Scott E. Pautler, M.D. Tampa

Treatment of diseases of the retina and vitreous

Blindness from Tattoo

Posted on April 30, 2021 by Scott Pautler

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

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

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.

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

Uveitis Diagnosis by Subtype

Posted on November 2, 2019 by Scott Pautler

Anterior Uveitis

Mimics: leukemia, lymphoma, RBCs, pigment dispersion, foreign body

Granulomatous:	Non-Granulomatous:
Sarcoidosis	HLA B27
TB	Herpes Group (esp unilateral)
Herpes group	TINU (esp acute/bilateral)
Toxoplasmosis	Fuch’s Uveitis (heterochromia)
SO/VKH	JIA
Blau Syndrome (child)	Spirochetes (Syphilis, Lyme)
Bactrim etc	Behcet
Moxifloxacin (iris transillumination)	Post-infectious/reactive
Spirochetes (Syphilis, Lyme)	Other: Posner Schlossman or drug-related
MS associated uveitis
Lens induced

Intermediate uveitis

(Primary vitreous involvement +/-retinal vascular sheathing, CME, disc edema)

Infectious:	Non-Infectious:
Syphilis	Multiple Sclerosis
TB	Sarcoidosis
Lyme Disease	Inflammatory bowel dz (Crohns, UC)
Bartonellosis (cat scratch)
Toxocara (unilateral)
HTLV-1 (joint/CNS findings)
Whipple’s Disease (bowel and neuro dz)
?Toxoplasmosis

Retinitis (chorioretinitis)

(Mimics: lymphoma, leukemia, met carcinoma, focal ischemia) Rule Out Infection!

Note: multimodal imaging is especially helpful in white dot syndromes

Infectious:	Non-Infectious:
Toxoplasmosis (most common focal)	White dot syndromes (e.g. APMPPE)
Herpes group (HSV/VZV/CMV)	Acute macular neuroretinitis (AMN)
Syphilis	Behcet Disease
Bartonella (cat scratch)
DUSN
Toxocara
Lyme Disease
Endogenous fungus or bacteria
Emerging (Dengue, Yellow fever, West Nile)

Choroiditis:

(mimics: benign and malignant tumors, Leukemic/lymphoproliferative infiltrates, scleritis)

Infectious:	Non-Infectious:
Syphilis	Sarcoidosis
Lyme Disease	APMMPE
TB (including Serpiginous-like)	Multifocal Choroiditis (+/- panuveitis)
Endogenous fungal/bacterial	Punctate Inner Choroiditis (PIC)
Cryptococcus (rare)	Ocular Histoplasmosis Syndrome
Coccidiodomycosis (rare)	Birdshot Choroiditis
Emerging dz (West Nile Virus)	Serpiginous and Relentless Placoid
	Blau Syndrome (AD, sarcoid-like)

Panuveitis:

Infectious:	Non-Infectious:
Syphilis	Sarcoidosis
TB	Multifocal Choroiditis with Panuveitis
Toxoplasmosis	VKH
ARN/PORN	Sympathetic Ophthalmia
Endogenous fungal/bacterial
Lyme Disease
Onchocerciasis (outside US)

Retinal Vasculitis:

Infectious:	Non-Infectious:
Syphilis	Sarcoidosis
Herpes group (Frosted branch)	Eales Disease (?TB)
para-viral syndrome	SLE, PAN, Churg Strauss, Wegener
HIV	Birdshot (before choroiditis)
Toxoplasmosis	Multiple Sclerosis
	Behcet Disease

Primary Artery:	Primary Vein:	Arteries and Veins:
Syphilis	Sarcoidosis	MS
Herpes Group	Eales Disease	Behcet Disease
SLE, PAN, Churg Strauss	para-viral syndromes	Wegener
Frosted Branch Angiitis	HIV	Frosted Branch Angiitis
	Toxoplasmosis
	Birdshot (before choroiditis)

By Scott E. Pautler, MD

Beovu for Macular Degeneration

Posted on October 22, 2019 by Scott Pautler

What is Beovu therapy?

Beovu (pronounced “BEE oh view”) therapy is a treatment for wet-type macular degeneration (AMD). It was approved by the FDA in the United States in 2019. It involves repeated injections of medication into the eye to stop abnormally leaky blood vessels. Other similar medications include Avastin, Lucentis, Eylea, and Vabysmo.

How effective is Beovu therapy?

Beovu was proven in FDA-approved studies to be as effective as Eylea. In wet-type macular degeneration, injections of Beovu over a one-year period offered a 95% chance of losing less than three lines on a standard eye chart. The results with Beovu were similar to treatment with Eylea; however, Beovu appeared to stop leakage in wet AMD more often than Eylea. Beovu therapy often starts with injections every 4-6 weeks. Afterwards, the injections may be given every two or three months to maintain vision. Half of eyes treated in a large study could be managed with injections every three months. At this time, it is not known whether Beovu is more effective than Eylea due to limitations in the studies to date.

What are the risks of Beovu therapy?

Severe complications are very rare, but risks of Beovu injection include inflammation (~10%), artery occlusion (~3.4%), bleeding, infection, retinal detachment, glaucoma, cataract, and loss of vision/loss of the eye. When inflammation occurs, it may affect the blood flow to the retina with an overall risk of ~3.4% in Beovu-treated eyes. This complication may result in permanent and profound loss of vision. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor. In initial studies there appeared to be a low risk of stroke with Beovu therapy. The risk of stroke may be related to the older age of patients in which it is used. Further investigation will provide more information. Pregnancy should be avoided while on Beovu therapy. Currently, caution is used in recommending Beovu due to the risk of inflammation and loss of vision, which appears greater than other available medications. In 2022, a new medication, V abysmo, was approved by the FDA. Vabysmo may offer the advantage of less frequent injections like Beovu, but with a lower risk of inflammation.

What do I expect after a Beovu 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. On the day of 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. After the day of injection, if you develop new floating dots, new pain, and/or loss of vision, contact your doctor.

By Scott E. Pautler, MD

Pentosan (Elmiron) and Your Eyes

Posted on October 13, 2019 by Scott Pautler

See Anatomy of the Eye

What side effects can pentosan polysulfate have on my eyes?

Although pentosan polysulfate (PPS) is of proven benefit for interstitial cystitis, it may cause damage to the eyes. Early symptoms may be subtle. Blurred vision, especially with reading, is common. Straight lines may appear wavy or distorted. There may be a slow adaptation from light to dark environments. Blind spots or missing areas may occur in the central vision. These symptoms are due to retinal damage; however, they are not specific to pentosan polysulfate damage. The Eye MD (retina specialist) must use special tests to determine whether vision symptoms are due to pentosan polysulfate or other types of retinal conditions such as macular degeneration.

Who is at risk of losing vision?

Ocular side effects appear to be related to a build-up of medicine in the body over years. The longer a person has been on PPS, the greater the chances of developing retinal damage. Although the average duration of use at the time of diagnosis is 15 years, some patients develop symptoms as early as three years after starting the medication. With continued use of PPS, additional permanent damage occurs that may result in loss of vision.

What can I do to protect myself?

Pentosan polysulfate is an effective medication for control of pain with interstitial cystitis. However, it is important to monitor your eyes for side effects that might indicate the need to stop the medication. The Amsler grid chart should be checked at least once a week testing each eye separately, using glasses if needed. Look for a missing part of the grid either above or below the central dot while looking only at the center of the grid. Additionally, your Eye MD should examine your eyes every year with specific testing to look for early signs of retinal changes. It may be useful to see a retinal specialist who has training in this area.

What happens if I develop retinal changes from pentosan polysulfate?

If early retinal changes are found, pentosan polysulfate may be discontinued. By discontinuing pentosan polysulfate at an early stage, vision may be saved. Continued examination is important to monitor the eyes for further changes. There is no specific treatment for retinal toxicity from pentosan polysulfate. However, if blood vessels grow under the retina, treatment may be helpful as with wet macular degeneration.

By Scott E. Pautler, MD

Treatment of Floaters

Posted on September 2, 2019 by Scott Pautler

What are floaters?

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. Floaters differ from blind spots in the vision in that floaters have some degree of independent movement. Blind spots are missing areas in the vision that move precisely with eye movement. Although floaters do follow the movement of the eye, there is usually some degree of continued movement after the eye stops moving. They are frequently seen when looking at 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.

What does this symptom mean?

Although many people have occasional floaters, the sudden onset of many new floaters with or without flashes is an important sign of abnormal pulling on the retina by the vitreous. Sometimes, the retina tears and may cause loss of vision from detachment of the retina. At other times, floaters may persist and chronically interfere with vision.

What causes floaters?

Floaters are usually due to degeneration of the vitreous gel in the eye from aging. Over time, the vitreous shrinks, condenses, and pulls away from the retina. The condensation causes fibers and cellular clumps to pull away from the retina and float freely inside the eye. The shadow of these opacities is what we see as floaters. Other causes of floaters include trauma, bleeding, retinal breaks and detachment, eye surgery, inflammation, and cancer (very rarely).

vitreous floaters and haze — Vitreous floaters and haze interfering with vision after repair of retinal detachment. The vitreous opacities appear as fibers and haze in this photo. They interfere with a clear view of the retina when looking into the eye and they interfere with the vision when looking out through the haze.

What can be done about floaters?

It is important to have a thorough dilated eye examination to determine the cause of floaters. Treatment is dictated by the cause of the floaters. If there is no serious underlying cause (retinal break, retinal detachment, etc.), no treatment may be needed. New floaters often fade without treatment. It can be helpful to avoid tracking or following floaters to allow your brain to ignore them. Floaters are less obvious in a darker environment, so wearing sunglasses outdoors may help minimize symptoms of floaters. Stress and depression appear to aggravate the symptoms of floaters and may be treated separately.

YAG Laser Treatment: A special laser may be useful in some cases of persistent floaters. It is an office treatment in which the laser in used to break the floating fibers and clumps into smaller fragments in the vitreous of the eye. Although it may help, YAG laser does not eliminate floaters. Repeat treatments are frequently necessary. Complications may include bleeding, increased floaters, retinal breaks and retinal detachment, which may require surgery to prevent blindness. There is limited evidence on the safety and effectiveness of YAG laser for floaters and it may not be covered by insurance. YAG laser may result in loss of vision/loss of the eye.

Vitrectomy Surgery: Vitrectomy is a surgery performed in the operating room. It is commonly used to treat serious problems of the vitreous and retina. It is very effective at reducing or eliminating floaters. However, complications include bleeding, infection, retinal break and retinal detachment, which may require surgery to prevent blindness. Serious complications occur in 1-2% of eyes reported in most studies, although some reports suggest the risk of complications may be as high as 10%. The most common problem with vitrectomy is cataract formation. After vitrectomy, cataract may develop over months to years and often requires cataract surgery. Glaucoma has been reported years after vitrectomy, but the exact incidence is not known. Vitrectomy surgery may result in loss of vision/loss of the eye.

For most patients the best course of action is observation of floaters without treatment at first. If symptoms persist and significantly interfere with vision despite 6-12 months of observation, treatment may be helpful. Most patients report good results with vitrectomy, but the possibility of complications must be carefully considered and accepted prior to embarking on surgery.

By Scott E. Pautler, MD

Amaurosis Fugax: A black-out of vision in one eye

Posted on August 13, 2019 by Scott Pautler

What is amaurosis fugax?

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 a retinal artery becomes blocked, it causes a sudden black-out of vision in one eye that may last minutes to hours. This symptom is called amaurosis fugax (pronounced, “am-a-ro-sis fyoo-jacks”).

What causes amaurosis fugax?

Amaurosis fugax (AF) is usually caused by a temporary blockage of blood flow to the eye from a piece of hardened artery in the neck (carotid artery) that breaks away and flows “down stream” to lodge in a small retinal artery. Abnormal tissue from a heart valve may also be the source of retinal artery blockage. Rarely, an interruption of blood flow to the eye may result from blood disorders or inflammation.

What is to be done?

First and foremost, a prompt eye exam is required to make an accurate diagnosis. Sometimes, intra-ocular hemorrhage, migraine, or retinal artery vasospasm may simulate amaurosis fugax. These other diagnoses are managed differently. If amaurosis fugax is confirmed, then evaluation is undertaken to find the cause of the blocked blood supply to the eye (retina or optic nerve). If the loss of vision is recent, the need for testing may be an emergency.

The reason for laboratory and x-ray testing is to identify treatable conditions that might cause stroke or permanent loss of vision if left untreated.

Where do I go for urgent care?

An urgent MRI brain scan (diffusion-weighted imaging) may be performed at a stroke center such as those available through the emergency room at Adventist Hospital, St. Joseph’s Hospital, or Tampa General Hospital. The brain scan can identify strokes that may be present without symptoms. Such strokes need to be treated in the hospital to prevent complications of paralysis and death.

Other important studies may also be performed to identify underlying treatable conditions. Blood tests may identify giant cell arteritis, a treatable inflammation of the arteries. A carotid sonogram studies the circulation of major arteries in the neck that lead to the brain and eyes. An ECHO cardiogram may identify an abnormal heart valve or a blood clot in the heart. These findings may be treatable to reduce the risk of future stroke.

Adventist Hospital Emergency Department

3100 East Fletcher Avenue

Tampa, FL 33613

(813) 971-6000

St. Joseph’s Hospital Emergency Department

3001 W Dr Martin Luther King Jr Blvd

Tampa, FL 33607

(813) 870-4000

Tampa General Hospital Emergency Department

1 Tampa General Circle

Tampa, FL 33606

(813) 844-7000

By Scott E. Pautler, MD

Intermediate Uveitis

Posted on December 15, 2018 by Scott Pautler

Eye — Vitreous is the gel that fills the eye (click on image to enlarge)

See Anatomy of the Eye

What 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. 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 or pars planitis.

What causes intermediate uveitis?

In other situations, uveitis is caused by inflammation without infection. For example, multiple sclerosis, sarcoidosis, HLA-B27, and inflammatory bowel disease 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.

What are the symptoms of intermediate uveitis?

How is intermediate uveitis managed?

To effectively treat intermediate uveitis, it is important to find the 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.

By Scott E. Pautler, MD

Retinal Rejuvenation

Posted on November 17, 2018 by Scott Pautler

Retinal rejuvenation is a name given by the company that sells a new-generation laser machine to ophthalmologists. The laser is used to treat the retina with the hope of delaying loss of vision from age-related macular degeneration (ARMD). Although the laser company calls this treatment “retinal rejuvenation,” this name may be overstating the true effects of this new laser.

The scientific basis for the use of the laser for macular degeneration is the LEAD study. This study evaluated 292 patients with ARMD over a three-year period. Half of the eyes were treated with the new micro-pulse laser and the remainder received sham treatment for comparison. Overall, the treatment was not shown to be of benefit in slowing the loss of vision from macular degeneration. However, when looking at subsets of eyes with certain types of macular degeneration (no reticular pseudodrusen), there was a trend toward a benefit. These results, however, had a weak fragility index (meaning that more research is needed). Conversely, eyes with reticular pseudodrusen (subretinal drusenoid deposits) lost vision at a greater rate after undergoing retinal rejuvenation than those eyes that were not treated.

“Retinal rejuvenation” needs more study before it is implemented on a wide scale basis. It is currently (2018) not approved for this use in the United States. More research is needed to better establish its helpfulness in reducing the risk of vision loss from age-related macular degeneration and to identify potential risks involved with its use.

I do not recommend the “retinal rejuvenation” treatment for age-related macular degeneration by the new micro-pulse laser at this time. I look forward to more high-quality research in the future to better establish the potential role of this laser for my patients with ARMD.

By Scott E. Pautler, MD

On-Time Doctor Award

Posted on October 31, 2018 by Scott Pautler

On-Time Award

Being on-time is an important issue for me, as waiting in the doctor’s office can seem like an eternity. I know your time is important. As such, I strive to train my staff to work with me to make your visit as pleasant and efficient as possible. When you approach the front desk, you are promptly greeted by our receptionist, not ignored as though you are invisible. Within short order a technician brings you back to the examination area of the office designed for optimal preparation for the doctor. You wait only long enough for the eye drops to dilate your eyes for retinal examination. I seek to spend time directing my attention to you and your eye problem, so I have my technicians take notes on the computer while I examine the retina. At this time, I use technical language that sound strange, but I soon translate the findings of my exam into everyday language. Because it is easy to forget what you hear in a doctor’s office, I encourage you to bring a family member or friend with you. Also, I supply information sheets for most retinal conditions and maintain an active blog site to help inform you about your condition.

Sometimes, the day does not go as planned. If an emergency patient is sent directly to see me for urgent care, I do fall behind. Nonetheless, I usually do not remain behind schedule for long because I allow extra time in my schedule for unforeseen delays in my schedule. Despite our best effort, first-time patients usually take extra time. Many forms are required by the government and the insurance company. An extensive history at the first visit is required to help identify the problem. Photographic testing can be time consuming. In complicated cases, we place a telephone call after the visit to communicate the results of exam and testing.

Regardless of how busy we are, I aim to treat you with courtesy and compassion. Wherever possible, I will minimize waiting. I am humbled and honored to have been awarded the “On-Time Doctor Award” by Vitals for 2018-2019. And I thank you for your patience on those days I am unable to meet my goal of “no wait.”

With sincerest regards,

Scott E. Pautler, MD, FACS

On-Time Award

Visudyne Photodynamic Therapy

Posted on September 30, 2018 by Scott Pautler

What is photodynamic therapy?

Photodynamic therapy (PDT) is a treatment for retinal conditions in which leaky blood vessels threaten to cause permanent loss of vision. PDT involves the injection of a light-sensitive dye into the vein of the arm. The dye, called Visudyne, concentrates in the abnormal blood vessels that leak fluid and/or blood under the retina. A diode laser then activates the Visudyne, which seals the leaky blood vessels without the use of cauterizing lasers. By avoiding the use of cautery, PDT is able to treat abnormal leaking vessels with a much lower chance of causing a blind spot in the vision from the treatment. For this reason PDT is sometimes called the “cold laser.” PDT has largely replaced the cauterizing (hot) laser in the treatment of age-related macular degeneration and central serous chorioretinopathy.

What do I expect after photodynamic therapy?

For 48 hours you should avoid direct sunlight, which could activate some of the dye in your system before it is eliminated from the body. Sunlight or Halogen light may cause a severe light reaction and should be avoided during this time. For this reason it is advisable to come to the office for treatment wearing a long-sleeved shirt, gloves, long pants, socks, closed shoes, and a hat. Make arrangements for someone else to drive, so you may remain shielded from light in the back seat of the car on the way home from the office. After PDT, there are no limitations in physical activity or visual activity. Some doctors recommend against straining or heavy work for one week after the treatment to avoid putting too much pressure on the blood vessels in the eye. Although some blurring of vision is common immediately after treatment, severe changes in the vision should be reported to the doctor. It may take months for the treatment to take effect. Repeated treatments with PDT may be used as needed in difficult cases.

By Scott E. Pautler, MD

Lens Implant Options

Posted on August 4, 2018 by Scott Pautler

See Eye Anatomy

Why are lenses implanted during cataract surgery?

Cataract is the name given to the natural lens inside your eye when it becomes cloudy. When cataract interferes with vision, surgery is performed to remove the cloudy lens. In order to replace the focusing power of your natural lens, a synthetic lens implant is placed inside the eye at the time of cataract surgery.

What lens implant power options are available?

The patient may choose to have the power of the lens implant adjusted to focus the eye at various distances. The power calculations are not perfect and often glasses still must be worn by many patients. Most people choose to have the lens implant focused mainly for distance. Rarely, near-sighted patients prefer to keep the primary focus at near. Standard lens implants are fixed-focus lenses. That is, they do not focus at distance and near. For example, an eye with a standard lens implant focused for distance must use reading glasses for near work.

How can we decrease our dependence on glasses after cataract surgery?

In order to decrease the need for glasses, there are options to consider, each with advantages and disadvantages. Options include bifocal contact lenses, mono-vision lens implant correction, and multifocal lens implants.

Bifocal Contact lenses: This option may be good for patients who already use bifocal contact lenses. The contacts lenses help focus at near and may refine distance vision as needed.

Mono-vision Lens Implants: In this option one eye is focused mainly at distance and one eye is focused mainly for near. Not everyone can adapt to this situation and there is slight loss of depth perception with mono-vision correction. This option is best for those who already have adapted to mono-vision contact lenses.

Multifocal Lens Implants: This is a new option offered by premium lens implants that cost more for the patient. Basically, these implants offer improved range of focus for both distance and near. Many brands are available. The choice of lens depends on how much help with distance and near vision is desired. However, the greater the range of focus a given lens offers, the greater the side effects of the multifocal lens. Side effects include decreased contrast sensitivity and glare/halos from light especially at night. Loss of contrast sensitivity makes it more difficult to see gray print on white paper. Glare and halos bother some patients more than others.

A combination of strategies may be used. For example, a low-range-of-focus multifocal lensimplant (Symfony) may be used with mild mono-visionfocusing to minimize the downsides compared with each method when used alone.

Examples of multifocal lens implants include Symfony, Restor 2.5, and Restor 3.0. There are many others. Below is a chart to demonstrate the trade-offs among these lenses.

Lens Implant Styles: Benefits and Limitations
Style	Distance vision	Intermediate vision	Near vision	Need for reading glasses	Contrast sensitivity	Glare/Halos
Standard IOL (monofocal)	Excellent	Fair	Poor	Most of the time	Excellent	Rare
Symfony IOL	Very good	Good	Fair	Much of the time	Good	Mild
Restor 2.5 IOL	Fairly good	Good	Good	Some of the time	Poor	Moderate
Restor 3.0 IOL	Fairly good	Fair	Good	Rarely needed	Poor	> Moderate

If you have strong preferences, be sure to communicate with your doctor to be given the best lens implant for your situation. Keep in mind that the eye changes over time and the need for glasses may change over months to years after cataract surgery.

By Scott E. Pautler, MD

Over-the-Counter Pain Medications

Posted on July 21, 2018 by Scott Pautler

What are over-the-counter pain medications?

Over-the-counter (OTC) pain medications are pills that can be purchased without a prescription. There are a number of brands available. Examples include ibuprofen (Motrin) and acetaminophen (Tylenol). As ibuprofen and acetaminophen work via different pathways, they can be used together for improved pain control.

What side effects might be expected?

Most drugs have many possible side-effects. The major concern with acetaminophen is liver damage especially seen in patients with known liver disease. The major concern with ibuprofen is kidney damage in patients with known kidney disorders. Also, ibuprofen may irritate the stomach and increase the risk of stomach ulcers. This is especially seen in patients over the age of 65, history of stomach ulcers, or taking medications such as aspirin, steroids, or warfarin (Coumadin). Ibuprofen thins the blood and, therefore, may increase the tendency to bleed by slowing the ability of the blood to clot. The risk of stomach problems with ibuprofen may be reduced by using Zantac or Pepcid, which are available over-the-counter.

How can OTC pain medications be optimally used to control post-operative pain?

Because pain from surgery is short-lived, drug dependence is not a significant issue. The best strategy is to stay ahead of severe pain rather than trying to catch up due a lapse in medication. The optimal use of OTC medication may reduce the need for prescription narcotic pain medication. Prescription narcotic pain medications have side-effects such as sedation, constipation, nausea, and vomiting. With the proper use of OTC pain medications, the need for narcotics can be minimized.

As most narcotic pain medication is combined with acetaminophen, the dosage of OTC acetaminophen (Tylenol) must be decreased so as to avoid exceeding the maximal daily dosage (3,000mg per day).

Maximal Use of OTC Pain Medication for Pain Control after Surgery
Dosing Schedule:	8AM	2PM	8PM	2AM	Daily Maximum
Ipubrofen	800mg	800mg	800mg	800mg	3200mg


Dosing Schedule:	11AM	5PM	11PM		Daily Maximum
Tylenol Extra-Strength	1000mg	1000mg	1000mg		3,000mg


Note: This schedule may need to be altered if you have kidney or liver disease.
This schedule is designed not to exceed maximum dosages of these medications.
Decrease the dosage as the pain improves after surgery.
Do not take additional medications that contain ibuprofen or acetaminophen without
adjusting the OTC medication dosage so as not to exceed the maximal daily dosages.
Consult with your doctor prior to using this medication schedule.

By Scott E. Pautler, MD

How can a tattoo cause blindness?

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Who is at greatest risk of TAGU?

How is TAGU diagnosed?

How is TAGU managed?

What are other risks of tattoos?

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Shape of the eye

The Tear Film

The Conjunctiva

The Sclera

The Cornea

The Iris and Pupil

The lens

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

The Vitreous

The Retina

The Choroid

The Optic Nerve

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What testing is needed?

What treatment is available?

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How is polypoidal choroidal vasculopathy (PCV) diagnosed?

How is polypoidal choroidal vasculopathy (PCV) treated?

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What is birdshot chorioretinopathy?

What causes birdshot chorioretinopathy?

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How is birdshot chorioretinopathy diagnosed?

How is birdshot chorioretinopathy managed?

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What is Lumega-Z?

What does Lumega-Z do?

What about the company that makes Lumega-Z?

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Questions?

How can we help?

What does it cost?

Does it matter where I live?

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Why are eye injections given?

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What can be done to prevent pain after injections?

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What is MacTel?

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How might the government have handled this issue better?

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