One of the most common ocular changes to occur with age is the breakdown of the gel (called ‘vitreous’) that fills the back of the eye and gives it form. This is called a Posterior Vitreous Detachment (PVD).
It is called posterior because the gel pulls away from the back of our eyes as it shrinks and becomes less viscous. In this process we begin to see small clumps of vitreous floating in our vision. The PVD process often begins abruptly and may be associated with new flashes of light. Although most PVDs are benign, you should have a dilated eye exam when symptoms begin to evaluate for the possibility of an associated retinal tear and/or retinal detachment.
When a PVD occurs it can sometimes pull just enough to cause a sight-threatening retinal tear.
The retina is the thin, light-sensitive neural tissue lining the interior of the eye. It is responsible for converting light to electrical impulses, which are then transmitted to the brain via the optic nerve. Retinal tears are small breaks in this delicate tissue. A tear must be treated in a timely way to prevent it from progressing to a retinal detachment. If recognized and treated early the likelihood of vision loss is very low. Treatment involves applying laser energy to 'spot weld' the retina in place.
Untreated retinal tears allow ocular fluid to work its way behind the retina (through the opening made by the tear).
This process detaches or lifts the delicate photoreceptors (rods and cones) from their source of nourishment on the back of the eye. Once detached you are in a race against time to prevent the highest-prized photoreceptors in your central vision from becoming affected. This is why every PVD, or new onset floater needs a good dilated eye exam. If you experience flashes of light, new floaters, or a shadow or curtain in your vision call your eye doctor immediately and request a same day or following day appointment. If a retinal tear or detachment is found you will often be referred to a retinal specialist for treatment.
Central serous retinopathy (CSR) is an eye disease that occurs most commonly in young men but can occur in men and women of any age.
It causes visual impairment, usually in only one eye. It is most often a temporary condition and in many cases can be treated. It occurs most commonly in young men but can occur in men and women of any age. It is thought to be aggravated by stress, use of steroids, caffeine and hypertension. Stress seems to be the major risk factor.
Symptoms and Causes of Central Serous Retinopathy
People typically notice a blurry spot in the center part of one eye. The blurry spot usually stays the same and doesn’t go away. Objects often appear smaller in the affected eye than in the other eye. In central serous retinopathy, fluid accumulates under the central retina because of failure of the “pump” that usually keeps the retina flat and dry.
Confirming Diagnosis of Central Serous Retinopathy
To confirm that a person has central serous retinopathy, your ophthalmologist will take images of the affected eye using a fluorescein angiography and optical coherence tomography. The procedure involves injecting a fluorescein dye into a vein in your arm. The dye travels throughout the body, including your eyes. Photographs are taken of your eye as the dye passes through the retinal blood vessels. Abnormal areas will be highlighted by the dye, showing your doctor whether you have central serous retinopathy.
Treatment of Central Serous Retinopathy
Central serous retinopathy often resolves on its own over the course of several months without treatment. However, it is important that your doctor monitors your eye until it has returned to normal vision because in some cases it may be necessary to perform laser treatment of photodynamic therapy to seal the leak and restore vision.
Diabetes Type II occurs when sugar levels in the blood rise because of the body’s poor response to insulin.
In type I Diabetes, the body doesn’t make enough insulin to bring blood sugar levels to the normal range. Over the years, elevation of blood sugar levels can weaken the blood vessels in the retina and lead to bleeding, leakage of fluid, and poor oxygen delivery. It is extremely important for people with diabetes to have regular comprehensive eye exams by an eye doctor to prevent this disease from progressing to serious vision problems.
Types of Diabetic Retinopathy
There are two stages of diabetic retinopathy: nonproliferative and proliferative. Nonproliferative retinopathy is the early stage where blood vessels in the retina leak or break. Small hemorrhages in the retina are very typical. If not detected it can advance to cause more severe vision problems. The second stage of diabetic retinopathy is more serious and called proliferative retinopathy. In this stage blood vessels close off and can interrupt blood flow to the retina. The retina then attempts to reestablish the blood flow by growing, or proliferating, new blood vessels. These new vessels are fragile and easily bleed causing loss of vision and scar tissue formation.
Macular edema develops when blood vessels begin to leak fluid into the retina. This causes the retina to swell and often results in blurred or reduced vision. Macular Edema can occur at any stage of diabetic retinopathy but is more likely to occur as the disease progresses and retinal blood vessels become weak.
This is the most advanced stage of the disease and occurs when fragile new blood vessels grow and bleed into the vitreous jelly. If left untreated, proliferative retinopathy usually leads to severe vision loss and even blindness.
Regular eye exams may detect the disease in very early stages and help us to monitor the progression of the disease. Careful blood sugar and blood pressure control can also help to reduce or prevent diabetic retinopathy.
To treat macular edema, small laser light is focused on the damaged retina to seal leaking blood vessels. For abnormal blood vessel growth, larger laser treatments are delivered to the peripheral retina. These treatments reduce abnormal blood vessel growth and help decrease fluid leakage or bleeding in the eye. Laser surgery can greatly reduce the chance of severe vision loss and should be considered early in the course of the disease rather than after vision loss has already occurred.
Newer drug therapies have been developed which are used to treat blood vessel growth, bleeding, and leakage. All of these newer agents are injected with a tiny needle into the eye in an almost painless fashion. These additional treatments have helped to treat specific problems created by diabetic eye disease and help patients regain vision.
This outpatient surgery is often beneficial to remove blood out of the jelly in the eye or to remove scar tissue that can pull on the retina.
Novel drug therapies have been discovered that are able to effectively treat many different eye diseases.
Because the eye is a “safe harbor”, eye drops, oral pills, or IV medications don’t enter the eye well enough to produce the desired long-term effect. Over the past 15-20 years we have discovered a few different medications that are safe and effective when injected directly into the vitreous jelly which fills the eye. This allows the medication direct access to the inside of the eye where it can remain effective for weeks or months with a single injection.
Avastin, Lucentis, and Eylea
Avastin was initially developed as a chemotherapy used to treat cancer. It works by attacking abnormal blood vessels that feed the cancer cells. In 2005 it was discovered that Avastin could be injected directly into the eye and stop abnormal blood vessel growth that occurs in various different eye diseases. Initially, it was found to be effective in patients with “wet” macular degeneration who would otherwise develop legal blindness. Lucentis is a smaller Avastin molecule that has undergone more extensive testing and is FDA approved for use in the eye (currently for “wet” macular degeneration and vein occlusion). Eylea is a newer treatment approved in November 2011 that is also very effective in “wet” macular degeneration. All of these medications are used commonly throughout the USA and the world and have revolutionized treatment of many eye conditions.
Kenalog or Triesence
Steroid injections into the eye have been effective for some time at treating swelling or “edema” of the retina. They are also used in management of uveitis and other diseases that cause inflammation in the eyes. While they have proven to be safe, they are known to cause worsening cataract over time and can cause the eye pressure to rise. While this usually is temporary and can be managed with drops, occasionally people can have a pressure spike, develop glaucoma, and even require surgery to bring the pressure down.
The fear of getting a shot in the eye causes a significant amount of apprehension among many of our patients (and rightly so!). Fortunately, we are specially trained and have extensive experience both administering eye injections and managing any possible complications. Our staff is compassionate and will make sure you are as comfortable as possible during the procedure. We perform each eye injection in a safe and almost painless fashion.
As with any needle entering the body, there is a small risk of infection. Fortunately, this is rare and occurs in less than one in a thousand shots. An infection occurs a few days after the shot when the vision suddenly becomes blurry and cloudy and the eye becomes sore and red. This is an emergency and requires an urgent examination and treatment because vision can be permanently lost. If you have any concerns after a shot, please don’t hesitate to call us directly at any time.
Age-related macular degeneration (AMD) is the leading cause of vision loss in people over the age of 50 in the United States.
While the exact cause of macular degeneration is being studied, we know that different genetic and age-related factors lead to an accelerated aging process in the eye. Macular degeneration affects only the central retina (macula) which is responsible for the clear vision required to read or drive. Although it usually affects both eyes, the eyes can be affected differently.
The most common type of macular degeneration. Early stages of the disease usually do not cause problems and vision usually remains good for many years. As the disease progresses to a more advanced form, most patients have a gradual visual decline over the years where reading and driving become more difficult. Any change in vision or distortion of the lines on an amsler grid may signify a change to the “wet” type.
If macular degeneration becomes “wet”, new blood vessels grow below the retina and begin to leak fluid and bleed under the retina. This causes objects to be distorted, dark spots to be seen, and central vision to be blurred. This is the most severe type of macular degeneration but thankfully has a safe and effective treatment. Ultimately, we treat the “wet” disease to make it “dry” again by stopping the leakage and bleeding.
Treatment for Macular Degeneration
Dry Macular Degeneration
Unfortunately there is no cure or treatment for dry macular degeneration. An amsler grid should be monitored daily and any changes require an urgent eye exam. Make sure you grab one of our amsler grid fridge magnets from the office’s front desk. Vitamin combinations of zinc, antioxidants, vitamin E, vitamin C, and beta-carotene have been shown to reduce the risk of developing advanced AMD. Eating a healthy diet including green leafy vegetables, omega-3 fatty acids, and fish may to be beneficial as well. Newer supplements such as lutein and xeozanthine are being studied in large clinical trials. Vitamin A (beta-carotine) supplementation should not be taken by anyone who smokes or has a history of lung cancer.
Wet Macular Degeneration
Avastin is the most commonly injected intraocular medication in the United States. It has proven to be very successful for preserving vision and even improving vision in patients with “wet” macular degeneration. It is often administered monthly until a response is seen and then treatment is tailored to the patients need. Lucentis is similar to Avastin and is FDA approved for use in the eye. These injections are used interchangeably and have revolutionized therapy for “wet” macular degeneration and helped millions of people around the world.
The macula is the central part of the retina that is responsible for the detailed, clear vision necessary when reading or driving.
If the retina develops a complete hole, a black “missing” spot is seen everywhere the eye looks.
Causes of a Macular Hole
Macular Holes are thought to occur from tangential traction exerted on the retina. The clear vitreous jelly fills the eye cavity and is attached to the retina from birth. With time, it liquefies and separates from the retina, usually occurring at age 50-60. If it does not separate cleanly, it can pull at the retina and cause traction or even a hole to develop in the very center of vision. While the majority of macular holes just happen on their own, severe eye trauma and other pathologic eye conditions may be related.
Typically, people will notice a central blurry spot that progresses to form a “missing area” right in the center part of vision. This makes reading and driving difficult and usually causes severe vision loss. Approximately 10-15% of people who develop a macular hole in one eye will develop one in the other as well. Those who have had a macular hole for less than 6 months have better chance of repair than those who have had the condition longer.
In some cases of vitreous traction, the jelly will separate and release from the retina, leading to spontaneous recovery. If a full hole develops, a surgical procedure called a vitrectomy is required to repair the macular hole. Small instruments are inserted through the white part of the eye and used to remove the jelly and relieve the traction. The jelly is replaced with a temporary gas bubble that that disappears over a few weeks. After the surgery, face down positioning is required for a week. Fortunately, we can help you rent a chair and other equipment to assist with staying on your stomach, face down. Without successful surgery, most people lose the ability to read in the affected eye and are “legally blind” because of poor central vision.
The macula is the central part of the retina that is responsible for the detailed, clear vision necessary when reading or driving.
If the retina develops wrinkle on its surface, it can blur and distort the center of vision.
Causes of a Macular Pucker
A Macular Pucker (Epiretinal membrane) is a thin wrinkle or scar tissue membrane that lies on the surface of the retina. It commonly occurs with increasing age. While the majority of macular puckers just happen on their own, severe eye trauma, eye surgery or laser, or other pathologic eye conditions may be related.
Symptoms of Macular Pucker
Typically, people will notice gradual blurring of the central vision. Usually some amount of distortion of straight lines can be seen. While macular puckers can cause significant problems when reading or driving, they do not require urgent removal and are what we consider an “elective surgery.” Careful consideration of visual and life benefits must be weighed against the small chance of having a complication from surgery.
The pucker (epiretinal membrane) can be surgically removed with a procedure called a “Vitrectomy”. It is an outpatient surgery typically performed with the patient awake but comfortable in a “twilight” state. We place small instruments through the white part of the eye, remove the eye jelly, and “peel” the macular pucker off of the retina. The jelly is replaced with clear fluid that lasts the rest of life and often eliminates floaters. After surgery is performed, no strenuous activity, lifting, or straining can be performed for one to two weeks. Unlike cataract surgery where vision improves in a few days, the benefits of macular pucker surgery are not seen for weeks or months.
The retina is the “film” of the eye that sits inside against the back wall, much like film in a camera.
It is a light-sensitive tissue that takes dynamic pictures of what you see and transmits them to the brain through the optic nerve. When the retina is detached, it is lifted or pulled from its normal position and separates from the back of the eye. If not properly reattached, the retina will die and complete, permanent vision loss occurs.
Most patients initially notice new floaters or flashes of light that look like “lightning” streaks. A shadow or curtain in the vision often indicates that a retinal detachment is occurring. A detached retina is an eye emergency and urgent treatment is usually required to preserve vision.
Although a detached retina can happen to anyone, those with high myopia, a posterior vitreous detachment (PVD), or trauma are at increased risk.
Different Types of Retinal Detachments
Rhegmatogenous – Most common type. This occurs when the retina develops a tear or hole and begins to separate from the back of the eye. Without urgent treatment, these will often lead to blindness.
Tractional – Occurs most commonly in severe diabetic eye disease when scar tissue on the retinal surface contracts and pulls the retina off the back of the eye. (See diabetic retinopathy)
Exudative – Caused by leakage of fluid under the retina from an abnormal blood vessel, inflammatory lesion, hypertension, or even a tumor.
Small tears and holes can be sealed with a laser or freezing treatment to “spot-weld” them closed. If a retinal detachment occurs, surgery is required for repair. Some combination of a Scleral Buckle, Vitrectomy, or Gas bubble are used to put the retina back in place and seal it down. A scleral buckle, which is a tiny silicone band, is attached to the outside of the eye to gently push the eye’s wall against the detached retina. A vitrectomy involves the surgeon making tiny holes in the white part of the eye in order to allow needle-like instruments inside the eye. The vitreous jelly is removed and the retina is flattened against the back eye wall and lasered in place. A temporary gas bubble helps the eye heal from surgery before dissolving on its own. Some patients may need more than one procedure to fix a retinal detachment.
Arteries from the optic nerve bring blood to the retina and veins drain blood out of the retina.
When a blockage develops in a vein, it is like a dam being placed in a river. The waters upstream overflow the banks and spill into the surrounding area. In the eye, blood and fluid leak out of the blood vessels into the retina causing poor vision in that area. Blood flow is permanently altered and can result in substantial vision loss.
Causes and Symptoms of a Vein Occlusion
The most common cause of a retinal vein occlusion is long-standing hypertension. Age and other vascular diseases such as diabetes are risk factors as well. Unfortunately, bad luck also plays a role as the anatomical path of the vein predisposes some people to developing a blockage.
Depending on the severity and which veins are affected, people often have decreased central vision and loss of some or all peripheral vision. The eye often works to “re-route” blood around the blockage but this often takes months or years.
There is no cure for a vein occlusion and no way to completely reverse the damage that has occurred. The best indicator of long term success with treatment is the initial visual acuity at presentation. We can often improve the vision with injections and laser but we are rarely able to bring the vision back to where it was.
New drug therapies have been developed which are used to improve the leakage and bleeding that can develop in vein occlusions. Avastin and the FDA approved drug Lucentis have proven to be successful in improving vision after a vein occlusion has occurred. Recently, the FDA has approved a new medication called Eylea. It may be as effective as Avastin and Lucentis and offers another option for future treatment. These medications are injected with a tiny needle into the eye in an almost painless fashion.
If leakage and swelling occur in the central retina, a light laser is occasionally used to treat the leaking blood vessels. For abnormal blood vessel growth, larger laser treatments are delivered to the peripheral retina. These treatments reduce abnormal blood vessel growth and help decrease fluid leakage or bleeding in the eye. While laser is sometimes necessary for long-term stability of vein occlusions, injections have proven be effective initially.
When inflammation occurs in the eye, it is referred to as Uveitis.
While inflammation can be caused from an infection, it often occurs from over-action of the body’s own immune system, much like the joint inflammation in arthritis. Similar to an arthritic joint, the eye can become red and swollen and the vision can be blurred.
Cause of Uveitis
While uveitis usually occurs for no apparent reason, autoimmune disorders such as rheumatoid arthritis, sarcoidosis, or ankylosing spondylitis make people more susceptible. Any time inflammation occurs in the eye, we must rule out an infection by a careful eye examination and occasionally blood work.
The most common form of this disease is anterior uveitis, which involves inflammation of the front part of the eye and is known as “Iritis.” If the entire eye becomes inflamed (termed panuveitis, vitritis, or retinitis), the retina is often affected and swelling and blood vessel changes can occur.
Symptoms of Uveitis
Different symptoms occur depending on where the primary inflammation occurs. Vision changes vary from mild blurring to inability to read or drive. Uveitis in the front of the eye (iritis) often leads to a red, uncomfortable eye that is very sensitive to light. If the vitreous jelly becomes inflamed (vitritis), people often see an increase in floaters. If the retina becomes involved (retinitis), moderate to severe vision loss can occur.
Treatment of Uveitis
There are multiple treatments for Uveitis depending on the severity of the episode or disease. Eye drops, steroid injections, oral prednisone, immunosuppressive medications, or even surgery or steroid implants are used to control the inflammation.
Most episodes of uveitis are mild and respond well to a series of eye drops. Unfortunately, uveitis can return after treatment is stopped so care must be taken to watch for any recurrence in symptoms. In rare cases, uveitis can be severe, chronic, and affect both eyes. These cases require aggressive, long term treatment to preserve vision. In cases where long term steroids as used, we carefully monitor the eye for signs of glaucoma.
After Hours Emergencies: Call 970-828-2200. Follow the prompts to leave a message for the on call physician. Proceed to nearest Emergency Room if you have not received a return call within an hour.