Tag Archives: retina

Byooviz Therapy

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

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

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 ©2022 Designs Unlimited of Florida.  All Rights Reserved

What is the Best Drug for Eye Injections?

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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 drugCostEffectivenessSafety
AvastinCheap: ~$50GoodRepackaging*
LucentisExpensive: ~$2,000Goodsafest systemically**
EyleaExpensive: ~$2,000Better1% inflammation
Eylea HDExpensive: ~$2000?Better1% inflammation or greater?
VabysmoExpensive: ~$2,000?Better 2% inflammation
BeovuExpensive: ~$2,000?Better4-5% 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

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 © 2022-2024 Designs Unlimited of Florida.  All Rights Reserved.

Diamox and Neptazane for the Eye

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What are carbonic anhydrase inhibitors (CAI)?

            CAI medicines are sometimes prescribed to lower the pressure in the eye either to control pain or to decrease the chances of damage to the eye from high pressure (as in glaucoma). They may also be used to decrease abnormal fluid leakage from blood vessels in the retina (e.g. retinitis pigmentosa). These pills are very effective and may be used along with eye drops to lower the eye pressure. The two most common pills used are Diamox (acetazolamide) and Neptazane (methazolamide).

What side effects might be encountered?

            While you are taking these medicines, you may notice a tingling sensation in the fingers, toes, or lips; an altered sense of taste; a loss of appetite; drowsiness; a “washed out” feeling; or an increase in urination. These are not allergic reactions, but should be reported to the doctor if they become bothersome.

            It may be helpful to take potassium supplements (e.g. banana) while on CAI to prevent low potassium levels in the blood. Low serum potassium may cause muscle cramps and weakess, abdominal cramps, palpitations, faintness from low blood pressure, and depression. 

            The dosage of CAI may be reduced in patients with reduced kidney function (see table below). CAI may not be used in advanced cases of liver cirrhosis.

            Only rarely do severe reactions occur. Be sure to report hives, skin rashes, gout, allergy to sulfa antibiotics, kidney stones, kidney failure, mental depression, liver failure, blood in stool or mouth, easy bruising, or anemia.

What other medicines might interact with CAI?

            Other drugs rarely interact with CAI and an adjustment in dosage is sometimes needed. CAI may increase the effect of diuretics (HCTZ, lasix, bumex, etc.), high-dose aspirin, and quinidine. CAI may increase the effect of digoxin (lanoxin), phenytoin (Dilantin), carbamazepine, primidone, and lithium. Caution should be used when taking metformin for diabetes; CAI may increase the risk of lactic acidosis. Be sure to notify your doctor if you are taking any of these medicines.

How to adjust the dosage in kidney failure?

            The table below shows how to adjust dosage of acetazolamide (Diamox) in the setting of kidney disease.

Glomerular Filtration Rate (GFR) in mL/minDosage
20-50 250 mg up to 4 times a day
10-20250 mg up to 2 times a day
<10 or on dialysis250 mg daily or 3 times a week

reference: https://kidneydiseaseclinic.net/renaldrugs/Acetazolamide.php

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  © 2022 Designs Unlimited of Florida.  All Rights Reserved.

Lattice Degeneration

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

What is lattice degeneration?

Lattice degeneration is a condition in which the retina develops areas of abnormal thinning.  The thinning occurs as the retina stretches during growth of the eye.  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.  Lattice degeneration is most common in near-sighted people and affects about 7% of the general population.          

What causes lattice degeneration?

Lattice degeneration appears to be an inherited condition that usually develops in childhood or early adulthood.  The eye, which is round like a ball at birth, becomes oval like an egg.  The elongation of the eye causes the retina to stretch.  As a result, thin areas develop in the retina similar to “stretch marks” that occur in the skin with growth or weight gain.    

Why is it important to know about lattice degeneration?

            Lattice degeneration in itself causes no symptoms or loss of vision.  It is important because lattice degeneration predisposes eyes to retinal detachment, which can cause permanent blindness without treatment.  With age, trauma, or inflammation, the vitreous gel that fills the eye begins to condense and pull away from the retina.  If the retina has become weakened by lattice degeneration, it is more likely to tear when pulled upon.  A tear in the retina allows fluid from the vitreous gel to seep under the retina as the retina detaches.  Fortunately, only one in 200 eyes with lattice degeneration ever develop retinal detachment.  Usually no treatment of lattice degeneration is needed, but symptoms of new floating spots or fibers should be reported to the doctor promptly. An examination may disclose breaks in the retina, which may be treated in the office with laser.  The appearance of a dark curtain or shadow from the side-vision like an eclipse of the moon is an even more serious symptom that may indicate retinal detachment and require major eye surgery to repair. 

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  ©2022 Designs Unlimited of Florida.  All Rights Reserved.          

Diabetic Vitreous Hemorrhage

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Eye Anatomy

What is diabetic vitreous hemorrhage?

            Diabetic vitreous hemorrhage means blood has leaked into the vitreous gel of the eye as a result of diabetic damage. The vitreous is a clear gel that fills the center of the eye and helps to hold the retina in place against the eye-wall like wallpaper in a room.  The retina is a thin layer of delicate nerve tissue, which acts like 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 many fine blood vessels that may become damaged from diabetes leading to bleeding into the vitreous.  Blood in the vitreous (vitreous hemorrhage) interferes with vision. 

What symptoms does diabetic vitreous hemorrhage cause?

            Diabetic vitreous hemorrhage usually causes many new floaters in the vision.  Floaters may appear as round specks, hair-like or bug-like debris, or clouds moving in your vision as though they were in front of your eye.  They are more noticeable when looking at a blank surface and may interfere with the good vision in the fellow eye.  If vitreous hemorrhage is severe, the vision may be severely limited.  Patients may only see shadows or light, but no details.

            Flashes are brief streaks of light that are usually seen off to the side, especially at night when you turn your head or eyes.  Flashes are caused by vitreous gel pulling on the retina with eye movement.  They may be seen in the setting of diabetic vitreous hemorrhage, but are not worrisome in themselves.

Although many people have occasional floaters or flashes of light, the sudden onset of many new floaters with or without flashes is an important sign of abnormal pulling on the retina by the vitreous.  In some people with these symptoms, the retina may tear and detach resulting in loss of vision.  Therefore, these new symptoms warrant prompt evaluation.

What causes diabetic vitreous hemorrhage?

            Diabetes can cause vitreous hemorrhage by weakening the blood vessels in the retina and by causing the vitreous gel to shrink and pull on the retinal vessels.  Aging also causes changes in the vitreous gel and can cause it to pull on the retina.  In any given patient with diabetes, both weakened retinal blood vessels, as well as tugging on the blood vessels from the vitreous play a role in causing vitreous hemorrhage.  However, in some eyes weakened blood vessels may be the main reason and in other eyes the main reason for bleeding may be tugging from the vitreous.  This is an important issue as diabetic vitreous hemorrhage may be treated differently depending on its underlying cause.   

How is diabetic vitreous hemorrhage treated?

            The most important step is to have a thorough eye examination with ultrasonography.  The ultrasound machine uses sound waves to safely and effectively “look through” the blood in the vitreous to see if the retina is attached.  If a retinal detachment is found, surgery is required in an attempt to repair it.  If no retinal detachment is found on ultrasound exam, your doctor may allow the vitreous hemorrhage to clear on its own with time.  The ultrasound exam may be repeated periodically to assure the retina remains attached.  If the hemorrhage does not clear on its own, vitrectomy surgery as a one-day surgery in the hospital operating room may be considered.  The amount of visual return depends on several factors including the health of the underlying retina.     

            In an effort to prevent additional bleeding, the underlying diabetic retinopathy may be treated with medication injections (e.g. Avastin, Lucentis, or Eylea) into the eye.  These injections can usually be given without significant pain by using anesthetics.  The injections reduce the risk of future bleeding, but do not hasten the clearing of the bleeding that has already occurred.   These medication injections may be especially important if no previous laser (or insufficient laser) has been given for diabetic retinal damage (diabetic retinopathy) prior to the vitreous hemorrhage.  Medication injections do not help with tugging on the retinal blood vessels by the vitreous.  Indeed, in rare cases the injections may increase the tugging.  Therefore, if tugging from the vitreous is determined to be the main factor in causing the diabetic vitreous hemorrhage, injections may not be used.  Instead, vitrectomy surgery is more effective at relieving the tugging.  

            Once the vitreous hemorrhage has cleared over time with observation or with vitrectomy surgery, laser is often used to stabilize the retinal blood vessels that have been weakened from diabetes.  This helps reduce the chances of reoccurrence of vitreous hemorrhage in the future.

What should I be on the lookout for?

            After examination or treatment for a vitreous hemorrhage, you should notify your doctor if you have a burst of new floaters, a loss of side vision, or pain.  Sometimes, retinal tears or a retinal detachment occur at a later date after the examination.

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 2021 Designs Unlimited of Florida.  All Rights Reserved.

Neovascular Glaucoma

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

What is neovascular glaucoma (NVG)?

            Neovascular glaucoma (NVG) is a severe type of glaucoma.  Glaucoma is a condition in which the pressure inside the eye damages the cells of the optic nerve.  The normal range of pressure in the eye is between 8-21 units of measurement.  There is a tissue inside the eye called the ciliary body that pumps a clear fluid (aqueous) into the eye keeping the eye from collapsing.  Another tissue called the trabecular meshwork drains the aqueous from the eye preventing the pressure from building up too high.  The pump and the drain are not connected and do not communicate with each other.  However, there is a normal balance between the pump and drain so that the eye pressure remains normal and healthy for the eye.  In neovascular glaucoma (NVG) abnormal blood vessels grow inside the eye where they block the drain resulting in high pressure.  High 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.  Therefore, NVG can cause pain, loss of vision, and blindness if left untreated.

What causes neovascular glaucoma (NVG)?

            The abnormal blood vessels in NVG grow inside the eye as a result of poor retinal blood supply.  There are many conditions that cause abnormal blood supply to the retina.  They include diabetic retinopathy, retinal vein occlusion, retinal artery occlusion, ocular ischemic syndrome, retinal detachment, and inflammation.  In these conditions the blood supply to the retina is impaired, so the retina sends out chemical messages that it needs more blood supply.   As a result, new blood vessels begin to grow inside the eye.  Unfortunately, these new blood vessels may grow into the drain (trabecular meshwork) where they cause harm.

What are the symptoms of neovascular glaucoma (NVG)?

            In the early stages of NVG, there may be no symptoms.  However, as the pressure inside the eye rises, symptoms include pain, redness, and loss of vision.  Sometimes, the pain is so severe that it causes nausea and vomiting.  If left untreated, NVG frequently results in a blind eye.  

How is neovascular glaucoma (NVG) 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 an eye exam.  In NVG the ophthalmologist then detects abnormal blood vessels growing in the drain (called NVA) by an office exam called gonioscopy.  The presence of high pressure in an eye with NVA makes the diagnosis of neovascular glaucoma.

What treatment is available?

            The key to treating NVG is addressing the underlying cause of poor blood supply to the retina.  Examination and testing usually provides the retinal diagnosis and treatment is directed toward treating that condition.  Frequently, medication injections (Avastin, Lucentis, and Eylea) initially help control the growth of abnormal blood vessels until laser or cryopexy can provide a more permanent effect.  

            If the drain (trabecular meshwork) has not been permanently damaged by scar tissue induced by the abnormal blood vessels, the pressure inside the eye may return to normal.  However, if permanent damage has occurred, eye drops and/or surgery may be needed to control the pressure.  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, surgery may help.  Surgery, performed in the operating room (trabeculectomy or glaucoma drainage device), creates 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 glaucoma surgery and result in severe damage or blindness.  In general, patients with glaucoma may require regular examinations every three to four months to preserve vision.

            The goal of treatment is to protect the vision and relieve pain.  If there is no usable vision, the pressure only needs to be controlled enough to prevent pain.  In severe cases surgery is performed to remove the eye (enucleation or evisceration) to relieve pain in a blind, painful eye.  An artificial eye is made to appear cosmetically acceptable.

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  © 2021 Designs Unlimited of Florida.  All Rights Reserved.

On-Time Doctor Award

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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

The Ocular Histoplasmosis Syndrome

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

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

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 © 2017-2022 Designs Unlimited of Florida. All Rights Reserved

Plaquenil Dosing Schedule

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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

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.

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

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

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

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 © 2017-2022 Designs Unlimited of Florida. All Rights Reserved.

Laser Surgery and the Retina

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Laser
Laser treatment (click to on image to enlarge)

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.

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

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

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.

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.

Preparing for Retinal Surgery

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How can I prepare for surgery?

One week prior to surgery: Unless your internist feels that stopping blood thinners unacceptably increases the risk of blood clots (stroke/heart attack), do not take aspirin-containing products, Effient, or Brilinta for one week prior to surgery. Coumadin may be stopped four days prior to surgery. Pradaxa, Xarelto, and Eliquis may be stopped two days prior to surgery. Your EyeMD will schedule an appointment with your primary care doctor if evaluation is needed prior to surgery. Please inform your doctor of any chest pain/pressure, fever, productive cough, shortness of breath, or bleeding tendencies.

The morning of surgery: Take no medications for diabetes unless instructed differently by your doctor. Please do take all of your other medications with a sip of water and you may use any prescribed eye drops as usual. Otherwise, do not eat or drink anything on the morning of the scheduled surgery. Report promptly to the hospital as scheduled, but expect to wait while the nurses prepare you for the operating room. Bring a complete list of your medicines with dosages. Do not wear make-up. Arrange for someone to drive you to and from the hospital.

What type of anesthesia is 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 there is usually no pain. It is important to lie still on the operating room table so that there is no movement of the head during surgery. The main advantage of local anesthesia is that the patient can leave the hospital more quickly than after general anesthesia.

With general anesthesia the patient is asleep throughout the surgery and remembers nothing of the surgery. The anesthesiologist places a tube down the throat into the trachea to breathe for the patient. After surgery the throat may be sore. Which type of anesthesia is best for a patient may be determined by the health of the patient. Otherwise, if a person cannot lie still for the surgery or if claustrophobia is a problem, general anesthesia is preferred.

What are the risks of 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, double vision, glaucoma, or loss of the eye. The most common problem following vitrectomy surgery is progression of cataract requiring cataract surgery at a later date.

Although serious problems are not encountered often, the risks and benefits must be weighed for each individual to arrive at a decision for surgery. For many eye problems, surgery is the only hope for improvement in vision or prevention of blindness.

What can I expect after 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. Tylenol (no more than 4,000 mg per day; caution with liver disease) or Ibuprofen (no more than 2,400 mg per day; caution with kidney disease) may be used if there is pain. 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 is due to sutures on the white of the eye. These sutures dissolve in about three weeks and you may use a lubricating ointment (Lacrilube is available without a prescription from the drugstore) as needed for comfort. 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 wear the hard protective shield at night for at least two weeks.

The vision usually returns slowly over days to weeks after surgery, but may take many months for final recovery. Use caution while walking as your depth perception may be altered until your vision returns after surgery. You may experience light flashes, floaters, and temporary double vision for days to weeks after the surgery. Do not be alarmed, but feel free to notify the doctor of any concerns that you may have. The swelling and redness slowly disappear over two or three months. There are no restrictions to using the eyes to read, watch TV, or bathe. Ask the doctor when you may resume driving. You may shower after the patch has been removed in the office. Avoid heavy lifting and straining for one week after surgery. You may resume taking all your medications after the surgery; however, blood thinners should be withheld until after the first visit in the office one day after the surgery.

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. Additionally, if a gas bubble is placed in your eye at the time of surgery, you may not fly on a plane until it has dissolved or you could risk severe pain and blindness. Similarly, nitrous oxide should not be used if any other surgery is required while you are healing from your eye surgery. Be sure to wear a wristband for six weeks after eye surgery to notify health care providers that you have a gas bubble in the eye. Remove the wristband only when your doctor has notified you that the gas bubble is gone.

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.

Stargardt Disease

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Stargardt disease image
Color photo and auto fluorescent fundus image of Stargardt disease

What is Stargardt disease?

Stargardt disease is an inherited problem of the retina. 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. Stargardt’s disease mainly affects the central part of the retina that normally provides sharp, central, reading vision and color vision.

What causes Stargardt disease?

Stargardt disease is usually inherited in a recessive pattern, which means it may skip many generations. An individual usually inherits the affected gene from both parents who carry the gene in order to have symptoms of the condition. Individuals who have inherited the gene from only one parent usually do not exhibit symptoms and are called “carriers”. If both parents carry the gene, then one in four children will have symptoms of Stargardt disease. If a person with Stargardt disease has children with someone who does not carry the gene, none of their children will have Stargardt disease, but half of their children will carry the gene. The gene variants that cause Stargardt disease are very common; they are present in about one in twenty people.

What are the symptoms of Stargardt disease?

Stargardt disease may cause no symptoms in the early stages. It may cause symptoms early or late in life. With time, symptoms may include the following:

  1. Photophobia—unusual sensitivity to light.
  2. Hemeralopia—difficulty seeing well in bright light.
  3. Decreased color vision.
  4. Blurring of central vision, sometimes with distortion or blind spots.

If Stargardt disease progresses over many years, it may cause a loss of vision to the point of legal blindness. In such cases, the loss of central vision interferes with the ability to read and drive, but the side-vision usually remains good. Sometimes it progresses very slowly and never causes significant visual loss. The rate of visual loss can be predicted by identifying others in the same family who also have Stargardt disease, as the pattern is often similar among family members. The visual symptoms may be monitored with the Amsler grid test.

How is Stargardt disease diagnosed?

The symptoms listed above may be the first clue to the diagnosis. A routine dilated eye examination can detect the retinal changes of Stargardt disease. In most cases a fluorescein angiogram is helpful. In this procedure the ophthalmologist injects a dye into the vein of the arm and photographs are taken of the retina, which show specific changes in the retina to make the diagnosis. A free genetic test can be ordered by my office and mailed to you.  It involves a painless swab of the lining of the mouth.  It is very reliable to detect the gene that causes Stargardt disease.

How is Stargardt disease treated?

There is no proven treatment for Stargardt disease, but studies are underway to find a treatment to slow the loss of vision. Researchers recommend avoiding excessive exposure to sunlight and avoid taking vitamin A supplements. It may also be helpful to avoid excessive dietary intake of foods that contain vitamin A, such as carrots and liver.

If significant loss of vision does occur, there are programs and devices that focus on helping a person find ways to cope with the visual impairment. Various low-vision optical devices such as magnifying devices, closed-circuit televisions, and large-print reading material can help to minimize the effects of visual impairment. Your ophthalmologist can prescribe optical devices or refer you to a low-vision specialist. Because side vision is less commonly affected, the remaining sight can be very useful.

A wide range of support services, rehabilitation programs, and devices are available to help people with cone dystrophy continue with many of their favorite activities. The Lighthouse for the Blind and the Pinellas Center for the Visually Impaired have classes and specialists in providing prescription lenses to magnify printed material. The Division of Blind Services provides rehabilitation services and financial aid for eye care in selected cases. Your doctor can give free access to the “talking book” library to make “books on tape” available. A form is available from your doctor that establishes legal blindness to be used for property tax and income tax deductions. As always, if you have any questions please do not hesitate to contact your doctor for more information.

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.

Cystoid Macular Edema (CME)

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

What is cystoid macular edema?

Cystoid macular edema (CME) is an accumulation of fluid in the center of the retina. The fluid is clear like water and comes from abnormal leakage of the blood vessels in 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” of objects you look at and sends the message to the brain. The macula is the central area of the retina that gives you sharp central vision and color vision. CME frequently causes a blurring of vision described as fuzzy, hazy, or cloudy. Cystoid macular edema is NOT related in anyway to macular degeneration.

What causes cystoid macular edema?

Although the exact causes of CME are unknown, it may accompany blood vessel problems or inflammation. It most commonly occurs after cataract surgery and may be seen in as many as 3% of eyes undergoing surgery.

How is cystoid macular edema treated?

Since many factors may lead to CME, many different types of treatment are available. Usually weeks to months are required to improve the vision. Sometimes more than one type of treatment is needed for best results. Rarely, vision cannot be restored.

Treatment may include eye drops (steroid, and non-steroid) instilled into the eye several times a day. Sometimes, pills are used to decrease inflammation. Occasionally, medication is injected next to the eye under the eyelid. Anesthetic eye drops help to make the injections painless. Sometimes, surgery is needed to look for infection or remove abnormal scar tissue from inside the eye. With treatment most cases of CME can be managed successfully with improvement in vision. For more information visit www.retinavitreous.com

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 © 2015-2022 Designs Unlimited of Florida. All Rights Reserved.

Posterior Uveal Effusion

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

What is posterior uveal effusion syndrome (PUES)?

PUES is an abnormal leakage of clear fluid under the retina, which causes symptoms of blurred vision, sometimes with distortion of straight lines. It is also call the peripapillary pachychoroid syndrome. This condition frequently presents as central serous retinopathy. 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 the picture” of objects you look at and sends the message to the brain.

What causes PUES?

PUES appears to be due to an abnormal leakage of serum (clear fluid) from blood vessels in the choroid. The choroid is a layer of tissue with many blood vessels lying under the retina. When the choroid is thick, it may abnormally leak fluid into the retina (Figure A-D) causing visual symptoms. Thick choroid is seen more commonly in far-sighted eyes than near-sighted eyes.

PUES
Thickened choroid leads to leakage of fluid into the retina

What is the treatment of PUES?

If the leakage is mild, observation may be all that is needed. If symptoms of blurred vision become significant, treatment may include eye drops or pills taken by mouth (Figure E-F). In rare cases, laser treatment or surgery in the operating room may be required to control the leakage. An attempt is made to eliminate aggravating factors such as ocular inflammation and, rarely, medications.

What will happen to my vision?

With prompt treatment the vision usually remains stable. In some cases, there may be a degree of permanent damage to the retina affecting the vision from past leakage that cannot heal. Treatment needs to be continued as a return of leakage may occur is medications is stopped (Figure G-H).

For more information see: Isolated Posterior Uveal Effusion: expanding the spectrum of the uveal effusion syndrome.

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 © 2015-2022 Designs Unlimited of Florida. All Rights Reserved.

Iluvien Fluocinolone Implant for Diabetic Macular Edema

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Iluvien
Iluvien Implant

What is the Iluvien implant?

The Iluvien implant is shaped like a small thin tube so that it can be injected into the eye in the office with a needle attached to an injector. The tube contains a corticosteroid medicine that is released into the eye slowly for up to 2-3 years. Repeated injections may be performed. When the tube-like implant is empty it remains in the eye and usually causes no problems.

What is the Iluvien implant used for?

The Iluvien implant decreases inflammation, leaky vessels and swelling inside the eye. It has been approved to treat diabetic macular edema. It helps keep the vision from worsening and may improve vision over time.

How is an Iluvien implant inserted into the eye?

Anesthetic solutions are used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation may be felt as the implant is injected into the eye with a very thin, short needle. The procedure is very brief.

What are the possible side-effects?

It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. It is rare to see the tube floating in the vision. Most eyes require cataract surgery several months after injection of the implant. About 30-40% of eyes experience a pressure increase (glaucoma) in the eye. Although the pressure is not usually painful, it may require eye drops to prevent permanent loss of vision. In 1-5% of eyes, glaucoma surgery is needed. Rare risks of injection include bleeding, infection, retinal detachment, and loss of vision/loss of the eye. Please report any severe loss of vision to the doctor without delay.

How do I care for the eye?

You may be given eye drops and instructions on how to use them. Physical activity is not limited. Tylenol or Ibuprofen may be used if there is discomfort, but severe pain should be reported to your doctor without delay. 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 © 2014-2022 Designs Unlimited of Florida. All Rights Reserved.

Intravitreal Steroid Injection

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vitreous gel
Clear vitreous gel fills the eye (click on image to enlarge)

Why is an intravitreal steroid injection performed?

An intravitreal steroid injection (ISI) is a painless office procedure performed to decrease inflammation, swelling, or leaky blood vessels inside the eye. Conditions that may require ISI include diabetic macular edema, retinal vein occlusion, uveitis, macular degeneration, and other causes of swelling and/or inflammation. The steroid medicine acts to decrease inflammation and leakage from blood vessels from a variety of causes, thereby offering the chance for improvement in vision. The effect of ISI lasts for several months after which repeated injection may be considered if necessary.

How is an intravitreal steroid injection performed?

Anesthetic solutions are used to make the procedure pain-free.  The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation is often felt as the steroid is injected into the eye with a very thin, short needle. The procedure is very brief.

intra-ocular injection
Intra-vitreal injection

What medications are injected?

Triamcinolone is a steroid that has been used for many years in the eye. The most common preparation contains preservatives that may be decanted from the preparation to avoid ocular inflammation. Triesence® is a form of triamcinolone for the eye that lacks preservatives, but is more expensive. These steroids usually provide anti-inflammatory effect for several months.

Dexamethasone may be injected into the eye in a slow-release implant, called Ozurdex®. The effect of Ozurdex® may last up to 3-6 months.

Iluvien® is a steroid implant (2014) approved for the treatment of diabetic macular edema. It may last up to 2-3 years.

Yutiq® is a steroid implant approved for the treatment of uveitis. It may last up to 2-3 years.

steroids
Intraocular steroid preparations

Will an intravitreal steroid injection affect my vision?

It is normal to see the steroid medication after the injection as many floating particles (triamcinolone) or a single large fiber (Ozurdex®, Iluvien®, Yutiq®), which slowly disappear over several weeks to months in the case of triamcinolone and Ozurdex. The anticipated improvement in vision occurs slowly during this time. Commonly, the pressure inside the eye increases and may require eye drops for several months. Sometimes the high pressure results in optic nerve damage (glaucoma) and rarely requires surgery in 1-4% of cases. There is also an increased rate of cataract formation. For these reasons ISI is best performed in eyes that have already had cataract surgery and are not at high risk of glaucoma damage. Rare risks of steroid injection include bleeding, infection, retinal detachment, and loss of vision or loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections. The risk of infection is about one in 1,000 injections. Please report pain or any severe loss of vision after injection to the doctor without delay.

How do I care for the eye?

You may be given eye drops and instructions on how to use them. Artificial tears may be used hourly until the eye feels less irritated from the iodine solution, which is used to prevent infection. Physical activity is not limited after ISI. 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 your doctor.

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

Pneumatic Retinopexy

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

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?

PR
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.

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

 

PR
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

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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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.

Central Serous Retinopathy

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central serous retinopathy
anatomy of the eye (click on image to enlarge)

 

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

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  © 2013-2023 Designs Unlimited of Florida.  All Rights Reserved.

Retinal Vein Occlusion

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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.

retinal vein occlusion
anatomy of the eye (click on image to enlarge)

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

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.

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

Copyright  © 2013-2023 Designs Unlimited of Florida.  All Rights Reserved.

Vitreomacular Traction Syndrome

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vitreous gel
Clear vitreous gel fills the eye (click on image to enlarge)
normal macular OCT
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 the vitreomacular traction syndrome?

The vitreomacular traction syndrome is a condition in which the vitreous gel, which fills the inside of the eye, pulls on the macula. The macula is the center of the retina and gives sharp central vision for reading and seeing fine details. The retina is a thin layer of tissue in the back of the eye that 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. When the macula is damaged, the central vision worsens.

What causes the vitreomacular traction syndrome?

The vitreomacular traction is caused when the clear gel that fills the eye (vitreous) pulls on the macula.  At birth the vitreous is a thick and perfectly clear gel.  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 vitreous may pull the macula away from its normal position, distorting this normally smooth tissue.

normal OCT
Normal macula as seen on optical coherence tomography (click to enlarge)
VMT
Vitreomacular traction as seen on optical coherence tomography (click to enlarge)

What are the symptoms of the vitreomacular traction syndrome?

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 vague blind spot in the center of vision. The visual symptoms may be detected and monitored with the Amsler grid test.

What treatment is available?

If the symptoms are mild, no treatment is needed.  Medicine injection (Jetrea®) or vitrectomy surgery may help if there is significant loss of vision.  In most cases the vision improves with injection or a surgery that releases the abnormal pulling of the vitreous on the macula.  A gas bubble may be placed in the eye to smooth out the macula.  Strict facedown positioning may be recommended for one week following surgery.  Special cushions and massage tables are available to help maintain the proper head position.  The surgery is usually successful in returning vision, though the vision may not return completely to normal.

The image below shows the separation of vitreous fibers from the macula after Jetrea injection:

Jetrea VMT
Vitreomacular traction relieved by Jetrea (click to enlarge)

Below is a video that reviews the anatomy of the eye, information on vitreomacular traction, and an example of vitrectomy surgery:
https://youtu.be/r-5Az8_DU3U

Below is the case of a 70-year-old woman who had mild VMT. She was observed over several years and the traction released without surgery.

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.