Retina Eye Diseases

What is Age-Related Macular Degeneration (AMD)?

The retina is a thin sheet of nervous tissue that covers the inside of the eye and interprets signals from light. Once light hits the retina, nerve impulses are created and then transmitted to the brain via the optic nerve. The brain interprets the signals into visual images. If you compare your eye to a camera, then the retina would be the 'film'. There is a small central area of concentrated cells on the retina called the macula. The macula is responsible for central vision and color vision. The unique make-up of the macula allows for us to see finer details, such as words in a book, features of someone’s face, or the leaves on a tree.

As we age, the macula is at an increased risk for deterioration. Age-related macular degeneration (AMD) is a medical term used to describe the deterioration of the macula that sometimes happens as we age. AMD can be caused by a combination of genetics, age, and environmental factors such as smoking and high cholesterol. Your doctor can determine if you have AMD.

Dry Age-Related Macular Degeneration (Dry AMD)

Dry AMD accounts for roughly 90% of all macular degeneration cases and generally occurs in both eyes. One of the most common early signs on clinical exam of dry AMD is the presence of drusen, which is the accumulation of extracellular material in Bruch's membrane in the eye. As the disease progresses, the macular photoreceptor cells slowly degenerate and cause vision loss.

As symptoms of this condition worsen, patients may notice a small blurred spot in their central vision. Over time, patients may experience a complete loss of central vision. The most common symptom of dry AMD is slightly blurry vision and the inability to make out details in faces or words while reading. It is important for people over 50 years old or who have a family history of AMD to undergo an annual dilated eye examination to look for macular degeneration.

Wet Age-Related Macular Degeneration (Wet AMD)

Exudative or wet AMD occurs when blood vessels in the retina grow abnormally behind the macula. When this occurs, these fragile blood vessels can leak fluid and blood. This can cause the macula to rise from its normal position in the eye and damage to the macula occurs rapidly. Bleeding, leaking, and scarring associated with wet AMD will ultimately cause irreversible damage to the macula when left untreated.

Different from dry AMD, wet AMD can cause central vision loss very quickly. Early symptoms are often described as seeing “wavy lines” when looking at straight lines. A simple but effective visual tool called an Amsler grid can be used to help diagnose wet AMD.

There are many new effective treatment options now available to manage wet AMD with the recent use of anti- vascular endothelial growth factors (anti-VEGF) such as Macugen®, Avastin® and Lucentis®. For this reason, a patient that might be experiencing any symptoms should see an eye specialist immediately.

What are common AMD symptoms?

It is important to know that both dry and wet AMD have no pain associated with them.

Patients that have dry AMD might experience blurred vision, loss of details, and a growing blind spot in the center of the field of vision. Patients that have wet AMD often begin seeing straight lines that appear crooked. A blind spot might also occur in the center of the field of vision. These symptoms advance much more quickly than dry AMD.

How is Dry AMD treated?

If dry AMD reaches the most advanced stage known as “geographic atrophy,” nothing can help the patient regain their central vision. However, a doctor might be able to delay and possibly prevent the early and middle stages of AMD from progressing to the advanced stage.

How is Wet AMD treated?

Laser Treatment Your surgeon can use laser treatment to remove the fragile, bleeding blood vessels, preventing further vision loss. Some surgeons may prefer not to use laser treatment, because it can cause damage to surrounding healthy tissue. This treatment is best for patients that have leaky blood vessels that have formed away from the fovea. Only certain patients will be good candidates for laser treatment, which is typically performed in the office.

Photodynamic Therapy (PDT)

With PDT, the doctor will inject a drug called verteporfin into the patient’s vein. This drug travels through the body and into the blood vessels of the eye. Next, the doctor uses a light in the eye for about 90 seconds which activates the drug and removes the new blood vessels. This helps slow vision loss by decreasing the leakage from blood vessels in the eye. It is important to avoid direct sunlight or bright light for about a week after treatment.

Anti-Vascular Endothelial Growth Factors (anti-VEGF) Injections- Intraocular Injections of anti-VEGF medications such as Macugen®, Avastin® or Lucentis® slows the growth of abnormal blood vessels. Often, patients will need multiple injections every 1-2 months. This procedure can slow down wet AMD and improve sight.

Diabetic Retinopathy

Diabetic retinopathy is the most common eye disease among diabetics. It’s also the leading cause of blindness in American adults. This disease occurs when blood vessels in the retina change, causing them to swell and leak fluid frequently. Sometimes abnormal new blood vessels even grow on the surface of the retina.

Diabetic retinopathy usually occurs in both eyes. The most common symptom of diabetic retinopathy is slight changes in vision. Over time, the condition can worsen, causing greater vision loss.

Four Stages of Diabetic Retinopathy

Mild Nonproliferative Retinopathy At this stage, small blood vessels in the retina might experience small areas of balloon-like swelling called microaneurysms.

Moderate Nonproliferative Retinopathy – As the disease progresses, some of the blood vessels that the retina depends on for nourishment are blocked or bleed.

Severe Nonproliferative Retinopathy – In this stage, more additional blood vessels become blocked and bleed. This deprives the retina of blood supply. Once this occurs, the retina begins to release growth factors to grow new blood vessels to provide more of a blood supply.

Proliferative Retinopathy – This is the most advanced stage of the disease. Additional blood vessels have grown to nourish the retina, but these new fragile blood vessels have grown along the retina and in the surface of the vitreous gel. These vessels leak blood and cause fractional retinal detachments, which can lead to severe vision loss or even blindness.

Who is at risk for diabetic retinopathy?

Anyone with type 1 or type 2 diabetes mellitus is at risk. It is important that everyone with diabetes get a dilated eye exam at least once a year to check for the disease. As those with diabetes age, they become even more at risk for getting diabetic retinopathy. It is estimated that 45% of diabetic Americans have some form of the disease.

Diabetic retinopathy can worsen in pregnancy. If you are a diabetic and pregnant, then it is important that you have diabetic eye exams.

What are the Symptoms?

Symptoms are similar to those of AMD. Many patients experience no pain or noticeable symptoms during the early stages of the disease. That is why it is recommended that diabetic patients get annual dilated eye exams before the disease progresses.

With time, patients become more symptomatic. Extreme light sensitivity can occur because of poor ocular blood perfusion. Blurred central vision may be noticed when macular edema or swelling is present. If the disease has progressed to where new blood vessels have grown, then blood can completely block vision.

What are the symptoms of proliferative retinopathy if bleeding occurs?

Patients normally notice specks or spots of blood (that appear gray or black) floating in their vision. If this occurs, see your eye doctor immediately before additional serious bleeding occurs. If treatment is not performed, proliferative retinopathy can cause complete vision loss.

How is diabetic retinopathy treated?

Usually, there is no treatment for the first three stages of diabetic retinopathy unless there is leakage of fluid onto the central retina known as macular edema. This condition is treated with a retinal laser in the office. It is recommended that patients with diabetes control their blood pressure, blood sugar and cholesterol.

The fourth stage, known as proliferative retinopathy, is treated by using a different retinal laser in the office. During this treatment, surgeons use the laser to photocoagulate the retina and cause the abnormal blood vessels to go away. Optimally, this treatment is performed before new blood vessels have begun to bleed. That’s why annual dilated eye exams are so important to catch the diseases before it progresses to that stage.

If bleeding has progressed beyond the point of laser treatment, a procedure called a vitrectomy might be necessary to remove blood from the center of the eye.

What is a vitrectomy?

A vitrectomy is usually recommended in the advanced stage of proliferative retinopathy. Your doctor may wait several months to see if the blood will dissipate on its own before proceeding with a vitrectomy. This procedure removes the blood-filled vitreous and replaces it with a clear fluid naturally produced by the eye. This procedure is performed under either local or general anesthesia in the operating room.

What is a Macular Hole?

Sometimes, a small circular hole develops in the central retina (macula). Idiopathic macular holes spontaneously occur in elderly patients from tangential traction of the vitreous overlying the macula. Other types of macular holes happen from trauma, high myopia (nearsightedness), and chronic macular edema. When this occurs, patients can notice blurred or distorted central vision. Usually the size of the hole and its location determines the amount of vision loss.

How is a macular hole treated?

Surgery is often necessary to improve vision and to prevent further damage. Usually a vitrectomy is performed to remove the vitreous gel to prevent it from pulling on the retina. Surgery is usually performed under local anesthesia on an outpatient basis. After surgery, patients must remain in a facedown position for 1 week. This allows the air bubble to press against the macular hole as it heals. Although uncomfortable, this is a crucial step to the success of the surgery.

What is a macular pucker?

A macular pucker is an epiretinal membrane that develops over the macula. The macula is responsible for the central vision. As a result, macular pucker often causes blurred and distorted central vision.

What are the symptoms of a macular pucker?

Symptoms can greatly vary from no visual loss to severe loss of central vision. Some patients may start to notice lines appearing wavy or their vision becoming blurry. Some patients may also notice difficulty seeing fine detail when reading.

How is a macular pucker treated?

In most cases, a macular pucker doesn’t require treatment. In many cases, the symptoms of blurriness or distortion are mild. Most patients can adjust to mild visual distortion, even while reading or driving a car. In some rare cases, the vision can decline to the point that daily activity becomes impossible. When this happens, surgeons will typically perform a vitrectomy.

What is retinal detachment?

The retina is a thin sheet of nerve tissue that covers the inside part of the eye and interprets signals from the light that focuses on it. Once light hits the retina, nerve impulses are transmitted to the brain which interprets it into visual images. If you compare your eye to a camera, then the retina would be the 'film'. On rare occasions, the retina can actually detach from the back of the eye. If not promptly treated, retinal detachment can cause permanent vision loss.

Who is at risk for retinal detachment?

A retinal detachment can occur at any age. However, it is more common in people over the age of 40. A retinal detachment is more likely to occur in those who have severe nearsightedness, a previous retinal detachment, a family history of retinal detachment, had cataract surgery, or had a prior eye injury.

What are the symptoms of retinal detachment?

The most common symptom is new onset of flashes and floaters. Floaters can appear as specks or cobwebs floating around in your vision. Flashes appear as flashes of light. Some patients even experience a curtain over their field of vision. IF YOU HAVE ANY OF THESE SYMPTOMS, SEE YOUR OPHTHALMOLOGIST IMMEDIATELY.

How is retinal detachment treated?

When a small tear or hole hasn't progressed to detachment, your doctor can usually perform an outpatient procedure to preserve your vision. Retinal laser photocoagulation can be used to barricade a small or focal retinal detachment. With photocoagulation, your doctor uses a laser beam to burn around the retinal tear, causing scarring that essentially barricades the retina in place

For a larger retinal detachment, the treatment can be more intense. Sometimes surgeons will use a scleral buckle that acts as a rubber band to gently push the eye wall against the retina. A more severe case would require a vitrectomy. This procedure is performed under either local or general anesthesia in a surgical suite. Often, gas or silicone oil is injected into the eye to hold the retina against the eye wall.

After surgery, patients must remain in a face down position for up to 1-3 weeks. This allows the air bubble to press against the retina as it heals and keeps the retina attached.

Central and Branch Retinal Vein Occlusion

Retinal vein occlusion occurs when a small vein that carries blood away from the retina becomes blocked. When a retinal vein is obstructed by an adjacent blood vessel, a hemorrhage in the retina occurs. This causes a sudden partial or complete loss of vision. This condition is most common in adults over the age of 60.

How is Retinal Vein Occlusion treated?

Some patients may regain vision without treatment. However, vision rarely returns to normal. Complications from retinal vein occlusion require treatment. Macular edema is treated with focal laser, steroid injections, or anti-vascular endothelial growth factor (anti-VEGF) drugs. Laser photocoagulation treatment is performed to prevent abnormal blood vessels from growing in an ischemic retina.