in the office one day after the surgery.

Depending upon the reason for your surgery, it may be very important to lie face down or on either side after your surgery. Be sure you understand any positioning requirements given by your surgeon. Additionally, if a gas bubble is placed in your eye at the time of surgery, you may not fly on a plane until it has dissolved or you could risk severe pain and blindness. Similarly, nitrous oxide should not be used if any other surgery is required while you are healing from your eye surgery. Be sure to wear a wristband for six weeks after eye surgery to notify health care providers that you have a gas bubble in the eye. Remove the wristband only when your doctor has notified you that the gas bubble is gone.

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 risk of stroke with treatment of Age-Related Macular Degeneration

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The mainstay of treatment of wet-type age-related macular degeneration (AMD) requires the intraocular injection of medication (e.g. Avastin, Lucentis, Eylea, Beovu, and Vabysmo) to prevent loss of vision. Although effective, this treatment entails some degree of risk. For example, infection may occur at a rate of about one in one thousand to one in five thousand injections. Moreover, there may be a low increased risk of stroke.

Although some studies do not show increase risk (Campbell), other large studies have demonstrated an increased risk of stroke. In one study the increased risk of stroke appeared to be 1 in 127 patients within one year after starting treatment for AMD (Schlenker). These studies were unable to prove that the medication itself was responsible for the increased risk of stroke. For example, it may be that people with new-onset wet AMD are at a higher risk of stroke than others. In 2019 a population-based study demonstrated no increased risk of stroke and heart attack related to AMD treatment (see reference). Additional research in ongoing.

Given this information what are the options? Certainly, a patient may decide not to treat macular degeneration and risk loss of vision in an effort to decrease the risk of stroke. Another option may be to minimize the frequency of injections. That is, if the macular degeneration remains stable after several monthly injections, consider extending the time interval between injections. In this manner there is less exposure to the drug. Furthermore, if the wet-AMD appears to have reached end-stage with significant loss of vision, the injections might be stopped altogether. If done carefully, one may reduce the risk of a sudden recurrence of wet-AMD with further loss of vision while off treatment.

The type of medication used for injection has not been proven to make a difference in the risk of stroke. Although Martin et al found a slight increase in stroke risk with Avastin compared with Lucentis, these findings were not supported by Chakravarthy and Schlenker. More research is needed to better define risk of stroke and how we may minimize the risk. A recent meta-analysis of current data as of 2022 (Reibaldi) supports Lucentis over the other agents as being safer from a systemic risk of heart attack and stroke.  Please refer to my blog on medication choices for treating retinal problems.

By Scott E. Pautler, MD

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

References:

Ophthalmology 2012 119:1604-1608 Campbell

AJO 2015 160:569-580 Schlenker

Ophthalmology 2012 119:1388-1398 Martin

Ophthalmology 2012 119:1399-1411 Chakravarthy

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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.

Ozurdex

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Ozurdex

 

What is Ozurdex and why is it used in the eye?

Ozurdex is a very small tube-like implant that contains steroid medication that is slowly released into the eye for up to 3-6 months. The Ozurdex implant is injected into the eye in the office setting in order to decrease inflammation, swelling, or leaky blood vessels inside the eye. It has been shown to improve vision in eyes with retinal vein occlusion, diabetic macular edema, and inflammation in the eye. The Ozurdex implant completely dissolves in the eye. Repeated injections may be necessary for continued improvement in vision.

How is an Ozurdex injection performed?

Anesthetics are used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation is often felt as the implant is injected into the eye with a very thin, short needle. The procedure is very brief.

What are the side effects of Ozurdex?

Although possible, it is rare to see the Ozurdex implant floating in the vision. In about 30-40% of patients, the pressure inside the eye increases and requires eye drops. About 1% of patients require glaucoma surgery to prevent loss of vision. Most eyes develop cataract and eventually require surgery. Rare risks of steroid injection include bleeding, infection, retinal detachment, and loss of vision/loss of the eye. The risk of infection is about one in 1,000 injections. Please report any severe loss of vision to the doctor without delay.

How do I care for the eye?

You may be given eye drops and instructions on how to use them. Physical activity is not limited after Ozurdex injection. Tylenol or Ibuprofen may be used if there is discomfort, but severe pain should be reported to your doctor without delay. It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. If you have any questions or concerns, please call the office. Additional information is available at www.ozurdex.com.

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.