Tag Archives: retinal vein occlusion

Pain After Eye Injections

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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

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.

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Copyright  © 2020-2022 Designs Unlimited of Florida.  All Rights Reserved.

The Amsler Grid Test

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What is the Amsler grid?

The Amsler grid is a test used to detect and monitor macular disease (see Anatomy of the Eye). The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision.  The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera.  In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.

How is the Amsler grid used?

The grid is observed one eye art a time with reading glasses if needed for proper focusing at normal reading distance. The patient is asked to fixate on the center of the grid while using “side vision” to see if there are any missing areas. The lines on the grid should appear straight and uniform. If any abnormalities are noted, an ophthalmologist (retinal specialist) may be consulted to determine the cause of the problem.

Below is a link to download or print an Amsler grid chart for use at home.

Amsler grid RVAF

Some patients prefer a more sensitive (and more expensive) test to monitor the vision called the Foresee Home Monitoring Program.

By Scott E. Pautler, MD

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

Copyright © 2018-2022 Designs Unlimited of Florida.  All Rights Reserved.

Distortion
Distortion of lines on Amsler Grid (click on image to enlarge)

Laser Surgery and the Retina

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Laser
Laser treatment (click to on image to enlarge)

There are many different kinds of lasers used to treat eye problems and many different ways lasers can be used to help the eye function. For example, the most common type of laser performed after cataract surgery is YAG capsulotomy. In this procedure the YAG laser is designed to open up a foggy window that develops behind the lens implant. It is a very brief, painless laser that usually gives a rapid improvement in vision. Other uses for lasers include treatment for glaucoma, droopy eyelids, and near-sightedness. Lasers with specific properties are chosen for a specific purpose. This blog discusses the photocoagulating laser used to treat retinal problems.

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.

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

What types of problems affect the retina?

The most common problems for which laser is used to treat the retina include diabetes, retinal vein occlusion, macular degeneration, retinal macroaneurysm, and retinal tears.

How does the laser help?

Most retinal lasers work by producing a carefully measured amount of heat to the retina in very small spot sizes. This heat may help to cauterize leaking blood vessels as in diabetes or macular degeneration. Alternatively, laser may simply seal down the retina to help keep it from detaching from the inside wall of the eye in cases of retinal tears and limited retinal detachments.

What are the risks of retinal laser treatment?

While laser is generally safe and effective, there is always some risk of adverse effects. Depending on the purpose of the laser, risks include blind spots in the vision that may be permanent, loss of central vision, loss of color vision, loss of night vision, and distortion of vision.

What is it like to experience a laser treatment?

Laser treatment is performed in the office in a matter of a several minutes. To avoid pain and discomfort, the ophthalmologist anesthetizes the eye with eye drops. An injection of anesthetic around the eye is rarely required. You sit in the examining chair with your chin in the chin-rest and forehead against the supporting bar. A contact lens is placed on the eye to hold the eyelids open. You may blink normally during the laser. Try not to squeeze your eyes together, because it may push the contact lens off the eye. You may be asked to look in a specific direction or follow a small light in order to keep the eye in position for treatment. It is important to follow instructions carefully to avoid side effects of laser treatment, which may include seeing blind spots in the vision afterwards. During treatment, it is normal to see bright flashes of light. Sometimes, you may feel a pulsing sensation with the flash. If it becomes painful, please notify the doctor. The treatment may last one to fifteen minutes depending on how much retinal damage is present.

What can you expect after a laser treatment?

Immediately after the contact lens is removed, your vision may be temporarily tinted red or blue. The vision is usually blurred for a few hours because of the dilating drops. Temporary blurring from laser sometimes lasts a week or more, but is usually mild. If your laser treatment was for macular degeneration, you may see a new permanent blind spot in the vision where abnormal blood vessels were cauterized. If you had laser for retinal break, it is normal for you to see floating specks in your vision and occasional flashes of light off to the side after laser. There are usually no restrictions to your activities. You may read, watch TV, stoop, bend, and lift objects just as before your treatment. No special eye drops are required after laser treatment, but be sure to continue any eye drops you were using before the treatment. You may use sunglasses for comfort, but they are not required. If you were told that laser is being used to improve your vision, it usually takes weeks or months to see the improvement. Sometimes, more than one treatment is required. Your doctor will give you an appointment to assess the results and determine whether any more treatment is needed.

What warning signs should I report after treatment?

Although it is normal to have blurred vision right after laser, the following symptoms are important to report to your Eye MD:

  • Pain
  • Severe loss of vision
  • Dark curtain or shadow across vision

By Scott E. Pautler, MD

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

Copyright © 2016-2022 Designs Unlimited of Florida. All Rights Reserved.

Ozurdex

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Ozurdex

 

What is Ozurdex and why is it used in the eye?

Ozurdex is a very small tube-like implant that contains steroid medication that is slowly released into the eye for up to 3-6 months. The Ozurdex implant is injected into the eye in the office setting in order to decrease inflammation, swelling, or leaky blood vessels inside the eye. It has been shown to improve vision in eyes with retinal vein occlusion, diabetic macular edema, and inflammation in the eye. The Ozurdex implant completely dissolves in the eye. Repeated injections may be necessary for continued improvement in vision.

How is an Ozurdex injection performed?

Anesthetics are used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation is often felt as the implant is injected into the eye with a very thin, short needle. The procedure is very brief.

What are the side effects of Ozurdex?

Although possible, it is rare to see the Ozurdex implant floating in the vision. In about 30-40% of patients, the pressure inside the eye increases and requires eye drops. About 1% of patients require glaucoma surgery to prevent loss of vision. Most eyes develop cataract and eventually require surgery. Rare risks of steroid injection include bleeding, infection, retinal detachment, and loss of vision/loss of the eye. The risk of infection is about one in 1,000 injections. Please report any severe loss of vision to the doctor without delay.

How do I care for the eye?

You may be given eye drops and instructions on how to use them. Physical activity is not limited after Ozurdex 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. Additional information is available at www.ozurdex.com.

By Scott E. Pautler, MD

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

Copyright © 2015-2022 Designs Unlimited of Florida. All Rights Reserved.

Intravitreal Steroid Injection

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

Why is an intravitreal steroid injection performed?

An intravitreal steroid injection (ISI) is a painless office procedure performed to decrease inflammation, swelling, or leaky blood vessels inside the eye. Conditions that may require ISI include diabetic macular edema, retinal vein occlusion, uveitis, macular degeneration, and other causes of swelling and/or inflammation. The steroid medicine acts to decrease inflammation and leakage from blood vessels from a variety of causes, thereby offering the chance for improvement in vision. The effect of ISI lasts for several months after which repeated injection may be considered if necessary.

How is an intravitreal steroid injection performed?

Anesthetic solutions are used to make the procedure pain-free.  The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation is often felt as the steroid is injected into the eye with a very thin, short needle. The procedure is very brief.

intra-ocular injection
Intra-vitreal injection

What medications are injected?

Triamcinolone is a steroid that has been used for many years in the eye. The most common preparation contains preservatives that may be decanted from the preparation to avoid ocular inflammation. Triesence® is a form of triamcinolone for the eye that lacks preservatives, but is more expensive. These steroids usually provide anti-inflammatory effect for several months.

Dexamethasone may be injected into the eye in a slow-release implant, called Ozurdex®. The effect of Ozurdex® may last up to 3-6 months.

Iluvien® is a steroid implant (2014) approved for the treatment of diabetic macular edema. It may last up to 2-3 years.

Yutiq® is a steroid implant approved for the treatment of uveitis. It may last up to 2-3 years.

steroids
Intraocular steroid preparations

Will an intravitreal steroid injection affect my vision?

It is normal to see the steroid medication after the injection as many floating particles (triamcinolone) or a single large fiber (Ozurdex®, Iluvien®, Yutiq®), which slowly disappear over several weeks to months in the case of triamcinolone and Ozurdex. The anticipated improvement in vision occurs slowly during this time. Commonly, the pressure inside the eye increases and may require eye drops for several months. Sometimes the high pressure results in optic nerve damage (glaucoma) and rarely requires surgery in 1-4% of cases. There is also an increased rate of cataract formation. For these reasons ISI is best performed in eyes that have already had cataract surgery and are not at high risk of glaucoma damage. Rare risks of steroid injection include bleeding, infection, retinal detachment, and loss of vision or loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections. The risk of infection is about one in 1,000 injections. Please report pain or any severe loss of vision after injection to the doctor without delay.

How do I care for the eye?

You may be given eye drops and instructions on how to use them. Artificial tears may be used hourly until the eye feels less irritated from the iodine solution, which is used to prevent infection. Physical activity is not limited after ISI. 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 your doctor.

By Scott E. Pautler, MD

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

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

Tobacco and Eye Disease

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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

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

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

Eylea (aflibercept) Therapy

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Eylea vial image


What is Eylea® therapy?

Eylea therapy is a treatment for diabetic retinopathy, retinal vein occlusion and wet-type macular degeneration.  It involves repeated painless injections of medication into the eye to prevent blindness by stopping abnormally leaky blood vessels that occur in the eye conditions listed above.  Other similar medications that are also used in these conditions include Avastin, Lucentis, Vabysmo, and Beovu.

How effective is Eylea therapy?

Eylea was proven in FDA-approved studies to be effective. In wet-type macular degeneration, monthly or bimonthly injections of Eylea over a one-year period offered a 95% chance of losing less than three lines on a standard eye chart. Eylea was also shown to be effective in the treatment of diabetic retinopathy and retinal vein occlusion to improve vision and prevent severe complications. The results with Eylea are similar to treatment with Lucentis, Avastin, and Beovu. Eylea therapy often starts with injections every 4-6 weeks. Afterwards, the injections may be given less frequently.  In some cases the injections may be stopped, but continued monitoring is necessary. There are several medication options apart from Eylea. The best choice of medication may depend on the underlying diagnosis. For example, patient who have glaucoma may have better pressure control while under treatment with Eylea compared with other drugs.

What are the risks of Eylea therapy?

Severe complications are very rare, but risks of Eylea injection include bleeding, inflammation, infection, retinal detachment, cataract, glaucoma, and loss of vision/loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor.  There may be an increased risk of difficultly with future cataract surgery estimated to be about 1% of cases. In these cases the fibers (zonules) that hold the cataract in place may become weaken from Eylea injection. When this occurs, special techniques are required to remove the cataract and place a lens implant. Rarely, two procedures are required to accomplish the task.  Studies are ongoing to determine if there may be an increased risk of stroke with Eylea therapy. The possible risk of stroke may be related to the older age of patients with AMD. Further investigation will provide more information. Pregnancy should be avoided while on Eylea therapy.

intra-ocular injection
Intra-vitreal injection

What do I expect after an Eylea injection?

Be careful not to rub the eye after the injection because the eye may remain anesthetized for several 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 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 doctor’s office.

By Scott E. Pautler, MD

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

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

Avastin Therapy for Retinal Disease

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What is Avastin therapy?

Avastin therapy is a treatment for retinal conditions involving abnormal blood vessel leakage including wet-type age-related macular degeneration, myopic macular degeneration,  retinal vein occlusion, diabetic retinopathy, and cystoid macular edema. The treatment involves the painless injection of medication into the eye to stop the leakage and improve vision. The benefits of treatment last one or more months. Repeat injections are common in order to keep the leakage from returning. When the problem has stabilized, the injections may be given less often or discontinued in some conditions. Avastin has not been reviewed by the FDA for use in the eye; therefore, it is used off-label. Safety and effectiveness has been established through extensive experience with the use of Avastin in the eye for a multitude of problems since 2005. There are other similar drugs that have been FDA-approved for use in the eye including Lucentis, Eylea, Vabysmo, and Beovu. These drugs are much more expensive than Avastin. Avastin costs about $50 compared to $2,000 with the FDA-approved drugs. There may be reasons to use one medication over another depending on the diagnosis.

How effective is Avastin therapy?

Avastin has been found to be effective in the treatment of a variety of retinal disorders of blood vessel leakage. It was shown to be as effective as Lucentis in the treatment of wet-type macular degeneration in most patients. Avastin is also effective in the treatment of macular edema, retinal vein occlusion, diabetic retinopathy and other conditions of the eye.

What are the risks of Avastin therapy?

Severe complications are very rare, but risks of Avastin injection include bleeding, infection, inflammation, glaucoma, retinal detachment, cataract, and loss of vision/loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor. There may be an increased risk of difficultly with future cataract surgery estimated to be about 1%. In these cases the zonules that hold the cataract in place may become weaken from Avastin injection. When this occurs, special techniques are required to remove the cataract and place a lens implant. Rarely, two procedures are required to accomplish the task. Studies are ongoing to determine if there may be an increased risk of stroke with Avastin therapy. Further research is needed. However, pregnancy should be avoided while on Avastin therapy.

There appears to be a greater risk of high eye pressure (glaucoma) in eyes treated with Avastin compared with Lucentis and Eylea. This may be especially important in patients at increased risk of glaucoma due to past high eye pressures or positive family history of glaucoma.

Because Avastin must be measured and placed in a syringe by a compounding pharmacy after manufacture, there may be increased risk of complications with Avastin compared with other similar drugs such as Lucentis, Eylea, Beovu, and Vabysmo. There may be an increased risk of infection due to the introduction of bacteria during repackaging.  Some patients experience persistent round floaters due to silicone droplets used to lubricate the syringe from the pharmacy.  Over the years, there have been concerns over needle quality (sharpness), which can make injection more uncomfortable.

intra-ocular injection
Intra-vitreal injection

What do I expect after an Avastin 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 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

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

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