Eylea HD (High Dose) is an FDA-approved medication for the treatment of wet AMD and diabetic retinopathy. It is a more concentrated form of Eylea, a medication that has been approved for use and effectively used for many years. Regular Eylea contains 2mg of medication per injection, whereas Eylea HD has 8mg of medication per injection. The higher dose allows for prolonged treatment effect for many patients. Currently, Eylea HD may be used no less than every 8 weeks after a loading dose. This has caused problems for patients who are helped by Eylea HD, but cannot sustain a treatment schedule of 8 weeks because the drug effect wears off too soon.
What is being done to expand the treatment schedule of Eylea HD?
A new drug trial has begun in order to gain FDA approval for the use of Eylea HD every 4 weeks. The study will accept patients who are already being treated for diabetic macular edema or wet macular degeneration. Prior to entering the study, patients must have had at least 3 medication injections within the past 5 months. Eylea HD injections in the study begin as early as 4 weeks from the last pre-study injection and are continued monthly for 7 shots. At that time, the eye is evaluated to extend the treatment to a longer time interval. The study lasts about two years (96 weeks) and all costs of treatment are covered by the sponsor.
How can I decide if the Eylea HD study is right for me?
Your doctor will help you to decide. The diagnosis will be confirmed and the entry criteria will be checked. If eligible, all details will be discussed prior to entry into the study.
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Small blood clots formed at the thrombus in the “stump” of internal carotid artery pass to the brain and eye along the path outlined by the white arrows. Image modified from Baker et al. Cureus 2022 Mar; 14(3): e22746
What is the carotid stump syndrome?
The internal carotid artery is the main artery in the neck that brings blood from the heart to the eye. Due to hardening of the arteries, the carotid artery may become blocked. Risk factors include high blood pressure, diabetes, high cholesterol, obesity, and tobacco use. If the carotid artery becomes completely blocked, there is a dead-end or stump beyond which the blood cannot flow. Due to lack of blood flow from this blockage, tiny blood clots may form in the carotid artery. Then, they may find their way to the eye through bypass channels that develop in response to the blocked carotid artery.
What eye symptoms result from the carotid stump syndrome?
When tiny blood clots enter the eye from the carotid artery, they may cause blind spots in the vision. Sometimes, the blind spots are small and may not be noticed by the patient. At other times, the blind spot may appear like a reddish or black bar or arc in the vision. In severe cases, the entire vision may black out…either temporarily or permanently.
How can the eye doctor help?
The symptoms from the carotid stump syndrome may also be caused by many other disorders. The role of the eye doctor is to determine the cause of the symptoms and determine if they are due to the carotid stump syndrome. Eye examination and testing is necessary. There is often no specific treatment needed for the eye condition. The symptoms frequently improve with time if the underlying condition is treated.
How is the carotid stump syndrome treated?
Medicines and surgery are used to treat the carotid stump syndrome. Anti-platelet medications are the mainstay of treatment. They work by limiting the tendency of the blood to clot. Surgery may open the blocked carotid artery.
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.
I reviewed 271 abstracts that were cited from the PubMed search terms “lens and capsule and deposit.” I have included some references from my search, as well as hyperlinks for convenience.
The preponderance of cases involved pseudoexfoliation (PEX). Uncommon manifestations of common problems must be considered1. It may be helpful to check the pupillary ruff for atrophy and gonio the angle looking for pigment deposition as seen in pre-clinical PEX.2
There are many rare causes of lens capsular deposits reported. I have listed some below along with suggested investigation:
-foreign substances (silicone oil3): did this patient have a silicone IOL? Consider reviewing the operative report for the IOL to see if they used anything unusual like triamcinolone.
-infectious agents4: remain on the look-out for inflammation into the future.
-Fabry disease5: rare but important to consider…any sign of retinal vascular tortuosity or cornea verticillata?
-familial amyloidosis6: amyloid deposits on anterior capsule are more prevalent than vitreous amyloid…but were there any vitreous opacities or retinal vascular changes?
-rock inhibitor7: (more out on a limb in terms of possibility). They affect the lens epithelial cells.
-Healon8: Any crystalline deposits on IOL surface?
1. Sorkou KN, Manthou ME, Meditskou S, Ziakas N, Tsinopoulos IT. Exfoliation Fibrils within the Basement Membrane of Anterior Lens Capsule: A Transmission Electron Microscopy Study. Curr Eye Res. 2019;44(8):882-886. doi:10.1080/02713683.2019.1608262
2. Suwan Y, Kulnirandorn T, Schlötzer-Schrehardt U, et al. Light and electron microscopic features of preclinical pseudoexfoliation syndrome. PLoS One. 2023;18(3):e0282784. Published 2023 Mar 9. doi:10.1371/journal.pone.0282784
3. Liu W, Huang D, Guo R, Ji J. Pathological Changes of the Anterior Lens Capsule. J Ophthalmol. 2021;2021:9951032. Published 2021 May 4. doi:10.1155/2021/9951032
5. Rothstein K, Gálvez JM, Gutiérrez ÁM, Rico L, Criollo E, De-la-Torre A. Ocular findings in Fabry disease in Colombian patients. Manifestaciones oculares de la enfermedad de Fabry en pacientes colombianos. Biomedica. 2019;39(3):434-439. Published 2019 Sep 1. doi:10.7705/biomedica.3841
6. Beirão JM, Malheiro J, Lemos C, Beirão I, Costa P, Torres P. Ophthalmological manifestations in hereditary transthyretin (ATTR V30M) carriers: a review of 513 cases. Amyloid. 2015;22(2):117-122. doi:10.3109/13506129.2015.1015678
8. Jensen MK, Crandall AS, Mamalis N, Olson RJ. Crystallization on intraocular lens surfaces associated with the use of Healon GV. Arch Ophthalmol. 1994;112(8):1037-1042. doi:10.1001/archopht.1994.01090200043019
A visual hallucination is the perception of a visual image that is not the result of seeing an object outside the eye. Normally, the eye perceives light from objects outside the eye and sends the image to the brain for interpretation. However, there are a number of circumstances that result in images being “seen” by a patient that do not originate from outside the eye. These images are referred to as hallucinations, especially if they appear as formed images of recognizable objects, like faces, trees, or other familiar things. Sometimes, hallucinations appear as dots, lines, or geometric shapes. The hallucinations may be in color or black and white.
What causes hallucinations?
A large list of problems may cause visual hallucinations. These include drug use and abuse, delirium, mental illness, and a variety of neurological conditions (including stroke, multiple sclerosis, and dementia). Sometimes, eye disease causes visual hallucinations; this is called the Charles Bonnet syndrome. It is a common condition in which the brain “makes up images” as a result of loss of vision from an eye condition (such as macular degeneration, diabetic retinopathy, or glaucoma). Charles Bonnet was an 18th century botanist and philosopher who described complex visual hallucinations in his grandfather after loss of vision.
How can a doctor find the underlying cause of visual hallucinations?
A doctor may determine the cause of visual hallucinations by careful examination and testing. If the hallucinations are interpreted by the patient as being “real,” the cause is more likely related to mental illness or may be due to drug intoxication or neurological disease. In these cases, the mental status exam is usually not normal. In the Charles Bonnet syndrome, the patient knows what he is seeing is not real, but sees the images nonetheless. An eye exam may make the diagnosis, but in some cases, further testing is needed. And these may include blood tests and imaging studies (CT scan and/or MRI brain scan). The final diagnosis of Charles Bonnet syndrome is made only after other more serious diagnoses are excluded.
What is the treatment of visual hallucinations?
The treatment depends on the underlying cause. In the case of the Charles Bonnet syndrome, counseling may help. Much relief comes from knowing that the symptoms are benign and do not represent a serious medical condition. Some patients find the symptoms improve if they move their eyes up-and-down, or left-and-right, or look away from the hallucinations. Others find it helps to stare at the hallucination until it fades away. It may help to talk about the hallucination with a family member or friend. Because stress and fatigue may precipitate the hallucinations, some recommend getting plenty of sleep and rest. Exercise and meditation are helpful. Thankfully, the visual hallucinations from Charles Bonnet syndrome often subside with time and may disappear over months to years. Rarely, medication may be prescribed by a neurologist. New treatments are on the horizon.
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Before we discuss laser for central serous retinopathy, we must ask what is central sero retinopathy. Central serous retinopathy (CSR) is an eye condition associated with loss of vision from water (serous) leakage from the choroid beneath the macula (central retina). Although it may be seen at any age, it is most common among young adult males. The leakage may be initiated by emotional stress and aggravating factors include stimulants (caffeine, cocaine, amphetamines), steroids (cortisone, prednisone, testosterone and other androgens), lack of sleep (sleep apnea), over-the-counter dietary supplements (niacin, body-builders), prescription medications (possibly Viagra and related meds), and medical conditions (Cushing’s syndrome, pheochromocytoma).
What treatment is available?
The first line of treatment is identification and elimination of any factors that are suspected to aggravate CSR. However, if leakage persists, there are a number of treatments that may be helpful. These include a special class of oral diuretics, antiVEGF injections, and lasers. Although thermal lasers may be used in selected cases, often cold lasers are preferred.
How do cold lasers (PDT) work?
Verteporfin photodynamic therapy (PDT) is the cold laser used in ophthalmology for the treatment of retinal problems. It is called “cold” because it does not use heat to cauterize tissue. Verteporfin dye is injected into the vein of the arm after which a laser is aimed into the eye to activate the dye. The activated dye releases highly reactive oxygen radicals, which chemically seal the leaking blood vessels under the retina. PDT is very effective in treating CSR. It is expensive and sometimes not covered by private insurance. PDT rarely causes a blind spot in the vision and this risk is minimized by using a low dose of Verteporfin or low power laser (reduced fluence). After PDT treatment has been completed, it is important to avoid direct sunlight (or exposure to halogen light) for 48 hours to allow time for the Verteporfin to leave the body.
Below are the photos of a 49-year-old man who had blurred vision and some distortion in his left eye for a year. His condition did not improve after a trial off caffeine. He had no medical problems and no other inciting factors were identified.
Color photos revealed some white changes in the retina (arrow) due to permanent degeneration of the retina near center of vision (fovea) due to longstanding leakage. Fundus autofluorescence photos are even more sensitive in showing this damage.
OCT (above) shows fluid under the retina (between the retina and the retinal pigment epithelium).
FA/ICGA photos (above) show the site of active leakage under the retina. Because of the lack of improvement with medical therapy and the threat of permanent loss of central vision due to long-standing leakage, this patient underwent reduce-fluence PDT. He experienced no adverse effects of laser and his vision returned to 20/20 over several months’ time.
The OCT above shows resolved subretinal fluid one month after PDT.
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Choroidal macrovessel is the term currently used for a rare choroidal vascular abnormality that may present as a small choroidal mass with or without symptoms. It usually appears as a dilated, tortuous choroidal vessel beneath the temporal macula and may extend to the periphery. A dilation of the posterior ampulla may elevate the overlying retina (see OCT image below) and cause secondary changes in the retinal pigment epithelium, rarely with subretinal fluid. Choroidal macrovessel is usually diagnosed during adulthood with a female predilection. There is no known associated systemic vascular abnormality.
Another term that may be somewhat more specific for this condition is posterior aneurysmal choroidal varix. An aneurysmal varix is a markedly dilated and tortuous vessel, sometimes used to describe a dilated vascular channel due to a direct communication of an artery and a vein. In the example below, there appeared to be a direct communication between a short posterior choroidal artery and a choroidal vein (Haller vein) as seen on ICG angiography where there was early filling of the lesion in the arterial phase. On the color photo, the prominence of the lesion diminishes in appearance as the vessels track toward the vortex outflow. This is likely due to numerous collateral venous channels that are known to exist, which allows for a reduction in blood flow and intraluminal pressure. Thus, the peripheral choroidal venous channels appear unremarkable.
The most helpful diagnostic tests include optical coherence tomography (OCT) and indocyanine green angiography (ICGA). OCT shows a small hyporeflective choroidal mass temporal to the fovea. There may be disruption of the outer retinal bands and/or subretinal fluid. ICGA shows early filling of the prominently dilated and tortuous choroidal vessel.
As choroidal macrovessels are usually asymptomatic, no treatment is needed. Their importance is primarily to differentiate them from tumors. Rarely, they cause disruption of retinal pigment epithelium resulting in simulated “tracks”, which may be confused for ophthalmomyiasis (subretinal larva).
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HTLV1 is a virus that causes HTLV1-associated uveitis. It is an abbreviation for human T-lymphotropic virus type 1. First isolated in 1980, HTLV1 belongs to the retrovirus group that also includes the virus that causes HIV/AIDS. Retroviruses are called “retro” because they use a pathway to reproduce that is the reverse of what most organisms use. The genetic map of retroviruses is RNA, which is converted inside host cells to DNA by a special enzyme (reverse transcriptase). The host cell is then directed to produce more virus particles. HTLV1 is called “lymphotropic” because it tends to infect lymphocytes, which are a type of white blood cell involved with immunity (see Legrand).
How and where do you get exposed to HTLV1?
Because most people with HTLV1 infection remain without symptoms, they carry the virus and spread it to others by sexual contact (semen), shared blood (e.g. IV drug-shared needles, organ transplantation), and by breast milk. HTLV1 is found in most frequently in people from Brazil, Japan, sub-Saharan Africa, Honduras, Iran and the Caribbean islands. However, due to international travel, HTLV1 may be found anywhere in the world.
What problems does HTLV1 cause?
Many people who are exposed to HTLV1 develop no symptoms. However, because HTLV1 affects white blood cells, it may cause autoimmune conditions, as well as blood cancer. For example, autoimmune conditions include seborrheic dermatitis (infective rash), paralysis (tropical spastic paresis), and uveitis (see Schierhout). Examples of blood cancer include T-cell lymphoma and leukemia.
What is Uveitis?
Uveitis (pronounced, “you-vee-EYE-tis”) is a general term used to describe inflammation inside the eye. The uvea is the name given to the layer of tissue in the eye that has a brown color (melanin pigment) and blood vessels, which serve to provide blood supply and protect the eye from excessive light. The uvea can be divided into separate parts, which perform different functions in the eye: the iris, the ciliary body, the pars plana, and the choroid (see anatomy of the eye). 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. Sometimes, uveitis affects tissues not considered a part of the uvea.
What type of uveitis is most common with HTLV1?
Intermediate uveitis is the most common type of uveitis caused by HTLV1. In intermediate uveitis the inflammation mainly centers in the vitreous gel (the clear gel that fills the eye). This type of uvetiis is called intermediate because it affects the middle or intermediate part of the eye. That is, the vitreous gel fills the eye and is located in an intermediate position between the front and the back of the eye. Vitritis and pars planitis are other names for intermediate uveitis.
Who is most likely to develop HTLV1-associated uveitis (HAU)?
The age group most likely to be affected by HAU is between 20-49 years; however, any age group may develop HAU (see Mochizuki). Female are affected by HAU twice as often as males (see Takahashi). It appears that the eye inflammation (uveitis) is caused by the effect of HTLV1 infection on the behavior of white blood cells (lymphocytes), rendering them more likely to mistakenly attack the eye (see Mochizuki). HAU may occur with or without other ocular inflammatory conditions, such as thyroid eye disease (see Nakao). Likewise, HAU may occur with or without non-ocular HTLV1-associated conditions, such as paralysis, rash, or blood cancer.
What are the symptoms of HTLV1-associated uveitis (HAU)?
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 (5-10% of cases). Symptoms may be mild or they may be severe and disabling. Only one eye is affected in about half of all cases of HAU (see Takahshi).
How is HTLV1-associated uveitis (HAU) diagnosed?
Diagnosis can be difficult. Blood tests are performed to identify HTLV1 infection in patients with findings that suggest HAU. One FDA-approved test is produced by MP Biomedicals Diagnostics: HTLV blot 2.4 (EIA). Sometimes, accurate diagnosis requires multiple tests.
How is HTLV1-associated uveitis (HAU) managed?
There is no cure for HTLV1 infection. To limit the damage from inflammation, HAU is treated with anti-inflammatory medication in the form of eye drops, injections, or pills. When pills are used, the eye doctor may coordinate medical care with the expert assistance of a rheumatologist. Rarely, surgery is required to treat uveitis. Episodes of inflammation may last from weeks to many years. HAU is a serious eye problem and may result in loss of vision (see Takahashi). However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized. Most people with HAU keep good vision (See Nakao). In some cases, HAU may go away, but return at a future date in about 50% of cases (see Takahashi). Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact your doctor.
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There are many conditions, which threaten loss of vision, that are treated by injecting various medications into the eye. The eye conditions include macular degeneration, diabetic retinopathy, retinal vein occlusion, uveitis, and others. The injections may be given into the tissues outside the eyeball (subtenon’s injections) or into the eyeball (intravitreal injections). It is very important to avoid pain as these injections may need to be given repeatedly over time.
Why do I have pain after eye injections?
Although pain during eye injections can usually be minimized with anesthetics given before the injection, sometimes there is pain for hours after the injection. There are many reasons why this may occur:
1.) The antibiotic (betadine) may irritate the eye for hours after it has been applied to the eye.
2.) The eye may become dried out after the injection due to insufficient blinking.
3.) The eye may be accidentally scratched by rubbing the eye while it is still anesthetized.
4.) The drug that is injected into the eye may cause an inflammatory reaction.
5.) Rarely, a severe infection called endophthalmitis may occur after injection into the eyeball.
What can be done to prevent pain after injections?
The key to eliminating pain after eye injections is to identify the underlying cause. This may take some detective work. Although betadine is given at the time of injection to prevent infection, only a small dose is needed. If a large amount of betadine is used or if the betadine has not been thoroughly rinsed off the eye, it may cause blurred vision, persistent burning, itching, and/or a scratchy sensation like sand in the eye (called a foreign body sensation). Therefore, it is important for the eye doctor or technician to completely rinse the betadine off the eye after an eye injection in order to avoid pain later.
Sometimes, the surface of the eye may become dry after an injection because the patient does not blink frequently enough or not completely enough. This often happens as a result of the anesthetic used in preparation for the injection. After the injection is over, the anesthetic may continue to work for 15-30 minutes. During that time, the patient does not have the normal sensation necessary to indicate that it is time to blink. If the eye does not blink often enough, the surface may dry out and cause blurred vision, pain or foreign body sensation. Therefore, the patient may need to purposefully blink frequently or simply rest the eye closed for a while after an eye injection in order to prevent drying. Similarly, if a patient does not close the eye completely with each blink, part of the eye can become dry. In some cases, it may be necessary to forcibly close the eyes with each blink in order to be sure the lids close completely.
At times a patient may unknowingly rub and scratch the eye after an injection because of persistent numbing after an injection. Therefore, it is very important to avoid touching the eye for 15-30 minutes after an injection. If the eye needs to be dried off, a clean tissue may be used with a gently damping or blotting motion in the corner of the eye where the lids come together at the bridge of the nose. It is best not to move the tissue left and right or up and down in a rubbing fashion. Once the eye becomes dry or irritated for any reason listed above, it may take 1-2 days for the pain to go away and the eye to return to normal.
Rarely, a drug that is injected into the eye can cause an inflammation that causes pain or blurred vision. The doctor makes this diagnosis by examining the eye under the biomicroscope (called a slit lamp). If a medication is determined to be the cause of inflammation, it is treated with prescription eye drops and the offending drug is not used again in that patient in the future.
Infection is an extremely rare cause of pain after an eye injection. In about one in several thousand injections, germs may enter the eye through the needle tract after an eye injection. This rare infection is called endophthalmitis (pronounced like “end-off-thal-my-tiss”). Symptoms usually start with pain, redness, and loss of vision several days to a few weeks after an injection. There is no perfect way to prevent endophthalmitis. The doctor uses techniques like applying betadine before the injection. The patient tries to avoid contaminating the eye by avoiding exposure the unclean areas (like a barnyard) and avoid rubbing the eyes after injection. Endophthalmitis is very serious and may result in permanent loss of vision. Therefore, any patient having deep aching pain, increasing redness, and loss of vision starting several days or weeks after an eye injection should notify their eye doctor for prompt evaluation.
What can be done to make the eye feel better?
If the cause of the pain and irritation is from betadine, drying, or rubbing the eye, the best treatment is lubrication. Lubricants are available over-the-counter in the form of eye drops, eye gels, and eye ointments (see examples at the end of this article). The thicker the lubricant, the better the relief of pain and discomfort. However, gels and ointments may be difficult to place into the eye and they tend to make the vision blurry for several minutes or more. Lubricants may be used as often as needed. Resting the eyes closed may also provide relief. Cold compresses help many patients. Over-the-counter pain medications like ibuprofen and/or Tylenol may be helpful. Prescription pain medications are rarely needed and may cause undesirable side effects.
If the cause of the pain and irritation is from a drug reaction or from infection inside the eye, the doctor will prescribe special anti-inflammatory eye drops. If the eye exam shows infection, antibiotic injections must be given into the eye and surgery in the operating room may be necessary.
If pain keeps occurring after eye injections despite taking the measures listed above, sometimes prescription eye medication can help. Non-steroid (NSAID) eyes drops or steroid/antibiotic ointments may help prevent the pain. Most instances of pain after eye injections may be avoidable. Please talk with your eye doctor to help resolve the problem in order to undergo treatment without pain.
Gels are easier to apply than ointments and may be used immediately after an eye injection to prevent eye pain and they may be used later to soothe eye discomfort.
Ointments are more difficult to place in the eye. However, they provide longer duration of action. They may be used immediately after an eye injection to prevent eye pain and they may be used later to soothe eye discomfort.
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We thank senior instructor David J. Browning, MD, PhD for organizing this course and we thank the attendees for their participation and input for improvement. The following are the handouts from the individual cases that may be downloaded for review. The files are listed in alphabetical order by instructor’s last name followed by case number and subject of the talk.
Before discussion about the best vitamins for macular degeneration, just what are vitamins? Vitamins are organic compounds that are needed by your body to function, but cannot be made by your body. Therefore, they must be consumed to promote good health. Vitamin and nutritional supplements are not regulated or tested by the Food and Drug Administration. Claims by manufacturers that these supplements improve health must be scientifically proven.
Should I take vitamins?
Doctors and nutritionists are limited in their ability to make firm recommendations in many situations because nutrition research is still in its infancy. Beware of authors and marketers who make grand claims as to the effectiveness of vitamins and herbs. Most healthy individuals who eat a well-rounded diet do not need to take supplemental vitamins, although there are some situations in which supplements have been shown to be beneficial. In general, vitamins are useful in the following situations: advanced age, age-related macular degeneration, food fads, gastrointestinal absorption abnormalities, and hemodialysis.
Vitamins and nutritional supplements—the more the better?
Although vitamin deficiency causes illness, excess vitamin intake may result in toxicity. Toxic effects are especially seen with the fat-soluble vitamins (Vitamins A, E, D, and K). However, even dosages of vitamin B6 exceeding 500mg per day may cause light sensitivity, and vitamin C may cause nausea and diarrhea in large doses of 2 grams per day. Vitamin A may cause liver damage, visual changes, and birth defects in dosages as low as 15,000 IU per day and long-term use of vitamin A may cause osteoporosis and increased risk of bone fracture. Beta carotene may cause smokers and former smokers/asbestos workers to be at increased risk of lung cancer. Vitamin E appears safe up to 400 IU, but daily dosages exceeding 800 IU may cause abnormal bleeding and dosages exceeding 1200 IU may cause headache, fatigue, nausea, diarrhea, cramping, weakness, blurred vision, and gonadal dysfunction. Vitamin D may cause abnormal calcium deposits in soft tissues when taken during kidney failure or in doses greater than 2,000 IU.
So what are the best vitamins for age-related macular degeneration (AMD)?
The AREDS2 formula is the most carefully studied vitamin combination proven to reduce the risk of vision loss in AMD. There are many companies that manufacture the AREDS2 formula, but the most economical source (to the best of my knowledge) is Equate Advanced Eye Care Complex from Walmart. Another more expensive brand is Preservision AREDS2. There is NO vitamin A or beta carotene in AREDS2. Be aware that mineral supplements such as zinc in the AREDS2 formula may interfere with the absorption of prescription medications such as thyroid pills. Therefore, take AREDS2 vitamins 4 hours apart from prescription medications to minimize their interactions. Iron supplements may worsen macular degeneration and should be avoided unless prescribed by a physician.
Click here to check updated prices of Preservision AREDS2 on Amazon.
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The optic nerve is the nerve that connects the eye to the brain. It sends the “picture” taken by the eye to the brain. The optic disc is the part of optic nerve that can be directly seen by the eye doctor on an examination. Optic disc drusen are calcified deposits in the optic disc that may be detected directly on exam or by testing with cameras or ultrasound. They are present in about 2% of the population.
Top color image shows optic disc as round structure without clearly seen drusen. Bottom fundus autofluorescence image shows the optic disc drusen as bright white spots in optic disc..
What causes optic disc drusen and why are they important?
Optic disk drusen are present from birth, but often go undetected until later in life. Usually they cause no problem, but they may crowd the nerve fibers in the optic nerve. The crowded optic nerve may be predisposed to blood vessel blockage later in life, especially with hardening of the arteries. The condition of blocked blood supply to the optic nerve is called ischemic optic neuropathy (ION). Sleep apnea may play a role in some patients and SSRI anti-depressants may be a risk factor for ION.
Sometimes, optic disc drusen can cause loss of side vision as in glaucoma. In this case, eye drops are sometimes prescribed. Rarely, bleeding under the retina may occur due to blood vessel growth (similar to wet macular degeneration). In that instance, medicine injections or laser may be used.
Finally, optic disc drusen may be buried in the optic disc and the appearance may resemble optic disc edema (papilledema). True papilledema is caused by elevated pressure in the brain. It is, therefore, important to make a correct diagnosis. Although a number of tests may be used, optical coherence tomography (OCT) is the single most reliable test for diagnosis.
How are optic disc drusen managed?
Most cases of optic disc drusen cause no problems and require no treatment. There is no accepted method to remove them. The usual recommendations to prevent hardening of the arteries may be helpful to avoid ION (avoid tobacco and control weight, blood pressure, cholesterol and blood sugar). In order to detect early changes in the vision, it may be helpful to monitor the vision each week with an Amsler grid test. If a sudden blind spot or distortion (straight lines look wavy or crooked) is detected, contact the eye doctor within 2-3 days for evaluation and management.
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.
Being on-time is an important issue for me, as waiting in the doctor’s office can seem like an eternity. I know your time is important. As such, I strive to train my staff to work with me to make your visit as pleasant and efficient as possible. When you approach the front desk, you are promptly greeted by our receptionist, not ignored as though you are invisible. Within short order a technician brings you back to the examination area of the office designed for optimal preparation for the doctor. You wait only long enough for the eye drops to dilate your eyes for retinal examination. I seek to spend time directing my attention to you and your eye problem, so I have my technicians take notes on the computer while I examine the retina. At this time, I use technical language that sound strange, but I soon translate the findings of my exam into everyday language. Because it is easy to forget what you hear in a doctor’s office, I encourage you to bring a family member or friend with you. Also, I supply information sheets for most retinal conditions and maintain an active blog site to help inform you about your condition.
Sometimes, the day does not go as planned. If an emergency patient is sent directly to see me for urgent care, I do fall behind. Nonetheless, I usually do not remain behind schedule for long because I allow extra time in my schedule for unforeseen delays in my schedule. Despite our best effort, first-time patients usually take extra time. Many forms are required by the government and the insurance company. An extensive history at the first visit is required to help identify the problem. Photographic testing can be time consuming. In complicated cases, we place a telephone call after the visit to communicate the results of exam and testing.
Regardless of how busy we are, I aim to treat you with courtesy and compassion. Wherever possible, I will minimize waiting. I am humbled and honored to have been awarded the “On-Time Doctor Award” by Vitals for 2018-2019. And I thank you for your patience on those days I am unable to meet my goal of “no wait.”
Cataract is the name given to the natural lens inside your eye when it becomes cloudy. When cataract interferes with vision, surgery is performed to remove the cloudy lens. In order to replace the focusing power of your natural lens, a synthetic lens implant is placed inside the eye at the time of cataract surgery.
What lens implant power options are available?
The patient may choose to have the power of the lens implant adjusted to focus the eye at various distances. The power calculations are not perfect and often glasses still must be worn by many patients. Most people choose to have the lens implant focused mainly for distance. Rarely, near-sighted patients prefer to keep the primary focus at near. Standard lens implants are fixed-focus lenses. That is, they do not focus at distance and near. For example, an eye with a standard lens implant focused for distance must use reading glasses for near work.
How can we decrease our dependence on glasses after cataract surgery?
In order to decrease the need for glasses, there are options to consider, each with advantages and disadvantages. Options include bifocal contact lenses, mono-vision lens implant correction, and multifocal lens implants.
Bifocal Contact lenses: This option may be good for patients who already use bifocal contact lenses. The contacts lenses help focus at near and may refine distance vision as needed.
Mono-vision Lens Implants: In this option one eye is focused mainly at distance and one eye is focused mainly for near. Not everyone can adapt to this situation and there is slight loss of depth perception with mono-vision correction. This option is best for those who already have adapted to mono-vision contact lenses.
Multifocal Lens Implants: This is a new option offered by premium lens implants that cost more for the patient. Basically, these implants offer improved range of focus for both distance and near. Many brands are available. The choice of lens depends on how much help with distance and near vision is desired. However, the greater the range of focus a given lens offers, the greater the side effects of the multifocal lens. Side effects include decreased contrast sensitivity and glare/halos from light especially at night. Loss of contrast sensitivity makes it more difficult to see gray print on white paper. Glare and halos bother some patients more than others.
A combination of strategies may be used. For example, a low-range-of-focus multifocal lensimplant (Symfony) may be used with mild mono-visionfocusing to minimize the downsides compared with each method when used alone.
Examples of multifocal lens implants include Symfony, Restor 2.5, and Restor 3.0. There are many others. Below is a chart to demonstrate the trade-offs among these lenses.
Lens Implant Styles: Benefits and Limitations
Style
Distance vision
Intermediate vision
Near vision
Need for reading glasses
Contrast sensitivity
Glare/Halos
Standard IOL (monofocal)
Excellent
Fair
Poor
Most of the time
Excellent
Rare
Symfony IOL
Very good
Good
Fair
Much of the time
Good
Mild
Restor 2.5 IOL
Fairly good
Good
Good
Some of the time
Poor
Moderate
Restor 3.0 IOL
Fairly good
Fair
Good
Rarely needed
Poor
> Moderate
If you have strong preferences, be sure to communicate with your doctor to be given the best lens implant for your situation. Keep in mind that the eye changes over time and the need for glasses may change over months to years after cataract surgery.
Pain is a symptom that often warns of serious problems. The nature of the pain may help to determine the origin of the pain and, sometimes, the cause. The following are types of pain and their causes:
Severe, sharp, jabbing pain in the eye: If persistent and associated with a sensation like sand in the eye, this pain often suggests a problem in the cornea. The cornea is the clear front window at the front of the eye. It is replete with very sensitive nerve endings that may be irritated by any disruption of the “skin” on the surface like a corneal abrasion. Treatment is important to relieve pain and prevent infection or scarring of the cornea as this may result in a loss of vision.
A very brief isolated episode of a jab in the eye: May be due to a benign blockage of an oil gland in the eyelid margin (blepharitis). It may also be a symptom of a type of migraine called an “ice pick” headache.
A burning, tingling pain over the forehead: May indicate the onset of shingles (Herpes Zoster). The pain often precedes the onset of a painful rash composed of small vesicles (blisters) on the forehead. It is important to start antiviral medication and evaluate the eye to determine if there is direct eye involvement.
Deep, boring pain: May be seen with sinus pathology alone and may be present in varying severity. However, this type of pain may also be due to problems in the brain such as aneurysm or brain tumor. This pain may also be caused by high pressure in the eye (acute glaucoma) or serious inflammation inside the eye (uveitis). Rarely, poor blood flow to the eye from the carotid artery may cause a deep pain around the eye; atherosclerosis or giant cell arteritis may be the cause.
Pain may be caused by dry eye syndrome. It is usually associated with dryness, burning, and foreign body syndrome.
This monograph does not cover all types or causes of eye pain. Any significant, persistent pain in the eye warrants evaluation. In many cases the more severe the pain, the more urgent the need for evaluation.
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.
Lumify is an eye drop to reduce redness of the eyes and is available without a prescription. It is a weaker concentration of a well-known eye drop used to treat glaucoma and it became available in 2018. Although Lumify works to reduce eye redness, It does not treat any underlying eye disease.
How does Lumify work?
Lumify works by constricting the tiny blood vessels on the surface of the eye so the white part of the eye looks whiter. Unlike older eye drops used to “get the red out,” Lumify does not tend to cause a rebound redness when it wears off.
How do you use Lumify?
Apply a drop of Lumify to each eye. The drop takes affect within an hour and lasts up to eight hours. It may be repeated as needed with little risk of rebound redness.
What are the precautions?
Lumify is not a treatment for eye disease. It is only used for the purpose of whitening the eyes. If there is an underlying ocular infection or inflammation, an examination by an ophthalmologist is essential. Symptoms that suggest the need for an eye examination include light sensitivity, pain, new floaters, discharge, matting of the eyelids, and/or loss of vision. Furthermore, if Lumify does not work well to whiten the eyes, there may be an underlying condition that needs to be diagnosed and treated.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
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Although medical and surgical treatments often help to restore vision or minimize loss of vision, many people lose vision permanently from various eye conditions. This information was compiled to inform you about what is available in the community to assist in overcoming some of the problems encountered with low vision. Keep in close contact with trusted friends and family members who can provide help. Remain as active as your health and vision with allow. Identify and treat depression with the help of your internist. You will not harm your eyes by trying to use them. You may sit close to the TV to see it better without risking damage to your eyes. When reading, good lighting is important (a gooseneck lamp may be helpful). To reduce glare when outdoors, consider wearing glasses tinted dark-yellow or amber.
Tax deductions on property tax and income tax are available to persons who are legally blind. Your eye doctor can supply you with proper documentation of legal blindness.
ADDITIONAL INFORMATION ON LOW VISION:
National Eye Health Educational Program
National Institutes of Health (English and Spanish)
www.nei.nih.gov
Association for Macular Diseases (1-212-605-3719)
www.macula.org
MD Support (information and video: Learning to live with low vision)
www.mdsupport.org
Self-Help Books:
Making Life More Livable, M. Duffy, NY: American Foundation for the Blind, 2001; 1-800-232-3044
Macular Degeneration: The Complete Guide to Saving and Maximizing Your Sight, L. Mogk, MD & M. Mogk, PhD, NY: Ballantine 2003; available in bookstores and www.amazon.com
Overcoming Macular Degeneration: A Guide to Seeing Beyond the Clouds, S. Soloman, MD and J. Soloman, NY: Avon 2000; available in bookstores and www.amazon.com
This list was compiled to help provide information on available services for the visually impaired. It does not represent an endorsement of listed businesses or services. Please verify phone numbers and addresses as they may have changed since this publication was printed.
According to the Amercian Academy of Ophthalmology 2017 guidelines, the dosage of Plaquenil should be adjusted for patient weight. Patients with lower weight may be at increased risk of retinal damage over time if treated with unadjusted dosing schedules. Other researchers emphasize the importance of dosing by height as well. The PDF document below may be downloaded and used as a reference guide. Please note that if a patient has kidney disease or liver disease the dose may need to be reduced by one half.
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.
Lid hygiene is the routine cleansing and care of the eyelids. It is especially important for people with skin problems such as seborrhea, rosacea, and acne. It is also important to improve comfort and vision in eye problems such as blepharitis and chalazion. Lid hygiene helps to remove oily secretions that build up and interfere with the tear film and also lead to bacterial overgrowth. The key to treating these problems is to routinely clean the eyelids with saline solution warm soaks. For additional comfort, take one flaxseed oil capsule by mouth twice a day.
How do I prepare the saline solution for the warm soaks?
Add 1/4th teaspoon of table salt to two cups (16 ounces) of warm tap water and mix thoroughly. Take care not to make the water so hot that it burns the eyelid as the skin is very thin in this area. Use sterile cotton balls soaked in the saline solution and slightly wrung. Place the moistened cotton ball on the closed eyelids until it cools. Replace with fresh warm cotton balls as needed for a total duration of ten minutes.
For a quicker method use a warm wet wash cloth at the sink. These soaks will dissolve secretions, help soothe burning eyes, and decrease the redness of the lids. It is often necessary to do the eye soaks several times a day for the first week and daily thereafter. A simple alternative to using saline solution is to use warm tap water and a wash cloth to soak the eyelids with or without baby shampoo.
A superior method to apply moist heat effectively to the eyelids is with the use of the Bruder mask.
Use a Q-tip moistened with warm salt water or diluted baby shampoo. Gently brush the lashes from the base to the lip of the lashes. The upper lashes can be easily cleaned with the eyelids closed. The lower lashes are more difficult and require extra care. Pull down the lower lid while cleaning these lashes to avoid touching the sensitive cornea (the clear window of the eye). The lashes should be cleansed twice a day for the first week and daily thereafter. Tea tree oil face wipes offer convenience and the added benefit of antibacterial qualities.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
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Glaucoma is a condition in which the pressure inside the eye damages the cells of the optic nerve. The optic nerve transmits information from the eye to the brain to provide vision. Glaucoma affects two million Americans and is the second leading cause of blindness in the United States.
What causes glaucoma?
There are many different types of glaucoma, but most types of glaucoma have in common an abnormally high pressure inside the eye. The pressure in the eye is not directly related to blood pressure. The normal range of pressure in the eye is between 8-21 units of measurement. There is a tissue inside the eye that pumps a clear fluid (aqueous) into the eye keeping the eye from collapsing. Another tissue called the trabecular meshwork normally drains the aqueous from the eye preventing the pressure from building up. In most types of glaucoma, the drain becomes clogged or blocked resulting in an increase of the pressure inside the eye. High pressure inside the eye damages the cells of the optic nerve. In an uncommon type of glaucoma (normal tension glaucoma), the pressure measurements are within the normal range, but the optic nerve is unusually sensitive and will become damaged if the pressure is not lowered even further.
Who is at risk for having glaucoma?
About two or three percent of Americans develop glaucoma. It may occur at any age, but usually occurs after the age of forty. It appears to be hereditary and, therefore, is more common in people who have family members with glaucoma. Diabetes increases the risk of glaucoma. African-Americans develop glaucoma fifteen times more frequently than European-Americans. Another risk factor for glaucoma is uveitis and trauma…especially, blunt injury to the eye. Steroid eyedrops and injections (triamcinolone and Ozurdex) may bring out glaucoma in eyes that are predisposed.
What are the symptoms of glaucoma?
The most common type of glaucoma is “open angle” glaucoma. In its early stages, glaucoma causes no obvious symptoms. However, driving vision can be impaired early on. Moreover, if it is not detected and treated early, glaucoma eventually may cause a gradual, severe, permanent loss of vision. Rarely, visual hallucinations may occur.
A less common type of glaucoma called “angle closure” glaucoma may cause sudden pain, redness, and blurred vision. It is more often seen in far-sighted eyes. In some cases, the tendency for an acute attack of glaucoma can be predicted on examination. In such cases laser treatment and/or cataract surgery may help to “open” the angle to prevent a future attack of angle closure glaucoma.
How is glaucoma diagnosed?
The most common test for glaucoma in an eye examination is tonometry. Tonometry measures the pressure inside the eye. Most people are first suspected to have glaucoma because high pressure is found on a routine exam. Another way to diagnose glaucoma is by examination of the optic nerve inside the eye. A nerve damaged by glaucoma has an abnormal appearance called “cupping,” which may provide a clue to the diagnosis. Additionally, a formal measurement of the peripheral vision (side vision) by a visual field test usually confirms the loss of vision that may not otherwise be noticeable. A visual field test is not part of a standard exam, but is performed if glaucoma is suspected. Repeated visual field tests help to determine whether treatment has been adequate to prevent loss of vision. Finally, sophisticated computerized tests (optical coherence tomography) are available to measure the thickness of optic nerve fibers to help in the diagnosis and assess the treatment of glaucoma.
What treatment is available?
Treatment of glaucoma is directed at lowering the pressure in the eye. The first line of treatment in most cases includes prescription eye drops. There are a number of very effective eye drops that work by either opening the drain or by slowing down the pump to lower the pressure. These drops are powerful medicines that should be used exactly as prescribed to prevent blindness from glaucoma and minimize side effects from the eye drops. Side effects are not common, but may include burning, itching, redness, dry mouth, and worsening of bronchitis or asthma. It is very important to take the eye drops exactly as prescribed to prevent blindness. If eye drops fail to control the pressure, laser surgery may help. Finally, surgery performed in the operating room (trabeculectomy) may create an artificial drain to lower the pressure. After trabeculectomy patients are warned to notify the doctor urgently if the eye becomes red or appears to be infected, because infection may enter the eye after trabeculectomy and result in severe damage or blindness. In general, patients with glaucoma may require regular examinations every three to four months to preserve vision.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
Cataract is a foggy lens inside the eye (click image to enlarge)
What is a cataract?
A cataract is a foggy lens inside the eye. The lens is positioned behind the iris to focus light that passes through the pupil (see drawing above). The lens inside the eye works like a lens in a camera. The normal lens is clear, but it may lose its clarity over time. When the lens loses its clarity, it causes hazy and cloudy vision, often with glare from on-coming lights. The distance vision is often affected more than the near vision.
What causes cataract?
Cataract is common with age. The older a person becomes, the more likely cataracts will form. Other causes include heredity (family history of cataract), inflammation, blunt injury to the eye, sun exposure, tobacco, high blood pressure, diabetes, and medications (such as corticosteroids (prednisone) and some anti-depressants known as SSRI inhibitors).
How is cataract treated?
The only treatment of cataract is surgery in the operating room, with or without the assistance of laser. There is no way to remove a cataract with vitamins, pills, or eye drops. However, a change in glasses may minimize the blurred vision caused by cataract in the early stages. There is no emergency to treat a cataract. It will not harm the eye to hold-off from having surgery except in extremely severe cases. At the time of cataract surgery, a lens implant will be placed inside the eye to improve the ability of the eye to focus.
When is surgery needed?
Surgery is needed when the haziness in the vision from cataract has become bad enough to require improvement in vision that cannot be achieved with glasses. This is a decision made by the patient with help from the doctor.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
Hemoglobin A1C is a blood test that measures the average blood sugar level in the blood over the past two or three months. Specifically, this test measures the amount of sugar that permanently attaches to hemoglobin, a protein in red blood cells. Because red blood cells live for about three months, this test shows the average blood sugar level during that time. This test gives some of the information that you could get if you measured your blood sugar every day continuously throughout the day and night.
Why is hemoglobin A1C important?
We know high blood sugar damages blood vessels and may cause blindness, kidney failure, nerve damage, amputation, heart attack, stroke, and premature death. Managing blood sugar dramatically reduces the risk of these complications. The hemoglobin A1C test helps to determine whether your blood sugar control has been adequate to minimize damage from diabetes.
Do I need both hemoglobin A1C and standard blood sugar testing?
Yes. Each test gives different information about blood sugar control. For example, your fasting blood sugar may be normal, but if your hemoglobin A1C is high, then you know there are times in the day that the blood sugars are too high and you are still at risk of having complications from diabetes. On the other hand, if your hemoglobin A1C is high, you need spot checks of the blood sugar level to know specifically what part of the day in which you may need to manage differently.
How do results from hemoglobin A1C compare with blood sugar levels?
The hemoglobin A1C test measures the percent of hemoglobin that is chemically bound to sugar. The normal range of hemoglobin A1C is 4-6%, which corresponds to an average blood sugar level of 60-120 mg/dl. Your doctor will help determine what level is best for you, but generally a hemoglobin A1C greater than 7% (average blood sugar equal to 140 mg/dl) means that measures must be taken to achieve better management.
The hemoglobin A1C test results may be inaccurate in certain conditions. The test results may be falsely low in the following situations: the use of dapsone, certain types of anemia, mechanical heart valves, recent blood transfusion, enlarged spleen, treatment with erythropoietin, severely elevated triglycerides, high-dose vitamin C or E.
Conversely, test results may be falsely elevated in the following situations: untreated hypothyroidism, after surgical removal of the spleen, Iron deficiency, vitamin B12 deficiency, reduced red blood cell production by the bone marrow, chronic alcoholism, chronic kidney disease.
If there is a question about the reliability of the test results, other means of testing may be considered, such as the fructosamine test.
Hemoglobin A1c
Blood Sugar
A1c
(mg/dL)
4%
60
5%
90
6%
120
7%
150
8%
180
9%
210
10%
240
11%
270
12%
300
13%
330
What can I do if my hemoglobin A1C results are high?
While it is important to keep blood sugar levels from being too high, it is also important not to risk frequent or severe episodes of dangerously low blood sugar levels. You and your doctor will evaluate your situation to determine which of the following factors may be playing a role:
Too little exercise
Inadequate medication type or dosing
Too much food
Wrong types of food
Increased stress
Infection
The hemoglobin A1C test provides you with more information to maintain good management of your diabetes. Better control means a longer, healthier life. And any positive change in your care, no matter how small, makes a difference. For example, each 1% decrease in the hemoglobin A1C reduces the risk of eye and kidney damage by 37% and reduces the risk of diabetes-related death by 21%. The more you are involved with your health care, the greater the likelihood of living a longer and healthier life.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
To the USF residents: I enjoyed meeting you for the lecture on infectious diseases. I hope this link to a movie version of the lecture is helpful to review the topics discussed on 12-19-13. Please give me feedback on how I may improve the presentation.
Doctor Scott E. Pautler has been named one of the Best Doctors in America® for 2014. The prestigious recognition marks the seventeenth time that Doctor Pautler has earned this honor.
The highly regarded Best Doctors in America® List, assembled by Best Doctors, Inc. and audited and certified by Gallup® results from exhaustive polling of over 45,000 physicians in the United States. In a confidential review, current physician listees answer the question, “If you or a loved one needed a doctor in your specialty, to whom would you refer?” Best Doctors, Inc. evaluates the review results, and verifies all additional information to meet detailed inclusion criteria.
Best Doctors has earned a sterling reputation for reliable, impartial results by remaining totally independent. Doctors cannot pay to be included in the Best Doctors database, nor are they paid to provide their input. The List is a product of validated peer review, in which doctors who excel in their specialties are selected by their peers in the profession.
Over the past 20 years, Best Doctors has earned global acclaim for its remarkable database of physicians, regarded as the world’s premier effort to create a validated, peer-reviewed database of excellence in medicine. The Best Doctors methodology is rigorously impartial and strictly independent; only those doctors recognized as the top 5% of their respective specialty earn the honor of being named one of the Best Doctors in America. The experts who are a part of the Best Doctors in America database provide the most advanced medical expertise and knowledge to patients with serious conditions – often saving lives in the process by finding the right diagnosis and right treatment.
About Best Doctors, Inc.:
Best Doctors works with the best five percent of doctors, ranked by impartial peer review, to help people get the right diagnosis and right treatment. The company’s innovative, peer-to-peer consultation service offers a convenient new way for physicians to collaborate with other physicians to ensure patients receive the best care. The global health solutions company, which has grown to over 30 million members worldwide, uses state-of-the-art technology capabilities to deliver improved health outcomes while reducing costs. Gallup® has audited and certified Best Doctors’ database of physicians, and its companion Best Doctors in America® List, as using the highest industry standards survey methodology and processes. Founded in 1989 by Harvard Medical School physicians, Best Doctors seamlessly integrates its trusted health services with Fortune 500 and Fortune 1000 employers, insurers and other groups in every major region of the world. The company also designs and implements international insurance programs that help people be sure they get the right health solutions.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
Tobacco use is widely known to cause lung damage, but the eyes are also affected. Bothersome irritation of the eyes is caused by smoke from tobacco especially in patients with dry eyes. However, permanent loss of vision may occur from such problems as macular degeneration, retinal vein occlusion, ocular histoplasmosis syndrome, glaucoma, cataract, Grave’s Disease (a thyroid condition that affects the eyes), uveitis (inflammation of the eye), ischemic optic neuropathy, and diabetic retinopathy. Tobacco appears to play a role in causing and/or worsening these conditions. Tobacco is known to promote hardening of the arteries, and this may harm blood flow to the eye. Tobacco also promotes the development of blood clots, which may block blood flow in the eye. Tissue damage also occurs from toxic compounds in tobacco that cause a chemical reaction called oxidation. More research is needed to fully understand the role of tobacco in causing loss of vision.
What resources are available to help stop tobacco use?
Because most people cannot stop tobacco “cold turkey,” many resources are available to help quit the habit. Counseling may provide much needed support in the process of stopping tobacco use. For free classes and one-month’s supply of nicotine replacement therapy, your doctor can refer you to the Area Health Education Center. Alternatively, you may call 1-877-848-6696. The class schedule may be viewed at www.ahectobacco.com/calendar. If you are interested in talking to informed support staff, please call 1-800-QUIT-NOW. Nicotine replacement therapy plays an important role and several preparations are available over-the-counter. These non-prescription forms of nicotine include gum, lozenges, and patches. Medicare and most insurance companies now cover the costs of prescription medications to help stop tobacco use. These include nicotine nasal sprays, nicotine inhalers, as well as pills (Zyban and Chantix). With the help of counseling, nicotine replacement, and prescription medication, you can live a longer and healthier life without tobacco. For more information please visit www.smokefree.gov.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
A sub-Tenon’s steroid injection (STS) is an office procedure performed to decrease inflammation, swelling, or leaky blood vessels inside the eye. The steroid medicine acts to decrease inflammation and leakage from blood vessels from a variety of causes, thereby offering the opportunity for improvement in vision. The effect of STS lasts for several months after which repeated injection may be considered if necessary.
How is a sub-Tenon’s steroid injection performed?
Anesthetic solutions are used to make the procedure pain-free. A pressure sensation is often felt as the steroid is injected next to the eye with a very thin, short needle. The procedure is brief.
Sub-Tenon’s Steroid Injection (click on image to enlarge)
Will the injection affect my vision?
The vision may be slightly blurred immediately after an injection. The anticipated improvement in vision occurs slowly over a period of weeks to months. Sometimes, the pressure inside the eye increases and may require eye drops for several months. There may also be an increased rate of cataract formation. It is common for the upper lid to droop slightly; this improves over several months. Rare risks of steroid injection include bleeding, infection, retinal detachment, glaucoma, and loss of vision. Please report any severe loss of vision to the doctor without delay.
How do I care for the eye after injection?
If a patch is placed on the eye, keep it on as directed by the doctor, usually 2-3 hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after STS. Tylenol or Ibuprofen may be used if there is discomfort after the injection, but severe pain should be reported to your doctor without delay. It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. If you have any questions or concerns, please call the office.
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.
