Scott E. Pautler, M.D. Tampa

Treatment of diseases of the retina and vitreous

Visual Snow Syndrome

Posted on August 14, 2022 by Scott Pautler

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

What is visual snow?

Visual snow is the name for a visual symptom that looks like static on a television not tuned to a station. It has also been likened to pixelation on a computer screen. Many tiny flickering lights are usually seen in both eyes at the same time and encompasses the entire visual field. In some instances, it is worse in bright illumination like a bright sunny day.

What is the difference between primary and secondary visual snow syndrome?

Visual snow may be seen in patients without an underlying disease. In these cases it appears to be caused by hyperexcitability of the visual cortex of the brain. This is often called primary visual snow syndrome (VSS). Primary VSS is a diagnosis of exclusion. That is, other diagnoses must be excluded before the diagnosis of primary VSS is made. Primary VSS is related to migraine; indeed, many people who report visual snow also have migraine visual symptoms with or without headache. Other related symptoms include palinopsia (visual persistence of an image after the eyes are closed or look away), floaters and spots (entopsia), difficulty seeing in dim light (nyctalopia), difficulty seeing in bright light (hemeralopia), and flashes of light (photopsia). Other associated symptoms include ringing in the ears (tinnitus) and dizziness that varies with head position (postural vertigo).

Visual snow may be a symptom of an underlying disease (secondary visual snow syndrome). In this situation, it is critical to identify the underlying cause and offer treatment where possible. Secondary visual snow may originate from the retina or the brain. A well-described retinal cause of visual snow is due to digoxin toxicity. It usually occurs in elderly people who take digoxin for heart problems. It indicates the need to stop taking digoxin or lower the dose. Failure to reduce the dose may result in severe complications, including death. Other rare causes of visual snow include eye disease, immune disease, infectious disease, psychiatric disease, prescription drugs, past use of hallucinogens, head trauma, brain tumor, seizure disorder, and brain degenerative disease.

What causes the primary visual snow syndrome?

The cause of primary VSS is not known. It is felt to be due to an error in central processing in the back of the brain (occipital lobe). Special brain scans show hypermetabolism in the lingual gyrus of the occipital lobe in the back of the brain.

How is primary visual snow syndrome diagnosed?

The diagnosis is made on the basis of typical symptoms after testing has ruled out an underlying disease of the eye or brain. MRI brain scan is often used to rule out tumor, multiple sclerosis, degeneration, and stroke. EEG may be used to rule out seizure disorder. A spinal tap may be needed to rule out idiopathic intracranial hypertension. Pattern reversal VEP usually demonstrates loss of habituation of the occipital lobe in the brain (indicative of hyperexcitability). A neurologist usually arranges for testing as needed. An ophthalmologist may be helpful in ruling out eye disease.

What can be done about these symptoms?

It is difficult to treat primary VSS. Medications such as lamotrigine and topirimate may be helpful in some patients. Tinted glasses or clip-on lenses may also be helpful to minimize the symptoms of visual snow. Placing a yellow or orange tinted cellophane sheet on top of reading material helps some. Riboflavin and magnesium supplements may be of benefit for migraine and visual snow, as well. For many patients it is helpful to know that primary VSS is a benign condition that does not progress to blindness.

By Scott E. Pautler, MD

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

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Black Spots After Eye Injection

Posted on August 6, 2022 by Scott Pautler

What are these circular spots in my vision after an eye injection?

Sometimes after an eye injection, a patient may see one or more black circular spots that move in the vision with head movement. They are usually in the lower part of the visual field, though they move up toward the center of the visual field if you position your head face down.

What causes these symptoms?

These black spots are due to air bubbles in the medicine that is injected into the eye. They appear immediately after injection. They are harmless and take 1-2 days to dissolve and disappear. Less commonly, small black circular spots may float in the vision after injection due to small silicone bubbles that are used to lubricate the syringe. These silicone bubbles do not dissolve, but they may float away from the retina and become less noticeable over time.

What should be done about these symptoms?

If the spots are due to air bubbles, these symptoms fade without treatment. If the spots are due to silicone bubbles, they may come and go over time. It is best not to track them with your eyes as they may become more bothersome. Try to look past these floaters and ignore them if possible. If they persistently interfere with the vision, vitrectomy surgery may be considered to remove them. This is rarely necessary.

What other symptoms can mimic this problem?

These black spots are considered a type of “floater.” Floaters are any visual spot in the vision that “floats” or moves somewhat independent of eye movement. Sometimes floaters may come on suddenly and appear like dots and fibers. This is typical for bleeding inside the eye. If dots and fiber-like floaters come on more slowly (hours to days), they may be a sign of infection or inflammation. Rarely, cancer may present as many tiny floating spots in the vision.

Floaters are distinct from blind spots (scotoma) that are fixed in the visual field and move only when the eye moves. You cannot “catch up” or move away from a blind spot by moving the eye. Blind spots are usually due to problems with the retina or optic nerve. A progressive blind spot that begins in the peripheral vision and enlarges over hours to days may be due to a retinal detachment and requires a prompt examination. Retinal detachment is often described as a curtain or shadow covering the vision.

By Scott E. Pautler, MD

Byooviz Therapy

Posted on July 30, 2022 by Scott Pautler

What is Byooviz?

Byooviz is a drug used to treat wet-type macular degeneration, wet-type myopic macular degeneration, and macular edema due to retinal vein occlusion. It involves repeated injections of medication into the eye to stop abnormal, leaky blood vessels. Byooviz is an FDA-approved biosimilar drug similar to Lucentis. Consequently, it costs less than Lucentis (About $1100 per injection of Byooviz compared with $1800 per injection with Lucentis). Unlike Lucentis, Byooviz is not approved for diabetic retinopathy.

What is the difference between biosimilar drugs and generic drugs?

While generic drugs are chemically identical with trade-name drugs, biosimilars are not identical to their reference drugs which they attempt to duplicate. Because biosimilar drugs are different chemically, they may behave differently in terms of effectiveness and side effects. They may not be as effective as their reference drug and they may have more side effects. For this reason, biosimilar drugs need to be monitored closely prior to approval by the FDA, as well as after approval by health care providers. Some adverse effects are not recognized until a drug has been used in thousands (if not more) of patients.

How effective is Byooviz therapy?

Byooviz was shown to be very effective and similar to Lucentis when given every 4wks up to 48 weeks for wet-type macular degeneration. Currently, therapy often starts with monthly injections until maximal vision is restored. Afterwards, the injections may be given less frequently to maintain stable vision. It is not known how Byooviz will perform in this setting.

What are the risks of Byooviz therapy?

Severe complications are very rare, but risks of Byooviz injection (like Lucentis) include bleeding, infection, retinal detachment, glaucoma, cataract, and loss of vision/loss of the eye. There appears to be a small increased risk (1%) of stroke with these types of medications. The risk of stroke may be related to the older age of patients in which it is used. Pregnancy should be avoided while on Byooviz therapy.

What do I expect after a Byooviz injection?

Be careful not to rub the eye after the injection because the eye may remain anesthetized for several hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after the injection. Tylenol or Ibuprofen may be used if there is discomfort, 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.

What does Dr Pautler think about Byooviz?

It is the opinion of the author that there are several concerns about Byooviz. First, the safety and effectiveness of Byooviz need to be determined on a large scale with many more patients than studied for FDA approval. This may take several years of use. Until then, I prefer Lucentis as it has a proven track record. Secondly, the cost of Byooviz appears too high. The cost of Byooviz is less than Lucentis, but not by much. A lower cost is more appropriate given the unknown risks and long-term effectiveness of Byooviz. If I have a patient whose insurance covers Lucentis, that is my choice over Byooviz at this time. If a patient has a Medicare Advantage insurance plan, I may be forced to use Byooviz.

By Scott E. Pautler, MD

What is the Best Drug for Eye Injections?

Posted on July 10, 2022 by Scott Pautler

Two common retinal causes of vision loss are wet age-related macular degeneration (wAMD) and diabetic macular edema (DME). In both of these conditions a signaling protein (called VEGF) is released that promotes blood vessel leakage with loss of vision. A major advance in treatment came about with the development of drugs that block the effect of VEGF. These drugs (called antiVEGF) reduce the risk of vision loss and offer some improvement in vision in patients with wAMD and DME. Unfortunately, these drugs need to be administered as an injection into the eye. Consequently, drug manufacturers work to design drugs offering the best vision with the longest interval between injections (fewer injections).

What drugs are available and how effective are they?

The first drug to reduce the rate of loss of vision in wAMD was Macugen (pegaptanib). It is no longer used because newer drugs are more effective in offering improvement in vision. While Lucentis (ranibizumab) was under development, its parent drug Avastin (bevacizumab) was found to be effective for wAMD. Both Avastin and Lucentis appear more effective than Macugen. Eylea (aflibercept) was developed to block the effect of VEGF and another factor (placental growth factor) involved in blood vessel leakage; consequently, there is moderate evidence that it is more effective than Avastin and Lucentis in DME and offers a longer treatment interval in wAMD. Newer drugs include Beovu (brolucizumab) and Vabysmo (faricimab). There is little evidence to know if they are more effective than Eylea. Finally, Eylea is now formulated in a higher concentration (Eylea HD).

What is the cost of these drugs?

All of the drugs used to treat wAMD and DME are expensive with the exception of Avastin. Avastin was manufactured and priced to treat colon cancer. After it was released, doctors at the Bascom Palmer Eye institute discovered it was effective in treating wAMD. Thus, the small dose needed to inject into the eye costs about $50. This is in contrast to the other drugs on the market, which cost around $2000 per injection.

What are the adverse effects of these drugs in the eye?

Problems may occur from the injection of medications into the eye. The injection itself has risks apart from the drug that is injected; we will not discuss those risks here, but they include pain, elevated eye pressure, hemorrhage, infection, retinal detachment, and loss of vision. The drugs themselves may cause inflammation in the eye. Usually, inflammation causes pain, redness, light sensitivity, floaters, and decreased vision. Typically, it can be treated with drops and it resolves without permanent damage. However, sometimes the inflammation can be severe with permanent loss of vision. Inflammation induced by drugs is very rare with Avastin and Lucentis. It occurs in about 1% of Eylea injections, 2% of Vabysmo injections, and 4-5% of Beovu injections. The inflammation with Beovu may be especially severe with permanent loss of vision. The risk of infection appears less in drugs that are pre-packaged in a syringe for injection (Lucentis and Eylea), and greater in drugs that must be prepared for injection (Avastin, Vabysmo, Eylea HD, and Beovu).

What are the adverse effects of these drugs outside the eye?

There is concern about effects of these drug outside the eye. All of these drugs leave the eye, enter the blood vessels and are removed from the body through the urine. On their way out of the body, there is concern that they may increase the risk of heart attack and/or stroke. There is considerable debate as to whether there is a measurable effect or not. Some have estimated that the systemic risk may be about 1%. However, patients with known risk factors (hardening of the arteries, tobacco use, high blood pressure, high cholesterol, overweight, and diabetes) may be more likely to suffer a heart attack or stroke with the use of antiVEGF drugs. In one study, patients with diabetic macular edema were at 17% (range: 2-33%) higher risk of death when undergoing frequent injections up to 2 years. Another study, demonstrated increased risk of stroke or heart attack in diabetic patients with a history of past stroke or heart attacks. Therefore, this group of patients may benefit from careful drug selection. Of all the drugs, Lucentis is cleared the most rapidly from the body and has the least systemic effects.

Want a summary of the cost, effectiveness, and safety?

Summary:

AntiVEGF drug	Cost	Effectiveness	Safety
Avastin	Cheap: ~$50	Good	Repackaging*
Lucentis	Expensive: ~$2,000	Good	safest systemically**
Eylea	Expensive: ~$2,000	Better	1% inflammation
Eylea HD	Expensive: ~$2000	?Better	1% inflammation or greater?
Vabysmo	Expensive: ~$2,000	?Better	2% inflammation
Beovu	Expensive: ~$2,000	?Better	4-5% inflammation

A list of drugs available in the US approved for injection into the eye

* Repackaging increases risk of infection, floaters, and discomfort for dull needles

** Especially relevant when repeated injections are required in diabetic patients

What is my professional preference?

I have employed all of these drugs for my patients. When cost is an issue, an insurance company may insist on the use of Avastin. I generally prefer Lucentis in my diabetic patients for its superior systemic safety. Eylea can be helpful to extend treatment intervals (longer time between injections) in wet macular degeneration. Eylea may also be safer in patients who also have glaucoma, or at risk of developing glaucoma. I have been favorably impressed with Vabysmo in extending treatment intervals even further in wAMD, but I am less impressed with any advantage in my patients with DME (diabetic macular edema). I am currently exploring the role of Eylea HD, especially to extend the treatment interval in patients with wet AMD. Due to the risk of inflammation with loss of vision from Beovu, it is not my preferred agent. Lucentis biosimilars (Cimerli and Byooviz) are not my preferred agents at this time…I am awaiting further evidence on their safety and effectiveness.

Are doctors paid by drug companies to use their drugs?

There are varying amounts of profit margins and rebates given to doctors by drug companies in an effort to promote the use of their drugs. Usually, the newer the drug, the greater the inducement. To determine if your doctor is receiving large payments by drug companies, visit the CMS website and enter your doctor’s name in the search box.

By Scott E Pautler, MD

Medicare Advantage: a Medical Disadvantage

Posted on May 31, 2022 by Scott Pautler

What is Medicare Advantage?

Medicare Advantage is an insurance plan available through Medicare Part B. Medicare Part B is the insurance that covers the cost of physician services. The traditional Medicare Part B insurance covers 80% of the physician’s fee after an annual deductible has been met. Medicare Advantage is a program designed to cut costs of medical care. It covers a greater part of the physician’s fee and also covers some accessory services such as eye glasses. However, it restricts access to some services compared with the traditional Medicare Part B insurance.

Why might someone choose Medicare Advantage?

The main reason for choosing Medicare Advantage is to reduce the out-of-pocket costs of health care. The benefits are obvious. However, the costs in terms of limited access to treatment must be carefully considered.

What are the limitations of Medicare Advantage?

Medicare Advantage attempts to reduce the cost of medical care. They do this by limiting access to expensive treatments. For example, they require that physicians use the least expensive drug (called Avastin) for retinal disorders such as diabetic retinopathy, macular degeneration and retinal vein occlusion. Avastin must be compounded by a pharmacy after it has been manufactured because it is not FDA-approved for use in the eye. Therefore, there are increased risks including infection and floaters from silicone oil droplets. Other, more expensive drugs (called Lucentis) reduce the risk of stroke and heart attack after injection into the eye, especially in people who require repeated injections (such as in diabetic retinopathy).

Patients who are on the traditional Medicare Part B plan currently have access to the newest drug for macular degeneration and diabetic retinopathy, called Vabysmo. As of the time of this article, Medicare Advantage plans do not allow doctors to use this drug even though it offers the potential for fewer injections compared with other drugs such as Avastin. As with most things in life, you get what you pay for. If you opt to save money by signing up for Medicare Advantage, you can expect less in terms of medical care. Medicare Advantage plans may turn out to put you at a disadvantage.

By Scott E. Pautler, MD

Tea Tree Oil for the Eyelid

Posted on August 29, 2021 by Scott Pautler

What is tea tree oil and how is it helpful?

Tea tree oil is an essential oil extracted from the leaves of the Australian tea tree, Melaleuca alternifolia. Tea tree oil has important anti-inflammatory and anti-microbial properties. It is effective against many different micro-organisms that can infect the eye (see reference).

How does tea tree oil improve the health of the eyelid?

Tea tree oil appears to help prevent the overgrowth of germs on the eyelid, which leads to blepharitis. Blepharitis is a common eyelid condition that causes symptoms of redness, irritation, itching, burning, and dry-eye symptoms. There are many ways to treat blepharitis and tea tree oil is becoming an important tool to reduce inflammation and infection by bacteria, fungi, and mites.

What evidence is there that tea tree oil works?
Tea tree oil has been studied in the treatment of blepharitis with very positive reports. However, high-level scientific evidence is lacking (see reference). I suspect the reason for this lack of evidence is the high cost of the studies rather than the effectiveness of tea tree oil. It takes large sums of money to complete the scientific trials required by the FDA and there is no corporate financial incentive to fund a large, randomized trial. In the meantime, low-cost tea tree oil is available for use without a prescription.

What preparations are available?

Tea tree is available as moist lid wipes, drops, and cleansing washes (see tables below). Follow the directions on each formulation. To keep the tea tree oil fresh, effective, and safe, store it in a cool, dark place (drawer or cupboard) with the lid securely attached.

What side-effects may occur?

Sometimes, a sensitivity reaction may occur with tea tree oil. Stop using tea tree oil, if your skin or eyes develop pain, redness, and/or itching. See an ophthalmologist as soon as possible for evaluation. Sensitivity reactions may occur more commonly with older, out-of-date tea tree oil, as well as with products with higher-concentrations of tea tree oil.

What brands are available?

The tables below serve as a reference list primarily for cost comparison. The various products have not been compared in a clinical study. Some contain ingredients in addition to tree tea oil. Review the product information, especially if you have known sensitivities. If you wear lash extensions, the oil in some of these products (including tea tree oil itself) may loosen the attachment of the extensions. Lash extensions are not recommended for patients with significant blepharitis.

Tea Tree Oil Products for Blepharitis
(Listed in order of least to most expensive per unit application)
Names of Lid Wipes	concen- tration	price as of (4-2021)	price/wipe	application
Dr Fischer Eyelid Wipes	unknown	$15.95	$ 0.53	wipes
Premium Eyelid Wipes	unknown	$22.95	$ 0.77	wipes
MediViz Eyelid Wipes	unknown	$24.97	$ 0.83	wipes
Optase Lid Wipes	unknown	$18.95	$ 0.95	wipes
Cliradex Eyelid Wipes	unknown	$39.42	$ 1.64	wipes

Names of Cleansers	concentration	price (4-2021)	price/ounce	application
Gentle Formula cleanser	1%	$ 15.00	$ 8.88	pump spray
Ocusoft Demodex cleanser	unknown	$ 18.17	$ 10.75	foam wash
Eye Eco Adv Formula	2%	$ 20.00	$ 11.83	pump spray
Heyedrate Foaming wash	<1%	$ 19.97	$ 11.95	foam wash
Cliradex Foam	unknown	$ 29.99	$ 19.99	foam cleanser
We Love Eyes	unknown	$ 24.00	$ 24.00	drops for Qtip

Check current prices via the links provided. This blog is supported by its readers and may earn commissions which do not increase the price to you and do not affect the content of this review article.

By Scott E. Pautler, MD

Sickle Cell and the Eyes

Posted on June 6, 2021 by Scott Pautler

What is Sickle Cell Disease?

Sickle cell disease is the most common genetic disease, affecting about 400,000 newborns each year. It is caused by a mutation in the gene that codes for the hemoglobin protein that carries oxygen in the blood stream. Sickle hemoglobin tends to clump into a sickle shape when it gives up its oxygen molecule to the tissues it supplies. When this occurs, the red blood cells lose their flexibility and tend to block the small blood vessels in the body. The retina in your eye is like the film inside a camera. The retina “takes the picture” of objects you look at and sends the message to the brain. The retina is a living tissue, which requires blood supplied by tiny vessels. These blood vessels may be damaged in people with sickle cell disease.

Who is at risk of eye problems in sickle cell disease?

Although more extensive blockage of retinal blood vessels occurs in sickle cell disease, more severe complications (bleeding and retinal detachment) occur in people with a combination of sickle hemoglobin and hemoglobin C (called Hemoglobin SC disease). Some studies suggest men are more likely than women to have loss of vision.

What are the visual symptoms of sickle cell disease?

Blurring of vision may occur if excess damage occurs to the retinal blood vessels. Floaters can look like tiny dots or cobwebs moving about in your vision. They may be due to bleeding from the retina into the central gel of the eye. Retinal detachment may cause a dark shadow to appear off to the side (in the peripheral visual field) and may progress to total loss of vision. Pain is rare and may be due to high pressure in the eye (neovascular glaucoma).

What treatment is available?

There is no cure, but treatment may improve vision or keep the vision from worsening. If bleeding occurs inside the eye due to blocked blood vessels, floaters are seen by the patient. Medicine injections may help recover vision and may be applied without pain in most cases. Laser may stabilize or improve the vision. In some situations, surgery is required. The vision may not return to normal following treatment as there may be some permanent damage to the retina. The earlier retinal problems are found, the better the outcome of treatment. Therefore, annual exams are important and it is critical to report new floaters without delay.

By Scott E Pautler, MD

Giant Cell Arteritis and the Eyes

Posted on May 14, 2021 by Scott Pautler

What is giant cell arteritis (GCA)?

Giant cell arteritis (also called cranial arteritis or temporal arteritis) is an inflammatory condition affecting medium to larger arteries in people over the age of 50 years. GCA may cause headache, neck stiffness, tenderness of the temple, and/or cramping of the tongue or jaw while eating or talking. It may also cause fever, fatigue, weight loss, depression, night sweats and general feeling of illness or feeling unwell.

What causes giant cell arteritis (GCA)?

The cause of GCA is not very well understood. The inflammation from GCA is not due to infection. In GCA, it appears the body’s immune system attacks itself, in some ways similar to rheumatoid arthritis.

How is giant cell arteritis (GCA) diagnosed?

The diagnosis is first suspected by typical symptoms in an older patient. Blood tests may include complete blood count (CBC), sedimentation rate (ESR), and C-reactive protein (CRP). Biopsy of the temporal artery is necessary in most cases to confirm to diagnosis. Firmly establishing the diagnosis is critical, because treatment needs to be started quickly and continued for a long time in GCA.

How does giant cell arteritis (GCA) affect the eyes?

Giant cell arteritis (GCA) causes loss of vision due to retinal artery occlusion or ischemic optic neuropathy. Early diagnosis is critical to begin treatment and limit the damage from blood vessel inflammation, which includes complications of brain stroke.

How is giant cell arteritis (GCA) treated?

Prompt steroid treatment is important to stop inflammation from causing further damage with loss of vision and brain stroke. Prednisone is continued at a low dose for a year or more to prevent the inflammation from returning. In an effort to avoid or manage side-effects of steroids, methotrexate is sometimes used. Tocilizumab was approved in 2017 for use in GCA. It avoids the use of steroids, but is very expensive.

By Scott E Pautler, MD

Inflammatory Bowel Disease and Your Eyes

Posted on April 23, 2021 by Scott Pautler

Eye — Anatomy of the eye (click on image to enlarge)

What is inflammatory bowel disease?

Inflammatory bowel disease includes conditions such as ulcerative colitis and Crohn’s disease. They are inflammatory conditions not caused by infection. Instead, the immune system appears to mistakenly attack the bowel. The same immune cells may also attack the eye in these bowel conditions. Ocular inflammation is called uveitis. And the most common type of uveitis caused by inflammatory bowel disease, 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 (see anatomy of the eye). 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.

What are other causes of 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 and sarcoidosis 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?

Treatment of the underlying inflammatory bowel disease will also help treat the uveitis. Separately, it is important to find any other 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. Also, vitamin D supplements may be helpful.

By Scott E. Pautler, MD

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Anatomy of the Eye

Posted on April 9, 2021 by Scott Pautler

Anatomy of the human eye. Image courtesy of Caitlin Albritton.

The eye is a specialized organ to provide sight. The various parts of the eye work to assist in this process. There are two eyes per human (many more if you are a spider or a scallop). The paired human eyes allow for improved depth perception. It takes two eyes for a human to best determine how far an object lies in front of him or her. Each eye has a slightly different view and the difference between the two images is used by the brain to make a three-dimensional (3-D) image. Test: you can see the difference in depth perception by trying to thread a needle or perform a similar fine task with one eye compared with two eyes. If the two eyes are not lined up straight, a person sees two images (double vision).

Shape of the eye

The shape of the eye is fairly round like a ball. This design helps the eye determine what direction light is coming from (see video: evolution of the eye). In near-sighted eyes, the eye becomes somewhat elongated (like an egg). This appears to be due to an adaptive response of the eye to aid in focusing at near. However, the elongation of the eye causes the tissues to stretch and this predisposes the eye to retinal detachment.

The Tear Film

This is an often-overlooked part of the eye. The tears form a smooth surface over the front of the cornea and help avoid scattering of light as it enters the eye. The tear film also provides nutrition, protection (antibacterial), and cleansing of the surface of the eye. The tear film is composed of three parts/layers: the aqueous (water), mucin, and lipid layers. The aqueous component is produced by lacrimal glands that rest in the eye socket behind a bone under the eye brow. The mucin layer is produced by specialized cells (goblet cells) in the conjunctiva. The mucin mixes with the aqueous layer and adds structure to the tears helping them to remain on the eye surface. The lipid layer (outer surface) produced by meibomian glands along the edge of the eye lids. The lipid helps protect against evaporation of the tears from the surface of the eye. Various conditions and diseases interfere with one or more layers of the tear film leading to d ry eyes and reduced vision.

The Conjunctiva

The conjunctiva (not labelled on image) is a smooth moveable outer “skin” overlying the white sclera (see below). The conjunctiva acts as a physical barrier against entry of infectious organisms, and contains many blood vessels which dilate and become inflamed if infection or foreign objects threaten to damage the eye. The smooth surface of the conjunctiva and loose attachment to the underlying sclera helps the eye turn smoothly.

The Sclera

The sclera is the tough outer coat of the eye. It provides structural support and protection of the sensitive tissues (like the retina) inside the eye. The sclera does allow for the outflow of water that is produced by the ciliary body. It also allows medications to pass into the eye. Nerves and blood vessels penetrate the sclera to reach the inside of the eye.

The Cornea

The cornea is the clear window at the front of the eyeball that allows light to enter the eye. It is continuous with the sclera. Most of the focusing of light happens at the corneal surface/tear film. As this outer layer of the eye is so critical for sight, there are many nerve endings in the cornea making it the most sensitive part of the eye to touch. The outer-most layer is the epithelium: a smooth surface to transmit light with tightly layered cells difficult for infections to penetrate. The epithelium acts as a barrier to keep the water-filled tears from entering the cornea as this would make the cornea lose its clarity. The middle layer of the cornea is called the stroma. It occupies most of the cornea with orderly layers of protein fibers to transmit light and minimize scattering. There is very little water in the stroma because the inner-most layer of the cornea (the endothelium) pumps out water from the cornea into the eye. When the cornea becomes hazy or opaque, a corneal transplant may be performed.

The Iris and Pupil

The iris is responsible for the color of the eye as seen from the outside. A circular opening in the iris is called the pupil, which is seen as a black spot in the center of the iris. Iris muscles expand and contract to change the size of the pupil and alters the amount of light entering the eye. In bright light, the pupil constricts so as to prevent too much light from entering the eye. There is no specific function of iris color and iridology is not a true science. However, lighter-colored irises (irides) may not block as much light as dark irides. From a medical perspective, eyes with lighter color eyes may be at higher risk of developing macular degeneration. Darker eyes are seen among people who evolved nearer the equator. In birds, iris color appears to play a role in the mating ritual.

The lens

The lens inside the eye is made of specialized crystalline protein fibers that help to focus light and allow for flexibility of the lens in order to focus light from different distances from the eye. With age the eye loses its ability to focus light; therefore, reading glasses are needed by most people around the age of 40 years. When the clear lens turns foggy, the lens is called a cataract. Surgery may be performed to remove a cataract and replace it with a clear plastic lens implant.

The ciliary body (SILL-ee-air-ee)

The ciliary body has two functions inside the eye. It contains muscles to focus the lens (the ciliary muscles are attached to the lens by fine fibers called zonules). The ciliary body also has a pump that produces aqueous (water). The aqueous pump works to keep the eye inflated. The aqueous also provides nutrition to the structures inside the eye. There is a constant flow of aqueous into the eye via the ciliary body and out of the eye through the sclera (i.e. the trabeculum). If the trabecular drain becomes blocked, the pressure in the eye goes up and damage may occur to the optic nerve. This condition is called glaucoma.

The Vitreous

The vitreous is a clear gel that fills most of the eye. There are no blood vessels and very few cells in the vitreous. The clarity of the vitreous is important in order to allow light to pass from the lens to reach the retina. The vitreous is mainly composed of water, but there are fine protein fibers and a gel (hyaluronin) providing a unique structure. If the eye becomes cut from an accidental trauma, the vitreous gel may plug the hole in the sclera keeping the eye from deflating. The vitreous also appears to protect the lens; there are anti-oxidants in the vitreous gel that help keep the lens clear.

With age, the vitreous loses its gel-like quality and the protein fibers begin to clump together. When this happens, fiber-like floaters may appear in the vision. These floaters occur earlier in life in near-sighted eyes and in eyes following inflammation or trauma. Occasionally, the vitreous fibers will pull on the retina causing brief, streak-like flashes of light in the vision. The pulling may cause a retinal break (retinal tear), which may lead to retinal detachment. In other situations, the vitreous fibers may pull on the macula resulting in distortion of vision from vitreo-macular traction syndrome, epiretinal membrane, or macular hole.

The Retina

The retina is a light-sensitive layer of nerve tissue that lines the inside of the eye wall. It acts like the film in a camera. The central portion of the retina is called the macula. The macula is designed for central vision. When you read or see fine details, you move your eye so that light focuses on the macula. The rest of the retina is used for peripheral vision (side-vision). The peripheral vision is essential for walking around a room without bumping into things. The peripheral retina is also sensitive to detect movement in the environment. The blood supply to the inner retinal layers (ten layers in all) comes from retinal blood vessels that enter and exit the eye through the optic nerve. The outer retinal layers are supplies by blood vessels in the choroid (see below). Blockage of the blood supply (retinal artery occlusion or retinal vein occlusion) causes a blind spot in the vision or blurred vision. If the retina becomes detached from the eye wall, it does not function well, and surgery is required to recover vision. Aging may result in macular degeneration.

The Choroid

The choroid is a layer of tissue under the retina filled with blood vessels. This important blood vessel layer provides oxygen and nutrition to the retina. It also evacuates waste materials from the outer retina and acts as a heat sump, keeping the retina from overheating. The choroid may be affected by a number of problems including inflammation, blood vessel blockage, and central serous retinopathy.

The Optic Nerve

The optic nerve connects the nerve tissue of the retina to the nerve tissue in the brain, like wire in an electric circuit. The optic nerve is sensitive to the pressure inside the eye. High intra-ocular pressure may cause loss of vision or blindness from glaucoma. The optic nerve may also be affected by blocked blood flow, inflammation, and pressure from outside the eye (tumors and aneurysms).

By Scott E. Pautler, MD

Lumega-Z: Worth the cost?

Posted on April 11, 2020 by Scott Pautler

What is Lumega-Z?

Lumega-Z is a vitamin/mineral/antioxidant supplement that is taken by mouth and is labelled a medical food. A medical food is simply a name used to identify a product that is taken by mouth and produced by a company for the purpose of treating disease and/or improving health. By definition, medical food must be prescribed by a physician and not sold over-the-counter. Lumega-Z is presumed to improve retinal health and potentially prevent or treat macular degeneration.

What does Lumega-Z do?

Lumega-Z aims to increase the amount of protective pigment in the macula with the hope that it will be helpful in the management of macular degeneration. Guardion is the company that makes Lumega-Z. They state in their website: “The Company’s current focus is on the Macular Protective Pigment (“MPP”), a bio-marker and major risk factor for developing Age-Related Macular Degeneration (“AMD”) and other retinal disorders.”

I take issue with this statement. “Macular Protective Pigment” has not been shown to be a major risk factor for AMD. Furthermore, the company cites no clinical research (even in their website for ophthalmologists) to support their claim that clinical benefit is derived from using their product.

Perhaps, we may assume there is benefit from Lumega-Z as another nutritional supplement (PreserVision AREDS-2) has been shown to reduce the risk of progression of macular degeneration. However, there are no current studies to compare the effectiveness of Lugema-Z with PreserVision AREDS-2. Alas, the company itself concludes: “Guardion Health Sciences, the maker of Lumega-Z, cannot guarantee…any vision benefit with treatment.”

What about the company that makes Lumega-Z?

Gardion’s business plan is provide medical food (a label that means their product is for medical use and must be provided via prescription) to patients with ophthalmologists who partner with Guardion (and may derive financial benefit). Gardion’s spokesman, Dr Hovenesian, is a refractive and cataract surgeon from California. His on their medical board of directors and a shareholder. He is not a retina specialist.

Is Lumega-Z worth the cost?

Lumega-Z costs twice as much as Preservision AREDS-2. However, it has not been scientifically demonstrated to be twice as good as PreserVision AREDS-2. Indeed, it has not even been shown to be equivalent to PreserVision AREDS-2. At the time of this publication, I am of the opinion that Lumega-Z is not worth the cost. I currently recommend PreserVision AREDS-2 to patients with AMD at risk for loss of vision as determined by examination.

By Scott E. Pautler, MD

Eye Care by Internet & Phone

Posted on March 25, 2020 by Scott Pautler

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

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.

Pain After Eye Injections

Posted on February 14, 2020 by Scott Pautler

Why are eye injections given?

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.

Check the current price of Systane Gel on Amazon.

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.

Check the current price of Lacri-Lube on Amazon.

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.

By Scott E. Pautler, MD

Please note: As an Amazon Associate I may earn from qualifying purchases. You pay no additional fees by accessing the link. These funds help defray the costs of maintaining this website. Thank you for supporting this blog.

On-Time Doctor Award

Posted on October 31, 2018 by Scott Pautler

On-Time Award

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.”

With sincerest regards,

Scott E. Pautler, MD, FACS

On-Time Award

Infectious Endophthalmitis

Posted on April 29, 2018 by Scott Pautler

What is endophthalmitis?

Endophthalmitis (“end-off-thal-my-tis”) is a severe inflammation inside the eye. The inflammation may be due to an infection or it may be “sterile.” Endophthalmitis threatens profound loss of vision and possible loss of the eye. Bacterial endophthalmitis usually requires urgent treatment to save the eye.

What causes endophthalmitis?

Endophthalmitis may be caused by an auto-immune reaction (the body attacks itself), it may be due to a foreign substance introduced into the eye in an accident or surgery, or it may be due to an infection. Here we will discuss endophthalmitis due to infection.

Infections may be caused by a number of viruses, fungi, parasites, and bacteria. Infectious endophthalmitis is classified as endogenous and exogenous. Endogenous endophthalmitis occurs when an infection enters the eye from inside the body, usually through the blood stream. Exogenous endophthalmitis occurs when an infection enters the eye from outside the body, usually from an opening into the eye from trauma, surgery, or intraocular injections.

Although the risk of endophthalmitis is low for a single surgery, the risk increases over time with multiple Intraocular injections. For example, after 5-6 years of injections for macular degeneration, the risk rises to about one in 200.

How is infectious endophthalmitis diagnosed?

Infectious endophthalmitis is suspected when severe inflammation is found inside the eye on an exam. It is usually accompanied by pain and loss of vision. Diagnosis is confirmed with a culture of the fluid inside the eye taken in the office or the operating room.

How is infectious endophthalmitis treated?

Infectious endophthalmitis is treated with antibiotic injections into the eye performed in the office or in the operating room. In severe cases, vitrectomy surgery is needed to remove some of the infected material. Vitrectomy is performed in the hospital operating room as a major eye surgery involving small incisions into the eye. Eye drops (steroid and non-steroid) are used frequently to help treat infection and to decrease the inflammation that can damage the eye. Sometimes additional steroid medications are used. The recovery of vision is very slow, taking weeks to months. If permanent damage occurs as a result of endophthalmitis, little or no recovery of vision may be possible. Frequent visits to the doctor are necessary at first to give the best results.

If you have questions, please do not hesitate to ask your doctor. Please visit www.retinavitreous.com

By Scott E. Pautler, MD

Whiter Eyes with Lumify

Posted on January 28, 2018 by Scott Pautler

What is Lumify?

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.

Click here for an updated price of Lumify on Amazon.

By Scott E. Pautler, MD

Note: As an Amazon Associate I earn a small commission from qualifying purchases. You pay no additional fees by accessing the link. These funds help defray the costs of maintaining this website. Thank you.

Ocular Shingles (Shingles affecting the eye)

Posted on July 14, 2017 by Scott Pautler

What is ocular shingles?

Ocular shingles (herpes zoster ophthalmicus) is an inflammation of the eye and surrounding skin caused by an infection of a virus in the Herpes group called the Varicella Zoster virus (the Chicken Pox virus). The name, shingles, comes from a Latin word meaning belt or girdle, as shingles usually presents as a rash along the path of a nerve in a band-like pattern.

What causes shingles?

Shingles is caused by the Chicken Pox virus that reactivates after years of “hibernation” in the nerve cells. When you contract Chicken Pox, the virus takes refuge inside nerve cells and remains there for life after the rash goes away. This is a common behavior of all viruses in the Herpes group. Years later, when the immune system “forgets” the virus, it re-emerges as shingles.

Why is shingles becoming more common?

Currently, it is estimated that half of all people will develop shingles during their lifetime. The reason appears to relate to the use of the Chicken Pox vaccine. Prior to vaccination, adults would be routinely exposed to the Chicken Pox virus as they were intermittently exposed to children with active Chicken Pox. This frequent exposure to the virus by adults used to keep the immune system primed to keep the virus contained inside the nerve cells. Now that children no longer contract Chicken Pox, adults no longer receive the benefit of immune priming. Over time the immune system forgets the virus and allows the escape of the virus from the nerve.

What are the symptoms of ocular shingles?

The symptoms of shingles depend on the location of the nerves that harbor the virus. If the chest wall is affected, the eyes are spared. If the trigeminal nerve is affected, the forehead develops a rash. If the rash reaches the tip of the nose, the eye is often affected. The rash starts with redness and tiny blisters that crust and scar over time. Pain may occur before the rash appears and is described as burning, sharp, jabbing or tingling. Pain may be severe. It is the persistence of pain that may be disabling.

Aside from the possibility of long-term pain, other problems may relate to shingles. There appears to be an increased risk (4.5x) of stroke after shingles. There may also be an increased risk of cancer, inflammation of blood vessels (temporal arteritis), heart attack, and depression.

Ocular shingles is when shingles affects the eye. It may cause inflammation of the front window of the eye (the cornea) with scarring. Glaucoma may occur and require life-long treatment to prevent blindness. Intraocular inflammation may affect the front of the eye (iritis) or deep inside the eye threatening loss of vision. The inflammation may persist or return intermittently into the future.

What treatment is available?

Antiviral and anti-inflammatory medications may help treat shingles. The systemic treatment of shingles is managed by an internal medicine doctor (and sometimes by an infectious disease specialist). Treatment may hasten the recovery from shingles, but does not eliminate the late complications of infection.

Ocular complications of shingles are treated by ophthalmologists. Apart from anti-viral pills, eyes drops can help prevent loss of vision. After the initial inflammation is controlled, regular exams are important to diagnose problems that may occur in the future.

What can be done to prevent shingles?

An ounce of prevention is worth a pound of cure. The chance of shingles can be reduced by the use of a vaccine. This vaccine reduces the risk, but does not eliminate the chance of getting shingles. If shingles does occur after vaccination, it us usually not as severe compared to those without the vaccine. Not surprisingly, the effect of the vaccine wears off over a period of five to ten years. Research suggests that booster shots may help extend the effect of the vaccine; however, the cost of the vaccine appears to hinder formal recommendations for repeat vaccination. The newest vaccine, Shingrix, became available in 2018 and offers the best protection.

By Scott E. Pautler, MD

The Ocular Histoplasmosis Syndrome

Posted on June 18, 2017 by Scott Pautler

What is the ocular histoplasmosis syndrome (OHS)?

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

What causes the ocular histoplasmosis syndrome?

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

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

What are the symptoms of the ocular histoplasmosis syndrome?

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

What treatment is available?

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

By Scott E. Pautler, MD

Plaquenil Dosing Schedule

Posted on June 4, 2017 by Scott Pautler

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.

By Scott E. Pautler, MD

Plaquenil dosing schedule 2017

ED Medication and Your Eyes: Viagra, Cialis, and Levitra

Posted on May 27, 2017 by Scott Pautler

What are ED medications?

Erectile dysfunction (ED) is a common problem among males involving an inability to achieve or maintain an erection. Medications have been developed to treat this condition. They work in part by promoting dilation of the blood vessels in the penis. This same dilation of the blood vessels also occurs in other parts of the body. Facial flushing, stuffy nose, and headache may result from vascular dilation in the head. A decrease in blood pressure may also occur due to pooling of blood in the larger dilated veins of the body. This drop in blood pressure may cause symptoms of insufficient blood flow, especially in patients with hardening of the arteries.

How can ED medications affect my eyes?

Medications prescribed for erectile dysfunction (ED) may cause temporary blurred vision, light sensitivity, or impaired color vision. If these symptoms occur, a decrease in dosage of medication may be in order. If these symptoms persist, contact your ophthalmologist.

Rarely, a severe permanent decrease in vision may occur after using ED medications…ischemic optic neuropathy. This condition occurs most often in patients with atherosclerosis (hardening of the arteries) and in eyes with crowded optic discs (often seen in far-sighted people). Any sudden decrease in blood pressure (including the use of ED medications) may precipitate ischemic optic neuropathy.

In some patients ED medications might aggravate central serous retinopathy (CSR). a condition more often seen in far-sighted eyes with a thick blood vessel layer in the choroid. This condition causes a round, blurred gray or brown spot in the center of the vision. If this symptom appears while taking ED medications, contact your ophthalmologist.

What other medicines or conditions might interact with ED Medications?

Certain foods and drugs may interact with ED medications. Eating grapefruit or drinking grapefruit juice may affect how your body eliminates ED medications from your body. The following medications should not be used with ED medications: nitrates (nitrogycerin, isosorbide), nitroprusside, certain recreational drugs called “poppers” (which contain amyl or butyl nitrite).

Other medications may also affect ED medications and should be reported to your doctor or pharmacist: prostate medications, blood pressure medications, HIV/AIDS medications, St. John’s wort, some seizure medications, and certain antibiotics.

By Scott E. Pautler, MD

Treatment of Uveitis

Posted on April 15, 2017 by Scott Pautler

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

HLA B-27 and the Eye

Posted on February 19, 2017 by Scott Pautler

What is HLA-B27?

HLA-B27 is the name of an inherited marker found on white blood cells. It is found to be present with blood testing in one to ten percent of the population (higher in Scandinavians and some Native American groups). HLA is an abbreviation for Human Leukocyte Antigen. HLA-B27 is important to identify as it may be associated with medical problems such as inflammation of the eye, arthritis, psoriasis, and bowel inflammation, which may require medical treatment. There is an estimated risk of one-in-four that a person with HLA-B27 will develop eye or joint inflammation. Low vitamin D levels may play a role in causing the inflammation.

How does it affect the eye?

People who inherit HLA-B27 may develop iritis at some time during their lives. Iritis (also called anterior uveitis) means inflammation of the iris (the colored part of the eye). This inflammation is an irritation without infection. The inflammation is due to the natural immune system in the body mistakenly attacking the eye (similar to the way the immune system attacks the joints in rheumatoid arthritis). Symptoms include deep aching eye pain, redness, tearing, and light sensitivity. Other conditions of the eye may cause similar symptoms, so it is important to see an eye doctor promptly to make the correct diagnosis. Symptoms may be mild or severe. Treatment with drops (steroid and non-steroid), shots, and/or pills is important to prevent complications such as decreased vision, glaucoma, cataract, scarring, deformity, and blindness.

In 15-20% of patients with ocular inflammation associated with HLA-B27, the posterior structures of the eye may be involved. This inflammation is called intermediate uveitis. Symptoms include floaters and blurred vision. Although eye drops may be helpful, steroid injections and systemic medications may be needed. It is important to know if there is joint inflammation when deciding how to treat eye inflammation, because Humira is preferred over other medications if immunosuppressive therapy is needed. Humira (and other TNF-apha inhibitors) are effective for both eye and joint inflammation. Whereas, methotrexate and mycophenolate are good for eye inflammation, but less effective against joint inflammation associated with HLA B27.

How can it affect other parts of the body?

HLA-B27 is associated with ankylosing spondylitis, reactive arthritis, inflammatory bowel disease, and psoriasis. Ankylosing spondylitis is an arthritis that involves the spine, and it usually causes back pain and stiffness. Reactive arthritis usually involves large joints like the knees, ankles, feet, and wrists. It may follow an episode of infection of the intestines, bladder, or genitals. Inflammatory bowel disease may involve the small intestine (Crohn’s disease) or the large intestine (ulcerative colitis). Psoriasis is a skin condition causing raised red areas of the skin with scaling. Rarely, patients with HLA-B27 will suffer from scarring of the lungs (apical pulmonary fibrosis) or inflammation of the large blood vessels (aortitis).

Who should I see for evaluation of HLA-B27?

If you test positive for HLA-B27, you should inform all of your doctors so they may be alert for associated medical problems. You may be referred to an ophthalmologist if you have eye symptoms. A rheumatologist may evaluate joint symptoms with examination and X-rays. A gastroenterologist evaluates stomach problems. Recognizing symptoms and reporting to the doctor in a timely fashion may prevent severe and permanent complications.

By Scott E. Pautler, MD

Ischemic Optic Neuropathy

Posted on January 31, 2017 by Scott Pautler

What is ischemic optic neuropathy?

Ischemic optic neuropathy is condition in which blood flow to the optic nerve is inadequate. The decreased blood flow results in a sudden and sometimes progressive loss of vision. The optic nerve is the nerve that connects the eye to the brain. It sends the “picture” taken by the eye to the brain.

What causes ischemic optic neuropathy?

The cause of ION is not very well understood, but it occurs in people over the age of 40 and may be related to hardening of the arteries (arteriolar sclerosis) caused by high blood pressure, diabetes, high cholesterol, tobacco, or obesity. Some people are predisposed to ION because of the way the eye developed from birth with a small opening in the back of the eye for the optic nerve. This “crowded” optic nerve may be predisposed to blood vessel blockage. Sometimes, ION is caused by an inflammation of the blood vessels (temporal arteritis or giant cell arteritis). Sleep apnea may play a role in some patients and SSRI anti-depressants may be a risk factor.

How is ischemic optic neuropathy managed?

When the doctor diagnoses ION, laboratory tests may be ordered to determine if any underlying problem is present outside the eye. If there are signs of inflammation, a biopsy of a blood vessel over the temple may be performed and treatment with steroid pills instituted if the tests are positive. Most cases of ION are not associated with inflammation. Unfortunately, no treatment has been proven to be effective. The visual loss is usually permanent. Because the fellow eye may be affected at a later date, some doctors recommend the use of a half aspirin a day for prevention.

By Scott E. Pautler, MD

Eyelid Hygiene

Posted on October 19, 2016 by Scott Pautler

What is lid hygiene and why is it important?

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.

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compress — Moist heat for eyelid hygiene

How do I clean the lashes?

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.

By Scott E. Pautler, MD

Multiple Sclerosis and Your Eyes

Posted on September 9, 2016 by Scott Pautler

What is multiple sclerosis?

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

How does multiple sclerosis affect the eyes?

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

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

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

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

How is multiple sclerosis diagnosed?

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

How is multiple sclerosis treated?

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

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

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

By Scott E. Pautler, MD

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What is Byooviz?

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What is tea tree oil and how is it helpful?

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What is Sickle Cell Disease?

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Shape of the eye

The Tear Film

The Conjunctiva

The Sclera

The Cornea

The Iris and Pupil

The lens

The ciliary body (SILL-ee-air-ee)

The Vitreous

The Retina

The Choroid

The Optic Nerve

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What is Lumega-Z?

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Questions?

How can we help?

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Why are eye injections given?

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