DIAGNOSIS AND TREATMENTS
Dislocated Intraocular Lenses - Dislocated Lens Fragments
Posterior Vitreous Detachment/Floaters and Flashers
Age-Related Macular Degeneration (AMD)
Age related macular degeneration is a disease which affects the macula, the center of the retina that is responsible for your central vision. As the name implies, it develops in people as they get older. In fact, it is the leading cause of central vision loss in developed countries in people over the age of 55. Symptoms that patients may develop with AMD include blurred central vision, distortion to straight lines, and blind spots in the central vision.
Drusen
There are two different types of AMD, the more common dry form, and the less common wet form. In the dry form, which accounts for 90% of the AMD patients, drusen or yellowish aging deposits can develop under the retina. These deposits usually do not change vision and only a small percentage of people that have drusen will develop a more advanced form of macular degeneration that can be threatening to sharp, detailed vision. In the wet form, abnormal blood vessels (choroidal neovascularization) begin to grow under the retina. These abnormal blood vessels tend to bleed and leak under the retina, hence the name wet AMD. The bleeding and leakage lead to swelling and scarring in the macula with resultant loss of central vision. Although only 10% of patients with AMD have the wet form, they comprise over 90% of the patients with severe vision loss.
Wet-AMD Dry-AMD
How is AMD diagnosed?
Your eye doctor can often diagnose AMD with a dilated eye examination. Often, additional testing such as fluorescein angiography, ICG angiography, and OCT will also be obtained to determine the type of macular degeneration that is present. These tests are also very useful in guiding treatment options.
Once your doctor has diagnosed you with macular degeneration, it is helpful to use the following eye test to test your vision periodically in between doctor visits to see if you notice any changes in your vision. This eye test is called the Amsler Grid (see section on Amsler Grid). If you notice any changes such as wavy lines or areas that are gray/dark/discolored it is important that you see your eye doctor as soon as possible.
What are the treatments?
While there are no cures for AMD, there are many new treatments that can help to control it.
For dry AMD, the Age-Related Eye Disease Study (AREDS) was a NIH-sponsored trial that demonstrated that certain high dose vitamin supplementation can significantly reduce the progression of AMD. These vitamin formulations are available over the counter. Your physician will determine whether or not you would benefit from taking these vitamins. Furthermore, a diet high in green leafy vegetables, fish oils, and lutein, may also be beneficial. Smoking is a huge risk factor for the progression of both the dry and wet forms of AMD, so patients with macular degeneration must stop smoking.
For wet AMD, many treatment options are available. They include thermal laser treatment, photodynamic therapy with a non-thermal laser, and injections of medicines directly into the eye (intravitreal injections) to attack the choroidal neovascularization.
The two most promising intravitreal injections for wet AMD include:
1. Lucentis (ranibizumab injection) - Newest FDA approved (6/30/06) intravitreal anti-VEGF drug that provides a significant chance for vision improvement. 33% - 40% of patients receiving monthly injections had vision improvement after one year (insert link to Genentech clinical trial page). Administered once every month for three months and then as recommended by your eye doctor. We were the first and only clinic in Hawaii to participate in the clinical trials that were necessary in helping to obtain the information necessary to get Lucentis approved. In addition, through our participation with the clinical trials, we were able to make Lucentis available to certain patients prior to FDA-approval and as early as 2003.
2. Avastin (bevicazumab injection) – This is a drug that is FDA approved for the treatment of colon cancer. However, it has also been found to be useful in the treatment of wet AMD. Although it is not the same, Avastin is similar to the smaller Lucentis molecule. Avastin has been used in many clinics around the world as an alternative treatment to help slow down the progression of wet-AMD.
Other treatment options
1. Combination Therapy- There is growing excitement over the possibility that combining PDT with intravitreal injections of medicines may improve visual outcomes, and reduce the number of overall treatments needed. There is a large international clinical trial that is examining this question. We were selected as the only site in Hawaii to participate in this trial.
2. Subretinal Surgery- In certain select cases, your physician may recommend a surgery to physically go into the back of the eye and remove the abnormal blood vessels through microscopic surgery from underneath the retina.
In conclusion, it is important to remember that the earlier the diagnosis the more likely the treatment is to be successful. Check your vision in each eye periodically, preferably with an Amsler grid card, and notify your doctor if there is any change, especially distortion or blurriness. There are many treatment options available in the fight to preserve vision in patients with wet AMD. Your physician will be able to discuss with you which option is best for you.
Instructions for AMSLER GRID TESTING:
Wear your reading glasses and cover one eye.
Look at the center dot and keep your eye focused on this dot at all times.
While looking at the center dot, make any notations of irregularly shaped boxes, wavy lines, distortions, discolorations.
Repeat while covering the other eye.
Below is an example of what an abnormal Amsler Grid may look like to someone that is taking this test that has retinal problems.
Diabetic retinopathy (DR) is an eye disease that is caused by both insulin-dependent and non-insulin dependent diabetes mellitus. There are 2 types of diabetic retinopathy, 1) non-proliferative (also commonly referred to as background) and 2) proliferative.
Non-proliferative DR always develops before proliferative DR. Patients develop areas of bleeding and/or swelling in the retina from damaged blood vessels. Patients may not have any symptoms at this stage. However, vision can sometimes be blurred if the swelling (called diabetic macular edema) is severe. The more serious and advanced type of diabetic retinopathy is the proliferative type. Patients with proliferative diabetic retinopathy develop new abnormal blood vessels that tend to bleed. Bleeding which fills the back of the eye (vitreous hemorrhage), retinal scarring and detachment, neovascular glaucoma are all complications from proliferative DR.
How is it diagnosed?
Your eye doctor will dilate your eyes, and look for areas of bleeding and swelling, abnormal blood vessels, scar tissue, and retinal detachment. Tests such as fluorescein angiography, optical coherence tomography, and ultrasound may be used to help determine the severity level of the diabetic retinopathy and help guide management options.
How is it treated?
The treatment depends on how severe the diabetic retinopathy is. There are specific grading scales for the level of severity. Many cases of diabetic retinopathy can simply be observed. Laser treatment (see section on lasers)may be recommended once the swelling (macular edema) or abnormal blood vessels (proliferative diabetic retinopathy) have reached a severe enough stage. Injection of medicines directly into or around the eye are sometimes needed. Surgery (see section on vitrectomy) is sometimes necessary if there is severe bleeding or retinal detachment in the eye.
Depending on the degree of your diabetes, it is important to follow the directions of your eye doctor. Visits may be needed every six to twelve months at a minimum. Currently, there is no cure for diabetic retinopathy. Along with working with your internist in controlling your diabetes, blood pressure, and cholesterol, most retinal treatments are designed to minimize future vision loss. The best treatment for diabetic retinopathy is prevention. It is important to maintain good control of blood sugar levels and work with your internist, endocrinologist, doctor to prevent further progression of your diabetes. Diet and exercise is stressed as well as good control of hypertension (high blood pressure. Other contributing factors that can cause additional damage and complications in the eye can be related to smoking. Smoking contributes to the obstruction of the blood vessels in the eye and should be stopped by diabetic patients.
Dislocation or subluxation of either a natural lens or a lens implant means that the lens has moved out of its proper position. If the shift in position is great enough, one’s vision will become distorted or blurred.
Shifting of one’s natural lens may occur after trauma or as a result of certain medical conditions. Shifting of a lens implant can occur when the implant is not adequately supported by the capsular bag in which it is placed. The capsular bag that supports the artificial lens can sometimes shift or develop openings that cause the lens implant inside to moves. If the lens moves but stays within the bag, it is called a subluxation. If the lens moves entirely out of the bag, it is called a dislocation. Depending on how bad one’s symptoms are, the lens may or may not need to be repositioned with surgery. A subluxed or dislocated lens can be put back into its proper position and sutured into position so that it is less likely to shift again. Other surgical alternatives include exchanging the lens altogether and placing it front of the iris so that it does not shift.
A retinal detachment occurs when the retina is pulled away from its normal position, lining the inside wall of the eye. The area of retina that is detached does not see light very well and the vision is blurred or lost. If left untreated, a retinal detachment may progress quickly and lead to complete loss of vision of the eye.
Early symptoms of
a retinal detachment may include flashing lights, new floaters, or a gray
curtain which moves across your field of vision. These symptoms do not always
mean a retinal detachment is present, however, you should see your eye doctor as
soon as possible if you experience them. Some retinal detachments progress so
quickly that the first symptom a patient notices is loss of vision of the eye
As the vitreous pulls away from the retina during a posterior vitreous
detachment, the retina may at times tear. Retinal detachment occurs if fluid
from within the vitreous passes through the tear and collects under the retina,
causing the retina the separate from the underlying tissue. An analogy would be
a hole that has developed in a room’s wallpaper. The hole in the wallpaper
usually needs to be repaired before it gets larger and leads to the wallpaper
bubbling off the wall. The detached retina is not capable of normal sight and
as the retinal detachment enlarges and approaches the central part of the retina
there will be an enlarging area of vision loss. This is sometimes described as a
shadow or veil covering the vision. Sometimes retinal tears occur without
associated floaters or flashing lights. In these cases, the first symptoms to
occur may be the loss of vision due to retinal detachment.
There are many different techniques to repair a retinal detachment which are
discussed below. The amount of vision recovered after successful retinal
detachment surgery is variable. The most important factors influencing the
postoperative vision are whether the macula is detached prior to surgery and the
duration the detachment has been present. If retinal detachment surgery can be
done before the detachment has extended to the macula (the center portion of the
retina which is responsible for central vision) the likelihood of maintaining
good central vision is excellent. In many cases however a retinal detachment may
not be detected until after the central vision is affected. If the macula is
detached prior to the surgical repair, there is usually some permanent vision
loss even after successful retinal detachment surgery. While it is common to
obtain some improvement in vision shortly after surgery, the final best vision
may at times take 6 months, a year, or even longer to obtain
A macular hole is a small hole that develops in the center of the retina (macula). Because the macula is responsible for critical vision including reading, driving, and watching television, patients with a macular hole will notice that the center of their vision may be distorted or reduced while their peripheral vision is spared. Your doctor will often be able to diagnose the hole with a careful dilated examination. Often, additional testing with either a fluorescein angiogram or OCT may be obtained to better assess the size and chronicity of the hole.
Macular holes usually develop in otherwise healthy individuals as they get older. Holes will rarely close on their own. Typically when left untreated, the holes tend to get larger with resulting worsening central vision.
The only treatment available to close the hole is with a vitrectomy. A gas bubble is placed inside the eye to help push the hole closed. Because a gas bubble in the eye will always rise to the top (like a bubbles rising to the surface when scuba diving), and because the macular hole is always directly in the back of the eye, patients are instructed to remain face down for several days to weeks after the operation. By remaining face down, it positions the bubble directly on the macular hole to help it close. The bubble gradually is replaced by the patient’s own tears, and the vision will slowly return. Rarely, silicone oil is used instead of a gas bubble.
The success rate for hole closure is over 90%. Most patients will experience an improvement in vision after the macular hole has closed. The distortion and blurred vision will likely improve, although it will never disappear altogether.
Fundus Photograph OCT Scan
Posterior Vitreous Detachment (PVD)/Flashes and floaters:
The back of the eye is normally filled with a jelly called the vitreous. As the eye ages, the vitreous becomes less like a gel and more like a fluid. This is considered a normal effect of aging. Not all the jelly becomes fluid like at once, so small clumps or strands of the jelly may first form. When the eye moves, the fluid/gel moves as well and can eventually pull away from the retina and the optic nerve in the back of the eye. These clumps of jelly move around in the eye. As the light comes into your eye, it is blocked by these clumps of jelly, thereby casting a shadow onto your retina. An analogy would be how a shadow is cast on the ground as a cloud passes over the sun. When this happens in the eye, you end up seeing these shadows as floaters. Although the floaters appear to us to be outside of the eye, they are actually within the eye. The floaters can have many different shapes. While most often they appear as dots or lines, sometimes they can also appear like circles, clouds, cobwebs or even like a spider or a fly. Most of the time these objects will appear to move.
Sometimes, as the jelly pulls away from the retina, the tugging on the retina may also cause you to see flashing lights. In rare instances, as the jelly pulls away, it can rip a blood vessel or even rip a tear in your retina. Therefore, if you notice new flashes or floaters, an exam should be performed just to make sure that there are no other serious problems. Your doctor will perform a dilated examination and likely push on your eye (scleral depression) to make sure that no small holes or tears have developed in the retina.
No treatment is necessary for a PVD unless it leads to a retinal tear or detachment. There is no cure for floaters unless they are disabling or prevent normal day to day functioning, and only then would removal of the gel within the eye be recommended.
As the vitreous pulls away from the retina, the jelly can sometimes pull hard enough to cause a hole or tear to develop in the retina. Patients with a retinal tear will usually, but not always, experience flashes or floaters.
Most retinal tears need to be sealed so that they do not become larger, or allow fluid to track under and lift off the retina (retinal detachment). An analogy would be a hole that has developed in a room’s wallpaper. The hole in the wallpaper usually needs to be repaired before it gets larger and leads to the wallpaper bubbling off the wall.
Retinal tears can be treated using either laser photocoagulation or cryotherapy
(freezing). Laser photocoagulation is a procedure where a special light is
directed to the retina and used to create burns in the retina surrounding the
retinal tear. Cyrotherapy is a procedure where a freezing probe is placed on the
surface of the eye and used to create a freeze extending to the retina
surrounding the retinal tear. Whether laser photocoagulation or cryotherapy is
used, as the eye heals a scar will form sealing the retinal tear and in most
cases preventing a retinal detachment from occurring. Both laser
photocoagulation and cryotherapy are usually performed in the doctor's office.
The treatment starts the healing process immediately, however, the full seal
does not occur for up to 4 to 6 weeks and your ophthalmologist may have you
limit your activities during that time. Treatment of retinal tears is usually
successful in preventing retinal detachment. Unfortunately, occasionally even
after treatment of a retinal tear, retinal detachment may still occur.
Therefore, if any new symptoms arise following treatment of a retinal tear the
retina should be re-examined and even in the absence of new symptoms continued
follow up after treatment of a retinal tear is needed.
This condition has a variety of names, all of which relate to the same findings. These include epiretinal membrane, cellophane maculopathy, and premacular gliosis. All these terms describe the presence of a scar tissue which grows over the surface of the macular, the central region of the retina, it is responsible for providing fine vision can develop spontaneously or they can develop secondary to other ocular conditions.
Many patients with macular puckers may be asymptomatic or may have normal
vision. However, as the macular pucker grows and contracts, it can cause the
retina to become more wrinkled. As the retina becomes more distorted, the
patient may experience when mild distortion to blurred vision. The onset is slow
but visual symptoms can sometimes become progressive.
Once patients present with symptoms, your eye doctor will make the diagnosis of
a macular pucker after a dilated retinal examination. A fluorescein angiogram
and/or OCT may be recommended to help evaluate whether there is leakage in the
retina associated with the scar tissue.
Treatment is not indicated unless the patient is bothered by one’s symptoms.
The only definitive treatment to remove the scar tissue is with a surgery
called vitrectomy. Surgery
can be considered if the patient's visual complaints are disturbing and create
difficulty for them functioning. It also considered if there is significant
leakage noted on fluorescein angiography which would cause a risk to the
patient's vision over time. Specialized instruments are used to peel the scar
tissue from the retinal surface.
It may take up to 2 - 3 months to gain back the majority of vision after the
surgery. However, patients who have had macular puckers present for extended
periods of time or have significant leakage may take longer for recovery. This
depends on many different issues including how long the pucker has been present,
whether there is associated retinal vascular leakage, or if there is a
significant cataract. Statistics show that the majority of patient's visual
improvement is at least 3 lines achieved, but again this depends on the
preexisting findings. Some patients may achieve 20/20 vision, although this is
less likely. Typically symptoms such as distortion and blurriness are alleviated
with successful surgery.
Arteries bring blood into the eyes while the veins take the blood out of the eyes back towards the heart. Sometimes a retinal vein can become occluded, and the blood gets backed up like a clogged drain. When this occurs, the blood ends up spilling into the retina, causing retinal bleeding and often retinal swelling (edema). The area of the retina affected by the blocked vein is not able to get the necessary nutrients and can often become ischemic. In severe cases, the retina in the affected area may die.
There are two main types of vein occlusions. A central retinal vein occlusion occurs when the single main vein that drains the retina becomes blocked. A branch vein occlusion occurs when a smaller branch off the main single main vein becomes blocked. Depending on how bad the occlusion is, both the central and branch vein occlusions can lead to severe ischemia and swelling of the retina. In these situations, the patient may experience painless loss of vision.
Your eye doctor will be able to diagnose this condition with a careful dilated examination. Additional testing with fluorescein angiograms and OCT are often obtained to assess the degree of damage to the retina.
Branch retinal vein occlusions can sometimes be helped with focal or grid macular laser treatment if macular edema has developed. Macular edema from central vein occlusions generally does not respond to laser. There is currently growing interest in using injectable steroids or other medicines to help with the macular swelling in both branch and central vein occlusions. Patients with vein occlusions need to be monitored on a regular basis for the development of abnormal blood vessels that the eye sometimes develops in its attempt to resupply the damaged retina. If these abnormal blood vessels are found, your doctor will recommend a different laser treatment (panretinal photocoagulation) to get rid of these abnormal blood vessels.
Central Retinal Vein Occlusion Branch Retinal Vein Occlusion
Arteries bring blood into the eyes while the veins take the blood out of the eyes back towards the heart. Sometimes a retinal artery can become occluded. In a way, one can think of a retinal artery occlusion as a “stroke or heart attack” of the eye. The patient will experience sudden painless loss of vision. If the blood flow is not restored within 90 minutes, the retina will begin to die and the vision loss will be permanent.
There are two main types of vein occlusions. A central artery occlusion occurs when the single main artery that supplies the retina becomes blocked. A branch artery occlusion occurs when a smaller branch off the main single main artery becomes blocked. Depending on how bad the occlusion is, both the central and branch artery occlusions can lead to severe ischemia and death of the retina.
Your eye doctor will be able to diagnose this condition with a careful dilated examination. Additional testing with fluorescein angiograms and OCT are often obtained to assess the degree of damage to the retina.
There are no good treatments for retinal artery occlusions. Usually by the time that symptoms have developed, the nerve tissue in the retina has already died because it had not been receiving the necessary blood and nutrients. Patients with artery occlusions need to be monitored on a regular basis for the development of abnormal blood vessels that the eye sometimes develops in its attempt to resupply the damaged retina. If these abnormal blood vessels are found, your doctor will recommend a different laser treatment (panretinal photocoagulation) to get rid of these abnormal blood vessels
Retinal artery occlusions can be caused by many different reasons. Usually, the artery becomes blocked by an embolus. The most common sources of the emboli come from the heart or the carotids (arteries in one’s neck). Finding the underlying source of the embolus is critical to trying to prevent more emboli from forming and blocking more arteries to the eye, or even to the heart or brain. Your doctor will therefore often order additional tests to examine your heart (EKG, echocardiogram), your neck vessels (carotid Dopplers), and sometimes your blood to determine if you have any conditions that would predispose you for developing more emboli. Your primary care physician may also elect to place you on blood thinners to lower your risk of future occlusions.
Pneumatic retinopexy is an office based procedure that is used for repair of a retinal detachment. A gas bubble is injected into the vitreous cavity. The patient is then positioned in such a way so that the gas bubble pushes against the retinal tear and temporarily seals the tear responsible for the retinal detachment. With the retinal tear covered by the gas bubble, the fluid that has accumulated under the retina will usually be reabsorbed by the eye within one or two days. To create a permanent seal around the retinal tear, pneumatic retinopexy is done in conjunction with either retinal cyropexy or laser photocoagulation. Sometimes the retinal cryopexy will be done prior to the injection of the gas bubble. On other occasions however, the cryopexy or laser photocoagulation will be done on a subsequent day, after there has been clearing of the subretinal fluid. Depending on which gas is used, the bubble takes from between two and six weeks to be cleared from the eye. While pneumatic retinopexy is a good option for the repair of certain types of retinal detachments, not all retinal detachments are suitable for this type of repair.
Scleral buckles are used to repair retinal detachments. A scleral buckle is a permanent band which is placed around the outside of the eye to help support the retina in good position, similar to a belt for one’s pants. They are made usually of either solid silicone rubber or sponge material. They are placed under the conjunctiva (white part of eye) and once healed, are not visible. They have been used for decades and are designed to be safely left in place forever. Cryotherapy is usually used with a scleral buckle to create a permanent seal surrounding the retinal tear. The fluid which has collected under the retina is either surgically removed or is allowed to spontaneously reabsorb. Sometimes a gas bubble will also be injected into the vitreous cavity as part of this procedure. Scleral buckling surgery is performed in an operating room. It is frequently done under local anesthesia and the patient will usually return home the same day as the surgery.
Vitrectomy is the surgical removal of the jelly in the back of the eye (vitreous). The vitreous is not needed to see well, and can be safely removed from the eye. Vitrectomy is performed to fix many conditions including but not limited to retinal detachment, macular hole, macular pucker, vitreous hemorrhage, diabetic retinopathy, vein occlusions, retained lens fragments, dislocated lens implant, and severe eye injury. Vitrectomy is performed in the operating room either under local or general anesthesia. Three small incisions (< 1mm in size ) are made into the sclera (white part of eye). An infusion line is placed into one of the incisions to fill the eye with a salt solution to replace the vitreous as it is removed from the eye. Microscopic instruments are then inserted into the two remaining incisions to perform the necessary operation. Instruments that are used for the vitrectomy include light sources to help with visualization, microscopic forceps, scissor, cutters, and lasers. At the end of the operation, it is sometimes necessary to place either a gas bubble or silicone oil into the eye to help push and keep the retina in good position. The gas bubble can last anywhere between several days to weeks and will eventually get reabsorbed by the eye and replaced with the body’s own fluids anywhere. During the time that one has a bubble in the eye, they will may need to maintain their head in certain positions and avoid flying at very high altitudes.
The choice of which of these procedures is most appropriate for the repair of a retinal detachment is dependent on many factors. These include the location of the responsible retinal tears and the presence or absence of scar tissue on the retina. The decision of which method of retinal detachment surgery is best can only be made after a careful evaluation. Fortunately, with these techniques it is possible to successfully repair most retinal detachments. While most retinal detachments are successfully repaired with a single operation, in some cases more than one operation may be needed.Different type of retinal lasers
Lasers are one of the most important tools that retinal specialists have. These lasers are very different from the types that are used in refractive surgery or glaucoma surgery. These lasers are usually performed right in the office.
Panretinal Photocoagulation (PRP)- In certain eye conditions such as diabetic retinopathy or vein occlusions, the usual flow of blood and nutrients to the retina can become compromised (ischemic). The eye will sometimes try to resupply the retina by growing new abnormal blood vessels (neovascularization). However, these blood vessels do not behave normally, and have a tendency to bleed and lead to the formation of scar tissue and retinal detachments. When neovascularization develops, your doctor will perform panretinal photocoagulation to get rid of these bad vessels. The laser is usually applied over several sessions.
Focal or Grid Macular Laser
Macular edema or swelling can develop in various eye conditions. When this occurs, the central vision becomes blurred. This type of laser treatment is designed to minimize worsening of the edema, and can sometimes reduce the swelling. The goal of the laser treatment is to prevent worsening of vision. Sometimes, vision may improve as the swelling improves.
Laser Retinopexy
When a hole or tear develops in the eye, it often needs to be sealed off to prevent it from getting larger and turning into a retinal detachment. The laser is applied to surround the retinal break. The laser acts like a glue to seal the edges of the break down. However, like glue, it takes up to 1-2 weeks for it to “harden”. During this time, your physician may place restrictions on your activity until the laser has had adequate time to seal the break.
Thermal Laser for Choroidal Neovascularization
In certain eye conditions such as wet macular degeneration, abnormal blood vessels can begin to grow under the retina (choroidal neovascularization). Laser treatment can be applied to destroy the choroidal neovascularization. This is a “hot” thermal laser that not only destroys the underlying bad blood vessel, but also the overlying retina. Therefore, care must be taken to avoid applying the laser too close to the center of the vision. Otherwise, the patient will notice a blind spot in the center of their vision. Other treatments exist for patients where the blood vessels have invaded the center of the vision and thermal laser is not a good option.
Photodynamic therapy for Choroidal Neovascularization
This is a “cold” laser that is sometimes used for the treatment of choroidal neovascularization that has involved the center of one’s vision. A special dye (Visudyne) is first injected into one’s arm vein and allowed to travel up into the eyes where the medicine is selectively taken up by the bad blood vessels. A “cold” laser is then applied to the area of the bad blood vessels to activate the medicine which in results in closure of the choroidal neovascularization. Because this is a non-thermal laser, the collateral damage to the overlying retina is minimized. Because light activates this medicine, patients receiving this treatment are advised to stay out of the sunlight or 5 days following treatment.