Scott E. Pautler, M.D. Tampa

Treatment of diseases of the retina and vitreous

Vuity Eye Drops for Near Vision

Posted on December 20, 2021 by Scott Pautler

Eye Anatomy. Image courtesy of Caitlin Albritton.

What is Vuity?

Vuity is a new eye drop to improve near vision in mature adults and is available with a prescription. It became available with FDA approval in 2021. The generic name for Vuity is pilocarpine, a drug used for years to treat some types of glaucoma.

How does Vuity work?

Vuity works by causing the pupil to constrict. The pupil is the small black opening in the center of the iris (the colored part of the eye, usually blue or brown). When the pupil constricts it provides a greater depth of field just like a camera with a small aperture. Vuity also constricts the ciliary muscle inside the eye. This is the muscle that normally focuses the eye from distance to near.

What did the studies of Vuity show?

Gemini I and II were studies to prove the benefit of Vuity. Between the two studies a total of 375 patients were treated. One hour after instilling Vuity, about 26% more patients on Vuity had an improvement in near vision (three lines on the eye chart) compared with patients given a placebo. This suggests that a majority of patients may experience less of an effect. Vuity likely provides a modest short-term effect with minimal risk to most people making it of marginal value (cost/benefit ratio).

How do you use Vuity?

Apply a drop of Vuity to each eye in the morning. The drop takes affect within an hour and slowly loses its effect over 6-10 hours. If Vuity is used more than once a day, it is more likely to cause side effects.

What are the adverse effects of Vuity?

Vuity should not be used by anyone with an allergy to pilocarpine. It should also be avoided in people prone to iritis. Some patients notice poor vision at night while using Vuity; this is especially true if it is used after noon or in eyes with cataract. Therefore, caution may be needed while driving at night. Sometimes, patients experience accommodative spasm in which they have trouble focusing from near to distance. A brow ache may occur when the drop is started, but usually subsides over time with continued use of Vuity. Little is known about the safety of Vuity in pregnancy and during breast feeding. If you use soft contact lenses, they should be removed before instilling Vuity. They may be placed back in the eye after 10 minutes. Use Vuity at least 5 minutes apart from other eye drops you use for other conditions. Very rare adverse effects from Vuity may include acute angle-closure glaucoma and retinal detachment. Therefore, the following symptoms should be reported promptly: new flashes and/or floaters, any loss of vision (including loss of side vision), pain, or significant redness.

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 with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Retinitis Pigmentosa

Posted on October 7, 2021 by Scott Pautler

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

What is retinitis pigmentosa?

Retinitis pigmentosa is a group of inherited problems of the retina. 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. Retinitis pigmentosa especially affects the peripheral part of the retina where there are many rod-shaped cells that normally provide side vision and night vision. In advanced cases it may also affect the sharp, central, reading vision and color vision.

What causes retinitis pigmentosa?

Retinitis pigmentosa is inherited through a variety of different genes. Because it is hereditary, other members of the family may have retinitis pigmentosa. However, sometimes the symptoms are mild and special testing is required. At other times the abnormal gene that causes retinitis pigmentosa may skip several generations. In these families no other members can be found to have the problem.

What are the symptoms of retinitis pigmentosa?

Retinitis pigmentosa may cause no symptoms in the early stages. And symptoms may begin early or late in life. Initially, night vision is impaired. This makes it difficult to walk in unfamiliar surroundings in dim illumination. When the peripheral vision (side vision) is affected, an individual with retinitis pigmentosa may accidentally bump into things that are not directly in view. The severity of these symptoms slowly progresses over years and may impair safe driving vision or result in legal blindness. The rate of progression tends to be consistent in each family affected. Therefore, older family members may be able to provide useful information to younger family members. Late in the course of retinitis pigmentosa, the central vision and color vision may be affected. Make a point to have trusted family and friends help to monitor your ability to drive safely and ask your doctor annually if you have sufficient vision to drive legally.

How is retinitis pigmentosa diagnosed?

The symptoms listed above may be the first clue to the diagnosis. A routine dilated eye examination can detect the retinal changes of retinitis pigmentosa. In some cases, a fluorescein angiogram is helpful. In this procedure the ophthalmologist injects a dye into the vein of the arm. Special photographs are taken of the eye, which show the degeneration of the retina. An electroretinogram (ERG) is also used to demonstrate faint electrical abnormalities in retinal function. In this test, electrodes are taped to the head and to contact lenses. A computer magnifies the electrical impulses generated by the retina in response to carefully programmed flashing lights. Finally, genetic testing may be considered in order to identify a specific gene variant that may be responsible for causing the problem. This may be important in confirming the diagnosis, genetic counseling, and treatment. Blueprint genetics offers free testing for US residents.

How is retinitis pigmentosa treated?

There is currently no proven treatment for most forms of retinitis pigmentosa. Although vitamins have been studied extensively, there is no proof that they are effective and some vitamins (vitamin E) may be harmful when used at high dosages. One type of retinitis pigmentosa is caused by a gene called RPE65. Patients with this gene variant may undergo gene therapy to treat this type of retinitis pigmentosa. Future research offers the hope of treatment of additional genes that cause retinitis pigmentosa. A mouth swab may be sent for free gene testing.

A wide range of support services, rehabilitation programs, and devices are available to help people with retinitis pigmentosa continue with many of their favorite activities. The use of a white cane can be a valuable aid in navigating in unfamiliar surroundings. It also serves to notify other people to be more courteous. The Lighthouse for the Blind and the Watson Center have classes and specialists in providing prescription lenses to magnify printed material. The Argus II Retinal Implant was approved by the FDA in 2013 for patients with very severe loss of vision from retinitis pigmentosa. The Division of Blind Services provides rehabilitation services and financial aid for eye care in selected cases. Your doctor can give free access to the “talking book” library to make “books on tape” available. A form is available from your doctor that establishes legal blindness to be used for property tax and income tax deductions. As always, if you have any questions please do not hesitate to contact your doctor for more information.

By Scott E. Pautler, MD

DNA And Your Privacy

Posted on September 30, 2021 by Scott Pautler

What is the unlawful use of DNA?

In 2021 the Florida legislature passed a law (House Bill 833) that makes it unlawful to collect tissue for DNA testing without the “express consent” of the patient. It is also unlawful to share the results of DNA testing without consent. We applaud the patient protection this law was intended to offer. This law applies to physicians, but exempts the state and federal governments.

What is DNA and why is it important?

DNA stands for deoxyribonucleic acid, which is the chemical name for the blueprint or road map each of your cells contain. Your unique DNA defines who you are and what medical conditions you either currently have or are predisposed to having in the future. This information is important for your doctor to care for you. However, because this information is personal, the results of DNA testing must be protected against misuse.

What type of DNA information is included in this law?

This new law includes many different situations. For example, it may be obvious that tissue samples (including saliva or cheek swabs) may be sent to a laboratory specifically for DNA analysis (as in retinitis pigmentosa) to identify medical conditions that require diagnosis and treatment for the benefit of the patient. However, the law also includes testing for tissue proteins that reveal part of the underlying DNA blueprint of your cells. For example, HLA testing is often performed to diagnose the cause of inflammation in the eyes. HLA markers are not DNA, but are proteins on the cell surface that are used to identify patients at risk for certain medical conditions.

How does this law impact you and your doctor?

We wish to comply with the new law and protect your privacy. As such, when you register as a new patient, we may ask for your express consent to share your DNA information obtained either in our office or received from another office or laboratory. We only share personal health information with your doctors or anyone else you specify. We will also ask for your express consent before collecting tissue for DNA tests.

By Scott E. Pautler, MD

Tea Tree Oil for the Eyelid

Posted on August 29, 2021 by Scott Pautler

What is tea tree oil and how is it helpful?

Tea tree oil is an essential oil extracted from the leaves of the Australian tea tree, Melaleuca alternifolia. Tea tree oil has important anti-inflammatory and anti-microbial properties. It is effective against many different micro-organisms that can infect the eye (see reference).

How does tea tree oil improve the health of the eyelid?

Tea tree oil appears to help prevent the overgrowth of germs on the eyelid, which leads to blepharitis. Blepharitis is a common eyelid condition that causes symptoms of redness, irritation, itching, burning, and dry-eye symptoms. There are many ways to treat blepharitis and tea tree oil is becoming an important tool to reduce inflammation and infection by bacteria, fungi, and mites.

What evidence is there that tea tree oil works?
Tea tree oil has been studied in the treatment of blepharitis with very positive reports. However, high-level scientific evidence is lacking (see reference). I suspect the reason for this lack of evidence is the high cost of the studies rather than the effectiveness of tea tree oil. It takes large sums of money to complete the scientific trials required by the FDA and there is no corporate financial incentive to fund a large, randomized trial. In the meantime, low-cost tea tree oil is available for use without a prescription.

What preparations are available?

Tea tree is available as moist lid wipes, drops, and cleansing washes (see tables below). Follow the directions on each formulation. To keep the tea tree oil fresh, effective, and safe, store it in a cool, dark place (drawer or cupboard) with the lid securely attached.

What side-effects may occur?

Sometimes, a sensitivity reaction may occur with tea tree oil. Stop using tea tree oil, if your skin or eyes develop pain, redness, and/or itching. See an ophthalmologist as soon as possible for evaluation. Sensitivity reactions may occur more commonly with older, out-of-date tea tree oil, as well as with products with higher-concentrations of tea tree oil.

What brands are available?

The tables below serve as a reference list primarily for cost comparison. The various products have not been compared in a clinical study. Some contain ingredients in addition to tree tea oil. Review the product information, especially if you have known sensitivities. If you wear lash extensions, the oil in some of these products (including tea tree oil itself) may loosen the attachment of the extensions. Lash extensions are not recommended for patients with significant blepharitis.

Tea Tree Oil Products for Blepharitis
(Listed in order of least to most expensive per unit application)
Names of Lid Wipes	concen- tration	price as of (4-2021)	price/wipe	application
Dr Fischer Eyelid Wipes	unknown	$15.95	$ 0.53	wipes
Premium Eyelid Wipes	unknown	$22.95	$ 0.77	wipes
MediViz Eyelid Wipes	unknown	$24.97	$ 0.83	wipes
Optase Lid Wipes	unknown	$18.95	$ 0.95	wipes
Cliradex Eyelid Wipes	unknown	$39.42	$ 1.64	wipes

Names of Cleansers	concentration	price (4-2021)	price/ounce	application
Gentle Formula cleanser	1%	$ 15.00	$ 8.88	pump spray
Ocusoft Demodex cleanser	unknown	$ 18.17	$ 10.75	foam wash
Eye Eco Adv Formula	2%	$ 20.00	$ 11.83	pump spray
Heyedrate Foaming wash	<1%	$ 19.97	$ 11.95	foam wash
Cliradex Foam	unknown	$ 29.99	$ 19.99	foam cleanser
We Love Eyes	unknown	$ 24.00	$ 24.00	drops for Qtip

Check current prices via the links provided. This blog is supported by its readers and may earn commissions which do not increase the price to you and do not affect the content of this review article.

By Scott E. Pautler, MD

Diabetic Vitreous Hemorrhage

Posted on July 22, 2021 by Scott Pautler

What is diabetic vitreous hemorrhage?

Diabetic vitreous hemorrhage means blood has leaked into the vitreous gel of the eye as a result of diabetic damage. The vitreous is a clear gel that fills the center of the eye and helps to hold the retina in place against the eye-wall like wallpaper in a room. The retina is a thin layer of delicate nerve tissue, which acts like film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. The retina has many fine blood vessels that may become damaged from diabetes leading to bleeding into the vitreous. Blood in the vitreous (vitreous hemorrhage) interferes with vision.

What symptoms does diabetic vitreous hemorrhage cause?

Diabetic vitreous hemorrhage usually causes many new floaters in the vision. Floaters may appear as round specks, hair-like or bug-like debris, or clouds moving in your vision as though they were in front of your eye. They are more noticeable when looking at a blank surface and may interfere with the good vision in the fellow eye. If vitreous hemorrhage is severe, the vision may be severely limited. Patients may only see shadows or light, but no details.

Flashes are brief streaks of light that are usually seen off to the side, especially at night when you turn your head or eyes. Flashes are caused by vitreous gel pulling on the retina with eye movement. They may be seen in the setting of diabetic vitreous hemorrhage, but are not worrisome in themselves.

Although many people have occasional floaters or flashes of light, the sudden onset of many new floaters with or without flashes is an important sign of abnormal pulling on the retina by the vitreous. In some people with these symptoms, the retina may tear and detach resulting in loss of vision. Therefore, these new symptoms warrant prompt evaluation.

What causes diabetic vitreous hemorrhage?

Diabetes can cause vitreous hemorrhage by weakening the blood vessels in the retina and by causing the vitreous gel to shrink and pull on the retinal vessels. Aging also causes changes in the vitreous gel and can cause it to pull on the retina. In any given patient with diabetes, both weakened retinal blood vessels, as well as tugging on the blood vessels from the vitreous play a role in causing vitreous hemorrhage. However, in some eyes weakened blood vessels may be the main reason and in other eyes the main reason for bleeding may be tugging from the vitreous. This is an important issue as diabetic vitreous hemorrhage may be treated differently depending on its underlying cause.

How is diabetic vitreous hemorrhage treated?

The most important step is to have a thorough eye examination with ultrasonography. The ultrasound machine uses sound waves to safely and effectively “look through” the blood in the vitreous to see if the retina is attached. If a retinal detachment is found, surgery is required in an attempt to repair it. If no retinal detachment is found on ultrasound exam, your doctor may allow the vitreous hemorrhage to clear on its own with time. The ultrasound exam may be repeated periodically to assure the retina remains attached. If the hemorrhage does not clear on its own, vitrectomy surgery as a one-day surgery in the hospital operating room may be considered. The amount of visual return depends on several factors including the health of the underlying retina.

In an effort to prevent additional bleeding, the underlying diabetic retinopathy may be treated with medication injections (e.g. Avastin, Lucentis, or Eylea) into the eye. These injections can usually be given without significant pain by using anesthetics. The injections reduce the risk of future bleeding, but do not hasten the clearing of the bleeding that has already occurred. These medication injections may be especially important if no previous laser (or insufficient laser) has been given for diabetic retinal damage (diabetic retinopathy) prior to the vitreous hemorrhage. Medication injections do not help with tugging on the retinal blood vessels by the vitreous. Indeed, in rare cases the injections may increase the tugging. Therefore, if tugging from the vitreous is determined to be the main factor in causing the diabetic vitreous hemorrhage, injections may not be used. Instead, vitrectomy surgery is more effective at relieving the tugging.

Once the vitreous hemorrhage has cleared over time with observation or with vitrectomy surgery, laser is often used to stabilize the retinal blood vessels that have been weakened from diabetes. This helps reduce the chances of reoccurrence of vitreous hemorrhage in the future.

What should I be on the lookout for?

After examination or treatment for a vitreous hemorrhage, you should notify your doctor if you have a burst of new floaters, a loss of side vision, or pain. Sometimes, retinal tears or a retinal detachment occur at a later date after the examination.

By Scott E. Pautler, MD

Neovascular Glaucoma

Posted on June 11, 2021 by Scott Pautler

What is neovascular glaucoma (NVG)?

Neovascular glaucoma (NVG) is a severe type of glaucoma. Glaucoma is a condition in which the pressure inside the eye damages the cells of the optic nerve. The normal range of pressure in the eye is between 8-21 units of measurement. There is a tissue inside the eye called the ciliary body that pumps a clear fluid (aqueous) into the eye keeping the eye from collapsing. Another tissue called the trabecular meshwork drains the aqueous from the eye preventing the pressure from building up too high. The pump and the drain are not connected and do not communicate with each other. However, there is a normal balance between the pump and drain so that the eye pressure remains normal and healthy for the eye. In neovascular glaucoma (NVG) abnormal blood vessels grow inside the eye where they block the drain resulting in high pressure. High pressure inside the eye damages the cells of the optic nerve. The optic nerve transmits information from the eye to the brain to provide vision. Therefore, NVG can cause pain, loss of vision, and blindness if left untreated.

What causes neovascular glaucoma (NVG)?

The abnormal blood vessels in NVG grow inside the eye as a result of poor retinal blood supply. There are many conditions that cause abnormal blood supply to the retina. They include diabetic retinopathy, retinal vein occlusion, retinal artery occlusion, ocular ischemic syndrome, retinal detachment, and inflammation. In these conditions the blood supply to the retina is impaired, so the retina sends out chemical messages that it needs more blood supply. As a result, new blood vessels begin to grow inside the eye. Unfortunately, these new blood vessels may grow into the drain (trabecular meshwork) where they cause harm.

What are the symptoms of neovascular glaucoma (NVG)?

In the early stages of NVG, there may be no symptoms. However, as the pressure inside the eye rises, symptoms include pain, redness, and loss of vision. Sometimes, the pain is so severe that it causes nausea and vomiting. If left untreated, NVG frequently results in a blind eye.

How is neovascular glaucoma (NVG) diagnosed?

The most common test for glaucoma in an eye examination is tonometry. Tonometry measures the pressure inside the eye. Most people are first suspected to have glaucoma because high pressure is found on an eye exam. In NVG the ophthalmologist then detects abnormal blood vessels growing in the drain (called NVA) by an office exam called gonioscopy. The presence of high pressure in an eye with NVA makes the diagnosis of neovascular glaucoma.

What treatment is available?

The key to treating NVG is addressing the underlying cause of poor blood supply to the retina. Examination and testing usually provides the retinal diagnosis and treatment is directed toward treating that condition. Frequently, medication injections (Avastin, Lucentis, and Eylea) initially help control the growth of abnormal blood vessels until laser or cryopexy can provide a more permanent effect.

If the drain (trabecular meshwork) has not been permanently damaged by scar tissue induced by the abnormal blood vessels, the pressure inside the eye may return to normal. However, if permanent damage has occurred, eye drops and/or surgery may be needed to control the pressure. The first line of treatment in most cases includes prescription eye drops. There are a number of very effective eye drops that work by either opening the drain or by slowing down the pump to lower the pressure. These drops are powerful medicines that should be used exactly as prescribed to prevent blindness from glaucoma and minimize side effects from the eye drops. Side effects are not common, but may include burning, itching, redness, dry mouth, and worsening of bronchitis or asthma. It is very important to take the eye drops exactly as prescribed to prevent blindness. If eye drops fail to control the pressure, surgery may help. Surgery, performed in the operating room (trabeculectomy or glaucoma drainage device), creates an artificial drain to lower the pressure. After trabeculectomy patients are warned to notify the doctor urgently if the eye becomes red or appears to be infected, because infection may enter the eye after glaucoma surgery and result in severe damage or blindness. In general, patients with glaucoma may require regular examinations every three to four months to preserve vision.

The goal of treatment is to protect the vision and relieve pain. If there is no usable vision, the pressure only needs to be controlled enough to prevent pain. In severe cases surgery is performed to remove the eye (enucleation or evisceration) to relieve pain in a blind, painful eye. An artificial eye is made to appear cosmetically acceptable.

by Scott E Pautler, MD

Sickle Cell and the Eyes

Posted on June 6, 2021 by Scott Pautler

What is Sickle Cell Disease?

Sickle cell disease is the most common genetic disease, affecting about 400,000 newborns each year. It is caused by a mutation in the gene that codes for the hemoglobin protein that carries oxygen in the blood stream. Sickle hemoglobin tends to clump into a sickle shape when it gives up its oxygen molecule to the tissues it supplies. When this occurs, the red blood cells lose their flexibility and tend to block the small blood vessels in the body. 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. These blood vessels may be damaged in people with sickle cell disease.

Who is at risk of eye problems in sickle cell disease?

Although more extensive blockage of retinal blood vessels occurs in sickle cell disease, more severe complications (bleeding and retinal detachment) occur in people with a combination of sickle hemoglobin and hemoglobin C (called Hemoglobin SC disease). Some studies suggest men are more likely than women to have loss of vision.

What are the visual symptoms of sickle cell disease?

Blurring of vision may occur if excess damage occurs to the retinal blood vessels. 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 of the eye. Retinal detachment may cause a dark shadow to appear off to the side (in the peripheral visual field) and may progress to total loss of vision. 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. If bleeding occurs inside the eye due to blocked blood vessels, floaters are seen by the patient. Medicine injections may help recover vision and may be applied without pain in most cases. Laser may stabilize or improve the vision. In some situations, surgery is required. The vision may not return to normal following treatment as there may be some permanent damage to the retina. The earlier retinal problems are found, the better the outcome of treatment. Therefore, annual exams are important and it is critical to report new floaters without delay.

By Scott E Pautler, MD

Vision Loss in ARMD

Posted on May 31, 2021 by Scott Pautler

Why am I losing vision despite treatment for age-related macular degeneration?

Age-related macular degeneration (ARMD) is the most common cause of visual loss in older Americans. Vision may be lost from dry-type or wet-type ARMD:

Dry-type macular degeneration is the most common type and involves the disintegration of the light-sensitive tissues in the macula. Loss of vision is usually gradual in dry macular degeneration. Small blind spots interfere with reading numbers in a row and all the letters of a word. Over time, these blind spots usually enlarge and take away most of the central vision.

Wet-type macular degeneration accounts for about 10% of all cases of ARMD. It occurs in patients with dry-type ARMD when abnormal blood vessels grow under the macula and cause fluid leakage, bleeding, and scarring of the macula. Vision loss may be rapid and severe. Straight lines may appear distorted and the central vision appears blurred early in wet-type ARMD. Over time, a large blind spot may develop in the center of the vision. If one eye develops wet ARMD, there is about a 50% chance the other eye will be affected within the next five years.

There is currently no proven drug treatment to stop dry-type ARMD. Eye vitamins are prescribed for dry-type ARMD. However, the main purpose of the vitamins is to stave off the start of wet-type ARMD. Although AREDS eye vitamins appear to slow the start of blind spots in the vision from dye-type AMD, they do not slow the progression of blind spots once they start. A Meditteranean diet appears to reduce the onset and progression of blind spots from dry-type macular degeneration. Therefore, it is important to limit red meat intake to once per week, eat two servings of whole fruit per day, include fish in the diet, and rely on olive oil rather than other oils with saturated fatty acids. There are a number of on-going research studies to find a treatment to slow or prevent loss of vision from dry-type ARMD. There is even hope for treatment to reverse the loss of vision from dry-type ARMD. Your doctor can put you in touch with study centers if you are interested in learning more about or participating in these research studies. Age-related macular degeneration appears to be an inherited condition. However, it may be aggravated by factors that cause hardening of the arteries like high blood pressure, high cholesterol, overweight, physical inactivity, and tobacco use. Efforts to control these factors may be helpful in slowing loss of vision in dry-type ARMD.

There are fairly good treatment options for wet-type ARMD. Injection therapy (Avastin, Lucentis, Eylea, and Beovu) is the first-line treatment for wet-type ARMD. Lasers are second-line treatment options. Lasers include photocoagulation (which is rarely used currently) and Visudyne photodynamic therapy. Treatment of wet-type ARMD is effective at slowing the loss of vision. Unfortunately, current treatments do not completely prevent the loss of vision from ARMD. There are several reasons why patients may continue to lose vision during treatment of ARMD:

1. Insufficient treatment

Some eyes require injection therapy every four weeks to optimal effect. If treatment is given less often, the wet-type ARMD may progress with loss of vision that may be irreversible. This is an important reason to continue monthly injections in some eyes (as determined by the retinal specialist).

2. Bleeding despite treatment

Bleeding under the retina from ARMD usually results in some degree of permanent scar tissue and loss of vision. Bleeding may occur if treatment is not given frequently enough and appears more likely in patients who take blood thinners. Blood thinners (including aspirin) are usually prescribed to prevent heart attack or stroke. If they are prescribed, the benefits likely outweigh the risks. However, if blood thinners are not prescribed for a patient with ARMD, they may be best avoided to reduce the risk of bleeding from ARMD.

3. Progression of dry-type ARMD while wet-type ARMD is being treated

Many patients are not aware that ARMD always starts with the dry-type. Wet-type ARMD develops later. Therefore, patients with wet-type ARMD may lose vision over time even though their wet-type ARMD is well controlled. That in, they may lose vision from a worsening of dry-type ARMD over time. Complicating this issue is the concern that the very treatment of wet-type ARMD may, in some cases, worsen the dry-type ARMD.

4. New eye problems develop during treatment of ARMD

The ophthalmologist will look for other problems that may cause a loss of vision unrelated to ARMD. Common causes of vision loss include cataract, which is treatable with surgery. Other problems include glaucoma, retinal vein occlusion, and diabetic retinopathy.

What is to be done about the continued loss of vision?

There are a number of actions that may be taken in response to continued loss of vision during treatment of ARMD. The retinal specialist will look for other causes of loss of vision and start appropriate treatment. The frequency of treatment may be changed in response to changes in the retina. Low vision aids (optical and electronic magnifiers) may be helpful. Specially-trained social workers may help make changes in the household to make it easier to remain self-sufficient. It is helpful to remember that the peripheral vision is rarely taken by ARMD. Therefore, although a patient may be determined to be legally blind, total blindness is rare. Most patients with advanced ARMD are able to ambulate and retain independence.

By Scott E Pautler, MD

Retinal Angiomatous Proliferation

Posted on May 23, 2021 by Scott Pautler

What is retinal angiomatous proliferation (RAP)?

Retinal angiomatous proliferation means there is a growth (proliferation) of abnormal blood vessels (angiomatous) in and under the retina (specifically, under the central part of the retina called the macula). Retinal angiomatous proliferation (RAP) is a sub-type of wet age-related macular degeneration (ARMD). Wet ARMD affects the central vision in older patients due to abnormal blood vessels growing under 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 through the lens onto the retina, which “takes the picture” and sends the image to the brain.

What causes retinal angiomatous proliferation (RAP)?

Retinal angiomatous proliferation (RAP) appears to be caused by the release of blood vessel growth factors in the retina in response to age-related changes. The age-related changes include the accumulation of cellular waste products under the retina (call subretinal drusenoid deposits). The build-up of waste products (SDD) under the retina interferes with retinal function. For one thing, the build-up of SDD separates the retinal cells from the normal blood vessels that nourish them. Without proper nourishment the retinal cells do not work well. Furthermore, when the retinal cells perceive that they are not getting enough oxygen and nutrients, they release growth factors (including one growth factor called VEGF). These growth factors stimulate the growth of new blood vessels to assist in delivering oxygen and nutrients. In other parts of the body, new blood vessels may grow to help or replace old blood vessels and it is a helpful response to poor blood supply. However, in RAP the new blood vessels cause loss of vision due to fluid leakage, bleeding, and scarring of the macula.

What are the symptoms of retinal angiomatous proliferation (RAP)?

Retinal angiomatous proliferation (RAP) may cause no symptoms in its early stages. Over time, symptoms may include blurred central vision, distortion of straight lines and/or a central, gray spot in the vision. In its advanced stages without treatment, RAP may cause a large permanent blind spot in the center of vision. At this stage no treatment is possible and low vision aids are used to compensate for loss of vision. If one eye develops wet AMD, there is about a 50% chance the other eye will be affected within the next five years.

How is retinal angiomatous proliferation (RAP) diagnosed?

Retinal angiomatous proliferation (RAP) is diagnosed in patients with known dry-type age-related macular degeneration. Before the proliferation or growth of blood vessels under the retina develop in RAP, subtle yellow deposits may be identified under the retina. These deposits are called subretinal drusenoid deposits (SDD). SDD develop many years before RAP occurs. A dilated eye examination can detect SDD and alert the retinal specialist to be on the lookout for RAP. Retinal angiomatous proliferation is suspected when a patient with SDD develops blurred vision and swelling (edema) is present in the retina on a retinal scan called OCT (optical coherence tomography). The diagnosis may be confirmed on a more extensive test called fluorescein angiography. This is a procedure where the ophthalmologist injects an organic dye into the vein of a patient’s arm. Then, photographs of the retina show the presence and location of the leaking blood vessels marked by the organic dye.

Why is this diagnosis important?

It is important to recognize RAP because it guides treatment recommendations. This type of wet ARMD is especially sensitive to antiVEGF therapy (injections with Avastin, Lucentis, and Eylea). RAP is so sensitive to antiVEGF therapy that the medication injections are sometimes not required as often as they are in other types of wet age-related macular degeneration such as PCV. Older treatments such as photocoagulation and photodynamic therapy historically do not work well in RAP and can be avoided. Treatment rarely returns vision to normal, but may limit the amount of vision loss from blood vessel growth and leakage. Frequent office visits and photographs are needed. It may be useful to stop smoking, avoid becoming overweight, exercise daily, and control blood pressure and cholesterol. Aspirin should only be used if required to treat disease as recommended by a doctor. Relatives should be checked for macular degeneration, as well.

By Scott E Pautler, MD

Giant Cell Arteritis and the Eyes

Posted on May 14, 2021 by Scott Pautler

What is giant cell arteritis (GCA)?

Giant cell arteritis (also called cranial arteritis or temporal arteritis) is an inflammatory condition affecting medium to larger arteries in people over the age of 50 years. GCA may cause headache, neck stiffness, tenderness of the temple, and/or cramping of the tongue or jaw while eating or talking. It may also cause fever, fatigue, weight loss, depression, night sweats and general feeling of illness or feeling unwell.

What causes giant cell arteritis (GCA)?

The cause of GCA is not very well understood. The inflammation from GCA is not due to infection. In GCA, it appears the body’s immune system attacks itself, in some ways similar to rheumatoid arthritis.

How is giant cell arteritis (GCA) diagnosed?

The diagnosis is first suspected by typical symptoms in an older patient. Blood tests may include complete blood count (CBC), sedimentation rate (ESR), and C-reactive protein (CRP). Biopsy of the temporal artery is necessary in most cases to confirm to diagnosis. Firmly establishing the diagnosis is critical, because treatment needs to be started quickly and continued for a long time in GCA.

How does giant cell arteritis (GCA) affect the eyes?

Giant cell arteritis (GCA) causes loss of vision due to retinal artery occlusion or ischemic optic neuropathy. Early diagnosis is critical to begin treatment and limit the damage from blood vessel inflammation, which includes complications of brain stroke.

How is giant cell arteritis (GCA) treated?

Prompt steroid treatment is important to stop inflammation from causing further damage with loss of vision and brain stroke. Prednisone is continued at a low dose for a year or more to prevent the inflammation from returning. In an effort to avoid or manage side-effects of steroids, methotrexate is sometimes used. Tocilizumab was approved in 2017 for use in GCA. It avoids the use of steroids, but is very expensive.

By Scott E Pautler, MD

COVID-19 and Facial Fillers

Posted on May 6, 2021 by Scott Pautler

How can COVID-19 affect cosmetic fillers?

COVID-19 infection or COVID-19 vaccines may cause cosmetic facial fillers to swell. The swelling may occur hours to a few weeks after exposure. Fortunately, this appears to be a rare adverse effect. The true frequency is not known because it represents a fairly minor reaction among the spectrum of symptoms of COVID-19.

What causes the swelling to occur?

Not much is known about this uncommon reaction. It is suspected to be due to an immune reaction to the spike protein on the virus surface. It does not appear to be due to direct infection of the COVID-19 virus in the filler material itself.

How long does the swelling last?

The duration of swelling varies. Usually, the swelling lasts only a few days, but it may wax and wane over several weeks. Treatment may make the swelling go away more rapidly. Fortunately, swelling of facial fillers does not appear to be a permanent problem.

What treatment is available?

Many different treatments have been used. The effectiveness of treatment is difficult to assess because of the rarity of the problem. Local treatment may include cold compresses. Oral antihistamines have not been universally effective. Anti-inflammatory medications such as prednisone may help; however, there is some concern about the potential interference in developing protective immunity. Of interest, lisinopril (commonly used to treat high blood pressure) may be useful to resolve the swelling. More knowledge will come with experience.

By Scott E. Pautler, MD

Blindness from Tattoo

Posted on April 30, 2021 by Scott Pautler

How can a tattoo cause blindness?

There are several ways in which a tattoo may threaten loss of vision. The most obvious situation is a scleral tattoo. This is a tattoo applied to the outer eye wall, the white sclera. The tattoo ink may have direct toxic effects on the eye and there is a risk of serious infection. However, even a skin tattoo applied far from the eyes may risk loss of vision. This is due to an autoimmune condition called tattoo granuloma with uveitis (TAGU). Autoimmune conditions occur when your own immune system attacks your body.

What are the symptoms of TAGU?

Various symptoms may be experienced depending on where the eye is most inflamed. Symptoms may be mild or they may be severe and disabling. The eye may be painful, red, tearing, and light sensitive. Tiny floating spots which move or “float” may be seen. Sometimes blind spots, blurred vision, distortion, or loss of side vision occurs. The visual symptoms are frequently associated with inflammation of the tattoo (elevation, redness, warmth, itching, tenderness and/or swollen lymph nodes).

Who is at greatest risk of TAGU?

Fortunately, TAGU appears to be a rare condition. However, risk factors that may increase the chance of TAGU include the size of the tattoo. The larger the tattoo, the greater the risk of TAGU. Also, a personal history or family history of other autoimmune conditions may increase the risk of TAGU. Other autoimmune conditions include sarcoidosis, rheumatoid arthritis, lupus, and Harada’s disease.

How is TAGU diagnosed?

The diagnosis of TAGU is first considered in anyone with inflammation of the eye (uveitis) in a person who has had a tattoo. A skin biopsy may be needed to demonstrate a typical form of inflammation of the tattoo. In addition, other tests may be needed to be sure the uveitis is not due to a problem unrelated to the tattoo (see uveitis questionnaire).

Take some time to carefully review and report to your doctor any unusual or unexplained symptoms such as rashes, back and joint problems. Tell your doctor if you travel abroad, spend time in rural settings, or may be exposed to animals or infections. Heredity may also play a role. Also, review and report your ancestry (for example, Asian, Mediterranean, or American Indian ancestry). When the doctor diagnoses uveitis, laboratory tests may be ordered to help determine its cause.

How is TAGU managed?

To limit the damage from inflammation, TAGU is treated with anti-inflammatory medication in the form of eye drops, injections (next to the eye or into the eye), or pills. When pills are used, the eye doctor frequently coordinates medical care with the expert assistance of a rheumatologist. Rarely, surgery is required to treat TAGU. In some cases, uveitis may be long-lasting. In these cases, years of therapy are needed to preserve vision. TAGU is a serious eye problem and may result in loss of vision or blindness. However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized.

In some cases, TAGU can resolve with treatment, but return at a future date. Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact your doctor.

What are other risks of tattoos?

Apart from eye inflammation, there are a host of health risks associated with tattoo. They include infection of the skin or blood (sepsis), hepatitis, HIV/AIDS, heart valve infection (endocarditis), scleroderma, scarring (keloid formation), and hypersensitivity reactions. Remember that the FDA does not regulate the contents of the ink that is injected into the skin. Also, government regulation is variable as it relates to training, sanitation, and infection control. Current regulations may not be adequate to protect you against harm.

By Scott E. Pautler, MD

Inflammatory Bowel Disease and Your Eyes

Posted on April 23, 2021 by Scott Pautler

Eye — Anatomy of the eye (click on image to enlarge)

What is inflammatory bowel disease?

Inflammatory bowel disease includes conditions such as ulcerative colitis and Crohn’s disease. They are inflammatory conditions not caused by infection. Instead, the immune system appears to mistakenly attack the bowel. The same immune cells may also attack the eye in these bowel conditions. Ocular inflammation is called uveitis. And the most common type of uveitis caused by inflammatory bowel disease, is intermediate 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 (see anatomy of the eye). 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. The part of the uvea in the front of the eye is called the iris (the round, blue or brown part of the eye that you can see in the mirror). Behind the iris is the ciliary body, which produces the fluid that fills the eye. The pars plana serves as the boundary between the ciliary body and the choroid. The back part of the uvea that lies under the retina (the “film” in the eye that “takes the picture”) is called the choroid. 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. In intermediate uveitis the inflammation is primarily located in the vitreous gel that fills the eye, which is located in an intermediate position between the front and the back of the eye. It is sometimes referred to as vitritis.

What are other causes of intermediate uveitis?

Uveitis may be caused by an infection, an injury from trauma, a disease in the body outside the eye, or sometimes for unknown reasons. Infection by a virus, bacteria, fungus, or other parasite may cause uveitis. Infections may be limited to the eye or may involve other organs as well. In intermediate uveitis, infection may be caused by syphilis, tuberculosis, Lyme disease, cat scratch disease, Whipple’s disease, toxocariasis, human lymphotrophic virus (HTLV-1), or toxoplasmosis.

In other situations, uveitis is caused by inflammation without infection. For example, multiple sclerosis and sarcoidosis may cause intermediate uveitis. Pars planitis is a sub-type of intermediate uveitis that often starts early in life during childhood. Its cause is unknown.

Uveitis commonly occurs following an injury to the eye. Very rarely, cancer or cancer-fighting drugs may cause intermediate uveitis. In some cases, no underlying cause can be found to be the cause of uveitis. Tobacco may be an aggravating factor and should be discontinued.

What are the symptoms of intermediate uveitis?

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. Symptoms may be mild or they may be severe and disabling.

How is intermediate uveitis managed?

Treatment of the underlying inflammatory bowel disease will also help treat the uveitis. Separately, it is important to find any other underlying cause whenever possible. Take some time to carefully review and report to your doctor any unusual or unexplained symptoms such as rashes, back and joint problems. Tell your doctor if you travel abroad, spend time in rural settings, or may be exposed to animals or infections. Heredity may also play a role. You should tell your doctor about any family members with inflammatory disorders anywhere in the body. Also, review and report your ancestry (for example, Asian, Mediterranean, or American Indian ancestry). When the doctor diagnoses uveitis, laboratory tests may be ordered to help determine its cause. Occasionally, a surgical biopsy is needed for diagnosis. If infection is found, antibiotics are prescribed. To limit the damage from inflammation, intermediate uveitis is treated with anti-inflammatory medication in the form of eye drops, injections, or pills. When pills are used, the eye doctor frequently coordinates medical care with the expert assistance of a rheumatologist. Rarely, surgery is required to treat uveitis. In some cases, intermediate uveitis may be long-lasting. In these cases, years of therapy are needed to preserve vision. Intermediate uveitis is a serious eye problem and may result in loss of vision or blindness. However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized.

In some cases, intermediate uveitis may go away, but return at a future date. Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact your doctor. Preliminary evidence suggests that tobacco use may be an aggravating factor in some cases of uveitis. Also, vitamin D supplements may be helpful.

By Scott E. Pautler, MD

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

Polymyalgia Rheumatica and your Eyes

Posted on April 18, 2021 by Scott Pautler

What is polymyalgia rheumatica (PMR)?

Polymyalgia rheumatica is an inflammatory condition affecting the hips and shoulders of people over the age of 50 years. PMR may cause sudden shoulder and/or hip pain, especially after or during rest from activity. It usually affects both sides of the body. It may also cause fever, fatigue, weight loss, depression, and night sweats.

What causes polymyalgia rheumatica (PMR)?

The cause of PMR is not very well understood. The inflammation from PMR is not due to infection, though various infections may need to be excluded before a diagnosis of PMR is made. In PMR, it appears the body’s immune system attacks itself, in some ways similar to rheumatoid arthritis.

How is polymyalgia rheumatica (PMR) diagnosed?

The diagnosis is first suspected by typical symptoms in an older patient. Blood tests may include complete blood count (CBC), sedimentation rate (ESR), and C-reactive protein. If needed, ultrasound may detect bursitis in the shoulder. PET/CT scan is also very sensitive and specific for PMR.

How does polymyalgia rheumatica (PMR) affect the eyes?

When PMR is associated with inflammation of the blood vessels, the eye can become affected. This closely-related blood vessel inflammation is called giant cell arteritis (also called cranial arteritis or temporal arteritis). Giant cell arteritis (GCA) causes symptoms similar to PMR with the addition of headache, neck stiffness, tenderness of the scalp, and cramping of the tongue or jaw when speaking or chewing. These symptoms indicate inflammation of the blood vessels of the head. Loss of vision may occur due to retinal artery occlusion or ischemic optic neuropathy. Early diagnosis is critical to begin treatment and limit the damage from blood vessel inflammation, which includes complications of brain stroke.

By Scott E. Pautler, MD

Anatomy of the Eye

Posted on April 9, 2021 by Scott Pautler

Anatomy of the human eye. Image courtesy of Caitlin Albritton.

The eye is a specialized organ to provide sight. The various parts of the eye work to assist in this process. There are two eyes per human (many more if you are a spider or a scallop). The paired human eyes allow for improved depth perception. It takes two eyes for a human to best determine how far an object lies in front of him or her. Each eye has a slightly different view and the difference between the two images is used by the brain to make a three-dimensional (3-D) image. Test: you can see the difference in depth perception by trying to thread a needle or perform a similar fine task with one eye compared with two eyes. If the two eyes are not lined up straight, a person sees two images (double vision).

Shape of the eye

The shape of the eye is fairly round like a ball. This design helps the eye determine what direction light is coming from (see video: evolution of the eye). In near-sighted eyes, the eye becomes somewhat elongated (like an egg). This appears to be due to an adaptive response of the eye to aid in focusing at near. However, the elongation of the eye causes the tissues to stretch and this predisposes the eye to retinal detachment.

The Tear Film

This is an often-overlooked part of the eye. The tears form a smooth surface over the front of the cornea and help avoid scattering of light as it enters the eye. The tear film also provides nutrition, protection (antibacterial), and cleansing of the surface of the eye. The tear film is composed of three parts/layers: the aqueous (water), mucin, and lipid layers. The aqueous component is produced by lacrimal glands that rest in the eye socket behind a bone under the eye brow. The mucin layer is produced by specialized cells (goblet cells) in the conjunctiva. The mucin mixes with the aqueous layer and adds structure to the tears helping them to remain on the eye surface. The lipid layer (outer surface) produced by meibomian glands along the edge of the eye lids. The lipid helps protect against evaporation of the tears from the surface of the eye. Various conditions and diseases interfere with one or more layers of the tear film leading to d ry eyes and reduced vision.

The Conjunctiva

The conjunctiva (not labelled on image) is a smooth moveable outer “skin” overlying the white sclera (see below). The conjunctiva acts as a physical barrier against entry of infectious organisms, and contains many blood vessels which dilate and become inflamed if infection or foreign objects threaten to damage the eye. The smooth surface of the conjunctiva and loose attachment to the underlying sclera helps the eye turn smoothly.

The Sclera

The sclera is the tough outer coat of the eye. It provides structural support and protection of the sensitive tissues (like the retina) inside the eye. The sclera does allow for the outflow of water that is produced by the ciliary body. It also allows medications to pass into the eye. Nerves and blood vessels penetrate the sclera to reach the inside of the eye.

The Cornea

The cornea is the clear window at the front of the eyeball that allows light to enter the eye. It is continuous with the sclera. Most of the focusing of light happens at the corneal surface/tear film. As this outer layer of the eye is so critical for sight, there are many nerve endings in the cornea making it the most sensitive part of the eye to touch. The outer-most layer is the epithelium: a smooth surface to transmit light with tightly layered cells difficult for infections to penetrate. The epithelium acts as a barrier to keep the water-filled tears from entering the cornea as this would make the cornea lose its clarity. The middle layer of the cornea is called the stroma. It occupies most of the cornea with orderly layers of protein fibers to transmit light and minimize scattering. There is very little water in the stroma because the inner-most layer of the cornea (the endothelium) pumps out water from the cornea into the eye. When the cornea becomes hazy or opaque, a corneal transplant may be performed.

The Iris and Pupil

The iris is responsible for the color of the eye as seen from the outside. A circular opening in the iris is called the pupil, which is seen as a black spot in the center of the iris. Iris muscles expand and contract to change the size of the pupil and alters the amount of light entering the eye. In bright light, the pupil constricts so as to prevent too much light from entering the eye. There is no specific function of iris color and iridology is not a true science. However, lighter-colored irises (irides) may not block as much light as dark irides. From a medical perspective, eyes with lighter color eyes may be at higher risk of developing macular degeneration. Darker eyes are seen among people who evolved nearer the equator. In birds, iris color appears to play a role in the mating ritual.

The lens

The lens inside the eye is made of specialized crystalline protein fibers that help to focus light and allow for flexibility of the lens in order to focus light from different distances from the eye. With age the eye loses its ability to focus light; therefore, reading glasses are needed by most people around the age of 40 years. When the clear lens turns foggy, the lens is called a cataract. Surgery may be performed to remove a cataract and replace it with a clear plastic lens implant.

The ciliary body (SILL-ee-air-ee)

The ciliary body has two functions inside the eye. It contains muscles to focus the lens (the ciliary muscles are attached to the lens by fine fibers called zonules). The ciliary body also has a pump that produces aqueous (water). The aqueous pump works to keep the eye inflated. The aqueous also provides nutrition to the structures inside the eye. There is a constant flow of aqueous into the eye via the ciliary body and out of the eye through the sclera (i.e. the trabeculum). If the trabecular drain becomes blocked, the pressure in the eye goes up and damage may occur to the optic nerve. This condition is called glaucoma.

The Vitreous

The vitreous is a clear gel that fills most of the eye. There are no blood vessels and very few cells in the vitreous. The clarity of the vitreous is important in order to allow light to pass from the lens to reach the retina. The vitreous is mainly composed of water, but there are fine protein fibers and a gel (hyaluronin) providing a unique structure. If the eye becomes cut from an accidental trauma, the vitreous gel may plug the hole in the sclera keeping the eye from deflating. The vitreous also appears to protect the lens; there are anti-oxidants in the vitreous gel that help keep the lens clear.

With age, the vitreous loses its gel-like quality and the protein fibers begin to clump together. When this happens, fiber-like floaters may appear in the vision. These floaters occur earlier in life in near-sighted eyes and in eyes following inflammation or trauma. Occasionally, the vitreous fibers will pull on the retina causing brief, streak-like flashes of light in the vision. The pulling may cause a retinal break (retinal tear), which may lead to retinal detachment. In other situations, the vitreous fibers may pull on the macula resulting in distortion of vision from vitreo-macular traction syndrome, epiretinal membrane, or macular hole.

The Retina

The retina is a light-sensitive layer of nerve tissue that lines the inside of the eye wall. It acts like the film in a camera. The central portion of the retina is called the macula. The macula is designed for central vision. When you read or see fine details, you move your eye so that light focuses on the macula. The rest of the retina is used for peripheral vision (side-vision). The peripheral vision is essential for walking around a room without bumping into things. The peripheral retina is also sensitive to detect movement in the environment. The blood supply to the inner retinal layers (ten layers in all) comes from retinal blood vessels that enter and exit the eye through the optic nerve. The outer retinal layers are supplies by blood vessels in the choroid (see below). Blockage of the blood supply (retinal artery occlusion or retinal vein occlusion) causes a blind spot in the vision or blurred vision. If the retina becomes detached from the eye wall, it does not function well, and surgery is required to recover vision. Aging may result in macular degeneration.

The Choroid

The choroid is a layer of tissue under the retina filled with blood vessels. This important blood vessel layer provides oxygen and nutrition to the retina. It also evacuates waste materials from the outer retina and acts as a heat sump, keeping the retina from overheating. The choroid may be affected by a number of problems including inflammation, blood vessel blockage, and central serous retinopathy.

The Optic Nerve

The optic nerve connects the nerve tissue of the retina to the nerve tissue in the brain, like wire in an electric circuit. The optic nerve is sensitive to the pressure inside the eye. High intra-ocular pressure may cause loss of vision or blindness from glaucoma. The optic nerve may also be affected by blocked blood flow, inflammation, and pressure from outside the eye (tumors and aneurysms).

By Scott E. Pautler, MD

Cotton-Wool Spots

Posted on March 26, 2021 by Scott Pautler

What is a cotton-wool spot?

A cotton-wool spot is the name given to a small white spot in the retina that resembles cotton wool (raw cotton). 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 called arteries. If the blood supply to the retina becomes impaired, a small white spot may develop in the inner retina resembling cotton or wool. This cotton-wool spot is a sign of stressed retina.

What causes a cotton-wool spot?

There are a wide variety of causes of cotton-wool spots. Most commonly, they occur along with other changes in the retina from diabetes, high blood pressure, or retinal blood vessel blockage. However, they may occur due to a great number of other problems including heart diseases, vascular diseases, blood diseases, inflammations, trauma, medications, and infections. Sometimes, no underlying condition can be identified.

What are the symptoms of a cotton-wool spot?

Often cotton-wools spots cause no symptoms at all. Sometimes they cause a blind spot or dark arc in the vision just off to the side of central vision. The symptoms come on suddenly and painlessly. The loss of vision may be temporary or permanent. Regardless, it usually fades over weeks to months.

What testing is needed?

Testing depends on the finding on the eye examination. Sometimes the underlying problem that caused the cotton-wools spots can be determined by the eye exam. If not, blood tests and scans may be ordered by the ophthalmologist.

What treatment is available?

Although there is no specific treatment for cotton-wool spots, treatment is directed toward any underlying conditions that caused the cotton-wool spots to appear. The spots themselves fade away over several months’ time.

By Scott E. Pautler, MD

Retinal photograph showing two cotton-wool spots

Polypoidal Choroidal Vasculopathy

Posted on March 13, 2021 by Scott Pautler

What is polypoidal choroidal vasculopathy (PCV)?

Polypoidal choroidal vasculopathy (PCV) is a type of age-related macular degeneration (AMD), 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. PCV 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 PCV alone does not result in total blindness.

In PCV, abnormal blood vessels grow under the macula from a deep layer of normal blood vessels (the choroid). The normal blood vessels in the choroid are usually separated by a tissue membrane from the macula. However, in PCV abnormal blood vessels start growing from the choroid and invade the tissue beneath the macula. These abnormal vessels leak fluid and blood under the macula causing loss of vision.

Image of the retina with bleeding due to PCV causing a blind spot in the vision

What causes polypoidal choroidal vasculopathy (PCV)?

Polypoidal choroidal vasculopathy appears to be an inherited condition. PCV may occur in anyone, but it is more common in people who descended from Asia or Africa. Therefore, genetic factors likely play a role in the cause of PCV. It may be aggravated by factors that cause hardening of the arteries like aging, high blood pressure, high cholesterol, overweight, physical inactivity, and tobacco use.

Before abnormal blood vessels grow under the macula, there are usually findings that predict eyes that are at risk of developing PCV. For example, the choroid (normal blood vessel layer under the macula) is usually thicker than average. A thicker choroid may result in higher blood flow beneath the macula that may cause the growth of abnormal blood vessels. In addition, pale deposits (drusen) may appear under the macula prior to the development of abnormal blood vessel growth. These deposits may contain waste products of cellular function, as well as cholesterol. Perhaps, newly growing blood vessels are called on by the macula to clear away the waste deposits. Regardless, the abnormal blood vessels threaten loss of vision due to leaking, bleeding, and scarring beneath the macula.

What are the symptoms of polypoidal choroidal vasculopathy (PCV)?

Polypoidal choroidal vasculopathy may cause no symptoms in its early stages, especially if the abnormal blood vessels are located away from the center of the macula or if they have not begun to leak significantly. Eventually, symptoms may include distortion of central vision or a blind spot in the vision.

How is polypoidal choroidal vasculopathy (PCV) diagnosed?

A dilated eye examination can often detect changes in the macula before visual loss occurs from PCV. The hallmark of PCV, as well as other forms of macular degeneration, is the presence of drusen—tiny yellow deposits of waste products from the retinal cells that appear as spots under the retina. After the diagnosis is made, a fluorescein angiogram may be needed. This is a procedure where the ophthalmologist injects an organic dye into the vein of a patient’s arm. Then, photographs of the retina show the presence and location of the leaking blood vessels marked by the organic dye.

How is polypoidal choroidal vasculopathy (PCV) treated?

There is evidence that taking vitamin/mineral supplements in specific dosages decreases the risk of visual loss from PCV. For high risk eyes, the following supplement is recommended: Preservision Soft Gels AREDS 2 Formula one capsule twice-a-day. To avoid toxic side effects, be careful about taking additional vitamins or zinc. However, you may take calcium, iron, and vitamin D if recommended by your doctor for problems not related to your eyes. Check pricing of Preservation on Amazon.

People with PCV can often be helped with medication injections and a special laser (PDT) performed in the office. The Everest Study found that the combination therapy with medication injection and PDT (photodynamic therapy) was more effective than medication injection alone. The combination treatment group recovered more vision and required fewer treatments by injection. This treatment regimen differs from other types of age-related macular degeneration.

Treatment rarely returns vision to normal, but may limit the amount of vision loss from blood vessel growth and leakage. Frequent office visits and photographs are needed. It may be useful to stop smoking, avoid becoming overweight, exercise daily, and control blood pressure and cholesterol. Aspirin should only be used if required to treat disease as recommended by a doctor. Relatives should be checked for polypoidal choroidal vasculopathy, as well.

By Scott E. Pautler, MD

NOTE: As an Amazon Associate I may earn from qualifying purchases. You pay no additional fees by accessing the link. These funds help defray the costs of maintaining this website. Thank you for supporting this blog.

Asteroid Hyalosis

Posted on February 28, 2021 by Scott Pautler

Eye — Vitreous is the gel that fills the eye (click on image to enlarge). Image courtesy of Caitlin Albritton.

See Anatomy of the Eye

What is asteroid hyalosis?

Asteroid hyalosis is a fairly rare, harmless eye condition in which calcium crystals form inside the eye. The name comes from the fact that the calcium crystals look like asteroids on the examination by the eye doctor and are seen in the vitreous gel (also known as the hyaloid) that fills the eye. These calcium crystals form slowly over time, usually in just one eye. Asteroid hyalosis is not considered an eye disease and rarely causes problems with the vision.

What causes asteroid hyalosis?

The cause is not known. Limited research has been carried out because asteroid hyalosis does not harm the eye. It is usually well-tolerated and may be observed by the eye doctor. Asteroid hyalosis is not associated with calcium-related problem outside the eye.

What symptoms may be seen?

Many patients have no symptoms at all, but sometimes floaters are seen. Floaters are small specks, fibers, or bug-shaped objects that may appear to move in front of your eye. At times they may appear like a veil or cloud moving in the vision. They are frequently seen when looking at a blank wall or blue sky. Usually, they can be ignored and tolerated.

What should be done about the symptoms?

The most important step is to have a thorough dilated eye examination. The eye doctor will check for the presence of a tear in the retina. If the retina is stable, the asteroid hyalosis may be observed without treatment. If the floaters become a problem for the patient and interfere with vision, vitrectomy surgery may be considered to remove the asteroid hyalosis.

By Scott E. Pautler, MD

Photograph of asteroid hyalosis appearing as white clumps inside the eye (vitreous) obscuring the view of the retina in the background.

Birdshot Chorioretinopathy

Posted on June 27, 2020 by Scott Pautler

What is birdshot chorioretinopathy?

See Anatomy of the Eye

Birdshot chorioretinopathy (BSC) is a type of uveitis (pronounced, “you-vee-EYE-tis”), a term used to describe inflammation inside the eye. BSC mainly causes inflammation of the choroid and retina, but may affect other parts of the eye as well. The choroid is the part of the uvea that lies under the retina, which is the “film” in the back of the eye that “takes the picture” of objects you look at. BSC is fairly rare form of inflammation affecting both eyes of men and women, usually starting in middle age.

What causes birdshot chorioretinopathy?

Birdshot chorioretinopathy (BSC) is strongly related to genetics. Most people with BSC have inherited a cell protein called HLA-A29. However, most individuals with HLA-A29 do not develop BSC; it appears to be triggered by an external event, such as an infection that “awakens” the immune response, which then abnormally attacks the eyes. BSC is most common in people of European ancestry.

What are the symptoms of birdshot chorioretinopathy?

Birdshot chorioretinopathy (BSC) usually presents with the slow-onset of floaters and blurred vision in both eyes. The floaters appear as tiny floating dots, which move or “float” in the vision and are seen especially well in bright environments. Shimmering lights may also be reported. Some patients note difficulty seeing at night. Symptoms may be very bothersome despite normal vision as measured on the eye chart. Over many years without treatment, the vision deteriorates further with loss of contrast, color vision, peripheral vision, and central vision. The symptoms vary from person to person and some have more rapid and severe deterioration than others.

How is birdshot chorioretinopathy diagnosed?

The diagnosis of birdshot chorioretinopathy (BSC) may be delayed due to the slow onset of symptoms and the subtle findings on the eye exam. A retinal specialist or uveitis specialist may be needed to perform sophisticated testing and make the diagnosis. Inflammation may be detected in many different parts of the eye, but the most typical findings include numerous pale spots inside the back of the eye. Blood testing for HLA-A29 is positive in the vast majority of patients with BSC. However, not all patients with uveitis who are positive for HLA-A29 have birdshot chorioretinopathy. Therefore, it is necessary to exclude other diseases that may simulate BSC including lymphoma, sarcoidosis, tuberculosis, syphilis, and cancer medications such as pembrolizumab and others.

How is birdshot chorioretinopathy managed?

Birdshot chorioretinopathy (BSC) usually requires management by an experienced retinal or uveitis specialist. In most cases, systemic treatment (pills or injections into the skin) are needed to control the inflammation. In a small subset of patients, localized treatment to the eye is sufficient. This is more often the case in older patients at onset of symptoms. When pills are used, the eye doctor frequently coordinates medical care with the expert assistance of a rheumatologist (a medical specialist with expertise in auto-immune diseases, like rheumatoid arthritis). In BSC the rheumatologist monitors the patient for medication side-effects that may develop outside the eyes. In many cases, the uveitis may be long-lasting. In these cases, years of therapy are needed to preserve vision.

Your doctor will choose from a variety of medications. Steroids (pills, eye drops, and injections) may be used at the start of treatment to gain rapid control of inflammation. However, long-term steroid treatment in high doses is usually avoided to prevent side-effects of steroid therapy. For long-term control methotrexate (MTX) pills or skin injections may be given weekly. MTX has a long record of safety and is affordable. If MTX fails or causes side-effects (liver or bone marrow), CellCept is another suitable medication, though it may cause diarrhea. Cyclosporin has been used effectively, but is fraught with a high incidence of problems with hypertension (high blood pressure) and kidney toxicity. Humira is a new biologic treatment given as an injection into the skin every two weeks. It has been approved by the FDA for treatment of uveitis, such as BSC. All medications used to treat BSC may have adverse effects and must be monitored for effectiveness and safety in a given patient.

Birdshot chorioretinopathy is a serious eye problem and may result in loss of vision or blindness. However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized.

By Scott E. Pautler, MD

Lumega-Z: Worth the cost?

Posted on April 11, 2020 by Scott Pautler

What is Lumega-Z?

Lumega-Z is a vitamin/mineral/antioxidant supplement that is taken by mouth and is labelled a medical food. A medical food is simply a name used to identify a product that is taken by mouth and produced by a company for the purpose of treating disease and/or improving health. By definition, medical food must be prescribed by a physician and not sold over-the-counter. Lumega-Z is presumed to improve retinal health and potentially prevent or treat macular degeneration.

What does Lumega-Z do?

Lumega-Z aims to increase the amount of protective pigment in the macula with the hope that it will be helpful in the management of macular degeneration. Guardion is the company that makes Lumega-Z. They state in their website: “The Company’s current focus is on the Macular Protective Pigment (“MPP”), a bio-marker and major risk factor for developing Age-Related Macular Degeneration (“AMD”) and other retinal disorders.”

I take issue with this statement. “Macular Protective Pigment” has not been shown to be a major risk factor for AMD. Furthermore, the company cites no clinical research (even in their website for ophthalmologists) to support their claim that clinical benefit is derived from using their product.

Perhaps, we may assume there is benefit from Lumega-Z as another nutritional supplement (PreserVision AREDS-2) has been shown to reduce the risk of progression of macular degeneration. However, there are no current studies to compare the effectiveness of Lugema-Z with PreserVision AREDS-2. Alas, the company itself concludes: “Guardion Health Sciences, the maker of Lumega-Z, cannot guarantee…any vision benefit with treatment.”

What about the company that makes Lumega-Z?

Gardion’s business plan is provide medical food (a label that means their product is for medical use and must be provided via prescription) to patients with ophthalmologists who partner with Guardion (and may derive financial benefit). Gardion’s spokesman, Dr Hovenesian, is a refractive and cataract surgeon from California. His on their medical board of directors and a shareholder. He is not a retina specialist.

Is Lumega-Z worth the cost?

Lumega-Z costs twice as much as Preservision AREDS-2. However, it has not been scientifically demonstrated to be twice as good as PreserVision AREDS-2. Indeed, it has not even been shown to be equivalent to PreserVision AREDS-2. At the time of this publication, I am of the opinion that Lumega-Z is not worth the cost. I currently recommend PreserVision AREDS-2 to patients with AMD at risk for loss of vision as determined by examination.

By Scott E. Pautler, MD

Eye Care by Internet & Phone

Posted on March 25, 2020 by Scott Pautler

Questions?

Do you need eye care, but are fearful of COVID-19?

Do you need a second opinion on your eye problem?

Do you need an accurate diagnosis?

Do you need to know the best treatment options?

How can we help?

Now you can obtain high quality information on the phone, on videoconference (Facetime, Skype, etc), and by e-visit on a confidential computer portal.

We offer assessments and treatment recommendations. We review your history directly, examine your eyes with a video device, and review photos and charts from past exams. If you live near Tampa, we are available to see you in the office. If you are distant, we can put you in contact with superb physicians closer to you.

What does it cost?

There is no charge to you with Medicare and most insurances. If you have no insurance, the cost is $35 for the first visit. Additional fees may apply if there is a need for review of photos and medical records.

Does it matter where I live?

Although it is best if you live near Tampa, we may be able to help even if you live afar. If you are local, we are available to examine your eyes directly if needed. If you live distant from Tampa, we can refer you to a reputable eye-care specialist in your area if you need an examination.

How do I make contact?

Call 1-888-622-8521. Ask the receptionist for a virtual appointment with Scott E. Pautler, MD. They will establish a patient account and arrange for a call-back within 24 hours.

Send a secure email to Dr Pautler: spautler@retinavitreous.intellechartdirect.net

Indicate your interest in a virtual exam and briefly state your eye problem. We will return your email or contact you by phone at your preference.

Pain After Eye Injections

Posted on February 14, 2020 by Scott Pautler

Why are eye injections given?

There are many conditions, which threaten loss of vision, that are treated by injecting various medications into the eye. The eye conditions include macular degeneration, diabetic retinopathy, retinal vein occlusion, uveitis, and others. The injections may be given into the tissues outside the eyeball (subtenon’s injections) or into the eyeball (intravitreal injections). It is very important to avoid pain as these injections may need to be given repeatedly over time.

Why do I have pain after eye injections?

Although pain during eye injections can usually be minimized with anesthetics given before the injection, sometimes there is pain for hours after the injection. There are many reasons why this may occur:

1.) The antibiotic (betadine) may irritate the eye for hours after it has been applied to the eye.

2.) The eye may become dried out after the injection due to insufficient blinking.

3.) The eye may be accidentally scratched by rubbing the eye while it is still anesthetized.

4.) The drug that is injected into the eye may cause an inflammatory reaction.

5.) Rarely, a severe infection called endophthalmitis may occur after injection into the eyeball.

What can be done to prevent pain after injections?

The key to eliminating pain after eye injections is to identify the underlying cause. This may take some detective work. Although betadine is given at the time of injection to prevent infection, only a small dose is needed. If a large amount of betadine is used or if the betadine has not been thoroughly rinsed off the eye, it may cause blurred vision, persistent burning, itching, and/or a scratchy sensation like sand in the eye (called a foreign body sensation). Therefore, it is important for the eye doctor or technician to completely rinse the betadine off the eye after an eye injection in order to avoid pain later.

Sometimes, the surface of the eye may become dry after an injection because the patient does not blink frequently enough or not completely enough. This often happens as a result of the anesthetic used in preparation for the injection. After the injection is over, the anesthetic may continue to work for 15-30 minutes. During that time, the patient does not have the normal sensation necessary to indicate that it is time to blink. If the eye does not blink often enough, the surface may dry out and cause blurred vision, pain or foreign body sensation. Therefore, the patient may need to purposefully blink frequently or simply rest the eye closed for a while after an eye injection in order to prevent drying. Similarly, if a patient does not close the eye completely with each blink, part of the eye can become dry. In some cases, it may be necessary to forcibly close the eyes with each blink in order to be sure the lids close completely.

At times a patient may unknowingly rub and scratch the eye after an injection because of persistent numbing after an injection. Therefore, it is very important to avoid touching the eye for 15-30 minutes after an injection. If the eye needs to be dried off, a clean tissue may be used with a gently damping or blotting motion in the corner of the eye where the lids come together at the bridge of the nose. It is best not to move the tissue left and right or up and down in a rubbing fashion. Once the eye becomes dry or irritated for any reason listed above, it may take 1-2 days for the pain to go away and the eye to return to normal.

Rarely, a drug that is injected into the eye can cause an inflammation that causes pain or blurred vision. The doctor makes this diagnosis by examining the eye under the biomicroscope (called a slit lamp). If a medication is determined to be the cause of inflammation, it is treated with prescription eye drops and the offending drug is not used again in that patient in the future.

Infection is an extremely rare cause of pain after an eye injection. In about one in several thousand injections, germs may enter the eye through the needle tract after an eye injection. This rare infection is called endophthalmitis (pronounced like “end-off-thal-my-tiss”). Symptoms usually start with pain, redness, and loss of vision several days to a few weeks after an injection. There is no perfect way to prevent endophthalmitis. The doctor uses techniques like applying betadine before the injection. The patient tries to avoid contaminating the eye by avoiding exposure the unclean areas (like a barnyard) and avoid rubbing the eyes after injection. Endophthalmitis is very serious and may result in permanent loss of vision. Therefore, any patient having deep aching pain, increasing redness, and loss of vision starting several days or weeks after an eye injection should notify their eye doctor for prompt evaluation.

What can be done to make the eye feel better?

If the cause of the pain and irritation is from betadine, drying, or rubbing the eye, the best treatment is lubrication. Lubricants are available over-the-counter in the form of eye drops, eye gels, and eye ointments (see examples at the end of this article). The thicker the lubricant, the better the relief of pain and discomfort. However, gels and ointments may be difficult to place into the eye and they tend to make the vision blurry for several minutes or more. Lubricants may be used as often as needed. Resting the eyes closed may also provide relief. Cold compresses help many patients. Over-the-counter pain medications like ibuprofen and/or Tylenol may be helpful. Prescription pain medications are rarely needed and may cause undesirable side effects.

If the cause of the pain and irritation is from a drug reaction or from infection inside the eye, the doctor will prescribe special anti-inflammatory eye drops. If the eye exam shows infection, antibiotic injections must be given into the eye and surgery in the operating room may be necessary.

If pain keeps occurring after eye injections despite taking the measures listed above, sometimes prescription eye medication can help. Non-steroid (NSAID) eyes drops or steroid/antibiotic ointments may help prevent the pain. Most instances of pain after eye injections may be avoidable. Please talk with your eye doctor to help resolve the problem in order to undergo treatment without pain.

Check the current price of Systane Gel on Amazon.

Gels are easier to apply than ointments and may be used immediately after an eye injection to prevent eye pain and they may be used later to soothe eye discomfort.

Check the current price of Lacri-Lube on Amazon.

Ointments are more difficult to place in the eye. However, they provide longer duration of action. They may be used immediately after an eye injection to prevent eye pain and they may be used later to soothe eye discomfort.

By Scott E. Pautler, MD

Please note: As an Amazon Associate I may earn from qualifying purchases. You pay no additional fees by accessing the link. These funds help defray the costs of maintaining this website. Thank you for supporting this blog.

Serine and MacTel

Posted on January 12, 2020 by Scott Pautler

What is MacTel?

MacTel (Macular Telangiectasia) is a degeneration of the center of the retina (called the macula) that affects central vision. The macula is a type of nerve tissue that works to give sharp central vision to read and see fine details. There is evidence that an amino acid called serine plays a role in the cause MacTel.¹

How does serine relate to MacTel?

Serine is an amino acid that is used by the body to build proteins and lipids. If this building block is not used properly by the body, abnormal nerve lipids (deoxysphingolipids) may accumulate and damage nerve cells.

In an inherited condition (hereditary sensory and autonomic neuropathy type 1) an abnormal enzyme causes abnormal nerve lipids in the body and can cause nerve damage. Peripheral nerve damage may cause numbness and tingling of the hands and feet. Autonomic nerve damage may interfere with internal organ function (e.g. intestines, bladder, heart). In addition, these patients frequently develop MacTel.

Even without this inherited condition of neuropathy, patients with MacTel often have low blood levels of serine that result in high blood levels of abnormal nerve lipids. These abnormal nerve lipids have been shown to damage retinal cells and likely play a role in loss of vision in MacTel.

What can be done with this information?

At present (1-2020) the authors of the research paper advise against starting treatment based on their paper. They caution that more research is needed. However, the FDA found that over-the-counter L-serine supplements to be generally safe. One study found the use of L-serine (400mg/kg/day) safely lowered the abnormal nerve lipids in a case of hereditary sensory and autonomic neuropathy.²Side effects of taking L-serine include stomach discomfort, diarrhea, constipation, and frequent urination. Most supplements come in the form of capsules containing L-serine 500mg. It is unknown what dosage might be most effective for MacTel. A patient may wish to take the dosage recommended on the bottle by the manufacturers.

Check for current prices of L-serine on Amazon.

Another option is the use of fenofibrate, a prescription medication that can lower the abnormal nerve lipid levels. This option may be especially useful in patients with MacTel who have abnormal cholesterol and/or triglycerides because fenofibrate has already been approved for use in the treatment of these conditions apart from potential benefit for MacTel.

In general, patients with MacTel who also have symptoms of sensory or autonomic neuropathy should notify their retinal specialist and internist for additional testing and consider treatment.

By Scott E. Pautler, MD

References:

1. Gantner, et al. Serine and lipid metabolism in macular disease and peripheral neuropathy. N Eng J Med 2019;10:1422-1433.

2. Auranen et al. Clinical and metabolic consequences of L-serine supplementation in hereditary sensory and autonomic neuropathy type 1C. Cold Spring Herb Case Stud 2017;3:6.

Please note: As an Amazon Associate I may earn from qualifying purchases. You pay no additional fees by accessing the link. These funds help defray the costs of maintaining this website. Thank you.

Step Therapy

Posted on December 14, 2019 by Scott Pautler

What is Step Therapy?

In August 2018 the Centers for Medicare and Medicaid Services (CMS) introduced “step therapy” to Medicare Advantage plans. CMS is the federal government agency that administers the Medicare program. Step therapy is concept in which doctors are required to use inexpensive medications before they use more expensive medications without regard to how well the medications work and what side effects might be caused by the medications. Medicare Advantage is a type of medical insurance provided by Medicare with the primary goal of reducing the costs of medical care. Private insurance companies have followed the Medicare Advantage lead in implementing step therapy in 2019.

What eye medications are affected by step therapy?

The most common effect step therapy has had on eye care is in the use of antiVEGF medications. AntiVEGF medications are a group of drugs that have in common the ability to stop abnormal blood vessels from growing and leaking in the eye. They help control abnormal blood vessels that can lead to blindness from a number of diseases including macular degeneration (caused by age, near-sightedness, and other conditions) macular edema, retinal vein occlusion, and diabetic eye disease.

Why are antiVEGF medications targeted?

There is a large price difference among antiVEGF drugs. The most commonly used antiVEGF drugs include Avastin, Lucentis, Eylea, Beovu, and Vabysmo. While a dose of Avastin costs about $50, the price of Lucentis, Eylea, and Beovu is about $2,000 per dose. Due to an unexpected fluke, Avastin was found to be very effective in the treatment of eye disease AFTER it had been approved by the FDA and priced by the drug company for the treatment of colon cancer. Because only a fraction of a vial of Avastin is used in the eye, the cost to treat eye disease is fairly low. Lucentis and Eylea underwent lengthy study to gain approval by the FDA for the treatment of eye disease. As a result, the drug companies were allowed under current law to set a higher price.

Are the antiVEGF drugs equal in safety and effectiveness?

Although there are no major differences in safety and effectiveness in most patients, there are some differences among the antiVEGF drugs that might be important in individual patients. Silicone oil droplets from the syringe may cause bothersome, persistent floaters. This appears to be more common with Avastin. Also, Avastin may place an eye at increased risk of infection and blindness because it must be packaged twice. The potency of the drugs appears to be less with Avastin than Lucentis, which appears to be less potent than Eylea. This difference in effectiveness may be important in certain patients. The ophthalmologist (fellowship-trained retinal specialist) is in the best position to make recommendations for the patient.

What can a patient do?

If step therapy is deemed not desirable by a patient, he or she may consider avoiding medical insurance coverage that mandates step therapy, such as Medicare Advantage. If step therapy is required by an existing insurer, the doctor may be forced to use Avastin for initial treatment. Often, the choice of medication may be changed after three or more injections if the treatment effect can be shown to be ineffective to the satisfaction of the insurance company.

How might the government have handled this issue better?

A better solution to the problem of controlling the costs of medications is competition. Competition fosters efficiency. Current federal laws inhibit competition by not allowing Medicare to negotiate prices of medications. Other laws require excessively expensive and inefficient processes to develop new drugs. The unintended consequence of these laws was that drug companies lost incentive to develop better drugs. To compensate drug companies for the laws that cause the high costs required to bring new drugs to market, the government passed more laws that barred competition and allowed drug companies to charge high prices for their drugs. This was supposed to help drug companies recoup the costs of drug development. However, the price of lack of competition and high drug costs is born by the patient.

The government can lower drug costs by increasing competition. Although Europe is not efficient by any stretch of the imagination, even they have more efficient systems in place for drug development compared with the United States. The FDA attempts to manage new drug development, but its regulations and processes need to be streamlined. Patent laws that prevent competition need to be reviewed. The government can provide a platform to open price negotiation with drug companies. Doctors should be allowed back into the scene as advocates for their patients instead being gagged by insurance companies due to government regulations. Patients should be given a transparent view of the process of drug efficacy and pricing.

By Scott E. Pautler, MD

Stem Cell Therapy for Macular Degeneration

Posted on November 27, 2019 by Scott Pautler

What is stem cell therapy?

Although there is on-going research to refine the use of stem cells to treat conditions like macular degeneration with the hope of halting or recovering lost vision, there is currently no proven therapy available in the United States. Unfortunately, private clinics have started promoting potentially blinding “cell therapy” for numerous problems including macular degeneration. The concept is that cells will be harvested from a number of sites (usually fat) and then injected into the eye. The promise is that this treatment will help treat eye disease.

What is the danger of stem cell therapy given in this fashion?

Stem cell therapy provided in these clinics has resulted in blindness/loss of the eye. Injections given into the eye have caused bleeding, scarring, and retinal detachment with loss of vision. The reason for the loss of vison may include the types of cells that are injected and the method of injection. There does not appear to be any uniformity of cell type that is used. In addition, the method of injection appears to be into the vitreous gel of the eye. This may create inflammation in the vitreous that results in scar tissue and traction on the retina. Inflammation and scar tissue formation in the vitreous may result in blindness from retinal detachment.

What is a patient to do?

It is very frustrating to lose vision from macular degeneration. Currently, FDA-approved treatments help many patients, but fall short of a cure. It is understandable for a desperate patient to seek care where hope is offered. However, current “cell therapy clinics” are not the answer. Seek the advice of your trusted ophthalmologist and utilize low vision care with magnification. Await the results of FDA-sponsored clinical trials to find safe and effective treatments for macular degeneration.

By Scott E. Pautler, MD

What is Vuity?

How does Vuity work?

What did the studies of Vuity show?

How do you use Vuity?

What are the adverse effects of Vuity?

Share this:

Like this:

What is retinitis pigmentosa?

What causes retinitis pigmentosa?

What are the symptoms of retinitis pigmentosa?

How is retinitis pigmentosa diagnosed?

How is retinitis pigmentosa treated?

Share this:

Like this:

What is the unlawful use of DNA?

What is DNA and why is it important?

What type of DNA information is included in this law?

How does this law impact you and your doctor?

Share this:

Like this:

What is tea tree oil and how is it helpful?

How does tea tree oil improve the health of the eyelid?

Share this:

Like this:

What is diabetic vitreous hemorrhage?

What symptoms does diabetic vitreous hemorrhage cause?

What causes diabetic vitreous hemorrhage?

How is diabetic vitreous hemorrhage treated?

What should I be on the lookout for?

Share this:

Like this:

What is neovascular glaucoma (NVG)?

What causes neovascular glaucoma (NVG)?

What are the symptoms of neovascular glaucoma (NVG)?

How is neovascular glaucoma (NVG) diagnosed?

What treatment is available?

Share this:

Like this:

What is Sickle Cell Disease?

Who is at risk of eye problems in sickle cell disease?

What are the visual symptoms of sickle cell disease?

What treatment is available?

Share this:

Like this:

Why am I losing vision despite treatment for age-related macular degeneration?

What is to be done about the continued loss of vision?

Share this:

Like this:

What is retinal angiomatous proliferation (RAP)?

What causes retinal angiomatous proliferation (RAP)?

What are the symptoms of retinal angiomatous proliferation (RAP)?

How is retinal angiomatous proliferation (RAP) diagnosed?

Why is this diagnosis important?

Share this:

Like this:

What is giant cell arteritis (GCA)?

Share this:

Like this:

How can COVID-19 affect cosmetic fillers?

What causes the swelling to occur?

How long does the swelling last?

What treatment is available?

Share this:

Like this:

How can a tattoo cause blindness?

What are the symptoms of TAGU?

Who is at greatest risk of TAGU?

How is TAGU diagnosed?

How is TAGU managed?

What are other risks of tattoos?

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Shape of the eye

The Tear Film

The Conjunctiva

The Sclera