Retinal Disorders

ANGIOID STREAKS

Angioid streaks are small cracks in the retina similar to those seen in a pane of glass that is partially broken. Angioid streaks are not a problem; however, the weakened retina is susceptible to the development of new blood vessel growth and scar formation. This blood vessel growth is called neovascularization. If patients develop neovascularization, then vision can be significantly affected.

Conditions that are commonly associated with angioid streaks include pseudoxanthoma elasticum (loose skin on the neck and elbows), heart difficulties, GastroIntestinal bleeding, Paget’s disease (bone pain and hearing loss) and Sickle cell disease.

Patients with angioid streaks should be aware of any distortion of vision and promptly report any changes. If a choroidal neovascular membrane is suspected, fluorescein angiography should be performed and laser treatment applied if indicated.

BEST’S DISEASE

Best’s disease is a specific type of degeneration of the macula or central retina. Patients with Best’s disease may be initially asymptomatic but with time, patients complain of blurred central vision. Best’s disease is inherited, family members should be evaluated. If you have children, there is a fifty percent chance that they will inherit the condition.. There is a wide range of severity in Best’s disease. Some patients have only very mild symptoms while others have very severely affected central vision.

Electrophysiological tests of the retina called an ERG and an EOG should be performed to confirm the diagnosis of Best’s disease.

BRANCH ARTERY OCCLUSION

In this condition there is blockage of one of the arteries that supply the retina. Because of the blockage, the retina does not receive proper nourishment and as a result, the tissue dies. The visual loss due to an artery occlusion is usually irreversible. Occasionally, there is some improvement over time. The most important step is to determine why the occlusion happened so as prevent any further artery occlusions. You should be seen by your medical doctor who will perform an examination as well as blood tests. A carotid ultrasound may sometimes be performed to look at the carotid arteries. Finally, an echocardiogram is sometimes performed to rule out the heart as a cause of the occlusion.

CENTRAL RETINAL ARTERY OCCLUSION

A central retinal artery occlusion occurs when there is blockage of blood flow in the main artery that supplies the retina. Without proper nourishment, the retina dies.. If the artery occlusion has been present for over 10 minutes the retina is usually irreversibly damaged. The most important step is to determine why the occlusion happened so as prevent any further artery occlusions. You should be seen by your medical doctor who will perform an examination as well as blood tests. A carotid ultrasound may sometimes be performed to look at the carotid arteries. Finally, an echocardiogram is sometimes performed to rule out the heart as a cause of the occlusion.

CENTRAL SEROUS RETINOPATHY

In this condition, a small blister of fluid is noted underneath the retina. This causes blurred vision, faded color vision and visual distortion. Occasionally, the condition may be asymptomatic. The blister of fluid is due to a small leak underneath the retina.

Stress may play since this condition is more commonly found in men (25-40) who are type A personalities. To better visualize the blister of fluid and the leak, a fluorescein angiogram may be performed. Fortunately, central serous retinopathy usually improves with time. If no improvement occurs over time, laser treatment can sometimes be used to treat this condition. The condition can recur.

CHOROIDAL DETACHMENT

In this condition either serum or blood lifts up the choroid, creating a choroidal detachment. This condition tends to be associated with eyes that have had surgery, trauma, or inflammation. Eye drops can be used to treat most choroidal detachments. If the choroidal detachments are very large, additional surgery to drain the fluid or blood may be necessary.

CHOROIDAL NEVUS (neh-VUS)

A nevus is a freckle and birthmarks found on the skin. They are found on the inside layer of the eye called the choroid, just behind the retina. These common pigmented areas occur in approximately 30% of the population. Like freckles and moles, a nevus is benign and is rarely of any concern. Like other freckles in the body they need to be watched to make sure that they do not change in color or size. Unfortunately, you cannot watch this freckle in your eye, therefore, I will need to watch it for you. Periodic dilated examinations and/or retinal photographs are recommended to ensure that there are no changes in its size, color or elevation.

LATTICE DEGENERATION

In this condition, there are small areas of thinned peripheral retina that are more prone to retinal tears or holes. Most people with lattice degeneration never develop retinal tears; however, it is prudent to be aware of the signs of a retinal hole, tear, or detachment. These signs include flashing lights, floating spots in front of your vision, or a “veil” coming down over your vision.

Lattice degeneration is more common as we get older, especially in nearsighted (myopic) patients. Fortunately, most patients with lattice degeneration do not develop serious problems from it. However, it needs to be watched with periodic dilated retinal examinations.

CYSTOID MACULAR EDEMA (CME)

In this condition there is swelling of the macula. When the retina swells, it does not function as well and vision is decreased. The diagnosis is made by careful examination of the back of the eye and/or fluorescein angiography which demonstrates leakage of fluid. There are many causes of cystoid macular edema (CME). The most common cause of CME is inflammation after ocular surgery. Even with the best of surgery CME can occur. Better surgery results in less frequent and milder CME. Cystoid macular edema generally resolves in time with or without medical treatment. However, it can become a chronic problem even with the best treatment.

There are a number of treatments to treat CME. In general, non-steroidal anti-inflammatory drops (Acular or ) are used cure the macular edema. The eye drops are typically taken for several weeks and the response is evaluated. If there is no improvement, then changes in medications are made.

It is discouraging for both the patient and the doctor to find CME following surgery. However, with time and medical treatment, the macular edema usually resolves.

HYPERTENSIVE RETINOPATHY

In hypertensive retinopathy, there are abnormalities in the blood vessels nourishing the retina. The abnormal blood vessels in the retina can lead to blurred vision. Hypertension can damage the retina of the eye by hemorrhaging or depriving the retina with vital nourishment and oxygen. Therefore, it is important that hypertension be well controlled. With this in mind, you should be seen by your internist who can help control the hypertension and search for treatable causes such as kidney disease, etc. The eye is often said to be a window into the body; blood vessel abnormalities in the eye often indicate blood vessel abnormalities elsewhere in the body. See your internist.

OCULAR ISCHEMIA SYNDROME

In this condition, blood flow to the eye is insufficient. This is usually caused by narrowing of the carotid arteries. A carotid ultrasound test may be performed to evaluate the carotid artery system. Patients with Ocular Ischemia Syndrome can have symptoms which include: blurred vision, pain, eye redness, floaters and dim vision. Patients with Ocular Ischemia Syndrome may undergo a test called fluorescein angiography to evaluate the status of the circulation in the eye. If the carotid ultrasound study shows narrowing of the carotid arteries, some patients undergo carotid artery surgery which can improve this condition.

MACULAR HOLE

A macular hole is a partial or full-thickness hole in the center of the retina or in the macular region. Since the macula is responsible for your central vision and fine, detailed vision the effect can be devastating. Loss of the macula makes such tasks as reading, driving, watching television and threading a needle difficult or impossible. The macular hole generally does not progress after occurring and never effects peripheral (side) vision. Macular holes generally affect one eye with a small percentage of patients, 5-10%, occurring in both eyes.

Recently new surgical techniques have been developed to help seal the macular hole. These techniques are improving but currently the success rate inclosing the hole are about 50-75%. Closure of the macular hole may result one to four lines of improved vision on the eye chart. However, some patients do not improve vision following surgery.

 

MACULAR PUCKER (Pre-retinal Fibrosis)

A thin layer of fibrous tissue has formed and rests on the retinal surface. The scar tissue contracts and causes wrinkling of the normally flat retina. Macular pucker is analogous to cellophane wrap that has been wrinkled. For this reason, macular pucker has also been called cellophane maculopathy.

If the macular puckering is significantly effecting your vision, surgery can be used to remove the fibrous tissue and smooth out the retina. Improvement varies some obtaining wonderful vision, others no improvement. On the average one can expect a 50% improvement.

If the macular puckering does not seriously effect your vision, then only observation is recommended. Most macular puckers do not progress and are mild.

MIGRAINE HEADACHES

A “classical” migraine headache is a throbbing or boring headache noted on one side of the head, often accompanied by nausea, vomiting, fatigue, light sensitivity, and a visual disturbance. The visual disturbance is often characterized as a zigzag line which tends to move or change shape by enlarging. It usually precedes the headache by ten to fifteen minutes. Only ten percent of migraine headache sufferers have these zigzag lines, called the visual aura. One must differentiate the migraine flashes from those caused by vitreous traction. Sometimes the aura occurs without the headache. These headaches have a strong genetic predisposition occurring most commonly in women decreasing with menopause or pregnancy.

Migraine headaches that occur without the zigzag lines or without the other signs of a classical migraine are called “common” migraine. Obviously, common migraines are more common. Though they may not have all the features of the classical migraine, they are always vascular or pounding/throbbing headaches.

Migraine headaches can be precipitated by certain foods and medications including birth control pills, chocolate, red wines and cheeses. Alcohol, fatigue and stress, can also trigger migraines. Patients with migraine headaches should see a neurologist, to rule out other serious causes of the headache. If these headaches occur frequently, treatment by a neurologist may be designed to suppress their development.

OPTIC PIT

Optic pits are small depression in the optic nerve that often leak fluid. The fluid that leaks can be responsible for a localized retinal detachment usually in one eye. Patients with an optic pit may be asymptomatic while others have distortion of their vision.

Most optic pits don’t need treatment. If the leakage affects the central vision, laser treatment can usually seal the leakage. Rarely surgery is necessary.

PARS PLANITIS (Intermediate Uveitis)

Patients with pars planitis may be asymptomatic or may note floating spots and cloudy vision. Most patients with pars planitis are young. Both eyes are usually affected by this inflammation of a portion of the retina known as the retina called the pars plana. The inflammation does not have a known cause in most cases.

If the vision is not affected or minimally blurred, treatment is not necessary. If there is significant blurring of vision or inflammation, then steroids are prescribed. The eyes muster be examined periodically to monitor the inflammation.

PLAQUENIL MACULOPATHY

Patients who are taking Plaquenil can develop a condition called Plaquenil maculopathy. In this condition patients taking high doses of Plaquenil for an years may develop alteration of the macula of the eye. This results in blurred vision, abnormal color vision and difficulty adapting to darkness. Plaquenil toxicity is a rare complication of treatment. However, since it is a potentially serious problem patients taking Plaquenil should be checked carefully and periodically for signs of toxicity. Examination requires examination every 6 mos combined with visual fields. The medication should be discontinued at the earliest signs of toxicity.

RADIATION RETINOPATHY

Due to radiation, the blood vessels within the eye rarely develop close down and/or leak fluid. Fluorescein angiogram is used to determine if the blood vessels are leaking. If leakage is present, laser treatment may be advised. Radiation retinopathy may not show up for years following radiation. The symptoms of radiation retinopathy include blurred vision, distorted vision and areas of dimmed vision often affecting color vision.

The laser can seal the leaks. Eyes with radiation retinopathy should be monitored periodically.

RETINAL DETACHMENT

Retinal detachment, separation of the retina from the back of the eye, is a serious problem. Without treatment, vision will be permanently lost. Retinal detachments are more common in patients who have a high degree of myopia (nearsightedness), those who have had a retinal detachment in the other eye, vitreous degeneration, a family history of retinal detachment and/or peripheral retinal degeneration. The incidence of retinal detachment increases in patients who have had cataract surgery and/or YAG capsulometry. Trauma may cause a retinal detachment.

Most retinal detachments require surgical repair known as a buckle. Small retinal detachments can be treated with laser or freezing treatments. However, most will require surgery. Fortunately, there is an 85% chance of re-attaching the retina. If the first surgery fails to re-attach the retina a second operation is possible.

Successful re-attachment of the retina does not necessarily mean restoration vision. The return of good vision depends on how long the retina was detached and whether or not the macula was detached. If the macula was detached before surgery, it is uncommon for total restoration of vision. It may take months before the final results are known.

During the postoperative period, the eye will be red and sore for a month or two. Frequent postoperative checks are required to detect complications such as infection, glaucoma cataract development, bleeding, proliferative vitreoretinopathy (scar tissue formation), or drooping of the upper eyelid.

RETINITIS PIGMENTOSA

Patients with retinitis pigmentosa have a defect in the retina which causes reduced night vision, restricted or narrowed visual fields and/or blurred central vision. There are a many different types of retinitis pigmentosa. Each having somewhat different characteristics. It is important to obtain a detailed family history and evaluation of other family members. The prognosis depends very much on the type of retinitis pigmentosa present. Some patients with retinitis pigmentosa maintain good vision throughout their life while others have progressive disease. Patients with retinitis pigmentosa should take large amounts of vitamin A and wear glasses with UV protection. A test called an electroretinogram should be preformed once and visual field tests should be performed to monitor progression.

RETINAL TEAR

A retinal tear typically occurs because the clear vitreous jelly, which fills the inside of the eye, has contracted and pulled away from the retina. In the process of pulling away from the retina, a tear occurred. If the vitreous does not let go of the retina (traction), a pocket is created and fluid can fill the pocket causing the retina to further separate from the back of the eye. this results in a retinal detachment with subsequent loss of vision. Thus, a retinal tear can be a potentially serious problem. When the retinal tears cause bleeding there is an even more serious problem. Retinal tear are treated with laser or cryotherapy to seal the retinal tear in order to prevent a retinal detachment.

RETINOSCHISIS

The retina splits into two layers in certain areas. The retina is like plywood with many laminated layers which rarely separate. This is called retinoschisis.

Most patients with retinoschisis are do not have symptoms and never develop problems. A small percentage of patients with retinoschisis develop a retinal detachment. If a retinal detachment is thought to be a risk then some areas of retinoschisis are treated with laser.

SICKLE CELL DISEASE

Sickle cell disease, like diabetes, can cause new blood vessels to grow within the eye. Neovascularization or new blood vessels is the most serious problem secondary to Sickle retinopathy. In this condition, fine new blood vessels, which are quite weak and predisposed to bleeding, grow in the eye. The blood vessels may form scar tissue, which can pull on the retina causing a retinal detachment. A fluorescein angiogram is used to evaluate the retinal blood flow. Laser treatment is performed on those patients who develop neovascularization.

STARGARDT’S DISEASE

Stargardt’s disease is first noted in children or young adults who have decreased visual acuity in both eyes. Sometimes, other family members may have the same condition. Unfortunately, there is no known medical or surgical therapy for Stargardt’s disease. However, with the use of low vision aids such as magnifying glasses and telescopic lenses, these patients function well. The condition can be inherited, thus, other family members should be examined. It is a recessive gene, which means your children are unlikely to inherit the disease unless your spouse also has a recessive gene.

TEMPORAL ARTERITIS

Temporal arteritis is an inflammation of the blood vessels in and around the head and eye. Patients with temporal arteritis may have symptoms such as headache, intermittent blurred vision, flu-like symptoms, trouble chewing, or arthritis. Temporal arteritis can cause blindness in one or both eyes if untreated. Treatment must be immediately undertaken. A blood test for the sedimentation rate (ESR) should be performed immediately. If the sedimentation rate is high, a biopsy of a small artery on the side of the head should be performed to confirm the presence of temporal arteritis. If temporal arteritis is diagnosed, it is treated with high amounts oral steroids.

TOXOPLASMOSIS

Toxoplasmosis retinitis is usually acquired this infection during gestation, i.e., born with this condition. Diagnosis is made by observation of the retina and sometimes by blood tests. Generally speaking what you have is what you have. Uncommonly, the infection flares up for unknown reasons. Symptoms include blurred vision, spots in front of the eyes and redness. If the infection is located far away from the macula, then only observation is necessary. However, if the infection threatens the central vision, strong medicines are necessary.

BRANCH RETINAL VEIN OCCLUSION

A blockage of a vein in the retina (branch retinal vein occlusion) is a condition, blood flow in a vein back to the heart in the affected area stops. Thus, the retina does not receive the proper nourishment and may die. This results in blurred vision. Branch retinal vein occlusion is often associated with hypertension, diabetes, glaucoma or arteriosclerosis. Occasionally, a branch retinal vein occlusion can be associated with conditions in the blood causing excessively thickened blood. A physical examination and blood tests are necessary. In some patients, laser treatment is beneficial while in others the occlusion can sometimes spontaneously improve without treatment. A fluorescein angiogrammay help determine the extent of the retinal damage and/or whether or not laser treatment is indicated.

CENTRAL VEIN OCCLUSION

The vein which drains blood from the eye is occluded. This stops the circulation of blood within the eye, causing retinal damage and blurred vision. Central retinal vein occlusions like branch vein occlusion is often associated with hypertension, diabetes, glaucoma or arteriosclerosis. Occasionally, a branch retinal vein occlusion can be associated with conditions in the blood causing excessively thickened blood. There are a large number of other less common causes that can cause a central retinal vein occlusion. A physical examination and blood tests are necessary. A central retinal vein occlusion may be either mild or severe.

A central retinal vein occlusion may have other complications. One is a very serious and sometimes painful form of glaucoma called neovascular glaucoma. The second significant complication is the development of new blood vessels in the retina. These new blood vessels are fragile and easily bleed. Both of these problems require urgent laser treatment. Thus, it is important that this condition be constantly monitored. Laser treatment is designed to prevent the above noted complications. It is important to note that the laser is not able to restore vision.

PROLIFERATIVE VITREORETINOPATHY

Proliferative vitreoretinopathy (PVR) is a very frustrating condition that may follow retinal detachment surgery or ocular trauma. This condition occurs as result of the body attempting to heal itself through the formation of scar tissue. The scar unfortunately can pull and tear the retina. Proliferative vitreoretinopathy may cause the retina to detach.

Surgery can help vitreoretinopathy. The scar tissue is gently peeled away off the retina surface. Even with successful removal of the scar tissue, the body will often try to replace the scar tissue with new scar tissue. Thus, more than one operation is needed when proliferative vitreoretinopathy is present.

OCULAR HISTOPLASMOSIS SYNDROME

Ocular histoplasmosis syndrome, a specific type of retinal infection, may be asymptomatic or associated with blurred vision. This condition appears as small round areas of scarring on the retina called “histo spots.” Patients with ocular histoplasmosis may develop scarring and new blood vessel formation in the retina. These new blood vessels are weak and liable to bleed. Most of the patients with this disease have lived in or visited the Ohio-Mississippi Valley; some believe that exposure to birds such as chickens, pigeons or parakeets is responsible for this disease. If new blood vessel growth is present, laser therapy is usually necessary.