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Eye Clinic Services

OCULAR DISORDERS AND TREATMENTS

 

 

Anatomy Of The Human Eye

 

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Hyperopia

 

Hyperopia, or farsightedness, is a type of refractive error. A farsighted person can see distant objects very well, but has difficulty seeing items upclose. After viewing nearby items for a long time, a farsighted person may experience blurred vision, and irritability. Simple eye exams such as reading an eye chart can miss hyperopia since individuals with this condition can see the distant chart very well.

In most cases, a person experiencing farsightedness has a compressed eyeball rather than a rounded one. This causes the light entering the eye to be focused behind the wall at the rear of the eyeball. The condition may also be caused by the cornea having too flat of an angle.

Hyperopia is generally thought to be an inherited condition, although other factors may contribute to it. It is not a disease. If the variation is slight, an individual's vision might not need correction. If it is great, however, glasses or contact lenses can be used to correct the condition.

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Myopia

 

Myopia is also known as nearsightedness. An individual with myopia can see items up close very well, but has difficulty seeing distant objects. This condition occurs either because the eyeball is elongated rather than rounded or the cornea's angle of curvature is too steep. This results in nearsightedness. Instead of the image being focused to a fine point in the back of the eye, the light comes to a focus in front of the retina.

Myopia is not a disease except in rare situation when it can predispose to degenerative changes in the retina or predispose to retinal detachment.  It is a normal variation in the shape of the eye that is experienced by many individuals. The condition usually begins between the ages of eight and twelve and nearly always before the age of twenty. The development of myopia tracks the rapid growth of the human body during adolescence and pre-adolescence. If the variation is great, glasses or contact lenses can be used to correct the distorted vision.

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Astigmatism

 

Astigmatism is one of several eye conditions known as refractive errors. Refractive errors are those that deal with the angle at which the light enters the eye. This affects the focus of the light on the retina, the nerve tissue that collects light that is transmitted to the brain.

An astigmatism usually results from an unequal curvature of the cornea , the front surface of the eye. It is not a disease, and is actually a common problem. It can cause blurring of both distant and nearby objects. This blurred vision can cause headache, fatigue, squinting, and eye discomfort or irritation

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Floaters and Flashes


Small Specks and Flashes of Light in the Field of vision.

Sometimes people see small spots or specks moving their field of vision or experience flashes of light.  These occurrences are called floaters and flashes.  Although annoying, floaters and flashes are generally of little importance.  However, in some cases, floaters and flashes may be the symptoms of a more serious eye problem, such as retinal detachment.  If these symptoms develop, an immediate exam is recommended.

What is a Floater?

floater A floater is a small clump of gel that forms in the vitreous, the clear jelly-like fluid which fills the cavity inside the eye.  Floaters may be seen as dots, lines, cobwebs or spiders and are most often noticed when reading, looking at a blank wall or gazing at a clear sky.
Although floaters appear to be in front of the eye, they are actually floating in the fluid inside the eye.  Sometimes, floaters do not interfere with vision at all.  However, when a floater enters the line of vision, light is blocked and a shadow is cast on the retina.  (The retina is the thin lining of nerve tissue at the back of the eye that converts images to electrical impulses which are then sent over the optic nerve to the brain.)

What causes floaters?

The appearance of floaters may cause much concern, especially if they develop suddenly.  However, floaters are usually a result of the aging process.  As we mature, the vitreous gel shrinks and pulls away from the retina.  Floaters are formed from the reorganization of the vitreous material and sometimes blood which occurs when the gel pulls away from the back of the eye.  Floaters are especially common in nearsighted people, in people who have suffered eye injuries, and after eye surgery.  Although uncommon, floaters can also result from inflammation within the eye or from crystal-like deposits which form in the vitreous gel.

Are floaters ever serious?

Sometimes, the retina may be torn as the vitreous shrinks and pulls away from the retina.  A tear through a small blood vessel in the retina may cause bleeding  Clotted blood and vitreous material may appear as a new set of floaters.  Retinal tears require immediate medical attention to prevent retinal detachment.  If the retina detaches from the back of the eye, partial or total loss of vision may occur.

How are floaters treated?

Although annoying, floaters are usually not vision threatening and do not require treatment.  Often floaters diminish and become less bothersome with time.  If a floater appears directly in the line of vision, moving the eye around will often help.  Looking up and down or back and forth will cause the vitreous fluid to swirl around and often allows the floater to move out of the way.  However, with a complete eye examination, it can be determined if floaters are harmless or the beginning of a more serious problem.
In cases where floaters do indicate a more serious condition, lasers can be used to prevent vision loss.  Retinal tears can be sealed with an Argon laser.  This painless treatment can usually be performed as an office procedure and prevents more serious conditions, such as retinal detachment.  

What are flashes?

Flashes appear as flashing lights or lightning streaks in the field of vision, although no light is actually flashing.  Flashes are similar to the sensation of "seeing stars" when one is hit on the head.  Flashes are most often noticed at night or in a dark room.  

What causes flashes?

Flashes are caused by the vitreous gel tugging on the retina.  If the gel actually separates from the retina >posterior vitreous detachment), flashes of light may appear periodically for several weeks.  As with floaters, flashes are usually a result of the aging process and do not indicate a serious vision problem.  However, flashes which appear along with a large number of new floaters or with a loss of part of the field of vision may indicate retinal detachment, requiring an immediate eye exam.

Flashes and Migraines

Flashes can also occur in association with migration headaches.  A migraine is caused by a spasm of blood vessels in the visual information center of the brain.  Migraine related flashes distort central vision for ten to twenty minutes and appear as jagged lines or "heat waves" in both eyes.

How are flashes treated?

Unless they represent the symptoms of a more serious condition, flashes do not require treatment.  Flashes which are a result of the vitreous pulling away from the retina will eventually stop.  However, flashes may indicate retinal detachment, which needs immediate medical treatment.  Migraines, which are often accompanied by flashes, can be treated with medical therapy if they occur frequently and are debilitating.

Prevention is the best medicine

Although floaters and flashes are usually not considered serious vision problems, one should have a complete eye examination to determine their importance.  In most cases, treatment is not necessary.  However, early detection and treatment of serious problems, such as retinal tears, can prevent permanent vision loss. If you are experiencing floaters, flashes or other vision problems, you should obtain a complete eye examination.

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Macular Degeneration


A Deterioration of the Retina Which Causes Poor Central Vision

Macular degeneration is the leading cause of impaired reading or central vision. It is caused by the breakdown of the macula, the central portion of the retina. Although macular degeneration causes distortion of central and color vision, side vision is not affected.

 

What is the retina?

The retina is a thin layer of light sensitive tissue which lines the back of the eye. When light enters the eye, it is focused by the cornea and the lens onto the retina. The retina then transforms the light images into electrical impulses which are sent to the brain through the optic nerve.

What is the macula?

The macula is a very small area of the retina which is responsible for central vision and color vision. The macula allows us to read, drive, and perform detailed work. Surrounding the macula is the peripheral retina which is responsible for side vision and night vision.

What causes macular degeneration?

Macular degeneration is most commonly a natural result of the aging process. With time, the retinal tissues break down and become thin. This deterioration causes a loss of function of the macula.

In about 10% of cases of macular degeneration, aging of the retina is compounded by leakage of the tiny blood vessels which nourish the retina. Growth of new, abnormal blood vessels in the scar tissue that forms from the leaking blood vessels is also common. Blood and leaking fluid destroy the macula, causing vision to become distorted and blurred. The formation of dense scar tissue blocks out central vision to a severe degree.

Occasionally, macular degeneration is caused by injury, infection, or inflammation. The disease may also be hereditary.

What are the symptoms of macular degeneration?

Macular degeneration may cause words in the center of a page to appear blurry.

The most notable symptom of macular degeneration is blurry or distorted central vision. Difficulty in reading, doing close work, or driving may also be noticed. A person with macular degeneration may experience blurry words on a page, distortion of the center of a scene, a dark or empty area in the center of vision, or the distortion of lines.

Macular degeneration may also cause a dimming of color vision. Fortunately, the disease does not cause total blindness, as side vision is not affected. Macular degeneration only affects central and color vision. However, if macular degeneration occurs in only one eye, the symptoms of the disease may not be noticed, as the "good" eye compensates for the "bad" eye.

How is macular degeneration diagnosed?

A clinical examination is necessary to visualize the back of the eye with various instruments. In addition, some special tests may be administered. The Amsler grid test, in which the patient looks at a page similar to graph paper, is used to detect blind spots or distortion of central vision. A color vision test will indicate damage to the macula if the patient cannot detect symbols or letters camouflaged in colored patterns.

If macular degeneration is detected, a procedure called fluorescein angiography may be done to check for blood vessel leakage. A dye, which quickly travels to the eye, is injected into the patient's arm. Photographs of the blood vessels in the retina are then taken to determine the extent of damage.

There are two forms of macular degeneration, wet and dry. Most cases of macular degeneration occur in later life, after fifty years of age. Because of this relationship to age, it is often referred to as age-related macular degeneration, ARMD.

The dry form involves about 90% of those individuals suffering from macular degeneration. The individual may experience some distortion of narrow vertical objects such as telephone poles or may experience black spots in the center of their vision. The dry form is more prevalent, but comparatively less serious than the wet form. It is slow moving and normally occurs over months and years, and may only occur in one eye. An individual's "good eye" typically compensates for the deteriorating eye. Individuals suffering from macular degeneration can also creatively adapt by turning their heads to see what is directly to their front.

The wet form of macular degeneration accounts for 90% of the most serious cases of ARMD, but involves only 10% of the total cases. In the wet form, the tiny blood vessels nourishing the macular develop small leaks. This may result in retinal swelling, breaks, or lesions that damage the retina's ability to collect and convert light to sight. These leaks can cause rapid deterioration and loss or central vision. The retina may actually "detach" itself from the eye wall.

 
How is macular degeneration treated?

For the dry form of macular degeneration, the AREDS (Age Related Eye Disease Study) showed that certain vitamins were useful in slowing the progression of the dry type of macular degeneration.  The vitamins shown to be most beneficial are zinc 80mg as zinc oxide, Vitamin C 500 mg, and Vitamin E 400 I.U.  Beta carotene (Vitamin A) has been shown to not be beneficial, and in fact has been associated with an increased risk for lung cancer in smokers.  It is not recommended.  Copper 2mg is recommended to prevent a zinc induced anemia.  Lutein 2 mg to 4 mg is being studied and there is good theoretical reasons for its use.  The vitamins listed are recommended only if a person has clinical findings of macular degeneration. 
It is recommended that in general, that a person stop smoking and adhere to a heart healthy diet with several servings of fruit, vegetables, and an oily fish such as salmon, sardines, or halibut each week.  Omega 3 fatty acids (fish oil) is recommended if a person is not getting the recommended servings of fish.
For the wet type of macular degeneration, the latest recommendations are for the injection into the eye of an anti Vascular Endothelial Growth Factor (anti-VEGF agent).  There are two drugs currently used, Lucentis (which has FDA approval) and Avastin (which is used off label).  Both appear to work equally well.  Patients can expect some visual improvement 30% of the time, visual stabilization 90% of the time, and visual worsening in spite of the injection 10% of the time.  These injections may need to be repeated every 4 to 5 weeks for an indefinite period of time.

Low vision aids

People who suffer from macular degeneration are able to compensate for much of their vision loss through the use of low vision aids. Many magnifying devices, such as spectacles and hand or stand magnifiers, are available. Bright illumination for reading and other close work can also be helpful. Books, news-papers, and other materials are available in large print.

Low vision aids assist many patients with macular degeneration in leading comfortable, normal lives with few interruptions of regular activities.

Prevention is the best medicine

Regular eye examinations are the only means of detecting macular degeneration, as the symptoms of the disease often go unnoticed. Early detection of macular degeneration may prevent further vision loss, since treatment is only effective when started early. Regular examinations are especially important for older adults and persons who have family members with a history of retinal problems.

If you are experiencing difficulty with central or color vision or have other vision problems, you should obtain a complete eye examination.

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Macular Dengeration and Nutrition

Both doctors and the public have shown growing interest in the relationship between diet and health. Good nutrition depends on a healthy mixture of proteins, carbohydrates, fats, vitamins and minerals. Protein is needed for the building blocks and chemical machinery of our bodies; carbohydrates are needed for immediate fuel and energy; fats are needed for long-term storage of fuel and energy. Vitamins are organic compounds that our bodies cannot manufacture but are essential for maintaining good health. The eye, like any other part of the body, benefits from a healthy diet. Although the exact causes of macular degeneration are not understood, there is some evidence that vitamins and minerals may play a preventive role.

Macular degeneration is damage or breakdown of the macula, the small part of the retina responsible for central vision. It affects both distance and close vision and can make some activities–like threading a needle or reading–very difficult or impossible. Macular degeneration is the leading cause of severe visual loss in people over 65.
Zinc, one of the most common minerals in our body, is very concentrated in the eye, particularly in the retina and macula. Zinc is necessary for the action of over 100 enzymes, including chemical reactions in the retina. Studies show some older people have low levels of zinc in their blood. Because zinc is important for the health of the macula, some think that supplements of zinc in the diet may slow down the process of macular degeneration. Scientific studies are not complete and there is no agreement concerning the value of zinc supplements. It is possible that too much zinc may interfere with other trace minerals such as copper.

Normal chemical reactions from light in the eye activate oxygen that may cause macular damage. Some vitamins function as antioxidants that work against this activated oxygen. It may be claimed that antioxidant vitamins (vitamins A, C and E) can help slow down macular degeneration and other aging problems. As in the controversy over zinc, there is no agreement that these antioxidants actually help macular degeneration.
The first step to overall good health is a balanced diet. Vitamins and minerals are commonly given as supplements to the diet in amounts determined by recommended daily allowances. These supplementary dosages cause no apparent harm and are commonly available. Large doses of vitamins, called therapeutic doses, in amounts many times the recommended daily allowances, may not be completely safe.
Nutrition and macular degeneration is still being researched. Consultation with your ophthalmologist before beginning to take therapeutic doses of any vitamin or mineral is advisable.


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Diabetic Retinopathy


diabetic-retinopathy-figure-3.jpg


A Complication of Diabetes Involving Abnormal Blood Vessels Which Nourish the Retina of the Eye


Diabetic retinopathy is the leading cause of blindness among adults. Approximately, 25% of current diabetics have some form of the disease. The risk of developing diabetic retinopathy increases with the age of the diabetic person and the duration of the disease. It is estimated that 90% of diabetics may experience some form of diabetic retinopathy over the course of their life. However, only a small percentage of those developing diabetic retinopathy have serious vision problems and even a smaller percentage become blind.

What is Diabetic retinopathy?

Diabetic retinopathy is a complication of diabetes mellitus which causes abnormalities in the tiny blood vessels nourishing the retina. These vessels weaken, leak fluid and blood, and fail to provide nutrients necessary for good health in the retina. Left untreated, diabetic retinopathy can result in severe visual loss, including blindness.

What is the retina?

The retina is a thin layer of delicate nerve tissue which lines the back portion of the eye. Light enters the eye and is focused by the lens through the transparent gel-like fluid (vitreous) onto the retina. The retina then changes the image into electric impulses which are carried to the brain by the optic nerve.

The retina has two main parts - the macula and the peripheral retina. The macula is located in the middle portion of the retina close to the optic nerve. The macula is responsible for central vision and color vision. The peripheral retina is the outer region of the retina and is responsible for side vision, as well as night vision.

What is background diabetic retinopathy?

Diabetic retinopathy can take two forms, background retinopathy and proliferative retinopathy. During the early stage of the disease (background retinopathy), small blood vessels in the retina leak a clear fluid (serum) into the surrounding tissue which causes swelling. Abnormal blood vessels may also hemorrhage or leak fats and proteins which form deposits. If fluid collects in the macula, diminished or blurred vision will result. However, if leakage or deposits occur in the outer edges of the retina, no symptoms may be noticed.

Sight is not usually seriously affected in cases of background retinopathy. In fact, the condition does not progress in 80% of patients. However, background retinopathy is a warning sign and can progress into the more serious stage of the disease, proliferative retinopathy.


What is proliferative diabetic retinopathy?

Proliferative diabetic retinopathy is the more advanced stage of the disease. New abnormal blood vessels grow over the retina and may grow into the clear vitreous. These new vessels bleed into the vitreous, blocking light from reaching the retina and causing vision to become cloudy. Connective tissue growing along with abnormal blood vessels may contract, pulling the retina off its underlying structures and toward the vitreous (retinal detachment).

Proliferative retinopathy affects approximately 5% of all diabetics and becomes more likely with increased duration of diabetes. If left untreated, proliferative retinopathy can lead to blindness.

What causes diabetic retinopathy?

The cause of diabetic retinopathy is not completely understood. However, it is known that diabetes weakens small blood vessels in various areas of the body, including the retina. Unfortunately, the development of diabetic retinopathy cannot be prevented.

What are the symptoms of diabetic retinopathy?

Though vision may gradually become blurred, significant loss of sight does not usually occur with background retinopathy. Since the patient does not experience pain or external symptoms such as blood-shot eyes or discharge, changes in the retina can go unnoticed unless detected by an eye examination.

When bleeding occurs in proliferative retinopathy, the patient has clouding or complete loss of sight. Connective tissue pulling on the retina causes distortion and blurring. However, if abnormalities occur in the peripheral retina, the patient may not experience any symptoms.

How is diabetic retinopathy diagnosed?

A comprehensive eye examination is the best protection against the progression of diabetic retinopathy. The disease can be detected by viewing the retina with instruments which illuminate and magnify the structures of the eye. If diabetic retinopathy is found, fluorescein angiography is performed to determine the extent of blood vessel leakage. In this procedure, a series of photographs are taken as a dye travels through the retinal vessels. In some cases, ultrasound equipment may be used to check for retinal detachment.

How is diabetic retinopathy treated?

Treatment of diabetic retinopathy depends on the location of the disease and the degree of damage to the retina. If retinopathy occurs in the peripheral retina, careful monitoring of the disease may be all that is necessary. When retinopathy affects the macula and central vision, laser treatment is usually necessary.

In cases of background diabetic retinopathy, lasers may be used to seal blood vessels that have leaked serum. laser treatment may not halt the disease entirely but can reduce further visual loss by delaying the onset of proliferative retinopathy.

The proliferative stage of the disease is also treated with lasers to curtail the growth of new abnormal blood vessels.

Laser treatment of diabetic retinopathy is usually done on an outpatient basis in an office or outpatient center.


Prevention is the best medicine

Early detection and management of diabetic retinopathy is important to arrest or slow the development of the more sight damaging stages of the disease. Even when no symptoms are noticed, the diabetic patient should have frequent eye examinations, as recommended by their doctor. Non-diabetics should also have their eyes examined periodically to help detect the presence of diabetes and other diseases. With careful monitoring, treatment of diabetic retinopathy can usually be started before sight is affected.

If you are experiencing the symptoms of diabetic retinopathy or other vision problems, you should obtain a complete eye examination. If you have diabetes mellitus, you should have a dilated eye examination at least once a year for the rest of your life.

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Glaucoma

Increased Fluid pressure in the Eye Causing loss of side vision

Glaucoma, one of the leading causes of blindness, is estimated to affect 1 of every 50 adults.  Although glaucoma can occur at any age, the risk of developing the disease increases dramatically after the age of 35.  Glaucoma is also more likely to develop in persons who are of older age, african american, persons with abnormal appearing optic nerves, persons with higher eye pressure, persons with thinner corneal measurements and persons with visual field defects. Because the symptoms of early glaucoma are so slight, the disease often goes unnoticed until permanent vision has occurred.  However, with early diagnostics and careful treatment, visual damage from glaucoma can be prevented.

What is glaucoma?

Glaucoma is a series of diseases which damage the optic nerve.  Damage to the optic nerve and retina causes blind spots in the field of vision.  If the entire nerve is destroyed, blindness will occur.  When light enters the eye, an image is focused onto the retina, the delicate nerve layer lining the inside back wall of the eye.  The retina then transforms the light images into electrical impulses which are carried to the brain by the optic nerve. If Glaucoma is not treated, pressure in the eye increases, causing a a loss of peripheral (side) vision.

What causes glaucoma?

Glaucoma is usually caused by an increase in the fluid pressure in the eye.  The front part of the eye contains a clear, nourishing fluid called the aqueous which constantly circulates through the eye.  Normally, this fluid leaves the eye through a drainage system and returns to the blood stream.
Glaucoma occurs from an overproduction of fluid or when the drainage system becomes blocked, causing fluid pressure to increase.  The high pressure causes damage to the optic nerve, resulting in permanent vision loss.  The exact reason the fluid system in the eye stops functioning properly is not completely understood.  Much research is being done in this area to further our understanding of glaucoma.

What are the symptoms of glaucoma?

The early symptoms associated with chronic open angle glaucoma, the most common type, are usually unnoticeable. At first, in most cases, the build up of pressure is gradual without any discomfort or pain. Most people do not detect a change in their vision until substantial sight loss has occurred. Certain parts of peripheral (side) vision are affected first with the top, sides, and bottom of the field of vision becoming decreased. Later in the course of the disease central vision becomes affected, mild headaches and difficulty with night vision might be experienced. And if left untreated, total blindness will result.

The patient stricken with acute closed angle glaucoma experiences more noticeable symptoms. The sudden onset of acute glaucoma can cause blurred vision, severe pain, nausea, and halos around lights. Congenital glaucoma also presents noticeable symptoms in the infant such as enlarged eyes, cloudy cornea, light sensitivity, and excessive tearing.

Types of Glaucoma

Depending on the type of glaucoma involved, symptoms may vary. The types of glaucoma are: chronic open-angle glaucoma, congenital glaucoma, acute angle-closure glaucoma, and secondary glaucoma.
         Chronic open-angle glaucoma is the most common type. It occurs in people over 40 and is a symptomatic, “quiet” disease. Drainage is slowly reduced over time and pressure continues to grow. It usually causes irreparable damage before it is diagnosed and treated. That is why regular glaucoma examinations are important.
         Congenital glaucoma is present at birth or shortly after. It is usually a defect in the drainage system that immediately causes pressure to accumulate. Any infant displaying sensitivity to light or eyes that are continually filled with tears should be checked for this conditions.
         Acute angle closure glaucoma results from an immediate and complete blockage of the drainage area. It is also known as primary narrow-angle glaucoma or acute glaucoma. The iris may press against the drainage area causing a sudden blockage and rapid build up of pressure. Symptoms include rainbow-like halos or circles around lights, severe pain in the forehead or eyes, nausea, and blurred vision. This type of glaucoma can occur at any age and is a medical emergency. Immediate professional medical care should be sought to preserve sight since blindness can occur in a day or two without treatment.
         Secondary glaucoma occurs as the result of another health problem being experienced by an individual. Its development may be rapid or slow. The symptoms are similar to that of acute angle-closure glaucoma and as with that form of glaucoma, immediate medical attention should be sought.

How is glaucoma diagnosed?

In most cases, glaucoma is detected in a routine eye examination before the patient experiences any vision problems. An evaluation for glaucoma is painless and includes checking the pressure or hardness" of the eye with a tonometer. The optic nerve is checked for damage with an ophthalmoscope, an instrument which illuminates and magnifies the back of the eye. A special mirrored magnifying lens called a gonioscope is used to examine the drainage channels for proper fluid outflow. If any sign of glaucoma is detected, the patient’s field of vision is tested for blind spots and any shrinkage in peripheral (side) vision.

How is glaucoma treated?

With early detection and treatment, glaucoma can almost always be controlled and vision preserved. However, glaucoma cannot be cured and once vision has been lost it cannot be restored. A combination of eye drops, medication, laser treatment and conventional surgery is used to treat glaucoma. Treatment is concentrated on lowering the pressure inside the eye to prevent damage to the optic nerve.

The most common treatment for glaucoma is the use of medications in the form of eye drops and pills. Some medications allow for faster drainage of fluid from the eye, while others reduce the production of fluid.

Because medications and eye drops can cause undesirable side effects or simply fail to control glaucoma, alternative methods of treatment may be needed. In some cases, laser treatment is performed to control glaucoma. A laser is used to improve drainage and reduce fluid pressure. If these methods fail to decrease fluid pressure, conventional surgery may be required to create a new drainage channel.

Treatment of glaucoma is usually a lifelong process. Glaucoma management requires frequent monitoring and constant treatment. Since there is no way to determine if glaucoma is under control based on how a person feels or their vision, a person with glaucoma generally should be examined every 3 to 4 months for the rest of their lives.

Who is at risk for getting glaucoma?

Anyone can get glaucoma, but some people are at higher risk. Increasing age, African ancestry, a family history of glaucoma, previous eye injuries or surgeries or health problems such as diabetes or high blood pressure increase your chances of getting glaucoma.

Prevention is the best medicine

Vision loss from glaucoma is permanent but can usually be prevented with early detection and treatment. Consequently, since the symptoms of the disease are often unnoticeable, regular eye examinations are important, especially for persons over the age of 35 or those in high risk groups.

If you have experienced a loss of peripheral vision or are having other difficulties with your vision, you should obtain a complete eye examination

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Herpes Zoster

One's first encounter with the herpes zoster virus is usually childhood chicken pox. Later in life, the virus may reactivate, causing a characteristic rash of small blisters, frequently on the chest or forehead, which form crusts and may leave scars. This second encounter is known as shingles.

Unlike chicken pox, this condition is usually quite painful. Although this disease often occurs in normal, healthy people, it occurs more frequently in elderly or immune-compromised individuals.

It is important to see an ophthalmologist when herpes zoster occurs on the face because the virus may invade the eye. An ophthalmologist looks for elevated pressure in the eye, inflammation, and herpes zoster lesions on the surface of the eye. All these problems can be treated but they are sometimes difficult to manage. Therefore, careful treatment and follow-up are required. New oral antiviral medications are providing sufferers with a quicker, more complete recovery

 


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Cataracts and No Stitch/Small Incision Surgery

A Clouding of the Lens of the eye causing blurred or
distorted vision.

Although the formation of a cataract can make activities such as reading and driving difficult, good vision can be safely restored with outpatient cataract surgery.  Today, with the development of no stitch/small incision cataract surgery, many patients are experiencing a faster recovery and a quicker return to good vision. Cataract surgery is the most frequently performed surgery in the United States. More than 20 million Americans over the age of 40 have cataracts, and more than two million people have cataract surgery each year in the United States. Over 95 percent of cataract surgeries are performed without complications and result in a significant improvement in vision.

What is a cataract?

A cataract is the clouding of the lens of the eye.  Normally, light passes through the clear lens and is focused onto the retina.  However, as a result of the natural aging process, the lens gradually becomes cloudy.  The cataract or cloudy lens blocks the passage of light through the eye and causes distorted or blurred vision.
Cataracts are not painful, but you may notice these symptoms:

  • Details are difficult to see
  • Cloudy, fuzzy or blurry vision
  • Double vision
  • Changes in the color of the pupil
  • Poor night vision
  • Sensitivity to light and glare, especially while driving at night
  • Frequent changes in your glasses prescription
  • Dull colors
  • Inability to perform activities such as reading or driving due to poor vision

When should you see your doctor?

If you experience any of the above mentioned symptoms, please make an appointment with your doctor as soon as possible. Early diagnosis is the best method of management. Regular office visits assist your doctor in determining if cataracts are affecting your ability to see. However, if your vision suddenly becomes worse, see your doctor promptly.

When should you schedule surgery?

If cataracts limit your daily activities, such as reading, driving or watching television, speak with your doctor about scheduling surgery. Changing your glasses prescription will not improve your vision. Surgically removing the cataract and inserting a clear artificial lens is the only treatment for restoring clear vision.

Does My Insurance Pay for the Procedure?

Cataracts are considered a medical condition. For this reason, most health insurances, including Medicare and Medicaid, will cover their portion of the surgery for the doctor as well as the facility. Specific plans have limitations, such as co payments, deductibles or percentage payments.
Our insurance department will research your specific coverage before your surgery. They will discuss your coverage and notify you of any fees that you may be responsible for remitting.

How many people get cataracts?

Nearly half of all people will have a cataract by the time they are 65 years of age.
In addition to aging, other causes of cataracts include:

  • A family history of cataracts
  • Medical problems, such as diabetes
  • Injury to the eye
  • Medications, such as steroids
  • High salt intake
  • Long-term unprotected exposure to sunlight

Can cataracts be prevented?

Currently, there are no medications or exercises that will cause cataracts to disappear. The most important thing that you can do to prevent cataracts is to protect your eyes from ultraviolet light. Parents should also make sure their children are protected from these harmful rays. Ultraviolet exposure occurs over an entire lifetime.

Will cataract surgery improve my vision?

The success rate of cataract surgery is excellent. Improved vision is achieved in the vast majority of patients. Only a very small number of patients continue to have problems following cataract surgery.

What are no-stitch/small incision surgery techniques?

No-stitch/small incision surgery are techniques used to restore vision loss due to cataracts.  The cloudy lens is removed and replaced with a plastic lens (IOL) implant.  Ultrasound technology (phacoemulsification) is used to remove the cataract.  A special lens can then be implanted through a smaller incision than is required in traditional cataract surgery.

What is phacoemulsification?

Phacoemulsification (phaco) is a surgical technique which uses ultrasound technology.  In “phaco” or small incision surgery, a small probe is inserted into the capsular membrane which surrounds the cloudy lens.  Ultrasound is used to gently break-up (or emulsify) the cloudy lens into tiny pieces which can be removed through the tip of the probe.  In comparison, traditional surgery techniques require the lens to be removed in one piece through a relatively large incision.
Traditional cataract surgery requires an incision that spans a third of the circumference of the cornea and needs as many as eight stitches to close.  In contrast, the phaco technique allows the cloudy lens to be removed through as incision as small as 1/6 of an inch wide.

No-stitch self sealing incision

In many cases the incision can be closed with just one stitch.  In cases where the surgeon can use a technique that does not require sutures, the natural pressure inside the eye is used to keep the incision closed while the eye heals.
What are the advantages of no-stitch/small incision surgery? 

  • Faster recovery of good vision
  • Faster return to normal activities
  • Good vision in a matter of days instead of weeks or even months
  • Return home within hours of the procedure
  • Reduces the chance of surgically induced astigmatism or ruptured sutures

No-stitch/small incision surgery not only speeds the healing and recovery process but also reduces the risk of possible complications.  In traditional surgery, tying the structures too tightly may create astigmatism or a distortion of vision.  The patient may experience blurred vision until natural healing corrects the astigmatism or rupture.  A no stitch/small incision can be closed very securely without causing astigmatism.  In addition, there is less chance of leakage and ruptured sutures.

What results can be expected after no-stitch/small incision surgery?

Most patients can expect a rapid return to good vision following no-stitch/small incision cataract surgery.  In many cases, patients are able to see relatively well the day after surgery without glasses.    However, some patients will need to wear glasses for reading and other activities following the procedure.  Quickly returning to an active lifestyle is one of the primary benefits of no stitch/small incision cataract surgery.  “Secondary” cataracts may develop following cataract surgery.  If this occurs an outpatient laser procedure will quickly restore good vision. 

Is no-stitch/small incision cataract surgery for everyone?

With the no-stitch/small incision techniques, fewer or no stitches are needed than with traditional techniques.  However, the size of the incision and the number of stitches used varies from patient to patient.  Some patients, because of their eye structure or other health factors, are not good candidates for no-stitch/ small incision surgery.  In these cases, patients can have traditional surgery and expect to do well.

Sight loss can be prevented

Although there is no way to prevent the development of cataracts, loss of sight from the disease is largely preventable.  With modern technology, cataracts can be removed and good vision restored.  Cataract surgery can be performed when a loss of vision begins interfacing with daily activities. If you are experiencing the symptoms of cataracts or other vision problems, you should obtain a complete eye examination.

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Central Retinal Artery Occlussion (CRAO)

You probably know high blood pressure and other vascular diseases pose risks to your overall health, but you may not know that they can affect your eyesight by damaging the arteries in your eye.

CRAO usually occurs in people between the ages of 50 and 70. The most common medical problem associated with CRAO is arteriosclerosis, hardening of the arteries. Carotid artery disease is found in almost half the people with CRAO.

The most common cause of CRAO is a thrombosis, an abnormal blood clot formation. Sometimes CRAO is caused by an embolus, a clot that breaks off from another area of the body and is carried to the retina by the bloodstream.

Central retinal artery occlusion (CRAO) blocks the central artery in your retina, the light-sensitive nerve layer at the back of the eye. The first sign of CRAO is a sudden and painless loss of vision that leaves you barely able to count fingers or determine light from dark.

Loss of vision can be permanent without immediate treatment. Irreversible retinal damage occurs after 90 minutes, but even 24 hours after symptoms begin, vision may still be saved. The goal of emergency treatment is to restore retinal blood flow. After emergency treatment, you should have a thorough medical evaluation.


Central Retinal Vein Occlusion (CRVO)

You probably know high blood pressure and other vascular diseases pose risks to overall health, but you may not know that they can affect eyesight by damaging the veins in the eye.

Central retinal vein occlusion (CRVO) blocks the main vein in the retina, the light-sensitive nerve layer at the back of the eye. The blockage causes the walls of the vein to leak blood and excess fluid into the retina. When this fluid collects in the macula—the area of the retina responsible for central vision—vision becomes blurry.

Floaters in your vision are another symptom of CRVO. When retinal blood vessels are not working properly, the retina grows new fragile vessels that leak blood into the vitreous, the fluid that fills the center of the eye. Blood in the vitreous clumps and is seen as tiny dark spots, or floaters, in the field of vision.

In severe cases of CRVO, the blocked vein causes painful pressure in the eye. Retinal vein occlusions commonly occur with glaucoma, diabetes, age-related vascular disease, high blood pressure, and blood disorders.

The first step is finding what is causing the vein blockage. There is no cure for CRVO. Your ophthalmologist may recommend a period of observation, since hemorrhages and excess fluid often subside on their own. Laser surgery may be effective in preventing further bleeding into the vitreous, or for treating glaucoma, but it cannot remove a hemorrhage or cure glaucoma once it is present.


Central Serous Retinopathy (CSR)

Central serous retinopathy is a small, round; shallow swelling that develops on the retina, the light sensitive nerve layer that lines the back of the eye. Although the swelling reduces or distorts vision, the effects are usually temporary. Vision generally recovers on its own within a few months.

In the initial stages of CSR, vision may suddenly become blurred and dim. If the macula—the area of the retina responsible for acute central vision—is not affected, there may be no obvious symptoms.

CSR typically affects adults between the ages of 20 to 50. People with CSR often lose their retinal swelling without treatment, and recover their original vision within six months of the onset of symptoms. Some people with frequent episodes may have some permanent vision loss. Recurrences are common and can affect 20 to 50 percent of people with CSR. While the cause of CSR is unknown, it seems to occur at times of major personal or work related stress.

As CSR usually resolves on its own, no treatment may be necessary. Sometimes laser surgery can reduce the swelling sooner but there is no evidence this improves the final visual outcome. If retinal swelling persists for over three to four months or if an examination reveals early retinal degeneration, laser surgery may be helpful.


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Dry Eyes

 

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Tear fluids are very important to eye health. They distribute three natural lubricants that protect eye tissue. An individual continually experiencing irritated eyes may be suffering from dry eyes. Over thirty million Americans suffer from this condition.

Ironically, dry eyes often results in excessive watering of the affected eye. The excess watering is a reaction to irritation. While the eyes may be wet, the fluid lacks one or more of the necessary natural lubricants. If left untreated, serious damage to the eye tissues may result causing a loss of vision.

Dry eyes may be caused by: a disruption in the normal blinking reflex; medications like antihistamines; environmental factors such as low humidity and wind; chemical or thermal burns; and some health problems such as arthritis. Treatments vary according to the cause. Common treatments include the use of eye drops and ointments especially formulated to simulate the eye's naturally occurring lubricants. Individuals living in climates with low humidity may benefit from an indoor humidifier.

What Are Dry Eye Symptoms?

The usual symptoms include:

  • Stinging or burning eyes
  • Scratchiness
  • Gritty sensation
  • Itching
  • Light Sensitivity
  • Stringy mucus in or around the eyes
  • Difficulty wearing contact lenses
  • Excessive eye irritation from smoke or wind
  • Tearing

Excessive tearing from Dry Eye sounds illogical, but if the tears responsible for maintaining lubrication do not keep the eye wet enough, the eye becomes irritated. When the eye is irritated, the lacrimal gland produces a large volume of tears that overwhelm the tear drainage system. These excessive tears then overflow from your eye.

What Causes Dry Eye?

Tear production normally decreases as we age. Although dry eye can occur in both men and women at any age, women are most often affected. This is especially true after menopause.
A wide variety of common medications can cause dry eye by reducing tear secretion. Be sure to tell our doctor the names of all the medications you are taking, especially if you are using diuretics, beta-blockers, antihistamines, sleeping pills, medications for “nerves” or pain relievers.

How Are Dry Eyes Treated?

Artificial Tears - Since many of the medications that can cause dry eyes are necessary, the use of “artificial tears” may be recommended. These eye drops are similar to your own tears. They lubricate the eyes and help maintain moisture.

Punctal Plugs - Conserving your eyes’ own tears is another approach to keeping the eyes moist. Tears drain out of the eye through a small channel into the nose.
Your doctor may close these channels with punctal plugs. The closure conserves your own tears and makes artificial tears last longer.
If you are experiencing any of the above symptoms, call our office for an appointment. After a through examination, our doctors will be able to determine the proper course of treatment to control this condition.

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How to Insert Eyedrops

Infections, inflammation, glaucoma, and many other eye disorders are treated with eye drops. Surprisingly, even the small amount of medication in an eye drop can create significant side effects in other parts of the body. It is important to remember that all medicines have side effects. There are ways to decrease the absorption of the eye drop into the system, and to increase the time the eye drop is on the eye, making the medicine more safe and effective.

Inserting eye drops may seem difficult at first but becomes easier with practice. To put in an eye drop, tilt the head back. Then create a pocket in front of the eye by pulling the lower lid down with an index finger or gently pinch the lower lid outward with the thumb and index finger. Let the drop fall into the pocket without touching your eye or eyelid (to prevent contamination of the bottle).

Immediately after instilling the drop, squeeze the bridge of your nose for two to three minutes with your thumb and forefinger. This prevents most of the drop from traveling down the tear duct to the rest of the body.

Keep your eyes closed for three to five minutes after instilling the drop. Because the volume of a single drop exceeds the capacity of the surface of the eye, it serves no purpose to use two drops at the same time.
Before opening your eyes, dab unabsorbed drops and tears from the closed lids with a tissue.

If you are taking two different types of eye drops, wait at least five minutes before instilling the second drop.

Eyelid Tumors

A tumor is an abnormal growth of any tissue or structure and can be either benign or malignant. A tumor can affect any part of the eye, such as the eye socket, eyeball, eye muscles, optic nerve, fat and tissues. Sometimes tumors grow into the eye area, or tumors from other parts of the body travel to the eye. Most tumors of the eye are benign.

Basal cell carcinomas are the most frequent type of malignant tumor to affect the eyelid (85-95% of all malignant eyelid tumors). The most frequent location is the inner portion of the lower eyelid, particularly in elderly fair-skinned people. Prolonged exposure to sunlight seems to be a risk factor for developing this form of tumor.

There are many different types of basal cell carcinomas but the nodular variety is one of the most common. It appears as a raised, firm, pearly nodule with tiny dilated blood vessels. If the nodule is in the eyelash area, some lashes may be missing. The nodule may have some superficial ulceration and crusting and look like a chalazion or stye. While these tumors are malignant, they rarely spread elsewhere in the body. For most of these tumors, surgery is the most effective treatment. In severe cases when the tumor has been neglected for a long time, it can spread into the eyesocket, which may ultimately require removal of the eye and adjacent tissue.

Squamous cell carcinoma is the next most frequent malignant eyelid tumor (occurring in approximately 5% of malignant eyelid tumors.) As with basal cell carcinoma, the most common location is the lower eyelid, particularly in elderly, fair-skinned people. This tumor also appears as a raised nodule that can lead to loss of eyelashes in the involved area. When detected and treated early, the outcome for this type of tumor is excellent. However, if the tumor is neglected, it can spread to the lymph nodes in the neck. Surgery is the most effective treatment.

Sebaceous cell carcinoma originates in glands of the eyelid in elderly individuals. It is relatively rare but still accounts for 1 to 5% of malignant eyelid tumors. These are highly malignant tumors that may recur, invade the eyesocket, or spread to lymph nodes. The tumor may look like a chalazion or stye, making it difficult to diagnose. Surgery is usually necessary for this type of tumor.

Malignant melanoma makes up almost 1% of all malignant eyelid tumors but accounts for many of the deaths from malignant eyelid tumors. As with any other type of malignant melanoma, these tumors on the eyelid can arise from a pre-existing nevus or mole, or may arise with no other pre-existing cause. Again, these tumors tend to occur in sun-exposed areas of elderly fair-skinned people. Any pigmented area should be examined, especially if it is growing or changing color. Surgical removal is usually the recommended treatment.

Eyelid Hygiene

How good is your eyelid hygiene? Have you ever experienced any of these symptoms: chronically red eyes, itchy eyelids, crusty eyelashes, lids sticking together in the morning, or heavy mucous build-up? If you answered yes, you may need to improve your eyelid hygiene regimen. It is a common misconception that simply washing one’s face is enough to adequately clean the eyelids and lashes.

All of us have bacteria that live on our skin without causing problems. However, occasionally (and by no fault of our own) these bacteria can overgrow and lead to problems such as blepharitis (infection of the eyelid margin), conjunctivitis (infection of the covering over the white of the eye), or Staphylococcal hypersensitivity (overactive immune response to bacterial waste products). When these conditions are present, the above symptoms are manifested.

How can you avoid these problems? The answer is lid scrubs. Lid scrubs should be done to prevent blepharitis just as tooth brushing should be done to prevent cavities. There are many variations on how to perform lid scrubs, but the idea is the same with all methods. We want to reduce the number of bacteria that live at the eyelid margin by cleaning the area where the eyelashes meet the eyelid. This can be done with over the counter medicated pads (Ocusoft), baby shampoo, or cetly alcohol based products (Cetaphil). The key is to perform the lid scrubs regularly, and make sure to remove all of the mucous and debris that may be present on the lashes. If you have any of these symptoms, come by and let us help.

 


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Conjunctivitis


The conjunctiva is what is commonly call the "white of the eye", but actually it is a thin tissue membrane covering the white portion of the eye (the sclera). Conjunctivitis is an inflammation of the conjunctiva. You may have heard of this as "pink eye".

Conjunctivitis has many causes including: bacterial infections, viral infections, allergies, and environmental irritants such as smoke and chemical fumes. The eyes normal reaction to this is to increase blood flow to the area that creates the red appearance.

If the amount of discharge from the eye is great or if pus is present, the infection may be acute (intense). Yet, some infections are chronic (long-lasting) and produce very little symptoms. You may experience little or no discharge and may only notice crusting of the eye lashes in the morning in addition to the redness. Prompt consultation with your ophthalmologist is advised for acute or chronic conjunctivitis.

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Allergic Conjuctivitis

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Eye Allergies

The eyes are one of the most sensitive and vulnerable organs of the body. Airborne allergens and other particles can land directly on the surface of the eye, causing irritation and redness. Although tears constantly wash the eyes, they can’t always keep out allergens like pollen or pet dander. Because of this ocular allergies are common.

What Are Ocular Allergies?

Eye allergies are no different than those that affect your sinuses, nose or lungs. When an allergen comes in contact with your eyes, your body releases histamine, a chemical produced in reaction to a substance that the immune system can’t tolerate. Special cells called mast cells make histamine. These cells are persent throughout the body but are highly concentrated in the eyes.

Ocular allergies tend to be airborne. The most frequent allergic triggers are pollen, pet hair or dander, dust and some medications.

Other triggers that irritate the eyes but are not true allergies are cigarette smoke, perfume and diesel exhaust.

Treatment

If you have ocular allergies or any kind of allergic disease, the most effective treatment is prevention. Try to avoid the allergens that trigger symptoms. This is not always an easy task, especially if your triggers are airborne, such as pollen.
When ocular allergies can’t be controlled, there are several medications that may help to relieve symptoms. Most of these treatments are topical, such as eye drops or ointment.

Allergic Conjunctivitis and conjunctivitis caused by an infection can be hard to distinguish. They both manifest themselves by an inflammation of the conjunctiva (the membrane lining under the eyelids). Both have similar symptoms, such as redness, itching and swelling in the eye area. However, when conjunctivitis is caused by allergies, both eyes are usually affected. Viral or Bacterial Conjunctivitis, also known as “pink eye”, can affect either a single eye or both eyes.

Common symptoms of Allergic Conjunctivitis are:

  • Redness and itching under the eyelid
  • Excessive watering
  • Swelling of the eyeball

Common symptoms of conjunctivitis associated with infection are:

  • Feeling that eyelids are “glued” shut upon waking
  • Sensitivity to light
  • Pus on the surface of the eye
  • Burning sensation

It is important to determine whether someone has conjunctivitis because of allergies or infection since each treatment is different. Because of this reason, it is necessary to schedule an appointment with your doctor so that he can accurately diagnosis your condition and prescribe the proper course of action to ensure your ocular health.
 


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Chalazion

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A chalazion is a lump-type swelling of the eyelid that is often confused with a stye. It is caused by an inflammation of the small oil producing glands located in the upper or lower eyelids. It is typically caused by trapped oil secretions and may involve a secondary bacterial infection. If it is not too large or does not cause blurred vision, it may disappear on its own. However, it is typically treated by a variety of methods. These include: antibiotic and/or steroid drops or injections; warm compresses (warm water washcloth compresses held against the eye for five to ten minutes); massage of the area; or in severe cases, a surgical procedure.

Chalazia usually respond well to treatment, but some individuals are prone to reoccurrence that might be symptomatic of other conditions. If you believe you are suffering from a chalazion, contact your ophthalmologist for advice.

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Blepharitis

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Blepharitis is a common and persistent inflammation of the eyelids frequently occurring in people with oily skin, dandruff, or dry eyes. Symptoms include irritation, itching, dandruff-like flaking along the lashes and eyelids, and occasionally a red eye. While everyone's skin has bacteria on its surface, in certain individuals the bacteria thrive at the base of the eye lashes. Blepharitis can be a stubborn condition. While there is no cure, it can be controlled through simple treatment at home. For more information, consult your ophthalmologist.

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Subconjunctival Hemorrhage

Overview

A subconjunctival hemorrhage occurs when a small blood vessel under the conjunctiva breaks and bleeds.  It may occur spontaneously or from coughing, heavy lifting, or vomiting. In some cases, it may develop following eye surgery or trauma.  Subconjunctival hemorrhage tends to be more common among those with diabetes and hypertension.

While it may look frightening, a subconjunctival hemorrhage is essentially harmless.  The blood becomes trapped underneath the clear conjunctival tissue, much like a bruise.  The blood is visible because it shows through the thin, clear conjunctiva.  The blood naturally absorbs within one to three weeks and no treatment is required. 
 
Signs and Symptoms

  • Red, bloody patch on the white of the eye
  • Painless
  • No change in vision  

 
Detection and Diagnosis

Most patients notice the subconjunctival hemorrhage when looking in the mirror, or friend or if afamily member points it out. 
 
Treatment

Although it may look like an emergency, a subconjunctival hemorrhage does not affect the vision and no treatment is required.  

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 Nevus

Nevus

Overview

A nevus is typically a flat, benign, pigmented area that may appear inside the eye or on its surface.  Nevi commonly appear on the choroid (the layer just behind the retina), the iris, and the conjunctiva.  Nevi are similar to freckles, and don’t typically change or grow. 


 

Signs and Symptoms

  • Brownish, freckle-like spot
  • Usually flat

Detection and Diagnosis

Nevi of the conjunctiva or iris can be detected with a slit lamp microscope.  If the nevus occurs within the eye, it is evaluated with an ophthalmoscope.

Treatment

Nevi are usually harmless, but it’s always wise to monitor them for changes.  This can be done with photos and sometimes ultrasound.  The doctor will document the size, shape and whether the nevus is elevated.  In rare cases, the nevus must be biopsied and examined for melanoma (cancer) cells.

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Corneal Ulcer Iris nevus photograph

Overview

A corneal ulcer forms when the surface of the cornea is damaged or compromised.  Ulcers may be sterile (no infecting organisms) or infectious.  The term infiltrate is also commonly used along with ulcer.   Infiltrate refers to an immune response causing an accumulation of cells or fluid in an area of the body where they don't normally belong.

Whether or not an ulcer is infectious is an important distinction for the physician to make and determines the course of treatment.  Bacterial ulcers tend to be extremely painful and are typically associated with a break in the epithelium, the superficial layer of the cornea.  In some cases, the inflammatory response involves the anterior chamber along with the cornea.  Certain types of bacteria, such as Pseudomonas, are extremely aggressive and can cause severe damage and even blindness within 24-48 hours if left untreated.  

Sterile infiltrates on the other hand, cause little if any pain.  They are often found near the peripheral edge of the cornea and are not necessarily accompanied by a break in the epithelial layer of the cornea.
There are many causes of corneal ulcers.  Contact lens wearers (especially soft) have an increased risk of ulcers if they do not adhere to strict regimens for the cleaning, handling, and disinfection of their lenses and cases.  Soft contact lenses are designed to have very high water content and can easily absorb bacteria and infecting organisms if not cared for properly.  Pseudomonas is a common cause of corneal ulcer seen in those who wear contacts.  

Bacterial ulcers may be associated with diseases that compromise the corneal surface, creating a window of opportunity for organisms to infect the cornea.  Patients with severely dry eyes, difficulty blinking, or are unable to care for themselves, are also at risk.  Other causes of ulcers include:  herpes simplex viral infections, inflammatory diseases, corneal abrasions or injuries, and other systemic diseases.

Signs and Symptoms

The symptoms associated with corneal ulcers depend on whether they are infectious or sterile, as well as the aggressiveness of the infecting organism.

  • Red eye 
  • Severe pain (not in all cases)
  • Tearing
  • Discharge 
  • White spot on the cornea, that depending on the severity of the ulcer, may not be visible with the naked eye
  • Light sensitivity

Detection and Diagnosis

Corneal ulcers are diagnosed with a careful examination using a slit lamp microscope.  Special types of eye drops containing dye such as fluorescein may be instilled to highlight the ulcer, making it easier to detect.  

If an infectious organism is suspected, the doctor may order a culture.  After numbing the eye with topical eye drops, cells are gently scraped from the corneal surface and tested to determine the infecting organism.

Treatment

The course of treatment depends on whether the ulcer is sterile or infectious.  Bacterial ulcers require aggressive treatment.  In some cases, antibacterial eye drops are used every 15 minutes.  Steroid medications are avoided in cases of infectious ulcers.  Some patients with severe ulcers may require hospitalization for IV antibiotics and around-the-clock therapy.  Sterile ulcers are typically treated by reducing the eye's inflammatory response with steroid drops, anti-inflammatory drops, and antibiotics.  



Corneal Abrasions

Sharp, severe eye pain with redness, tearing, light sensitivity, and a foreign body sensation can occur when the ocular surface is scratched. This is a common occurrence and is usually due to a corneal abrasion.

The cornea is the clear, dome-like window on the front surface of the eye; it is the structure on which contact lenses rest. The epithelium is a thin carpet like layer of cells that cover the cornea. These cells protect the deeper layers of the cornea against infection and help to provide a smooth ocular surface to focus light onto the retina. When these cells are traumatized, the nerve endings that run in this layer are exposed, resulting in knife-like pain. This pain is similar to the pain experienced by the exposed nerve endings in a tooth cavity.

If you experience ocular trauma with pain, or if you feel that there is something in your eye that you cannot seem to get out, don’t delay; see one of the HEA ophthalmologists promptly. Your Eye M.D. will examine the eye and likely start an antibiotic drop to help prevent infection. Neglect of this problem could lead to more serious problems such as a potentially sight threatening corneal ulcer. Unfortunately, the only true cure for the pain is complete healing of the abrasion, but luckily these usually heal in 24 to 48 hours.
Since prevention is the best medicine, try to avoid corneal abrasions by wearing protective eyewear anytime you are using machinery, striking metal on metal (i.e. hammering), or working in the yard.

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Cystoid Macular Edema

Overview

In this retinal photograph, the swelling is the yellowish spots (arrow) in the macula.

Cystoid macular edema (CME), or swelling of the macula, typically occurs as a result of disease, injury or more rarely, eye surgery.  Fluid collects within the layers of the macula, causing blurred, distorted central vision.  CME rarely causes a permanent loss of vision, but the recovery is often a slow, gradual process.  The majority of patients recover in 2 to 15 months.  


Signs and Symptoms

  • Blurred central vision
  • Distorted vision (straight lines may appear wavy)
  • Vision is tinted pink
  • Light sensitivity

Detection and Diagnosis

It is very difficult to detect CME during a routine examination.  A diagnosis is often based on the patient’s symptoms and a special dye test called a fluorescein angiogram (FA).

Treatment

The first line of treatment for CME is usually anti-inflammatory drops.  In certain cases, medication is injected near the back of the eye for a more concentrated effect.  Oral medications are sometimes prescribed to reduce the swelling.

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Cytomegalovirus Retinitis (CMV Retinitis)

CMV retinitis is a serious eye infection of the retina, the light-sensing nerve layer that lines the back of the eye. It is a significant threat to people with weak immune systems, such as people with HIV and AIDS, newborns, the elderly, people taking chemotherapy, and recipients of organ transplants. About 20 to 30 percent of people with AIDS develop CMV retinitis.

Infection with cytomegalovirus, one of the herpes viruses, is extremely common and does not pose a problem for someone with a strong immune system. But when immunity is weak, the CMV can reactivate and spread to the retina through the bloodstream.
First signs of CMV retinitis are loss of peripheral vision or a blind spot, which can progress to loss of central vision. Without treatment or improvement in the immune system, CMV retinitis destroys the retina and damages the optic nerve, which results in blindness.
Injection of one or two drugs daily is the current treatment for CMV retinitis. A promising new therapy involves placing a small implant inside the eye that slowly releases the anti-CMV drug ganciclovir.

Warning signs that should be examined by an ophthalmologist immediately are floating spots or spider webs, flashing lights, blind spots or blurred vision. Recurrence of CMV retinitis is common so monthly check-ups with an ophthalmologist are important.


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Epi-retinal Membrane (Macular Pucker)

Epi-retinal membrane - macular pucker

Overview
Epi-retinal membrane (ERM) or macular pucker is a cellophane-like membrane that forms over the macula.  It is typically a slow-progressing problem that affects the central vision by causing blur and distortion.  As it progresses, the traction of the membrane on the macula may cause swelling.  
ERM is seen most often in people over 75 years of age.  It usually occurs for unknown reasons, but may be associated with certain eye problems such as: diabetic retinopathy, posterior vitreous detachment, retinal detachment, trauma, and many others.  

Signs and Symptoms

  • Blurred vision
  • Double vision that is noticeable even with one eye covered
  • Distorted vision (straight lines may appear bent or wavy)


Detection and Diagnosis

The doctor is able to detect ERM with ophthalmoscopy during an examination of the retina.  It has a glistening, cellophane-like appearance.  The affect of ERM on the patient's central vision is assessed with a visual acuity test and the Amsler Grid.  If the doctor suspects macular swelling, he may order fluorescein angiography.  

 
Treatment

A procedure called a membrane peel is performed when vision has deteriorated to the point that it is impairing the patient's lifestyle.  Most vitreo-retinal surgeons recommend waiting for treatment until vision has decreased to the point that the risk of the procedure justifies the improvement.  
The membrane peel is performed under a local anesthesia in an operating room.  After making tiny incisions The membrane peel is often done in conjunction with a procedure called a vitrectomy.  

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Fuchs' Corneal Dystrophy

Overview

Fuchs’ dystrophy is an inherited condition that affects the delicate inner layer (endothelium) of the cornea.  The endothelium functions as a pump mechanism, constantly removing fluids from the cornea to maintain its clarity.  Patients gradually lose these endothelial cells as the dystrophy progresses.  Once lost, the endothelial cells do not grow back, but instead spread out to fill the empty spaces.  The pump system becomes less efficient, causing corneal clouding, swelling and eventually, reduced vision.
In the early stages, Fuchs’ patients notice glare and light sensitivity.  As the dystrophy progresses, the vision may seem blurred in the morning and sharper later in the day.  This happens because the internal layers of the cornea tend to retain more moisture during sleep that evaporates when the eyes are open.  As the dystrophy worsens, the vision becomes continuously blurred.  Fuchs’ affects both eyes and is slightly more common among women then men.  It generally begins at 30-40 years of age and gradually progresses
 
Signs and Symptoms

  • Hazy vision that is often most pronounced in the morning
  • Fluctuating vision
  • Glare when looking at lights
  • Light sensitivity
  • Sandy, gritty sensation

 
Detection and Diagnosis

Fuchs’ is detected by examining the cornea with a slit lamp microscope that magnifies the endothelial cells thousands of times.  The health of the endothelium is evaluated and monitored with pachymetry and specular microscopy.

 
Treatment

Fuchs’ cannot be cured; however, with certain medications, blurred vision resulting from the corneal swelling can be controlled.  Salt solutions such as sodium chloride drops or ointment are often prescribed to draw fluid from the cornea and reduce swelling.  Another simple technique that reduces moisture in the cornea is to hold a hair dryer at arm’s length, blowing air into the face with the eyes closed.  This technique draws moisture from the cornea, temporarily decreases swelling, and improves the vision. .  If the vision becomes significantly impaired, a corneal transplant may be indicated.  Sometimes corneal transplant (also known as penetrating keratoplasty or PKP) is performed along with cataract and intraocular lens implant surgery.

A new procedure called DSAEK (descemets striping automated endothelial keratoplasy) has been developed in an attempt to improve upon corneal transplantation.  If successful, it has many advantages.  In this procedure only the diseased endothelial cells are removed and replaced with a thin strip of donor tissue with donor endothelial cells.

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Giant Papillary Conjunctivitis

Giant papillary conjunctivitis (GPC) is an inflammation of the inner surface of the eyelids, most frequently associated with contact lens wear. It can develop in people who wear either soft or rigid gas permeable contact lenses and can occur at any time, even if an individual has successfully worn contacts for a number of years. Although not vision threatening, GPC can be inconvenient and may require one to stop wearing contacts temporarily or even permanently.

The typical symptoms of GPC include red, irritated eyes, often with itching and mucus discharge. Blurred vision and light sensitivity can also occur. GPC is not an infection, but a hypersensitivity of the membrane covering the inner lids and the whites of the eyes. The inner lining of the eyelid becomes roughened and inflamed by constant blinking over a contact lens or other foreign body such as an artificial eye. Hard, flat elevations in a cobblestone pattern develop on the undersurface of the upper eyelid. Eventually the entire eye becomes irritated.

In most cases, treatment of GPC involves discontinuing the use of contact lenses to allow the eye to rest. Eyedrops are frequently prescribed to control inflammation. Many people find their symptoms are relieved when contact lens wear is discontinued. Unfortunately, the symptoms can return when lens wear is resumed.

Once GPC is under control, it may be helpful to consider changing to new contacts or disposable contacts. Changing lens care systems and cleansing solutions can also be helpful. After an episode of GPC, limit the amount of time lenses are worn, and increase the time slowly.

Once it develops, GPC may be an ongoing problem. Prolonged GPC may be more difficult to treat.


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Hyphema

Overview

Hyphema is a term used to describe bleeding in the anterior chamber (the space between the cornea and the iris) of the eye.  It occurs when blood vessels in the iris bleed and leak into the clear aqueous fluid.  Hyphemas are usually characterized by pooling of blood in the anterior chamber that may be visible to the naked eye.  The red blood cells of very small hyphemas are visible only with magnification.  Even the slightest amount of blood in the anterior chamber will cause decreased vision when mixed in the clear aqueous fluid.  

Bleeding in the anterior chamber is most often caused by blunt trauma to the eye.  It may also be associated with surgical procedures.  Other causes include abnormal vessel growth in the eye and certain ocular tumors.

Signs and Symptoms

  • Decreased vision (Depending on the amount of blood in the eye, vision may be reduced to only hand movements and light perception only)
  • Pool of blood in the anterior chamber
  • Elevated intraocular pressure (in some cases)


Detection and Diagnosis

It is very important for the doctor to determine the cause of the hyphema.  If the hyphema is related to an ocular injury, any detail regarding the nature of the trauma is helpful.  The doctor will assess visual acuity, measure intraocular pressure, and examine the eye with a slit lamp microscope and ophthalmoscope.

Treatment

The treatment is dependent on the cause and severity of the hyphema.  Frequently, the blood is reabsorbed over a period of days to weeks.  During this time, the doctor will carefully monitor the intraocular pressure for signs of the blood preventing normal flow of the aqueous through the eye's angle structures.  If the eye pressure becomes elevated, eye drops may be prescribed to control it.  The pupils are also evaluated to rule out damage to the iris.

In some cases, a procedure is performed to irrigate the blood from the anterior chamber to prevent secondary complications such as glaucoma and blood stains on the cornea.
Patients with a significant hyphema must rest and avoid strenuous activity to prevent a rebleed and give the blood a chance to reabsorb.


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Hypopyon

 

 

An accumulation of pus in the front of the eye. This condition is most often seen associated with an infection of the cornea or inside the eye and should be examined by an ophthalmologist as soon as possible. In this image, the pus is seen as a pool of whitish fluid between the iris and cornea.


 

Lattice Degeneration

Lattice degeneration is thinning and weakening of the retina, the light-sensitive layer of cells lining the back of the eye, that can lead to a retinal tear.

The vitreous, a clear gel-like substance that fills the inside of the eye, is contained in a sac loosely attached to the retina. As one ages, the vitreous takes on a more fluid consistency and the sac sometimes separates from the retina. In lattice degeneration, there are places where the sac is strongly attached to the retina and pulls on it. This pulling weakens the retina and creates lattice lesions that look like white crisscrossing lines on the retina.

If part of the vitreous sac becomes detached from the retina, the friction and pulling where it is still attached can create a tear in the retina. Lattice degeneration can sometimes cause retinal detachments when holes or tears in the lattice formation permit vitreous fluid to get under the retina.

Fortunately, most people with lattice degeneration do not develop a retinal detachment. Preventive treatment of lattice degeneration has not been shown to prevent retinal detachment, but lattice degeneration should be monitored. If you have a history of lattice degeneration, you should be aware of the symptoms of retinal tears and detachment.

 


Legal Blindness

Normal vision, or 20/20, means a person sees the smallest letters or pictures on an eye chart when standing 20 feet away from the chart. Some people cannot see normally, even with glasses or contacts, because a medical condition affects their vision. These people are called visually impaired or visually handicapped.

If a visual handicap limits vision to 20/200, or one-tenth of normal, a person is legally blind. Legally blind does not mean totally unable to see. Someone legally blind cannot see the line below the second big E at the top of the eye chart. People with 20/20 vision but less than 20 degrees of side vision can also qualify as legally blind. People who see well with only one eye are not considered legally blind, nor are people who wear glasses to see better than 20/200.

Most legally blind people function quite well, especially if they have been visually handicapped since childhood. Older children and adults with visual handicaps may need magnifying lenses for reading and telescopes for distance viewing. People with very poor vision may need to learn Braille and walk with a seeing-eye dog or a cane.
Young children with visual impairments should have help from a teacher of the visually impaired and should be evaluated for developmental problems by professionals experienced with visual handicaps. Parents may need to be advocates for their child to obtain needed services through the school system.

Visually handicapped people of all ages benefit from social service, occupational therapy, and orientation and mobility training. Many new devices are available to cope with vision loss, including books on audio tapes, scanners that turn print into Braille, watches that can be "read" with the fingers, and talking computers and calculators.

 


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Optic Neuritis


Overview

Optic neuritis refers to swelling or inflammation of the optic nerve.  It is often associated with diseases causing demyelination (a loss of the protective myelin layer) of the optic nerve, but sometimes the cause is unknown.  Multiple sclerosis (MS) is the disease most often associated with optic neuritis.  It is not uncommon to have an episode of optic neuritis prior to being diagnosed with MS.  In fact, optic neuritis is often the initial sign of MS.

Most patients with optic neuritis experience a sudden onset of decreased vision along with pain and soreness when moving the eye.  Optic neuritis usually affects only one eye and may be a recurring problem with certain diseases such as MS. 
 
Signs and Symptoms

The following symptoms of optic neuritis may not occur in all cases; however, they are the most common problems associated with the condition.

  • Pain with eye movement (more than 90% of patients)
  • Tender, sore eye
  • Mild to severe decrease in central vision 
  • Dull, dim vision
  • Reduced color perception
  • Decreased peripheral vision 
  • Central blind spot
  • Fever 
  • Headache 
  • Nausea
  • Decreased vision following exercise, hot bath or shower (activities that elevate body temperature)

 
Detection and Diagnosis

The doctor takes several factors into consideration when diagnosing optic neuritis.  The problem may not always be readily apparent by examining the optic nerve, so special attention is paid to the patient's symptoms and other tests.  Pain with eye movement is a hallmark symptom of optic neuritis.  The doctor may evaluate the pupils' reaction to light and order tests such as:  visual field, color vision, and imaging of the brain (MRI).

 
Treatment

Since the Optic Neuritis Treatment Trial (ONTT), doctors have discovered that treating patients with intravenous steroid medication (but not oral steroids) reduces the risk of developing MS later on.  This finding is very significant since approximately 50% of those who experience an initial occurrence of optic neuritis will develop MS.  While this treatment has little if any impact on vision, it is important for overall health.
Optic neuritis characteristically improves over a period of days to weeks.  For some, a complete recovery may take months.


Ptosis

 Ptosis:

Normal Eye:

Overview

Ptosis (pronounced toe' sis), or drooping of the upper eyelid, may occur for several reasons such as: disease, injury, birth defect, previous eye surgery and age.  In most cases, it is caused by either a weakness of the levator muscle (muscle that raises the lid), or a problem with the nerve that sends messages to the muscle. 
Children born with ptosis may require surgical correction of the lid if it covers the pupil.  In some cases, it may be associated with a crossed or misaligned eye (strabismus).  Left untreated, ptosis may prevent vision from developing properly, resulting in amblyopia, or lazy eye.
Patients with ptosis often have difficult blinking, which may lead to irritation, infection, and eyestrain.  If a sudden and obvious lid droop is developed, an ophthalmologist should be consulted immediately.  
 
Signs and Symptoms

The causes of ptosis are quite diverse.  The symptoms are dependent on the underlying problem and may include:

  • Drooping lid (may affect one or both eyes)
  • Irritation 
  • Difficulty closing the eye completely
  • Eye fatigue from straining to keep eye(s) open
  • Children may tilt head backward in order to lift the lid
  • Crossed or misaligned eye
  • Double vision

 
Detection and Diagnosis

When examining a patient with a droopy lid, one of the first concerns is to determine the underlying cause.  The doctor will measure the height of the eyelid, strength of the eyelid muscles, and evaluate eye movements and alignment.  Children may require additional vision testing for amblyopia. 
 
Treatment 

Ptosis does not usually improve with time, and nearly always requires corrective surgery by an ophthalmologist specializing in plastic and reconstructive surgery.  In most cases, surgery is performed to strengthen or tighten the levator muscle and lift the eyelid.  If the levator muscle is especially weak, the lid and eyebrow may be lifted.  Ptosis can usually be performed with local anesthesia except with young children.  


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Keratoconus


What is Keratoconus

The cornea is the window of the eye. Light travels through the cornea past the lens to the retina and then the brain to form a visual image. The normal corneal surface is smooth and aspheric i.e. round in the center, flattening towards its outer edges. Light rays passing through it moves in an undistorted manner to the retina to project a clear image to the brain.

In patients with keratoconus the cornea is cone shaped (hence the name keratoconus, derived from the greek word for cornea (‘kerato’) and cone shaped (‘conus’). In patients with keratoconus, the cornea is not only cone shaped but the surface is also irregular, resulting in a distorted image being projected onto the brain.
 
Treatment of Keratoconus

Because the cornea is irregular and cone shaped, glasses may not adequately correct the vision in patients with keratoconus since they cannot conform to the shape of the eye. Patients with keratoconus see best with rigid contact lenses since these lenses provide a clear surface in front of the cornea, allowing the light rays to be projected clearly to the retina. Hence the vast majority of patients are treated with rigid contact lenses.

Some people with keratoconus can’t tolerate a rigid contact lens.  At this time more aggressive treatment of keratoconus may be required in order to provide the vision desired.  This would mean surgery such as penetrating keratoplasty (PKP), also known as corneal transplantation or corneal graft.  Sometimes a deep partial thickness keratoplasty (deep lamellar keratoplasty) can be performed. 

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Macular Hole

 A macular hole is a problem that develops in the central part of vision or the macula. The most common cause of a macular hole is posterior vitreous traction. The posterior vitreous (clear, gel-like substance in the center of the eyeball), as part of the aging process can partially separate. Sometimes this separation can cause traction or pulling on the retina,thus causing a hole to form.
Holes form gradually and affect vision in varying degrees depending on the severity of the problem. Some patients may only experience blurry, distorted vision while others may have a total loss of central vision.


Signs and Symptoms

blurry or distorted central vision
gray or black area in central vision
inablity to perform tasks requiring detail vision

Diagnosis

A dilated fundus examination will be performed to evaluate the macula. In addition, a fluorescein angiogram or optical coherence tomogram will most likely be performed as well.

Treatment

While some holes will close on their own, in most cases surgery is necessary to close the hole and restore useful vision. During surgery, a vitrectomy is performed to remove the gel in the eye. Then, a gas bubble is injected to "splint" the edges of the hole and help it to close. After the surgery, you will be required to maintain "face-down positioning."

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Pterygium
(pronounced ter ig ee um)

A pterygium is a raised, wedge-shaped growth of the conjunctiva.  It is most common among those who live in tropical climates or spend a lot of time in the sun.  Symptoms may include irritation, redness, and tearing.  Pterygia are nourished by tiny capillaries that supply blood to the tissue.  For some, the growth remains dormant; however, in other cases it grows over the central cornea and affects the vision.  As the pterygium develops, it may alter the shape of the cornea, causing astigmatism.  If the pterygium invades the central cornea, it is removed surgically.  
Since pterygia are most commonly caused by sun exposure, protecting the eyes from sun, dust and wind is recommended.  Instilling artificial tears liberally is also helpful to decrease irritation.  In some cases, steroid drops are prescribed to reduce inflammation.

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Pinguecula

Pinguecula


Overview

A pinguecula (pin gwe' cue la) is a benign, yellowish growth that forms on the conjunctiva.  They usually grow near the cornea on the nasal side.  Pingueculae (plural form of pinguecula) are thought to be caused by ultraviolet light and are most common among people who spend a great deal of time outdoors.  
This growth does not affect vision, but may cause irritation if it becomes elevated.  In rare cases, the pinguecula may gradually extend over the cornea, forming a pterygium.  

Signs and Symptoms

Pingueculae are harmless growths and rarely cause symptoms.

  • Yellowish, raised area on the conjunctiva
  • Irritation and scratchiness
  • Dry eye
  • Occasional inflammation of the conjunctiva
  • Redness if the area becomes irritated

Detection and Diagnosis

Pingueculae can often be seen with the naked eye; however, the doctor diagnoses the growth with a careful examination with a slit lamp microscope.

Treatment

Because of their benign nature, pingueculae rarely require treatment.  Occasionally, the growth may become inflamed, causing irritation and dryness.  The doctor may prescribe artificial tears for lubrication and mild anti-inflammatory medication to reduce swelling.

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Posterior Capsulotomy

A posterior capsulotomy is a surgical laser procedure that may be necessary after cataract surgery.

During cataract surgery part of the front (anterior) capsule that holds the lens is removed. The clear back (posterior) capsule remains intact. As long as that capsule stays clear one has good vision. But in 10 to 30% of people, the posterior capsule loses its clarity. When this happens, an opening can be made in the capsule with a laser (posterior capsulotomy) to restore normal vision.

Before the laser procedure, the ophthalmologist does a thorough ophthalmic examination to make sure there is no other reason for vision loss.

A posterior capsulotomy is painless and takes five minutes. Eye pressure is taken a half hour after the operation to make sure it is not elevated and antibiotic drops are usually prescribed for three days following the procedure. Vision should improve within hours.
Potential but rare complications following laser posterior capsulotomy are increased intraocular pressure and retinal detachment.

 


Uveitis (Iritis)

Definition

uveitis3.jpgUveitis means "inflammation of the uvea", or the middle layer of the eye. The uvea consists of three structures: the iris, the ciliary body, and the choroid. The iris is the colored structure surrounding the pupil, visible in the front of the eye. The ciliary body is a structure containing muscle and is located behind the iris which focuses the lens. The choroid is a layer containing blood vessels that line the back of the eye and is located between the inner visually sensitive layer, called the retina, and the outer white eye wall, called the sclera. Inflammation occurring in any of these three structures is termed "uveitis".

Inflammation in uveitis may involve any but not necessarily all of these three structures. Depending upon which structures are inflamed, uveitis may be further subcategorized into one of three main diagnoses, these include:

  • iritis or anterior uveitis,
  • iridocyclitis or intermediate uveitis, and
  • choroiditis or posterior uveitis.

Uveitis may develop following eye trauma or surgery, in association with diseases which affect other organs in the body, or may be a condition isolated to the eye itself. Severe and permanent visual loss can result from uveitis. In addition, uveitis can lead to other ocular complications, which may produce vision loss, including glaucoma, cataracts, or retinal damage. Early detection and treatment is necessary to reduce the risk of permanent vision loss.

Symptoms

Depending on which part of the eye is inflammed in uveitis different combinations of these symptoms may be present.

  • Redness
  • Light sensitivity
  • Floaters
  • Blurry vision
  • Pain

These symptoms may come on suddenly, and you may not experience any pain. The symptoms described above may not necessarily mean that you have uveitis. However, if you experience one or more of these symptoms, contact your eye doctor for a complete exam.

Treatment

Treatment may include steroid eyedrops, injections, or pills, as well as eyedrops to dilate the pupil and reduce pain. More severe cases of uveitis may even require treatment with chemotherapeutic agents to suppress the immune system.

Ocular Inflammation

The term uveitis specifically refers to inflammation involving the uvea, the middle of the three layers of the eye, but the common usage includes any inflammatory process of the eye. Ocular inflammatory disorders such as uveitis, scleritis, orbital inflammation, and mucous membrane pemphigoid are a leading cause of visual impairment and blindness.

Ocular inflammation occurs in all ages, including very young children, and may represent the aftermath of an infection, such as cytomegalovirus or shingles in the eye, or may be associated with an autoimmune disease, such as rheumatoid arthritis, juvenile rheumatoid arthritis, lupus and sarcoidosis. It may also occur in the absence of systemic inflammation.

The most common symptoms of uveitis are blurred vision, floaters, eye pain, light sensitivity, and redness. Ocular inflammation may not include all of these symptoms but only one or two. If you or your family physician, rheumatologist, or general ophthalmologist suspects that you have uveitis, a thorough ophthalmologic examination and treatment to control the inflammation are of urgent importance.


 Visual Field Test

The visual field is the entire area one can see. It includes central and peripheral (side) vision. A visual field test can detect problems with vision in any part of the visual field. Changes in the visual field may be difficult to notice since both eyes are generally used at the same time. One eye can sometimes compensate for some vision loss in the other. A problem may not be detected until each eye is tested separately.

The visual field test provides information that no other test can. It is used to detect many diseases, such as glaucoma or retinitis pigmentosa, which affect the eye, optic nerve, and brain. It can also help diagnose brain tumors, strokes, and other conditions. Visual field testing helps diagnose the disease and can follow the progress of the disease and its treatment.

During a visual field test, one eye is temporarily patched while the other eye is being tested. You are asked to look straight ahead at a fixed spot and watch for targets to appear in your field of vision.

There are two kinds of visual field tests. One method uses moving targets. Targets are moved from outside the visual field (where you can't see them) toward the center of your vision. When you see them, you press a button. The test can be done using a dark screen on a wall (called tangent screen testing) or using a large bowl-shaped instrument (called Goldmann testing).

The other testing method uses small fixed targets that appear briefly as bright or dim lights (called computerized static perimetry). You sit in a chair facing either a bowl-shaped instrument or a computer screen and indicate when you see the targets appear.



Vitrectomy Surgery

Vitrectomy is a type of eye surgery used to treat disorders of the retina (the light-sensing cells at the back of the eye) and vitreous (the clear gel-like substance inside the eye). It may be used to treat a severe eye injury, diabetic retinopathy, retinal detachments, macular pucker (wrinkling of the retina) and macular holes.

During a vitrectomy operation, the surgeon makes tiny incisions in the sclera (the white part of the eye). Using a microscope to look inside the eye and microsurgical instruments, the surgeon removes the vitreous and repairs the retina through the tiny incisions. Repairs include removing scar tissue or a foreign object if present.

During the procedure, the retina may be treated with a laser to reduce future bleeding or to fix a tear in the retina. An air or gas bubble that slowly disappears on its own may be placed in the eye to help the retina remain in its proper position or a special fluid that is later removed may be injected into the vitreous cavity.

Recovering from vitrectomy surgery may be uncomfortable but the procedure often improves or stabilizes vision. Once the blood- or debris-clouded vitreous is removed and replaced with a clear medium (often a saltwater solution), light rays can once again focus on the retina. Vision after surgery depends on how damaged the retina was before surgery.


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Retinal Vein Occlusion


Overview

A retinal vein occlusion occurs when the circulation of a retinal vein becomes obstructed by an adjacent blood vessel, causing hemorrhages in the retina.  Swelling and ischemia (lack of oxygen) of the retina as well as glaucoma are fairly common complications. 

The visual symptoms can vary in severity from one person to the next, and are dependent on whether the central retinal vein or a branch retinal vein is involved.  Patients who experience a branch vein occlusion often notice a gradual improvement in their vision as the hemorrhage resolves.  Recovery from a central vein occlusion is much less likely since it affects the macula.  This problem appears equally in males and females and is more common after the age of 60. 
 
Symptoms

  • Sudden onset
  • Blurred or missing area of vision (if a branch vein is involved)
  • Severe loss of central vision (if a central vein is involved)

Detection and Diagnosis

Vein occlusion is diagnosed by examining the retina with an ophthalmoscope.  Fluorescein angiography may be performed in some cases to study the circulation of the retina and to determine the extent of macular edema or swelling.

The following are common risk factors for vein occlusion:
· Diabetes
· Hypertension
· Cardiovascular disease  

 
Treatment

Following a vein occlusion, the primary concern is to treat the secondary complications.  If areas of the retina are oxygen-deprived, laser may be used to prevent growth of delicate vessels that could break, bleed or cause glaucoma. 

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Retinistis Pigmentosa

Retinitis pigmentosa (RP) describes a group of related diseases that tend to run in families and cause a slow but progressive loss of vision. RP affects the rods and cones of the retina, the light-sensitive nerve layer at the back of the eye, and results in a decline in vision in both eyes. RP usually affects both eyes equally with severity ranging from no visual problems in some families to blindness at birth in others. RP gets its name from the fact that one of the symptoms is a clumping of the retinal pigment that can be seen during an eye exam.

The earliest symptom of retinitis pigmentosa, usually noticed in childhood, is night blindness or difficulty with night vision. People with normal vision adjust to the dark quickly, but people with night blindness adjust very slowly or not at all. A loss of side vision, or tunnel vision, is also common as RP progresses. Unfortunately, the combination of night blindness and the loss of peripheral vision can be severe and lead to legal blindness in many people.

While there is a pattern of inheritance for RP, 40% of RP patients have no known previous family history. Learning more about RP in your family can help you and your ophthalmologist predict how RP will affect you.

Usher's syndrome, in which a person is both deaf and blind, can be associated with RP. The incidence of Usher's syndrome is difficult to determine but surveys of patients suggest up to 10% of RP patients are deaf. The incidence of Usher's syndrome is three cases per 100,000. It is the most frequent cause of combined deaf-blindness in adults.
Considerable research is being done to find the hereditary cause of RP. As hereditary defects are discovered it may be possible to develop treatments to prevent progression of the disease. While developments are on the horizon, particularly in the area of genetic research, there is currently no cure for retinitis pigmentosa.

Nutritional supplements may have an effect on RP. It has been reported that Vitamin A can slow the progression of RP. Large doses of Vitamin A are harmful to the body and supplements of Vitamin E alone may make RP worse. Vitamin E is not harmful if taken with Vitamin A or in the presence of a normal diet. Your ophthalmologist can advise you about the risks and benefits of Vitamin A and how much you can safely take.
Despite visual impairment, people with RP can maintain active and rewarding lives through the wide variety of rehabilitative services that are available today. Until there is a cure, periodic examinations by your ophthalmologist will keep you informed of legitimate scientific discoveries as they develop.


 

Retinoblastoma

Retinoblastoma, a malignant tumor that grows in the retina, the layer of light-sensing cells in the back of the eye, can destroy a child's vision and be fatal. Affecting children of all races, boys and girls equally, retinoblastoma occurs in one or both eyes, usually in the first year or two of life.

The most common sign is a change in the color of the pupil, which can appear white in reflected light. This phenomenon is referred to as a cat's eye reflex. Sometimes the affected eye will cross or turn outward. Retinoblastoma can be hereditary and is more likely to develop in children with a family history of the disease.

With early diagnosis, retinoblastoma treatment is remarkably effective. More than 90% of children survive and many eyes are saved with a combination of medications, radiation therapy, and heat, freezing, or laser treatments. In severe cases, the affected eye is removed.

If a child has had retinoblastoma there is an increased chance for a second cancer to develop. Children with retinoblastoma should have regular examinations by an ophthalmologist and a pediatric oncologist.


Retinoschisis

Retinoschisis is a genetic eye disease that splits the retina, the light-sensitive layer of cells lining the back of the eye. It occurs in two forms, one affecting young children, the other older adults. Both forms usually affect both eyes, though one eye may be worse than the other.

Because the disease is inherited on the X chromosome, childhood retinoschisis occurs in boys more than girls. It is usually detected because of poor vision.
If the split retina involves the peripheral or side retina, peripheral vision is lost. One is also at risk for a retinal detachment. But more commonly, retinoschisis affects the macula, the area of the retina responsible for central vision. In this location, one loses central vision.

Peripheral retinoschisis, more common in adults, is usually caused by aging and does not affect vision, but it can cause a retinal detachment. If detected early, a retinal detachment can be treated with surgery or laser therapy.

 


Stargardt's Disease

Stargardt's is an inherited disease that affects the retina, the layer of light-sensitive cells lining the back of the eye. It usually becomes apparent between the ages of 8 and 14. Boys and girls are equally susceptible and more than one child in a family may have it.
Stargardt's disease begins with slightly blurry vision that gradually gets worse. By the late 20s, vision is typically about 20/200, the level labeled legally blind. Remaining vision is good enough for most people to live fairly normal lives, though they won't drive, or read without using magnification devices.

A build-up of lipofuscin (fatty substance) in retinal cells is thought to cause Stargardt's disease. The buildup typically happens in the central retina, or macula, where it resembles beaten bronze. Or, it can occur in the side retina where it causes small white flecks. This form is called fundus flavimaculatus. Angiography, a special photograph of the retina, may aid in the diagnosis. Although no specific medical or surgical treatment is available, glasses and magnification help affected people adapt to the disease.

 


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Retinal Tear and Detachment

Retinal detachment

Overview

Retinal Tear

Retinal tears commonly occur when there is traction on the retina by the vitreous gel inside the eye.  In a child’s eye, the vitreous has an egg-white consistency and is firmly attached to certain areas of the retina.  Over time, the vitreous gradually becomes thinner, more liquid, and separates from the retina.  This is known as a posterior vitreous detachment (PVD).

PVDs are typically harmless and cause floaters in the eye; but in some cases, the traction on the retina may create a tear.  Retinal tears frequently lead to detachments as fluids seep underneath the retina, causing it to separate and detach.

Retinal Detachment

A retinal detachment occurs when the retina’s sensory and pigment layers separate.   Because it can cause devastating damage to the vision if left untreated, retinal detachment is considered an ocular emergency that requires immediate medical attention and surgery.  It is a problem that occurs most frequently in the middle-aged and elderly. 

There are three types of retinal detachments.  The most common type occurs when there is a break in the sensory layer of the retina, and fluid seeps underneath, causing the layers of the retina to separate.  Those who are very nearsighted, have undergone eye surgery, or have experienced a serious eye injury are at greater risk for this type of detachment.  Nearsighted people are more susceptible because their eyes are longer than average from front to back, causing the retina to be thinner and more fragile. 

The second most common type occurs when strands of vitreous or scar tissue create traction on the retina, pulling it loose.  Patients with diabetes are more likely to experience this type.

The third type happens when fluid collects underneath the layers of the retina, causing it to separate from the back wall of the eye.  This type usually occurs in conjunction with another disease affecting the eye that causes swelling or bleeding.
 
Signs and Symptoms

· Light flashes
· “Wavy,” or “watery” vision
· Veil or curtain obstructing vision
· Shower of floaters that resemble spots, bugs, or spider webs
· Sudden decrease of vision

Detection and Diagnosis

Retinal detachments are usually found because the patient calls the doctor’s office with a symptom listed above.  It is critical that these problems are reported early, because early treatment can greatly improve the chance of restoring vision. 

The doctor makes the diagnosis of a retinal detachment after thoroughly examining the retina with ophthalmoscopy.  The retinal surgeon’s first concern is to determine whether the macula (the center of the retina) is attached.  This is critical because the macula is responsible for the central vision.  Whether or not the macula is attached determines the type of corrective surgery required and the patient’s chances of having functional vision after the operation.

Ultrasound imaging of the eye is also very useful for the doctor to see additional detail of the condition of the retina from several angles. 

 
Treatment

There are a number of ways to treat retinal detachment.  The appropriate treatment depends on the type, severity and location of the detachment.  
   
Pneumatic retinopexy is one type of procedure to reattach the retina.  After numbing the eye with a local anesthesia, the surgeon injects a small gas bubble into the vitreous cavity.  The bubble presses against the retina, flattening it against the back wall of the eye.  Since the gas rises, this treatment is most effective for detachments located in the upper portion of the eye.  In order to manipulate the bubble into the ideal location, the surgeon may ask the patient to keep his or her head in a specific position.  

The gas bubble slowly absorbs over the next 1-2 weeks.  At that time, an additional procedure is usually performed to “tack down” the retina.  This can be done either with cryotherapy, a procedure that uses nitrous oxide to freeze the retina, sealing it in place, or with laser.  Local anesthesia is used for both procedures. 

Some types of retinal detachments, because of their location or size, are best treated with a procedure called a scleral buckle.  With this technique, a tiny sponge or band made of silicone is attached to the outside of the eye, pressing inward and holding the retina in position.  The scleral buckle is not visible and remains permanently attached to the eye.  This technique of reattaching the retina may elongate the eye, causing nearsightedness.  Sometimes, the surgeon will determine that the vitreous gel must be removed from the eye and replaced with a special gas in order to increase the chances that the retina will reattach. In these cases the head must be positioned appropriately in order for the surgery to be successful.  In rare cases where other types of retinal detachment surgeries are either inappropriate or unsuccessful, silicone oil may be used to reattach the retina.  The vitreous gel is removed and replaced with silicone oil, which presses the retina into place.  While the oil is inside the eye, the vision is extremely poor.  After the retina has resealed itself against the back of the eye, a second procedure may be performed to remove the oil.

What you can do…

Early detection is key in successfully treating retinal detachments and tears.  Awareness of the quality of your vision in each eye is extremely important, especially if you are in a higher-risk group such as those who are nearsighted or diabetic.  Compare the vision of your eyes daily by looking straight ahead and covering one eye and then the other. 
Notify your doctor immediately if you notice any of the following:

  • An obstruction of your peripheral vision (veil, shadow, or curtain)
  • Sudden shower of floaters
  • Light flashes
  • Spider webs
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Strabismus

Strabismus refers to misaligned eyes. If the eyes turn inward (crossed), it is called esotropia. If the eyes turn outward (wall-eyed), it is called exotropia. Or, one eye can be higher than the other which is called hypertropia (for the higher eye) or hypotropia (for the lower eye). Strabismus can be subtle or obvious, intermittent (occurring occasionally), or constant. It can affect one eye only or shift between the eyes.
Strabismus usually begins in infancy or childhood. Some toddlers have accommodative esotropia. Their eyes cross because they need glasses for farsightedness. But most cases of strabismus do not have a well-understood cause. It seems to develop because the eye muscles are uncoordinated and do not move the eyes together. Acquired strabismus can occasionally occur because of a problem in the brain, an injury to the eye socket, or thyroid eye disease.

When young children develop strabismus, they typically have mild symptoms. They may hold their heads to one side if they can use their eyes together in that position. Or, they may close or cover one eye when it deviates, especially at first. Adults, on the other hand, have more symptoms when they develop strabismus. They have double vision (see a second image) and may lose depth perception. At all ages, strabismus is disturbing. Studies show school children with significant strabismus have self-image problems.
Amblyopia, or lazy eye, is closely related to strabismus. Children learn to suppress double vision so effectively that the deviating eye gradually loses vision. It may be necessary to patch the good eye and wear glasses before treating the strabismus. Amblyopia does not occur when alternate eyes deviate, and adults do not develop amblyopia.

Strabismus is often treated by surgically adjusting the tension on the eye muscles. The goal of surgery is to get the eyes close enough to perfectly straight that it is hard to see any residual deviation. Surgery usually improves the conditions though the results are rarely perfect. Results are usually better in young children. Surgery can be done with local anesthesia in some adults, but requires general anesthesia in children, usually as an outpatient. Prisms and Botox injections of the eye muscles are alternatives to surgery in some cases. Eye exercises are rarely effective


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Double vision
Also referred to as: Diplopia

Diplopia is the medical term for double vision. The condition has many potential causes and is not a diagnosis in and of itself, but rather a symptom.  It is important to note whether diplopia is present when one or both eyes are open.  If double vision disappears when either eye is closed, the problem is likely related to misalignment of the eyes.  

Double vision in one eye only (monocular) may have a variety of causes.  In some cases, simple correction of refractive errors (use of glasses or contact lenses) resolves the condition.  Other common causes of monocular diplopia include corneal opacity (e.g., corneal ulcer) or swelling (corneal edema) and cataract. Less common but important causes of monocular double vision include cranial nerve palsies, a dislocated intraocular lens implant, orbital fracture, retinal detachment, and myasthenia gravis. Other causes are rare. 

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Tearing
Also referred to as: Epiphora

The most common cause of tearing, i.e., tears running out of the eye and down the face, is probably dry eye syndrome, with nasolacrimal duct (tear duct) obstruction being just slightly less common. Both conditions are relatively frequent, and both are more common in the middle-aged and elderly. 

Tearing in a patient with dry eye syndrome appears initially to be a paradox. However, when baseline tear production is low, the eye may become intermittently severely dry, especially in hot, dry, windy conditions, and the eye may react as if a foreign body was present due to local irritation. This sends signals for tear production to increase, thereby flushing away the perceived foreign body. For more on dry eye syndrome, please refer to that section elsewhere in this library. 

Nasolacrimal duct obstruction can be diagnosed by an ophthalmologist after one or more in-office tests.

There are many other causes of tearing, including corneal abrasion, ulceration, and foreign body, iritis, glaucoma (especially in infancy), and eyelashes rubbing the eye (trichiasis). In the great majority of cases, an ophthalmic exam will reveal the cause and the condition can be treated successfully.

DCR (Dacryocystorhinostomy) for Tearing

Clogged tear ductDacryocystorhinostomy - DCRTears are made primarily by the lacrimal gland, which is anatomically located in the upper lateral aspect of the upper eyelid. With each blink, however, tears are drained from the eye through the tear drainage system, into the nose. There are normally two openings to the tear drainage system; one in the upper eyelid and one in the lower eyelid. These tiny orifices are situated along the margin of the eyelid, closest to the nose, and are known as puncta. The puncta lead to tiny ducts known as canaliculi which lead to the lacrimal sac, situated just along the inside corner of the eye, on the side of the bridge of the nose. Tears are carried from the lacrimal sac down the nasolacrimal duct into the nose. It is usually toward the bottom of the nasolacrimal duct that obstructions of this passageway occur. 


When an individual develops tearing due to acquired obstruction of the nasolacrimal (tear) duct, a DCR procedure is usually offered. However, diagnosis of the condition must be made first, and this usually requires one or more in-office tests by the ophthalmologist. This may include a dye disappearance test, whereby fluorescein dye is placed on the eye surface, and the disappearance between the two eyes compared. A second test for obstruction of the nasolacrimal duct might include irrigation of the tear drainage pathways. This non-painful test is completed by placing a small, blunt irrigating syringe just inside the initial opening of the tear duct, and irrigating fluid (water or saline) through the tear drainage system. If the nasolacrimal duct is determined to be relatively or completely obstructed, a DCR procedure is often appropriate. 

The DCR Procedure 

In this procedure, the tear drainage pathways are reconnected to the inside of the nose. A small incision is usually placed approximately midway between the corner of the eye and the bridge of the nose. The lacrimal sac is located, incised, and then connected to the nasal mucosa creating a new tear drainage pathway. Tiny plastic tubes (stents) are then placed in the newly created tear drainage pathway for a few months to prevent scarring of the tear drainage ducts, which might otherwise result in failure of the surgery. The tubes can usually be removed in the office with little if any discomfort or need for anesthesia.


The Balloon (Non-Incisional) DCR

A balloon DCR is similar to the incisional DCR in objective, although the procedure is completed without an incision. The surgeon advances tiny tubing through the blocked tear duct, utilizing an inflatable balloon to help create a new tear drainage pathway into the nose. The inflatable balloon is the same type of balloon used in coronary (heart) artery angioplasty procedures. The surgeon then places thin plastic tubing in the newly created tear duct system, which is generally removed in the office 4 to 6 months later. Removal of the tubing causes little if any discomfort and typically does not require anesthesia. 

If you’ve been troubled or embarrassed by tears running down your face, consider seeing an oculoplastic surgeon in consideration of one of the latest DCR procedures. These advanced procedures performed by experienced surgeons offer tremendous potential to effectively and permanently resolve your tearing, in some cases without even so much as an incision! 


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Ectropion


Also referred to as: Outwardly Turned Eyelid

An ectropion is an outwardly turned eyelid.  The lower eyelid is nearly always affected.  In most cases, the cause is involutional and associated with the aging process.  Normal aging may cause laxity of the small muscle groups that hold the eyelid in place.  When the eyelid muscles can no longer keep the lid taut against the eye, it sags, causing dryness and irritation. 

Other causes of ectropion include paralysis (e.g., facial nerve palsy), scarring (e.g., from a burn, surgery, or laceration of the eyelid), mass, congenital disorders, or inflammatory conditions.

Repair of ectropion usually requires surgery to tighten the eyelid muscles.

Ectropion Repair

An ectropion is an outwardly turned (everted) eyelid. The condition most often is associated with aging, though it may also occur congenitally, as a result of scarring or other surgeries, or secondary to facial nerve paralysis (Bell’s palsy). If not repaired, the condition may lead to thickening of the mucosal surface on the inside of the eyelid (conjunctiva) with consequent inflammation of and danger to the health of the eye itself. 

The best method of repair for an ectropion often depends on the underlying cause. In the involutional type of ectropion (associated with aging), most surgeons elect to shorten and tighten the lower lid, thereby resolving the outwardly turned lid. This typically is completed with an incision of the skin at the lateral corner of the eye. The surgeon then excises a small segment of the lateral aspect of the lower eyelid, and subsequently reconnects the eyelid to underlying tissues and the upper eyelid. 

Usually only a few stitches are placed in the skin at the lateral corner of the eye, and these are often removed 7 to 14 days later. There is typically almost immediate resolution of the condition. Most patients have little if any discomfort with the procedure. There may be mild bruising and swelling following the procedure. This should resolve within about two weeks. 

Ectropion which occurs as a result of scarring (cicatricial ectropion) is most likely to follow another surgical procedure of the face or eyelids, especially excision of skin lesions such as skin cancers. This type of ectropion repair often requires skin grafting. The donor site for the skin graft is most often taken from the patient’s upper eyelid or from behind the ear. The skin from these sites will most closely match that of the patient’s lower eyelid skin. Both the donor site for the graft and the surgical site will usually heal nicely within two weeks following the surgery. 


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Entropion


Also referred to as: Inwardly Turned Eyelid

An entropion is an inwardly turned eyelid margin. The condition almost invariably affects the lower eyelid of an aging patient. This presentation is known as the involutional type. Patients or family members will almost always notice the inwardly turned eyelid and the patient will typically have tearing, a foreign-body sensation, and a red eye from the eyelashes rubbing the eye. The condition may also occur with scarring processes secondary to trauma, inflammatory syndromes, and infections. Other causes are rare. 

Treatment for entropion is nearly always surgical in nature.

Entropion Repair

An entropion is an inwardly turned (inverted) eyelid. The condition occurs primarily as a result of advancing age with consequent weakening of certain eyelid muscles. The imbalance between eyelid muscle groups results in the inward turning of the eyelid. The condition almost always affects the lower, rather than the upper, eyelids. 

Repair of involutional entropion (associated with aging) may be completed with a variety of procedures. Most cases are completed with an incision in the lateral corner of the eye or an incision just beneath the lower eyelashes. In either case, a tightening of tissues is required to resolve the imbalance between the muscle groups of the lower lid. 

Most patients experience immediate resolution of the problem once surgery is completed with little if any post-operative discomfort. Most cases will require subsequent removal of sutures located along the lower eyelashes or the lateral corner of the eyelid. Minor bruising or swelling may be expected and will likely resolve in one to two weeks following surgery. 

A non-incisional entropion repair, known as a Quickert procedure, may be completed as an in-office procedure. This form of entropion repair requires two or three strategically placed sutures which will evert the eyelid. The procedure can be completed under local anesthesia with little if any discomfort. 

The most important drawback of this procedure is that there is a significantly higher chance of recurrence of the entropion subsequently. The Quickert procedure, however, is an excellent procedure for patients who do not desire, or are not good candidates for, a trip to the operating room. 


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Thyroid Eye Disease - Orbital Decompression for Grave's Disease


Grave’s disease, also known as thyroid associated orbitopathy, thyroid eye disease, and Grave’s orbitopathy, is an autoimmune condition. That is, the immune system mistakenly attacks the thyroid gland, eye and orbital tissues, and skin of the lower legs in patients with the condition. 

When patients with Grave’s disease develop ocular symptoms, the condition is known as Grave’s ophthalmopathy or Grave’s orbitopathy. These patients may develop proptosis, or bulging eyes. The space between the lids may widen producing a staring appearance. Because the eye muscles are involved, some patients may develop double vision. In the worst cases, vision may be threatened due to compression of the optic nerve. 

The Procedure

Orbital decompression surgery is a procedure that may be necessary for patients with visual loss due to compromise of optic nerve function or for patients whose Grave’s disease has caused significant disfigurement. In orbital decompression, the surgeon creates fractures of the thin bones of the orbital walls, allowing the orbital contents to be displaced into the sinuses. This permits a significant diminution of proptosis, i.e., the bulging eyes fall backward into the orbit creating a more natural appearance. 

The risks of orbital decompression include numbness of the cheek, upper teeth, and lip on the operated side, which may persist for months following the surgery. Double vision may persist (if already present) or develop after the surgery. Some patients with double vision may respond well to prisms (in glasses) or to eye muscle (strabismus) surgery afterwards. Rarely, a patient might develop leaking of cerebrospinal fluid (CSF). This rare complication could require a second procedure for repair. 


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Eyelid Skin Cancers


Skin cancers may occur on the eyelids, on the nose, in the “corner” of the eye, and in the eyebrow area. In the worst cases, they may invade the orbit (eye socket) as well. They typically appear as nodules, often with pearly borders and ulcerated centers. Many patients believe they have a sore that won’t heal when they are found to have a skin cancer. 

Treatment of any type of skin cancer must typically follow two principles of management. The first is complete excision of the lesion, and the second is reconstructive surgery. Any type of cancer must be completely destroyed or removed in order to prevent recurrence or continued growth. In most cases, this is completed with surgical excision, unless the tumor is too large or the patient is not a good surgical candidate for any reason. In these cases, some tumors are treated with irradiation. 

For relatively large tumors in locations in which tissue removal must be carefully restricted (e.g., the eyelids or nose) some surgeons may opt for the Mohs surgical technique. This type of tumor excision requires excision of small areas of tissue, followed each time by microscopic tissue analysis by a pathologist. Once the cancer is completely excised, the region of surgery must then be reconstructed. This may require simple or complex incision closures, tissue transfer procedures, and skin grafting when necessary. 

If you believe you have a skin cancer, or even a sore that won’t heal, be sure to discuss the issue with your EyeMD. More than likely, he or she will have an answer as to the appropriate treatment of the lesion. Be sure not to delay. The earlier the treatment, the better the outcome. 


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Ocular Trauma - Orbital Reconstruction / Ocular Prosthetics (False Eyes)


Traumatic accidents and treatment of ocular and orbital cancers, blind and painful eyes, and other diseases sometimes lead to the need for reconstruction of the orbit (eye socket) and the placement of an orbital implant. Loss of an eye doesn’t necessarily mean that a favorable cosmetic outcome is not possible. In fact, with advances in orbital implant materials and surgical techniques, the cosmetic outcome is frequently excellent. 

Orbital Reconstruction

When a diseased, traumatized, or blind and painful eye must be removed (enucleated), most patients will have the option of an orbital implant. In this procedure, the muscles of the eye are preserved and are attached to the spherical implant, thereby creating proper volume of the orbit and allowing motility of the implant. The outer layers of the natural eye (tenon’s capsule and conjunctiva) are usually sutured closed over the implant material, further securing the implant in place. Certain types of orbital implant materials allow the ingrowth of tissues into the implant, thereby decreasing the risk that the implant material might be extruded or become infected. 

The Ocular Prosthesis (False Eye) 

About 6 weeks following orbital reconstruction, the ophthalmologist will refer the patient to an ocularist. An ocularist is a technical professional who specializes in the fitting of ocular prostheses, also known as false eyes. The prosthesis itself is a thin, often porcelain, shell which is designed to look like the patient’s opposite eye. The prosthesis is designed after taking moldings of the patient’s orbital tissues and eyelids, such that the prosthesis fits nicely and comfortably. The prosthesis is often designed after making measurements and taking photos of the opposite eye. 

The prosthesis itself is placed beneath the eyelids and on top of the orbital implant (and overlying tissues). It is typically left in place for weeks or months at a time, occasionally needing to be removed to examine the underlying tissues or for cleaning and polishing of the prosthesis itself. If the surgeon was able to attach the muscles of the natural eye to the orbital implant, the prosthesis will usually have motility that tracks the opposite eye. In some cases, when motility of the prosthesis is limited, the surgeon may place a peg in the implant, which fits into a depression in the back surface of the prosthesis. This will often allow greater and more natural eye movements. In many cases, when the eye muscles are attached to the orbital implant, it is difficult for the casual observer to distinguish the natural eye from the artificial one. 


 

Ocular Histoplasmosis Syndrome

OHS is a major cause of visual impairment in the eastern and central United States where 90 percent of adults have been exposed to histoplasma capsulatum. This common fungus is found in molds from soil enriched with bat, chicken or starling droppings and yeasts from animals.

Although the fungus is not found directly in the eye, people with OHS usually test positive for previous exposure to histoplasma capsulatum.
Histoplasmosis is usually mistaken for a cold. The symptoms are very similar. The body's immune system normally overcomes the infection in a few days. The only evidence of histoplasmosis is histo spots, tiny scars on the retina. Generally histo spots do not affect vision, but for unknown reasons, some people can have ocular complications years or decades later.

Doctors believe that the histoplasmosis spores travel from the lungs to the eye where they settle in the choroid, the layer of tiny blood vessels that provides blood and nutrients to the retina, the light-sensing layer of cells lining the back of the eye.
Ocular histoplasmosis develops when fragile, abnormal blood vessels grow under the retina. The abnormal blood vessels form a lesion known as choroidal neovascularization (CNV). If left untreated, the CNV lesion can turn into scar tissue and replace the normal retinal tissue in the macula.

The only proven treatment for OHS is a form of laser surgery called photocoagulation. The laser's small, powerful beam of light destroys the abnormal blood vessels, as well as a small amount of the retinal tissue. Treatment is not necessary unless the new vessels are in the macula, the part of the retina responsible for acute central vision.
Although only a tiny fraction of people infected with the histoplasmosis virus develop OHS, if you have been exposed to histoplasmosis you should be sensitive to any changes in your eyesight.


 

Toxoplasmosis

Toxoplasmosis is a common parasitic infection. When contracted by a pregnant woman, toxoplasmosis can pose serious risks to the unborn baby. Simple precautions can reduce the chance of infection.

Pregnant women should avoid handling litter boxes and eating raw meat because the parasite may originate in cat feces or undercooked meat. If acquired during the first trimester of pregnancy, the infection can be devastating to an infant.
Toxoplasmosis affects the retina, the light-sensitive cells lining the back of the eye. Both eyes are usually involved. If the infection settles in the macula, the area of the retina responsible for central vision, good vision is lost forever.

When toxoplasmosis heals, it leaves a scar. The infection may recur years later, sometimes near the previously infected area. Swelling that fights the infection may cause floating spots in one's vision, red, painful eyes, and poor vision.

Treating toxoplasmosis with oral medications can be very effective. Pyrimethamine and sulfa drugs are the classic antibiotics although some doctors add or substitute clindamycin. Occasionally steroids, laser, or freezing (cryotherapy) treatments are prescribed.

Screening tests can identify women of childbearing age who are at risk of passing the infection to an unborn child.

 


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Trichiasis


Trichiasis refers to the acquired development of eyelashes that are misdirected toward the ocular surface. As such, the eyelashes frequently rub the eye, producing irritation, tearing, and occasionally, corneal ulceration (infection). Unless another underlying disorder is present, the treatment for trichiasis is epilation (lash removal). This usually consists of simple lash removal with forceps, electrocautery of individual lashes (hyfrecation), or cryotherapy (freezing). The latter method is usually reserved for patients with many offending lashes, whereas the former two methods are typically utilized when only one or a few lashes require removal.


Blepharospasm

Also referred to as: Eyelid Spasm

Blepharospasm refers to uncontrolled closure or blinking of the eyes. Benign essential blepharospasm (BEB) is the most common type of blepharospasm. The cause of BEB is unknown. Known causes of blepharospasm include Tourette's syndrome and tardive dyskinesia. 

Blepharospasm is a type of dystonia, which indicates a sustained muscular contraction of an involuntary nature. Blepharospasm usually begins with a gradual onset, often precipitated by eye irritation or emotional stresses. With progression of the disorder, episodes of blepharospasm tend to worsen in severity, often resulting in embarrassment and even loss of vision temporarily due to lid closure. In some cases, the spasms are so prolonged and forceful that the patient is functionally blind for up to several hours. 

Treatment of blepharospasm usually entails botulinum toxin injections as first line therapy, followed by surgery for only the most intractable cases. Botulinum toxin, which comes from the bacteria known as Clostridium botulinum, acts by temporarily causing disruption of nerve impulses to muscles. When the agent is injected locally into the affected muscles, there is relaxation of those muscles, and resolution of the symptoms in the majority of patients. Benefits typically begin within one to fourteen days, and typically last for 3 to 4 months. About 90% of patients will have complete relief of their symptoms with the first injection. A second injection may be given if blepharospasm persists following the initial botulinum toxin injection. Some patients will experience a droopy eyelid (ptosis), blurred vision, or double vision following the injection, which may last several months. Patients may continue to require repeat injections, perhaps every 3 to 6 months. 

Patients who fail to have clinical resolution of symptoms with botulinum toxin injection, or do not wish to have the injection for any reason, may be candidates for surgery. The most common surgical procedure for this condition is protractor myectomy. This is a procedure in which surgical removal of some or all of the muscles of eyelid closure is completed. This procedure is effective approximately 70 to 80% of the time, although the risks may be greater than botulinum toxin injection, i.e., the risks of surgery are relatively permanent.

Treatment for Blepharospasm – Botox Injections

Botox is a toxin that has been used extensively for a variety of conditions, including facial wrinkles, eyelid spasm (blepharospasm), hemifacial spasm, spastic entropion (inward turning of the lower eyelid) and even certain types of strabismus (crooked eyes). Botox is the brand name for botulinum toxin A, a type of toxin produced by the bacteria Clostridium Botulinum. This toxin, responsible for the condition botulism, blocks nerve impulses to muscles by blocking the receptor site for the appropriate neurotransmitter. Botox, however, has been FDA approved and has been shown to be extraordinarily safe and effective for these treatments.

Botox for Blepharospasm

Blepharospasm is a condition in which one or both eyelids spasm forcefully and uncontrollably closed in repeated fashion. This involuntary closure of the eyelids may sometimes even result in temporary loss of vision. The cause of blepharospasm is unknown but seems to be associated with emotional stress and fatigue. Botox injections, when administered in tiny dosages by injection in the upper and lower eyelids of the involved eye, may result in effective resolution of the condition. The effect of the treatment usually begins in 1 to 14 days and lasts for 3 to 6 months. Repeat injections may be required every 3 to 6 months depending on recurrence and severity of the condition.


Botox for Hemifacial Spasm

Hemifacial spasm is a condition which involves spastic contractures of one half of the face that are forceful, uncontrollable, and agonizing to the afflicted. Hemifacial spasm may be due to vascular compression of the facial nerve or an intracranial tumor and, therefore, neuroimaging (CT or MRI) is often considered. 

Treatment of hemifacial spasm may include surgery for the underlying cause, selective ablation of branches of the facial nerve, or Botox injections. The Botox injections would certainly be considered appropriate symptomatic treatment (for hemifacial spasm) if an underlying cause cannot be found or is otherwise not treatable. The Botox injections may be given in select locations of the face with a tiny needle; treatments are typically required every 3 to 6 months. 
 
Botox for Facial Wrinkles

Botox has more recently been found to have application in the treatment of facial wrinkles as well. It is especially useful for wrinkles adjacent to the eyes and in the forehead. Tiny doses of Botox are administered with a very fine needle in the areas of concern, often alleviating the wrinkles for about 3 to 6 months. This alternative is a welcome one to many individuals who have concerns about more invasive cosmetic surgical procedures. 


 

Branch Retinal Vein Occlusion (BRVO)

Most people know high blood pressure and other vascular diseases pose risks to overall health, but many may not know that high blood pressure can affect vision by damaging veins in the eye. High blood pressure is the most common condition associated with BRVO. About 10 to 12 percent of the people who have BRVO also have glaucoma (high pressure in the eye).

Branch retinal vein occlusion blocks small veins in the retina, the layer of light sensing cells at the back of the eye. If the blocked retinal veins are ones that nourish the macula, the part of the retina responsible for straight-ahead vision, some central vision is lost. During the course of vein occlusion, sixty percent or greater will have swelling of the central macular vision area. In about one third of people, this macular edema will remain for over one year.

BRVO causes a painless decrease in vision, resulting in misty or distorted vision. If the veins cover a large area, new abnormal vessels may grow on the retinal surface, which can bleed into the eye and cause blurred vision.

There is no cure for BRVO. Finding out what caused the blockage is the first step in treatment. Your ophthalmologist may recommend a period of observation, since hemorrhages and excess fluid may subside on their own. Depending on how damaged the veins are, laser surgery may help reduce the swelling and improve vision. Laser surgery may also shrink the abnormal new blood vessels that are at risk of bleeding.
If you have had a branch retinal vein occlusion, regular visits to your ophthalmologist are essential to protect vision.


Branch Retinal Artery Occlusion (BRAO)

Most people know high blood pressure and other vascular diseases pose risks to overall health, but many may not know that high blood pressure can affect vision by damaging arteries in the eye.

Branch retinal artery occlusion (BRAO) blocks the small arteries in the retina, the light- sensing nerve layer lining the back of the eye. The most common cause of BRAO is a thrombosis, the formation of a blood clot. Sometimes the blockage is caused by an embolus, a clot carried by the blood from another part of the body.

Central vision is lost suddenly if the blocked retinal artery is one that nourishes the macula, the part of the retina responsible for fine sharp vision. Following BRAO, vision can range from normal (20/20) to barely detecting hand movement. BRAO poses significant risks to vision. If you have had a branch retinal artery occlusion or have high
blood pressure, regular visits to your ophthalmologist are essential.


 

Cotton-Wool Spots

Cotton-wool spots are tiny white areas on the retina, the layer of light-sensing cells lining the back of the eye. Caused by a lack of blood flow to the small retinal blood vessels, they usually disappear without treatment and do not threaten vision. They can, however, be an indication of a serious medical condition.

Diabetes is the most common cause of cotton-wool spots. The presence of more than eight cotton-wool spots has been associated with a higher risk of the more severe form of diabetic retinopathy known as proliferative diabetic retinopathy.

Cotton-wool spots are also a common sign of infection with the Human Immunodeficiency Virus (HIV). They are present in more than half of the people with full-blown AIDS. Their presence can be an important sign of the severity of HIV-related disease.


 Contact Lenses

Over 24 million people choose contact lenses to correct vision. When used with care and proper supervision, contacts are a safe and effective alternative to eyeglasses. And with today's new lens technology, many people who wear eyeglasses can also successfully wear contacts.

Contacts are thin, clear discs that float on the tear film that coats the cornea, the curved front surface of the eye. Contacts correct the same refractive conditions eyeglasses correct: myopia (nearsightedness), hyperopia (farsightedness) and astigmatism (an oval- rather than round-shaped cornea).

Contact lenses can be made from a number of different plastics. The main distinction among them is whether they are hard or soft. Most contact lens wearers in the United States wear soft lenses. These may be daily wear soft lenses, extended wear lenses or disposable lenses. Toric soft lenses provide a soft lens alternative for people with slight to moderate astigmatism.

Hard lenses are usually not as comfortable as soft lenses and are not as widely used. However, rigid gas permeable lenses provide sharper vision for people with higher refractive errors or larger degrees of astigmatism.

The majority of people can tolerate contact lenses, but there are some exceptions. Conditions that might prevent an individual from successfully wearing contact lenses include dry eye, severe allergies, frequent eye infections, or a dusty and dirty work environment.

Individuals who wear any type of contact lens overnight have a greater chance of developing infections in the cornea. These infections are often due to poor cleaning and lens care.


 Allergies and the Eyes

Approximately 22 million people in the US suffer from seasonal itchy, swollen, red eyes. Airborne allergens, such as house dust, animal dander and mold constantly bombard the eyes and can cause ocular allergies at any time. But when spring rolls around and the plant pollen starts flying, it seems like everyone starts crying.

Seasonal allergic conjunctivitis, or hay fever, is the most common allergic eye problem. Various antihistamine and decongestant drops and sprays can soothe irritated eyes and nose.

Make every effort to avoid allergens. An allergist can help determine what you are allergic to so you can stay away from it. Staying away from outdoor pollen may be impossible, but remaining indoors in the morning when the outdoor pollen levels are highest may help control symptoms. If you are allergic to house dust, open windows and keep household filters clean.

Cool compresses decrease swelling and itching. Artificial tears dilute the allergens and form a protective barrier over the surface of the eye. Avoid rubbing the eyes. It makes the symptoms worse.

If seasonal allergic conjunctivitis is a problem, see an ophthalmologist. There are several new safe and effective anti-allergy drops that can be prescribed. An ophthalmologist can also make sure symptoms are not being caused by a more serious problem.


 

 

 


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