Tag Archives: eye

Hypertensive Retinopathy

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

What is hypertensive retinopathy?

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

How does blood pressure damage the retina?

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

What are the symptoms of hypertensive retinopathy?

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

What treatment is available?

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

By Scott E. Pautler, MD

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

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

Retinal Arteriolar Macroaneurysm

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

What is a retinal macroaneurysm?

A retinal macroaneurysm is an abnormal out-pouching in a retinal blood vessel (arteriole) where the arteriolar wall has been weakened. It looks like a tiny balloon in the blood vessel. The retina in your eye is like the film inside a camera. The retina “takes the picture” of objects you look at and sends the message to the brain. The retina is a living tissue, which requires blood supplied by tiny vessels. Retinal arterioles are blood vessels that bring blood to the retina.

Retinal MA
Retinal Arteriolar Macroaneursym
Arteriolar MA
Fluorescein angiogram of macroaneursym
Retinal MA by OCT
OCT scan of retinal macroaneurysm

Who is at risk for a retinal macroaneurysm?

Retinal macroaneurysms are more common in older people who have high blood pressure or hardening of the arteries. These conditions appear to weaken the blood vessels in the eye causing a ballooning of the vessel wall. Retinal macroaneurysms are NOT related to aneurysms in the brain.

What are the symptoms of a retinal macroaneurysm?

Blurring of vision may occur if excess fluid (edema) leaks from the macroaneurysm. Bleeding (vitreous hemorrhage) from a macroaneurysm causes floaters that can look like tiny dots or cobwebs moving about in your vision.  Sometimes, bleeding under the retina causes the sudden onset of a large blind spot in the vision.

What treatment is available?

Laser may improve the vision by sealing the macroaneurysm to keep it from bleeding and leaking fluid, but the vision rarely returns completely to normal. There may be some permanent damage to the retina from the macroaneurysm. In some cases the macroaneurysm may be observed without laser to see if it will heal on its own. In other cases, medication injections may be used to improve vision.  Your doctor is going to order appropriate tests and recommend the best course of action to take at this time. The retinal macroaneurysm will not be worsened by your daily activities or by using your eyes. See your internist to keep your blood pressure under good control.

By Scott E. Pautler, MD

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

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

The risk of stroke with treatment of Age-Related Macular Degeneration

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

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

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

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

By Scott E. Pautler, MD

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

References:

Ophthalmology 2012 119:1604-1608 Campbell

AJO 2015 160:569-580 Schlenker

Ophthalmology 2012 119:1388-1398 Martin

Ophthalmology 2012 119:1399-1411 Chakravarthy

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

Glaucoma

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globe anatomy

anatomy of the eye (click on image to enlarge)

What is Glaucoma?

Glaucoma is a condition in which the pressure inside the eye damages the cells of the optic nerve. The optic nerve transmits information from the eye to the brain to provide vision. Glaucoma affects two million Americans and is the second leading cause of blindness in the United States.

What causes glaucoma?

There are many different types of glaucoma, but most types of glaucoma have in common an abnormally high pressure inside the eye. The pressure in the eye is not directly related to blood pressure. The normal range of pressure in the eye is between 8-21 units of measurement. There is a tissue inside the eye that pumps a clear fluid (aqueous) into the eye keeping the eye from collapsing. Another tissue called the trabecular meshwork normally drains the aqueous from the eye preventing the pressure from building up. In most types of glaucoma, the drain becomes clogged or blocked resulting in an increase of the pressure inside the eye. High pressure inside the eye damages the cells of the optic nerve. In an uncommon type of glaucoma (normal tension glaucoma), the pressure measurements are within the normal range, but the optic nerve is unusually sensitive and will become damaged if the pressure is not lowered even further.

Who is at risk for having glaucoma?

About two or three percent of Americans develop glaucoma. It may occur at any age, but usually occurs after the age of forty. It appears to be hereditary and, therefore, is more common in people who have family members with glaucoma. Diabetes increases the risk of glaucoma.  African-Americans develop glaucoma fifteen times more frequently than European-Americans. Another risk factor for glaucoma is uveitis and trauma…especially, blunt injury to the eye. Steroid eyedrops and injections (triamcinolone and Ozurdex) may bring out glaucoma in eyes that are predisposed.

What are the symptoms of glaucoma?

The most common type of glaucoma is “open angle” glaucoma. In its early stages, glaucoma causes no obvious symptoms. However, driving vision can be impaired early on. Moreover, if it is not detected and treated early, glaucoma eventually may cause a gradual, severe, permanent loss of vision.  Rarely, visual hallucinations may occur.

A less common type of glaucoma called “angle closure” glaucoma may cause sudden pain, redness, and blurred vision. It is more often seen in far-sighted eyes. In some cases, the tendency for an acute attack of glaucoma can be predicted on examination. In such cases laser treatment and/or cataract surgery may help to “open” the angle to prevent a future attack of angle closure glaucoma.

How is glaucoma diagnosed?

The most common test for glaucoma in an eye examination is tonometry. Tonometry measures the pressure inside the eye. Most people are first suspected to have glaucoma because high pressure is found on a routine exam. Another way to diagnose glaucoma is by examination of the optic nerve inside the eye. A nerve damaged by glaucoma has an abnormal appearance called “cupping,” which may provide a clue to the diagnosis. Additionally, a formal measurement of the peripheral vision (side vision) by a visual field test usually confirms the loss of vision that may not otherwise be noticeable. A visual field test is not part of a standard exam, but is performed if glaucoma is suspected. Repeated visual field tests help to determine whether treatment has been adequate to prevent loss of vision. Finally, sophisticated computerized tests (optical coherence tomography) are available to measure the thickness of optic nerve fibers to help in the diagnosis and assess the treatment of glaucoma.

What treatment is available?

Treatment of glaucoma is directed at lowering the pressure in the eye. The first line of treatment in most cases includes prescription eye drops. There are a number of very effective eye drops that work by either opening the drain or by slowing down the pump to lower the pressure. These drops are powerful medicines that should be used exactly as prescribed to prevent blindness from glaucoma and minimize side effects from the eye drops. Side effects are not common, but may include burning, itching, redness, dry mouth, and worsening of bronchitis or asthma. It is very important to take the eye drops exactly as prescribed to prevent blindness. If eye drops fail to control the pressure, laser surgery may help. Finally, surgery performed in the operating room (trabeculectomy) may create an artificial drain to lower the pressure. After trabeculectomy patients are warned to notify the doctor urgently if the eye becomes red or appears to be infected, because infection may enter the eye after trabeculectomy and result in severe damage or blindness. In general, patients with glaucoma may require regular examinations every three to four months to preserve vision.

By Scott E. Pautler, MD

For more information on glaucoma contact the Glaucoma Research Foundation at 1-800-826-6693 (www.glaucoma.org).

Copyright © 2014-2023 Designs Unlimited of Florida. All Rights Reserved.

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

Hydroxychloroquine (Plaquenil) and your eyes

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What side effects can Plaquenil have in the eye?

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

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

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

What can you do to protect yourself?

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

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

What happens if you develop retinal changes from Plaquenil?

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

By Scott E. Pautler, MD

Reference: Article on early detection

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

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

Tobacco and Eye Disease

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How does tobacco affect the eyes?

Tobacco use is widely known to cause lung damage, but the eyes are also affected. Bothersome irritation of the eyes is caused by smoke from tobacco especially in patients with dry eyes. However, permanent loss of vision may occur from such problems as macular degeneration, retinal vein occlusion, ocular histoplasmosis syndrome, glaucoma, cataract, Grave’s Disease (a thyroid condition that affects the eyes), uveitis (inflammation of the eye), ischemic optic neuropathy, and diabetic retinopathy. Tobacco appears to play a role in causing and/or worsening these conditions. Tobacco is known to promote hardening of the arteries, and this may harm blood flow to the eye. Tobacco also promotes the development of blood clots, which may block blood flow in the eye. Tissue damage also occurs from toxic compounds in tobacco that cause a chemical reaction called oxidation. More research is needed to fully understand the role of tobacco in causing loss of vision.

What resources are available to help stop tobacco use?

Because most people cannot stop tobacco “cold turkey,” many resources are available to help quit the habit. Counseling may provide much needed support in the process of stopping tobacco use. For free classes and one-month’s supply of nicotine replacement therapy, your doctor can refer you to the Area Health Education Center. Alternatively, you may call 1-877-848-6696. The class schedule may be viewed at www.ahectobacco.com/calendar.  If you are interested in talking to informed support staff, please call 1-800-QUIT-NOW. Nicotine replacement therapy plays an important role and several preparations are available over-the-counter. These non-prescription forms of nicotine include gum, lozenges, and patches. Medicare and most insurance companies now cover the costs of prescription medications to help stop tobacco use. These include nicotine nasal sprays, nicotine inhalers, as well as pills (Zyban and Chantix). With the help of counseling, nicotine replacement, and prescription medication, you can live a longer and healthier life without tobacco. For more information please visit www.smokefree.gov.

By Scott E. Pautler, MD

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

Copyright  © 2013-2022 Designs Unlimited of Florida.  All Rights Reserved.

Sub-Tenon’s Steroid Injection

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Why is a sub-Tenon’s steroid injection performed?

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.

Periocular steroid injeciton
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.

By Scott E. Pautler, MD

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

Copyright  © 2013-2022 Designs Unlimited of Florida.  All Rights Reserved.