Retinal Vascular Occlusions

Just like any other organ in the body, the retina needs a healthy blood supply to function properly. When a blood vessel in the retina becomes blocked, sudden loss of vision can occur. Such blockages, known as retinal vascular occlusions, often occur in older adults. Because there are effective treatments available, seeing a specialist promptly can prevent further problems or even restore vision.

Retinal arterial occlusions

Arteries are the vessels that bring fresh blood containing oxygen and nutrients to different parts of the body. The artery that supplies the retina is known as the central retinal artery. After it enters the eye, the central retinal artery splits up into branch retinal arteries that serve different areas of the retina.

Symptoms
The symptoms of a central retinal artery occlusion include a sudden, painless loss of vision in one eye. Because the circulation to the entire retina is disrupted, the vision loss is profound and encompasses the entire field of vision. In contrast, a branch retinal artery occlusion only leads to loss of vision in a part of the field of vision. This is because only part of the retinal circulation in compromised. Similar to a central retinal artery occlusion, a branch retinal artery occlusion is also typically sudden and painless.

Evaluation
Retinal arterial occlusions can usually be diagnosed simply by examining the retina. Often, the retina is whitened in the area of the occlusion due to the lack of blood flow. Most arterial occlusions occur in patients with diseases such as high blood pressure or diabetes. On occasion, fragments of cholesterol or blood clots can be cause of the occlusion. Therefore, the treating physician will usually order tests looking for the source of these deposits in the carotid arteries or the heart. Another important cause of central retinal artery occlusions is a condition known as temporal arteritis. Temporal arteritis is an inflammatory disorder that can also produce fever, pain, or weight loss. Blood tests are ordered if temporal arteritis is suspected.

Retinal vascular occlusions — Figure 1. Whitening of the retina due to a central retinal artery occlusion

Treatment
Unfortunately, there is no proven, reliable treatment for retinal arterial occlusions at this time. Various methods including hyperbaric oxygen, ocular massage, and anterior chamber paracentesis may or may not be effective if the occlusion is treated right away. However, if the occlusion is due to temporal arteritis, treatment with corticosteroids is effective at preventing loss of vision in the other eye. An unwanted, late complication of retinal arterial occlusions is neovascularization. Neovascularization refers to the growth of new, abnormal blood vessels in different parts of the eye that can result in bleeding, detachment of the retina, or glaucoma. Neovascularization is treated with laser or injections of anti-neovascular medications into the eye.

Retinal venous occlusions

After blood has passed into the eye through the retinal arteries, it leaves through the retinal veins. Blood travels first through the smaller, branch retinal veins and then enters the central retinal vein.

Symptoms
A central retinal vein occlusion usually causes sudden, painless vision loss in one eye. Unlike a central retinal artery occlusion, which causes profound vision loss, the visual deficit in a central retinal vein occlusion can range from mild to severe. More severe occlusions cause more severe deprivation of vital oxygen to retinal tissue. In addition, a central retinal occlusion can result in macular edema, swelling of the retina that also leads to blurred vision. A branch retinal vein occlusion usually leads to blurring of vision in only part of one eye. Like central retinal vein occlusions, branch retinal vein occlusions can vary in severity, but often result in macular edema as well.

Evaluation
Retinal venous occlusions are also diagnosed by examining the retina. The blocked vein will appear dilated and engorged. In addition, the area of the retina served by that vein will contain hemorrhages or become swollen. To assess the amount of oxygen deprivation to the retina, a specialist will often recommend a fluorescein angiogram. The angiogram involves the injection of a yellow dye known as fluorescein intravenously. Subsequent photos allow visualization of the abnormal blood flow within the retina. In addition, optical coherence tomography is often performed to determine the amount of swelling within the retina.

Figure 2. A retinal vein occlusion with hemorrhages seen as the red spots in the bottom half of the image.

Treatment
Treatment of retinal venous occlusions is largely aimed at decreasing swelling in the macula in hopes of improving vision. Currently, the most effective treatments involve injections of medication into the eye. FDA approved medications such as Lucentis and Eylea, that target abnormal levels of growth factors in the eye, can result in significant gains in vision in approximately two thirds of patients with branch retinal vein occlusions and half of patients with central vein occlusions. In addition, injectable steroid medications such as Ozurdex can also be effective, with approximately one third of patients having a significant visual gain. Laser can also be used to treat macular edema due to branch retinal vein occlusions. Keep in mind that these treatments likely need to be repeated on a routine basis or used in combination to achieve maximum benefits. If neovascularization occurs, it is treated as previously described in the section about retinal arterial occlusions.

In conclusion, occlusions of either retinal arteries or veins can cause significant visual impairment. Prompt evaluation and ongoing treatment with a retinal specialist can often improve and maintain vision.

9/24/15

David Liao, MD, PhD
Retina-Vitreous Medical Group

Which Eye Care Specialist Do You Need?

It’s time to get your eyes checked – do you go to an ophthalmologist, optometrist or optician? Your optometrist sees the beginnings of age-related macular degeneration, but is sending you to see and ophthalmologist, why?

One of the most confusing things about taking care of your eyes can be differentiating between an ophthalmologist, optometrist and optician. Each eye care specialist has a very important part to play in the health of your eyes and here is a quick synopsis of what each does so you can choose the best one for your vision issues and treatment.

Ophthalmologist
These specialists are fully trained medical doctors that have completed the eight years of training beyond a bachelor’s degree. Their training has included a full spectrum of eye care, from prescribing glasses and contact lenses and giving eye injections, to carrying out intricate eye surgeries. Many doctors may also be involved eye research to better understand vision, improve eye disease treatments or potentially find a cure. They are easily identified by the MD following their name.

Optometrist
These medical professionals have completed a four-year program at an accredited school of optometry. They have been trained to prescribe and fit glasses and contact lenses, as well as diagnose and treat various eye diseases. They provide treatments through topical therapeutic agents and oral drugs, and are licensed to perform certain types of laser surgery, such as Lasik. They are easily identified by the OD following their name.

Optician
These eye care professionals are not licensed to perform eye exams, medical tests or treat patients. Their purpose is to take the prescription from the ophthalmologist or optometrist and work with you to determine which glasses or contact lenses work best for you. If you suffer from an eye disease like keratoconus, these specialists can make the difference between a relatively normal life, or one that is dictated short periods of vision because of contact lens pain. These eye care professionals may hold and associate optician degree or have apprenticed fore required number of hours.

While each one of these eye specialists has their own area of expertise, they can form a team whose only concerns are your eye health and the ability to see as clearly as possible.

8/11/15

Susan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Eye Issues For Every Age Recap

Vision is something we take for granted, but when we start to have trouble seeing it is easy to panic. This blog has covered a variety of eye issues for every age, from children through older adults. Here are a few articles from leading doctors and specialists that you may have missed and might be of interest.

Bill Takeshita, OD, FAAO – Visual Aids and Techniques When Traveling

Michelle Moore, CHHC – The Best Nutrition for Older Adults

Arthur B. Epstein, OD, FAAO – Understanding and Treating Corneal Scratches and Abrasions

The National Eye Health Education Program (NEHEP) – Low Vision Awareness
Maintaining Healthy Vision

Sandra Young, OD – GMO and the Nutritional Content of Food

S. Barry Eiden, OD, FAAO – Selecting Your Best Vision Correction Options

Suber S. Huang, MD, MBA – It’s All About ME – What to Know About Macular Edema

Jun Lin, MD, PhD and James Tsai, MD, MBA – The Optic Nerve And Its Visual Link To The Brain

Ronald N. Gaster, MD FACS – Do You Have a Pterygium?

Anthony B. Nesburn, MD, FACS – Three Generations of Saving Vision

Chantal Boisvert, OD, MD – Vision and Special Needs Children

Judith Delgado – Driving and Age-Related Macular Degeneration

David L. Kading OD, FAAO and Charissa Young – Itchy Eyes? It Must Be Allergy Season

Lauren Hauptman – Traveling With Low Or No Vision / Must Love Dogs, Traveling with Guide Dogs / Coping With Retinitis Pigmentosa

Kate Steit – Living Well With Low Vision Online Courses

Bezalel Schendowich, OD – What Are Scleral Contact Lenses?

In addition here are few other topics you might find of interest, including some infographics and delicious recipes.

Pupils Respond to More Than Light

Watery, Red, Itchy Eyes

10 Tips for Healthy Eyes (infographic)

The Need For Medical Research Funding

Protective Eyewear for Home, Garden & Sports

7 Spring Fruits and Vegetables (with some great recipes)

6 Ways Women Can Stop Vision Loss

6 Signs of Eye Disease (infographic)

Do I Need Vision Insurance?

How to Help a Blind or Visually Impaired Person with Mobility

Your Comprehensive Eye Exam (infographic)

Famous People with Vision Loss – Part I

Famous People with Vision Loss – Part II

Development of Eyeglasses Timeline (infographic)

What eye topics do you want to learn about? Please let us know in the comments section below.

7/21/15

Susan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Your Comprehensive Eye Exam

Being able to see clearly is important to all of us. But it is also something we have a tendency to take for granted until we notice changes in our vision. The point of the yearly comprehensive exam is to monitor your eyes before any problems arise, and address any concerns that could affect your vision later. Here is what to expect at your next comprehensive eye exam.

An eye exam involves an external examination of your eyes followed by a series of tests designed to evaluate your vision and check for eye diseases. Each test evaluates a different aspect of your vision and includes specific tests for visual acuity, pupil function, muscle function, visual fields, eye pressure and viewing the back of the eye through a dilated pupil.

External Exam
The external examination consists of inspecting the eyelids, surrounding tissues and the eyeball including the sclera (white part of the eye), iris and cornea.

Visual Acuity & Fields
Visual acuity is your eye’s ability to detect fine details and see an in-focus image at a certain distance. A Snellen chart and a phoropter are used. The standard definition of normal visual acuity is 20/20. The term 20/20 comes from even sized objects that can be seen by a “person of normal vision” at the specified distance. For example, if a person can see at a distance of 20 feet an object that normally can be seen at 20 feet, then they have 20/20 vision. If they can see at 20 feet what a normal person can see at 40 feet, then they have 20/40 vision. For the visual acuity test each eye is tested separately to gauge your side or peripheral vision.

Pupil Function
An examination of the pupil begins with inspecting your pupils for equal size, regular shape, reaction to light, and direct and consensual reaction (meaning the pupil of one eye constricts when the other eye is exposed to light).

Eye Muscle Function
Eye movement is assessed two ways. First by having you move your eye quickly to a target at the far right, left, top and bottom. Then by slow tracking which uses the ‘follow my finger’ test, which tests all the muscles that move your eye.

Eye Pressure Measurement
Intraocular pressure, or IOP, is measured using a tonometer to determine the fluid pressure inside your eye. This test provides information regarding your potential for glaucoma.

Viewing the Back of the Eye
Increasing the size of your pupil with eye drops (known as dilating your eyes) allows the doctor to have a larger view of the back of your eye, including the retina, as demonstrated by this diagram. This is very important for diagnosis and tracking of macular degeneration and diabetic retinopathy.

Eye Structure
A special, high-powered microscope, called a slit-lamp, is used to view the structures of your eye clearly and in detail, enabling early diagnosis of a variety of eye conditions such as cataracts, presbyopia and corneal injury.

Taking care of your eyes, especially as you become older, is very important. Changes in vision may be gradual, or fast, but in both cases, early diagnosis is key to successful treatment and retaining your vision. It is suggested that individuals 40 and over have a comprehensive eye exam every one to two years. Exceptions would be if you have diabetes, in which case you should see your eye doctor yearly; or there is a family history of eye diseases such as glaucoma, macular degeneration, or corneal diseases, which may require more frequent visits to your eye doctor. If you have any degree of sudden vision loss, eye pain, or significant irritation, contact your eye doctor immediately.

4/23/15

Susan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Do I Need Vision Insurance?

With the rising costs of health insurance, many people are looking for ways to reduce their costs. Since not all insurance packages include vision insurance, many people wonder, do I need vision insurance?

Standard Vision Insurance

Vision insurance is a type of health insurance that entitles you to specific eye care benefits such as routine eye exams and other procedures, as well as a specified dollar mount or discount for the purchase of eyeglasses and contact lenses. It only supplements regular health insurance and is designed to help reduce your costs for routine preventative eye care and eyewear.

You can get vision insurance as part of a group, such as your employer, an association, etc., through a government program such as Medicare or Medicaid, or as an individual. It is often a benefit linked to your regular HMO (health maintenance organization) or PPO (preferred provider organization) health insurance.

There are two primary vision insurance plans available:

Vision Benefits Package – provides free eye care services and eyewear within a fixed dollar amount for which you pay an annual premium or membership fee and a small co-pay. It may also include a deductible.
Discount Vision Plan – provides eye care and eyewear at a discounted rate after you pay an annual premium or membership fee.

Both insurance plans generally include:

Annual eye exams
Eyeglass frames (usually once every 24 months)
Eyeglass lenses (usually once every 24 months)
Contact lenses (usually once every 24 months)
Discounted rates for LASIK and PRK

Here is where you can check for a list of some vision insurance providers.

Medicare and Medicaid

Different kinds of vision care are included in the US government programs, Medicare and Medicaid. These programs are for qualifying American age 65 and older, individuals with specific disabilities and people with low income.

The Types of Medicare For Vision:

Medicare Part A (Hospital Insurance) –Medical eye problems that require a hospital emergency room attention, but routine eye exams are NOT covered.
Medicare Part B (Medical Insurance) – Visits to an eye doctor that are related to an eye disease, but routine eye exams are NOT covered.
Medicare Part D (Prescription Drug Coverage) – Will help pay for prescription medications for eye diseases.

If you have Medicare Parts A & B you are generally eligible for the following vision coverage, however, there is a deductible before Medicare will start to pay, at which point you will still be paying a percentage of the remaining costs.

Cataract surgery – covers many of the cost including a standard intraocular lens (IOL). If you chose a premium IOL to correct your eyesight and reduce your need for glasses, you must pay for this added cost out-of-pocket.
Eyewear after cataract surgery – one pair of standard eyeglasses OR contact lenses.
Glaucoma screening – an annual screening for people at high risk for glaucoma, including people with diabetes or a family history, and African-Americans whom are 50 or older.
Ocular prostheses – costs related to the replacement and maintenance of an artificial eye.

There is also Medicare Supplement Insurance (Medigap) which is sold by private insurance companies to supplement only Medicare Parts A & B. It is intended to cover your share of the costs of Medicare-covered services including coinsurance, co-payments and deductibles. For more details about Medicare plans and coverage check their website or call 800-633-4227.

Medicaid is the US health program that gives medical benefits to low-income people who may have no or inadequate medical insurance. A person eligible for Medicaid may be asked to make a co-payment at the time medical service is provided. Vision benefits for children under the age of 21 include eye exams, eyeglass frames and lenses. Each state determines how often these services are provided and some states offer similar vision services to adults. To learn more about Medicaid eligibility requirements and vision benefits call your state’s Medicaid agency or visit their website.

Defined Contribution Health Plans

A way to lower your vison care costs is to take part in a defined contribution health plan (DCHP). You are given a menu of health care benefits to choose from where a portion of the fees you receive for health coverage come from money that is deducted from our paycheck before federal, state and social security taxes are calculated. Four types of DCHP are:

Cafeteria Plans – your employer takes a portion of your salary and deposits it into a non-taxable account for health care spending. The amount taken depends on the number and costs of the benefits you select.

Flexible Spending Accounts (FSA) – your employer takes a predetermined portion of your pre-tax salary and deposits it into health care account for you to pay medical expenses. But generally preventative care such as routine eye exams and are not reimbursable. Nor are eyeglasses and contact lenses reimbursable. You would need to verify with your employer. If you do not use all the money at the end of a 12 month period, the money goes back to your employer.

Health Reimbursement Arrangement (HRA) – this is similar to an FSA except you can use it for preventative care like eye exams and you do not lose the money if it isn’t spent within a certain time period as it can be carried from year to year.

Health Savings Account (HSA) – it can be employer-sponsored of you can set up one independently; however you must purchase a high-deductible health insurance plan to open an HSA and you cannot exceed the annual deductible of your health insurance plan. You cannot be enrolled in Medicare of be a depended on someone else’s tax return. You can use it for preventive care such as eye exams. You can learn more about HSAs by visiting the US Treasury’s website.

There are a variety of options when it comes to vision insurance. You just need to determine your needs and ask providers the correct questions.

4/14/15

Susan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Medical Research Funding Needs Individual Donors

The Need for Medical Research Funding

About 1.75 million U.S. residents currently have advanced age-related macular degeneration with associated vision loss, with that number expected to grow to almost 3 million by the year 2020.

About 8.4 million individuals worldwide are blind from primary open-angle glaucoma, with that number expected to grow to almost 11 million by the year 2020.

About 22 million Americans have cataracts affecting their vision, with that number expected to grow to more than 30 million by the year 2020.

The economic impact of this increase of people with vision loss will be tremendous. But right now scientist are working on ways to treat and eventually cure many eye diseases. The only problem is the funding necessary to support this sight-saving research. Here is a look at the decline of medical research funding in the US and what you can do to help.

3/17/15

Susan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

It’s All About ME – What to Know About Macular Edema

“You’ve got the macular? I’ve got some but my sister, she’s got all kinds!” Even as the word retina has become commonplace, the macula and its diseases are often feared and misunderstood. The retina is the light-sensitive layer of cells that line the inside of the eye. The many layers of the retina work together to convert what we see into an exquisitely coded signal that travels to the brain. There the message is decoded and directs us to take action – “that’s a fine looking piece of pie!”

The macula is the part of the retina that helps us see fine detail, far away objects, and color. It’s packed with more photoreceptors than any TV or monitor which is why it is prized real estate. It is the small, central area of the retina that’s worth the most – the bullseye of sight. When things happen to the macula, it gets an “r”. Macular edema, macular degeneration, macular hole, pucker, drusen, scar, fibrosis, hemorrhage, and vitreomacular traction are common conditions that involve the macula. When present, distorted vision (metamorphopsia), blank spots (scotoma), and blurred vision are common symptoms.

Four. Ang. - Macular Edema — Figure 1: Fluorescein angiography: Macular edema may be seen as a pinpoint leak (left, large arrow) in mild cases. In serious cases, ME may diffusely involve the macula. Note how the image becomes brighter as more dye leaks from damaged macular capillaries. (Center and Right)

Macular edema refers to an abnormal accumulation of fluid in the layers of the macula. From the side, it looks like the snake that ate the pig. Like a droplet of water on your computer screen, images are distorted by the swollen retina – making it more difficult to see clearly. The more widespread, thicker, and severe the swelling becomes, more likely one will notice visual symptoms. If untreated, chronic macular edema can lead to irreversible damage to the macula and permanent vision loss.

OCT - Macular Edema — Figure 2: Optical Coherance Tomogrphy and Macular Edema: OCT is a useful test to study macular edema (ME)
-The top image has is normal. Note the even layers and gently sloping dip of the macula called the fovea. This eye has excellent vision.
– The middle OCT has ME, black-appearing cysts (arrows) which threaten the normal fovea. This eye also has good vision.
– The bottom OCT shows ME involving the macula. Because ME involves the macular center (the fovea), vision is poor (large red arrow).

Macular edema is not a disease but the result of one. As with other conditions where abnormal fluid accumulates (leg swelling, pulmonary edema, hives, and allergy), macular edema can be caused by many conditions including metabolic (diabetes), aging (macular degeneration), hereditary (retinitis pigmentosa), inflammatory (sarcoidosis, uveitis), toxic, neoplastic (eye tumors), traumatic, surgical, and unknown causes (idiopathic, macular hole, macular pucker, vitreomacular traction). Macular edema occurs when the retina’s ability to keep fluid out of the retina is overwhelmed by the fluid leaking into it. (If more rain falls on the lawn than it can handle, you get puddles of fluid. In the retina, blisters of fluid form and swell the retina – this is macular edema. Fluorescein angiography (Figure 1) and optical coherence tomography (Figure 2) are two common tests to evaluate macular edema.

Macular edema is typically caused by increased leakage or growth of abnormal blood vessels. The most effective treatment strategies address the underlying cause (diabetes, blood vessel occlusion, neovascularization, inflammation, etc) as well as the hyperpermeability of the capillaries in and around the macula. Eye drops, laser, placement of long-acting medication implants, and surgery are effective in many diseases but the mainstay of treatment is now intravitreal injections (IVI). The IVI is an office procedure painlessly performed under topical anesthesia in which medication is placed inside the eye by a very small needle. IVI should be performed by a trained retina specialist with meticulous monitoring of treatment efficacy and of extremely rare but potentially serious complications. IVI is considered one of the most commonly performed procedure in the world.
Lucentis, Eyelea, and Ozurdex are the trade names of the three most common FDA-approved medications for the treatment of the common conditions causing macular edema. Avastin is not FDA approved but has also been extensively studied in large, well-designed, federally-funded clinical trials and is felt to have efficacy and safety no less than any of the other available options. Each option has a considerable track record of success and works by decreasing the amount of fluid leaking from abnormal blood vessels.

Macular edema is a common finding in many diseases of the retina, most which can be treated to improve vision. The physician’s therapeutic armamentarium continues to expand. There has never been a more successful time in the treatment of macular edema and macular disease. While much has been discovered, many promising therapies await.

3/5/15

Suber S. Huang, MD, MBA
Chair, National Eye Health Education Program
Philip F. and Elizabeth G. Searle – Suber Huang MD Professor
Case Western Reserve University School of Medicine
Past-President American Society of Retina Specialists
CEO, Retina Center of Ohio

Uveitis Explained

12/18/14

Uveitis is defined as inflammation of the uveal tissue. The uvea includes the iris, ciliary body, and the choroid of the eye. The iris is located in the anterior compartment of the eye and acts like the aperture of the camera, precisely filtering the amount of light entering the eye. The ciliary body, which is attached posteriorly to the iris, is involved in both the production of the aqueous fluid in the eye as well as the accommodation of the lens apparatus. The choroid is a dense layer of blood vessels that sits underneath the retina on the back wall of the eye, helping to nourish and remove metabolic waste products from the retina. Inflammation of any of these structures will consequently cause disruption of the visual pathway and over the long term can cause permanent visual loss. In fact, uveitis is the third most common cause of preventable blindness in the developed world.

Symptoms of uveitis include blurry vision, ocular pain, photophobia, redness, and floaters. These can be acute in nature, lasting a few days to weeks, and in some cases can be chronic, lasting weeks or months. Anyone with any of these symptoms should see their eye care provider as soon as possible, as faster treatment of uveitis has shown to result in better long term visual outcomes.

Uveitis can affect virtually any part of the eye, from front to back. Anterior uveitis or iridocyclitis is confined to the iris, ciliary body, anterior chamber, and cornea. Inflammation affecting the vitreous is termed intermediate uveitis, or pars planitis, and any inflammation affecting only the retina or choroid is termed posterior uveitis. The term panuveitis may be used when multiple layers of the eye are affected.

There are many possible causes of uveitis, including infection, inflammatory diseases, autoimmune diseases, and trauma. However, the majority of cases of uveitis, approximately half, are considered idiopathic, where no etiology is ever found. Trauma is the next most common cause of intraocular inflammation, accounting for approximately 20% of all cases. The remaining cases are secondary to a systemic disorder or localized ocular condition. Systemic etiologies can include inflammatory disorders such as sarcoidosis, infections such as tuberculosis and syphilis, as well as autoimmune diseases such as rheumatoid arthritis and lupus.

Treatment of uveitis is aimed at both blunting the intraocular inflammation as well as addressing any underlying systemic etiology. The most common treatment is the use of corticosteroids. These can be taken orally, or used topically as eye drops. In some cases, corticosteroids can be injected in or near the eye as well. If the uveitis is caused by an infection, such as tuberculosis or syphilis, the patient is also given antibiotics. Systemic corticosteroids can have major side effects when taken chronically, such as weight gain, hair loss, osteoporosis, hypertension, secondary diabetes, psychosis, and reduced growth in children. Because of these potential problems, the chronic use of systemic corticosteroids is not recommended. In cases of chronic uveitis that require long term treatment, immunosuppressive agents with less known side effects such as methotrexate, cyclosporine, and mycophenolate mofetil (Cellcept) are more commonly used. However, these biologic agents have their own set of potential side effects and therefore, it is recommended that a rheumatologist should also be involved in the care of the patient when using these agents. Topical and intraocular steroids localized to the eye can cause elevated intraocular pressure as well as cataracts. In most cases, elevated intraocular pressure can be controlled with topical glaucoma drops, but in some cases surgical intervention is required to prevent severe glaucomatous damage.

The most common type of uveitis is acute anterior uveitis or iridocyclitis. Many cases of anterior uveitis are idiopathic though almost half of all cases are associated with the HLA- B27 haplotype. Systemic diseases associated with HLA-B27 include psoriatic arthritis, ankylosing spondylitis, reactive arthritis, and inflammatory bowel syndrome. Signs of anterior uveitis include redness of the eye, sometimes termed ciliary flush. The conjunctiva can become extremely red, and when associated with ocular pain and photophobia, is a strong indicator of anterior uveitis. Inflammatory cells found in the anterior chamber are the hallmark of anterior uveitis, sometimes deposited on the corneal endothelium (keratic precipitates) or iris (Bussaca nodules). Patients with anterior uveitis are typically treated with topical corticosteroid and cycloplegic eye drops. A laboratory workup for systemic etiologies is usually not necessary unless the patient experiences a recurrent episode.

Inflammation affecting primarily the vitreous cavity is known as intermediate uveitis or pars planitis. Inflammatory cells in the vitreous, known as vitritis, are typically bilateral, and when severe, can be found clumped in the vitreous cavity (snowballs) or deposited on the inferior pars plana (snowbanking). Intermediate uveitis is typically idiopathic though sarcoidosis, multiple sclerosis, and Lyme disease are also possible causes. Certain malignancies such as lymphoma can also ‘masquerade’ as intermediate uveitis, and when seen in older patients, should be suspected and ruled out.

Posterior uveitis involves the retina, choroid, and/or the retinal vasculature, and usually is more difficult to treat than anterior uveitis.

Uveitis Explained — This patient with Cat-scratch disease, caused by infection with Bartonella henselae, is an example of posterior uveitis. Note the characteristic star-like pattern of exudate in the macula along with optic nerve swelling.

In many cases, patients with posterior uveitis will exhibit characteristic exam findings that help narrow the differential diagnosis. For instance, an area of active retinitis next to an old pigmented chorioretinal scar is highly suggestive of toxoplasmosis. The most common symptom in patients with posterior uveitis is blurred vision. One of the more typical findings in posterior uveitis is macular edema, which is usually treated with periocular or intraocular corticosteroids.

In summary, uveitis is a visually threatening inflammatory condition that should be diagnosed and treated immediately. It is important to determine as best as possible the etiology of the uveitis and treat appropriately. In general, most patients with uveitis have good visual recovery with the proper management. However, in some cases, severe damage can occur, either due to the inflammation itself (usually chronic) or as a side effect of therapy (corticosteroids).

Richard H. Roe, MD, MHS
Retina-Vitreous Associates Medical Group

Drugs to Treat Dry AMD and Inflammation

12/2/14

Below is an article from the monthly Macular Degeneration Partnership E-Update on potential drugs to treat dry AMD and inflamation. To learn more about dry AMD, including stem cell treatments, go to AMD.org. You can also subscribe and have the monthly newsletter delivered to your inbox.

There are many causes of age-related macular degeneration and any of them may prove a good target for treatment for dry AMD. A long list of these was discussed at the recent Academy of Ophthalmology meeting. They were divided into the types of drugs being studied. We’ll look first at inflammation and the complement factor system, which is part of the immune system.

Inflammation is known to be associated with macular degeneration. The target may be the inflammation itself, or the cause of the inflammation.

Lampalizumab (or anti-Factor D) is a drug that is injected into the eye. In earlier Phase II trials, it was shown to reduce the area of the geographic atrophy by 20%. A Phase III clinical trial is now underway for individuals with geographic atrophy from dry AMD. Several research sites are actively recruiting now and many others will start recruiting in the near future. For more information and a list of participating centers, visit Clinical Trials.

LFG316 is also an antibody and an injection. This Phase 2 study is a randomized clinical trial of a drug that targets the C5 complement pathway (part of our immune system). It is designed to test the safety and efficacy of different doses of LFG316. There are three arms in the study: one group receiving a higher dose of the drug; one group receiving a lower dose of the drug; one group receiving a sham injection (no drug). These are successive monthly injections for people with geographic atrophy (GA). It is taking place in multiple locations throughout the U.S. and is sponsored by Novartis. For more information and a list of participating centers, visit Clinical Trials.

Oracea is a pill for dry macular degeneration, now in Phase II/III clinical trials around the U.S.. The pill contains doxycyline, which suppresses inflammation. Participants will be randomly assigned to either receive the drug or a placebo. More information at Clinical Trials.

Zimura by Ophthotech has been tested as a drug for wet AMD, but also seems to affect the drusen of dry AMD. Zimura targets the complement pathway plays a significant role in dry AMD. A Phase 2/3 clinical trial investigating ZimuraTM for treatment of geographic atrophy, is in the planning stages.

Eculizumab was also presented. This intravenous treatment for dry AMD did not show the desired effect in clinical trial, so no further development is planned at this time.

POT-4 is another drug that targets the complement factor system involved in inflammation. It is delivered through injection into the eye. The Phase I trial is completed and a Phase II clinical will be announced soon.

Iluvien is a drug delivery system that has been used in patients with diabetic retinopathy. A Phase II clinical trial for dry AMD is underway, though it is no longer recruiting patients. This is an implant inside the eye that releases fluocinolone acetonide. For more information, see Clinical Trials.

Judith Delgado
Executive Director
Macular Degeneration Partnership
A Program of the Discovery Eye Foundation

Diabetes And The Potential For Diabetic Retinopathy

11/20/14

Defining Diabetes

Diabetes mellitus is a group of metabolic disorders in which a person has high blood sugar levels. It occurs either because the pancreas does not produce enough insulin, or because the body does not respond appropriately to the insulin that is produced. Insulin is the hormone that converts sugar into energy for the body. There are several forms of diabetes.

Type 1 diabetes occurs when the pancreas does not produce adequate levels of insulin. It usually develops during childhood or adolescence; however, it can also occur in adults. Those with type 1 diabetes must take insulin injections. About 10 percent of those with diabetes have type 1.

Type 2 diabetes is the most common type of diabetes, affecting about 90 percent of those with diabetes. It is caused by the combination of the body’s resistance to insulin (not using its own insulin efficiently) and the pancreas not producing enough insulin. As a result, there is an increase in the level of sugar, or glucose, in the blood.

Gestational diabetes occurs in pregnant woman who have not previously had diabetes but whose blood sugars become elevated during pregnancy. In many patients, their blood sugars will return to normal after the pregnancy is over. Placental hormones make the mother resistant to insulin, causing a buildup of blood sugars. These women are at high risk for type 2 diabetes later on in their lives.

Diabetic Retinopathy: An Overview

Anyone with uncontrolled diabetes is at risk for developing diabetic retinopathy. According to the National Eye Institute, between 40 to 45 percent of Americans with diabetes have some form of diabetic retinopathy, the most common eye condition associated with diabetes.

In the United States, the Centers for Disease Control and Prevention reports between 12,000 and 24,000 new cases of blindness each year due to diabetic retinopathy, making it the leading cause of vision loss among American adults, ages twenty to seventy-four. The Center also projects that by 2050, the number of Americans age forty and older with diabetic retinopathy will grow from a current 5 million individuals to about 16 million. Although these statistics are alarming, you can prevent or delay damage to your vision by controlling your diabetes, along with obtaining regular eye evaluations and treatment.

Defining Diabetic Retinopathy
Diabetic retinopathy is a disease affecting the retina, caused by elevated blood sugar levels. It usually affects both eyes and occurs when uncontrolled blood sugar levels damage the small vessels of the retina, the light-sensitive tissue in the back of your eye. The retina is responsible for processing images that make vision possible. To produce clear, distortion-free vision, the retina must lie completely flat. If the delicate retinal tissue is damaged, images that you see may be blurred or distorted.

Diabetic retinopathy is a progressive disease, and thus worsens over time. Although some effects, such as blurriness and distortions, may be mild or subtle, the long-term consequences can cause severe vision loss.

Symptoms of Diabetic Retinopathy

Because diabetic retinopathy rarely causes pain, symptoms are not always apparent in the earliest stages. In fact, damage to your retina could be occurring long before you have noticeable signs. When symptoms do occur, they’re often caused by retinopathy affecting the macula, the area at the center of the retina. Symptoms may include the following:

• blurred vision

• seeing dark spots or “floaters” (small specs in your field of vision)

• decreased night vision

• vision loss

• problems seeing colors

It’s important that you see your eye specialist immediately if you have any such symptoms. Diabetic retinopathy cannot be cured, but with careful monitoring, it can be diagnosed and treated, before your vision is impaired. The treatment is typically less invasive and more effective when diagnosed at an earlier stage, before permanent damage has occurred.

How the Retina Works

The retina is made up of specialized nerve tissue that contain microscopic receptors (called cones and rods) and other nerve cells that line the back of the eyeball.

These cells carry signals (images that we see) along the optic nerve to a special area of the brain, where they’re interpreted into what we perceive as sight. You might compare the retina to film in a camera—the film delivers the photo image that the camera captures.

There are two main areas of the retina that can be damaged by diabetic retinopathy:

• The macula, the center of the retina. The macula allows you to read and see fine details and recognize colors. At the very center of the macula is a dimple known as the fovea. It is the most sensitive portion of the macula and makes sharp vision possible.

• The peripheral retina, which is the portion of the retina that is outside the macula. It’s responsible for your side vision and also makes night vision possible.

The retina lies on a nutrient-rich flat “carpet” of vessels that nourish it with necessary oxygen and nutrients. To reach the retina, however, nutrients must pass through two buffers—a thin membrane called Bruch’s membrane and a single layer of specialized cells called the retinal pigment epithelium. Waste products are also transported away from the retina through these two membranes. Diabetic retinopathy can interfere with this constant import of necessary nutrients and export of waste products.

Risk Factors for Diabetic Retinopathy

There are many factors that can raise your risk for diabetic retinopathy. However, you’ll note that many of these risk factors can be controlled.

Duration of Diabetes and Glucose Control

The longer you’ve had poorly controlled blood glucose levels, the higher your risk for diabetic retinopathy. Most diabetic individuals develop eye problems overtime, making duration of their diabetes one of the strongest predictors that they will develop this eye disease. Research has shown that nearly all type 1 diabetics and 60 percent of type 2 diabetics develop the condition within the first two decades of their diabetes diagnosis.

The American Diabetes Association (ADA) recommends fasting glucose levels between 70 and 120 mg/dL and less than 180 mg/dL two hours after meals. They also recommend a hemoglobin A1c of 7 percent of less. Hemoglobin A1c is a protein in red blood cells that bonds with blood sugars. Since red blood cells can live from 90 to 120 days, the hemoglobin A1c stays in the blood for that length of time. Accordingly, it is effective in measuring the average blood sugars over a period of time. This test tells doctors how well your treatment plan is working. You should always know what your hemoglobin A1c values are, as they may affect the interval between your retinal examinations.

Obesity

The more fatty tissue you have, the more resistant your cells are to insulin. Obesity increases your risk for diabetes as well as other serious conditions such as heart disease. Estimates suggest that 65 percent of Americans may be overweight. Being overweight aggravates high blood pressure and cholesterol. Achieving a healthy weight is important in controlling blood sugars and diabetes related complications.

Lifestyle Choices

A sedentary lifestyle, especially if you are overweight, contributes to many diseases, including diabetes, heart disease, high blood pressure, and high cholesterol levels. On the other hand, physical exercise improves circulation, lowers blood sugars, and improves your body’s use of insulin. This results in improved blood sugar levels. This benefit of increased sensitivity to insulin continues for hours after you stop exercising.

Exercise also promotes weight loss. A sedentary lifestyle contributes to insulin resistance, and makes it more difficult to keep weight off. Even light or moderate physical activity can help lower blood sugars.

Smoking is another major risk factor for developing diabetic retinopathy. Smoking also causes diabetic retinopathy to progress faster. The nicotine in tobacco not only contributes to higher blood pressure and higher cholesterol levels, but it also impairs insulin activity. Even though quitting can be difficult, it is critical to heart health and diabetes control.
Unlike smoking, alcohol consumption doesn’t have a direct influence on diabetic retinopathy. Yet because it can affect diabetes control, drinking in excess can affect the health of your eyes. Your doctor can tell you what constitutes drinking in moderation for you.

High Cholesterol Levels

Diabetes puts you at risk for chronically high cholesterol or blood fats that promote the buildup of plaque in your arteries. Although the tiniest vessels of the retina are too small for such build-up, uncontrolled cholesterol can contribute to macular edema and the development of hard exudates, the small yellow spots or lipid deposits that may form in the macula. Both conditions are associated with a higher risk of vision loss.

Doctors advise keeping “bad” or low density cholesterol (LDLs) less than 70 mg/dL. Good cholesterol or high density lipoproteins (HDLs) should be greater than 40 mg/dL in men and 50 mg/dL in women. Both men and women should strive for triglycerides, another type of fat, at levels less than 150.

High Blood Pressure

If you have both diabetes and high blood pressure (also called hypertension), you may be at higher risk for a number of eye-related problems, including retinopathy, glaucoma and optic nerve damage. Seriously elevated blood pressure not only stresses your heart, it also raises the risk for eye problems, particularly macular edema and bleeding. Chronic hypertension combined with long-term diabetes also increases the chance that your retinopathy will be more destructive and progress more rapidly. Research has consistently shown that keeping your blood pressure below 130/80 mmHg is important in minimizing the risk of hypertension related complications.

Race/Ethnicity

Diabetic retinopathy is more common in some ethnic and racial groups than others. African Americans, Asian Americans, Hispanic/Latino Americans, American Indians and Alaskan Natives are at higher risk for type 2 diabetes than non-Hispanic whites.

African Americans and Mexicans are almost twice as likely as whites to have eye problems, according to the American Diabetes Association. Native Americans also have an increased for diabetic retinopathy. Researchers aren’t sure why some ethnic groups have higher rates of diabetes, which increase the risk for retinopathy and other problems.

Age and Gender

As mentioned earlier, the longer you have diabetes, the greater your risk for diabetic retinopathy. Not surprisingly, this complication is rare among children but common among older diabetic adults. A recent study by Prevent Blindness America and the National Eye Institute, demonstrated that older adult Americans are facing a bigger threat of all age-related eye diseases (diabetic retinopathy, age-related macular degeneration, cataracts and open angle glaucoma) today than at any other time.

Genetics

Our genetic make up has an important effect on our predisposition for many health issues such as diabetes. Scientists believe that many genes or combinations of genes either promote diabetes in certain individuals or protect them from developing it.

Scientists have yet to identify every gene involved in type 1 and type 2 diabetes, but they have shown that genetics are a factor. Research studies of identical twins, for instance, have demonstrated that if one twin has type 1 diabetes, the other twin has a 50 percent change of developing the disease. If one twin has type 2 diabetes, the other twin has a 75 percent chance of developing it.

Pregnancy

Gestational diabetes is a type of diabetes linked to pregnancy; however, diabetic retinopathy is usually not a complication in these women. However, if you’re already a diabetic and become pregnant, you are at an increased risk of developing diabetic retinopathy. This is a result of the hormonal and metabolic changes that occur during pregnancy, making the disease and its complications progress more rapidly. It is recommended that you see a retinal specialist for evaluation and monitoring.

In Summary

• Diabetic retinopathy is a serious complication of diabetes that results from high glucose levels damaging the retinal blood vessels. This can cause loss of vision.

• Between 40 and 45 percent of diabetic Americans have some form of diabetic retinopathy.

• The earliest form of the disease is called background diabetic retinopathy. With time it progresses to mild, moderate, or severe nonproliferative diabetic retinopathy.

• Without proper diagnosis and treatment of nonproliferative diabetic retinopathy, the condition can advance to proliferative diabetic retinopathy, which is a serious sight-threatening stage of the disease.

• Macular edema is due to build up of fluid and thickening of the macula and can occur with any type of diabetic retinopathy. It is the most common cause of vision loss in those with diabetes.

• The duration of your diabetes and how well blood glucose is controlled are major risk factors for the development and progression of diabetic retinopathy.

• Other risk factors that play a significant role in the development of retinopathy, include high blood pressure, high cholesterol, and smoking.

• As an individual with diabetes, you’re also at increased risk for other eye diseases, especially glaucoma, cataracts, retinal vein occlusion and optic nerve damage.

• Good blood sugar control, regular eye examination, and timely treatment are the key factors in reducing the damage to the eye and keeping your vision.

Pouya N. Dayani, MD
Retina-Vitreous Associates Medical Group

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