A cataract is a clouding of the normally clear lens of the eye. It can be compared to a window that is frosted or “fogged” with steam. More than half of all Americans develop cataracts by age 80.
A cataract is a clouding of the normally clear lens of the eye. It can be compared to a window that is frosted or “fogged” with steam. More than half of all Americans develop cataracts by age 80.
A cataract is a clouding of the normally clear lens of the eye. It can be compared to a window that is frosted or yellowed. The amount and pattern of cloudiness within the lens can vary. If the cloudiness is not near the center of the lens, you may not be aware that a cataract is present. There are many misconceptions about cataract. Cataract is not:
Common symptoms of cataract include:
How quickly the cataract develops varies among individuals and may even be different between the two eyes. Most age-related cataracts progress gradually over a period of years. Other cataracts, especially in younger people and people with diabetes, may progress rapidly over a short time. It is not possible to predict exactly how fast cataracts will develop in any given person.
Surgery is the only way a cataract can be removed. However, if symptoms of cataract are not bothering you very much, surgery may not be needed. Sometimes a simple change in your eyeglass prescription may be helpful. No medications, dietary supplements or exercises have been shown to prevent or cure cataracts. Protection from excessive sunlight may help slow the progression of cataracts. Sunglasses that screen out ultraviolet (UV) light rays or regular eyeglasses with a clear, anti-UV coating offer this protection.
By performing a thorough eye examination, your ophthalmologist (Eye M.D.) can detect the presence of a cataract. A careful evaluation will rule out any other conditions that may be causing blurred vision or other eye problems. Problems with other parts of the eye (such as the cornea, retina or optic nerve) can be responsible for vision loss and may prevent you from having much or any improvement in vision after cataract surgery. If improvement in your vision is unlikely, cataract removal may not be recommended. Your ophthalmologist can tell you how much visual improvement is likely.
Surgery should be considered when cataracts cause enough loss of vision to interfere with your daily activities. It is not true that cataracts need to be “ripe” before they can be removed or that they need to be removed just because they are present. Cataract surgery can be performed when your visual needs require it. You must decide if you can see well enough to do your job, drive safely, and read or watch TV in comfort. Does your vision allow you to perform daily tasks, such as cooking, shopping, doing yard work or taking medications without difficulty? Based on your symptoms, you and your ophthalmologist should decide together when surgery is appropriate.
Over 1.8 million people have cataract surgery each year in the United States, and more than 95 percent of those surgeries are performed with no complications. During cataract surgery, which is usually performed under local or topical anesthesia as an outpatient procedure, the cloudy lens is removed from the eye. In most cases, the focusing power of the natural lens is restored by replacing it with a permanent intraocular lens implant. Your ophthalmologist performs this delicate surgery using a microscope, miniature instruments and other modern technology. After surgery, you will have to take eyedrops as your ophthalmologist directs. Your surgeon will check your eye several times to make sure it is healing properly. Cataract surgery is a highly successful procedure. Improved vision is the result in over 95 percent of cases, unless there is a problem with the cornea, retina, optic nerve or other structures. It is important to understand that complications can occur during or after the surgery, some severe enough to limit vision. If you experience even the slightest problem after cataract surgery, your ophthalmologist will want to hear from you immediately. In many people who have cataract surgery, the natural capsule that supports the intraocular lens becomes cloudy. If this occurs, your ophthalmologist can perform an outpatient laser procedure to open this cloudy capsule, restoring clear vision.
Cataracts are a common cause of decreased vision, particularly for the elderly, but they are treatable. Your ophthalmologist can tell you whether cataract or some other problem is the cause of your vision loss and can help you decide if cataract surgery is appropriate for you.
To determine if your cataract should be removed, your ophthalmologist (Eye M.D.) will perform a thorough eye examination. Before surgery, your eye will be measured to determine the proper power of the intraocular lens that will be placed in your eye. Ask your ophthalmologist if you should continue taking your usual medications before surgery.
Surgery is usually done on an outpatient basis, either in a hospital, an outpatient surgical center, or an ambulatory surgery center. You may be asked to skip breakfast, depending on the time of your surgery. When you arrive for surgery, you will be given eyedrops and perhaps a mild sedative to help you relax. A local anesthetic will numb your eye. The skin around your eye will be thoroughly cleansed, and sterile coverings will be placed around your head. Your eye will be kept open by an eyelid speculum. You may see light and movement, but you will not be able to see the surgery while it is happening. Under an operating microscope, a small incision is made in the eye. In most cataract surgeries, tiny surgical instruments are used to break apart and remove the cloudy lens from the eye. The back membrane of the lens (called the posterior capsule) is left in place. After surgery is completed, your doctor may place a shield over your eye. After a short stay in the outpatient recovery area, you will be ready to go home.
You will need to:
You can continue most normal daily activities. Over-the-counter pain medicine may be used, if necessary.
Laser surgery is not used in cataract removal surgery. However, the lens capsule (the part of the eye that holds the lens in place) sometimes becomes cloudy several months or years after the original cataract operation. If the cloudy capsule blurs your vision, your ophthalmologist can perform a second surgery using a laser. During the second procedure, called a posterior capsulotomy, a laser is used to make an opening in the cloudy lens capsule, restoring normal vision.
The success rate of cataract surgery is excellent. Improved vision is achieved in the majority of patients. Only a small number of patients continue to have problems following cataract surgery.
Though they rarely occur, serious complications of cataract surgery are:
Call your ophthalmologist immediately if you have any of the following symptoms after surgery:
Even if cataract surgery is successful, some patients may not see as well as they would like to. Other eye problems such as macular degeneration (aging of the retina), glaucoma or diabetic retinopathy may limit vision after surgery. Even with these problems, cataract surgery may still be worthwhile.
Periodic eye and vision examinations are an important part of preventive health care. Many eye and vision problems have no obvious signs or symptoms. As a result, individuals are often unaware that problems exist. Early diagnosis and treatment of eye and vision problems are important for maintaining good vision and eye health, and when possible, preventing vision loss.
A comprehensive adult eye and vision examination may include, but is not limited to, the following tests. Individual patient signs and symptoms, along with the professional judgment of the doctor, may significantly influence the testing done.
A patient history helps to determine any symptoms the individual is experiencing, when they began, the presence of any general heath problems, medications taken and occupational or environmental conditions that may be affecting vision. The doctor will ask about any eye or vision problems you may be having and about your overall health. The doctor will also ask about any previous eye or health conditions of you and your family members.
Reading charts are often used to measure visual acuity. Visual acuity measurements evaluate how clearly each eye is seeing. As part of the testing, you are asked to read letters on distance and near reading charts. The results of visual acuity testing are written as a fraction such as 20/40.
When testing distance vision, the top number in the fraction is the standard distance at which testing is done, twenty feet. The bottom number is the smallest letter size you were able to read. A person with 20/40 visual acuity would have to get within 20 feet of a letter that should be seen at 40 feet in order to see it clearly. Normal distance visual acuity is 20/20.
Preliminary testing may include evaluation of specific aspects of visual function and eye health such as depth perception, color vision, eye muscle movements, peripheral or side vision, and the way your pupils respond to light.
This test measures the curvature of the cornea, the clear outer surface of the eye, by focusing a circle of light on the cornea and measuring its reflection. This measurement is particularly critical in determining the proper fit for contact lenses.
Determining refractive error with a phoropter and retinoscope Refraction is conducted to determine the appropriate lens power needed to compensate for any refractive error (nearsightedness, farsightedness, or astigmatism). Using an instrument called a phoropter, your Ophthalmologist places a series of lenses in front of your eyes and measures how they focus light using a hand held lighted instrument called a retinoscope. The doctor may choose to use an automated instrument that automatically evaluates the focusing power of the eye. The power is then refined by patient’s responses to determine the lenses that allow the clearest vision.
This testing may be done without the use of eye drops to determine how the eyes respond under normal seeing conditions. In some cases, such as for patients who can’t respond verbally or when some of the eyes focusing power may be hidden, eye drops are used. The drops temporarily keep the eyes from changing focus while testing is done.
Assessment of accommodation, ocular motility and binocular vision determines how well the eyes focus, move and work together. In order to obtain a clear, single image of what is being viewed, the eyes must effectively change focus, move and work in unison. This testing will look for problems that keep your eyes from focusing effectively or make using both eyes together difficult.
Tonometry measures eye pressure. Elevated pressure in the eye signals an increased risk for glaucoma. External examination of the eye includes evaluation of the cornea, eyelids, conjunctiva and surrounding eye tissue using bright light and magnification
Evaluation of the lens, retina and posterior section of the eye may be done through a dilated pupil to provide a better view of the internal structures of the eye.
Measurement of pressure within the eye (tonometry) is performed. Normal eye pressures range from 10 to 21 millimeters of mercury (mm Hg), averaging about 14 to 16 mm Hg. Anyone with eye pressure greater than 22 mm Hg is at an increased risk of developing glaucoma, although many people with normal pressure also develop glaucoma
Additional testing may be needed based on the results of the previous tests to confirm or rule out possible problems, to clarify uncertain findings, or to provide a more in-depth assessment.
At the completion of the examination, your Ophthalmologist will assess and evaluate the results of the testing to determine a diagnosis and develop a treatment plan. He or she will discuss with you the nature of any visual or eye health problems found and explain available treatment options. In some cases, referral for consultation with, or treatment by, another Ophthalmologist or other health care provider may be indicated
If you have questions regarding any eye or vision conditions diagnosed, or treatment recommended, don’t hesitate to ask for additional information or explanation from your ophthamologist.
If you have diabetes mellitus, your body does not use and store sugar properly. High blood-sugar levels can damage blood vessels in the retina, the nerve layer at the back of the eye that senses light and helps to send images to the brain. The damage to retinal vessels is referred to as diabetic retinopathy.
There are two types of diabetic retinopathy: Nonproliferative Diabetic Retinopathy (NPDR) and Proliferative Diabetic Retinopathy (PDR).
NPDR, commonly known as background retinopathy, is an early stage of diabetic retinopathy. In this stage, tiny blood vessels within the retina leak blood or fluid. The leaking fluid causes the retina to swell or to form deposits called exudates.
Many people with diabetes have mild NPDR, which usually does not affect their vision. When vision is affected it is the result of macular edema (pronounced eh-DEEM-uh) and/or macular ischemia (pronounced ih-SKEE-mee-uh).
PDR, is present when abnormal new vessels (neovascularization) begin growing on the surface of the retina or optic nerve. The main cause of PDR is widespread closure of retinal blood vessels, preventing adequate blood flow. The retina responds by growing new blood vessels in an attempt to supply blood to the area where the original vessels closed. Unfortunately, the new abnormal blood vessels do not resupply the retina with normal blood flow. The new vessels are accompanied by scar tissue that may cause wrinkling or detachment of the retina.
PDR may cause more severe vision loss than NPDR because it can affect both central and peripheral vision. Proliferative diabetic retinopathy causes visual loss in the following ways:
A medical eye examination is the best way to detect changes inside your eye. An ophthalmologist (Eye M.D.) can often diagnose and treat serious retinopathy before you are aware of any vision problems. The ophthalmologist dilates your pupil and looks inside of the eye with special equipment and lenses. If your ophthalmologist finds diabetic retinopathy, he or she may order color photographs of the retina or a special test called fluorescein angiography to find out if you need treatment. In this test a dye is injected into your arm and photos of your eye are taken to detect where fluid is leaking.
The best treatment is to prevent the development of retinopathy as much as possible. Strict control of your blood sugar will significantly reduce the long-term risk of vision loss from diabetic retinopathy. If high blood pressure and kidney problems are present, they need to be treated.
In certain cases, your Eye M.D. may choose to treat your macular edema with injections of medicine in your eye. These special shots of medicine — called intravitreal injections — may be steroids or other medications. They are designed to shrink the swelling of the macula or reduce neovascularization.
Laser surgery often is recommended for people with macular edema, PDR, and NPD glaucoma. For macular edema, the laser is focused on the damaged retina near the macula to decrease the fluid leakage. The main goal of treatment is to prevent further loss of vision. It is uncommon for people who have blurred vision from macular edema to recover normal vision, although some may experience partial improvement. A few people may see the laser spots near the center of their vision following treatment. The spots usually fade with time but may not disappear. For PDR, the laser is focused on all parts of the retina except the macula. This panretinal photocoagulation treatment causes abnormal new vessels to shrink and often prevents them from growing in the future. It also decreases the chance that vitreous bleeding or retinal distortion will occur. Multiple laser treatments over time are sometimes necessary. Laser surgery does not cure diabetic retinopathy and does not always prevent further loss of vision.
In advanced PDR, your ophthalmologist may recommend a vitrectomy. During this microsurgical procedure, which is performed in the operating room, the blood-filled vitreous is removed and replaced with a clear solution. Your ophthalmologist may wait for several months to see if the blood clears on its own before performing a vitrectomy. Vitrectomy often prevents further bleeding by removing the abnormal vessels that caused the bleeding. If the retina is detached, it can be repaired during the vitrectomy surgery. Surgery should usually be done early because macular distortion or traction retinal detachment will cause permanent visual loss. The longer the macula is distorted or out of place, the more serious the vision loss will be.
If you have diabetes, it is important to know that today, with improved methods of diagnosis and treatment, a smaller percentage of people who develop retinopathy have serious vision problems. Early detection of diabetic retinopathy is the best protection against loss of vision. You can significantly lower your risk of vision loss by maintaining strict control of your blood sugar and visiting your ophthalmologist regularly.
People with diabetes should schedule examinations at least once a year. More frequent medical eye examinations may be necessary after a diagnosis of diabetic retinopathy. Pregnant women with diabetes should schedule an appointment in the first trimester, because retinopathy can progress quickly during pregnancy. If you need to be examined for eyeglasses, it is important that your blood sugar be consistently under control for several days when you see your ophthalmologist. Eyeglasses that work well when blood sugar is out of control will not work well when blood sugar is stable. Rapid changes in blood sugar can cause fluctuating vision in both eyes even if retinopathy is not present.
You should have your eyes checked promptly if you have visual changes that:
When you are first diagnosed with diabetes, you should have your eyes checked:
Diabetes is the leading cause of blindness in working-age Americans. Approximately 29 million Americans age 20 or older have diabetes — but almost one-third don’t know they have the disease and are at risk for vision loss and other health problems. Early symptoms are often unnoticed, therefore vision may not be affected until the disease is severe and less easily treated. Diabetic eye disease, a group of eye problems that affects those with diabetes, includes diabetic retinopathy, cataracts and glaucoma. The most common of these is diabetic retinopathy, which affects 5.3 million Americans age 18 and older. Diabetic retinopathy is a potentially blinding condition in which the blood vessels inside the retina become damaged from the high blood sugar levels associated with diabetes. This leads to the leakage of fluids into the retina and the obstruction of blood flow. Both may cause severe vision loss.
Once you are diagnosed with diabetes, schedule a complete dilated eye examination with your Eye M.D. at least once a year. Make an appointment promptly if you experience blurred vision and/or floaters that:
Diabetes can also affect your vision by causing cataracts and glaucoma. If you have diabetes, you may get cataracts at a younger age and your chances of developing glaucoma are doubled. Early diagnosis of diabetes and most importantly, maintaining strict control of blood sugar and hypertension through diet, exercise and medication can help to reduce your risk of developing eye diseases associated with diabetes. An Eye M.D. is an Ophthalmologist — a medical doctor who provides the full spectrum of eye and vision care. From eyeglasses and contact lenses to medication and surgery, your Eye M.D. will help you keep your sight for life.
Eyelid surgery (technically called blepharoplasty) is a procedure to remove fat – usually along with excess skin and muscle from the upper and lower eyelids. Eyelid surgery can correct drooping upper lids and puffy bags below your eyes – features that make you look older and more tired than you feel, and may even interfere with your vision. However, it won’t remove crow’s feet or other wrinkles, eliminate dark circles under your eyes, or lift sagging eyebrows. While it can add an upper eyelid crease to Asian eyes, it will not erase evidence of your ethnic or racial heritage. Blepharoplasty can be done alone, or in conjunction with other facial surgery procedures such as a facelift or browlift.
If you’re considering eyelid surgery, this information will give you a basic understanding of the procedure-when it can help, how it’s performed, and what results you can expect. It can’t answer all of your questions, since a lot depends on the individual patient and the surgeon. Please ask your surgeon about anything you don’t understand.
Before: Left Photo After: Right Photo
Blepharoplasty can enhance your appearance and your self-confidence, but it won’t necessarily change your looks to match your ideal, or cause other people to treat you differently. Before you decide to have surgery, think carefully about your expectations and discuss them with your surgeon.
The best candidates for eyelid surgery are men and women who are physically healthy, psychologically stable, and realistic in their expectations. Most are 35 or older, but if droopy, baggy eyelids run in your family, you may decide to have eyelid surgery at a younger age.
A few medical conditions make blepharoplasty more risky. They include thyroid problems such as hypothyroidism and Graves’ disease, dry eye or lack of sufficient tears, high blood pressure or other circulatory disorders, cardiovascular disease, and diabetes. A detached retina or glaucoma is also reason for caution; check with your ophthalmologist before you have surgery.
When eyelid surgery is performed by an Ophthalmologist, complications are infrequent and usually minor. Nevertheless, there is always a possibility of complications, including infection or a reaction to the anesthesia. You can reduce your risks by closely following your surgeon’s instructions both before and after surgery.
The minor complications that occasionally follow blepharoplasty include double or blurred vision for a few days; temporary swelling at the corner of the eyelids; and a slight asymmetry in healing or scarring. Tiny whiteheads may appear after your stitches are taken out; your surgeon can remove them easily with a very fine needle.
Following surgery, some patients may have difficulty closing their eyes when they sleep; in rare cases this condition may be permanent. Another very rare complication is ectropion, a pulling down of the lower lids. In this case, further surgery may be required.
The initial consultation with your surgeon is very important. The surgeon will need your complete medical history, so check your own records ahead of time and be ready to provide this information. Be sure to inform your surgeon if you have any allergies; if you’re taking any vitamins, medications (prescription or over-the-counter), or other drugs; and if you smoke. In this consultation, your surgeon or a nurse will test your vision and assess your tear production. You should also provide any relevant information from your ophthalmologist or the record of your most recent eye exam. If you wear glasses or contact lenses, be sure to bring them along.
You and your surgeon should carefully discuss your goals and expectations for this surgery. You’ll need to discuss whether to do all four eyelids or just the upper or lower ones, whether skin as well as fat will be removed, and whether any additional procedures are appropriate. Your surgeon will explain the techniques and anesthesia he or she will use, the type of facility where the surgery will be performed, and the risks and costs involved. (Note: Most insurance policies don’t cover eyelid surgery, unless you can prove that drooping upper lids interfere with your vision. Check with your insurer.)
Don’t hesitate to ask your doctor any questions you may have, especially those regarding your expectations and concerns about the results.
Your surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain vitamins and medications. Carefully following these instructions will help your surgery go more smoothly. While you’re making preparations, be sure to arrange for someone to drive you home after your surgery, and to help you out for a few days if needed.
Eyelid surgery may be performed in a surgeon’s office-based facility, an outpatient surgery center, or a hospital. It’s usually done on an outpatient basis; rarely does it require an inpatient stay.
Blepharoplasty usually takes one to three hours, depending on the extent of the surgery. If you’re having all four eyelids done, the surgeon will probably work on the upper lids first, then the lower ones.
In a typical procedure, the surgeon makes incisions following the natural lines of your eyelids; in the creases of your upper lids, and just below the lashes in the lower lids. The incisions may extend into the crow’s feet or laugh lines at the outer corners of your eyes. Working through these incisions, the surgeon separates the skin from underlying fatty tissue and muscle, removes excess fat, and often trims sagging skin and muscle. The incisions are then closed with very fine sutures.
If you have a pocket of fat beneath your lower eyelids but don’t need to have any skin removed, your surgeon may perform a transconjunctival blepharoplasty. In this procedure the incision is made inside your lower eyelid, leaving no visible scar. It is usually performed on younger patients with thicker, more elastic skin.
Eyelid surgery is usually performed under local anesthesia – which numbs the area around your eyes – along with oral or intravenous sedatives. You’ll be awake during the surgery, but relaxed and insensitive to pain. (However, you may feel some tugging or occasional discomfort.) Some surgeons prefer to use general anesthesia; in that case, you’ll sleep through the operation.
After surgery, the surgeon will probably lubricate your eyes with ointment and may apply a bandage. Your eyelids may feel tight and sore as the anesthesia wears off, but you can control any discomfort with the pain medication prescribed by your surgeon. If you feel any severe pain, call your surgeon immediately.
Your surgeon will instruct you to keep your head elevated for several days, and to use cold compresses to reduce swelling and bruising. (Bruising varies forn person to person: it reaches its peak during the first week, and generally lasts anywhere from two weeks to a month.) You’ll be shown how to clean your eyes, which may be gummy for a week or so. Many doctors recommend eyedrops, since your eyelids may feel dry at first and your eyes may burn or itch. For the first few weeks you may also experience excessive tearing, sensitivity to light, and temporary changes in your eyesight, such as blurring or double vision. Your surgeon will follow your progress very closely for the first week or two. The stitches will be removed two days to a week after surgery. Once they’re out, the swelling and discoloration around your eyes will gradually subside, and you’ll start to look and feel much better.
You should be able to read or watch television after two or three days. However, you won’t be able to wear contact lenses for about two weeks, and even then they may feel uncomfortable for a while. Most people feel ready to go out in public (and back to work) in a week to 10 days. By then, depending on your rate of healing and your doctor’s instructions, you’ll probably be able to wear makeup to hide the bruising that remains. You may be sensitive to sunlight, wind, and other irritants for several weeks, so you should wear sunglasses and a special sunblock made for eyelids when you go out.
Your surgeon will probably tell you to keep your activities to a minimum for three to five days, and to avoid more strenuous activities for about three weeks. It’s especially important to avoid activities that raise your blood pressure, including bending, lifting, and rigorous sports. You may also be told to avoid alcohol, since it causes fluid retention.
Healing is a gradual process, and your scars may remain slightly pink for six months or more after surgery. Eventually, though, they’ll fade to a thin, nearly invisible white line. On the other hand, the positive results of your eyelid surgery-the more alert and youthful look-will last for years. For many people, these results are permanent.
You may sometimes see small specks or clouds moving in your field of vision. They are called floaters. You can often see them when looking at a plain background, like a blank wall or blue sky. Floaters are actually tiny clumps of gel or cells inside the vitreous, the clear jelly-like fluid that fills the inside of your eye.
You may sometimes see small specks or clouds moving in your field of vision. They are called floaters. You can often see them when looking at a plain background, like a blank wall or blue sky. Floaters are actually tiny clumps of gel or cells inside the vitreous, the clear jelly-like fluid that fills the inside of your eye.
While these objects look like they are in front of your eye, they are actually floating inside. What you see are the shadows they cast on the retina, the nerve layer at the back of the eye that senses light and allows you to see. Floaters can have different shapes: little dots, circles, lines, clouds or cobwebs.
When people reach middle age, the vitreous gel may start to thicken or shrink, forming clumps or strands inside the eye. The vitreous gel pulls away from the back wall of the eye, causing a posterior vitreous detachment. It is a common cause of floaters.
Posterior vitreous detachment is more common for people who:
The appearance of floaters may be alarming, especially if they develop suddenly. You should see an ophthalmologist (Eye M.D.) right away if you suddenly develop new floaters, especially if you are over 45 years of age.
The retina can tear if the shrinking vitreous gel pulls away from the wall of the eye. This sometimes causes a small amount of bleeding in the eye that may appear as new floaters. A torn retina is always a serious problem, since it can lead to a retinal detachment. You should see your ophthalmologist as soon as possible if:
If you notice other symptoms, like the loss of side vision, you should see your ophthalmologist.
Because you need to know if your retina is torn, call your ophthalmologist if a new floater appears suddenly. Floaters can get in the way of clear vision, which may be quite annoying, especially if you are trying to read. You can try moving your eyes, looking up and then down to move the floaters out of the way. While some floaters may remain in your vision, many of them will fade over time and become less bothersome. Even if you have had some floaters for years, you should have an eye examination immediately if you notice new ones.
When the vitreous gel rubs or pulls on the retina, you may see what look like flashing lights or lightning streaks. You may have experienced this same sensation if you have ever been hit in the eye and seen “stars.” The flashes of light can appear off and on for several weeks or months. As we grow older, it is more common to experience flashes. If you notice the sudden appearance of light flashes, you should visit your ophthalmologist immediately to see if the retina has been torn.
When the vitreous rubs or pulls on the retina, it creates a sensation of flashing lights.
When an ophthalmologist examines your eyes, your pupils will be dilated with eye drops. During this painless examination, your ophthalmologist will carefully observe your retina and vitreous. Because your eyes have been dilated, you may need to make arrangements for someone to drive you home afterwards.
Floaters and flashes of light become more common as we grow older. While not all floaters and flashes are serious, you should always have a medical eye examination by an ophthalmologist to make sure there has been no damage to your retina.
Glaucoma is the leading cause of blindness in the United States. Since the disease may progress without pain or early warning symptoms, an estimated three million Americans who have the disease may not even know it. Early detection of glaucoma is now easier with current technology.
Capital Eye Center uses the Heidelberg Retinal Tomographer (HRT), a highly advanced diagnostic instrument that helps detect glaucoma early and monitor its progression. This technology uses a scanning confocal laser to create a three dimensional image of the optic nerve and surrounding tissue.
The laser, which is not powerful enough to harm the eye, first focuses on the surface of the nerve and captures the image. Subsequently the laser can focus through the top layer unlike a photographic image. It obtains images deeper and deeper below the surface (similar to how a CT scan takes thin slice images of our body). The stack of 32 images is then analyzed to create a very accurate three dimensional image of the optic nerve. All of these images can be obtained in just a few seconds.
The images are used to compute things such as optic cup volume, mean retina nerve fiber layer thickness, and the area or volume of the optic nerve rim. These parameters can be helpful in diagnosing or following glaucoma patients. For example, the images can be compared to a normal population database to highlight areas of the nerve that fall outside of the “normal range”. This could help in the diagnosis of glaucoma.
Changes in the optic nerve are a sign of glaucoma. As these optic nerve structural changes often precede visual field changes, one may be better able to diagnose glaucoma by closely following the optic nerve appearance. Serial HRT testing, just like serial visual field testing, can show glaucoma progression. Changes in rim or cup volume may indicate worsening of the disease.
Glaucoma is a disease of the optic nerve — the part of the eye that carries the images we see to the brain. The optic nerve is made up of many nerve fibers, like an electric cable containing numerous wires. When damage to the optic nerve fibers occurs, blind spots develop. These blind spots usually go undetected until the optic nerve is significantly damaged. If the entire nerve is destroyed, blindness results. Early detection and treatment by your ophthalmologist (Eye M.D.) are the keys to preventing optic nerve damage and blindness from glaucoma. Glaucoma is a leading cause of blindness in the United States, especially for older people. But loss of sight from glaucoma can often be prevented with early treatment.
Clear liquid called aqueous humor circulates inside the front portion of the eye. To maintain a healthy level of pressure within the eye, a small amount of this fluid is produced constantly while an equal amount flows out of the eye through a microscopic drainage system. (This liquid is not part of the tears on the outer surface of the eye). Because the eye is a closed structure, if the drainage area for the aqueous humor — called the drainage angle — is blocked, the excess fluid cannot flow out of the eye. Fluid pressure within the eye increases, pushing against the optic nerve and causing damage.
If the drainage angle is blocked, excess fluid cannot flow out of the eye, causing the fluid pressure to increase.
This is the most common form of glaucoma in the United States.
The risk of developing chronic open-angle glaucoma increases with age. The drainage angle of the eye becomes less efficient over time, and pressure within the eye gradually increases, which can damage the optic nerve. In some patients, the optic nerve becomes sensitive even to normal eye pressure and is at risk for damage. Treatment is necessary to prevent further vision loss.
Typically, open-angle glaucoma has no symptoms in its early stages, and vision remains normal. As the optic nerve becomes more damaged, blank spots begin to appear in your field of vision. You typically won’t notice these blank spots in your day-to-day activities until the optic nerve is significantly damaged and these spots become large. If all the optic nerve fibers die, blindness results.
Some eyes are formed with the iris (the colored part of the eye) too close to the drainage angle. In these eyes, which are often small and farsighted, the iris can be sucked into the drainage angle and block it completely. Since the fluid cannot exit the eye, pressure inside the eye builds rapidly and causes an acute closed-angle attack.
This is a true eye emergency. If you have any of these symptoms, call your ophthalmologist immediately. Unless this type of glaucoma is treated quickly, blindness can result. Unfortunately, two-thirds of those with closed-angle glaucoma develop it slowly without any symptoms prior to an attack.
Your ophthalmologist considers many kinds of information to determine your risk for developing the disease.
Your ophthalmologist will weigh all of these factors before deciding whether you need treatment for glaucoma, or whether you should be monitored closely as a glaucoma suspect. This means your risk of developing glaucoma is higher than normal, and you need to have regular examinations to detect the early signs of damage to the optic nerve.
Regular eye examinations by your ophthalmologist are the best way to detect glaucoma. A glaucoma screening that checks only the pressure of the eye is not sufficient to determine if you have glaucoma. The only sure way to detect glaucoma is to have a complete eye examination.
Photography of the optic nerve or other computerized imaging may be recommended. Some of these tests may not be necessary for everyone. These tests may need to be repeated on a regular basis to monitor any changes in your condition.
Visual field testing is used to monitor peripheral, or side, vision.
As a rule, damage caused by glaucoma cannot be reversed. Eyedrops, laser surgery, and surgery in the operating room are used to help prevent further damage. In some cases, oral medications also may be prescribed. With any type of glaucoma, periodic examinations are very important to prevent vision loss. Because glaucoma can progress without your knowledge, adjustments to your treatment may be necessary from time to time.
Glaucoma is usually controlled with eyed drops taken daily. These medications lower eye pressure, either by decreasing the amount of aqueous fluid produced within the eye or by improving the flow through the drainage angle. Never change or stop taking your medications without consulting your ophthalmologist. If you are about to run out of your medication, ask your ophthalmologist if you should have your prescription refilled.
All medications can have side effects or can interact with other medications. Therefore, it is important that you make a list of the medications you take regularly and share this list with each doctor you see.
Treatment for glaucoma requires teamwork between you and your doctor. Your ophthalmologist can prescribe treatment for glaucoma, but only you can make sure that you follow your doctor’s instructions and use your eye drops. Once you are taking medications for glaucoma, your ophthalmologist will want to see you more frequently. Typically, you can expect to visit your ophthalmologist every three to six months. This will vary depending on your treatment needs.
Laser surgery treatments may be recommended for different types of glaucoma. In open-angle glaucoma, the drain itself is treated. The laser is used to modify the drain (trabeculoplasty) to help control eye pressure. In closed-angle glaucoma, the laser creates a hole in the iris (iridotomy) to improve the flow of aqueous fluid to the drain.
When surgery in the operating room is needed to treat glaucoma, your ophthalmologist uses fine microsurgical instruments to create a new drainage channel for the aqueous fluid to leave the eye. Surgery is recommended if your ophthalmologist feels it is necessary to prevent further damage to the optic nerve. As with laser surgery, surgery in the operating room is typically an outpatient procedure.
If there is clinically significant macular edema or swelling of the macula as a result of the leaky capillaries and microaneurysms in the retina, laser eye surgery may be indicated in order to restore and preserve vision. Ophthalmologists apply very rigid criteria in order to determine who should have the laser eye surgery procedure called, Focal Laser Photocoagulation . These strict guidelines have been developed after many years of clinical trials and protocols in the Early Treatment Diabetic Retinopathy Study (ETDRS) in conjunction with the National Institutes of Health.
Patients with proliferative diabetic retinopathy are often treated with the laser eye surgery procedure called scatter laser photocoagulation of the peripheral retina. This laser eye surgery technique is also called Pan Retinal Laser Photocoagulation or PRP. By using the laser to stop and hopefully reverse the formation of the neovascularization Ophthalmologists are able to lessen the chance of significant vision loss. As with most types of laser eye surgery, Pan Retinal Photocoagulation is performed as an in-office or out-patient procedure.
Laser trabeculoplasty is a surgical treatment for open-angle glaucoma that lowers the intraocular pressure. The ophthalmologist who performs this procedure must have a thorough knowledge of anatomy of the anterior chamber angle, techniques of gonioscopy, and operation of the laser. The technique is more effective in treating primary open-angle glaucoma, pigmentary glaucoma, and exfoliation syndrome glaucoma. It appears to be appropriate for use in patients with these conditions whose intraocular pressure remains uncontrolled, despite maximum-tolerated medical therapy, and as an alternative to glaucoma filtering surgery. In some cases, it may be an appropriate alternative to certain forms of medical therapy. The procedure entails relatively minor risks to the patients, although the long-term results of the treatment are still unknown.
Copyright © 1996 by American Academy of Ophthalmology
YAG capsulotomy, is performed when someone who has already undergone cataract surgery develops a “secondary cataract” or “after-cataract.” This occurs when the original lens capsule that holds the new lens implant becomes cloudy. Using a YAG laser, the eye surgeon makes a tiny opening in the capsule, which allows light to enter the lens once again. The treatment is quick and painless and is performed in the office of your eye surgeon. Other lasers are used routinely to treat different abnormal conditions of the eye, among them macular degeneration and diabetic retinopathy.
From Clarifying Eye Surgery – July 5, 2002 By Ralph M. Bishop, M.D., F.A.C.S.
Age-related Macular Degeneration (AMD) is a chronic eye disease associated with aging that gradually destroys central vision. It’s one of the leading causes of legal blindness and vision impairment in older Americans.
Macular degeneration affects central vision, but not peripheral vision — therefore, it doesn’t cause total blindness. The progression of AMD can be slow or rapid, but the deterioration of central vision generally occurs over a period of a few years. Pain is not associated with AMD, but if you experience any of the following conditions, see your Eye M.D. right away:
Although the exact cause of macular degeneration is unknown, several studies have shown the following are more at risk:
The “dry” form of macular degeneration occurs in approximately 90 percent of those with AMD. Studies have found that high levels of zinc and antioxidants (such as Leutin) play a key role in slowing the progression of dry macular degeneration in advanced cases.
The “wet” form occurs in only 10 percent of those with AMD, but it accounts for 90 percent of all severe vision loss from the disease. “Wet” AMD can be treated with conventional laser treatment and photodynamic therapy (PDT) and certain medications called anti-VEGF treatments. PDT is used to reduce the risk of moderate to severe vision loss in patients with a few specific forms of “wet” macular degeneration. Anti-VEGF drugs, which are delivered directly into the eye by injection, block VEGF (vascular endothelial growth factor), the molecule that promotes the growth of troublesome abnormal blood vessels in “wet” macular degeneration.
Early detection and treatment is the best defense against losing your vision. If you are at risk for macular degeneration, see your Eye M.D. for a complete eye exam at least every one to two years. If your vision has been reduced, you do not have to live a lonely and isolating life. Low vision rehabilitation resources are available to help you preserve your quality of life and maintain maximum independence. See your Eye M.D. for these resources.
An Eye M.D. is an Ophthalmologist — a medical doctor who provides the full spectrum of eye and vision care. From eyeglasses and contact lenses, to medication and surgery, your Eye M.D. will help you keep your sight for life.
Primary care providers need a plan to assess the patient who presents with complaints of redness of the eye. In a primary care setting, specific equipment and familiarity may not be readily available. A few symptoms and signs help separate the common from the difficult choices. Dr. Munn has arranged this diagnostic approach as a reference for evaluating and treating the patient with red eye.
Ask the following questions. When did it start? Was there trauma? Pain scale 1 – 10? Is there a serous or mucosal discharge? Decreased vision or visual field loss? Nausea or vomiting? Itchy or scratchy feeling? Exposure to anyone sick with a cold or flu recently y? History of allergy, recurrent red eye, glaucoma or past ocular problems?
Choose from these directed inquiries to narrow the differential diagnosis. Check the vision (with glasses on) with a near reading card. Redness scale: 0 – 4. One or both eyes involved? Check the eye pressure (normal = 10 – 20 mmHg). Check the motion of the eye (up, down, right, left) looking for restrictions to gaze. Swelling of the eyelids (grade 1 – 4). Check the pupils with a swinging penlight (looking for unequal pupillary constrictions). Determine the character of any discharge (water-serous, stringy-ropy, mucusy) and if there’s an abundance or just a bit. Fluorescein stain the eye surface and check for any corneal yellow fluorescence pattern with a Cobalt Blue Light. Slit lamp exam if possible (or do the best that you can with a direct Ophthalmoscope) for conjunctival swelling (chemosis – grade 1 to 4), conjunctival bleeding under the tissue or through and open wound, corneal surface irregularities, hazy appearance (or blood) in the anterior chamber. Look at the retina with the Ophthalmoscope for the Optic Nerve (follow the blood vessels back as tbey originate from the middle of the Optic Nerve) and fovea for bleeding or swelling. Since you may not have dilating drops, the retina red reflex may be all you can accurately asses and that’s all right for now.
The following descriptions assist in separating the relatively benign from the dangerous. This guide helps you focus from the most to the less common causes and highlights what to beware of. As this cannot be a complete list of all red eye etiologies, when in doubt, refer the patient to an Ophthalmologist.
Chronic irritation, some intermittent vision blurring, scratch eyes (especially after reading or computer use.
Itchy eyes, ropy discharge, normal vision, +/- chemosis, especially if recurrnt and/or seasonal (February to April, September, usually bilateral).
Eyelids stuck together in AM, one to three days duration, normal vision, likely bilateral, young to middle age, children and/or friends with similar presentation, velvety red interiror of inferior eyelid.
Elderly patient, crusted mucus on eyelashes, bilateral, chronic duration, chronic irritation, may have some vision decrease with corneal involvement.
White spot on cornea (fluorescein +), decreased vision, pain, photophobia, unilateral, prior trauma and/or contact lens wear.
Chronic irritation greater than one month, resistant to treatment, bilateral, thin discharge, normal to slight decrease in vision, blood vessels prominent on eyelid margin and/or maxillary facial regions.
Chronic irritation greater than one month, resistant to treatment, bilateral, thin discharge, fairly normal vision, teenage or older, often unmarried.
Cornea fluorescein postive (yellow glow under cobalt blue light) in a “tree branching” pattern, photophobia, serous discharge, mostly unilateral, may have eyelid or margin vesicles, may have Shingles (especially frontal-temporal area), pain and decreased vision.
Decreased vision, photophobia, pain, cloudy appearance to aqueous humor, perilimbal injection.
Nausea,/vomiting, constant pain, decreased vision, increased intraocular pressure, cornea fluorescein negative.
Blood spot under part or the entire conjuctiva, no history of trauma, vision normal, no pain, history of blood thinner use.
Swollen eyelids, history of trauma or stye on eyelid, one or two day onset, slight injection. With restriction of eye motion = Postseptal Cellulitis.
History of trauma, distorted iris appearance outside anteriror chamber, poor vision, blood anywhere and black red reflex.
OTC eye drops (Systane, Optive, Genteal, etc.) one gtt ou qd to qid. If severe, try adding ophthalmic gel or ointment (Lacrilube) at night.
If mild try OTC eye drops, one gtt ou bid to qid prn red itchy eyes (Zaditor, Optivar, Naphcon-A, etc.), if severe then Rx (Pataday, Elestat, Bepreve) 5.0 ml bottle on gtt ou bid prn red itchy eyes.
Usually self-limited (one day to 2 weeks), OTC eye drops (Zaditor, Naphcon-A, Optivar, etc.) one gtt ou qd to qid prn to decrease pain and relieve redness.
Antibiotic eye drops (Tobramyacin 0.3% 5.0 ml, Polytrim 10ml, Vigamox, etc.) one gtt qid X 7 days. Likely recurrent in elderly, refer if chronic.
Rx systematic anivirals (Acyclovir 200 mg #30, Famvir, Valtrex) and add topical Viroptic 5.0 ml one gtt qid. Urgent referral to Ophthalmologist.
Metrogel to face, Doxycycline 100 mg po bid X 7 days, refer to Ophthalmologist for chronic eye tx.
Z pack X 2, improves in a few days but takes 3 to 4 weeks to resolve.
No treatment, should resolve in 3 weeks depending on size, refer to Ophthalmologist if recurs.
po Antibiotics (Cipro 500 mg bid or Keflex 250/500 mg tid).
Need MRI, antibiotics (likely IV) and probable hospital admission.
Unexplained vision loss over time, new floaters unresolved or worsening red eye, HSV/HZV. Shingles.
Acute Glaucoma, Retinal Detachment, Open Globe, Iritis, Corneal Ulcer, trauma, vision loss, intractable eye pain.
Steroid eye drops – legal landmine – don’t use them without Ophthalmogy consultation. Some lymphomas, cancers, cavernous-sinus fistulas, drug allergies and many systemic diseases (Lyme disease, CMV, thyroid, etc.) present initially as a red eye. Consult an Ophthalmologist if in doubt or when things get worse. Patients will be seen quickly. We always appreciate the call.
Strabismus is a visual defect in which the eyes are misaligned and point in different directions. One eye may look straight ahead, while the other eye turns inward, outward, upward or downward. The eye turn may be constant, or it may come and go. The turned eye may straighten at times, and the straight eye may turn. Strabismus is a common condition among children. About 4 percent of all children in the United States have strabismus. It also can occur later in life. Strabismus occurs equally in males and females. Strabismus may run in families; however, many people with strabismus have no relatives with the problem.
Strabismus. Notice the asymmetrical light reflection.
With normal vision, both eyes aim at the same spot. The brain then combines the two pictures into a single three-dimensional image. This three-dimensional image gives us depth perception. When one eye turns out of alignment, two different pictures are sent to the brain. In a young child, the brain learns to ignore the image of the misaligned eye and sees only the image from the straight or better-seeing eye. The child then loses depth perception. Adults who develop strabismus often have double vision because the brain is already trained to receive images from both eyes and cannot ignore the image from the turned eye. A child generally does not see double.
Good vision develops during childhood when both eyes have normal alignment. Strabismus may cause reduced vision, or amblyopia, in the misaligned eye. The brain will pay attention to the image of the straight eye and ignore the image of the crossed eye. This misaligned eye will then fail to develop good vision, or may even lose vision, developing amblyopia. This occurs in approximately half the children who have strabismus. Amblyopia can be treated by patching the “good” eye to strengthen and improve vision in the weaker eye. If amblyopia is detected in the first few years of life, treatment is usually successful. If treatment is delayed until later, amblyopia usually becomes permanent. As a rule, the earlier amblyopia is treated, the better the visual result.
The eyes of infants often appear to be crossed, though actually they are not. This condition is called pseudostrabismus. Young children often have a wide, flat nose and a fold of skin at the inner eyelid that can make the eyes appear crossed. This appearance of strabismus may improve as the child grows. A child will not outgrow true strabismus. An ophthalmologist can usually tell the difference between strabismus and pseudostrabismus.
The exact cause of strabismus is not fully understood. Six eye muscles, controlling eye movement, are attached to the outside of each eye. In each eye, one muscle moves the eye to the right, one-muscle moves the eye to the left. The other four muscles move it up or down and at an angle. To line up and focus both eyes on a single target, all of the muscles in each eye must be balanced and working together. In order for the eyes to move together, the muscles in both eyes must be coordinated. The brain controls these eye muscles.
Strabismus is especially common among children with disorders that may affect the brain, such as:
A cataract or eye injury that affects vision also can cause strabismus. The vast majority of children with strabismus, however, have none of these problems. Many do have a family history of strabismus.
The main sign of strabismus is an eye that is not straight. Sometimes children will squint one eye in bright sunlight or tilt their head to use their eyes together.
Congenital esotropia, where the eye turns inward, is the most common type of strabismus in infants. Young children with esotropia cannot use their eyes together. In most cases, early surgery can align the eyes.
Accommodative esotropia is a common form of esotropia that occurs in children usually 2 years or older. In this type of strabismus, when the child focuses the eyes to see clearly, the eyes turn inward. This crossing may occur when focusing at a distance, up close, or both. Glasses reduce the focusing effort and often straighten the eyes. Sometimes bifocals are needed for close work. If significant crossing of the eyes persists with the glasses, surgery may be required.
Exotropia, or an outward-turning eye, is another common type of strabismus. This occurs most often when a child is focusing on distant objects. The exotropia may occur only from time to time, particularly when a child is daydreaming, ill or tired. Parents often notice that the child squints one eye in bright sunlight. Although glasses, exercises, patching or prisms may reduce or help control the outward turning eye in some children, surgery is often needed.
Strabismus can be diagnosed during an eye exam. It is recommended that all children between 3 and 3 ½ years of age have their vision checked by their pediatrician, family practitioner, or an individual trained in vision assessment of preschool children. Any child who fails this vision screening should then have a complete eye exam by an ophthalmologist (Eye M.D.). If there is a family history of strabismus or amblyopia, or a family history of wearing thick glasses, an ophthalmologist should check vision even earlier than age 3.
After a complete eye examination, an ophthalmologist can recommend appropriate treatment. In some cases, eyeglasses can be prescribed for your child to straighten the eyes. Other treatments may involve surgery to correct the unbalanced eye muscles or to remove a cataract. Covering or patching the strong eye to improve amblyopia is often necessary. Treatment for strabismus works to straighten the eyes and restore binocular (two-eyed) vision.
The eyeball is never removed from the socket during any kind of eye surgery. The ophthalmologist makes a small incision in the tissue covering the eye to reach the eye muscles. The eye muscles are removed from the wall of the eye and repositioned during the surgery, depending on which direction the eye is turning. It may be necessary to perform surgery on one or both eyes.
When strabismus surgery is performed on children, a general anesthetic is required. Recovery time is rapid. Children are usually able to resume their normal activities within a few days. After surgery, glasses may still be required. In some cases, more than one surgery may be needed to keep the eyes straight.
As with any surgery, eye muscle surgery has certain risks. These include infection, bleeding, excessive scarring and other rare complications that can lead to loss of vision. Strabismus surgery is usually a safe and effective treatment for eye misalignment. It is not, however, a substitute for glasses or amblyopia therapy
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