The Amsler grid is a test used to detect and monitor macular disease (see Anatomy of the Eye). 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 onto the retina, which “takes the picture” and sends the image to the brain.
How is the Amsler grid used?
The grid is observed one eye art a time with reading glasses if needed for proper focusing at normal reading distance. The patient is asked to fixate on the center of the grid while using “side vision” to see if there are any missing areas. The lines on the grid should appear straight and uniform. If any abnormalities are noted, an ophthalmologist (retinal specialist) may be consulted to determine the cause of the problem.
Below is a link to download or print an Amsler grid chart for use at home.
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.
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.
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.
Vitreous gel fills the eye (click on image to enlarge)
What is vitrectomy surgery?
Vitrectomy surgery is an advanced form of eye surgery that is performed in the operating room under a microscope. It is often used to treat conditions such as retinal detachment, macular pucker, macular hole, vitreomacular traction, diabetic retinopathy, vitreous hemorrhage, dislocated cataract/lens implant, endophthalmitis, and uveitis. Vitrectomy may take thirty minutes to several hours to perform depending upon what task is being accomplished. Despite common tales, the eye is not taken out and placed on the cheek. It remains in its normal position throughout the surgery. Vitrectomy may be performed under general anesthesia to avoid pain and to avoid eye movement during surgery. During vitrectomy, tiny needle-like incisions are made to enter the white of the eye to gain access to the central core of the eye, which contains a gel called vitreous. Various instruments no larger around than needles are placed into the small incisions to perform tasks such as peeling or cutting membranes from the retinal surface, cauterizing blood vessels, removing blood or inflammatory debris from the eye, and applying laser. The surgeon views the tips of the instruments through the dilated pupil with an operating microscope. Sometimes, a gas bubble or silicone oil is placed in the eye to hold the retina in position to heal properly.
What type of anesthesia is available?
Although some surgeons and patients choose local anesthesia, general anesthesia is also available. With local anesthesia the patient is sedated with IV medication so there is no memory of the anesthetic injection around the eye. Surgical drapes are placed over the face leaving plenty of breathing room. During surgery the patient is awake, but generally does not feel pain. It is important to lie still on the operating room table as movement during surgery may result in damage to the eye and affect the final visual result.
General anesthesia offers some advantages over local anesthesia. With general anesthesia the patient is motionless and remembers nothing of the surgery. The anesthesiologist places a tube to hold the airway open. Which type of anesthesia is best for a patient may be determined by the health of the patient, so you may wish to ask your internist for advice. If a person cannot lie still for the surgery or if claustrophobia is a problem, general anesthesia is preferred. Although there are risks with any type of anesthesia, modern techniques offer a high degree of safety for the patient.
How can I prepare for vitrectomy surgery?
Your retinal specialist may schedule an appointment with your primary care doctor if evaluation is needed prior to surgery. Please inform your doctor of any chest pain or pressure, fever, productive cough, or shortness of breath. Unless otherwise notified by your doctor, do not take aspirin-containing products or any herbal supplements for two weeks prior to surgery. Coumadin may be stopped four days prior to surgery. On the morning of surgery, take no medications for diabetes unless instructed differently by your doctor, but please do take all of your other medications with a sip of water. Otherwise, do not eat or drink anything after midnight the day before surgery. If you usually use eye drops in the morning, they may be taken on the morning of surgery. Please click on this link for further information on how to prepare for surgery.
What are the risks of vitrectomy surgery?
Although uncommon, problems such as bleeding and infection may arise from any surgery. Retinal detachment or abnormal scar tissue formation may require additional surgery. Rarely, there may be loss of vision/loss of the eye. The most common problem following vitrectomy surgery is progression of cataract. Although serious problems are not encountered often, the risks and benefits must be weighed for each individual prior to surgery. For many eye problems, vitrectomy surgery is the only way to improve vision or prevent blindness.
What can I expect after vitrectomy surgery?
A soft eye patch and a hard eye shield are placed on the eye at the end of surgery. Leave these in place until your exam on the day after surgery. You may use Tylenol or Advil for aching pain, but call the doctor for a prescription if your pain is not relieved. It is not common to have severe pain after vitrectomy surgery. A scratchy feeling may result from sutures on the white of the eye. These sutures dissolve in about three weeks. At your exam after surgery, you will be given eye drops and/or an ointment to keep the eye comfortable, to prevent infection, and to promote healing. Wearing the eye patch is optional after you are seen in the office, but you may wear the hard protective shield as needed to prevent trauma to the eye. Depending upon the reason for your surgery, it may be very important to lie face down or on either side after your surgery. Be sure you understand any positioning requirements given by your surgeon and feel free to ask about special pillows and equipment available to help maintain head position. If a gas bubble is placed in your eye at the time of surgery, you may not fly on a plane or undergo nitrous-oxide anesthesia until the gas has dissolved, or you could risk severe pain and blindness. You may see the gas bubble as a horizontal, dark, curved line or as a dark ball in the vision. If a gas bubble is used during surgery, please keep a MedicAlert bracelet on your wrist until the gas has disappeared. The vision usually returns slowly over days to weeks after surgery, but may take many months for final recovery. The swelling and redness slowly disappear over weeks to months.
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.
The macula is the center of the retina (in box). The bottom image is an optical coherence tomogram of the macula. (Click to enlarge)
What is a macular hole?
Macular hole means there is a tiny hole in the center of the retina. The retina is a thin layer of tissue in the back of your eye which lines the inside wall like the film inside the back of a camera. The retina “takes a picture” of objects you look at and sends it to the brain. The macula is the center of the retina and gives you sharp central vision for reading and seeing fine details. When the macula is damaged, the central vision worsens. Macular hole is not macular degeneration and does not lead to macular degeneration. Macular hole affects both eyes in only about 10% of cases.
What causes a macular hole?
A macular hole is caused when the clear gel that fills the eye (vitreous) pulls on the macula. When you are born the vitreous gel is thick, clear, and filled with tiny, invisible fibers. With age or trauma, the vitreous gel begins to condense and pull away from the retina. If the attachment of the vitreous to the macula is unusually strong, the pulling may result in a macular hole.
What are the symptoms of a macular hole?
Blurring of vision is mild at first, noted especially while trying to read fine print. It slowly worsens; often with distortion (straight lines look crooked). Sometimes there is a small blind spot in the center of vision. The visual symptoms may be detected and monitored with the Amsler grid test.
What treatment is available?
In a small number of cases, a macular hole may heal itself. In other cases the vision improves with a medicine injection (Jetrea®). If this fails or is not possible, a surgery may be performed that releases the abnormal pulling of the vitreous on the macula. A gas bubble (pneumatic retinopexy) is then placed in the eye to close the hole in the macula. Strict facedown positioning is recommended for several days following surgery. Special cushions and massage tables are available to help maintain the proper head position. The most common side effect of surgery is cataract formation. Cataracts develop after surgery in most eyes over several months to years. About 5% of eyes require more than one surgery to close the macular hole. In 2-3% of eyes, the retina may detach during or soon after surgery as a result of continued pulling on the retina by vitreous fibers. This requires additional surgery to prevent profound loss of vision. Unommon risks of surgery include hemorrhage, infection, blindness and loss of the eye.
Surgery to close macular hole is usually successful in improving vision, though the vision rarely returns completely to normal. Some residual distortion and central blurring of vision is common. The vision improves very slowly after surgery over several months to years.
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.
