Tag Archives: vitrectomy

Treatment of Floaters

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What are floaters?

Floaters are small specks, fibers, or bug-shaped objects that may appear to move in front of your eye.  At times they may appear like a veil or cloud moving in the vision.  Floaters differ from blind spots in the vision in that floaters have some degree of independent movement.  Blind spots are missing areas in the vision that move precisely with eye movement.  Although floaters do follow the movement of the eye, there is usually some degree of continued movement after the eye stops moving.  They are frequently seen when looking at a blank wall or blue sky. Floaters are actually tiny clumps of fiber or cellular debris within the jelly-like fluid (vitreous) that fills the inside of the eye.

What does this symptom mean?

Although many people have occasional floaters, the sudden onset of many new floaters with or without flashes is an important sign of abnormal pulling on the retina by the vitreous.  Sometimes, the retina tears and may cause loss of vision from detachment of the retina. At other times, floaters may persist and chronically interfere with vision.

What causes floaters?

Floaters are usually due to degeneration of the vitreous gel in the eye from aging.  Over time, the vitreous shrinks, condenses, and pulls away from the retina.  The condensation causes fibers and cellular clumps to pull away from the retina and float freely inside the eye. The shadow of these opacities is what we see as floaters. Other causes of floaters include trauma, bleeding, retinal breaks and detachment, eye surgery, inflammation, and cancer (very rarely). 

vitreous floaters and haze
Vitreous floaters and haze interfering with vision after repair of retinal detachment. The vitreous opacities appear as fibers and haze in this photo. They interfere with a clear view of the retina when looking into the eye and they interfere with the vision when looking out through the haze.

What can be done about floaters?

It is important to have a thorough dilated eye examination to determine the cause of floaters.  Treatment is dictated by the cause of the floaters.  If there is no serious underlying cause (retinal break, retinal detachment, etc.), no treatment may be needed. New floaters often fade without treatment.  It can be helpful to avoid tracking or following floaters to allow your brain to ignore them. Floaters are less obvious in a darker environment, so wearing sunglasses outdoors may help minimize symptoms of floaters. Stress and depression appear to aggravate the symptoms of floaters and may be treated separately. 

YAG Laser Treatment:  A special laser may be useful in some cases of persistent floaters. It is an office treatment in which the laser in used to break the floating fibers and clumps into smaller fragments in the vitreous of the eye.  Although it may help, YAG laser does not eliminate floaters.  Repeat treatments are frequently necessary. Complications may include bleeding, increased floaters, retinal breaks and retinal detachment, which may require surgery to prevent blindness.  There is limited evidence on the safety and effectiveness of YAG laser for floaters and it may not be covered by insurance. YAG laser may result in loss of vision/loss of the eye.

Vitrectomy Surgery: Vitrectomy is a surgery performed in the operating room. It is commonly used to treat serious problems of the vitreous and retina.  It is very effective at reducing or eliminating floaters.  However, complications include bleeding, infection, retinal break and retinal detachment, which may require surgery to prevent blindness.  Serious complications occur in 1-2% of eyes reported in most studies, although some reports suggest the risk of complications may be as high as 10%.  The most common problem with vitrectomy is cataract formation.  After vitrectomy, cataract may develop over months to years and often requires cataract surgery.  Glaucoma has been reported years after vitrectomy, but the exact incidence is not known.  Vitrectomy surgery may result in loss of vision/loss of the eye.

For most patients the best course of action is observation of floaters without treatment at first.  If symptoms persist and significantly interfere with vision despite 6-12 months of observation, treatment may be helpful.  Most patients report good results with vitrectomy, but the possibility of complications must be carefully considered and accepted prior to embarking on surgery.

By Scott E. Pautler, MD

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

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

Over-the-Counter Pain Medications

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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).

Copyright © 2018 Designs Unlimited of Florida.  All Rights Reserved.

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

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.

Proliferative Vitreoretinopathy (PVR)

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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 PVR?

The retina is a “tissue-paper” thin layer of nerve tissue that lines the inside of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. Proliferative vitreoretinopathy is a condition in which sheets of scar tissue grow on the surface of the retina. It usually occurs after retinal detachment as a part of the healing process. Unfortunately, the PVR scar tissue pulls on the retinal and is the most common cause of failure of attempted repair of retinal detachment. There is evidence of PVR in about 10% of eyes that present with retinal detachment.

What is retinal detachment?

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

What causes PVR?

Proliferative vitreoretinopathy is caused by the excessive formation of scar tissue. Scar tissue is a common healing mechanism in the body. For example, if the skin is cut, scar tissue closes the laceration. In the eye scar tissue develops in response to retinal detachment and surgical repair. If it becomes excessive, the scar tissue causes the retina to detach again. The abnormal production of scar tissue in the eye is called PVR. Tobacco use may increase the risk of PVR.

How is PVR treated?

The treatment of PVR requires one or more surgeries. Your doctor is skilled in a number of techniques to prevent blindness. Which type of surgery is recommended depends on the precise findings on examination.

Scleral buckle surgery:  Some retinal detachments require the placement of a permanent plastic supporting belt around the eye to create a “ledge of support” for the retina. This belt is placed in the hospital operating room in a major surgery. The eye is often rendered more near sighted by this procedure. Rarely, side effects include double vision.

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

With one or more surgeries most retinal detachments with PVR can be repaired keeping useful vision. The vision usually does not return to normal. It is frequently blurred or distorted. There are always risks to surgery including hemorrhage, infection, scarring, glaucoma, cataract, and double vision. Sometimes despite all efforts with surgery, all vision may be lost. Surgery is recommended for retinal detachments with PVR because blindness usually results if treatment is withheld. If you have questions, please do not hesitate to ask your doctor.

By Scott E. Pautler, MD

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  © 2017-2023 Designs Unlimited of Florida.  All Rights Reserved.

Vitreous Hemorrhage

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

What is vitreous hemorrhage?

Vitreous hemorrhage means blood has leaked into the vitreous gel of the eye. 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, which sometimes leak blood into the vitreous and cause a loss of vision.

What symptoms does vitreous hemorrhage cause?

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.

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.

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.

What causes vitreous hemorrhage?

There are many causes of 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. Hardening of the arteries in the eye can cause vitreous hemorrhage by blocking a retinal vein where the arteries cross over the veins in the retina. Ageing changes of the vitreous gel can cause it to pull on the retina and tear it. The tearing of the retina may result in bleeding into the vitreous. Less common causes of vitreous hemorrhage include birthmarks inside the eye, inflammation, trauma, tumor, surgery, blood disorders, and macular degeneration.

How is 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 (scleral buckle, pneumatic retinopexy, and/or vitrectomy) 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. In many cases the cause of the vitreous hemorrhage cannot be determined until the hemorrhage has cleared. 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.

What should I be on the lookout for?

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

By Scott E. Pautler, MD

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

Copyright 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

Uveitis

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

What is 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. For example, inflammation of the iris is called iritis. When inflammation is mainly in the central vitreous gel of the eye, it is called intermediate uveitis.

What causes uveitis?

Uveitis may be caused by infection, injury from trauma, 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 other cases uveitis is caused by inflammation without infection. For example, arthritis, multiple sclerosis, lupus, and inflammatory bowel disease may cause uveitis. Uveitis commonly occurs following an injury to the eye. In some cases, no underlying cause can be found to be the cause of uveitis. Very rarely, cancer may cause uveitis. Tobacco may be an aggravating factor and should be discontinued.

What are the symptoms of uveitis?

Various symptoms may be experienced depending on where is uvea is most inflamed. Symptoms may be mild or they may be severe and disabling. The eye may be painful, red, tearing, and light sensitive. Tiny floating spots which move or “float” may be seen. Sometimes blind spots, blurred vision, distortion, or loss of side vision occurs.

How is uveitis managed?

To effectively treat 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 (see uveitis questionnaire) such as rashes, inflamed tattoos, back and joint problems. Tell your doctor if you have been exposed to TB (tuberculosis), traveled abroad, spent 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, uveitis is treated with anti-inflammatory medication in the form of eye drops (steroid and non-steroid), eye injections, and/or systemic therapy (pills or injections into the skin). When systemic therapy is 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, uveitis may be long-lasting. In these cases, years of therapy are needed to preserve vision. 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, uveitis can return at a future date. Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact 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 © 2016-2023 Designs Unlimited of Florida. All Rights Reserved.

Macular Pucker

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

What is the Macula?

The macula is a special area of the retina that gives you fine, central, reading vision. The retina is a thin layer of tissue that lines the back of the eye. It acts like the film in a camera. The retina “takes a picture” of objects you look at and sends it to the brain.

What is Macular Pucker?

Macular pucker occurs when abnormal scar tissue grows like a sheet of cellophane on the macula and causes wrinkling. Macular pucker is present in about one in twenty eyes and is more common later in life. It may occur from aging of the gel inside the eye (vitreous separation), from a torn or detached retina, or from inflammation. Macular pucker is also called cellophane maculopathy, and “wrinkled retina.”  Macular pucker is not the same problem as macular degeneration. Macular pucker does not lead to macular degeneration

What are the Symptoms?

The presence and severity of symptoms vary widely with macular pucker. Symptoms include distortion and blurred vision. Distortion means that straight lines look crooked or wavy. It is readily detected and monitored with the Amsler grid test. Many patients have few or no symptoms and the macular pucker remains stable without worsening.

What is the Treatment?

If symptoms are mild and well-tolerated, no treatment is needed. The macular pucker may not progress and the vision may not worsen further. New glasses will not restore the vision to normal. There is no role for vitamins, exercises, eye drops, pills, or laser in the treatment of macular pucker. This problem usually affects one eye, although occasionally both eyes are involved. When the symptoms of macular pucker interfere with daily activities, vitrectomy surgery can improve vision by removing the abnormal tissue that wrinkles the retina. The amount of visual improvement depends upon the health of the retina under the scar tissue. Usually, there is a significant improvement in vision with much less distortion. Rarely, does the vision return completely to normal. Improvement in vision after surgery takes month to years. The most common side effect from vitrectomy is progression of cataract.

Below is a time-lapse video of a retina scan (OCT) of a 64 year-old woman with longstanding blurred vision and distortion in her right eye with 20/100 vision. After surgery her thickened retina gradually thinned (although it did not return to normal). Her vision returned to 20/25 over time.

For more information please visit Retina Vitreous Associates of Florida.

By Scott E. Pautler, MD

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

Copyright © 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

Preparing for Retinal Surgery

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How can I prepare for surgery?

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

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

What type of anesthesia is available?

With local anesthesia the patient is sedated with IV medication so there is no memory of the anesthetic injection around the eye. Surgical drapes are placed over the face leaving plenty of breathing room. During surgery the patient is awake, but there is usually no pain. It is important to lie still on the operating room table so that there is no movement of the head during surgery. The main advantage of local anesthesia is that the patient can leave the hospital more quickly than after general anesthesia.

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

What are the risks of surgery?

Although uncommon, problems such as bleeding and infection may arise from any surgery. Retinal detachment or abnormal scar tissue formation may require additional surgery. Rarely, there may be loss of vision, double vision, glaucoma, or loss of the eye. The most common problem following vitrectomy surgery is progression of cataract requiring cataract surgery at a later date.

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

What can I expect after surgery?

A soft eye patch and a hard eye shield are placed on the eye at the end of surgery. Leave these in place until your exam on the day after surgery. Tylenol (no more than 4,000 mg per day; caution with liver disease) or Ibuprofen (no more than 2,400 mg per day; caution with kidney disease) may be used if there is pain. Call the doctor for a prescription if your pain is not relieved. It is not common to have severe pain after vitrectomy surgery. A scratchy feeling is due to sutures on the white of the eye. These sutures dissolve in about three weeks and you may use a lubricating ointment (Lacrilube is available without a prescription from the drugstore) as needed for comfort. At your exam after surgery, you will be given eye drops and/or an ointment to keep the eye comfortable, to prevent infection, and to promote healing. Wearing the eye patch is optional after you are seen in the office, but wear the hard protective shield at night for at least two weeks.

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

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

By Scott E. Pautler, MD

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

Copyright © 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

Cystoid Macular Edema (CME)

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

What is cystoid macular edema?

Cystoid macular edema (CME) is an accumulation of fluid in the center of the retina. The fluid is clear like water and comes from abnormal leakage of the blood vessels in the retina. The retina is a thin layer of delicate nerve tissue which lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina which “takes the picture” of objects you look at and sends the message to the brain. The macula is the central area of the retina that gives you sharp central vision and color vision. CME frequently causes a blurring of vision described as fuzzy, hazy, or cloudy. Cystoid macular edema is NOT related in anyway to macular degeneration.

What causes cystoid macular edema?

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

How is cystoid macular edema treated?

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

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

By Scott E. Pautler, MD

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

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

Retinal Detachment

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

What is the retina?

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

What is retinal detachment?

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

Retinal break
Horseshoe-shaped retinal tear as seen in an eye with retinal detachment (Click on image for enlargement)

What causes retinal detachment?

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

What are the symptoms of retinal detachment?

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

How is retinal detachment treated?

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

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

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

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

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

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

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

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

By Scott E. Pautler, MD

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

How do I use my eye drops?

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How do eye drops work?

You ask, “how do I use my eye drops?” but first let’s talk about the drops. Prescription eye drops contain a calculated amount of carefully tested medication.  The medication in the eye drops is rapidly absorbed into the tissues of the eye over a period of seconds to minutes after they are placed in the eye.  For this reason it is important to administer the correct amount of drops and to prevent the drops from spilling out of the eye or passing down the back of your throat through your tear duct.

What side-effects might be encountered?

In some patients eye drops can cause stinging, redness, or irritation.  These are not allergic reactions, but should be reported to the doctor if they become bothersome.  A significant amount of itching might be due to an allergic reaction to the drops. Only rarely do severe reactions occur.  Be sure to report wheezing or shortness of breath to the emergency department.

How do I properly use this medicine?

Be sure your hands are clean.  While looking up with head tilted back, pull the lower eyelid away from the eye with one finger and place one-drop of medicine inside the lower lid onto the eye.  Continue to hold the eyelid away from the eye for about 15 seconds. Then, gently close the eye without blinking.  Keep the eye closed for a minute or two while pressing with your index finger against the side of your nose where the upper and lower eyelids come together.  Finally, dry the remainder of the medicine from your eyes with a tissue paper.  This allows the medicine to be absorbed into the eye and keeps the medicine from going down your throat minimizing side effects.  Using this routine, the next eye drop may be instilled without the need to wait. Use any ointments only after all the recommended drops have been placed in the eye.  Try to use your medication on schedule as missing an eye drop may result in damage to your eye.

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  © 2001-2023 Designs Unlimited of Florida.  All Rights Reserved.

Macular Hole

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globe anatomy
anatomy of the eye (click on image to enlarge)
normal macular OCT
The macula is the center of the retina (in box). The bottom image is an optical coherence tomogram of the macula. (Click to enlarge)

What is a macular hole?

Macular hole means there is a tiny hole in the center of the retina.  The retina is a thin layer of tissue in the back of your eye which lines the inside wall like the film inside the back of a camera.  The retina “takes a picture” of objects you look at and sends it to the brain.  The macula is the center of the retina and gives you sharp central vision for reading and seeing fine details.  When the macula is damaged, the central vision worsens.  Macular hole is not macular degeneration and does not lead to macular degeneration. Macular hole affects both eyes in only about 10% of cases.

What causes a macular hole?

A macular hole is caused when the clear gel that fills the eye (vitreous) pulls on the macula.  When you are born the vitreous gel is thick, clear, and filled with tiny, invisible fibers.  With age or trauma, the vitreous gel begins to condense and pull away from the retina.  If the attachment of the vitreous to the macula is unusually strong, the pulling may result in a macular hole.

What are the symptoms of a macular hole?

Blurring of vision is mild at first, noted especially while trying to read fine print.  It slowly worsens; often with distortion (straight lines look crooked).  Sometimes there is a small blind spot in the center of vision. The visual symptoms may be detected and monitored with the Amsler grid test.

What treatment is available?

In a small number of cases, a macular hole may heal itself. In other cases the vision improves with a medicine injection (Jetrea®). If this fails or is not possible, a surgery may be performed that releases the abnormal pulling of the vitreous on the macula.  A gas bubble (pneumatic retinopexy) is then placed in the eye to close the hole in the macula.  Strict facedown positioning is recommended for several days following surgery.  Special cushions and massage tables are available to help maintain the proper head position.  The most common side effect of surgery is cataract formation.  Cataracts develop after surgery in most eyes over several months to years.  About 5% of eyes require more than one surgery to close the macular hole.  In 2-3% of eyes, the retina may detach during or soon after surgery as a result of continued pulling on the retina by vitreous fibers.  This requires additional surgery to prevent profound loss of vision.  Unommon risks of surgery include hemorrhage, infection, blindness and loss of the eye.

Surgery to close macular hole is usually successful in improving vision, though the vision rarely returns completely to normal.  Some residual distortion and central blurring of vision is common. The vision improves very slowly after surgery over several months to years.

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  © 2001-2022 Designs Unlimited of Florida.  All Rights Reserved.

For more information please visit Retina Vitreous Associates of Florida.