Tag Archives: uveitis

Birdshot Chorioretinopathy

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What is birdshot chorioretinopathy?

Eyeball Anatomy

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

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  © 2020-2023 Designs Unlimited of Florida.  All Rights Reserved.

Uveitis Diagnosis by Subtype

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Anterior Uveitis

Mimics: leukemia, lymphoma, RBCs, pigment dispersion, foreign body

Granulomatous:Non-Granulomatous:
SarcoidosisHLA B27
TBHerpes Group (esp unilateral)
Herpes groupTINU (esp acute/bilateral)
ToxoplasmosisFuch’s Uveitis (heterochromia)
SO/VKHJIA
Blau Syndrome (child)Spirochetes (Syphilis, Lyme)
Bactrim etcBehcet 
Moxifloxacin (iris transillumination)Post-infectious/reactive 
Spirochetes (Syphilis, Lyme)Other: Posner Schlossman or drug-related
MS associated uveitis 
Lens induced 

Intermediate uveitis 

(Primary vitreous involvement +/-retinal vascular sheathing, CME, disc edema)

Infectious:       Non-Infectious:
SyphilisMultiple Sclerosis
TBSarcoidosis
Lyme DiseaseInflammatory bowel dz (Crohns, UC)
Bartonellosis (cat scratch) 
Toxocara (unilateral) 
HTLV-1 (joint/CNS findings) 
Whipple’s Disease (bowel and neuro dz) 
?Toxoplasmosis 

Retinitis (chorioretinitis)

(Mimics: lymphoma, leukemia, met carcinoma, focal ischemia) Rule Out Infection!

Note: multimodal imaging is especially helpful in white dot syndromes

Infectious:    Non-Infectious:
Toxoplasmosis (most common focal)White dot syndromes (e.g. APMPPE)
Herpes group (HSV/VZV/CMV)Acute macular neuroretinitis (AMN)
SyphilisBehcet Disease
Bartonella (cat scratch) 
DUSN 
Toxocara 
Lyme Disease 
Endogenous fungus or bacteria 
Emerging (Dengue, Yellow fever, West Nile) 

Choroiditis:

(mimics: benign and malignant tumors, Leukemic/lymphoproliferative infiltrates, scleritis)

Infectious:Non-Infectious:
SyphilisSarcoidosis
Lyme DiseaseAPMMPE
TB (including Serpiginous-like)Multifocal Choroiditis (+/- panuveitis)
Endogenous fungal/bacterialPunctate Inner Choroiditis (PIC)
Cryptococcus (rare)Ocular Histoplasmosis Syndrome
Coccidiodomycosis (rare)Birdshot Choroiditis
Emerging dz (West Nile Virus)Serpiginous and Relentless Placoid 
 Blau Syndrome (AD, sarcoid-like)

Panuveitis:

Infectious:Non-Infectious:
SyphilisSarcoidosis
TBMultifocal Choroiditis with Panuveitis
ToxoplasmosisVKH
ARN/PORNSympathetic Ophthalmia
Endogenous fungal/bacterial 
Lyme Disease 
Onchocerciasis (outside US) 

Retinal Vasculitis:

Infectious:Non-Infectious:
SyphilisSarcoidosis
Herpes group (Frosted branch)Eales Disease (?TB)
para-viral syndromeSLE, PAN, Churg Strauss, Wegener
HIVBirdshot (before choroiditis)
ToxoplasmosisMultiple Sclerosis
 Behcet Disease
Primary Artery:Primary Vein:Arteries and Veins:
SyphilisSarcoidosisMS
Herpes GroupEales DiseaseBehcet Disease
SLE, PAN, Churg Strausspara-viral syndromesWegener
Frosted Branch AngiitisHIVFrosted Branch Angiitis
 Toxoplasmosis 
 Birdshot (before choroiditis) 

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  © 2019-2022 Designs Unlimited of Florida.  All Rights Reserved.

Intermediate Uveitis

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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

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  © 2018-2022 Designs Unlimited of Florida.  All Rights Reserved.

Steroid Eye Drops

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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 Prices6/25/18 
    
GenericTradeCostSource
PrednisolonePred Forte $            27GoodRx
FluorometholoneFML Forte $            35GoodRx
DexamethasoneDecadron $            60CVS
RimexoloneVexol $            93GoodRx
DifluprednateDurezol $          180GoodRx
LoteprednolLotemax $          230GoodRx

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

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 © 2018-2022 Designs Unlimited of Florida.  All Rights Reserved.

Pain in and Around the Eye

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

Pain is a symptom that often warns of serious problems. The nature of the pain may help to determine the origin of the pain and, sometimes, the cause. The following are types of pain and their causes:

Severe, sharp, jabbing pain in the eye: If persistent and associated with a sensation like sand in the eye, this pain often suggests a problem in the cornea. The cornea is the clear front window at the front of the eye. It is replete with very sensitive nerve endings that may be irritated by any disruption of the “skin” on the surface like a corneal abrasion. Treatment is important to relieve pain and prevent infection or scarring of the cornea as this may result in a loss of vision.

A very brief isolated episode of a jab in the eye: May be due to a benign blockage of an oil gland in the eyelid margin (blepharitis). It may also be a symptom of a type of migraine called an “ice pick” headache.

A burning, tingling pain over the forehead: May indicate the onset of shingles (Herpes Zoster). The pain often precedes the onset of a painful rash composed of small vesicles (blisters) on the forehead. It is important to start antiviral medication and evaluate the eye to determine if there is direct eye involvement.

Deep, boring pain: May be seen with sinus pathology alone and may be present in varying severity. However, this type of pain may also be due to problems in the brain such as aneurysm or brain tumor. This pain may also be caused by high pressure in the eye (acute glaucoma) or serious inflammation inside the eye (uveitis). Rarely, poor blood flow to the eye from the carotid artery may cause a deep pain around the eye; atherosclerosis or giant cell arteritis may be the cause.

Pain may be caused by dry eye syndrome. It is usually associated with dryness, burning, and foreign body syndrome.

This monograph does not cover all types or causes of eye pain. Any significant, persistent pain in the eye warrants evaluation. In many cases the more severe the pain, the more urgent the need for evaluation.

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  © 2018-2022 Designs Unlimited of Florida. All rights reserved.

Infectious Endophthalmitis

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

What is endophthalmitis?

Endophthalmitis (“end-off-thal-my-tis”) is a severe inflammation inside the eye. The inflammation may be due to an infection or it may be “sterile.” Endophthalmitis threatens profound loss of vision and possible loss of the eye. Bacterial endophthalmitis usually requires urgent treatment to save the eye.

What causes endophthalmitis?

Endophthalmitis may be caused by an auto-immune reaction (the body attacks itself), it may be due to a foreign substance introduced into the eye in an accident or surgery, or it may be due to an infection. Here we will discuss endophthalmitis due to infection.

Infections may be caused by a number of viruses, fungi, parasites, and bacteria. Infectious endophthalmitis is classified as endogenous and exogenous. Endogenous endophthalmitis occurs when an infection enters the eye from inside the body, usually through the blood stream. Exogenous endophthalmitis occurs when an infection enters the eye from outside the body, usually from an opening into the eye from trauma, surgery, or intraocular injections.

Although the risk of endophthalmitis is low for a single surgery, the risk increases over time with multiple Intraocular injections. For example, after 5-6 years of injections for macular degeneration, the risk rises to about one in 200.

How is infectious endophthalmitis diagnosed?

Infectious endophthalmitis is suspected when severe inflammation is found inside the eye on an exam. It is usually accompanied by pain and loss of vision. Diagnosis is confirmed with a culture of the fluid inside the eye taken in the office or the operating room.

 How is infectious endophthalmitis treated?

Infectious endophthalmitis is treated with antibiotic injections into the eye performed in the office or in the operating room. In severe cases, vitrectomy surgery is needed to remove some of the infected material. Vitrectomy is performed in the hospital operating room as a major eye surgery involving small incisions into the eye. Eye drops  (steroid and non-steroid) are used frequently to help treat infection and to decrease the inflammation that can damage the eye. Sometimes additional steroid medications are used. The recovery of vision is very slow, taking weeks to months. If permanent damage occurs as a result of endophthalmitis, little or no recovery of vision may be possible. Frequent visits to the doctor are necessary at first to give the best results.

If you have questions, please do not hesitate to ask your doctor. Please 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 © 2018-2023 Designs Unlimited of Florida.  All Rights Reserved.

NSAID Eye Drops

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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

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.

Ocular Shingles (Shingles affecting the eye)

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

What is ocular shingles?

Ocular shingles (herpes zoster ophthalmicus) is an inflammation of the eye and surrounding skin caused by an infection of a virus in the Herpes group called the Varicella Zoster virus (the Chicken Pox virus). The name, shingles, comes from a Latin word meaning belt or girdle, as shingles usually presents as a rash along the path of a nerve in a band-like pattern.

Zoster
Shingles

What causes shingles?

Shingles is caused by the Chicken Pox virus that reactivates after years of “hibernation” in the nerve cells. When you contract Chicken Pox, the virus takes refuge inside nerve cells and remains there for life after the rash goes away. This is a common behavior of all viruses in the Herpes group. Years later, when the immune system “forgets” the virus, it re-emerges as shingles.

Why is shingles becoming more common?

Currently, it is estimated that half of all people will develop shingles during their lifetime. The reason appears to relate to the use of the Chicken Pox vaccine. Prior to vaccination, adults would be routinely exposed to the Chicken Pox virus as they were intermittently exposed to children with active Chicken Pox. This frequent exposure to the virus by adults used to keep the immune system primed to keep the virus contained inside the nerve cells. Now that children no longer contract Chicken Pox, adults no longer receive the benefit of immune priming. Over time the immune system forgets the virus and allows the escape of the virus from the nerve.

What are the symptoms of ocular shingles?

The symptoms of shingles depend on the location of the nerves that harbor the virus. If the chest wall is affected, the eyes are spared. If the trigeminal nerve is affected, the forehead develops a rash. If the rash reaches the tip of the nose, the eye is often affected. The rash starts with redness and tiny blisters that crust and scar over time. Pain may occur before the rash appears and is described as burning, sharp, jabbing or tingling. Pain may be severe. It is the persistence of pain that may be disabling.

Aside from the possibility of long-term pain, other problems may relate to shingles. There appears to be an increased risk (4.5x) of stroke after shingles. There may also be an increased risk of cancer, inflammation of blood vessels (temporal arteritis), heart attack, and depression.

Ocular shingles is when shingles affects the eye. It may cause inflammation of the front window of the eye (the cornea) with scarring. Glaucoma may occur and require life-long treatment to prevent blindness. Intraocular inflammation may affect the front of the eye (iritis) or deep inside the eye threatening loss of vision. The inflammation may persist or return intermittently into the future.

What treatment is available?

Antiviral and anti-inflammatory medications may help treat shingles. The systemic treatment of shingles is managed by an internal medicine doctor (and sometimes by an infectious disease specialist). Treatment may hasten the recovery from shingles, but does not eliminate the late complications of infection.

Ocular complications of shingles are treated by ophthalmologists. Apart from anti-viral pills, eyes drops can help prevent loss of vision. After the initial inflammation is controlled, regular exams are important to diagnose problems that may occur in the future.

What can be done to prevent shingles?

An ounce of prevention is worth a pound of cure. The chance of shingles can be reduced by the use of a vaccine. This vaccine reduces the risk, but does not eliminate the chance of getting shingles. If shingles does occur after vaccination, it us usually not as severe compared to those without the vaccine. Not surprisingly, the effect of the vaccine wears off over a period of five to ten years. Research suggests that booster shots may help extend the effect of the vaccine; however, the cost of the vaccine appears to hinder formal recommendations for repeat vaccination. The newest vaccine, Shingrix, became available in 2018 and offers the best protection.

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 © 2018-2022 Designs Unlimited of Florida. All Rights Reserved.

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

Uveitis Questionnaire

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Below is a downloadable form to fill out and bring to your doctor. This questionnaire may help identify the underlying cause and help with treatment of uveitis.  

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to RvaAdmin@rvaf.com. We accept Medicare, most insurances, and self-pay.

Uveitis-Questionnaire-v20220204Download

Treatment of Uveitis

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anatomy of the eye (click on image to enlarge)

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

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.

Prednisone for Eye Inflammation

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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

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

HLA B-27 and the Eye

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anatomy of the eye (click on image to enlarge)

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

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.

Anterior Uveitis (Iritis)

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

What is iritis?

Iritis (pronounced, “eye-RYE-tis”) is a general term used to describe inflammation in the front of the eye. Specifically, it means inflammation of the iris. The iris is the name given to the layer of tissue in the eye that gives it a brown or blue color and serves to protect the eye from excessive light. Iritis is also called anterior uveitis.

What causes iritis?

Iritis may be caused by systemic inflammatory disease, trauma, infection, or sometimes for unknown reasons. Infection by a virus, bacterium, fungus, or other parasite rarely causes iritis. Infections may be limited to the eye or may involve other organs as well. More commonly, iritis is caused by inflammation without infection. For example, sarcoidosis, arthritis, lupus, and inflammatory bowel disease may cause iritis. The most common type of arthritis that causes iritis is ankylosing spondylitis, a condition that causes low back stiffness in the morning. Iritis also commonly follows an injury to the eye. In some cases, no underlying cause of iritis can be found.

What are the symptoms of iritis?

The eye may be painful, red, tearing, and light sensitive. Tiny floating spots which move or “float” may be seen. Symptoms may be mild, or they may be severe and disabling. Iritis may cause glaucoma, cataract, or scarring of the iris producing a distorted pupil (the part of the eye that is normally round and black). Blurred vision is common, and blindness may occur if iritis is not treated.

 How is iritis managed?

When the doctor diagnoses iritis, laboratory tests may be ordered to help determine its cause. A questionnaire may be reviewed. Occasionally, a surgical biopsy is needed. If infection is found, antibiotics are prescribed. Dilating drops are used to limit pain and scarring of the iris. To limit the damage from inflammation, iritis is treated with anti-inflammatory medication in the form of eye drops (steroid and non-steroid), injections, or prednisone pills. The eye drops must be used very frequently to break an acute attack of iritis. Sometimes, non-steroid pills (e.g. methotrexate) or biologics (e.g. Humira) maybe needed. Aggressive treatment is recommended to prevent complications and permanent injury to the eye. Surgery may be required to treat complications of iritis such as glaucoma and cataract. Iritis is a serious eye problem and may result in loss of vision or blindness. However, by seeing your eye doctor promptly and taking the medications exactly as recommended, permanent damage from iritis can be minimized. In some cases, iritis can return in either eye at a future date. Therefore, if you become aware of the return of symptoms of iritis in the future, contact your doctor without delay.

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.

Multiple Sclerosis and Your Eyes

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

What is multiple sclerosis?

Multiple Sclerosis is a condition of the brain and spinal cord in which there is a loss of the insulating coat of the nerve cells (demyelination). The cause is unknown, but viral and auto-immune causes are suspected along with genetic predisposition. Because the brain controls movement and sensation, multiple sclerosis may cause a variety of symptoms. The symptoms may occur from time to time with normal periods in between (relapsing form). Alternatively, the symptoms may slowly progress and persist over time (progressive form).

How does multiple sclerosis affect the eyes?

Multiple sclerosis may disrupt the nerves that affect the vision or the movement of the eyes. It may also cause inflammation inside the eye. The following are well-recognized problems involving the eyes:

Optic Neuritis: Inflammation of the optic nerve may cause a sudden loss of vision. Often, there is pain in or behind the eye made worse with eye movement.

Internuclear Ophthalmoplegia (INO): An interruption of the nerve fibers that coordinate movement of the two eyes may cause a loss of alignment. If the two eyes are not pointing in the same direction, double vision occurs.

Intermediate Uveitis: A low-grade inflammation inside the eye (vitritis) may cause the slow-onset of fine floating specks in the vision. Over time, the vision may become blurred due to the accumulation of specks, as well as swelling of the retina.

How is multiple sclerosis diagnosed?

When visual symptoms occur, the ophthalmologist may undertake a number of tests in the office to diagnose multiple sclerosis. The optical coherent tomogram (OCT) can identify defects in the optic nerve and diagnose macular edema. Usually, an MRI scan is needed to identify degenerative plaques seen in the brain due to multiple sclerosis. Ultimately, a neurologist is consulted to confirm the diagnosis.

How is multiple sclerosis treated?

A neurologist orchestrates the treatment of multiple sclerosis. Medication and physical therapy help to manage symptoms. There is no cure. The clinical course of multiple sclerosis is variable. The least long-term disability is usually seen in women, those with onset of symptoms early in life, and those with few intermittent symptoms at onset.

The ophthalmologist manages the ocular symptoms. Loss of vision usually returns over time and may be accelerated with the use of IV steroids. Double vision may also improve over time and may be managed by patching one eye.

Intermediate uveitis usually requires medication to prevent progressive permanent loss of vision. Although mild cases may be carefully observed, treatment is needed if floaters interfere with vision or if macular edema (retinal swelling) is present. Steroid medications may be used by pills or by injection. They are best used for short-term management of flare-ups of inflammation. Other non-steroid medications help to suppress the inflammation over the long-term. These medications often require the assistance of a rheumatologist who watches for side effects while the ophthalmologist monitors the inflammation.

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.

Ozurdex

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Ozurdex

 

What is Ozurdex and why is it used in the eye?

Ozurdex is a very small tube-like implant that contains steroid medication that is slowly released into the eye for up to 3-6 months. The Ozurdex implant is injected into the eye in the office setting in order to decrease inflammation, swelling, or leaky blood vessels inside the eye. It has been shown to improve vision in eyes with retinal vein occlusion, diabetic macular edema, and inflammation in the eye. The Ozurdex implant completely dissolves in the eye. Repeated injections may be necessary for continued improvement in vision.

How is an Ozurdex injection performed?

Anesthetics 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 implant is injected into the eye with a very thin, short needle. The procedure is very brief.

What are the side effects of Ozurdex?

Although possible, it is rare to see the Ozurdex implant floating in the vision. In about 30-40% of patients, the pressure inside the eye increases and requires eye drops. About 1% of patients require glaucoma surgery to prevent loss of vision. Most eyes develop cataract and eventually require surgery. Rare risks of steroid injection include bleeding, infection, retinal detachment, and loss of vision/loss of the eye. The risk of infection is about one in 1,000 injections. 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 after Ozurdex 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. Additional information is available at www.ozurdex.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.

Glaucoma

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anatomy of the eye (click on image to enlarge)

What is Glaucoma?

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

What causes glaucoma?

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

Who is at risk for having glaucoma?

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

What are the symptoms of glaucoma?

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

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

How is glaucoma diagnosed?

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

What treatment is available?

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

By Scott E. Pautler, MD

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

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

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

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.

Cataract

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Cataract
Cataract is a foggy lens inside the eye (click image to enlarge)

What is a cataract?

A cataract is a foggy lens inside the eye. The lens is positioned behind the iris to focus light that passes through the pupil (see drawing above). The lens inside the eye works like a lens in a camera. The normal lens is clear, but it may lose its clarity over time. When the lens loses its clarity, it causes hazy and cloudy vision, often with glare from on-coming lights. The distance vision is often affected more than the near vision.

What causes cataract?

Cataract is common with age. The older a person becomes, the more likely cataracts will form. Other causes include heredity (family history of cataract), inflammation, blunt injury to the eye, sun exposure, tobacco, high blood pressure, diabetes, and medications (such as corticosteroids (prednisone) and some anti-depressants known as SSRI inhibitors).

How is cataract treated?

The only treatment of cataract is surgery in the operating room, with or without the assistance of laser. There is no way to remove a cataract with vitamins, pills, or eye drops. However, a change in glasses may minimize the blurred vision caused by cataract in the early stages. There is no emergency to treat a cataract. It will not harm the eye to hold-off from having surgery except in extremely severe cases. At the time of cataract surgery, a lens implant will be placed inside the eye to improve the ability of the eye to focus.

When is surgery needed?

Surgery is needed when the haziness in the vision from cataract has become bad enough to require improvement in vision that cannot be achieved with glasses. This is a decision made by the patient with help from the 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.

Ocular Toxoplasmosis

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

What is ocular toxoplasmosis?

Ocular toxoplasmosis is an inflammation of the eye caused by an infection of the retina by a parasite called Toxoplasma gondii. 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 ocular toxoplasmosis?

Toxoplasma gondii infects humans and animals throughout the world. Twenty to fifty percent of adults in the United States test positive for exposure, but few people experience symptoms. The most common presentation resembles mononucleosis with symptoms of fever, fatigue, and swollen lymph glands. Because the toxoplasma organism can become inactive and form a protective microscopic cyst within human cells, it can cause relapses of infection and spread to new areas of the body months to years after the initial infection. If the parasite spreads through the blood stream to the eye, ocular toxoplasmosis may threaten blindness.

How is toxoplasmosis contracted?

The most common ways to contract infection are as follows: 1.) Hand-to-mouth transmission of the toxoplasma organism in cat feces e.g. cleaning the litter box. 2.) Eating undercooked meat, chicken, or eggs from infected animals. 3.) Eating unwashed fruits and vegetables that are contaminated by animal feces. 4.) Hand-to-mouth transmission from handling infected raw meat or animal products. 5.) Transmission from infected mother to child through the placenta during pregnancy. 6.) Rarely, Toxoplasma infection may acquired through contaminated drinking water or dust in the air.

Toxoplasma gondii completes its life cycle by producing millions of oocysts (eggs) in the intestines of the cat. These infectious eggs leave the cat in the feces and may lie dormant in the ground for up to two years. These eggs may infect an animal that may eat from the ground or a human who eats unwashed, contaminated fruits and vegetables from the ground. Once inside a human or animal, the eggs “hatch”, multiply, and spread throughout the body. When the immune system attacks the parasite, it becomes dormant and “hibernates” inside cells throughout the body. In months or years in the future, it may become active to cause infection again.

What are the symptoms of ocular toxoplasmosis?

If toxoplasma reaches the eye, early symptoms include seeing new tiny floating spots (floaters), pain, redness, tearing, light sensitivity, and blurred vision. Late symptoms include permanent blind spots in the vision and, rarely, blindness. These symptoms are not specific for ocular toxoplasmosis, but they are especially important to recognize in people with known toxoplasma scars in the retina. If such symptoms are promptly reported to the doctor, treatment may minimize permanent damage to the eye.

What treatment is available?

Sulfa antibiotics (Septra or Bactrim) are frequently used for several weeks to treat active infection. In some cases of toxoplasmosis, another antibiotic called clindamycin is used. This medicine may rarely cause a severe bloody diarrhea, which should be reported to the doctor immediately for effective treatment. Prednisone pills and similar eyedrops may be used to decrease inflammation. Rarely, antibiotics may be injected into the eye.  Often, the pupil of the eye is dilated with eyedrops during the active infection to prevent scarring and to relieve pain.

It is not uncommon for untreated ocular toxoplasmosis to result in loss of vision. It is rare to experience serious side effects from medication used to treat toxoplasmosis. Armed with the knowledge to report side effects promptly to the doctor, you can minimize the chance of suffering from any permanent ill-effects from treatment.

Finally, notify your doctor if you had a toxoplasma infection in the past as it may be important to avoid intraocular steroid injections to prevent a return of infection.

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.