Macular degeneration is the physical disturbance of the center of the retina called the macula. The macula, which is about the size of the capital letter "O" in this sentence, is the part of the retina which is capable of our most acute and detailed vision. We use the macula for reading, driving, recognizing faces, watching television, and fine work. Macular degeneration is the leading cause of legal blindness in people over age 55. (Legal blindness means that a person can see 20/200 or less with eyeglasses.) Even with a loss of central vision, however, color vision and peripheral vision may remain clear. Vision loss usually occurs gradually and typically affects both eyes at different rates.
The root causes of macular degeneration are still unknown. There are two forms of age-related macular degeneration, "wet" and "dry". Seventy percent of patients have the "dry" form, which involves thinning of the macular tissues and disturbances in its pigmentation. Thirty percent have the "wet" form, which can involve bleeding within and beneath the retina, opaque deposits, and eventually scar tissue.
The "wet" form accounts for ninety percent of all cases of legal blindness in macular degeneration patients. Different forms of macular degeneration may occur in younger patients. These non-age related cases may be linked to heredity, diabetes, nutritional deficits, head injury, infection, or other factors. At this time doctors and scientists are undertaking the basic research necessary to determine the causes of these disorders. Finding the cause is the first important step toward prevention and cure.
Declining vision noticed by the patient or by their doctor during a routine eye exam may be the first indicator of macular degeneration. The formation of new blood vessels and exudates, or "drusen," from blood vessels in and under the macular is often the first physical sign that macular degeneration may develop. In addition, the following signs may be indicative of macular problems.
Anyone experiencing these symptoms should contact for an exam immediately:
The following are NOT known to be linked to macular degeneration:
Should the presence of wet macular degeneration be suspected, your doctor may order a fluorescein angiogram. This is a special photographic test where a dye is injected into the arm. As the dye passes through the blood vessels of the retina the angiogram can detect leakage and the presence of abnormal vessels called subretinal neovascular membranes or nets. Certain forms of wet macular degeneration are somewhat treatable with laser therapy to prevent severe vision loss. The key is early detection of treatable forms along with immediate laser treatment.
A recent National Eye Institute study was published in the Journal of the American Medical Association (October 2001). The 8 year study, called the Age Related Eye Disease Study (AREDS), evaluated 3,500 subjects between the ages of 55 and 80 (some with various stages of macular degeneration and others without macular degeneration). A specific formula of vitamins were randomly given to half of the subjects and a placebo given to the other half. Results indicated that those with intermediate or advanced macular degeneration showed a small but measurable decrease in the progression of macular degeneration when they took a vitamin formula that consisted of high potency antioxidants with zinc and copper. This formulation is available over the counter as Ocuvite - PreserVision AREDS Formula.
Subsequent to the AREDS results, more information is coming out that suggests a protective effect of Luteinin dry forms of macular degeneration. So far there are no well controlled studies published to prove this scientifically. Another element thought to have protective effects is Beta Carotene. It is important to note that you should not take beta carotene if you are a smoker.
A diet high in antioxidants, low in saturated fats, and high in fruits and vegetables is thought to be not only good for your cardio-vascular health, but for your eyes in general. Specifically, dark leafy vegetables such as spinach, kale, and collard greens are full of carotenoids like lutein.
Due to severe loss of central vision that can occur in some cases of macular degeneration, patients may lose their ability to read, watch television, and drive among other activities. This can lead to a loss of independence that can dramatically upset one's life. Fortunately many patients with central vision loss from macular degeneration can be helped with low vision aids. The use of magnification and telescopic systems along with closed circuit TV/video systems are just some examples of means by which individuals with significant macular degeneration are able to regain their ability to visually function once again.
It is very common for people to see tiny floaters from time to time. They become evident when you look at a uniform surface, especially white or blue (for example while looking at the sky). These common and occasionally seen floaters are of no concern.
The eye is hollow like an egg. Within the hallow center of the eye is a gel called the vitreous. The vitreous is analogous to the white of an egg. Just like all gels, the solid component of the gel can form areas of coagulation. These small areas of more solid vitreous float in the gel and are what causes the occasional floater to be noticed. In addition, you can actually occasionally perceive blood cells flowing through the tiny vessels of the retina which can also result in the floaters you see. This is called an entoptic phenomenon.
A key warning sign of potential trouble is when you see a sudden onset of floaters. This is even more concerning when the sudden onset of floaters is dramatic and associated with hundreds and hundreds of floaters (a "shower of floaters") as if someone was shaking a pepper shaker in front of your eyes. Other significant warning signs of trouble include associated flashes of light and/or loss of peripheral (side) vision. Most often a sudden onset of floaters results in seeing only one or a few floaters. Typically they appear like a "cob-web" or "spider-like". This type of experience may be associated with some flashes of light for the first day or so only, but typically not associated with peripheral vision loss or hundreds of floaters. This very common condition is called Posterior Vitreous Detachment (PVD). This is a condition when the more solid portion of the vitreous separates from the watery or "aqueous" portion of the vitreous.
If you experience these symptoms you must be evaluated immediately to rule out retinal tear.
PVD's are usually very frightening to patients when they occur due to a fear of retinal detachment. Fortunately, the vast majority of PVD's are benign and become less bothersome (in terms of noticing the floaters) over time. Virtually all persons will eventually have PVD. Not everyone perceives the symptoms of PVD, but it occurs with greater frequency with advancing age. It occurs at earlier ages in nearsighted (myopic) patients and with blunt eye trauma as well. Unfortunately a small percentage of PVD's are associated with retinal tears (less than 1%). There can be traction on the retina as the more solid vitreous moves forward with PVD. This traction may result in a break in the retinal surface. The danger of a retinal tear is that fluid from the vitreous can seep under the tear and cause a retinal detachment, which is a very serious condition. It is very difficult to differentiate a PVD without break from a PVD with retinal break without performing an extensive examination of the vitreous and retina. Thus, if you have symptoms of any sudden onset of floaters or flashes you must be examined immediately.
Retinal tears can occur due to PVD's, or other factors such as: retinal thinning disorders like "lattice degeneration of the retina", blunt trauma to the eye, and nearsightedness (Myopia). Retinal tears are very treatable and once treated are no longer a risk for detachment. Symptoms of a "shower of floaters" where hundreds of tiny dark spots are acutely perceived are common with retinal tears. The multitude of spots is actually blood cells that have leaked into the vitreous due to a break in tiny retinal blood vessels associated with the retinal tear. A retinal detachment is a condition where the retina separates from its connection to the deeper layers of the eye. When a detachment occurs the blood supply to the retina is compromised and the retinal cells eventually die with associated loss of vision. Depending on the location of the detachment, a person may lose only peripheral (side) vision, central vision (with "macular detachment"), or in the worst cases there can be a total loss of vision if the entire retina is detached. Early diagnosis and appropriate treatment is absolutely critical to preserving vision in cases of retinal detachment.
Retinal Break (tear or hole): sudden onset of a "shower of floaters". Hundreds of tiny dark spots will be seen. Flashes are common and typically persistent due to the torn retina being stimulated by the traction of the vitreous.
If not associated with detachment, then peripheral vision will be normal. Only macula retinal holes are associated with loss of central vision. If you experience these symptoms you must be evaluated immediately. Treatment involves the use of a retinal laser or a Cryo (freezing) probe to seal the break in the retina and prevent secondary retinal detachment.
Retinal Detachment (RD): loss of peripheral vision, as if a dark, blurry curtain was progressing from the side. Since most RD's are associated with breaks in the retina, the "shower of floaters" is also a common symptom as well. If the macula is affected then central vision may be very blurry as well. This is a true ocular emergency and must be seen the same day. New surgical methods have made the treatment of retinal detachments highly successful. The key however still remains early diagnosis and treatment.
Risk Factors for Retinal Tears and Detachments
Caution: Read below if you had been highly nearsighted and had LASIK
LASIK surgery to treat nearsightedness (Myopia) only reshapes the surface of the cornea. It has no effect on the back of the eye. Nearsighted eyes are at higher risk for retinal tears and detachments due to the longer axial length and secondary retinal thinning that occurs. Following LASIK these factors remain the same. Therefore, if you have had LASIK, keep in mind that your retina is still just as nearsighted as before the surgery. You are still at the same risk level for retina problems and as such should have annual eye health examinations (including retinal examinations) even if your vision without glasses is 20/20.
If you have symptoms of any sudden onset of floaters or flashes you must be examined immediately!
Properly termed hordeolum, a sty is a localized infection of various glands in the eyelid. Those that are associated with the glands of the lashes are called external hordeolum and those associated with the oil or Meibomian glands are called internal hordeolum.
The most common cause of hordeolum is infection caused by staph. bacteria. However, unless there is associated discharge from the area, a hordeolum is not typically contagious.
Hordeolum generally appear as local areas of redness and elevation or swelling of the eyelid. In some cases there can be a "white-head" to the area or a pustule. The area is typically tender and irritated. It will be especially tender or even painful to touch. Hordeolum will form when the lid glands are obstructed with dirt or debris. This allows for normally present bacteria of the lid to multiply within the gland and for the area to become infected.
Occasionally a hordeolum can result in a spread of infection which leads to a much greater degree of eyelid swelling, pain, and redness known as preseptal cellulitis.
Treatment for a hordeolum includes hot compresses to the area, the use of topical antibiotic or antibiotic/steroid combination ointments, oral antibiotics, and drainage of the hordeolum. If a secondary preseptal cellulitis develops then oral antibiotics are always required.
Blepharitis is an inflammation of the eyelid margins adjacent to your eyelashes. It is characterized by redness, irritation, and debris associated with this section of your eye. The symptoms you may experience with blepharitis include tenderness of the area, burning of the eyes, and dryness that tends to get worse as the day goes on. You may notice the debris at the base of the eyelashes, most notably when you wake up in the morning. The debris is termed "scurf" or "collarettes."
Causes of blepharitis include acute bacterial infection of the eyelids and associated glands, chronic infection of this area, or a localized form of seborrhea. Blepharitis may be associated with various systemic and dermatological conditions such as Rosacea and generalized Seborrhea. These conditions tend to be chronic and require1 ongoing treatment. Your doctor will make the specific diagnosis and prescribe the most appropriate treatment for your case of blepharitis.
Treatment for blepharitis is dependent on the specific cause of the condition. For acute cases a short term course of topical antibiotic drops or ointment may be recommended. Occasionally, combination antibiotic and steroid medication must be considered, especially if the patient is highly symptomatic with a great deal of inflammation. A mainstay for the treatment of chronic blepharitis is the use of oral antibiotics, especially those related to tetracycline. These drugs act to kill local bacteria, but they also promote the natural secretion of oils from the glands of the lid margins which leads to healing and prevents subsequent episodes of blepharitis. The mainstay of maintenance therapy for blepharitis is the performance of daily or twice daily eyelid hygiene. This includes the use of warm compresses and lid "scrubs."
The term "Pink Eye" is a very common one and can often be confusing in terms of understanding what might be causing an eye to look red or pink. Any time an eye is inflamed, no matter what the cause; the eye will become pink to red in color. This is due to dilation of the blood vessels that supply the white of the eye (the "sclera") or the mucus membrane that covers the sclera called the "conjunctiva." Inflammation of the conjunctiva is commonly and medically termed "conjunctivitis." The causes of Pink Eye include, among others: infection (viral, bacterial, or other microorganisms), allergy, toxic inflammation, generalized or non-specific inflammation, and trauma.
Viral conjunctivitis is most commonly caused by a variety of viruses known as adenovirus. These common viruses can in addition to conjunctivitis also cause respiratory infections and common colds. The conjunctivitis associated with viral infections often has a mild pink color to the white of the eye, and is associated with tearing, but no discharge of the eye. Currently there are no anti-viral medications for the treatment of common viral conjunctivitis, although research is going on for the development of such agents. Supportive treatment with warm compresses, lubricating agents, and possible anti-inflammatory agents are the current mainstay of therapy.
Bacterial conjunctivitis is most commonly characterized by the redness of the eyes along with a green or yellow discharge and mattering of the eyelids upon waking in the morning. Topical treatment with antibiotic eye drops is very successful in the management of bacterial conjunctivitis. A significant problem however is the development of bacteria that are resistant to antibiotics. The use of up-to-date, effective antibiotics is key in the management of this uncomfortable condition.
Allergic conjunctivitis is a very common eye condition and is characterized by pink looking eyes along with significant itching symptoms and occasionally associated with a white, stringy type of discharge. The symptoms may be seasonal, or can be year round depending on what the individual patient is allergic to. The use of contact lenses can be difficult during active bouts of allergic conjunctivitis. Treatment of allergic conjunctivitis includes the use of cold compresses, lubrication of the eyes with tear drops, proper contact lens cleaning and hygiene, and the use of new types of anti-allergy prescription eye drops. Contemporary pharmaceutical agents work on multiple aspects of the allergic eye response and are successful with only twice per day application. Your eye doctors at Sacramento Contact Lenses and Optometry can determine which form of therapy will be most successful for you based on a careful examination of your eyes. There are two types of allergic conjunctivitis: seasonal and perennial. Seasonal allergic conjunctivitis is the most common and affects people during specific seasons of the year. Perennial allergic conjunctivitis impacts people throughout the year. Whether seasonal or perennial, allergic conjunctivitis can cause severe discomfort.
Seasonal allergies include any and all of the miserable symptoms that attack patients in Spring and Fall. The symptoms are triggered by pollen released from flowers, grass, weeds and trees. Patients with seasonal allergies often complain of nasal congestion and sneezing as well as red, swollen, itching and tearing eyes.
During the spring and fall months, pollen levels are at their highest. Most eye allergies due to a pollen last 4 to 6 weeks, which is the length of most pollen seasons. Another type of allergen, mold, is also released through the air from substances such as leaves, grass, and hay.
Seasonal allergies should not prevent you from enjoying the Spring and Fall or enjoying the outdoors. Our doctors will try to find a treatment that will keep you comfortable.
Non-seasonal allergies such as dog or cat dander (skin flakes) and dust mites (tiny bugs that are related to spiders and ticks) also cause allergic conjunctivitis. Cleanliness, moisture levels, and other factors have impact on the number of dust mites found in your home. Mold can also develop in damp atmospheres within the home, such as the kitchen or bathroom.
Pollution is also commonly associated with allergic conjunctivitis. While it comes in many forms, air pollution, such as the type released from automobiles and factories, is commonly one of the more powerful types of contamination linked to allergic conjunctivitis. The most common therapy for this type of conjunctivitis is the eye drop that combines an antihistamine for relief of symptoms and a mast cell stabilizing agent to prevent further allergic reaction.
Avoiding the allergens that affect you is the best way to prevent allergy eyes. Staying indoors when mold and pollen levels are high, vacuuming the house to lift pet hair, pet dander, and dust mites are some examples of actions one can take to avoid or minimize allergic conjunctivitis reactions. But, most people who have seasonal allergies to pollen find it impossible to stay indoors in the Spring and Fall when pollen levels are the highest. If these techniques are insufficient in preventing or combating allergic conjunctivitis, please discuss your symptoms with your doctor and he will consider alternative therapy including oral medications to offer you relief. Your doctor will first diagnosis the exact type of allergy, then prescribe a course of therapy, which may include prescription medication in the form of eye drops, compresses, removal of offending allergens, and oral antihistamines, if necessary.
Your doctor has several new medications to offer you and will choose the one that is just right for your and your condition. Recent advances in medication offer your doctors many that are quite effective yet safe to use every day. Several of these medications are used as preventive therapy and can help you avoid having symptoms before they start. New studies suggest that using these medications just once a day may be enough for many patients. This is very good news for contact lenses wearers. These drops work best when placed in the eyes before contact with the allergen. Drops should be placed in the eye at least ten minutes before soft contact lenses are inserted.
Occasionally a pink looking eye may be associated with a more serious inflammatory condition that not only involves the surface of the eye, but affects the internal structures of the eye. A condition called Iritis or "Uveitis" will cause the eye to appear pink or red; however there is internal inflammation of the blood vessel rich layers of the eye called the "Uvea." One of the key symptoms in these conditions is sensitivity to light and greater eye pain or discomfort than in other external inflammations. In rare instances Uveitis is associated with serious systemic general health diseases such as rheumatoid arthritis, Lupus, and many others. The treatment involves the use of topical and occasionally systemic steroid medications. The greatest concern is the misdiagnosis and subsequent mistreatment of Uveitis. This is why our doctors do not suggest treatment and prescribing "over the telephone" simply based on what our patients describe to us. Additionally, we feel that eye problems should be diagnosed and treated by eye specialists, not by general doctors or pediatricians due to the possibility of this critical misdiagnosis.
The eye is filled with two types of fluid; the aqueous humor and the vitreous humor. The aqueous humor is contained between the cornea and the iris while the thicker, gel-like vitreous humor fills the entire volume of the eye behind the lens. The aqueous humor is produced behind the iris and flows forward through the pupil. It is then drained out through the trabecular meshwork. The trabecular meshwork is located at the perimeter of the iris and cornea. Where the iris and cornea meet, they form an angle; in this angle is the meshwork which drains out the fluid.
Glaucoma results from high pressure in the eye; this pressure increase occurs whenever more fluid is being produced than is being drained. So glaucoma can be the result of over-production of fluid or reduced outflow of fluid. Glaucoma is very serious because left untreated can cause blindness. It does not cause any real symptoms until it is in the later stages so the only way to know if you have it is to have your eyes examined and have the pressures measured, perform visual field test and examine the optic nerve. There are many ways to measure the pressure â€" all of them take only a few seconds and it doesn't hurt. It is very important to understand that having normal eye pressure DOES NOT mean that you can not have glaucoma. About 10% of all individuals with glaucoma will have a normal eye pressure measurement at the time of their examination. A form of glaucoma called Normal Tension Glaucoma is often misdiagnosed and must be considered at all times.
Glaucoma is treatable. There are eye drops that increase the outflow of fluid, and drops which reduce production of fluid. There are also surgical options for glaucoma. But most importantly, you must be tested for glaucoma.
Dry eye syndrome, also known as "keratitis sicca," affects patients of all ages but tends to be more common as individuals get older. Natural aging processes result in a decrease in the volume of tears produced and a change in the quality of the tear film. Other causes of dry eye include:
Our doctors will perform a variety of tests to diagnose dry eye based on your symptoms. A comprehensive dry eye related history will be taken to determine your environmental conditions, general health history, medications taken and other factors affecting tear supply of the eye. The quality of your tear film is evaluated by observing the tears under a high powered microscope. A coloring dye is used to determine the evaporation rate of your tears.
Artificial Tears - The mainstay of dry eye therapy is the use of tear supplements. The idea is to add to your tear volume and to improve the quality of the tear film at the same time. Various tear supplements are available over the counter at pharmacies everywhere. New tear supplements have been developed to match and complement the natural tear film. Some examples of tear products on the market currently include:
Tear supplements often only have a short duration of action and symptoms are not alleviated adequately for many patients with the use of tear drops only. A very effective method of treatment for these patients, especially if the dryness is due to low tear volume, is the use of Punctal Occlusion, or Punctal Plug.
Tears naturally drain out of the eye through small openings located on the margins of the upper and lower lid towards the nose, called puncta (plural for punctum). Small semi-microscopic inserts known as punctum plugs are placed into the puncta in a way that is analogous to nose plugs. The plugs reduce the rate of drainage out of the eye so that the tear volume is increased. The plugs remain in place for extended periods of time exerting their effect in an ongoing way.
The fees associated with punctual occlusion therapy are typically covered under health insurance and Medicare as medically necessary.
The next horizon for the treatment of dry eye involves the use of medications to stimulate tear production. The first such drug, Restasis (cyclosporine 0.05%) by Allergan pharmaceuticals, has reached the market. This medication increases the tear volume by stimulating tear production. It is taken twice daily in eye drop form. An important thing to remember is that Restasis may take up to a few months before results are noticed. It is taken as an ongoing therapy to continually maintain improved tear production. Once again, not all patients who suffer from dry eye will benefit from Restasis therapy. Your doctor will be able to determine if you are a candidate during your eye examination. A number of other new medications (both oral and topical), calledsecretagogues, are currently being investigated for the treatment of dry eye. Stay tuned.
Diabetes Mellitus has been diagnosed in over 14 million individuals in the United States. There are two basic forms of diabetes. Type II diabetes or non-insulin dependent diabetes (NIDDM) is also known as adult onset diabetes. It is most typically diagnosed in adults who tend to be overweight. Type II diabetes is most typically treated with oral medications; however a significant number of these individuals do require insulin therapy. A more severe form of diabetes is termed Type I diabetes, or insulin dependent diabetes. Also known as juvenile onset diabetes, this form tends to require insulin therapy. Eye complications can be found with either forms of diabetes.
There are numerous complications that can occur in the eye secondary to diabetes, some of which are mild, insignificant, or transient and others of which are severe and vision threatening. Diabetes is the leading cause of blindness among patients under the age of 65. Eye complications of diabetes include:
Diabetic retinopathy is a term used to describe consequences of abnormalities in the blood vessels of the retina that occur in diabetes. There are basically two forms of diabetic retinopathy, "Background" and "Proliferative."
Background diabetic retinopathy by far is the most common and least severe form. It involves bleeding within the various layers of the retina (hemorrhages) and leakage of serum into the retina which results in protein deposits called "exudates." This form of retinopathy typically does not cause any vision loss, but may be a precursor to proliferative retinopathy. Should fluid leak into the central retina called the "macula," then central vision is threatened. This condition is termed diabetic macula edema.
Proliferative diabetic retinopathy occurs when the retina is not receiving enough oxygen due to the severity of the background retinopathy. In response to this inadequate level of retinal oxygenation (or "hypoxia") a vasoactive substance is produced which stimulates the production of new retinal vessels called "neovascular vessels." These new vessels are very fragile and tend to bleed and leak profusely. Severe bleeds can enter the vitreous or pre-retina space and severely effect vision. These large bleeds may require surgery to remove the blood. Over time the new vessels form fibrous connective tissue bands that create traction to the retina and can lead to a very special form of retinal detachment. The presence and severity of diabetic retinopathy has been shown to be directly related to both the duration of having the disease and the control of blood sugar levels.
Our doctors examine you for any changes in vision that may be due to diabetes. They also examine your retina either by dilating your eyes or using Optomap retinal scan. If it is determined that eye disease may be related to diabetes, we will refer you to your family doctor for a diabetes work-up. If it is necessary to treat your diabetic retinopathy, we will refer you to retinal specialists.
The most critical aspect of treatment for diabetic eye complications involves the tight control of the disease itself. This relates to tight control of blood sugar levels, weight, and blood pressure. This is crucial in the prevention of ocular complications in diabetes as well as in slowing the progression of the disease.
Laser therapy is used in one of two ways for retinopathy. First focal laser treatment is used to seal specific areas of blood vessel leakage. This is especially useful if macula edema is due to a localized area of leakage. Occasionally the macula edema is more diffuse and a "grid pattern" of laser is used. In cases of proliferative diabetic retinopathy a form of laser therapy known as "pan retinal photocoagulation" (PRP) is used. In this case large areas of retina are treated with a multiple laser burns. The destruction of this already damaged retina reduces the oxygen demand of the retina as a whole, thus reducing the proliferation of leaky blood vessels. PRP is destructive in nature and not intended to improve vision per se, but to prevent further vision loss and potentially blinding complications of diabetic retinopathy. Following PRP there can be some loss of side vision and color vision in some cases. All laser treatments for diabetic retinopathy are performed by a retinal specialist as an outpatient procedure and do not require hospitalization.
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