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.
Artistic illustration of migraine aura (click on image to enlarge)
What is migraine?
Migraine is a common cause of headache that affects 10% of the population. Migraine may also cause unusual visual symptoms that occur with or without a headache.
What causes migraine?
The cause of migraine is unknown, but heredity may play a role. Many people with migraines have family members who also have had migraine. Migraine may be caused by abnormal episodes of blood vessel constriction within the brain. A number of events may trigger a migraine (ref): emotional stress, hunger, lack of sleep, hormonal changes (puberty, menopause, and hormone pills), bright lights, loud noises, a change in altitude or weather conditions, exercise, and certain foods (including caffeine, chocolate, alcohol, and red wine). Sometimes eye problems can worsen or bring on migraine. Such problems include improper eyeglasses, eye dryness, double vision, past eye injury or eye surgery. There is evidence that links migraine with a defect in the wall of the upper chamber of the heart (patent foramen ovale). It has been theorized that small particles (e.g. platelet-thrombin emboli) may originate in the venous circulation and pass through the defect in the heart wall into the arterial circulation and on to the brain. This might explain small defects in the brain sometimes seen on MRI scans in patients with migraine.
What are the symptoms of a migraine?
Migraine is associated with a great number of symptoms. Hours or days before a migraine episode occurs, subtle symptoms may be noticed. These symptoms include depression, fluid retention, and stomach disturbances. Visual symptoms can occur before a headache or be the sole symptom of a migraine. These visual symptoms occur without warning when the vision is impaired just off to the side of central vision. A jagged light (“like cracked glass”), which appears to shimmer or repeatedly flash, borders the area of impaired vision. The jagged light causes a missing area of vision and gradually works away from the center to the peripheral vision, taking on a C shape over a period of 15 to 30 minutes. It sometimes is described as heat waves, bubbles, tunnel vision, or a kaleidoscope, and it may be silver and white or in color. Objects may appear too small or too big (This is called the Alice in Wonderland Syndrome). In middle-aged patients a brief loss of vision may occur in one eye resembling a stroke-like symptom. It usually involves both eyes but may appear more prominently in one eye. In younger patients, nausea and a throbbing headache often follow the light flashes. In older patients, the visual symptoms may occur without headaches. Keep in mind that there are many types and causes of flashing lights.
Migraine may also cause other symptoms that do not involve the eyes. Such symptoms include tingling of the face and hands, weakness, or trouble with speech. If this occurs, it may be helpful to call a neurologist for consultation.
The headache may be described as a deep, penetrating pain or a painful stretching sensation. The headache often begins on one side of the head, but it may spread over the entire head. It may be throbbing nor non-throbbing.
Simulation of migraine aura (click on image to enlarge)
What treatment is available?
Making the correct diagnosis is the most important step. Light flashes may be caused by other problems such as retinal detachment. Therefore the eye doctor is often called on to make this important distinction. If migraine symptoms occur infrequently, no treatment is needed. Establishing regular sleep, a healthful diet, and regular exercise programs may help. Riboflavin and magnesium supplements may be of benefit as well. Prescription medication is available if headaches are severe or frequent. They are usually prescribed by a neurologist.
If there is any significant change in symptoms or if permanent loss of function occurs, please contact your doctor without delay. In rare instances, a brain aneurysm or tumor may cause unusual light flashes and headache. Your doctor will decide whether further examination or testing is required.
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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Why is it necessary to find a good retinal doctor?
Finding a good retinal doctor is important to receive the best level of care. Your doctor should be up-to-date on the latest treatments and be able to choose from among the many choices of treatment to determine which is the best for you as an individual. Some doctors may not keep up with new treatment options and, therefore, may not offer these choices to you as a patient. Moreover, some treatments work better for some patients, but do not work well for others. You must rely on your retinal specialist to offer the best treatment for you. To do so, your doctor must get to know your eyes and you as a person in order to choose what is best for you. The retinal specialist must then review the options and explain why he/she has chosen your treatment plan. All treatments have benefits, risks, and limitations. All of this information must be explained to you. It is helpful if the doctor gives you written information to take home to review after the visit.
How do you go about finding a good retina doctor?
This task is not easy or as obvious as it may seem. At a minimum, your retina doctor should be a medical doctor (MD or DO) and completed a residency in ophthalmology and should be board-certified by the American Board of Ophthalmology. You can find out online if your doctor is certified. Board certification is essential, but it is only the first step in finding your retina doctor.
Be aware that some ophthalmologists call themselves retina specialists, but they have not completed a retina fellowship program. A retina fellowship is a one or two-year program of highly specialized training, which is undertaken after a general ophthalmology residency program. You may ask your doctor if he/she completed a fellowship in retinal disease and for how long (one or two years). Some information is available to you at the web site of the American Society of Retinal Specialists. You may prefer a doctor who has been trained at a highly reputable university. One source of information is Castle Connolly.
A number of additional factors may be important in the decision to choose the best retina doctor for you:
Does your doctor do research? This issue has a good side and a possible bad side. In general, research may help a doctor to stay up-to-date on diagnosis and treatment. On the other hand, intensive research may draw the doctor’s attention away from information that does not pertain to his/her research interest. In this scenario, the doctor may become an expert in a small area of research and fall behind in the general knowledge of patient care that is important to your care. Simply put, you may prefer a doctor whose primary interest is patient care, not scientific research. Having said that, there are superb retina doctors who excel at both research and patient care. When interviewing a retinal specialist, try to gain a sense as to whether the doctor is more interested in you and your eye problem or his/her research.
Who referred you to the retinal specialist? Although this may not be an important issue, it is something to consider. In years past, doctors referred their patients to other doctors primarily on the basis of their knowledge about who provided the best care. There was no incentive to refer to anyone but the best for their patients. Due in large part to considerable financial duress imposed by government regulation and the insurance industry, general eye doctors have found the need to reap financial gains by hiring retina doctors to work for them. In this setting, the referring doctor may choose a retina doctor who works in the same clinic (or a separate building owned by the same clinic) because he/she makes money from doing so. The clinic retinal doctor may well not be the best doctor available in the area for your care. When in doubt, get a second opinion outside the clinic.
Are you comfortable with your retina doctor? This is a simple, but exceedingly important question to ask yourself. If you do not feel comfortable with your doctor, you may not follow through with instructions properly. You may not ask questions and gain an understanding of your problem. Never hesitate to seek a second opinion. A good doctor is not threatened by second opinions. In fact, good doctors often offer second opinions to their patients who appear uncertain or distressed.
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.
