Floaters and Flashes

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vitreous gel
Vitreous gel fills the eye (Click on image to enlarge)

 

What are floaters and flashes?

Floaters are small specks, fibers, or bug-like objects that may appear to move in front of your eye.  They appear black or gray and may be few or numerous.  At times they may appear like a veil or cloud moving in the vision even after the eye is still.  They are frequently seen when looking at a brightly lit background, like a blank wall or blue sky.  Floaters are actually tiny clumps of fiber or cellular debris within the jelly-like fluid (vitreous) that fills the inside of the eye. Many dot-like floaters may be due to bleeding inside the eye, especially when they come on suddenly. Long-standing, numerous, dot-like floaters may represent inflammation in the eye.

Floaters image
Floaters as simulated in photograph (click on image to enlarge)

Flashes are brief streaks of light that are usually seen off to the side, especially at night when you turn your head or eyes.  They may appear curved or like a brief lightning flash and last for only a second. Flashes are caused by fibers in the vitreous gel tugging on the retina with eye movement. This type of flashing light is different from migraine.

What do these symptoms mean?

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 instances, the retina may tear and cause blindness from detachment of the retina.

What causes floaters and flashes?

Floaters and flashes are usually due to degeneration of the vitreous gel in the eye from ageing.  Over time, the vitreous shrinks, condenses, and pulls away from the retina.  The condensation causes floaters and the pulling irritates the retina and is perceived as flashes of light. Myopia (near-sightedness) is a common cause of long-standing floaters.

What should be done about these symptoms?

The most important step is to have a thorough dilated eye examination, preferably by a retinal specialist.  The need for examination is urgent if the onset of symptoms is sudden. The eye doctor will check for the presence of a tear in the retina.  If a tear is found, laser or cryopexy is usually recommended to decrease the chances of blindness from retinal detachment.  If a retinal detachment is found, more extensive surgery is required in attempt to repair it.

Once an exam has demonstrated no retinal damage, he symptoms of flashes and floaters do not require specific treatment.  The flashes usually occur less frequently over time.  It may take days or weeks for the flashes to subside. Rarely, flashes will continue over many years.  Likewise, floaters subside with time, but take weeks to months to become less noticeable.  It is best not to concentrate on following floaters by moving your eyes as it may make them more bothersome. Depression and stress may worsen the degree in which floaters interfere with daily visual activities.

Many people have long-standing floaters that are not bothersome. In these cases, no treatment is needed after an examination to insure good eye health. Very rarely floaters will persist and interfere with vision. In these unusual cases, vitrectomy surgery may be considered. There are options to consider.

What should you be on the lookout for?

After examination or treatment, any significant new floaters (especially, many new dot-like floaters) or any loss of side vision should be reported to the doctor without delay.  An occasional flash of light in itself is not usually indicative of damage to the retina.  Sometimes, new tears or a retinal detachment can occur at a later date after the initial examination.

By Scott E. Pautler, MD

Copyright  © 2014-2022 Designs Unlimited of Florida.  All Rights Reserved.

Jetrea Injection (Ocriplasmin)

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vitreous gel
Clear vitreous gel fills the eye (click on image to enlarge)

What is Jetrea® injection used for?

Prior to being discontinued, Jetrea therapy was a treatment for retinal conditions involving abnormal pulling of fibers on the retina. Usually due to ageing, fibers which normally lie on the surface of the retina begin to pull on the retina causing a loss of vision. The treatment involved the injection of medication into the eye to cause of release of traction (pulling) on the retina. It may take weeks to months for Jetrea to take effect.

Jetrea

How effective is Jetrea therapy?

In vitreomacular traction syndrome about 40% of cases improve when the traction is limited. In macular hole cases, successful closure of the hole is seen within six months in as many as 60% of eyes with small holes. Please refer to separate literature on these conditions.

Jetrea VMT
Vitreomacular traction relieved by Jetrea (click to enlarge)

What are the risks of Jetrea therapy?

Severe complications are very rare, but risks of Jetrea injection include bleeding, infection, inflammation, glaucoma, dislocation of lens, retinal detachment, cataract, and loss of vision/loss of the eye. A common side effect of treatment is the appearance of new floaters in the vision. Less than one percent of injections are associated with sudden decreased vision for unknown reasons. Fortunately, the vision returns in most cases within a two week period. About 2% of eyes injected with Jetrea experience a yellow tint in the vision which usually clears with time. Currently, it does not appear that Jetrea has any significant systemic adverse effects.  However, pregnancy should be avoided while on Jetrea therapy.

What do I expect after a Jetrea injection?

If a patch is placed on the eye, keep it on as directed by the doctor, usually 3-4 hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after the injection. Tylenol or Ibuprofen may be used if there is discomfort, but severe pain should be reported to your doctor without delay. It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. If you have any questions or concerns, please call the office. If Jetrea is not successful, vitrectomy surgery may be considered.

Note: Since June 30, 2020, Jetrea stopped being manufactured.

By Scott E. Pautler, MD

Copyright  © 2013-2020 Designs Unlimited of Florida.  All Rights Reserved.

Macular Hole

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globe anatomy
anatomy of the eye (click on image to enlarge)
normal macular OCT
The macula is the center of the retina (in box). The bottom image is an optical coherence tomogram of the macula. (Click to enlarge)

What is a macular hole?

Macular hole means there is a tiny hole in the center of the retina.  The retina is a thin layer of tissue in the back of your eye which lines the inside wall like the film inside the back of a camera.  The retina “takes a picture” of objects you look at and sends it to the brain.  The macula is the center of the retina and gives you sharp central vision for reading and seeing fine details.  When the macula is damaged, the central vision worsens.  Macular hole is not macular degeneration and does not lead to macular degeneration. Macular hole affects both eyes in only about 10% of cases.

What causes a macular hole?

A macular hole is caused when the clear gel that fills the eye (vitreous) pulls on the macula.  When you are born the vitreous gel is thick, clear, and filled with tiny, invisible fibers.  With age or trauma, the vitreous gel begins to condense and pull away from the retina.  If the attachment of the vitreous to the macula is unusually strong, the pulling may result in a macular hole.

What are the symptoms of a macular hole?

Blurring of vision is mild at first, noted especially while trying to read fine print.  It slowly worsens; often with distortion (straight lines look crooked).  Sometimes there is a small blind spot in the center of vision. The visual symptoms may be detected and monitored with the Amsler grid test.

What treatment is available?

In a small number of cases, a macular hole may heal itself. In other cases the vision improves with a medicine injection (Jetrea®). If this fails or is not possible, a surgery may be performed that releases the abnormal pulling of the vitreous on the macula.  A gas bubble (pneumatic retinopexy) is then placed in the eye to close the hole in the macula.  Strict facedown positioning is recommended for several days following surgery.  Special cushions and massage tables are available to help maintain the proper head position.  The most common side effect of surgery is cataract formation.  Cataracts develop after surgery in most eyes over several months to years.  About 5% of eyes require more than one surgery to close the macular hole.  In 2-3% of eyes, the retina may detach during or soon after surgery as a result of continued pulling on the retina by vitreous fibers.  This requires additional surgery to prevent profound loss of vision.  Unommon risks of surgery include hemorrhage, infection, blindness and loss of the eye.

Surgery to close macular hole is usually successful in improving vision, though the vision rarely returns completely to normal.  Some residual distortion and central blurring of vision is common. The vision improves very slowly after surgery over several months to years.

By Scott E. Pautler, MD

Copyright  © 2001-2022 Designs Unlimited of Florida.  All Rights Reserved.

For more information please visit Retina Vitreous Associates of Florida.

Vitreomacular Traction Syndrome

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vitreous gel
Clear vitreous gel fills the eye (click on image to enlarge)
normal macular OCT
The macula is the center of the retina (in box). The bottom image is an optical coherence tomogram of the macula. (Click to enlarge)

What is the vitreomacular traction syndrome?

The vitreomacular traction syndrome is a condition in which the vitreous gel, which fills the inside of the eye, pulls on the macula. The macula is the center of the retina and gives sharp central vision for reading and seeing fine details. The retina is a thin layer of tissue in the back of the eye that lines the inside wall like the film inside the back of a camera.  The retina “takes a picture” of objects you look at and sends it to the brain. When the macula is damaged, the central vision worsens.

What causes the vitreomacular traction syndrome?

The vitreomacular traction is caused when the clear gel that fills the eye (vitreous) pulls on the macula.  At birth the vitreous is a thick and perfectly clear gel.  With age or trauma the vitreous gel begins to condense and pull away from the retina.  If the attachment of the vitreous to the macula is unusually strong, the vitreous may pull the macula away from its normal position, distorting this normally smooth tissue.

normal OCT
Normal macula as seen on optical coherence tomography (click to enlarge)
VMT
Vitreomacular traction as seen on optical coherence tomography (click to enlarge)

What are the symptoms of the vitreomacular traction syndrome?

Blurring of vision is mild at first, noted especially while trying to read fine print.  It slowly worsens, often with distortion (straight lines look crooked).  Sometimes there is a vague blind spot in the center of vision. The visual symptoms may be detected and monitored with the Amsler grid test.

What treatment is available?

If the symptoms are mild, no treatment is needed.  Medicine injection (Jetrea®) or vitrectomy surgery may help if there is significant loss of vision.  In most cases the vision improves with injection or a surgery that releases the abnormal pulling of the vitreous on the macula.  A gas bubble may be placed in the eye to smooth out the macula.  Strict facedown positioning may be recommended for one week following surgery.  Special cushions and massage tables are available to help maintain the proper head position.  The surgery is usually successful in returning vision, though the vision may not return completely to normal.

The image below shows the separation of vitreous fibers from the macula after Jetrea injection:

Jetrea VMT
Vitreomacular traction relieved by Jetrea (click to enlarge)

Below is a video that reviews the anatomy of the eye, information on vitreomacular traction, and an example of vitrectomy surgery:
https://youtu.be/r-5Az8_DU3U

Below is the case of a 70-year-old woman who had mild VMT. She was observed over several years and the traction released without surgery.

By Scott E. Pautler, MD

Copyright  © 2013-2022 Designs Unlimited of Florida.  All Rights Reserved.

How to find a good retina doctor?

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Why is it necessary to find a good retinal doctor?

Finding a good retinal doctor is important to receive the best level of care. Your doctor should be up-to-date on the latest treatments and be able to choose from among the many choices of treatment to determine which is the best for you as an individual. Some doctors may not keep up with new treatment options and, therefore, may not offer these choices to you as a patient. Moreover, some treatments work better for some patients, but do not work well for others. You must rely on your retinal specialist to offer the best treatment for you. To do so, your doctor must get to know your eyes and you as a person in order to choose what is best for you. The retinal specialist must then review the options and explain why he/she has chosen your treatment plan. All treatments have benefits, risks, and limitations. All of this information must be explained to you. It is helpful if the doctor gives you written information to take home to review after the visit.

How do you go about finding a good retina doctor?

This task is not easy or as obvious as it may seem. At a minimum, your retina doctor should be a medical doctor (MD or DO) and completed a residency in ophthalmology and should be board-certified by the American Board of Ophthalmology.  You can find out online if your doctor is certified. Board certification is essential, but it is only the first step in finding your retina doctor.

Be aware that some ophthalmologists call themselves retina specialists, but they have not completed a retina fellowship program. A retina fellowship is a one or two-year program of highly specialized training, which is undertaken after a general ophthalmology residency program. You may ask your doctor if he/she completed a fellowship in retinal disease and for how long (one or two years). Some information is available to you at the web site of the American Society of Retinal Specialists. You may prefer a doctor who has been trained at a highly reputable university. One source of information is Castle Connolly.

A number of additional factors may be important in the decision to choose the best retina doctor for you:

Does your doctor do research? This issue has a good side and a possible bad side. In general, research may help a doctor to stay up-to-date on diagnosis and treatment. On the other hand, intensive research may draw the doctor’s attention away from information that does not pertain to his/her research interest. In this scenario, the doctor may become an expert in a small area of research and fall behind in the general knowledge of patient care that is important to your care. Simply put, you may prefer a doctor whose primary interest is patient care, not scientific research. Having said that, there are superb retina doctors who excel at both research and patient care. When interviewing a retinal specialist, try to gain a sense as to whether the doctor is more interested in you and your eye problem or his/her research.

Who referred you to the retinal specialist? Although this may not be an important issue, it is something to consider. In years past, doctors referred their patients to other doctors primarily on the basis of their knowledge about who provided the best care. There was no incentive to refer to anyone but the best for their patients. Due in large part to considerable financial duress imposed by government regulation and the insurance industry, general eye doctors have found the need to reap financial gains by hiring retina doctors to work for them. In this setting, the referring doctor may choose a retina doctor who works in the same clinic (or a separate building owned by the same clinic) because he/she makes money from doing so. The clinic retinal doctor may well not be the best doctor available in the area for your care. When in doubt, get a second opinion outside the clinic.

Are you comfortable with your retina doctor? This is a simple, but exceedingly important question to ask yourself. If you do not feel comfortable with your doctor, you may not follow through with instructions properly. You may not ask questions and gain an understanding of your problem. Never hesitate to seek a second opinion. A good doctor is not threatened by second opinions. In fact, good doctors often offer second opinions to their patients who appear uncertain or distressed.

By Scott E. Pautler, MD

Diabetic Retinopathy

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Diabetes mellitus is a group of conditions characterized by abnormally high blood sugar levels.  Short-term side effects include increased thirst, frequent urination, and weight changes.  Long-term complications include numbness of the hands and feet, loss of vision, kidney failure, as well as hardening of the arteries leading to amputation, heart attack, stroke, and premature death.  Diabetes affects about one million Floridians and 16 million Americans.  It is the leading cause of blindness in America among adults.  Several studies have proven that strict control of blood sugar levels dramatically decreases the risk of blindness and other complications of diabetes.  The National Eye Institute proved that laser treatment may save vision if diabetic eye damage is detected early.  The American Diabetes Association recommends annual eye examinations for all adults with diabetes to prevent blindness.

What is the retina?

The retina is a thin layer of delicate nerve tissue, which 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.  The retina has two main areas.  The macula is the central area that gives you sharp, central vision and color vision.  The peripheral retina is the part of the retina that gives you side vision and night vision.

What is diabetic retinopathy?

Diabetic retinopathy is a condition that occurs after many years of high blood sugar.  It consists of damage to tiny blood vessels within the retina resulting in abnormal leakage of fluid and blood inside the eye.  If not detected or treated, diabetic retinopathy may cause bleeding, scar tissue formation, retinal detachment, and blindness.

Stages of diabetic retinopathy:

Non-proliferative diabetic retinopathy: The first stage of retinal damage consisting of a weakening or blockage of tiny blood vessels, which does not require treatment with laser unless macular edema develops.

Diabetic macular edema: Swelling of the central retina (the macula) due to abnormal leakage of fluid from small blood vessels weakened by diabetes.  Blurring of central vision may advance to legal blindness.

Proliferative diabetic retinopathy: The second stage of diabetic retinopathy in which abnormal, weak blood vessels begin to grow from the retina into the clear gel (vitreous) which fills the inside of the eye.  If not treated, this serious stage often results in blindness from bleeding.  Symptoms include new “floaters” or sudden loss of vision.  Retinal detachment may occur from diabetic scar tissue, which pulls the retina off the eye wall.  Retinal detachment causes a dark shadow in the vision or total loss of vision.  Laser and vitrectomy surgery best control these problems if detected early.

How is diabetic retinopathy diagnosed?

Because no symptoms may be present until severe damage to the retina has occurred, it is essential that all adults with diabetes have a complete, dilated eye examination at least once a year.  The eye doctor can see into the eye with an ophthalmoscope to diagnose retinopathy.  If significant changes are found, photographs can be taken to record the changes. A fluorescein angiogram may be performed in the office by injecting a fluorescent dye into the vein of the arm while photographs are taken of the retina.  It supplies important information about the health of the retinal blood vessels.

How is diabetic retinopathy treated?

No treatment is needed if the vision is not threatened.  If blood vessel damage is significant, painless injections of medicine (Avastin) may be required to improve vision. Laser treatment performed in the office can often prevent severe visual loss.  Laser produces heat, which serves to cauterize the damaged retinal blood vessels.  Usually there is no pain, but if extensive laser is needed, an anesthetic injection may be given around the eye.  In severe cases of bleeding and scar tissue formation, vitrectomy surgery is performed as a one-day surgery in the hospital.  With laser and vitrectomy surgery, most people can retain useful vision. However, some people lose vision despite all efforts with treatment.

What can I do to prevent diabetic damage?

Strict control of the blood sugar has been proven to reduce the rate of progression of diabetic retinopathy by about 70%.  In addition, loss of vision can be minimized by optimal control of other health problems such as physical inactivity, obesity, hypertension (<130/<80), cholesterol (<200) and triglycerides (<150), heart failure, and kidney failure.  Tobacco use is strongly discouraged.  Daily aspirin use is recommended.

PREVENT BLINDNESS THROUGH GOOD MANAGEMENT OF DIABETES AND REGULAR DILATED EYE EXAMINATIONS.

By Scott E. Pautler, MD

Copyright  © 2013 Designs Unlimited of Florida.  All Rights Reserved.