Scott E. Pautler, M.D. Tampa

Treatment of diseases of the retina and vitreous

Visual Snow Syndrome

Posted on August 14, 2022 by Scott Pautler

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

What is visual snow?

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

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

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

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

What causes the primary visual snow syndrome?

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

How is primary visual snow syndrome diagnosed?

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

What can be done about these symptoms?

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

By Scott E. Pautler, MD

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Black Spots After Eye Injection

Posted on August 6, 2022 by Scott Pautler

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

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

What causes these symptoms?

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

What should be done about these symptoms?

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

What other symptoms can mimic this problem?

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

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

By Scott E. Pautler, MD

Byooviz Therapy

Posted on July 30, 2022 by Scott Pautler

What is Byooviz?

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

What is the difference between biosimilar drugs and generic drugs?

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

How effective is Byooviz therapy?

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

What are the risks of Byooviz therapy?

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

What do I expect after a Byooviz injection?

Be careful not to rub the eye after the injection because the eye may remain anesthetized for several hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after the injection. Tylenol or Ibuprofen may be used if there is discomfort, but severe pain should be reported to your doctor without delay. It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. If you have any questions or concerns, please call the office.

What does Dr Pautler think about Byooviz?

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

By Scott E. Pautler, MD

What is the Best Drug for Eye Injections?

Posted on July 10, 2022 by Scott Pautler

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

What drugs are available and how effective are they?

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

What is the cost of these drugs?

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

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

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

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

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

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

Summary:

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

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

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

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

What is my professional preference?

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

Are doctors paid by drug companies to use their drugs?

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

By Scott E Pautler, MD

Diamox and Neptazane for the Eye

Posted on March 12, 2022 by Scott Pautler

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/min	Dosage
20-50	250 mg up to 4 times a day
10-20	250 mg up to 2 times a day
<10 or on dialysis	250 mg daily or 3 times a week

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

By Scott E. Pautler, MD

Tea Tree Oil for the Eyelid

Posted on August 29, 2021 by Scott Pautler

What is tea tree oil and how is it helpful?

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

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

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

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

What preparations are available?

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

What side-effects may occur?

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

What brands are available?

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

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

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

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

By Scott E. Pautler, MD

Diabetic Vitreous Hemorrhage

Posted on July 22, 2021 by Scott Pautler

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

Sickle Cell and the Eyes

Posted on June 6, 2021 by Scott Pautler

What is Sickle Cell Disease?

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

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

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

What are the visual symptoms of sickle cell disease?

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

What treatment is available?

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

By Scott E Pautler, MD

Vision Loss in ARMD

Posted on May 31, 2021 by Scott Pautler

Why am I losing vision despite treatment for age-related macular degeneration?

Age-related macular degeneration (ARMD) is the most common cause of visual loss in older Americans. Vision may be lost from dry-type or wet-type ARMD:

Dry-type macular degeneration is the most common type and involves the disintegration of the light-sensitive tissues in the macula. Loss of vision is usually gradual in dry macular degeneration. Small blind spots interfere with reading numbers in a row and all the letters of a word. Over time, these blind spots usually enlarge and take away most of the central vision.

Wet-type macular degeneration accounts for about 10% of all cases of ARMD. It occurs in patients with dry-type ARMD when abnormal blood vessels grow under the macula and cause fluid leakage, bleeding, and scarring of the macula. Vision loss may be rapid and severe. Straight lines may appear distorted and the central vision appears blurred early in wet-type ARMD. Over time, a large blind spot may develop in the center of the vision. If one eye develops wet ARMD, there is about a 50% chance the other eye will be affected within the next five years.

There is currently no proven drug treatment to stop dry-type ARMD. Eye vitamins are prescribed for dry-type ARMD. However, the main purpose of the vitamins is to stave off the start of wet-type ARMD. Although AREDS eye vitamins appear to slow the start of blind spots in the vision from dye-type AMD, they do not slow the progression of blind spots once they start. A Meditteranean diet appears to reduce the onset and progression of blind spots from dry-type macular degeneration. Therefore, it is important to limit red meat intake to once per week, eat two servings of whole fruit per day, include fish in the diet, and rely on olive oil rather than other oils with saturated fatty acids. There are a number of on-going research studies to find a treatment to slow or prevent loss of vision from dry-type ARMD. There is even hope for treatment to reverse the loss of vision from dry-type ARMD. Your doctor can put you in touch with study centers if you are interested in learning more about or participating in these research studies. Age-related macular degeneration appears to be an inherited condition. However, it may be aggravated by factors that cause hardening of the arteries like high blood pressure, high cholesterol, overweight, physical inactivity, and tobacco use. Efforts to control these factors may be helpful in slowing loss of vision in dry-type ARMD.

There are fairly good treatment options for wet-type ARMD. Injection therapy (Avastin, Lucentis, Eylea, and Beovu) is the first-line treatment for wet-type ARMD. Lasers are second-line treatment options. Lasers include photocoagulation (which is rarely used currently) and Visudyne photodynamic therapy. Treatment of wet-type ARMD is effective at slowing the loss of vision. Unfortunately, current treatments do not completely prevent the loss of vision from ARMD. There are several reasons why patients may continue to lose vision during treatment of ARMD:

1. Insufficient treatment

Some eyes require injection therapy every four weeks to optimal effect. If treatment is given less often, the wet-type ARMD may progress with loss of vision that may be irreversible. This is an important reason to continue monthly injections in some eyes (as determined by the retinal specialist).

2. Bleeding despite treatment

Bleeding under the retina from ARMD usually results in some degree of permanent scar tissue and loss of vision. Bleeding may occur if treatment is not given frequently enough and appears more likely in patients who take blood thinners. Blood thinners (including aspirin) are usually prescribed to prevent heart attack or stroke. If they are prescribed, the benefits likely outweigh the risks. However, if blood thinners are not prescribed for a patient with ARMD, they may be best avoided to reduce the risk of bleeding from ARMD.

3. Progression of dry-type ARMD while wet-type ARMD is being treated

Many patients are not aware that ARMD always starts with the dry-type. Wet-type ARMD develops later. Therefore, patients with wet-type ARMD may lose vision over time even though their wet-type ARMD is well controlled. That in, they may lose vision from a worsening of dry-type ARMD over time. Complicating this issue is the concern that the very treatment of wet-type ARMD may, in some cases, worsen the dry-type ARMD.

4. New eye problems develop during treatment of ARMD

The ophthalmologist will look for other problems that may cause a loss of vision unrelated to ARMD. Common causes of vision loss include cataract, which is treatable with surgery. Other problems include glaucoma, retinal vein occlusion, and diabetic retinopathy.

What is to be done about the continued loss of vision?

There are a number of actions that may be taken in response to continued loss of vision during treatment of ARMD. The retinal specialist will look for other causes of loss of vision and start appropriate treatment. The frequency of treatment may be changed in response to changes in the retina. Low vision aids (optical and electronic magnifiers) may be helpful. Specially-trained social workers may help make changes in the household to make it easier to remain self-sufficient. It is helpful to remember that the peripheral vision is rarely taken by ARMD. Therefore, although a patient may be determined to be legally blind, total blindness is rare. Most patients with advanced ARMD are able to ambulate and retain independence.

By Scott E Pautler, MD

Retinal Angiomatous Proliferation

Posted on May 23, 2021 by Scott Pautler

What is retinal angiomatous proliferation (RAP)?

Retinal angiomatous proliferation means there is a growth (proliferation) of abnormal blood vessels (angiomatous) in and under the retina (specifically, under the central part of the retina called the macula). Retinal angiomatous proliferation (RAP) is a sub-type of wet age-related macular degeneration (ARMD). Wet ARMD affects the central vision in older patients due to abnormal blood vessels growing under the macula. The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision. The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused through the lens onto the retina, which “takes the picture” and sends the image to the brain.

What causes retinal angiomatous proliferation (RAP)?

Retinal angiomatous proliferation (RAP) appears to be caused by the release of blood vessel growth factors in the retina in response to age-related changes. The age-related changes include the accumulation of cellular waste products under the retina (call subretinal drusenoid deposits). The build-up of waste products (SDD) under the retina interferes with retinal function. For one thing, the build-up of SDD separates the retinal cells from the normal blood vessels that nourish them. Without proper nourishment the retinal cells do not work well. Furthermore, when the retinal cells perceive that they are not getting enough oxygen and nutrients, they release growth factors (including one growth factor called VEGF). These growth factors stimulate the growth of new blood vessels to assist in delivering oxygen and nutrients. In other parts of the body, new blood vessels may grow to help or replace old blood vessels and it is a helpful response to poor blood supply. However, in RAP the new blood vessels cause loss of vision due to fluid leakage, bleeding, and scarring of the macula.

What are the symptoms of retinal angiomatous proliferation (RAP)?

Retinal angiomatous proliferation (RAP) may cause no symptoms in its early stages. Over time, symptoms may include blurred central vision, distortion of straight lines and/or a central, gray spot in the vision. In its advanced stages without treatment, RAP may cause a large permanent blind spot in the center of vision. At this stage no treatment is possible and low vision aids are used to compensate for loss of vision. If one eye develops wet AMD, there is about a 50% chance the other eye will be affected within the next five years.

How is retinal angiomatous proliferation (RAP) diagnosed?

Retinal angiomatous proliferation (RAP) is diagnosed in patients with known dry-type age-related macular degeneration. Before the proliferation or growth of blood vessels under the retina develop in RAP, subtle yellow deposits may be identified under the retina. These deposits are called subretinal drusenoid deposits (SDD). SDD develop many years before RAP occurs. A dilated eye examination can detect SDD and alert the retinal specialist to be on the lookout for RAP. Retinal angiomatous proliferation is suspected when a patient with SDD develops blurred vision and swelling (edema) is present in the retina on a retinal scan called OCT (optical coherence tomography). The diagnosis may be confirmed on a more extensive test called fluorescein angiography. This is a procedure where the ophthalmologist injects an organic dye into the vein of a patient’s arm. Then, photographs of the retina show the presence and location of the leaking blood vessels marked by the organic dye.

Why is this diagnosis important?

It is important to recognize RAP because it guides treatment recommendations. This type of wet ARMD is especially sensitive to antiVEGF therapy (injections with Avastin, Lucentis, and Eylea). RAP is so sensitive to antiVEGF therapy that the medication injections are sometimes not required as often as they are in other types of wet age-related macular degeneration such as PCV. Older treatments such as photocoagulation and photodynamic therapy historically do not work well in RAP and can be avoided. Treatment rarely returns vision to normal, but may limit the amount of vision loss from blood vessel growth and leakage. Frequent office visits and photographs are needed. It may be useful to stop smoking, avoid becoming overweight, exercise daily, and control blood pressure and cholesterol. Aspirin should only be used if required to treat disease as recommended by a doctor. Relatives should be checked for macular degeneration, as well.

By Scott E Pautler, MD

Polypoidal Choroidal Vasculopathy

Posted on March 13, 2021 by Scott Pautler

What is polypoidal choroidal vasculopathy (PCV)?

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

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

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

What causes polypoidal choroidal vasculopathy (PCV)?

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

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

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

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

How is polypoidal choroidal vasculopathy (PCV) diagnosed?

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

How is polypoidal choroidal vasculopathy (PCV) treated?

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

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

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

By Scott E. Pautler, MD

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

Birdshot Chorioretinopathy

Posted on June 27, 2020 by Scott Pautler

What is birdshot chorioretinopathy?

See Anatomy of the Eye

Birdshot chorioretinopathy (BSC) is a type of uveitis (pronounced, “you-vee-EYE-tis”), a term used to describe inflammation inside the eye. BSC mainly causes inflammation of the choroid and retina, but may affect other parts of the eye as well. The choroid is the part of the uvea that lies under the retina, which is the “film” in the back of the eye that “takes the picture” of objects you look at. BSC is fairly rare form of inflammation affecting both eyes of men and women, usually starting in middle age.

What causes birdshot chorioretinopathy?

Birdshot chorioretinopathy (BSC) is strongly related to genetics. Most people with BSC have inherited a cell protein called HLA-A29. However, most individuals with HLA-A29 do not develop BSC; it appears to be triggered by an external event, such as an infection that “awakens” the immune response, which then abnormally attacks the eyes. BSC is most common in people of European ancestry.

What are the symptoms of birdshot chorioretinopathy?

Birdshot chorioretinopathy (BSC) usually presents with the slow-onset of floaters and blurred vision in both eyes. The floaters appear as tiny floating dots, which move or “float” in the vision and are seen especially well in bright environments. Shimmering lights may also be reported. Some patients note difficulty seeing at night. Symptoms may be very bothersome despite normal vision as measured on the eye chart. Over many years without treatment, the vision deteriorates further with loss of contrast, color vision, peripheral vision, and central vision. The symptoms vary from person to person and some have more rapid and severe deterioration than others.

How is birdshot chorioretinopathy diagnosed?

The diagnosis of birdshot chorioretinopathy (BSC) may be delayed due to the slow onset of symptoms and the subtle findings on the eye exam. A retinal specialist or uveitis specialist may be needed to perform sophisticated testing and make the diagnosis. Inflammation may be detected in many different parts of the eye, but the most typical findings include numerous pale spots inside the back of the eye. Blood testing for HLA-A29 is positive in the vast majority of patients with BSC. However, not all patients with uveitis who are positive for HLA-A29 have birdshot chorioretinopathy. Therefore, it is necessary to exclude other diseases that may simulate BSC including lymphoma, sarcoidosis, tuberculosis, syphilis, and cancer medications such as pembrolizumab and others.

How is birdshot chorioretinopathy managed?

Birdshot chorioretinopathy (BSC) usually requires management by an experienced retinal or uveitis specialist. In most cases, systemic treatment (pills or injections into the skin) are needed to control the inflammation. In a small subset of patients, localized treatment to the eye is sufficient. This is more often the case in older patients at onset of symptoms. When pills are used, the eye doctor frequently coordinates medical care with the expert assistance of a rheumatologist (a medical specialist with expertise in auto-immune diseases, like rheumatoid arthritis). In BSC the rheumatologist monitors the patient for medication side-effects that may develop outside the eyes. In many cases, the uveitis may be long-lasting. In these cases, years of therapy are needed to preserve vision.

Your doctor will choose from a variety of medications. Steroids (pills, eye drops, and injections) may be used at the start of treatment to gain rapid control of inflammation. However, long-term steroid treatment in high doses is usually avoided to prevent side-effects of steroid therapy. For long-term control methotrexate (MTX) pills or skin injections may be given weekly. MTX has a long record of safety and is affordable. If MTX fails or causes side-effects (liver or bone marrow), CellCept is another suitable medication, though it may cause diarrhea. Cyclosporin has been used effectively, but is fraught with a high incidence of problems with hypertension (high blood pressure) and kidney toxicity. Humira is a new biologic treatment given as an injection into the skin every two weeks. It has been approved by the FDA for treatment of uveitis, such as BSC. All medications used to treat BSC may have adverse effects and must be monitored for effectiveness and safety in a given patient.

Birdshot chorioretinopathy is a serious eye problem and may result in loss of vision or blindness. However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized.

By Scott E. Pautler, MD

Serine and MacTel

Posted on January 12, 2020 by Scott Pautler

What is MacTel?

MacTel (Macular Telangiectasia) is a degeneration of the center of the retina (called the macula) that affects central vision. The macula is a type of nerve tissue that works to give sharp central vision to read and see fine details. There is evidence that an amino acid called serine plays a role in the cause MacTel.¹

How does serine relate to MacTel?

Serine is an amino acid that is used by the body to build proteins and lipids. If this building block is not used properly by the body, abnormal nerve lipids (deoxysphingolipids) may accumulate and damage nerve cells.

In an inherited condition (hereditary sensory and autonomic neuropathy type 1) an abnormal enzyme causes abnormal nerve lipids in the body and can cause nerve damage. Peripheral nerve damage may cause numbness and tingling of the hands and feet. Autonomic nerve damage may interfere with internal organ function (e.g. intestines, bladder, heart). In addition, these patients frequently develop MacTel.

Even without this inherited condition of neuropathy, patients with MacTel often have low blood levels of serine that result in high blood levels of abnormal nerve lipids. These abnormal nerve lipids have been shown to damage retinal cells and likely play a role in loss of vision in MacTel.

What can be done with this information?

At present (1-2020) the authors of the research paper advise against starting treatment based on their paper. They caution that more research is needed. However, the FDA found that over-the-counter L-serine supplements to be generally safe. One study found the use of L-serine (400mg/kg/day) safely lowered the abnormal nerve lipids in a case of hereditary sensory and autonomic neuropathy.²Side effects of taking L-serine include stomach discomfort, diarrhea, constipation, and frequent urination. Most supplements come in the form of capsules containing L-serine 500mg. It is unknown what dosage might be most effective for MacTel. A patient may wish to take the dosage recommended on the bottle by the manufacturers.

Check for current prices of L-serine on Amazon.

Another option is the use of fenofibrate, a prescription medication that can lower the abnormal nerve lipid levels. This option may be especially useful in patients with MacTel who have abnormal cholesterol and/or triglycerides because fenofibrate has already been approved for use in the treatment of these conditions apart from potential benefit for MacTel.

In general, patients with MacTel who also have symptoms of sensory or autonomic neuropathy should notify their retinal specialist and internist for additional testing and consider treatment.

By Scott E. Pautler, MD

References:

1. Gantner, et al. Serine and lipid metabolism in macular disease and peripheral neuropathy. N Eng J Med 2019;10:1422-1433.

2. Auranen et al. Clinical and metabolic consequences of L-serine supplementation in hereditary sensory and autonomic neuropathy type 1C. Cold Spring Herb Case Stud 2017;3:6.

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

Stem Cell Therapy for Macular Degeneration

Posted on November 27, 2019 by Scott Pautler

What is stem cell therapy?

Although there is on-going research to refine the use of stem cells to treat conditions like macular degeneration with the hope of halting or recovering lost vision, there is currently no proven therapy available in the United States. Unfortunately, private clinics have started promoting potentially blinding “cell therapy” for numerous problems including macular degeneration. The concept is that cells will be harvested from a number of sites (usually fat) and then injected into the eye. The promise is that this treatment will help treat eye disease.

What is the danger of stem cell therapy given in this fashion?

Stem cell therapy provided in these clinics has resulted in blindness/loss of the eye. Injections given into the eye have caused bleeding, scarring, and retinal detachment with loss of vision. The reason for the loss of vison may include the types of cells that are injected and the method of injection. There does not appear to be any uniformity of cell type that is used. In addition, the method of injection appears to be into the vitreous gel of the eye. This may create inflammation in the vitreous that results in scar tissue and traction on the retina. Inflammation and scar tissue formation in the vitreous may result in blindness from retinal detachment.

What is a patient to do?

It is very frustrating to lose vision from macular degeneration. Currently, FDA-approved treatments help many patients, but fall short of a cure. It is understandable for a desperate patient to seek care where hope is offered. However, current “cell therapy clinics” are not the answer. Seek the advice of your trusted ophthalmologist and utilize low vision care with magnification. Await the results of FDA-sponsored clinical trials to find safe and effective treatments for macular degeneration.

By Scott E. Pautler, MD

Beovu for Macular Degeneration

Posted on October 22, 2019 by Scott Pautler

What is Beovu therapy?

Beovu (pronounced “BEE oh view”) therapy is a treatment for wet-type macular degeneration (AMD). It was approved by the FDA in the United States in 2019. It involves repeated injections of medication into the eye to stop abnormally leaky blood vessels. Other similar medications include Avastin, Lucentis, Eylea, and Vabysmo.

How effective is Beovu therapy?

Beovu was proven in FDA-approved studies to be as effective as Eylea. In wet-type macular degeneration, injections of Beovu over a one-year period offered a 95% chance of losing less than three lines on a standard eye chart. The results with Beovu were similar to treatment with Eylea; however, Beovu appeared to stop leakage in wet AMD more often than Eylea. Beovu therapy often starts with injections every 4-6 weeks. Afterwards, the injections may be given every two or three months to maintain vision. Half of eyes treated in a large study could be managed with injections every three months. At this time, it is not known whether Beovu is more effective than Eylea due to limitations in the studies to date.

What are the risks of Beovu therapy?

Severe complications are very rare, but risks of Beovu injection include inflammation (~10%), artery occlusion (~3.4%), bleeding, infection, retinal detachment, glaucoma, cataract, and loss of vision/loss of the eye. When inflammation occurs, it may affect the blood flow to the retina with an overall risk of ~3.4% in Beovu-treated eyes. This complication may result in permanent and profound loss of vision. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor. In initial studies there appeared to be a low risk of stroke with Beovu therapy. The risk of stroke may be related to the older age of patients in which it is used. Further investigation will provide more information. Pregnancy should be avoided while on Beovu therapy. Currently, caution is used in recommending Beovu due to the risk of inflammation and loss of vision, which appears greater than other available medications. In 2022, a new medication, V abysmo, was approved by the FDA. Vabysmo may offer the advantage of less frequent injections like Beovu, but with a lower risk of inflammation.

What do I expect after a Beovu 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. On the day of injection, 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. After the day of injection, if you develop new floating dots, new pain, and/or loss of vision, contact your doctor.

By Scott E. Pautler, MD

Intermediate Uveitis

Posted on December 15, 2018 by Scott Pautler

Eye — Vitreous is the gel that fills the eye (click on image to enlarge)

See Anatomy of the Eye

What is intermediate uveitis?

Uveitis (pronounced, “you-vee-EYE-tis”) is a general term used to describe inflammation inside the eye. The uvea is the name given to the layer of tissue in the eye that has a brown color (melanin pigment) and blood vessels, which serve to provide blood supply and protect the eye from excessive light. The uvea can be divided into separate parts, which perform different functions in the eye: the iris, the ciliary body, the pars plana, and the choroid. The part of the uvea in the front of the eye is called the iris (the round, blue or brown part of the eye that you can see in the mirror). Behind the iris is the ciliary body, which produces the fluid that fills the eye. The pars plana serves as the boundary between the ciliary body and the choroid. The back part of the uvea that lies under the retina (the “film” in the eye that “takes the picture”) is called the choroid. Therefore, in any one patient uveitis is usually given a more specific name depending on where most of the inflammation is located in the eye. In intermediate uveitis the inflammation is primarily located in the vitreous gel that fills the eye, which is located in an intermediate position between the front and the back of the eye. It is sometimes referred to as vitritis or pars planitis.

What causes intermediate uveitis?

Uveitis may be caused by an infection, an injury from trauma, a disease in the body outside the eye, or sometimes for unknown reasons. Infection by a virus, bacteria, fungus, or other parasite may cause uveitis. Infections may be limited to the eye or may involve other organs as well. In intermediate uveitis, infection may be caused by syphilis, tuberculosis, Lyme disease, cat scratch disease, Whipple’s disease, toxocariasis, human lymphotrophic virus (HTLV-1), or toxoplasmosis.

In other situations, uveitis is caused by inflammation without infection. For example, multiple sclerosis, sarcoidosis, HLA-B27, and inflammatory bowel disease may cause intermediate uveitis. Pars planitis is a sub-type of intermediate uveitis that often starts early in life during childhood. Its cause is unknown.

Uveitis commonly occurs following an injury to the eye. Very rarely, cancer or cancer-fighting drugs may cause intermediate uveitis. In some cases, no underlying cause can be found to be the cause of uveitis. Tobacco may be an aggravating factor and should be discontinued.

What are the symptoms of intermediate uveitis?

The most common symptoms include tiny floating spots which move or “float” in the vision. They are usually numerous and may cause a veil-like appearance in the vision. Sometimes blind spots, blurred vision, distortion, or loss of side vision occurs. The eye may be painful, red, tearing, and light sensitive if other parts of the eye are also inflamed. Symptoms may be mild or they may be severe and disabling.

How is intermediate uveitis managed?

To effectively treat intermediate uveitis, it is important to find the underlying cause whenever possible. Take some time to carefully review and report to your doctor any unusual or unexplained symptoms such as rashes, back and joint problems. Tell your doctor if you travel abroad, spend time in rural settings, or may be exposed to animals or infections. Heredity may also play a role. You should tell your doctor about any family members with inflammatory disorders anywhere in the body. Also, review and report your ancestry (for example, Asian, Mediterranean, or American Indian ancestry). When the doctor diagnoses uveitis, laboratory tests may be ordered to help determine its cause. Occasionally, a surgical biopsy is needed for diagnosis. If infection is found, antibiotics are prescribed. To limit the damage from inflammation, intermediate uveitis is treated with anti-inflammatory medication in the form of eye drops, injections, or pills. When pills are used, the eye doctor frequently coordinates medical care with the expert assistance of a rheumatologist. Rarely, surgery is required to treat uveitis. In some cases, intermediate uveitis may be long-lasting. In these cases, years of therapy are needed to preserve vision. Intermediate uveitis is a serious eye problem and may result in loss of vision or blindness. However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized.

In some cases, intermediate uveitis may go away, but return at a future date. Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact your doctor. Preliminary evidence suggests that tobacco use may be an aggravating factor in some cases of uveitis.

By Scott E. Pautler, MD

Retinal Rejuvenation

Posted on November 17, 2018 by Scott Pautler

Retinal rejuvenation is a name given by the company that sells a new-generation laser machine to ophthalmologists. The laser is used to treat the retina with the hope of delaying loss of vision from age-related macular degeneration (ARMD). Although the laser company calls this treatment “retinal rejuvenation,” this name may be overstating the true effects of this new laser.

The scientific basis for the use of the laser for macular degeneration is the LEAD study. This study evaluated 292 patients with ARMD over a three-year period. Half of the eyes were treated with the new micro-pulse laser and the remainder received sham treatment for comparison. Overall, the treatment was not shown to be of benefit in slowing the loss of vision from macular degeneration. However, when looking at subsets of eyes with certain types of macular degeneration (no reticular pseudodrusen), there was a trend toward a benefit. These results, however, had a weak fragility index (meaning that more research is needed). Conversely, eyes with reticular pseudodrusen (subretinal drusenoid deposits) lost vision at a greater rate after undergoing retinal rejuvenation than those eyes that were not treated.

“Retinal rejuvenation” needs more study before it is implemented on a wide scale basis. It is currently (2018) not approved for this use in the United States. More research is needed to better establish its helpfulness in reducing the risk of vision loss from age-related macular degeneration and to identify potential risks involved with its use.

I do not recommend the “retinal rejuvenation” treatment for age-related macular degeneration by the new micro-pulse laser at this time. I look forward to more high-quality research in the future to better establish the potential role of this laser for my patients with ARMD.

By Scott E. Pautler, MD

Visudyne Photodynamic Therapy

Posted on September 30, 2018 by Scott Pautler

What is photodynamic therapy?

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

What do I expect after photodynamic therapy?

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

By Scott E. Pautler, MD

Over-the-Counter Pain Medications

Posted on July 21, 2018 by Scott Pautler

What are over-the-counter pain medications?

Over-the-counter (OTC) pain medications are pills that can be purchased without a prescription. There are a number of brands available. Examples include ibuprofen (Motrin) and acetaminophen (Tylenol). As ibuprofen and acetaminophen work via different pathways, they can be used together for improved pain control.

What side effects might be expected?

Most drugs have many possible side-effects. The major concern with acetaminophen is liver damage especially seen in patients with known liver disease. The major concern with ibuprofen is kidney damage in patients with known kidney disorders. Also, ibuprofen may irritate the stomach and increase the risk of stomach ulcers. This is especially seen in patients over the age of 65, history of stomach ulcers, or taking medications such as aspirin, steroids, or warfarin (Coumadin). Ibuprofen thins the blood and, therefore, may increase the tendency to bleed by slowing the ability of the blood to clot. The risk of stomach problems with ibuprofen may be reduced by using Zantac or Pepcid, which are available over-the-counter.

How can OTC pain medications be optimally used to control post-operative pain?

Because pain from surgery is short-lived, drug dependence is not a significant issue. The best strategy is to stay ahead of severe pain rather than trying to catch up due a lapse in medication. The optimal use of OTC medication may reduce the need for prescription narcotic pain medication. Prescription narcotic pain medications have side-effects such as sedation, constipation, nausea, and vomiting. With the proper use of OTC pain medications, the need for narcotics can be minimized.

As most narcotic pain medication is combined with acetaminophen, the dosage of OTC acetaminophen (Tylenol) must be decreased so as to avoid exceeding the maximal daily dosage (3,000mg per day).

Maximal Use of OTC Pain Medication for Pain Control after Surgery
Dosing Schedule:	8AM	2PM	8PM	2AM	Daily Maximum
Ipubrofen	800mg	800mg	800mg	800mg	3200mg


Dosing Schedule:	11AM	5PM	11PM		Daily Maximum
Tylenol Extra-Strength	1000mg	1000mg	1000mg		3,000mg


Note: This schedule may need to be altered if you have kidney or liver disease.
This schedule is designed not to exceed maximum dosages of these medications.
Decrease the dosage as the pain improves after surgery.
Do not take additional medications that contain ibuprofen or acetaminophen without
adjusting the OTC medication dosage so as not to exceed the maximal daily dosages.
Consult with your doctor prior to using this medication schedule.

By Scott E. Pautler, MD

Steroid Eye Drops

Posted on June 25, 2018 by Scott Pautler

What are Steroid Eye Drops?

Steroid eye drops are prescription medications used to reduce pain, swelling and inflammation. This class of medication is separated from non-steroids by mechanism of action, effectiveness, and side effects. There are a number of steroid eye drop brands available. Examples include prednisolone (Pred Forte, AK-Pred), fluorometholone (FML, FML Forte, Flarex), dexamethasone (Ocu-dex), loteprednol (Lotemax, Alrex), difluprednate (Durezol), rimexolone (Vexol).

How do steroid eye drops work?

Steroid eye drops work by inhibiting a wide variety of biochemicals in the body that promote inflammation. Steroid eye drops are usually more effective that non-steorid eye drops (NSAID eye drops) when used alone, but these two classes of anti-inflammatory drops often work best when used together.

There are advantages and disadvantages to the various brands of steroid eye drops. To varying degrees, all steroid drops reduce inflammation and they all have side effects. The most important side effects include cataract formation and elevation of Intraocular pressure (glaucoma). Prednisolone acetate has been the gold standard for treating ocular inflammation. Dexamethasone generally is not as effective and it has comparable side effects. Difluprednate (Durezol®) is as effective as prednisolone and can be used less often, but it is much more expensive. Loteprednol (Lotemax®) and rimexolone (Vexol®) are less likely to cause glaucoma, but they are expensive. Low concentrations of fluorometholone (FML®) is not likely to cause cataract or glaucoma, but it is not as strong as prednisolone and are mainly used for treating inflammation outside the eye, as in cases of blepharitis (inflammation of the eyelids) and keratitis (inflammation of the cornea).

How does the doctor choose which steroid drop to use?

In some cases the doctor has had good experience with a specific agent for a given situation. In other cases the choice may be guided by convenience and cost. For convenience the costlier difluprednate may be used twice a day compared to 4 times a day for prednisolone. Patients with a tendency for glaucoma, may require more expensive medication such as rimexolone or loteprednol.

If you have strong preferences, be sure to communicate with your doctor to be given the best steroid eye drops for your situation. Always use your eye drops exactly as prescribed and keep all appointments as scheduled in order to monitor for effectiveness and safety.

Ophthalmic Steroid Prices	6/25/18

Generic	Trade	Cost	Source
Prednisolone	Pred Forte	$ 27	GoodRx
Fluorometholone	FML Forte	$ 35	GoodRx
Dexamethasone	Decadron	$ 60	CVS
Rimexolone	Vexol	$ 93	GoodRx
Difluprednate	Durezol	$ 180	GoodRx
Loteprednol	Lotemax	$ 230	GoodRx

By Scott E. Pautler, MD

What is the Amsler grid?

The Amsler grid is a test used to detect and monitor macular disease (see Anatomy of the Eye). The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision. The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.

How is the Amsler grid used?

The grid is observed one eye art a time with reading glasses if needed for proper focusing at normal reading distance. The patient is asked to fixate on the center of the grid while using “side vision” to see if there are any missing areas. The lines on the grid should appear straight and uniform. If any abnormalities are noted, an ophthalmologist (retinal specialist) may be consulted to determine the cause of the problem.

Below is a link to download or print an Amsler grid chart for use at home.

Amsler grid RVAF

Some patients prefer a more sensitive (and more expensive) test to monitor the vision called the Foresee Home Monitoring Program.

By Scott E. Pautler, MD

NSAID Eye Drops

Posted on October 7, 2017 by Scott Pautler

What are NSAID Eye Drops?

NSAID eye drops are prescription medications used to treat macular edema or reduce pain and inflammation. NSAID stands for Non-Steroidal Anti-Inflammatory Drug. This class of medication is separated from steroids by mechanism of action, effectiveness, and side effects. There are a number of NSAID eye drop brands available. Examples include Ketorolac, Acular, Acuvail, Voltaren, Nevanac, Ilevro, Xibrom, Bromday, Prolenza, Ocufen, and Bromsite.

How do NSAIDS work?

NSAIDS work by inhibiting the COX enzyme that produces specific prostaglandins, which promote inflammation. Prostaglandins are a major class of inflammatory mediators in the body. There are other mediators of inflammation that sometimes need to be controlled, so steroid eye drops are often used in addition to NSAIDS.

There is conflicting evidence as to whether one NSAID drug is better than another. Some believe that Nevanac and Ilevro are better for pain control. Others believe that Voltaren is better to control signs of inflammation inside the eye.

How does the doctor choose which NSAID to use?

In some cases the doctor has had good experience with a specific agent for a given situation. In other cases the choice may be guided by convenience and cost. For convenience some drops may be used once or twice a day (e.g. Ilevro, Xibrom, Bromday, Prolenza, and Bromsite). Although their prices vary, they tend to be expensive in comparison to generic drugs.

As an alternative, other NSAIDS are used more frequently, but cost less. Acular and Voltaren are available in generic formulations that cost under $20. These drops are frequently used four times a day. They are less expensive even though more eye drops are used per day. They may cause eye irritation in some patients.

If you have strong preferences, be sure to communicate with your doctor to be given the best NSAID eye drops for your situation. Be sure to use your eye drops exactly as prescribed and keep all appointments as scheduled in order to determine the effect of the medication and to look for side effects.

By Scott E. Pautler, MD

Treatment of Uveitis

Posted on April 15, 2017 by Scott Pautler

How is Uveitis treated?

The key to treating uveitis is to identify the underlying cause. However, the specific cause may not always be found. Therefore, it is helpful to place a given case of uveitis into various classifications in order to treat most effectively. In some cases there is an infection that requires treatment with antibiotics. In other cases there is an underlying inflammation in the body outside the eye that is not associated with infection. In such cases the treatment of the systemic condition is required to settle the eye. Finally, there are inflammatory conditions not associated with infection that only affect the eyes. In these cases treatment may be directed to the eye alone. Such treatment often starts with eye drops.

What infections cause uveitis?

A large variety of organisms may infect the eye: bacteria, viruses, fungi, worms, insect larvae, protozoa, and other parasites. Some infect the eye alone. Others infectious agents affect other parts of the body as well. Infectious agents may enter the eye from a cut or opening into the eye from an eye injury. This is called endophthalmitis. Urgent antibiotic treatment is required as the risk of permanent loss of vision is high.

In other types of infection, the organism enters the eye through the blood stream. An infectious agent may enter the body through a cut in the skin, through the gastro-intestinal tract, the uro-genital tract or through the lungs. Once it is in the body the organism may enter the blood vessels and travel to the eye. For example, toxoplasmosis is a parasite found in contaminated food that enters the gastro-intestinal tract. It then spreads to the eye through the blood stream and infects the retina.

Because a large variety of infectious agents may enter the eye, the patient must inform the doctor of possible exposure to infection and carefully complete a uveitis questionnaire. Sometimes, a medical specialist in infectious disease is consulted.

What systemic inflammatory conditions can affect the eye?

Many autoimmune conditions cause inflammation without infection. The immune system abnormally identifies the body as being “foreign.” The resultant inflammation may affect various organs of the body. For example, rheumatoid arthritis in an autoimmune condition that affect the joints and sometimes causes inflammation of the sclera (the white outer coat of the eye).

In order to identify an autoimmune disease, the doctor will ask many questions about inflammation outside the eye (uveitis questionnaire) and order appropriate tests.

What are inflammatory conditions that affect the eye alone?

Sometimes, the immune system attacks the eye without affecting other organs in the body. The underlying trigger or cause of inflammation cannot usually be found. These conditions are placed into categories that help plan treatment strategies. For example, anterior uveitis (inflammation of the front of the eye) is initially treated with anti-inflammatory eye drops. On the other hand, Birdshot Chorioretinitis (BSCR) is an inflammation of the back part of the eye that usually requires long-term systemic treatment (pills or injections in the skin). There are many different ocular inflammatory conditions, which are identified by tests ordered by the doctor.

What medications are used for uveitis?

The type of treatment depends on the cause and category of inflammation. Antibiotics are used if an infection is suspected. The doctor prescribes antibiotics by pill or IV (intravenous) if the infection affects organs outside the eye. The doctor prescribes eye drops, pills, and/or injections if the infection affects only the eye.

The eye doctor may consult a rheumatologist to help monitor treatment with a systemic anti-inflammatory medication (pills and/or injections) if an inflammation affects organs outside the eye. Sometimes, an inflammation only affecting the eye requires the use of systemic medication, too. The ophthalmologist may also use eye drops and painless eye injections to control the inflammation.

Anti-inflammatory eye drops include steroid eye drops and non-steroid eye drops. They may be used separately or together depending on the type of inflammation. Steroid eye drops may cause the intra-ocular pressure to rise and must be monitored. Non-steroid eye drops may irritate the cornea (the front window of the eye). Dilating drops are often used to minimize pain from inflammation and help prevent harmful scar tissue from damaging the iris (the brown or blue part on the front of the eye).

Steroid injections may be given next to the eye (subtenon’s injection) or into the eye (intravitreal injection). Anesthetics help prevent pain with injection. Steroid implant injections (Ozurdex and Iluvien) offer longer duration of effect. Steroid injections may be especially useful in the treatment of macular edema (swelling of the retina) in patients with uveitis.

Steroid pills are often used at the beginning of treatment to control severe inflammation. Prednisone is the most common medication used to treat uveitis. It is usually used at high starting doses and then is slowly tapered down to an acceptable dose for long-term use or is completely discontinued. Prednisone has unacceptable side effects if used in high doses for many months to years.

Non-steroidal anti-inflammatory drugs (NSAIDS) given as pills may provide steroid-free treatment for some cases of uveitis. Some are available over-the-counter. Others are available by prescription. They may adversely affect the stomach and kidney.

Immune system suppressants help to quell uveits. Methotrexate, azathioprine, mycophenolate mofetil, cyclosporin are often used safely and effectively. Routine blood tests help detect side effect before permanent damage occurs. Although there was concern of an increased risk of skin cancer and lymphoma due to immune suppression, the SITE extension study showed that cancer risk is not increased. Very strong medications are used in very severe inflammation that threatens life or blindness (cyclophosphamide and chlorambucil). Pregnancy is avoided while on immune suppressants.

Biologic medications are new and very effective in the treatment of uveitis. Humira is given at home as an injection under the skin every two weeks. Long-term effects are being studied.

By Scott E. Pautler, MD

Prednisone for Eye Inflammation

Posted on March 5, 2017 by Scott Pautler

What is prednisone?

Prednisone is a very powerful medication related to a hormone produced by your body. Prednisone is very effective at decreasing inflammation. Inflammation in the eye can result from infection, injury, systemic diseases like arthritis, and sometimes from unknown causes. If left untreated, inflammation may cause permanent damage to the eye and loss of vision.

How is prednisone used?

A form of prednisone can be used as eye drops to control inflammation in the front of the eye. Often these drops must be used frequently for best results. If stronger dosages or deeper penetration of medication is required, another medicine like prednisone may be injected next to the eye. This injection is given with little discomfort by using anesthetic eye drops before the injection. If severe, vision-threatening inflammation is present, prednisone pills are prescribed.

What side effects might be encountered?

As prednisone is powerful, many side effects may occur. More frequent and severe side effects are seen the longer the medication is used. Fairly mild, common side effects include temporary mood swings, appetite changes, fluid retention, acne-like rash, trouble sleeping, and difficulty controlling diabetes. More serious side effects usually seen with prolonged treatment include reactivation of TB, stomach ulcer, brittle bones and hip fracture. Any worrisome symptom is reason to contact your doctor. It is important to report all other medication you are taking because interactions between drugs can occur. Finally, serious side effects can occur if prednisone is discontinued too rapidly. Follow the instructions of your doctor carefully.

Your doctor has identified a serious, vision-threatening eye problem that warrants the use of prednisone, a very powerful medicine that should be used with care. Be sure to inform your general medical doctor that you are going to start taking prednisone. Additional tests or medications may be needed to protect you against the side effects of prednisone.

How to take prednisone and protect against side-effects?

To protect yourself against bone loss and fractures, take calcium 1,500 mg (Tums EX) and vitamin D 800 Units every day. Also, make sure your internist approves before starting prednisone. Notify your doctor if you have had a positive TB test or have been exposed to TB (tuberculosis).

Take prednisone after breakfast in the morning. You may use antacids such as Maalox to prevent upset stomach. It is very important for your health to discontinue prednisone by gradually decreasing the dosage as recommended.

Follow a tapering schedule of dosing to avoid serious reactions. Your doctor will make recommendations based on your situation.

AS YOU LOWER THE DOSE OF PREDNISONE, BE SURE TO REPORT TO YOUR DOCTOR ANY SIGNIFICANT WEAKNESS, TIREDNESS, DIZZINESS, OR LOW BLOOD PRESSURE. THESE SYMPTOMS MAY REPRESENT A SERIOUS SIDE-EFFECT OF PREDNISONE WITHDRAWAL.

By Scott E. Pautler, MD

HLA B-27 and the Eye

Posted on February 19, 2017 by Scott Pautler

What is HLA-B27?

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

How does it affect the eye?

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

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

How can it affect other parts of the body?

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

Who should I see for evaluation of HLA-B27?

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

By Scott E. Pautler, MD

Slow Myopic Progression

Posted on December 3, 2016 by Scott Pautler

Although most people with myopia (near-sightedness) do not suffer from complications, highly near-sighted eyes (greater than 6 diopters) are at risk of vision loss. Myopia is fairly prevalent, affecting about 25-35% of adults in the United States. Extensive visual tasks focused at near may be increasing the risk of myopia. Highly myopic eyes are at increased risk of myopic macular degeneration, cataract, glaucoma, and retinal detachment. Therefore, treatment to reduce the progression of myopia is important to prevent loss of vision.

The simple act of spending time away from near work appears to offer help in reducing the onset of myopia. In one study the incidence of myopia was decreased by 10% by spending 40 minutes per day outdoors.

Recent studies support the use of dilute atropine eye drops to slow the progression of myopia. Atropine 0.01% must be prepared by a pharmacy with a doctor’s prescription. The cost is about $20-30 per month. The drop is used once per day. This low-concentration eye drop had minimal effects on the eye. A dilated pupil and difficulty focusing at near are rarely encountered. Therefore, light sensitivity is minimized. Very rare side effects of atropine including rapid heart rate, dry mouth, and urinary retention, constipation, and flushing of the skin are not generally reported with diluted atropine used to treat myopia. Allergic reactions with redness and itching are rare with low-concentration atropine, as well.

Eligible patients include children (aged 5-15) with progressively worsening myopia (1 diopter of more in one year). However, there are no hard and fast rules; a strong family history of high myopia may play into the decision to treat a child with myopia to slow its progression. Treatment may continue until age 18 years. More studies are needed to better define the best time to start treatment and the optimal duration of treatment. For now, however, it appears that atropine may be the safest and most effective pharmacological treatment to slow the progression of myopia.

By Scott E. Pautler, MD

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