Conditions
- Macular Hole
- Macular Pucker
- Retinal Vein Occlusions
- Retinal Detachments
- Floaters and Retinal Tears
- Diabetic Retinopathy
- Macular Degeneration
- Central Serous Retinopathy
For information, please visit: www.asrs.org/patients/retinal-diseases
Macular Hole
The retina is the photosensitive tissue lining the back wall of the eye and the macula is the central region of the retina. The macula is the region that allows one to have reading vision and perform tasks that require high definition.
Macular Hole
The retina is the photosensitive tissue lining the back wall of the eye and the macula is the central region of the retina. The macula is the region that allows one to have reading vision and perform tasks that require high definition.
What is a macular hole?
A macular hole is caused by a defect in the very center of the macula with the symptoms being the loss of reading vision. Although blunt trauma to the eyeball can cause a macular hole, the usual causes are attributed to an aging process called posterior vitreous detachment (PVD). Although untreated macular holes do not lead to blindness when diagnosed early (within one year after the onset of symptoms), vitrectomy surgery has a good chance of recovering significant vision. A gas bubble is commonly utilized as an adjunct to such surgery.
Learn more about macular hole at ASRS.org.
Causes
Most macular holes develop spontaneously without clear cause, though some may be related to trauma, prior swelling or inflammation of the retina.
Diagnosis
They are diagnosed with a dilated eye exam and non-invasive imaging called optical coherence tomography.
Treatments
The most common and most effective treatment for macular holes is a surgical procedure called vitrectomy.
Macular Pucker
For reasons not understood, the separation of the vitreous gel inside the eye (posterior vitreous detachment – PVD) can be associated with a reparative process in which fibrous cells form a film on the surface of the macula.
Macular Pucker
The retina is the photosensitive tissue lining the back wall of the eye and the macula is the central region of the retina. The macula is the region that allows one to have reading vision and perform tasks that require high definition.
What is a macular pucker/epiretinal membrane?
For reasons not understood, the separation of the vitreous gel inside the eye (posterior vitreous detachment – PVD) can be associated with a reparative process in which fibrous cells form a film on the surface of the macula. This film of tissue is often called an epiretinal membrane or a macular pucker. This film of tissue has contractile properties that can cause the surface of the macula to wrinkle. This wrinkling can elicit symptoms such as distortion and blurring of vision. When the symptoms become bothersome enough, vitrectomy surgery to remove the film may be beneficial.
Causes
They most commonly form as a result of an aging process of the eye that causes the internal gel to liquefy and separate from the surface of the retina. Some cases may be related to prior trauma, inflammation in the eye, diseases of the retinal blood vessels, or prior eye surgery. They are often found incidentally on routine eye exams.
Diagnosis
A non-invasive imaging test called optical coherence tomography is helpful for diagnosis and to monitor for change over time.
Treatments
Most macular puckers are mild, cause minimal symptoms, and do not require treatment. However, they can progress over time and some result in significant blurring or distortion of the central vision. These cases can be treated with surgical removal called vitrectomy with membrane peel.
How are macular holes and macular puckers diagnosed?
Macular holes and macular puckers both cause disturbances of central vision. The symptoms of macular holes and macular puckers may be similar to the symptoms of wet macular degeneration, but the treatments and their urgencies are vastly different. If one notes central blurring with distortion, then an evaluation by an ophthalmologist would be recommended. Imaging studies that include optical coherence tomography (OCT) are often utilized.
Retinal Vein Occlusions
This disorder is caused by blockage of a retinal vein leading to hemorrhaging and leakage of damaged blood vessels in the area of the blockage.
Retinal Vein Occlusion
This disorder is caused by blockage of a retinal vein leading to hemorrhaging and leakage of damaged blood vessels in the area of the blockage. Most retinal vein occlusions are associated with arteriosclerosis (hardening of the arteries) causing compression of the affected vein by an adjacent artery. Patients experience varying degrees of visual loss depending on the location and severity of the vein occlusion. If the macula (the central retina) is not involved, the patient may be asymptomatic and unaware of the problem.
Common risk factors for vein occlusions include high blood pressure, elevated cholesterol, being overweight, a history of cardiovascular disease, glaucoma, and blood disorders causing abnormal clotting.
There are two categories of retinal vein occlusions:
Branch Retina Vein Occlusion – when a small retinal vein becomes blocked thus affecting a portion of the retina.
Central Retinal Vein Occlusion – when the main vein supplying the retina becomes blocked and causing diffuse retinal hemorrhaging throughout the retina.
Treatment
The retinal vein occlusion itself is not treatable but may resolve if an underlying condition such as hypertension is identified and treated. Thus, it is of primary importance to determine and treat the underlying condition leading to the retinal vein occlusion. A thorough and comprehensive evaluation, often with the assistance of the patient’s primary care physician, is essential to identify modifiable risk factors of arteriosclerosis such as uncontrolled high blood pressure, elevated cholesterol, etc. In younger patients, an evaluation for sources of abnormal blood clotting may be recommended.
Secondary complications of vein occlusions, most commonly macular edema and abnormal retinal and iris blood vessel growth (neovascularization) can be treated with intravitreal injections of anti-vascular endothelial growth factor medications. Prior to the availability of these medications, patients often experienced significant loss of vision from this disease. Now these injectable medications are vital to maintaining vision and are considered the standard of care. Laser treatment remains useful in selected cases.
Retinal Tears and Detachments
The retina is a thin layer of nerve tissue which normally lines the inside wall of your eye, like wallpaper.
Retinal Tears and Detachments
What is a retinal detachment?
The retina is a thin layer of nerve tissue which normally lines the inside wall of your eye, like wallpaper. A retinal detachment occurs when the retina pulls away from the eye wall. When this occurs, the retina cannot function normally, and permanent damage can develop. A retinal detachment is a very serious problem that will almost always lead to blindness if not treated.
Learn more about retinal detachment at ASRS.org.
Learn more about retinal tears at ASRS.org.
What causes a retinal detachment?
The center of the eye is filled with a clear gel called the vitreous. Over time, the vitreous becomes more condensed, which causes it to pull away from the surface of the retina. This process (called a posterior vitreous detachment, or PVD), usually occurs without damaging the retina, but in some cases the vitreous may pull hard enough to tear the retina in one or more places. Fluid can pass through the tear and begin accumulating beneath the retina, causing a retinal detachment. There are some conditions that are associated with a higher likelihood of developing a retinal detachment: myopia (nearsightedness), prior eye surgery, trauma, prior retinal detachment in either eye, or family history of retinal detachment.
Are there warning signs of a retinal detachment?
Early symptoms of a retinal detachment include new floaters, flashes of lights like a flashbulb, or a loss of part of the peripheral vision in one eye. These symptoms do not always indicate a detachment is present, but they should be promptly evaluated by your eye doctor.
How are retinal tears and detachments treated?
If your eye doctor discovers a retinal tear, it can usually be treated in the office with laser or cryotherapy. Both procedures seal the retina around the tear and prevent the development of a retinal detachment. These procedures are usually performed with little or no discomfort in the office and are highly successful. There are sometimes circumstances where a tear or retinal hole may not require treatment, or cases when despite treatment, new tears or a detachment occurs. If the retina has already detached, surgery is typically required to correct the problem. There are several different techniques, and in some cases, a procedure can be done in the office to repair the detachment. Your doctor will discuss which technique is most appropriate for your case.
Pneumatic retinopexy is a procedure that can be performed in the office to repair a retinal detachment. Depending on the characteristics of the detachment, this sometimes can be an ideal treatment that avoids the need for a trip to the operating room. This procedure is accomplished by injecting a gas bubble into the center of the eye, where the vitreous gel is located. The bubble then floats up against the tear in the retina, and pushes the retina back up against the wall of the eye. The tear still needs to be sealed with cryotherapy or laser. The gas bubble will dissipate on its own.
Scleral buckle surgery is performed in the operating room and involves placing a flexible band around the outside of the eye to counteract the pulling force of the vitreous gel and support the retina. This also involves cryotherapy to seal the retinal tear. The band usually remains in place indefinitely.
Vitrectomy surgery is performed in the operating room and involves the removal of the vitreous gel from the inside of the eye. Laser is used to reattach the retina, and a self-dissolving gas bubble is placed inside the eye to hold the retina in place while it heals. The vitreous does not regenerate, but the eye will function normally without it.
Sometimes these procedures are performed simultaneously or sequentially depending on the particular characteristics of the detachment.
Retinal detachments can cause permanent vision loss so it’s important to seek immediate medical attention if you experience a sudden onslaught of floaters and/or flashes. Patients should note that PVD symptoms closely mirror retinal tear symptoms, so any sudden flashes or floaters should be evaluated by a doctor immediately.
Flashes and Floaters
“Floaters” is the term used to describe the symptom of seeing small lines or dots that move. Floaters are tiny clumps of the vitreous gel, the fluid that fills the inside of the eye.
Flashes and Floaters - Posterior Vitreous Detachments
What are floaters?
“Floaters” is the term used to describe the symptom of seeing small lines or dots that move. Floaters are tiny clumps of the vitreous gel, the fluid that fills the inside of the eye. As the eye moves, these floaters also move within the eye, casting shadows onto the retina. Typically they are most noticeable when looking at a plain background such as a white wall or a bright blue sky.
What causes flashes and floaters?
The vitreous is a jelly-like liquid that fills the inside of your eye. Over many years, the vitreous gel becomes more condensed, forming tiny clumps and strands. Eventually, the vitreous becomes so condensed that it will pull inward and separate away from the retina which lines the inside of the eye. This is known as a posterior vitreous detachment (PVD). It should be emphasized that PVD is a natural process that will happen to most people at some point in their lives. While PVD can occur at any age, it is more common after age 50. It may occur at a younger age among nearsighted people, people who have had eye injuries, or those who have recently undergone an eye surgery.
Usually, when a PVD occurs it will cause the sudden appearance of numerous dots, lines, or cobwebs in one eye. Flashes may also occur during a PVD as the vitreous pulls away from the retina surface as it separates. This often can be observed as a shooting arc of light, or a burst of light in the corner of your vision.
Are flashes and floaters ever serious?
Occasionally, the retina can be torn when as the vitreous gel is pulling away. A retinal tear is serious, in that it can cause the retina to begin to fall out of position like wet wallpaper falling off of a wall, which is called a retinal detachment. If caught early, a retinal tear can be treated and the risk of the potentially serious complication of a retinal detachment can be markedly reduced. As the symptoms of a PVD and retinal tear are identical, any sudden onset of new flashes or floaters should be promptly evaluated.
Can anything be done about floaters?
Floaters can often interfere with normal vision and be bothersome while reading or driving. Fortunately, most floaters are harmless and become much less noticeable over time, although this may take several months.
Diabetic Retinopathy
Diabetes Mellitus occurs when the body is unable to use and/or store sugar properly, resulting in high blood sugar levels.
Diabetic Retinopathy
Diabetes Mellitus occurs when the body is unable to use and/or store sugar properly, resulting in high blood sugar levels. Abnormal blood glucose especially affects the smallest blood vessels of the body, including those in the eyes, kidneys, and at the ends of the fingertips and toes (this leads to diabetic retinopathy, diabetic nephropathy, and diabetic neuropathy, respectively).
According to population studies, 40-45% of people with diabetes may have diabetic retinopathy. When elevated blood sugar levels damage the tiny blood vessels located in the retina, they can leak fluid, blood, and start causing new abnormal blood vessels to grow. This can also lead to scar tissue developing over time and cause symptoms such as floaters, blurriness, distortion, and in severe cases, blindness.
How diabetes affects the eye
Diabetes tends to affect the eyes in two ways:
- Diabetic retinopathy, including abnormal blood vessel growth and bleeding into the eye, as well as having inadequate blood flow/oxygen to the tissues of the retina
- Swelling in the central retinal tissue, also termed diabetic macular edema.
Diabetic retinopathy
Diabetic retinopathy is a progressive disease. The earlier form of the disease is categorized as different stages of nonproliferative or background diabetic retinopathy (NPDR or BDR), which can eventually progress to the more dangerous proliferative diabetic retinopathy (PDR).
Nonproliferative diabetic retinopathy (NPDR) can be mild, moderate, severe, or very severe. At the early stage, high blood glucose levels damage the lining of the retinal blood vessels, causing these vessels to leak, bleed, and create pockets of swelling within the retina. The blood flow in certain areas of the retina is not normal, causing loss of the normal capillary structure. As this unhealthy retina becomes starved for nutrients and oxygen, it is unable to function well and can also create a driving force for the body to try to create new blood vessels. This can lead to PDR, which is more severe.
Proliferative diabetic retinopathy (PDR) is when the blood vessel damage and demand for oxygen from the tissue are so severe that the retina tries to grow new blood vessels to compensate (a process called neovascularization). The problem is that these are very abnormal, curly, and leaky blood vessels that are unstable and do not help the retina but tend to cause bigger problems. Sometimes these vessels will bleed into the vitreous cavity of the eye causing sudden vision loss and severe floaters. Other times the vessels grow into larger networks over time and create scar tissue that tends to contract and pull the retina off the back of the eye (like wallpaper being lifted off the wall), ultimately causing a tractional retinal detachment. Sometimes the abnormal blood vessels can grow in the front section of the eye which can cause high intraocular pressure known as neovascular glaucoma.
Diabetic Macular Edema
The leakage of fluid into the central retina area, known as the macula, is a more immediate and visually symptomatic problem that can happen at any stage of the disease. Diabetic macular edema (DME) is when swelling occurs in the most important part of the retina, causing central vision issues such as distortion, blurriness, and dullness. Exudates or yellowish-colored lipid remnants can develop as the leakage waxes and wanes. There can be immediate problems from the initial edema or long-lasting damage from the anatomy of the retinal layers being disrupted or poor blood supply.
Some symptoms of diabetic retinopathy include:
- Floaters
- Blurry vision
- Missing parts in the vision or "dark areas"
- Vision that changes from blurry to clear
- Color washing or fading
How is diabetic retinopathy diagnosed?
Early diabetic retinopathy is often not noticeable to patients with very mild or no symptoms. This is the most important time to learn about the risks of the disease as well as possible symptoms, as early detection offers patients the best chance at preserving optimal vision. All diabetic patients should have an eye exam with their ophthalmologist or a diabetic eye specialist at least once a year so that any changes to the retina can be observed and treated immediately. If diabetic retinopathy is detected, additional appointments may be required.
How is diabetic retinopathy treated?
Diabetic retinopathy can be treated in several ways depending on the severity and location of the problem. As noted in many other circumstances, prevention is key, especially in the long-term implications of glucose control. This should ensure the long-term health of your vision. Patients with diabetes should carefully monitor their blood sugar and blood pressure, follow a healthy diet, and exercise regularly as advised by their doctor. These steps will reduce your risk of developing diabetic retinopathy.
Anti-VEGF Medications
Medications that go after the Vascular Endothelial Growth Factor (anti-VEGF medications) within the eye are a great treatment strategy to reduce the swelling within the retina and also decrease the drive for the eye to make new abnormal blood vessels. These medications are injected through the white part of the eye (scleral) into the internal vitreous cavity with a tiny needle; this delivers the anti-VEGF directly to the site. This is performed in-office with local or topical anesthesia.
Laser Surgery
Laser photocoagulation can be used in multiple ways to address the problems associated with diabetic retinopathy and macular edema. Laser is light-energy that can be used to help seal off leaking blood vessels and reduce swelling within the retina. Laser surgery can also be performed on the unhealthy part of the peripheral retina to help protect the central retina in a process called pan-retinal photocoagulation (PRP). This can decrease the rate of blood vessel growth. This treatment is normally performed in-office with topical anesthesia.
Vitrectomy
In more severe cases of proliferative diabetic retinopathy or if there is bleeding into the eye or a tractional retinal detachment present, vitrectomy surgery may be necessary. During this procedure, blood is removed from within the central cavity of the eye and any abnormal blood vessels are treated. Contracted scar tissue is removed from the back of the eye using small forceps and careful segmentation of these scarring areas may be needed to allow the retina to return to its normal position. Laser photocoagulation is used to treat the retina during this procedure to help seal the vessels, treat the abnormal non-vascularized retina, and create a PRP laser pattern to reduce future risk of bleeding. Of note for vitreous hemorrhage, often a waiting period is recommended before surgery to see if the blood will clear on its own, even if vision is impaired.
Macular Degeneration
As a person ages, their vision can deteriorate over time. One of the most common causes of vision loss in older adults is age-related macular degeneration (AMD).
Macular Degeneration / AMD
As a person ages, their vision can deteriorate over time. One of the most common causes of vision loss in older adults is age-related macular degeneration (AMD).
AMD occurs when the macular cells deteriorate and cease to function properly. The macula is the central area of the retina that controls our central vision; it’s used for fine-detail activities such as driving, facial recognition, reading, and recognizing color. As macular degeneration progresses, it can make objects in your line of vision appear distorted. Patients with AMD may also experience clouded vision or a layer of darkness over the central visual field. Eventually, patients may lose the ability to see details, which can impair normal daily activities. AMD is categorized into two different types: wet and dry AMD.
Fortunately, because macular conditions like AMD impact only the macula, the rest of the retina typically remains unaffected, keeping peripheral vision intact. As such, AMD rarely results in total vision loss.
What is dry age-related macular degeneration?
The most common type of macular degeneration is dry AMD. In dry AMD, the macular cells gradually reduce in number and become less sensitive. Vision loss tends to occur slowly over time, with cases ranging from mild to severe.
Typically, an ophthalmologist will note the presence of drusen, which are yellow deposits of debris that build up under the macula. Drusen are normally seen in patients aged 50 and older. While drusen deposits are not responsible for vision loss alone, their presence signifies a greater risk for developing macular issues in the future.
What is wet age-related macular degeneration?
Dry AMD sometimes progresses into wet AMD, which is characterized by the growth of abnormal blood vessels that leak fluid or bleed into the macula. If left untreated, wet AMD can cause permanent loss of central vision. Unlike dry AMD which happens over time, the onset of wet AMD can happen suddenly and result in a severe decline in vision.
AMD Symptoms
AMD may present with no symptoms at first, especially dry AMD. As time goes on, you may experience several changes in vision, such as:
- Blurriness
- Straight lines appearing wavy and other distortions
- Missing areas of vision
- Clouded or darkened vision
- Difficulty performing fine-detail activities, such as reading
AMD Risk Factors
There are several risk factors that can increase a patient’s chance of developing macular degeneration. These risk factors include:
- Age
- Genetics
- Tobacco use
- Obesity
- High-fat diet
- High cholesterol
- High blood pressure
- Cardiovascular diseases, such as atherosclerosis
Can AMD be prevented?
Because macular degeneration is so closely linked to aging, prevention recommendations normally involve a healthy diet, weight management, cutting out tobacco use, and protecting your eyes from the sun’s harmful UV rays. The Age-Related Eye Disease Study 2 (AREDS 2) looked at the effects of antioxidant vitamins and minerals on patients with AMD. It found that patients who took a high amount of these substances had a lower risk of developing more severe types of vision loss. The doses used in the study were:
- Vitamin C, 500 mg
- Vitamin E, 400 IU
- Lutein, 10mg
- Zeaxanthin, 2mg
- Zinc, 80mg
- Copper, 2mg
Please connect with your doctor directly per advice for supplement use, including type(s) and dosage to best ensure healthy vision.
AMD Treatment
Treatment for dry AMD typically consists of preventative measures and vitamin usage. However, as of February 2023, there is now a medication known as Syfovre™ that has been approved by the US Food and Drug Administration (FDA) for treating geographic atrophy – an advanced complication of late-stage dry AMD that causes blindness. Connect with Retina Group of Florida to learn more about this groundbreaking treatment.
In cases of wet AMD, your doctor will recommend treatment depending on the severity of your symptoms. When wet AMD is detected early the current treatments give a reasonable chance to recover vision in many patients thus emphasizing the importance of early detection strategies. These treatments include intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) medications and laser treatments. Although vision loss from wet AMD is typically permanent, early detection and treatment can often provide an optimal outcome.
While there is currently no cure, AMD is one of the most researched retinal conditions, with many clinical trials dedicated to developing new and improved treatments.
What should I watch for?
Your doctor will schedule regular follow-up appointments to monitor your condition. In addition, monitor your vision with an Amsler grid at least twice a week, so that any changes in vision will be recognized as early as possible. Instructions on how to use the grid will be provided. Any persistent changes—waviness of the lines, blank or missing lines, or blurring of the lines—should be reported to your doctor immediately. Early detection is our best defense against visual loss in macular degeneration!
Central Serous Retinopathy
Central serous chorioretinopathy, commonly referred to as CSC, is a condition in which fluid accumulates under the retina, causing a serous (fluid-filled) detachment and vision loss.
Central Serous Chorioretinopathy
Central serous chorioretinopathy, commonly referred to as CSC, is a condition in which fluid accumulates under the retina, causing a serous (fluid-filled) detachment and vision loss.
CSC most often occurs in young and middle-aged adults. For unknown reasons, men develop this condition more commonly than women. Vision loss is usually temporary but sometimes can become chronic or recur.
The causes of CSC are not fully understood. It is thought that any systemic exposure to a corticosteroid drug can bring about or worsen CSC. Corticosteroids are found in allergy nose sprays and anti-inflammatory skin creams available over the counter, and are often prescribed to treat a variety of medical conditions.
An association has also been made between CSC and patients with emotional distress and/or “type A” personalities. It is possible that the body produces natural corticosteroids in times of stress that may trigger CSC in an individual prone to this condition.
CSC is typically a self-limiting disease, and visual recovery usually occurs within a few weeks to months without treatment. Depending on the severity and timeline of your symptoms, your doctor will choose the best treatment option, which often begins with a trial of observation.
