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Retina
Age Related Macular Degeneration
Age related macular degeneration is the leading cause of vision loss in adults over the age of 50. ARMD is a disease of the macula, which is the central part of the retina. The macula is responsible for focusing your central vision controlling our ability to read, drive a car, recognize faces, and see objects in fine detail. For example, imagine you are looking at a clock with hands. With ARMD you might see the clock numbers but not the hands. Many people do not realize they have macular degeneration until their vision is very blurry. This is why it is important to have regular visits to an ophthalmologist.
There are two basic types of macular degeneration: Dry and Wet macular degeneration. Most ARMD is the dry form with approximately 85-90% of the cases.
Dry ARMD
Dry ARMD develops when parts of the macula begin to thin as we age and tiny clumps of protein called drusen grow. As this process continues, you will slowly lose central vision. There is no treatment for dry ARMD
Wet ARMD
This form is much less common, usually only affecting around 10% of patients with ARMD but accounts for 90% of all severe vision loss with ARMD. Wet ARMD develops when new, abnormal blood vessels grow underneath the retina. These abnormal blood vessels are very fragile and can either leak fluid or blood into the macula resulting in swelling of the macula. This causes rapid damage to the macula resulting in vision loss in a short period of time. This form of macular degeneration is the most threatening to your central vision. Overtime, wet ARMD can lead to scarring and profound vision loss.
You are more likely to develop ARMD if you:
- are over the age of 50 years old
- smoke cigarettes
- have a family history of ARMD
- have high blood pressure
- are Caucasian
ARMD usually starts as a slowly progressive disease without pain, so it will often go undetected in patients early in the disease. That is why it is important to have regular eye exams by your ophthalmologist especially if you have risk factors for the disease. During your eye exam, your doctor will perform a dilated eye exam. He or she will put dilating drops in your eyes to open the pupil. This will allow him or her to look inside your eye at your macula in great detail with a special lens.
Your ophthalmologist may also perform testing as needed to help better examine the macula. One common test is optical coherence tomography or OCT. An OCT is a non-invasive test to look at various structures of the retina in an extremely high level of detail. The test involves a patient sitting at a machine and having a picture of their eye taken in seconds. This test will provide more information and find abnormal blood vessels that sometimes cannot be seen during the eye exam. Other diseases can also be detected with this technology.
There is currently no known cure for macular degeneration. However, there are things you can do now to reduce your risk and possibly slow the progression once you have been diagnosed with the disease.
- Do not smoke
- Eat foods rich in antioxidants - Studies show that eating foods such as fresh fruits and dark green leafy vegetables (Kale, collard greens and spinach for example) may delay the onset or reduce the severity of dry ARMD. These types of foods contain lutein and zeaxanthin which may protect the macula from sun damage.
- Nutritional supplements - If you have already been diagnosed with ARMD, your doctor may recommend AREDS2 vitamin supplements. Speak with your eye doctor before starting this vitamin.
- Exercise regularly and maintain a healthy weight
- Keep your blood pressure and cholesterol under control
- Wear sunglasses outdoors to block UV and blue light that may cause damage to the macula
- Have regular eye exams
For the development of wet macular degeneration, there are several types of treatments based on your disease. Your eye doctor will choose the best treatment for you.
Anti-VEGF drugs
This is the most common treatment for wet ARMD. This class of medications stop the abnormal blood vessels from forming and block the leakage of these harmful blood vessels in the macula. Some people who take these drugs have been able to regain vision they lost from macular degeneration. This medication is injected into your eye in the doctor's office. Patients may be apprehensive about having a “shot” in the eye, but there is little to no discomfort during the injection.
Laser therapy
Your doctor may suggest a treatment with a high-energy laser to destroy actively growing abnormal blood vessels in the macula.
Photodynamic laser therapy
This is a two step procedure. First, a medication injected into your bloodstream targets the abnormal blood vessels. Next, a laser is used to activate the drug which will destroy the abnormal blood vessels.
Diabetic Retinopathy
People with diabetes can develop a disease called diabetic retinopathy. Diabetic retinopathy is a common complication of diabetes. High blood sugar levels in patients with diabetes causes retinal blood vessels to break down, leak, or become blocked over time. This damage impairs vision causing significant vision loss if not treated. In some people with diabetic retinopathy, serious damage to the eye can occur when abnormal blood vessels grow on the surface of the retina.
Diabetic retinopathy can affect almost anyone with diabetes. The U.S. Centers for Disease Control and Prevention (CDC) estimates that over 10 million Americans have been diagnosed with diabetes while an additional 5.4 million have diabetes without being diagnosed. Because of its dangers to good vision, people are urged to have annual diabetic eye exams. Patients with diabetes can reduce their risk of diabetic retinopathy with good blood sugar control.
Symptoms of Diabetic Retinopathy
- Loss of central vision
- Color vision loss
- Blurry vision
- Black spots or holes in your vision
- Floaters or small spots in your vision from bleeding in the eye
Diagnosis of Diabetic Retinopathy
During your eye exam, your doctor will perform a dilated eye exam. He or she will put dilating drops in your eyes to open the pupil. This will allow him or her to look inside your eye at your retina in great detail with a special lens.
Your ophthalmologist may also perform testing as needed to help better examine the retina. One common test is optical coherence tomography or OCT. An OCT is a non-invasive test to look at various structures of the retina in an extremely high level of detail. The test involves a patient sitting at a machine and having a picture of their eye taken in seconds. This test will provide more information in making the diaganosis. Other diseases can also be detected with this technology.
Treatment of Diabetic Retinopathy
Anti-VEGF Therapy
Drugs that block vascular endothelial growth factor (VEGF), a protein that makes abnormal blood vessels grow in your eye, can reverse the blood vessel growths and reduce swelling in your retina. This medication is injected into your eye in the doctor's office. Patients may be apprehensive about having a “shot” in the eye, but there is little to no discomfort during the injection.
Focal/grid macular laser surgery
A laser is used to make tiny burns focused on the blood vessels which are leaking in the retina. Your doctor will identify the individual blood vessels for treatment and make a limited number of laser burns to seal them off.
Pan-retinal Photocoagulation
A laser is used to make hundreds of laser burns on the retina to stop abnormal blood vessels from growing. This type of laser treatment is usually not painful.
Corticosteroids
Doctors can implant or inject corticosteroids into the eye to reduce macular edema caused from damage to the blood vessels. This medication can increase your chance of developing cataracts or glaucoma. Your doctor will monitor for these changes.
Vitrectomy
A vitrectomy is a surgical procedure performed in the vitreous humor and retina to remove blood that may be causing vision loss. A vitrectomy may also be formed if significant scar tissue has developed on the retina.
Retina Tear and Detachment
A retinal detachment is a disorder of the eye where the retina peels away from the back of the eye. Usually this is caused from a posterior vitreous detachment. The vitreous gel is a clear material that fills the back of the eye. As we get older, the vitreous begins to liquify, and eventually will pull away from the retina resulting in a vitreous detachment. Usually a vitreous detachment will not cause a problem for the patient. However, if the vitreous gel pulls hard enough, it can tear a piece of the retina, resulting in a retinal tear. Fluid then can move into the retinal tear, lifting the retina off of the back of the eye resulting in a retinal detachment. This is much like wallpaper peeling off of a wall. Other causes such as high nearsightedness (myopia), inflammation, and trauma can also lead to a vitreous detachment and possible retinal detachment.
Symptoms of Retina Tear and Detachment
- A sudden increase in floaters in your vision
- A sudden appearance of Flashes in your vision
- Having a shadow appear in your side vision
- Seeing a grey curtain moving across your vision
- Sudden decrease in your vision
Diagnosis of Retina Tear and Detachment
During your eye exam, your doctor will perform a dilated eye exam. He or she will put dilating drops in your eyes to open the pupil. This will allow him or her to look inside your eye at your retina in great detail with a special lens. Some retinal detachments are found during routine eye examinations. That is why it is so important to have regular eye exams.
Treatment of Retina Tear and Detachment
Most retinal tear can be treated by sealing the retinal tear to the back of the eye. This can be done by laser or cryotherapy
Laser Photocoagulation
Your ophthalmologist will use a laser to make small burns around the retinal tear to cause scarring which will seal the retina to the back of the eye. This will stop the retina from detaching.
Cryopexy (freezing treatment)
Your Eye surgeon uses a special freezing probe on the outside of the eye to freeze the retina around the tear.
Retinal Detachment Treatment
Once the retina has detached, surgery is needed to place the retina back into it’s normal anatomic position. If the retina is not re-attached, it will lose the ability to function normally, resulting in permanent vision loss.
Pneumatic Retinopexy
During this procedure, an air bubble is injected in the vitreous space in combination with laser or cryotherapy. The gas bubble pushes the tear back in place and holds it there while the tear seals. This procedure is done in the doctor's office. After the procedure you will be asked to maintain a certain head position for several days. The air bubble will gradually disappear
Vitrectomy
This surgery is performed in the operating room. The vitreous which is pulling on the retina is removed and replaced with a gas bubble to hold the retina in place. A laser or cryotherapy is used to seal the tear. After the procedure you will be asked to maintain a certain head position for several days. The gas bubble will gradually disappear.
Scleral Buckle
This surgery is performed in the operating room. This treatment involves placing a flexible band (scleral buckle) around the outside of the eye to force the retina back into its normal position. Laser or Cryotherapy is then used to seal the tear. The scleral buckle is not visible to the patient.
After successful surgery for retinal detachment, vision can take months to improve. For some more serious or long standing retinal detachments, vision may not recover fully or for some there will be no improvement in vision at all. For this reason, it is important to see your ophthalmologist at the first sign of any vision problems.
Other Retinal Diseases
Epiretinal Membranes (ERM)
A thin layer of tissue or membrane may grow over the surface of the retina. This can result from abnormal healing responses in the eye. Most epiretinal membranes occur in otherwise healthy eyes without any underlying condition. Most ERMs cause none or minimal symptoms and can be simply observed. Many epiretinal membranes are found on routine eye examinations without any visual complaints from the patient. However, some epiretinal membranes can contract causing traction on the retina resulting in the retina becoming distorted or wrinkled. This leads to visual disturbances for the patient. Patients may notice blurred vision or central vision loss. Patients may also experience distorted vision such as straight lines becoming bent or curved.
There are no eye drops or medications to treat ERMs. Most epiretinal membranes do not have to be treated and can be simply observed unless vision is affected. If vision is affected, then a vitrectomy surgery is the only option. With vitrectomy, the vitreous gel inside the eye is replaced with saline. This allows access to the surface of the retina where the ERM can be removed, allowing for the macula to relax and become less wrinkled.
Macular Hole
A macular hole is a small tear in the macula, the part of the retina responsible for our central vision. Macular holes often begin gradually with a person first noticing a slight distortion or blurriness in their central vision. As the hole progresses, a blind spot develops in the central vision impairing both reading and distance vision. Macular holes commonly affect people over the age of 55 and more often in women.
The vast majority of cases develop spontaneously without an obvious cause. Because of this, there is currently no way to prevent their formation. There are various conditions that can increase the risk of a macular hole forming including;
diabetic eye disease, high myopia (nearsightedness), epiretinal membranes, retinal detachments, and blunt trauma to the eye. If a macular hole develops in one eye, there is a 5% to 15% risk in developing in the other eye.
Treatment for a macular hole is vitrectomy surgery. With vitrectomy, the vitreous gel inside the eye is replaced with saline. This allows access to the surface of the retina where a special gas bubble is placed to help flatten the macular hole and hold it in place until it heals. You must maintain a constant face-down position for one to two weeks after surgery to keep the gas bubble in contact with the macula. A successful result often depends on how well this position is maintained. The bubble will dissolve over time. As the macular hole closes, the eye will slowly regain part of the vision lost. The visual outcome will depend on the size of the hole and how long it was present before surgery. Vision does not return all the way to normal.