Scott E. Pautler, M.D. Tampa

Treatment of diseases of the retina and vitreous

Polypoidal Choroidal Vasculopathy

Posted on March 13, 2021 by Scott Pautler

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

What is polypoidal choroidal vasculopathy (PCV)?

Polypoidal choroidal vasculopathy (PCV) is a type of age-related macular degeneration (AMD), the most common cause of visual loss in older Americans. The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision. The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused through the lens onto the retina, which “takes the picture” and sends the image to the brain. PCV is a disease that affects the central vision. It does not affect peripheral vision— the ability to see objects off to the side when looking straight ahead. This means that PCV alone does not result in total blindness.

In PCV, abnormal blood vessels grow under the macula from a deep layer of normal blood vessels (the choroid). The normal blood vessels in the choroid are usually separated by a tissue membrane from the macula. However, in PCV abnormal blood vessels start growing from the choroid and invade the tissue beneath the macula. These abnormal vessels leak fluid and blood under the macula causing loss of vision.

Image of the retina with bleeding due to PCV causing a blind spot in the vision

What causes polypoidal choroidal vasculopathy (PCV)?

Polypoidal choroidal vasculopathy appears to be an inherited condition. PCV may occur in anyone, but it is more common in people who descended from Asia or Africa. Therefore, genetic factors likely play a role in the cause of PCV. It may be aggravated by factors that cause hardening of the arteries like aging, high blood pressure, high cholesterol, overweight, physical inactivity, and tobacco use.

Before abnormal blood vessels grow under the macula, there are usually findings that predict eyes that are at risk of developing PCV. For example, the choroid (normal blood vessel layer under the macula) is usually thicker than average. A thicker choroid may result in higher blood flow beneath the macula that may cause the growth of abnormal blood vessels. In addition, pale deposits (drusen) may appear under the macula prior to the development of abnormal blood vessel growth. These deposits may contain waste products of cellular function, as well as cholesterol. Perhaps, newly growing blood vessels are called on by the macula to clear away the waste deposits. Regardless, the abnormal blood vessels threaten loss of vision due to leaking, bleeding, and scarring beneath the macula.

What are the symptoms of polypoidal choroidal vasculopathy (PCV)?

Polypoidal choroidal vasculopathy may cause no symptoms in its early stages, especially if the abnormal blood vessels are located away from the center of the macula or if they have not begun to leak significantly. Eventually, symptoms may include distortion of central vision or a blind spot in the vision.

How is polypoidal choroidal vasculopathy (PCV) diagnosed?

A dilated eye examination can often detect changes in the macula before visual loss occurs from PCV. The hallmark of PCV, as well as other forms of macular degeneration, is the presence of drusen—tiny yellow deposits of waste products from the retinal cells that appear as spots under the retina. After the diagnosis is made, a fluorescein angiogram may be needed. This is a procedure where the ophthalmologist injects an organic dye into the vein of a patient’s arm. Then, photographs of the retina show the presence and location of the leaking blood vessels marked by the organic dye.

How is polypoidal choroidal vasculopathy (PCV) treated?

There is evidence that taking vitamin/mineral supplements in specific dosages decreases the risk of visual loss from PCV. For high risk eyes, the following supplement is recommended: Preservision Soft Gels AREDS 2 Formula one capsule twice-a-day. To avoid toxic side effects, be careful about taking additional vitamins or zinc. However, you may take calcium, iron, and vitamin D if recommended by your doctor for problems not related to your eyes. Check pricing of Preservation on Amazon.

People with PCV can often be helped with medication injections and a special laser (PDT) performed in the office. The Everest Study found that the combination therapy with medication injection and PDT (photodynamic therapy) was more effective than medication injection alone. The combination treatment group recovered more vision and required fewer treatments by injection. This treatment regimen differs from other types of age-related macular degeneration.

Treatment rarely returns vision to normal, but may limit the amount of vision loss from blood vessel growth and leakage. Frequent office visits and photographs are needed. It may be useful to stop smoking, avoid becoming overweight, exercise daily, and control blood pressure and cholesterol. Aspirin should only be used if required to treat disease as recommended by a doctor. Relatives should be checked for polypoidal choroidal vasculopathy, as well.

By Scott E. Pautler, MD

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Visudyne Photodynamic Therapy

Posted on September 30, 2018 by Scott Pautler

What is photodynamic therapy?

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

What do I expect after photodynamic therapy?

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

By Scott E. Pautler, MD

Retinal Cryopexy

Posted on May 21, 2016 by Scott Pautler

What is retinal cryopexy?

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

How is retinal cryopexy performed?

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

What conditions may require retinal cryopexy?

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

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

What are the risks of retinal cryopexy?

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

What is expected after retinal cryopexy?

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

By Scott E. Pautler, MD

The Retinal Break: Holes and Tears

Posted on May 1, 2016 by Scott Pautler

What is a retinal break?

A break is a tear or hole in the retina. The retina is a thin layer of nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. Because the retina is very thin, breaks may develop and cause retinal detachment with loss of vision. There are two kinds of retinal breaks: holes and tears. Retinal tears cause retinal detachments more often than retinal holes.

What are the causes and symptoms?

Retinal breaks are fairly common in near-sighted eyes because near-sightedness is usually due to an elongation of the eye. As the eye enlarges deep in the eye socket, the retina has to stretch over a larger area. This stretching causes the retina to become thinner and may result in tiny round holes. These holes may cause no symptoms and may not cause retinal detachment.

In any eye, near-sighted or not, tears can occur from abnormal pulling on the retina by the vitreous (a clear gel that fills the eye and normally helps to hold the retina in place). Usually due to degeneration from aging, the vitreous gel condenses inside the eye and pulls on the retina. When this happens, patients usually notice the sudden onset of floating spots or “cobwebs”. Sometimes, brief lightning-like flashes of light occur in the side vision. About 10-15% of the time, new floaters and flashes mean a retinal tear has developed. This event places the eye at high risk of blindness from retinal detachment.

How is a retinal break treated?

Not all retinal breaks require treatment. The doctor may recommend observation alone. If a retinal break threatens to cause retinal detachment, the break is usually treated by laser or a freezing probe (cryopexy) to seal the retina to the eye wall at the site of the break. Treatment is NOT aimed at eliminating the flashes and floaters. Flashes usually disappear over a few weeks or months. The floaters gradually fade over many months, but they rarely disappear completely.

Treatment does not always prevent retinal detachment, so the patient should always report the new onset of more floaters or, more importantly, any progressive loss of side-vision or “curtain across the vision.”

Rarely, the central vision may become blurred and distorted due to scar tissue formation from the retinal break. This problem cannot be prevented with laser or cryopexy, though the scar tissue can be removed by surgery if it interferes with vision.

By Scott E. Pautler, MD

Laser Surgery and the Retina

Posted on April 2, 2016 by Scott Pautler

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

What is the retina?

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

What types of problems affect the retina?

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

How does the laser help?

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

What are the risks of retinal laser treatment?

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

What is it like to experience a laser treatment?

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

What can you expect after a laser treatment?

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

What warning signs should I report after treatment?

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

Pain
Severe loss of vision
Dark curtain or shadow across vision

By Scott E. Pautler, MD

Retinal Arteriolar Macroaneurysm

Posted on March 6, 2016 by Scott Pautler

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.

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

Pneumatic Retinopexy

Posted on April 21, 2014 by Scott Pautler

What is pneumatic retinopexy?

Pneumatic retinopexy is a surgical procedure to repair retinal detachment, close macular holes, treat vitreomacular traction, and displace blood from beneath the center of the retina as occurs in some cases of wet type age-related macular degeneration. A gas bubble that is injected into the eye is used to gently push against the retina to hold it in position. Strict positioning of the head is essential for success.

How is pneumatic retinopexy performed?

Pneumatic retinopexy can be performed in the office or in the operating room of a hospital. An injection of anesthetic around the eye is used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection. If there is a retinal break, cryopexy is used to seal the break. Cryopexy is performed by holding a pencil-like probe with a freezing tip against the white of the eye. It may cause a pressure sensation of coldness. Sometimes, laser is also used to seal retinal breaks. In preparation of the gas injection, fluid is removed from the eye with a small needle to make room for the gas bubble. After the gas injection, the eye is patched.

Will I be able to see the gas bubble?

It is normal to see the gas bubble while looking out of the eye. It appears as a black curved line across the vision, a single black ball in the bottom of the visual field, or as many black “fish eggs.” The gas bubble will move in the vision with head and eye movements. Usually, there is very little vision when looking through the gas bubble when it is large. The vision slowly improves as the gas bubble disappears by dissolving in the fluids of the eye over four to six weeks.

How does pneumatic retinopexy work?

Image of retinal detachment (top) and pneumatic retinopexy (bottom).

The gas bubble in the eye floats upward and gently holds the retina in position. Depending on what part of the retina needs support, the head must be kept in proper position. For example, if there is a break in the part of the retina that corresponds to the twelve O’clock position on a clock, then the head must remain upright so that the bubble floats up against the superior part of the retina. Otherwise, the bubble will not provide proper support and the retina will not heal properly and more surgery may be needed.

A retinal detachment is present in the top left-hand side of the photograph.

Intra-ocular gas bubble seen on photograph following pneumatic retinopexy.

How long do I need to stay in position?

You may need to stay in position from a few days to two weeks depending on your surgeon’s recommendations. It is best to attempt to remain in the recommended head position for 90% of the day and night. While in position, you may use your eyes to read or watch TV. A special pillow may be purchased to sleep in a face down position, which is recommended to close a macular hole. For five or ten minutes of every hour or two, you may stop the positioning to rise, stretch, and quietly move about the house to use the bathroom or eat. Until the gas bubble is gone, you should not fly in an airplane or undergo anesthesia using nitrous oxide, as doing so may result in blindness. Keep a MedicAlert band on your wrist until the gas bubble is gone.

How well does pneumatic retinopexy work for retinal detachment?

The PIVOT study compared the results of pneumatic retinopexy versus vitrectomy in the repair of retinal detachment. On average, pneumatic retinopexy resulted in less distortion and an additional line of visual improvement on the eye chart compared with vitrectomy. However, strict positioning is needed for success with pneumatic retinopexy; therefore, the success rate of reattaching the retina with a single procedure was 81% for pneumatic retinopexy compared to 93% with vitrectomy. Additional surgery, when necessary, usually results in successful reattachment.

What are the risks of pneumatic retinopexy?

Although generally a safe procedure, pneumatic retinopexy is not without risks. Adverse effects include pain, bleeding, infection, scarring, glaucoma, cataract, loss of vision, deformity, blindness, and loss of the eye. When pneumatic retinopexy is recommended, the benefits outweigh the risks of surgery.

How do I care for the eye?

Keep the patch on and use no eye drops in the operated eye until the patch has been removed in the office on the first day after surgery. After the office visit you may shower and shampoo your hair being careful not to bump or rub the eye. The eye can be gently dried by patting it with a clean, dry towel. You may be given eye drops and instructions on how to use them. Tylenol (no more than 4,000 mg per day) or Ibuprofen (no more than 2,400 mg per day) may be used if there is pain. Patients with liver disease should be cautious about taking Tylenol, and patients with kidney disease should be cautious about taking ibuprofen. Prescription pain medication is available if needed. It is normal to have some discomfort, but severe pain should be reported to your doctor. It is normal to experience eyelid swelling and bruising. The eye will be red and watery. Sometimes, there is a sensation resembling an eyelash in the eye. After the patch has been removed, this discomfort is best managed with Lacrilube (available in the pharmacy without a prescription), which may be used in the eye as often as needed. After the first office visit following the surgery, an eye patch is not necessary. However, at night a hard shield may be used to cover the eye to protect it from trauma. If you have any questions or concerns, please call the office.

By Scott E. Pautler, MD

Retinal Detachment

Posted on February 1, 2014 by Scott Pautler

What is the retina?

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

What is retinal detachment?

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

What causes retinal detachment?

Retinal breaks (holes and tears in the retina) cause retinal detachment. These retinal breaks are usually caused by a degeneration of the vitreous (the clear gel that fills the eye and normally helps to hold the retina in place). Vitreous degeneration is common in aging and near-sightedness, but may also follow a direct blow to the eye, hemorrhage, infection, or inflammation inside the eye. When the vitreous degenerates and condenses, it pulls on the retina and may cause retinal tears, which often lead to retinal detachment.

What are the symptoms of retinal detachment?

Prior to retinal detachment, most people notice warning signs such as new floating spots or “cobwebs” in the vision. Sometimes, brief lightning-like flashes of light are seen in the side vision. These are the symptoms of vitreous degeneration and retinal breaks. The retinal detachment that follows usually causes a dark “curtain” or “shadow” to form in the side-vision. The “shadow” often comes from below and on the side near the nose. If it is not treated, the shadow gradually covers all of the vision resulting in blindness. There is generally no pain with retinal detachment.

How is retinal detachment treated?

The treatment of most retinal detachments requires surgery. Your doctor is skilled in a number of techniques to prevent blindness. Which type of surgery is recommended depends on the precise findings on examination. Surgery is not usually aimed at eliminating flashes and floaters. Flashes usually disappear in a few weeks or months. The floaters gradually fade over many months, but rarely disappear completely. Some retinal detachments that do not cause symptoms may be observed without initial surgery.

Laser/Cryopexy demarcation: Small areas of the retinal detachment (especially before any side vision has been lost) can sometimes be treated with laser or cryopexy to “seal down” the retinal along the edges of the detachment in an effort to prevent it from extending further. This surgery is performed in the office. If it is not successful in stopping the detachment, more extensive surgery is required.

Pneumatic retinopexy: Many retinal detachments can be repaired by this surgery performed in the office by anesthetizing the eye, sealing the break(s) with laser or a freezing probe (cryopexy), and pushing the retina into proper position with a gas bubble which is injected into the eye. Although this procedure is successful most of the time, it requires the strict cooperation of the patient to remain in proper head position for about five days. If this procedure fails, more extensive surgery in the hospital operating room is sometimes needed.

Scleral buckle surgery: Some retinal detachments require the placement of a permanent plastic supporting belt around the eye to create a “ledge of support” for the retina. This is a major surgery in which a belt is placed around the eye in the hospital operating room. The eye is often rendered more near sighted by this procedure. Rarely, permanent side effects include double vision. If this surgery is not successful, vitrectomy surgery may be recommended. Scleral buckle surgery is preferred over other methods of surgery if the retinal breaks are located in the inferior (bottom portion) of the retina, where gas bubbles may not be effective in holding the retinal in position. Scleral buckle is also preferred over vitrectomy in eyes with a clear lens, because vitrectomy surgery usually results in cataract formation. Scleral buckle surgery is often used when other attempts at surgery have failed.

The video below demonstrates scleral buckle surgery. If you are uncomfortable watching surgery, please do not click on this video:

Vitrectomy surgery: Performed in the hospital operating room as a major eye surgery, vitrectomy surgery involves making small incisions into the eye to remove floaters, dissect scar tissue, remove fluid from under the retina, apply laser, and place a gas bubble or silicone oil into the eye to hold the retina in place. Specific head positioning is sometimes needed. Sometimes a cataract or lens implant must be removed to adequately repair the retina. This surgery may be repeated if necessary to prevent blindness.

The video below demonstrates vitrectomy surgery. If you are uncomfortable watching surgery, please do not click on this video:

With one or more surgeries most retinal detachments can be repaired keeping useful vision. Vision may not return to normal, as there may be some permanent damage from the retinal detachment resulting in blurred or distorted vision. In some cases additional surgery is needed to removed scar tissue that forms after retinal reattachment surgery. There are always risks to surgery including hemorrhage, infection, scarring, glaucoma, cataract, double vision, deformity, loss of vision/loss of the eye. Sometimes despite all efforts with surgery, all vision may be lost. Surgery is recommended for retinal detachments because blindness usually results if treatment is withheld. If you have questions, please do not hesitate to ask your doctor.

By Scott E. Pautler, MD

Central Serous Retinopathy

Posted on December 1, 2013 by Scott Pautler

What is central serous retinopathy (CSR)?

Central serous retinopathy (also known as central serous chorioretinopathy) is an abnormal leakage of clear fluid under the retina, which causes symptoms of blurred vision often associated with a round or oval dark spot in the central vision. The retina is a thin layer of delicate tissue in the back of your eye, which lines the inside wall like the film in a camera. The retina “takes a picture” of objects you look at and sends the message to the brain.

What causes central serous retinopathy (CSR)?

The exact cause of CSR has not been well-defined. Classically, it occurs in middle-aged people with type-A personality and who are often under stress at home or work. However, anyone may be affected regardless of age, personality type, and level of stress. Individuals with type-A personality are perfectionists who often feel pressured by time constraints. Research suggests that hormones released under stress can affect the blood vessels beneath the retina (in the choroid). These vessels may leak an abnormal amount of fluid, which then works its way under the center of the retina. Far-sighted eyes are more commonly affected than near-sighted eyes.

What other things can aggravate central serous retinopathy (CSR)?

A host of factors may aggravate CSR. Sometimes, medical conditions (Cushing’s Syndrome, systemic lupus erythematosus, polycystic ovary disease, sleep apnea), medications (pseudephedrine, prednisone/cortisone/steroid by mouth/cream/injection/spray, OTC medication for the common “cold”, OTC nasal sprays, diet pills, muscle relaxants, and medications for erectile dysfunction), and other agents (testosterone, cocaine, caffeine, niacin, amphetamines, estrogen blockers, etc.) may contribute to the development of CSC. Rarely, CSC may be triggered by pregnancy, or by a viral infection or bacterial infection. Intense exercise has been implicated, as well. Indeed, anything that causes emotional or physiological stress in the body, including intense fasting, may contribute to the development of CSC.

What are non-medical treatments of CSC?

In many cases, the symptoms will disappear with time. Over a period of weeks to months, the abnormal leakage may stop with normal healing. Importantly, avoiding known triggers (listed above) may help. Other helpful measures include stress management, getting 8 hours of sleep per night, and treatment of sleep apnea.

What are medical treatments of CSC?

The doctor can recommend the best course of action by taking special pictures of the eye called a fluorescein angiogram. The fluorescein angiogram shows where the leak is coming from and how active the leak is. Prescription medication may be helpful if fluid leakage does not go away with time alone. Patients with high blood pressure may benefit from beta-blocker medications. Thermal laser photocoagulation may be helpful if the site of leakage is not close to the center of vision. Side-effects are rare, but may include the appearance of a small, permanent blind spot in the vision. Another laser called Visudyne photodynamic therapy (PDT) may successfully avoid blind spots in the vision in eyes with areas of leakage close to the center of vision. Medicine injections may also be used to treat this condition.

What will happen to the vision?

Usually the vision returns to normal or near normal. Rarely, central serous chorioretinopathy will cause permanently limited central vision with distortion. In about a third of cases, CSC will return at a later date in the same or other eye. Repeated episodes of leakage may result in a build-up of permanent damage to the retina. Therefore, any future decrease in vision should be promptly reported to the doctor. The vision may be monitored with the Amsler grid test.

By Scott E. Pautler, MD

Retinal Vein Occlusion

Posted on September 2, 2013 by Scott Pautler

What is a retinal vein occlusion (RVO)?

Retinal vein occlusion means blockage of a vein in the retina. 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 veins are blood vessels that drain blood out of the retina. An abnormal blood clot in a retinal vein causes a blockage (occlusion) of the blood flowing out of the retina. Depending on the location of the occlusion, vein occlusions are divided into branch retinal vein occlusion and central retinal vein occlusion.

Who is at risk for a retinal vein occlusion?

Retinal vein occlusions occur in 1-2% of people over 40 years of age. Retinal vein occlusions are more common in people who are overweight, use tobacco or estrogen, or have hardening of the arteries, diabetes, high blood pressure, sleep apnea, glaucoma, or blood disorders.

What are the symptoms of a retinal vein occlusion?

Blurring of vision may occur if excess fluid (edema) leaks from the veins into the center of the retina. 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. 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. Your doctor may allow time for the vein to heal. Sometimes eye drops or pills may be prescribed. Medicine injections (Avastin, Lucentis, Eylea, steroids) may help recover vision and may be applied without pain in most cases. Injections may be required for the long-term; about half of eyes with central retinal vein occlusion require injections for at least three years. Injections for retinal vein occlusion are safe in regard to risks of problems outside the eye. However, there appears to be a low risk of stroke (intracranial hemorrhage) of <4/1000 every year of treatment.

Laser may stabilize or improve the vision. The vision may not return to normal following treatment as there may be some permanent damage to the retina from the occlusion. In some cases when treatment cannot improve the vision, laser is used to prevent severe pain and complete blindness.

Your doctor is going to order appropriate tests and recommend the best course of action to take at this time. The retinal vein occlusion will not be worsened by your daily activities or by using your eyes. You may monitor the vision with the Amsler grid test. It is important to be seen by your primary care doctor to treat risk factors of hardening of the arteries to prevent stroke and heart attack.

By Scott E. Pautler, MD

recent BRVO — blood spots and white exudates in retina from recent brach retinal vein occlusion (click on image to enlarge)

healing BRVO — Fewer blood spots as vein occlusion heals with Avastin (click on image to enlarge)

CRVO — Recent-onset central retinal vein occlusion of left eye

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