Category Archives: Uncategorized

Glaucoma

Posted on by
globe anatomy

anatomy of the eye (click on image to enlarge)

What is Glaucoma?

Glaucoma is a condition in which the 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. Glaucoma affects two million Americans and is the second leading cause of blindness in the United States.

What causes glaucoma?

There are many different types of glaucoma, but most types of glaucoma have in common an abnormally high pressure inside the eye. The pressure in the eye is not directly related to blood pressure. The normal range of pressure in the eye is between 8-21 units of measurement. There is a tissue inside the eye that pumps a clear fluid (aqueous) into the eye keeping the eye from collapsing. Another tissue called the trabecular meshwork normally drains the aqueous from the eye preventing the pressure from building up. In most types of glaucoma, the drain becomes clogged or blocked resulting in an increase of the pressure inside the eye. High pressure inside the eye damages the cells of the optic nerve. In an uncommon type of glaucoma (normal tension glaucoma), the pressure measurements are within the normal range, but the optic nerve is unusually sensitive and will become damaged if the pressure is not lowered even further.

Who is at risk for having glaucoma?

About two or three percent of Americans develop glaucoma. It may occur at any age, but usually occurs after the age of forty. It appears to be hereditary and, therefore, is more common in people who have family members with glaucoma. Diabetes increases the risk of glaucoma.  African-Americans develop glaucoma fifteen times more frequently than European-Americans. Another risk factor for glaucoma is uveitis and trauma…especially, blunt injury to the eye. Steroid eyedrops and injections (triamcinolone and Ozurdex) may bring out glaucoma in eyes that are predisposed.

What are the symptoms of glaucoma?

The most common type of glaucoma is “open angle” glaucoma. In its early stages, glaucoma causes no obvious symptoms. However, driving vision can be impaired early on. Moreover, if it is not detected and treated early, glaucoma eventually may cause a gradual, severe, permanent loss of vision.  Rarely, visual hallucinations may occur.

A less common type of glaucoma called “angle closure” glaucoma may cause sudden pain, redness, and blurred vision. It is more often seen in far-sighted eyes. In some cases, the tendency for an acute attack of glaucoma can be predicted on examination. In such cases laser treatment and/or cataract surgery may help to “open” the angle to prevent a future attack of angle closure glaucoma.

How is glaucoma 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 a routine exam. Another way to diagnose glaucoma is by examination of the optic nerve inside the eye. A nerve damaged by glaucoma has an abnormal appearance called “cupping,” which may provide a clue to the diagnosis. Additionally, a formal measurement of the peripheral vision (side vision) by a visual field test usually confirms the loss of vision that may not otherwise be noticeable. A visual field test is not part of a standard exam, but is performed if glaucoma is suspected. Repeated visual field tests help to determine whether treatment has been adequate to prevent loss of vision. Finally, sophisticated computerized tests (optical coherence tomography) are available to measure the thickness of optic nerve fibers to help in the diagnosis and assess the treatment of glaucoma.

What treatment is available?

Treatment of glaucoma is directed at lowering the pressure in the eye. 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, laser surgery may help. Finally, surgery performed in the operating room (trabeculectomy) may create 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 trabeculectomy and result in severe damage or blindness. In general, patients with glaucoma may require regular examinations every three to four months to preserve vision.

By Scott E. Pautler, MD

For more information on glaucoma contact the Glaucoma Research Foundation at 1-800-826-6693 (www.glaucoma.org).

Copyright © 2014-2023 Designs Unlimited of Florida. All Rights Reserved.

Cataract

Posted on by
Cataract
Cataract is a foggy lens inside the eye (click image to enlarge)

What is a cataract?

A cataract is a foggy lens inside the eye. The lens is positioned behind the iris to focus light that passes through the pupil (see drawing above). The lens inside the eye works like a lens in a camera. The normal lens is clear, but it may lose its clarity over time. When the lens loses its clarity, it causes hazy and cloudy vision, often with glare from on-coming lights. The distance vision is often affected more than the near vision.

What causes cataract?

Cataract is common with age. The older a person becomes, the more likely cataracts will form. Other causes include heredity (family history of cataract), inflammation, blunt injury to the eye, sun exposure, tobacco, high blood pressure, diabetes, and medications (such as corticosteroids (prednisone) and some anti-depressants known as SSRI inhibitors).

How is cataract treated?

The only treatment of cataract is surgery in the operating room, with or without the assistance of laser. There is no way to remove a cataract with vitamins, pills, or eye drops. However, a change in glasses may minimize the blurred vision caused by cataract in the early stages. There is no emergency to treat a cataract. It will not harm the eye to hold-off from having surgery except in extremely severe cases. At the time of cataract surgery, a lens implant will be placed inside the eye to improve the ability of the eye to focus.

When is surgery needed?

Surgery is needed when the haziness in the vision from cataract has become bad enough to require improvement in vision that cannot be achieved with glasses. This is a decision made by the patient with help from the doctor.

By Scott E. Pautler, MD

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

Better Diabetes Management with the Hemoglobin A1c Test

Posted on by

What is hemoglobin A1C?

Hemoglobin A1C is a blood test that measures the average blood sugar level in the blood over the past two or three months. Specifically, this test measures the amount of sugar that permanently attaches to hemoglobin, a protein in red blood cells. Because red blood cells live for about three months, this test shows the average blood sugar level during that time. This test gives some of the information that you could get if you measured your blood sugar every day continuously throughout the day and night.

Why is hemoglobin A1C important?

We know high blood sugar damages blood vessels and may cause blindness, kidney failure, nerve damage, amputation, heart attack, stroke, and premature death. Managing blood sugar dramatically reduces the risk of these complications. The hemoglobin A1C test helps to determine whether your blood sugar control has been adequate to minimize damage from diabetes.

Do I need both hemoglobin A1C and standard blood sugar testing?

Yes. Each test gives different information about blood sugar control. For example, your fasting blood sugar may be normal, but if your hemoglobin A1C is high, then you know there are times in the day that the blood sugars are too high and you are still at risk of having complications from diabetes. On the other hand, if your hemoglobin A1C is high, you need spot checks of the blood sugar level to know specifically what part of the day in which you may need to manage differently.

How do results from hemoglobin A1C compare with blood sugar levels?

The hemoglobin A1C test measures the percent of hemoglobin that is chemically bound to sugar. The normal range of hemoglobin A1C is 4-6%, which corresponds to an average blood sugar level of 60-120 mg/dl. Your doctor will help determine what level is best for you, but generally a hemoglobin A1C greater than 7% (average blood sugar equal to 140 mg/dl) means that measures must be taken to achieve better management.

The hemoglobin A1C  test results may be inaccurate in certain conditions. The test results may be falsely low in the following situations: the use of dapsone, certain types of anemia, mechanical heart valves, recent blood transfusion, enlarged spleen, treatment with erythropoietin, severely elevated triglycerides, high-dose vitamin C or E.

Conversely, test results may be falsely elevated in the following situations: untreated hypothyroidism, after surgical removal of the spleen, Iron deficiency, vitamin B12 deficiency, reduced red blood cell production by the bone marrow, chronic alcoholism, chronic kidney disease.

If there is a question about the reliability of the test results, other means of testing may be considered, such as the fructosamine test.

Hemoglobin A1cBlood Sugar
A1c(mg/dL)
4%60
5%90
6%120
7%150
8%180
9%210
10%240
11%270
12%300
13%330

What can I do if my hemoglobin A1C results are high?

While it is important to keep blood sugar levels from being too high, it is also important not to risk frequent or severe episodes of dangerously low blood sugar levels. You and your doctor will evaluate your situation to determine which of the following factors may be playing a role:

  • Too little exercise
  • Inadequate medication type or dosing
  • Too much food
  • Wrong types of food
  • Increased stress
  • Infection

The hemoglobin A1C test provides you with more information to maintain good management of your diabetes. Better control means a longer, healthier life. And any positive change in your care, no matter how small, makes a difference. For example, each 1% decrease in the hemoglobin A1C reduces the risk of eye and kidney damage by 37% and reduces the risk of diabetes-related death by 21%. The more you are involved with your health care, the greater the likelihood of living a longer and healthier life.

By Scott E. Pautler, MD

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

USF Resident Post 2013

Posted on by

To the USF residents: I enjoyed meeting you for the lecture on infectious diseases. I hope this link to a movie version of the lecture is helpful to review the topics discussed on 12-19-13. Please give me  feedback on how I may improve the presentation.

DOCTOR SCOTT E. PAUTLER NAMED TO PRESTIGIOUS BEST DOCTORS IN AMERICA® LIST

Posted on by

Best Doctors

Doctor Scott E. Pautler has been named one of the Best Doctors in America® for 2014. The prestigious recognition marks the seventeenth time that Doctor Pautler has earned this honor.

The highly regarded Best Doctors in America® List, assembled by Best Doctors, Inc. and audited and certified by Gallup® results from exhaustive polling of over 45,000 physicians in the United States. In a confidential review, current physician listees answer the question, “If you or a loved one needed a doctor in your specialty, to whom would you refer?”  Best Doctors, Inc. evaluates the review results, and verifies all additional information to meet detailed inclusion criteria.

Best Doctors has earned a sterling reputation for reliable, impartial results by remaining totally independent. Doctors cannot pay to be included in the Best Doctors database, nor are they paid to provide their input. The List is a product of validated peer review, in which doctors who excel in their specialties are selected by their peers in the profession.

Over the past 20 years, Best Doctors has earned global acclaim for its remarkable database of physicians, regarded as the world’s premier effort to create a validated, peer-reviewed database of excellence in medicine.  The Best Doctors methodology is rigorously impartial and strictly independent; only those doctors recognized as the top 5% of their respective specialty earn the honor of being named one of the Best Doctors in America.  The experts who are a part of the Best Doctors in America database provide the most advanced medical expertise and knowledge to patients with serious conditions – often saving lives in the process by finding the right diagnosis and right treatment.

About Best Doctors, Inc.:

Best Doctors works with the best five percent of doctors, ranked by impartial peer review, to help people get the right diagnosis and right treatment. The company’s innovative, peer-to-peer consultation service offers a convenient new way for physicians to collaborate with other physicians to ensure patients receive the best care. The global health solutions company, which has grown to over 30 million members worldwide, uses state-of-the-art technology capabilities to deliver improved health outcomes while reducing costs. Gallup® has audited and certified Best Doctors’ database of physicians, and its companion Best Doctors in America® List, as using the highest industry standards survey methodology and processes. Founded in 1989 by Harvard Medical School physicians, Best Doctors seamlessly integrates its trusted health services with Fortune 500 and Fortune 1000 employers, insurers and other groups in every major region of the world. The company also designs and implements international insurance programs that help people be sure they get the right health solutions.

Tobacco and Eye Disease

Posted on by

How does tobacco affect the eyes?

Tobacco use is widely known to cause lung damage, but the eyes are also affected. Bothersome irritation of the eyes is caused by smoke from tobacco especially in patients with dry eyes. However, permanent loss of vision may occur from such problems as macular degeneration, retinal vein occlusion, ocular histoplasmosis syndrome, glaucoma, cataract, Grave’s Disease (a thyroid condition that affects the eyes), uveitis (inflammation of the eye), ischemic optic neuropathy, and diabetic retinopathy. Tobacco appears to play a role in causing and/or worsening these conditions. Tobacco is known to promote hardening of the arteries, and this may harm blood flow to the eye. Tobacco also promotes the development of blood clots, which may block blood flow in the eye. Tissue damage also occurs from toxic compounds in tobacco that cause a chemical reaction called oxidation. More research is needed to fully understand the role of tobacco in causing loss of vision.

What resources are available to help stop tobacco use?

Because most people cannot stop tobacco “cold turkey,” many resources are available to help quit the habit. Counseling may provide much needed support in the process of stopping tobacco use. For free classes and one-month’s supply of nicotine replacement therapy, your doctor can refer you to the Area Health Education Center. Alternatively, you may call 1-877-848-6696. The class schedule may be viewed at www.ahectobacco.com/calendar.  If you are interested in talking to informed support staff, please call 1-800-QUIT-NOW. Nicotine replacement therapy plays an important role and several preparations are available over-the-counter. These non-prescription forms of nicotine include gum, lozenges, and patches. Medicare and most insurance companies now cover the costs of prescription medications to help stop tobacco use. These include nicotine nasal sprays, nicotine inhalers, as well as pills (Zyban and Chantix). With the help of counseling, nicotine replacement, and prescription medication, you can live a longer and healthier life without tobacco. For more information please visit www.smokefree.gov.

By Scott E. Pautler, MD

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

Sub-Tenon’s Steroid Injection

Posted on by

Why is a sub-Tenon’s steroid injection performed?

A sub-Tenon’s steroid injection (STS) is an office procedure performed to decrease inflammation, swelling, or leaky blood vessels inside the eye. The steroid medicine acts to decrease inflammation and leakage from blood vessels from a variety of causes, thereby offering the opportunity for improvement in vision. The effect of STS lasts for several months after which repeated injection may be considered if necessary.

How is a sub-Tenon’s steroid injection performed?

Anesthetic solutions are used to make the procedure pain-free. A pressure sensation is often felt as the steroid is injected next to the eye with a very thin, short needle. The procedure is brief.

Periocular steroid injeciton
Sub-Tenon’s Steroid Injection (click on image to enlarge)

Will the injection affect my vision?

The vision may be slightly blurred immediately after an injection. The anticipated improvement in vision occurs slowly over a period of weeks to months. Sometimes, the pressure inside the eye increases and may require eye drops for several months. There may also be an increased rate of cataract formation. It is common for the upper lid to droop slightly; this improves over several months.  Rare risks of steroid injection include bleeding, infection, retinal detachment, glaucoma, and loss of vision. Please report any severe loss of vision to the doctor without delay.

How do I care for the eye after injection?

If a patch is placed on the eye, keep it on as directed by the doctor, usually 2-3 hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after STS. Tylenol or Ibuprofen may be used if there is discomfort after the injection, 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.

By Scott E. Pautler, MD

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

Migraine with or without a headache

Posted on by

 

Migraine aura
Artistic illustration of migraine aura (click on image to enlarge)

What is migraine?

Migraine is a common cause of headache that affects 10% of the population. Migraine may also cause unusual visual symptoms that occur with or without a headache.

What causes migraine?

The cause of migraine is unknown, but heredity may play a role. Many people with migraines have family members who also have had migraine. Migraine may be caused by abnormal episodes of blood vessel constriction within the brain. A number of events may trigger a migraine (ref): emotional stress, hunger, lack of sleep, hormonal changes (puberty, menopause, and hormone pills), bright lights, loud noises, a change in altitude or weather conditions, exercise, and certain foods (including caffeine, chocolate, alcohol, and red wine). Sometimes eye problems can worsen or bring on migraine. Such problems include improper eyeglasses, eye dryness, double vision, past eye injury or eye surgery.  There is evidence that links migraine with a defect in the wall of the upper chamber of the heart (patent foramen ovale).  It has been theorized that small particles (e.g. platelet-thrombin emboli) may originate in the venous circulation and pass through the defect in the heart wall into the arterial circulation and on to the brain.  This might explain small defects in the brain sometimes seen on MRI scans in patients with migraine.   

What are the symptoms of a migraine?

Migraine is associated with a great number of symptoms. Hours or days before a migraine episode occurs, subtle symptoms may be noticed. These symptoms include depression, fluid retention, and stomach disturbances. Visual symptoms can occur before a headache or be the sole symptom of a migraine. These visual symptoms occur without warning when the vision is impaired just off to the side of central vision. A jagged light (“like cracked glass”), which appears to shimmer or repeatedly flash, borders the area of impaired vision. The jagged light causes a missing area of vision and gradually works away from the center to the peripheral vision, taking on a C shape over a period of 15 to 30 minutes. It sometimes is described as heat waves, bubbles, tunnel vision, or a kaleidoscope, and it may be silver and white or in color. Objects may appear too small or too big (This is called the Alice in Wonderland Syndrome). In middle-aged patients a brief loss of vision may occur in one eye resembling a stroke-like symptom. It usually involves both eyes but may appear more prominently in one eye. In younger patients, nausea and a throbbing headache often follow the light flashes. In older patients, the visual symptoms may occur without headaches.  Keep in mind that there are many types and causes of flashing lights.

Migraine may also cause other symptoms that do not involve the eyes. Such symptoms include tingling of the face and hands, weakness, or trouble with speech. If this occurs, it may be helpful to call a neurologist for consultation.

The headache may be described as a deep, penetrating pain or a painful stretching sensation. The headache often begins on one side of the head, but it may spread over the entire head. It may be throbbing nor non-throbbing.

aura from Migraine
Simulation of migraine aura (click on image to enlarge)

 

What treatment is available?

Making the correct diagnosis is the most important step. Light flashes may be caused by other problems such as retinal detachment. Therefore the eye doctor is often called on to make this important distinction. If migraine symptoms occur infrequently, no treatment is needed.  Establishing regular sleep, a healthful diet, and regular exercise programs may help. Riboflavin and magnesium supplements may be of benefit as well. Prescription medication is available if headaches are severe or frequent.  They are usually prescribed by a neurologist.  

If there is any significant change in symptoms or if permanent loss of function occurs, please contact your doctor without delay. In rare instances, a brain aneurysm or tumor may cause unusual light flashes and headache. Your doctor will decide whether further examination or testing is required.

By Scott E. Pautler, MD

Copyright  © 2013-2023 Designs Unlimited of Florida.  All Rights Reserved.

Note: This blog is supported by its readers via small commissions that may be earned through hyperlinks.  The commissions do not increase the price you pay and do not affect the content of this article.  Thank you for your support.

How to find a good retina doctor?

Posted on by

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