The Best Artificial Tears to Buy

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The tear film covers the cornea for clear vision and comfort (click on image to enlarge)

What are artificial tears and why are they used?

Artificial tears are lubricants manufactured to simulate the normal tears that coat your eyes.  They come in many different preparations.  They are used by people who have dry eyes due to insufficient tear film from a variety of causes including lid problems, auto-immune disease (like Sjogren’s syndrome), and ageing. 

What are the main types of artificial tears?

Depending on the underlying cause of the dry eye, different types of artificial tears are recommended.  For example, evaporative dry eye is a condition in which the natural oils are missing from the normal tears (usually due to blepharitis).  The lack of oil allows the tears to quickly evaporate from the surface of the eye, leaving it dry.  Therefore, some artificial tears include oils to prevent evaporation.  Examples of artificial tears with oils include Soothe XP, Systane Balance, Refresh Optive and Refresh Digital.

Another cause of dry eye is aqueous deficiency.  That is, the tear glands do not produce enough water to coat the eye. This may be caused by ageing or auto-immune disease.  In this case, hypotonic tears help.  They are labelled, “hypotonic” or “hypo-osmolar.”

Many people have a combination of problems that cause their dry eye, and a combination of artificial tears may help.  Examples of good basic artificial tears include Soothe, Blink, Refresh, and Systane.

Preservatives or no preservatives?

Artificial tears come both with and without preservatives.  Preservatives are used to keep the bottle free of contamination allowing for a prolonged expiration date.  Unfortunately, some people are sensitive to preservatives, especially if drops are required more than 4-times-a-day for comfort.  Therefore, preservative-free tears are made to improve comfort (at the price of a shorter expiration date).  Examples of tears with preservatives includes Systane and Blink Tears.  If there are no preservatives in a preparation of artificial tears, the box is usually labelled clearly.

Why do some artificial tears last longer than others?

Artificial tears come in varying degrees of viscosity or thickness.  The thicker the tears, the longer they last.  However, thicker preparations may blur the vision for several minutes.  The thickest preparations include gels (e.g.  Genteal Gel) and ointments (e.g. Lacrilube Ointment and Sooth Nighttime).  They may be best used at night before sleeping as they coat the eye overnight, making the eyes feel better upon awakening. 

What more can be done for dry eyes?

If artificial tears do not give relief from dry eye symptoms, there are a variety of options.  In patients with evaporative dry eye, flaxseed oil or fish oil supplements by mouth may improve the tear film after a month or so.  Similarly, warm compresses may improve the teat film.  Punctal plugs may be used to block the outflow of tears from the eye.  And prescription eye drops (Restasis and Xiidra) may be helpful to treat aqueous deficiency.  If blepharitis contributes to the dry eye, tea tree oil preparations may also help.   

By Scott E. Pautler, MD 

Copyright  © 2024 Designs Unlimited of Florida.  All Rights Reserved.

Note:  As an Amazon Associate I may earn a small commission from qualifying purchases.  You pay no additional fees by accessing the links provided.  These funds help defray the costs of maintaining this website.  Thank you for your support.

Ozempic and Retina Problems

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Ozempic and retina problems

anatomy of the eye

What is the issue of Ozempic and retina problems?

Many people are prescribed Ozempic (and related medications) for type 2 diabetes mellitus and weight loss. There are reports of increased risk of diabetes-related retina complications after starting Ozempic. Complications include loss of vision (usually, not permanent when treated), vitreous hemorrhage, macular edema, and the need for laser treatment or injection treatment for diabetic retinopathy.

How does Ozempic cause retina problems?

It appears that Ozempic does not directly cause damage to the eyes. Rather, Ozempic may cause rapid lowering of blood sugar (especially, when used with other medications for diabetes). It is well-known that any treatment that rapidly lowers blood sugar may initially cause a worsening of diabetic retinopathy. It is as though the retina becomes adjusted to higher-than-normal blood sugars in diabetes. And then, when blood sugars drop, the retina becomes “starved.” The effect wears off as the retina becomes used to the lower blood sugar levels. Furthermore, in the long-run, the retina will be healthier with improved blood sugar control.

Who is at risk for retina problems and loss of vision with Ozempic?

Risk factors for retina problems from Ozempic include: prior damage from high blood sugar (diabetic retinopathy), rapid lowering of blood sugar, and continued use of other diabetes medications,

What can I do to prevent loss of vision with Ozempic?

If you have diabetes, see an ophthalmologist (or better yet, a retina specialist) for an eye exam before starting Ozempic. If you already have vision-threatening changes, early treatment will prevent worsening with Ozempic. In addition, routine monitoring of the retina during treatment with Ozempic may prevent permanent loss of vision from diabetic retinopathy.

By: Scott E. Pautler MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2024 Designs Unlimited of Florida.  All Rights Reserved.

Which is better: Syfovre or Izervay?

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Which is better: Syfovre or Izervay?

What are Syfovre and Izervay?
Syfovre and Izervay are medications used to treat geographic atrophy (GA) caused by dry-type age related macular degeneration (AMD).  It is given by injection into the eye.

What is geographic atrophy (GA)?

Geographic atrophy is a common cause of loss of central vision in AMD.  It occurs when retinal receptor cells die.  GA leaves blinds spots and missing areas in the vision.  It is different from wet AMD.  Until now, there was no treatment for geographic atrophy from AMD.    

How do Syfovre and Izervay work?

Syfovre and Izervay block the complement proteins in the body.  Complement is involved in the normal inflammatory response of the body.  The inflammatory response is important to fight infection.  However, in AMD the complement proteins appear to be involved in the development on geographic atrophy and loss of vision.  

How well do Syfovre and Izervay work?

Syfovre and Izervay are not cures for dry AMD.  They do not reverse the past damage by geographic atrophy.  Syfovre and Izervay, when given by monthly injection, was shown to reduce the rate of worsening of geographic atrophy by a small amount in a two-year study.  

What are the adverse effects of Syfovre and Izervay?

As with all intraocular injections there are risks.  The risks involved with the introduction of a needle into the eye include bleeding, inflammation, infection, and retinal detachment.  These problems may require surgery and risk loss of vision.  The known risks of Syfovre and Izervay include the new start of wet AMD threatening loss of vision.  This appears to occur in 10-20% of eyes.  This risk of new wet AMD may be reduced by avoiding treatment in high-risk eyes.  It is important to avert the development of new wet AMD because the treatment of wet AMD involves routine, long-term injection of another medication to prevent severe loss of vision. 

There is a risk of infection (endophthalmitis) after any eye injection.  There is some concern that Syfovre and Izervay may increase the risk of developing infection or worsen the final vision after infection.  The suppression of the natural defense against infection by both of these drugs, explains the concern over increased risk of infection. Not surprisingly, similar drugs given systemically have been shown to increase the risk of infection outside the eye.   

 Which is better: Syfovre or Izervay?

There have been no studies to date directly comparing Syfovre and Izervay.  However, Syfovre has rarely been associated with loss of vision from ischemic optic neuropathy (1-2%) and ischemic retinal vasculitis (~1 in 10,000).  To date it is not known if Izervay also shares this adverse effect.  Regardless, some doctors prefer Izervay because the injection may be given with a finer needle (i.e. it is less viscous), making the injection more comfortable compared with Syfovre.

The decision to use Syfovre or Izervay with the intent to slow the progression of dry AMD (geographic atrophy) must be weighed against the potential adverse effects in any given patient.  Your doctor will help you decide.

By Scott E Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright 2023-2024 Designs Unlimited of Florida. All Rights Reserved.

Lucentis Biosimilars: Byooviz and Cimerli

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Lucentis Biosimilars

What is a Lucentis biosimilar?

Lucentis is a medication used in the treatment of a variety of conditions including wet-type macular degeneration, diabetic retinopathy, and retinal vein occlusion.  Lucentis biosimilars are less-expensive medications manufactured to work in a fashion similar to Lucentis. It is important to remember that Lucentis biosimilars are not identical medications to Lucentis. In the US, Lucentis biosimilars include Byooviz and Cimerli.  

How effective are Lucentis biosimilars?      

Lucentis was proven in extensive studies to be very effective. In wet-type macular degeneration, a large study showed that monthly injections of Lucentis over a two-year period offered a 90% chance of stable or improved vision. Similar benefits are seen in other retinal conditions as well. The biosimilars were approved for use by the FDA as they appear to be non-inferior.  Further research will reveal more details.  

What are the risks of Lucentis biosimilars? 

Severe complications are very rare, but risks of Lucentis injection include bleeding, infection, inflammation, retinal detachment, glaucoma, cataract, and loss of vision. There may be a small increased risk (1%) of stroke or heart attack with Lucentis. The risk of stroke may be related to concurrent illness and the older age of patients in which these medications are used. Pregnancy should be avoided while on Lucentis therapy.  All of these risks apply to biosimilars, as well.  Furthermore, the question of whether biosimilars pose additional (or less) risk will be determined over time.                    

Why change from Lucentis to a biosimilar medication?

Usually an insurance company prompts the need to change from Lucentis to a biosimilar medication to lower their costs.  This may be a disadvantage to signing up for a Medicare Advantage insurance plan.  When a doctor must change from Lucentis to a biosimilar, he may need to take precautions in order to reduce the risk of problems.  For example, he may initially inject Byooviz or Cimerli at 4-week intervals before attempting to extend the treatment interval in order to assure effectiveness.  He may monitor the patient more closely to identify inflammation or high eye pressure.  After injection, patients should report any new symptoms without delay.   

Are doctors given financial incentives to prescribe Cimerli and Byooviz?

Manufacturers of new medications often provide incentives in the form of rebates to doctors. To determine if your doctor receives large payments from drug companies, visit the CMS website and enter your doctor’s name in the search box. I take great pride in advocating for my patients in the selection of medications, rather than pander to the drug companies.

By Scott E Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright ©2023 Designs Unlimited of Florida.  All Rights Reserved.

Eye Injections: Finer Needle = Less Discomfort

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Eye Injections: Finer Needle = Less Discomfort

What is the finest needle available to date for intravitreal injection?

Ocuject, LLC engineered the VitreJect needle for intravitreal injections.  Several features make this a popular needle among ophthalmologists and patients.  First, it is supplied in various small-caliber needle sizes.  For most injections, the 33G needle is preferred by patients for improved comfort over standard 30G needles.  The smaller 33G caliber reduces the rate of vitreous prolapse from the injection site following injection.  Hopefully, this may reduce the risk of endophthalmitis.  However, the larger caliber 30G VitreJect needle is preferred for more viscous medications such as pegcetacoplan (Syfovre). 

What about persistent floaters after eye injections?

Ocuject reports 70% less silicone content in their 33G needles compared with standard 30G needles.  This feature may reduce the incidence of persistent symptomatic floaters in the vision following injections. 

Can we eliminate the eyelid speculum? 

The VitreJect needle features a sliding shield that protects the needle from contact with the lids and lashes during the injection.  This feature obviates the need for an eyelid speculum, with which many patients report discomfort.  The sliding shield is secured in place by a twist-lock in order to avoid unintentional retraction of the shield and exposure of the needle.

Can we eliminate the extra caliper?

The VitreJect needle has an integrated caliper in the form of three nubs or studs that project from the end of the sliding shield that rests against the conjunctiva during injection (see image below).  When the edge of one nub is placed at the limbus, the needle will insert 4mm from the limbus.  When the edge of two contiguous nubs are placed at the limbus, the needle will inset 3.5mm from the limbus.  A choice of three nubs are located on the shield for convenience of positioning. 

What are the potential pitfalls?

If a technician opens the plastic wrapper part-way to place the needle on a syringe in preparation for injection, the twist-lock may be unintentionally unlocked.  The sliding sleeve may then be accidentally retracted causing the needle to be exposed.  The needle may be bent or contaminated in this situation.  Technician training avoids this issue.  Or, alternatively, I usually have the needle opened onto a sterile field in the exam room.  I place the needle on the syringe myself.  

Note: During actual injections, I wear sterile gloves.

By Scott E. Pautler, MD

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

What is the Difference Between Dry and Wet AMD?

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Age-Related Macular Degeneration: Dry or Wet?

What is the difference between dry and wet age-related macular degeneration?

Age-related macular degeneration (AMD) is the most common cause of visual loss in older Americans.  Doctors often talk about dry and wet types of AMD.  But what is the difference?  Simply put, dry AMD means there are no abnormal, leaky blood vessels.  Whereas, in wet AMD there are abnormal blood vessels that grow and leak under the macula.  However, this system of naming wet and dry AMD can be confusing.  Therefore, newer names for the stages of AMD have been proposed.

Why is it important to distinguish between wet and dry AMD?

Dry and wet AMD cause different symptoms and are treated differently.  Early and intermediate stages of AMD are often called dry AMD.  These stages usually cause few symptoms, which include the need for good lighting.  The treatment involves AREDS2 vitamins and a Mediterranean diet.  Advanced stages of AMD are called geographic atrophy (advanced dry AMD) and neovascular AMD (wet AMD).  Both types of advanced AMD are usually associated with decline in central vision, frequently affecting the ability to read, see the computer, and drive a car.  Geographic atrophy (advanced dry AMD) progresses slowly with blind spots that interfere with the ability to see.  Neovascular AMD (wet AMD) may advance more rapidly with distortion, blurred areas of vision, and blind spots.  It is possible to have both forms of advanced AMD…geographic atrophy (advanced dry AMD) and neovascular AMD (wet AMD).

What is the treatment of advanced AMD?

The treatment of the two forms of advanced AMD is different.  Furthermore, the treatment of one type of advanced AMD may aggravate the other form of AMD.  However, both forms of advanced AMD benefit from the use of magnifiers and other low vision aids.

What is the treatment of geographic atrophy (advanced dry AMD)?

Geographic atrophy (GA) is currently treated with medications that inhibit the complement systems of proteins in the body that normally cause inflammation to fight infection.  The two FDA-approved medications are Syfovre and Izervay.  They are both given as an injection into the eye.  They do not reverse the damage from GA and do not prevent GA from getting worse.  They do slow down the rate of worsening of GA.  There is no good evidence to show that one medication is better than the other.  Long-term injections are needed over the years.  And, unfortunately, both medications may cause wet AMD (neovascular AMD) to start.

What is the treatment of wet AMD (neovascular AMD)?

Wet AMD is treated with injections to stop the leaking blood vessels under the macula.  These medications (Avastin, Lucentis, Eylea, Beovu, and Vabysmo) prevent further worsening of vision from wet AMD in about 90% of cases over several years.  In about 40% of cases, the vision may improve.  Long-term injections are usually needed over the years.  There is limited evidence to suggest benefits of some medications over others.  There is also some concern that the treatment of wet AMD may aggravate geographic atrophy (advanced dry AMD).  

What do you do when an eye has both forms of advanced AMD?       

The presence of both neovascular AMD (wet AMD) and geographic atrophy (advanced dry AMD) poses a serious problem.  Both forms of advanced AMD may result in legal blindness (the loss of central vision).  However, advanced AMD almost never results in complete blindness.  Treatment is usually aimed at the greatest threat to vision.  Specific treatment plans are made on a case by case basis.  In some situations, injections are given on an alternating schedule for GA and neovascular AMD.  In end-stage situations in which the chance of further loss of vision is low, all injections may be stopped.  Low vision aids and assistance (family and social services) often results in high-level functioning and independence. 

By Scott E. Pautler, MD  

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

The Carotid Stump Syndrome and the Eye

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Carotid Stump Syndrome
Small blood clots formed at the thrombus in the “stump” of internal carotid artery pass to the brain and eye along the path outlined by the white arrows. Image modified from Baker et al. Cureus 2022 Mar; 14(3): e22746

What is the carotid stump syndrome?

The internal carotid artery is the main artery in the neck that brings blood from the heart to the eye.  Due to hardening of the arteries, the carotid artery may become blocked.  Risk factors include high blood pressure, diabetes, high cholesterol, obesity, and tobacco use.  If the carotid artery becomes completely blocked, there is a dead-end or stump beyond which the blood cannot flow.  Due to lack of blood flow from this blockage, tiny blood clots may form in the carotid artery.  Then, they may find their way to the eye through bypass channels that develop in response to the blocked carotid artery.

What eye symptoms result from the carotid stump syndrome?

When tiny blood clots enter the eye from the carotid artery, they may cause blind spots in the vision. Sometimes, the blind spots are small and may not be noticed by the patient.  At other times, the blind spot may appear like a reddish or black bar or arc in the vision.  In severe cases, the entire vision may black out…either temporarily or permanently. 

How can the eye doctor help?

The symptoms from the carotid stump syndrome may also be caused by many other disorders.  The role of the eye doctor is to determine the cause of the symptoms and determine if they are due to the carotid stump syndrome.  Eye examination and testing is necessary.  There is often no specific treatment needed for the eye condition.  The symptoms frequently improve with time if the underlying condition is treated.    

How is the carotid stump syndrome treated?

Medicines and surgery are used to treat the carotid stump syndrome.  Anti-platelet medications are the mainstay of treatment.  They work by limiting the tendency of the blood to clot.  Surgery may open the blocked carotid artery. 

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Lens Anterior Capsular Deposits

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I reviewed 271 abstracts that were cited from the PubMed search terms “lens and capsule and deposit.”  I have included some references from my search, as well as hyperlinks for convenience. 

The preponderance of cases involved pseudoexfoliation (PEX).  Uncommon manifestations of common problems must be considered1. It may be helpful to check the pupillary ruff for atrophy and gonio the angle looking for pigment deposition as seen in pre-clinical PEX.2

There are many rare causes of lens capsular deposits reported.  I have listed some below along with suggested investigation:

-foreign substances (silicone oil3): did this patient have a silicone IOL? Consider reviewing the operative report for the IOL to see if they used anything unusual like triamcinolone.

-infectious agents4: remain on the look-out for inflammation into the future.

-Fabry disease5: rare but important to consider…any sign of retinal vascular tortuosity or cornea verticillata?

-familial amyloidosis6: amyloid deposits on anterior capsule are more prevalent than vitreous amyloid…but were there any vitreous opacities or retinal vascular changes?

-rock inhibitor7: (more out on a limb in terms of possibility).  They affect the lens epithelial cells.

-Healon8: Any crystalline deposits on IOL surface?

By Scott E Pautler, MD

References:

1. Sorkou KN, Manthou ME, Meditskou S, Ziakas N, Tsinopoulos IT. Exfoliation Fibrils within the Basement Membrane of Anterior Lens Capsule: A Transmission Electron Microscopy Study. Curr Eye Res. 2019;44(8):882-886. doi:10.1080/02713683.2019.1608262

https://pubmed.ncbi.nlm.nih.gov/30986086/

2. Suwan Y, Kulnirandorn T, Schlötzer-Schrehardt U, et al. Light and electron microscopic features of preclinical pseudoexfoliation syndrome. PLoS One. 2023;18(3):e0282784. Published 2023 Mar 9. doi:10.1371/journal.pone.0282784

https://pubmed.ncbi.nlm.nih.gov/36893133/

3. Liu W, Huang D, Guo R, Ji J. Pathological Changes of the Anterior Lens Capsule. J Ophthalmol. 2021;2021:9951032. Published 2021 May 4. doi:10.1155/2021/9951032

https://pubmed.ncbi.nlm.nih.gov/34055399/

4. Tandon A, Tay-Kearney ML, Metcalf C, McAllister L. Bacillus circulans endophthalmitis. Clin Exp Ophthalmol. 2001;29(2):92-93.

https://pubmed.ncbi.nlm.nih.gov/11341454/

5. Rothstein K, Gálvez JM, Gutiérrez ÁM, Rico L, Criollo E, De-la-Torre A. Ocular findings in Fabry disease in Colombian patients. Manifestaciones oculares de la enfermedad de Fabry en pacientes colombianos. Biomedica. 2019;39(3):434-439. Published 2019 Sep 1. doi:10.7705/biomedica.3841

https://pubmed.ncbi.nlm.nih.gov/31584758/

6. Beirão JM, Malheiro J, Lemos C, Beirão I, Costa P, Torres P. Ophthalmological manifestations in hereditary transthyretin (ATTR V30M) carriers: a review of 513 cases. Amyloid. 2015;22(2):117-122. doi:10.3109/13506129.2015.1015678

https://pubmed.ncbi.nlm.nih.gov/26096568/

7. Imaizumi T, Kurosaka D, Tanaka U, Sakai D, Fukuda K, Sanbe A. Topical administration of a ROCK inhibitor prevents anterior subcapsular cataract induced by UV-B irradiation. Exp Eye Res. 2019;181:145-149. doi:10.1016/j.exer.2019.01.016

https://pubmed.ncbi.nlm.nih.gov/30690025/

8. Jensen MK, Crandall AS, Mamalis N, Olson RJ. Crystallization on intraocular lens surfaces associated with the use of Healon GV. Arch Ophthalmol. 1994;112(8):1037-1042. doi:10.1001/archopht.1994.01090200043019

https://pubmed.ncbi.nlm.nih.gov/8053816/

Save on AREDS Eye Vitamins

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Save on AREDS Eye Vitamins

What is age-related macular degeneration?

Age-related macular degeneration (AMD) is the most common cause of visual loss in older Americans.  It comes on with age and affects the central vision.  However, AREDS-2 vitamins lower the risk of vision loss.

What are AREDS-2 vitamins?

The AREDS-2 formula consists of carefully dosed vitamins, minerals and antioxidants aimed at protecting a patient against loss of vision from AMD.  It consists of vitamin C, vitamin E, Zinc, Copper, lutein, and zeaxanthin.  

Are there other vitamins in the market for AMD?

There are many vitamins and nutritional supplements marketed for AMD.  However, the AREDS-2 formula has undergone the most testing to date.  It offers the most assurance for protection against loss of vision.  Other supplements have been studied much less extensively and the safety is less certain.  For example, beta-carotene was used in AMD vitamins in the past, but it increases the risk of lung cancer in current and former smokers.  

What are the popular brands of AREDS-2 vitamins?

There are many brands of vitamins that contain the AREDS-2 formula.  PreserVision AREDS-2 and Ocuvite AREDS-2 are two popular brands.  They offer good quality; however, they are expensive.  

What is the least expensive brand of AREDS-2 vitamin?

There is now a high-quality alternative to the popular brands and it is much less expensive.  The name is Equate Advanced Eye Health Complex by Walmart.  In Tampa on September 9, 2023 the price for a box of 140 softgels (two-month’s supply) was $19.96.  This compares favorably with the price of PreserVision AREDS-2 of identical quantity selling for $34.47.  

By Scott E. Pautler, MD  

Note: Dr Pautler has no financial interest in any of the vitamin supplements.

Will I Lose Vision from AMD?

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Will I lose vision from AMD?
anatomy of the eye (click on image to enlarge)

What are the risk factors of losing vision?

If you have been diagnosed with AMD, you may ask, “Will I lose vision from AMD?” There are many risk factors that lead to the worsening of age-related macular degeneration (AMD).  Some are genetic (inherited) and some are environmental.  However, one the greatest risk factors is age.  This is, the older you are with AMD, the greater the risk of loss of vision.  Genetic testing can reveal high risk genes, such as CFH and ARMS2.  Therefore, a family history of vision loss from AMD increases your risk.  Other important factors that affect the risk of losing vision include tobacco use and diet.

What are the stages of AMD?

There are several stages of AMD that affect the risk of severe loss of vision: early, intermediate, and late AMD.  Early AMD presents with medium sized deposits under the retina called drusen.  These eyes usually have no symptoms and the vision is good.  Intermediate AMD have large drusen and/or brown pigmentary changes under the retina.  These changes frequently result in slow recovery from bright light (like coming in from outdoors) and the need for good lighting while reading.  Late AMD causes distortion of straight lines and blind spots in the vision from geographic atrophy (loss of retinal tissue) and/or neovascularization (new blood vessels grow under the retina that bleed and cause blind spots from scar tissue).  Geographic atrophy is also called advanced dry AMD, whereas neovascularization is called wet AMD.  

How can I determine my risk of late AMD with vision loss?

A point system has been developed to determine your risk of loss of central vision from late AMD.  Exam findings in each eye are given a point value.  Then, all the points are added together from the two eyes to arrive at risk of progression to late AMD within 5 years.  

Exam FindingPoint Value
medium drusen0.5
large drusen1
pigmentary changes1
geographic atrophy or neovascularization2
Add the points from findings in each eye
From: Ferris FL 3rd, Wilkinson CP, Bird A, et al. Clinical classification of age-related macular degeneration. Ophthalmology. 2013;120(4):844-851. doi:10.1016/j.ophtha.2012.10.036

At total score of 1 yields a low risk of late AMD of under 5% in five years.  With 2 points, the risk is 12 percent.  Three points means a risk of 25% at five years.  And 4 points means there is a 50% chance of late AMD in five years.  Another way to calculate your risk of late AMD is to use an online calculator.  

How bad can the vision fall from late AMD?

Late macular degeneration may cause a large blind spot in the center of the vision in both eyes.  Although this renders an individual legally blind, it is important to remember that it is extremely rare to lose all vision from AMD.  The peripheral vision usually remains strong and this allows a person to get around a room and care for himself independently.  

Does everyone lose most of their central vision in late AMD?

No.  Many people retain useful vision.  Patients with advanced dry AMD may be treated with Syfovre or Izervay to slow the progression of geographic atrophy.  There are a host of medications that slow the loss of vision from wet AMD, including Avastin, Lucentis, Eylea, Beovu, and Vabysmo.  There is high expectation that further developments from ongoing research will offer even better odds of retaining useful vision in the future.  Those patients who do lose vision from AMD can be helped with low vision aids.  

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Izervay for Dry Macular Degeneration

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Izervay for dry macular degeneration
anatomy of the eye (click on image to enlarge)

What is Izervay?
The FDA approved Izervay for dry macular degeneration in August 2023. It is a new medication for the treatment of geographic atrophy caused by dry-type age related macular degeneration (AMD).  Izervay is given by injection into the eye.

What is geographic atrophy?

Geographic atrophy is a common cause of loss of central vision in AMD.  It occurs when retinal receptor cells die.  It leaves blinds spots and missing areas in the vision.  Until 2023, there was no treatment for geographic atrophy from AMD.    

What does Izervay do?

Izervay blocks complement proteins (C5) in the body.  Complement participates in the normal inflammatory response.  And the inflammatory response is important to fight infection.  However, in AMD the complement proteins contribute to the development of geographic atrophy and loss of vision.  

How well does Izervay work?

Izervay is not a cure for dry AMD.  Importantly, it does not reverse past damage by geographic atrophy.  Izervay, when given by monthly injection, reduces the rate of worsening of geographic atrophy by 28% over 18 months of treatment as compared with sham injection.  We anticipate this will delay blind spots from interfering with central vision.  

What are the adverse effects of Izervay?

As with all intraocular injections there are risks.  The risks involved with the introduction of a needle into the eye include bleeding, infection, and retinal detachment.  These complications may require surgery and risk loss of vision.  

Can Izervay cause wet macular degeneration to start?

The known risks of Izervay include the new occurrence of wet AMD with blood vessel growth threatening loss of vision.  In the phase 2/3 study, wet AMD developed in 12% of eyes treated with Izervay compared with 3% in eye with sham injection over a period of 18 months.  This represents a 400% increased risk of new-onset wet AMD.  It is important to avert the development of wet AMD because the treatment of wet AMD involves routine, long-term injections of antiVEGF medications to prevent severe loss of vision. 

What about the risk losing vision from infection?

There is a risk of infection (endophthalmitis) after any eye injection.  At this time, we do not know if Izervay may increase the risk of developing infection or worsen the final vision after infection.  The suppression of the natural defense against infection by Izervay, explains the concern over increased risk of infection with Izervay.  

Should I receive Izervay injections?

If you have dry age-related macular degeneration with geographic atrophy, Izervay appears to delay the loss of central vision over time.  However, long-term monthly injections are required.  And you must carefully consider the risks of treatment.  Your doctor will help you make this important decision.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright 2023 Designs Unlimited of Florida. All Rights Reserved.

Burning Eyes

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What is the symptom of burning eyes?

Burning eyes is a common problem.  Sometimes, you can feel burning isolated to the eyelids.  At other times, the entire eye may seem to burn.  The burning may be low-grade or severe and it may come and go.  In addition, there may be associated symptoms such as redness, itchiness, crusting, and dry eye.  But usually there is no loss of vision.    

What are the causes of burning eyes?

There are many causes of a burning sensation.  First, make sure you don’t have a sensitivity to make-up or eye drops that you place in your eyes.  One clue is that the burning comes on right after you are exposed to the offending agent.  However, a very common cause of burning is blepharitis.    

What is blepharitis?

Blepharitis is an inflammation of the eyelid border where the lashes emerge.  With blepharitis, the edge of the lid is usually red.  Sometimes, seborrhea or rosacea is the cause of blepharitis.  At other times, blepharitis is an isolated problem.  Regardless, the symptoms are the same.  Frequently, infection from bacteria or skin mites cause or aggravate blepharitis.  Blepharitis is diagnosed by the eye doctor.       

What treatment is available?

There are a host of treatments available.  Warm compresses often help.  Although a warm wet washcloth may help, it cools down rapidly.  Therefore, warming masks may work better.  Artificial tears help symptoms of dry eyes.  They may be used 3-4 times a day.  Sometimes, antibiotic drops, ointments, and/or pills are used.    

Can tea tree oil help?

Tea tree oil provides rapid improvement in symptoms.  It not only rapidly soothes the eyes, but it also works against infection by bacteria and mites.  However, pharmacists must prepare tea tree oil for use around the eye to avoid irritation and complications.  Various preparations include drops, washes, and lid wipes.  Daily use of tea tree oil helps keep the eyes healthy and comfortable.  

Where do I go for diagnosis and treatment?

A general ophthalmologist, trained to diagnose and treat burning eyes, is the doctor to see.  Further consultation is available with an ophthalmologist specializing in cornea and external disease.  In Tampa, I recommend Dr Mark Arey, Dr Allen Pusateri, and Dr Edgar Espana, among others.  

By Scott E Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Note: As an Amazon Associate I may earn a small commission through links above. There is no increased cost to you and the funds are used to defray the costs of this blog. Thank you for your support.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Is Eylea HD for Me?

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Is Eylea HD for me?
anatomy of the eye (click on image to enlarge)

What is Eylea HD?

You may ask yourself, “Is Eylea HD for me?” Eylea HD is an FDA-approved medication for the treatment of wet AMD and diabetic retinopathy.  It is a more concentrated form of Eylea, a medication that has been approved for use and effectively used for many years.  Eyela contains 2mg of medication per injection, whereas Eylea HD has 8mg of medication per injection.

When is it helpful to use Eylea HD over Eylea?

There are several reasons Eylea HD may be better than Eylea.  For example, in some eyes with severe macular degeneration or diabetic damage, current medications may not appear to be strong enough to help.  Eylea HD may offer the strength needed to help prevent loss of vision in these cases.  In addition, if Eylea does not last as long as needed, injections may need to be given frequently.  Eylea HD offers a longer duration of action.  Therefore, it may allow more time between injections.  

What are the side effects?

The same side effects of Eylea remain for Eylea HD.  That is, they are both given by injection into the eye.  Therefore, risks include infection, inflammation, bleeding, and retinal detachment, among others.  Over time, these risks are less with Eylea HD if injections can be given less often; the fewer the number of injections, the lower the risk of complications from the injection procedure. However, because Eylea HD is more concentrated, there may be increased risk of complications outside the eye.  As Eylea leaves the eye and enters the blood stream, it may cause increased risk of hypertension, stroke, heart attack, and kidney disease.  There is much debate about whether this risk is significant or not, but evidence suggests the risk may be higher in diabetic patients.   

How can I decide if Eylea HD is right for me?

Your doctor will help you to decide.  If you do not have diabetes, or past history of stroke or heart attack, the decision may be easy.  However, if you have diabetes or are at high risk of stroke and heart attack, you may wish to hold off using Eylea HD until doctors have had more experience with the medication, which was newly approved for use in August 2023. 

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Seeing Zig Zag lines?

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seeing zig zag lines?
anatomy of the eye (click on image to enlarge)

What are zig zag lines in the vision?

Do you have a problem seeing zig zag lines?  This can be an alarming symptom.  Sometimes, they are described as jagged or resembling a heat wave coming off of a hot asphalt road.  Others describe the symptom as looking like a kaleidoscope.  The zig zag lines usually come on without warning and may slowly increase in size and intensity over several minutes.  They often interfere with vision by blocking out part of the vision.  For example, you may only be able to see part of a person’s face or part of a printed word.  After 15–20 minutes or so, they disappear without any permanent vision loss.      

What causes this symptom?

There are many causes of zig zag lines in the vision.  However, the most common cause is a migraine phenomenon, called a visual aura.  Migraines with visual aura may occur with or without a headache.  Often, they often follow stress by several weeks.  Migraine is a diagnosis of exclusion.  That means it is necessary to exclude or rule out other more serious causes of zig zag lines before settling with the diagnosis of migraine. 

What are more serous causes of zig zag lines in the vision?

Serious causes of may include problems in the eyes, the brain, the heart, and other medical problems.  Eye problems include retinal breaks, retinal detachment, and  inflammation in the eyes.  Brain problems include bleeding, aneurysm, seizure, and tumors.  Sometimes, zigzag lines are associated with a heart problem, such as patent foramen ovale.  In this case, a cardiologist assesses and provides treatment as needed. Rarely, blood clot problems and connective tissue disease are implicated.      

Who should I see about this problem?

The ophthalmologist (Eye MD) is equipped with the knowledge, skill, and equipment to diagnose the cause of your zig zag lines.  Sometimes, you may need to see a retinal specialist (a type of ophthalmologist with specialty education in retinal disease).  In some cases, the ophthalmologist will send you for a brain scan or to a neurologist for further care.    

What is the treatment for zig zag lines?

The treatment of zig zag lines depends on the cause.  Once the doctor excludes serious diseases, he may diagnosis migraine.  In that case, no treatment is usually necessary.  However, if the symptoms are recurrent and bothersome, the ophthalmologist will usually send you to a neurologist for assessment and possible medication.  

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Diet and Age-Related Macular Degeneration

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diet and age-related macular degeneration
anatomy of the eye (click on image to enlarge)

What is age-related macular degeneration?

A Mediterranean diet can protect against loss of vision from AMD.  But first, what is AMD?  Age-related macular degeneration (AMD) is the most common cause of visual loss in older Americans.  The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision.  The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera.  In the eye, light is focused through the lens onto the retina, which “takes the picture” and sends the image to the brain.  Macular degeneration is a disease that affects the central vision. It does not affect peripheral vision— the ability to see objects off to the side when looking straight ahead.  This means that macular degeneration alone does not result in total blindness.  

What lifestyle changes offer protection against macular degeneration?

Over the years, mounting evidence shows that lifestyle changes appear helpful to limit the risk of vision loss from age-related macular degeneration.  For example, tobacco exposure appears to worsen macular degeneration.  This means do not smoke tobacco and limit second-hand exposure to tobacco. Conversely, exercise appears to lessen the risk of vision loss from AMD.  Try to walk 20 minutes a day for starters.  Later, try to add some light weight-bearing exercises with dumbbells.  Finally, there is marginal evidence to recommend protecting your eyes from excessive sunlight.  Wear a hat and sunglasses if outdoors for several hours.  Diet is another way in which a patient may afford protection against AMD.  The Mediterranean diet is associated with reduced risk of cardiovascular disease and reduced risk of vision loss from AMD.

What is a Mediterranean diet?

The Mediterranean diet includes high intake of extra-virgin olive oil, vegetables (especially, leafy greens), fruits, cereals, nuts/legumes, moderate intake of fish and other meat, dairy products, and red wine, and low intake of eggs and sweets.   Red meats appear inflammatory.  Therefore, many recommend eating red meat only on rare occasions.  Also, avoid high intake of alcohol (greater than two alcoholic beverages per day).  Fish and seafood, on the other hand appear protective.  Try to include a serving of fatty fish like salmon at least three times a week.  If you are not a fan of seafood, consider taking coated fish oil capsules once a day.  The coated formulations help to avoid a fishy aftertaste.    

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Note: As an Amazon Associate, I may earn a small commission through the link on this page. However, you pay no increased price. The proceeds help to cover the cost of this blog. Thank you for your support.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Stop Injections for Wet AMD

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

Can I stop injections for wet AMD?

May I stop injections for wet AMD?  This is a common question.  Injections are the mainstay of treatment for wet AMD.  They reduce the risk of vision loss.  However, they are inconvenient, uncomfortable, and costly.  At first, Injections are given every month.  Over time, they may be given every few months.  Unfortunately, long term injections are usually needed to prevent loss of vision.  However, there are situations in which injections may be stopped.  

In what circumstance may injections be stopped temporarily?

In certain situations, the doctor may recommend a period of observation without injection in wet AMD.  For example, a patient may have been unable to return in a timely fashion for injection.  Upon delayed examination, the retinal specialist may find the wet AMD to be inactive.  Moving forward, injections may be held in this case.  Continued close observation is needed to detect recurrent active leakage of abnormal blood vessels in wet AMD.  

Rarely, injections may result in inflammation inside the eye.  Medication is prescribed to quell the inflammatory reaction to protect against permanent damage.  The wet AMD may become inactive in this situation and it may be observed for reactivation.  

When might the injections be stopped for the long term?

After months to years of treatment, the vision may decline despite injection therapy.  This may happen due to atrophy (loss of tissue) or scarring (fibrosis).  If the vision is very poor, injections may be stopped if it is clear that continued treatment will not improve the vision and further treatment is not necessary to prevent worsening of vision.  Furthermore, there is limited evidence that suggests injections for wet AMD may worsen dry AMD. 

What are the risks of stopping injections?

The main risk of stopping injections for wet AMD is that leaking and bleeding from abnormal blood vessels may cause further loss of vision.  This may result in a larger and/or darker central blind spot.  However, rarely it may result in total loss of vision in that eye.  

The chances of further loss of vision off injections largely depends on whether the macula has active leakage at the time injections are stopped.  In a study of 821 eyes observed for one year after stopping injection, Cornish and others found that 8% of all eyes had serious loss of vision.  However, 15% of eyes with leakage at the time injections were stopped experienced severe further loss of vision.  Therefore, if you have usable vision and wish to avoid further loss of vision, continued injections are preferable.  However, if you do not have functional vision and there is no active leakage of the macular degeneration, the risk of further profound loss of vision is low.  

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

The Smudged Contact Lens

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smudged-contact-lens
The contact lens rests on the cornea (see anatomy of the eye)

Blurred vision due to smudge on the contact lens?

There are many causes of blurred vision.  Sometimes, the eye doctor needs to update the power of the contact lens.  At other times, there may be an eye disorder that requires diagnosis and treatment by an ophthalmologist.  However, a smudged contact lens may be the problem.  To find out, remove and inspect the contact lens for a smudge.  

What are the causes of a smudge on the contact lens?

Many things may cause a smudge on the contact lens.  A factory defect is rare and the contact lens specialist usually detects damaged lenses prior to dispensing.  Makeup, creams, oils, or moisturizers on your fingers may cause the contact lens to be smudged.  A moisturizer in your hand soap may cause blurred vision by smudging the lens.  

What can be done to prevent smudges on the contact lens?

Proper contact lens maintenance and hygiene is important.  Follow all instructions given by your contact lens provider to the letter.  Make sure to wash your hands with hand detergent without moisturizers prior to inserting your contact lenses.  This is very important to keep your lenses clear and free of germs that can cause serious infection.

How do you remove a smudge from a contact lens?

The management of a smudged contact lens depends, in part, on the type of contact lens you wear.  If you use daily-wear contact lenses, it may be best to dispose of the smudged contact lens and replace it with a new lens.  When wearing lenses made to wear for longer than a day, carefully clean them daily by following the manufacturer’s recommendations. 

Rigid gas-permeable lenses are made for long-term use.  If they become smudged, gently rinse them with conditioning solution or a cleaning solution.  If this fails, an enzymatic cleaner may help.  Follow all instructions on the contact lens product recommended by your doctor.  Professional polishing is available by your contact lens provider.    

Where do I go for urgent care? 

If you have pain while wearing your contact, remove it immediately. If your eye remains blurred after you remove the contact lens, you may have a damaged cornea.  Make a prompt appointment with your eye doctor.  If you have pain or persistent foreign-body sensation (a feeling like sand in the eye), notify your eye doctor without delay.  If you are unable to contact your eye doctor and there is significant pain and/or loss of vision, report to the hospital emergency department urgently. 

By Scott E. Pautler, MD

Note:  As an Amazon Associate I may earn a small commission from qualifying purchases.  You pay no additional fees by accessing the links provided.  These funds help defray the costs of maintaining this website.  Thank you for your support.

Dome-Shaped Maculopathy

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dome-shaped maculopathy
anatomy of the eye (click on image to enlarge)

What is dome-shaped maculopathy (DSM)?

Dome-shaped maculopathy (DSM) is a type of myopic macular degeneration.  Myopic macular degeneration (MMD) is a degeneration of the center of the retina seen in some people who are myopic (near-sighted).  The cause of DSM and MMD is related to an elongation of the eye commonly seen in myopia.  MMD is not the same as age-related macular degeneration, which is a common cause of vision loss in the elderly. DSM is often mistaken for central serous retinopathy. 

What is the macula?

The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision.  The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera.  In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.  Although macular problems affect the central vision, they do not affect peripheral vision— the ability to see objects off to the side when looking straight ahead.  This means that macular problems alone do not result in total blindness.

Why is it called dome-shaped maculopathy (DSM)?

As the name suggests, in dome-shaped maculopathy, the macula assumes the shape of a dome or elevation as seen on special imaging, called optical coherence tomography (OCT).  A dome-shaped macula is the result of the eye attempting to keep the eye focused at near.  The elongation of the eye may result in an irregular eye shape, including a dome or ridge shape.

In the sketch above, A represents the normal eye. B shows how the eye is elongated in near-sighteness (myopia). C and D show a focal out-pouching at the back of the eye. This out pouching is called a staphyloma. At the edge of the staphyloma (green arrowhead), the tissues inside the eye are stretched. This area appears as a dome on retinal imaging.

What causes fluid leakage under the retina in DSM?

 A dome-shaped macula may cause an abnormal leakage of clear fluid under the macula, which causes symptoms of blurred vision often associated with distortion or a round/oval dark spot in the central vision.  Other factors may aggravate the situation and contribute to a leakage of fluid beneath the macula.  Research suggests that hormones released under stress can affect the blood vessels beneath the retina. These vessels may leak an abnormal amount of fluid, which then works its way under the center of the retina. Sometimes, medical conditions (Cushing’s Syndrome, pheochromocytoma, sleep apnea), medications (pseudephedrine, prednisone, cold medication, diet pills, and medications for erectile dysfunction), and other agents (testosterone, cocaine, caffeine, amphetamines, etc.) may contribute to the development of leakage.

What is the treatment of DSM?

There is no universally effective treatment.  In some cases, the symptoms will disappear with time. Over a period of weeks to months, the abnormal leakage may stop with normal healing. In other situations, treatment may be needed to recover vision. Prescription medication (spironolactone or diamox) may be helpful if fluid leakage does not go away with time alone. Sometimes, eye drops can help. Other treatment that have been tried without uniform success include thermal laser photocoagulation, Visudyne photodynamic therapy (PDT), and medicine injections. The doctor can recommend the best course of action by taking special pictures of the eye called a fluorescein angiogram. The fluorescein angiogram shows where the leak is coming from, how active the leak is, and whether laser might be helpful. Optical coherence tomography (with and without angiography) may also be helpful to guide treatment.

In rare situations, blood vessels grow beneath the retina from the choroid (choroidal neovascularization, CNV).  When CNV is detected by fluorescein angiography or by optical coherence tomography, antiVEGF injections are the first time of treatment. 

What will happen to my vision?

Over a period of months to a few years, the vision may remain normal or near normal under observation without treatment. Sometimes over time, dome-shaped maculopathy may cause permanent loss of central vision.  More aggressive treatment may be considered in cases of persistent fluid leakage causing progressive loss of vision.  

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Visual Hallucinations and the Eye

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What are visual hallucinations?

A visual hallucination is the perception of a visual image that is not the result of seeing an object outside the eye. Normally, the eye perceives light from objects outside the eye and sends the image to the brain for interpretation. However, there are a number of circumstances that result in images being “seen” by a patient that do not originate from outside the eye.  These images are referred to as hallucinations, especially if they appear as formed images of recognizable objects, like faces, trees, or other familiar things.  Sometimes, hallucinations appear as dots, lines, or geometric shapes.  The hallucinations may be in color or black and white.     

What causes hallucinations?

A large list of problems may cause visual hallucinations.  These include drug use and abuse, delirium, mental illness, and a variety of neurological conditions (including stroke, multiple sclerosis, and dementia).  Sometimes, eye disease causes visual hallucinations; this is called the Charles Bonnet syndrome.  It is a common condition in which the brain “makes up images” as a result of loss of vision from an eye condition (such as macular degeneration, diabetic retinopathy, or glaucoma).  Charles Bonnet was an 18th century botanist and philosopher who described complex visual hallucinations in his grandfather after loss of vision.  

How can a doctor find the underlying cause of visual hallucinations?

A doctor may determine the cause of visual hallucinations by careful examination and testing.  If the hallucinations are interpreted by the patient as being “real,” the cause is more likely related to mental illness or may be due to drug intoxication or neurological disease.  In these cases, the mental status exam is usually not normal.  In the Charles Bonnet syndrome, the patient knows what he is seeing is not real, but sees the images nonetheless.  An eye exam may make the diagnosis, but in some cases, further testing is needed.  And these may include blood tests and imaging studies (CT scan and/or MRI brain scan). The final diagnosis of Charles Bonnet syndrome is made only after other more serious diagnoses are excluded.   

What is the treatment of visual hallucinations?

The treatment depends on the underlying cause.  In the case of the Charles Bonnet syndrome, 
counseling may help. Much relief comes from knowing that the symptoms are benign and do not represent a serious medical condition.  Some patients find the symptoms improve if they move their eyes up-and-down, or left-and-right, or look away from the hallucinations.  Others find it helps to stare at the hallucination until it fades away.  It may help to talk about the hallucination with a family member or friend.  Because stress and fatigue may precipitate the hallucinations, some recommend getting plenty of sleep and rest.  Exercise and meditation are helpful.  Thankfully, the visual hallucinations from Charles Bonnet syndrome often subside with time and may disappear over months to years.  Rarely, medication may be prescribed by a neurologist.  New treatments are on the horizon. 

Related blog: The Visual Snow Syndrome   

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Central Retinal Vein Occlusion

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

What is a central retinal vein occlusion (CRVO)?

Retinal vein occlusion means blockage of a vein in the retina.  A central retinal vein occlusion is a blockage of the main (central) vein on the retina. The retina in your eye is like the film inside a camera.  The retina “takes the picture” of objects you look at and sends the message to the brain.  The retina is a living tissue, which requires blood supplied by tiny vessels.  Retinal veins are blood vessels that drain blood from the retina. The veins form as branches that drain sections of the retina.  The branch veins all drain into the central retinal vein that exists the eye with the optic nerve.  An abnormal blood clot in a retinal vein causes a blockage (occlusion) of the blood flowing out of the retina.

Who is at risk of a central retinal vein occlusion?

Retinal vein occlusions are more common in people who have risk factors for hardening of the arteries, which may compress the veins where they come in contact in the retina.  Hardening of the arteries (arteriolar sclerosis) occurs in people who are overweight, use tobacco, or have diabetes, high blood pressure, or sleep apnea.  Glaucoma is also a risk factor as intraocular pressure spikes affect blood flow in the retinal veins, and slow blood flow promotes blood clots.  There are a number of blood disorders that may play a role in CRVO, especially in younger individuals.  Estrogens may increase coagulation of the blood and lead to CRVO. Less commonly, inflammation may cause retinal vein occlusion.  

What are the symptoms of a central retinal vein occlusion?

Blurring of vision may occur if excess fluid (edema) leaks from the veins into the center of the retina.  Floaters can look like tiny dots or cobwebs moving about in your vision.  They may be due to bleeding from the retina into the central gel (vitreous) of the eye.  Pain is rare and may be due to high pressure in the eye (neovascular glaucoma).

What treatment is available?

There is no cure, but treatment may improve vision or keep the vision from worsening.  Your doctor may allow time for the vein to heal, but this is rarely advisable if the vision is impaired.  Medicine injections may help recover vision and may be given with little discomfort.  The vision may not return to normal following treatment as there may be some permanent damage to the retina from the occlusion.  Injections must be repeated in order to maintain vision.  Over time, the retina does heal to some degree.  However, after three years of treatment about half of eyes continue to require injections.  In some cases when treatment cannot improve the vision, laser is used to prevent severe pain and complete blindness. Your doctor is going to order appropriate tests and recommend the best course of action to take at this time.  The retinal vein occlusion will not be worsened by your daily activities or by using your eyes. 

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

The Use of Steroids in Endophthalmitis

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the use of steroids in endophthalmitis

Why use steroids in endophthalmitis?

Ophthalmologists often consider the use of steroids in endophthalmitis treatment. Steroids reduce inflammation in endophthalmitis.  The decrease in inflammation helps improve comfort and potentially reduces inflammatory tissue damage, such as scarring.  Although it is key to treat with appropriate antibiotics for infectious endophthalmitis, topical steroids (steroid eye drops) are included in the therapeutic regimen. The physician orders the steroid eye drops frequently at the onset and monitors inflammation and eye pressure to determine the best treatment schedule. 

What is the role of intravitreal steroid injections?

The role of intravitreal steroids (dexamethasone) is controversial.  In a recent review and meta-analysis of endophthalmitis, there was no added benefit with the use of intravitreal dexamethasone.  The reason for lack of benefit may include the short half-life of intravitreal dexamethasone (<3 hours).  Nonetheless, there may be benefit derived from the use of intravitreal dexamethasone in severe bacterial infections such as those caused by Bacillus species.  

What about other ways to give steroids?

In select cases there may also be a role for periocular or systemic steroids for a more prolonged steroid effect. Periocular steroids require an injection next to the eye. My preferred technique is a subtenant’s injection as described by Nozik because it is fairly pain-free. Systemic steroids are given as a pill. There are potential side-effects to the use of steroids. With steroid injections come the risk of elevation of eye pressure, which may cause glaucoma. Many side effects may occur with steroid pills including depression, high blood sugar, weight gain, brittle bones, acne, stomach ulcers, and others. Usually side-effects are preventable or treatable. The final decision of how and when to use steroids lies with the treating physician based on the circumstances of the case.   

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright 2023. Designs Unlimited of Florida. All Rights Reserved.

Laser for Central Serous Retinopathy

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anatomy of the eye (click on image to enlarge)

What is central serous retinopathy?

Before we discuss laser for central serous retinopathy, we must ask what is central sero retinopathy. Central serous retinopathy (CSR) is an eye condition associated with loss of vision from water (serous) leakage from the choroid beneath the macula (central retina).  Although it may be seen at any age, it is most common among young adult males.  The leakage may be initiated by emotional stress and aggravating factors include stimulants (caffeine, cocaine, amphetamines), steroids (cortisone, prednisone, testosterone and other androgens), lack of sleep (sleep apnea), over-the-counter dietary supplements (niacin, body-builders), prescription medications (possibly Viagra and related meds), and medical conditions (Cushing’s syndrome, pheochromocytoma).      

What treatment is available?

The first line of treatment is identification and elimination of any factors that are suspected to aggravate CSR.  However, if leakage persists, there are a number of treatments that may be helpful. These include a special class of oral diuretics, antiVEGF injections, and lasers.  Although thermal lasers may be used in selected cases, often cold lasers are preferred.

How do cold lasers (PDT) work?

Verteporfin photodynamic therapy (PDT) is the cold laser used in ophthalmology for the treatment of retinal problems.  It is called “cold” because it does not use heat to cauterize tissue.  Verteporfin dye is injected into the vein of the arm after which a laser is aimed into the eye to activate the dye.  The activated dye releases highly reactive oxygen radicals, which chemically seal the leaking blood vessels under the retina.  PDT is very effective in treating CSR.  It is expensive and sometimes not covered by private insurance.  PDT rarely causes a blind spot in the vision and this risk is minimized by using a low dose of Verteporfin or low power laser (reduced fluence).  After PDT treatment has been completed, it is important to avoid direct sunlight (or exposure to halogen light) for 48 hours to allow time for the Verteporfin to leave the body. 

Below are the photos of a 49-year-old man who had blurred vision and some distortion in his left eye for a year.  His condition did not improve after a trial off caffeine.  He had no medical problems and no other inciting factors were identified.  

Color photos revealed some white changes in the retina (arrow) due to permanent degeneration of the retina near center of vision (fovea) due to longstanding leakage. Fundus autofluorescence photos are even more sensitive in showing this damage.  

OCT (above) shows fluid under the retina (between the retina and the retinal pigment epithelium).  

FA/ICGA photos (above) show the site of active leakage under the retina.  Because of the lack of improvement with medical therapy and the threat of permanent loss of central vision due to long-standing leakage, this patient underwent reduce-fluence PDT.  He experienced no adverse effects of laser and his vision returned to 20/20 over several months’ time.  

The OCT above shows resolved subretinal fluid one month after PDT.    

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida. All rights reserved.

Choroidal Macrovessel

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Choroidal macrovessel is the term currently used for a rare choroidal vascular abnormality that may present as a small choroidal mass with or without symptoms.  It usually appears as a dilated, tortuous choroidal vessel beneath the temporal macula and may extend to the periphery. A dilation of the posterior ampulla may elevate the overlying retina (see OCT image below) and cause secondary changes in the retinal pigment epithelium, rarely with subretinal fluid.  Choroidal macrovessel is usually diagnosed during adulthood with a female predilection.  There is no known associated systemic vascular abnormality.

Another term that may be somewhat more specific for this condition is posterior aneurysmal choroidal varix. An aneurysmal varix is a markedly dilated and tortuous vessel, sometimes used to describe a dilated vascular channel due to a direct communication of an artery and a vein. In the example below, there appeared to be a direct communication between a short posterior choroidal artery and a choroidal vein (Haller vein) as seen on ICG angiography where there was early filling of the lesion in the arterial phase. On the color photo, the prominence of the lesion diminishes in appearance as the vessels track toward the vortex outflow. This is likely due to numerous collateral venous channels that are known to exist, which allows for a reduction in blood flow and intraluminal pressure. Thus, the peripheral choroidal venous channels appear unremarkable.

The most helpful diagnostic tests include optical coherence tomography (OCT) and indocyanine green angiography (ICGA).  OCT shows a small hyporeflective choroidal mass temporal to the fovea.  There may be disruption of the outer retinal bands and/or subretinal fluid.  ICGA shows early filling of the prominently dilated and tortuous choroidal vessel.  

As choroidal macrovessels are usually asymptomatic, no treatment is needed.  Their importance is primarily to differentiate them from tumors.  Rarely, they cause disruption of retinal pigment epithelium resulting in simulated “tracks”, which may be confused for ophthalmomyiasis (subretinal larva). 

By Scott E Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright © 2023 Designs Unlimited of Florida.  All Rights Reserved.

HTLV1-Associated Uveitis

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HTLV1-associated uveitis
Anatomy of the eye (click on image to enlarge)

What is HTLV1?

HTLV1 is a virus that causes HTLV1-associated uveitis. It is an abbreviation for human T-lymphotropic virus type 1.  First isolated in 1980, HTLV1 belongs to the retrovirus group that also includes the virus that causes HIV/AIDS.  Retroviruses are called “retro” because they use a pathway to reproduce that is the reverse of what most organisms use.  The genetic map of retroviruses is RNA, which is converted inside host cells to DNA by a special enzyme (reverse transcriptase).  The host cell is then directed to produce more virus particles.  HTLV1 is called “lymphotropic” because it tends to infect lymphocytes, which are a type of white blood cell involved with immunity (see Legrand).  

How and where do you get exposed to HTLV1?

Because most people with HTLV1 infection remain without symptoms, they carry the virus and spread it to others by sexual contact (semen), shared blood (e.g. IV drug-shared needles, organ transplantation), and by breast milk.  HTLV1 is found in most frequently in people from Brazil, Japan, sub-Saharan Africa, Honduras, Iran and the Caribbean islands.  However, due to international travel, HTLV1 may be found anywhere in the world.

What problems does HTLV1 cause?

Many people who are exposed to HTLV1 develop no symptoms. However, because HTLV1 affects white blood cells, it may cause autoimmune conditions, as well as blood cancer. For example, autoimmune conditions include seborrheic dermatitis (infective rash), paralysis (tropical spastic paresis), and uveitis (see Schierhout). Examples of blood cancer include T-cell lymphoma and leukemia.

What is Uveitis?

Uveitis (pronounced, “you-vee-EYE-tis”) is a general term used to describe inflammation inside the eye.  The uvea is the name given to the layer of tissue in the eye that has a brown color (melanin pigment) and blood vessels, which serve to provide blood supply and protect the eye from excessive light.  The uvea can be divided into separate parts, which perform different functions in the eye: the iris, the ciliary body, the pars plana, and the choroid (see anatomy of the eye).  Therefore, in any one patient uveitis is usually given a more specific name depending on where most of the inflammation is located in the eye. Sometimes, uveitis affects tissues not considered a part of the uvea.

What type of uveitis is most common with HTLV1?

Intermediate uveitis is the most common type of uveitis caused by HTLV1. In intermediate uveitis the inflammation mainly centers in the vitreous gel (the clear gel that fills the eye). This type of uvetiis is called intermediate because it affects the middle or intermediate part of the eye. That is, the vitreous gel fills the eye and is located in an intermediate position between the front and the back of the eye. Vitritis and pars planitis are other names for intermediate uveitis.    

Who is most likely to develop HTLV1-associated uveitis (HAU)?

The age group most likely to be affected by HAU is between 20-49 years; however, any age group may develop HAU (see Mochizuki).  Female are affected by HAU twice as often as males (see Takahashi).  It appears that the eye inflammation (uveitis) is caused by the effect of HTLV1 infection on the behavior of white blood cells (lymphocytes), rendering them more likely to mistakenly attack the eye (see Mochizuki).  HAU may occur with or without other ocular inflammatory conditions, such as thyroid eye disease (see Nakao). Likewise, HAU may occur with or without non-ocular HTLV1-associated conditions, such as paralysis, rash, or blood cancer. 

What are the symptoms of HTLV1-associated uveitis (HAU)?

The most common symptoms include tiny floating spots which move or “float” in the vision.  They are usually numerous and may cause a veil-like appearance in the vision.  Sometimes blind spots, blurred vision, distortion, or loss of side vision occurs. The eye may be painful, red, tearing, and light sensitive if other parts of the eye are also inflamed (5-10% of cases).  Symptoms may be mild or they may be severe and disabling.  Only one eye is affected in about half of all cases of HAU (see Takahshi).

How is HTLV1-associated uveitis (HAU) diagnosed?

Diagnosis can be difficult.  Blood tests are performed to identify HTLV1 infection in patients with findings that suggest HAU.  One FDA-approved test is produced by MP Biomedicals Diagnostics: HTLV blot 2.4 (EIA).  Sometimes, accurate diagnosis requires multiple tests.  

How is HTLV1-associated uveitis (HAU) managed?

There is no cure for HTLV1 infection.  To limit the damage from inflammation, HAU is treated with anti-inflammatory medication in the form of eye drops, injections, or pills.  When pills are used, the eye doctor may coordinate medical care with the expert assistance of a rheumatologist.  Rarely, surgery is required to treat uveitis.  Episodes of inflammation may last from weeks to many years.  HAU is a serious eye problem and may result in loss of vision (see Takahashi).  However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized.  Most people with HAU keep good vision (See Nakao).  In some cases, HAU may go away, but return at a future date in about 50% of cases (see Takahashi).  Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact your doctor. 

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023 Designs Unlimited of Florida.  All Rights Reserved.

Reduce the Risk of Wet AMD from Syfovre

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how to reduce the risk of wet AMD from Syfovre
anatomy of the eye (click on image to enlarge)

What is Syfovre?

Before talking about how to reduce the risk of wet AMD from Syfovre, we must learn about AMD and Syfovre. Syfovre is the first FDA-approved treatment to reduce the risk of losing vision from dry age-related macular degeneration (AMD) due to geographic atrophy.  In the phase 2 study, eyes treated by monthly injection of Syfovre showed a reduction in the rate of progression of 29%.  It is important to note that Syfovre does not reverse past damage from dry AMD, and it is not a cure for dry AMD.  

Does Syfovre increase the risk of wet AMD?

A major concern of treatment is the adverse effect of new wet AMD developing in eyes treated with Syfovre.  Wet AMD is another form of advanced AMD in which abnormal blood vessels start to grow under the center of the retina (the macula).  The abnormal vessels in wet AMD will cause a large central blind spot in the vision unless treated with regular injections of antiVEGF medicines.  Among eyes treated with Syfovre in the phase 2 study, 20.9% of treated eyes developed new wet AMD compared with 1.2% of eyes in the study who did not receive this treatment.  Therefore, in an effort to prevent loss of vision from dry AMD, Syfovre raises the risk of vision loss from new wet AMD. 

How can we reduce the risk of wet AMD in eyes treated with Syfovre?

There are several things to consider that may be helpful in reducing risk.  Table 1 shows the effect of avoiding the use of Syfovre in eyes whose fellow eye already has wet AMD.  This is a risk factor for developing wet AMD in the second eye.  The risk of the second eye developing wet AMD appears to be further increased with the use of Syfovre.  Among eyes undergoing monthly Syfovre injection, the risk of new wet AMD is reduced to 12% compared with 20.9% of all study eyes and 33.3% of eyes with wet AMD in the fellow eye.  Similarly, in eyes undergoing Syfovre injection every other month, the risk of new wet AMD is reduced to 3.9% compared with 8.9% of all study eyes and 17.9% of eyes with wet AMD in the fellow eye.  Therefore, patients who already have one eye with wet AMD may wish to reduce their risk of developing wet AMD in their second eye by avoiding the use of Syfovre.

Table 1: FILLY phase 2 study: New wet AMD among study eyes. Studying the effect of wet AMD in the fellow eye

ParametersSham (no drug)Monthly drug injectionEvery other Month drug injection
All study eyes1.2%20.9%8.9%
Fellow wAMD0%33.3%17.9%
No fellow wAMD1.9%12%3.9%
Eyes without wet AMD in the fellow eye had lower rates of wet AMD (wAMD) among treated eyes.

Table 2 (below) shows the difference among study eyes with and without a known risk factor for developing wet AMD…the double layer sign (DLS).  The risk of an eye with DLS in developing wet AMD appears to be further increased with the use of Syfovre.  Therefore, among eyes undergoing monthly Syfovre injection, the risk of new wet AMD is reduced to 13.3% among eyes without the DLS compared with 20.9% of all study eyes and 30% of eyes with the double layer sign.  Similarly, in eyes undergoing Syfovre injection every other month, the risk of new wet AMD is reduced to 2% among eyes without the DLS compared with 8.9% of all study eyes and 17.9% of eyes with DLS.  Therefore, patients who have the double layer sign may wish to reduce their risk of developing wet AMD by avoiding the use of Syfovre.  

Table 2: FILLY phase 2 study: New wet AMD among study eyes. Studying the effect of the double layer sign (DLS) which elevates the risk of wet AMD

ParametersSham (no drug)Monthly drug injectionEvery other Month drug injection
All study eyes1.2%20.9%8.9%
DLS present4.2%30%24%
DLS absent0%13.3%2%
Eyes without the double layer sign (DLS) had lower rates of wet AMD among treated eyes.

Comments on the use of Syfovre:

Studies show that It may take over two years of treatment in order to see a benefit in vision. Patient selection may reduce the risk of new wet AMD in treated eyes.  However, patient selection alone will not reduce the risk of other adverse effects including inflammation, infection, hemorrhage, retinal detachment, and ischemic optic neuropathy.  Further risk reduction may be possible by reducing treatment frequency from monthly to every other month, but this reduces the effectiveness of the treatment in slowing the rate of progression of GA from 29% to 20%.  Careful assessment is warranted for each patient to determine if the benefits of Syfovre outweigh the potential risks.

By Scott E. Pautler

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida.

Copyright  © 2023. Designs Unlimited of Florida. All Rights Reserved.