Age Related Macular Degeneration

Age Related Macular Degeneration (ARMD) is one of the principal causes of permanent vision loss within the elderly community. This condition distorts the central vision, the clearest portion of our visual field, and leaves the side vision intact. ARMD has been shown to increase in incidence with age, smoking, and ultraviolet light exposure, occurring most frequently in the Caucasian population.

What is Macular Degeneration?
Macular Degeneration begins with the deterioration of one layer within the retina, the retinal pigment epithelium, and cascades into the degeneration of many layers of the retina. The degeneration occurs at the macula, an anatomical area within the eye whose primary function is our central vision. ARMD manifests in two forms, Nonexudative (Dry), and Exudative (Wet). Wet ARMD exhibits new blood vessel growth that leak and bleed into the macula, further damaging the central vision. Dry ARMD does not manifest this bleeding, therefore the vision loss is usually less extensive.

Is There a Treatment?

Exudative (Wet) Macular Degeneration
Medical intervention is necessary in most forms of wet macular degeneration to stop the bleeding and prevent further vision loss. Currently, there are three different treatment methods with two of these procedures being actively used, and one still in medical trials for efficacy and safety. Each treatment method is implemented to prevent further bleeding and vision loss, and does not promise an improvement in vision. Also, the recurrence of a bleeding membrane after treatment is quite common. The three current treatments for wet ARMD are:

Argon Laser Photocoagulation: a treatment method that uses a laser to diminish the bleeding area.

Photodynamic Therapy: where specific wavelengths are utilized on the affected area, resulting in dissipation of the bleeding vessels.

Transpupillary Thermal Therapy: currently still in trials, where thermal energy is employed for stopping the leakage.

Non-exudative (dry) macular degeneration
Dry macular degeneration does not require ancillary treatment. A recent study has found a significant decrease in the rate of progression of macular degeneration from the dry to the wet form when taking specific vitamin supplements. Ocuvite or Icaps are such supplements, and are available over the counter at the pharmacy. Other preventive measures to initiate include wearing sunglasses, leading a healthy lifestyle, and reducing (quitting) smoking. Practicing these guidelines is the best way to keep all forms of macular degeneration from progressing further.

 

Presbyopia

What is presbyopia?

Presbyopia occurs when the lens inside the eye, used to accommodate or focus for up close, begins to slowly lose its ability to function. The symptoms of presbyopia begin with having to hold material further away to see it clearly, and it taking longer to "focus" when viewing material at near. Presbyopia begins to occur around the age of forty, where reading glasses are all of a sudden necessary to improve vision and comfort when viewing up close material. Many notice an increase in prescription is necessary every 2-3 years to continue the clarity and comfort needed in their daily work and home lives. Also, most find separate computer glasses helpful in achieving visual comfort at work without having to move closer to the computer screen as experienced with the stronger reading glasses. The increase in reading prescription plateaus off when most are in their sixties.

How does presbyopia affect my current refractive status?

Myopia & Presbyopia

Myopia = nearsightedness
             -A prescription is worn to clear up distance tasks
Those with moderate myopia & presbyopia may notice
             -with their distance glasses on, reading is difficult
             -with their distance glasses off, reading is clear and comfortable

This occurs because due to the curvature of the cornea, and length of the eye,
myopes eyes are focused for near without glasses
(depending on the prescription)

Hyperopia & Presbyopia

Hyperopia = farsightedness
             -A prescription may be worn to see at distance, but mostly worn for near work
Those with moderate hyperopia & presbyopia may notice:
             -presbyopia occurs a few years earlier
             -early on, reading glasses are helpful
             -over time, many are relying on a prescription for computer and up close work
             -later, a prescription is necessary for distance, computer, and reading

The reason for this is with moderate hyperopes, the lens is being used not only for near but for distance also. As the lens’ ability to focus slowly diminishes over time due to presbyopia, the blur is noticed first at near, then at intermediate, and eventually at distance.

Astigmatism & Presbyopia

Astigmatism = two separate curvatures on the cornea
             -A prescription may be worn for distance and near
Those with moderate astigmatism & presbyopia may notice:
             -the majority will need a reading portion added to the current prescription

Astigmatism causes blur at distance and reading length. Presbyopia sets in
and causes added blur at near, therefore a bifocal portion or separate reading glasses with the astigmatism incorporated are necessary.

Diagnostic testing
a) Visual acuity at distance and near
b) Refraction
c) Accommodative testing

Treatment and management
There are several treatment and management options for presbyopia. It is important to be aware of your needs and daily tasks along with your treatment options in order to determine which one will best serve your needs.

a) Glasses
         Reading only
         Separate distance and reading
         Bifocals
b) Contact lenses
         Soft Contact Lenses
             -with reading glasses
             -bifocal soft contact lenses
             -monovision soft contact lenses - (one eye focused for distance, one eye focused for near)
         Rigid Gas Permeable
            -with reading glasses
            -bifocal rigid gas permeable lenses
            -monovision rigid gas permeable lenses
c) Refractive surgery
          Laser procedure to eliminate distance prescription with readers for near
          Laser procedure with monovision – 1 eye focused for distance
          1 eye focused for near

Myopia

What is Myopia?

Myopia is a type of refractive error or glasses prescription. Those that have difficulty seeing at distance, but can see clearly up close, are nearsighted or myopic. Anatomically, myopia occurs because the eye is longer or the cornea is steeper than average, causing the image to be focused in front of the retina. This leaves a blur spot of that image on the back of the eye, which is perceived as unclear. Myopia follows a pattern of showing up within the first to second decade of life, and can continue to progress until one is in their mid-twenties to thirties. Myopia can be inherited, and those with a family history of nearsightedness run an increased risk of manifesting myopia.

Signs and symptoms of myopia and myopic progression

a) Difficulty seeing when driving, watching television, or viewing an overhead presentation
b) Squinting to improve your vision
c) Starbursts or glare around headlights with night driving
d) Strained or tired eyes after long periods of distance tasks
e) Headaches from squinting

Diagnostic testing

a) Visual acuity
b) Refraction
c) Dilated fundus exam for those highly nearsighted

Treatment and management options
There are several options to treat and manage myopia. It is best to discuss with your eye care professional what treatment modality best suits you and your needs.

a) Glasses
b) Contact lenses
         Soft contact lenses
             - easy to adapt to
             - can be specialized for astigmatism, dry eye syndrome, and extended wear
         Rigid gas permeable lenses
             - can help slow down the progression of myopia
             - increased longevity of lenses(last 1-2 years, if properly cared for)
             - can be specialized to treat astigmatism, keratoconus, and myopic progression
             - mild adaptation period to lenses
c) Corneal Refractive Therapy
             Specialty contact lenses worn at night to eliminate myopia
d) Refractive surgery
             Laser procedure to eliminate myopia


Ocular Conditions associated with myopia
Those highly nearsighted are at an increase risk for certain ocular conditions. A yearly eye examination is recommended, along with further testing when deemed necessary. Your eye care professional will inform you if you are within this classification. The ocular conditions high myopes are at increased risk and therefore continually monitored for are as follows:

a) Glaucoma
b) Retinal detachment
c) Lattice degeneration
d) Posterior staphyloma
e) Choroidal neovascular membrane


Hyperopia

What is Hyperopia?

Hyperopia is a type of refractive error, or glasses prescription. Those that have more difficulty seeing up close than at a distance, have farsightedness or hyperopia. Most hyperopes initially have problems seeing up close, but begin to notice later in life that they rely on their glasses more and more near, intermediate and even distance. The reason for this is the lens, a structure inside the eye whose function is to accommodate or focus for near, is used in hyperopes to see at a distance as well as for up close. As the len’s ability to accommodate diminishes over time (called presbyopia) the blur is noticed first at near, intermediate , and lastly at distance. Hyperopia, anatomically, is when the eye has a shorter length or the cornea is flatter than average, causing the image to be focused behind the retina. This leaves a blur spot of that image on the back of the eye, which is perceived as unclear.

Signs and symptoms of hyperopia

a) Blur with close work
b) Tired eyes or eyestrain with prolonged computer or near work
c) Headaches towards the end of the day
d) Difficulty focusing at computer and distance length
e) Becoming more reliant on your prescription now for computer and some distance tasks
f) Some eyeturns in children

Diagnostic testing

a) Visual acuity
b) Refraction
c) Dilation and cycloplegia - (in special cases with children to assess their full prescription)


Treatment and management options

There are several treatment and management options for hyperopia. It is important to be aware of your needs and daily tasks along with your treatment options in order to determine which one will best serve those needs.

a) Glasses
           Reading only
           Separate distance and reading
           Bifocals
b) Contact lenses
           Soft contact lenses
                -with reading glasses
                -bifocal soft contact lenses
                -monovision soft contact lenses
                  (one eye focused for distance, one eye focused for near)
          Rigid gas permeable
              -with reading glasses
              -bifocal rigid gas permeable lenses
              -monovision rigid gas permeable lenses
c) Refractive surgery
          Laser procedure to eliminate hyperopia


Glaucoma

What is glaucoma?

Glaucoma is a silent ocular disease that progresses slowly, accumulates over time, and leads to blindness if left undetected and untreated. In the anterior (front) portion of the eye, fluid called aqueous humor is produced and drained. With the most common form of glaucoma, primary open angle glaucoma, the eye produces aqueous humor but does not drain it properly. This leads to a build-up and "elevation" of the pressure inside the eye. This elevated pressure affects the blood flow to the optic nerve, causing structural damage that appears as excessive thinning and excavation of the optic nerve. The optic nerve functions as the connection between the eye and the brain, carrying the electrical signal of what we see from the retina to be interpreted and comprehended by the brain. The glaucomatous optic nerve manifests permanent damage causing the transmission of that electrical signal from the eye to be diminished. The result is vision loss that begins with our peripheral or side vision, and progresses to the central vision in advanced stages of the disease. Blindness ensues if the optic nerve sustains complete excavation and damage due to uncontrolled advanced chronic glaucoma.

Who is at risk for glaucoma?

There is an increased incidence of glaucoma with: Symptoms of glaucoma

Primary Open Angle Glaucoma: a silent blinding disease with no symptoms until advanced stages cause extensive vision loss to be apparent.

Normal Tension Glaucoma: no symptoms until advanced stages of vision loss.

Pigmentary Glaucoma: no symptoms to transient blur, halos, or ocular discomfort shortly after physical exercise.

Acute Angle Closure Glaucoma: acute onset of unilateral ocular pain, blur, starbursts around lights, and nausea. This is considered an ocular emergency.

How is glaucoma detected?

Through a series of specialized tests performed by your eye care professional: What is the treatment for glaucoma?
  1. Anti-glaucoma ocular medication
    • First line agent of treatment.
    • Anti-glaucoma eye drops decrease the production of the aqueous humor within the eye, or increase the rate of drainage.
    • Begin with one eye drop, and when necessary, several different anti-glaucoma eye medications can be used to control the intraocular pressure

  2. Argon laser treatment
    • Second line treatment agent
    • Resorted to when glaucoma continues to advance despite multiple ocular medications
    • Laser markings are made within the drainage system to promote openings and improve outflow at the site of this structure

  3. Trabeculectomy
    • Third line treatment agent
    • Used when ocular medications and argon laser treatment together have not succeeded in controlling the glaucoma
    • A surgical procedure where an alternative drainage system is made within the wall of the eye for the aqueous humor to safely drain out

Flashes, Floaters, and Retinal Detachment

The Retina
The retina is the neurosensory tissue that lines the inside of the eye that enables us to see. The retina functions by receiving light and turning it into an electrical wave. This wave is then carried by the optic nerve to the brain for image interpretation, and comprehension. The retina is composed of many layers that all play a role in it’s functioning. The retina is extremely fragile and complex. Damage including tears, bleeding, or inflammation of this tissue will lead to VISION LOSS in that area of the retina.

Vitreous and Posterior Vitreal Detachments
The vitreous is the liquid in the center of the eye which is attached to the retina by collagen strands. The vitreous functions to preserve the round firm form of the eye. As we age, the vitreous condenses and pulls away from the retina, pulling the collagen strands along with it. When this occurs, one of two things can occur, a posterior vitreal detachment (PVD) or a retinal tear. When the collagen strand pulls from the retina cleanly without causing a break or tear in the retina, this is a posterior vitreal detachment. If the collagen strand as it pulls from the back of the eye, tears the retina, this is deemed a retinal tear. Retinal tears are an OCULAR EMERGENCY because they can lead to a retinal detachment within hours.

Retinal Detachment
A retinal detachment (RD) is the pulling of the retina off the back of the eye. This is an urgent, sight threatening condition, dependent upon where it occurs in the eye. If it causes a detachment of the macula, the area that controls our central vision, vision loss may be permanent if not treated immediately. The most common cause of a RD is when a tear in the retina has occurred through trauma, age related changes, thinning along the sides of the eyes, or without cause. A retinal tear allows vitreal fluid behind the retina to sever its connection to its blood supply and the back of the eye. In those areas where the retina has been pulled off it loses its blood supply damaging vital layers and causing the retina to atrophy and die in that region.

SYMPTOMS OF FLASHES AND FLOATERS ARE AN OCULAR EMERGENCY. It is recommended to see your eye care professional immediately for further testing to rule out retinal tears, breaks, holes, and detachment.

  Posterior Vitreal Detachment (PVD) Retinal Detachment (RD)
Cause 1. Vitreous condenses
2. Collagen strand pull away from retina, notice "flashes"
3. Collagen strand floats in vitreous perceived as "floaters" 		1. Tear or hole in retina
2. Allows vitreous to get behind retina
3. Retinal pulls away from back of eye, notice "flashes"
4. Retina floats in vitreous perceived as large "floater"
Signs & Symptoms Flashes
Floaters		 Flashes
Floaters
Curtain coming down over your vision
Sudden vision loss in one eye
Diagnostic Testing Dilated retinal exam Dilated retinal exam
Status OCULAR EMERGENCY
           -until RD ruled out
Stable condition		 OCULAR EMERGENCY
Progressive
Treatment None
Monitor		 Laser treatment
Surgical treatment





Dry Eye Syndrome

What is Dry Eye Syndrome?

Dry Eye Syndrome is when the tear layer functioning to keep the eyes moist and comfortable begins to decrease in production. The tear film is comprised of three layers that include a mucin layer for adhesion, a water layer for comfort, and an oily layer to decrease evaporation. Together they work to enhance longevity of the tear film to the front surface of the eye and enable visual comfort and clarity. Age-related changes and certain medical conditions are the cause of the decreased tear film production. The glands around the eye that produce the tear layer are compromised leading to irritation, discomfort, and even watering of the eyes.

Causes of Dry Eye Syndrome

Dry eye syndrome is a chronic condition that affects most men and women as they get older, as specific changes within the body induce it’s occurrence. These age related changes occur at the level of the lacrimal and meibomian glands which supply the eye with its tear film. Women may also notice a worsening of this condition as hormonal changes take place with menopause. Medical conditions such as Sjogrens syndrome, rheumatoid arthritis, scleralderma, and systemic lupus erythematosus also exacerbate severe dryness of the eyes. Specific medications that cause drying of the body such as antihistamines will cause drying of the mucus membranes including the eye. Environmental factors also play a role in ocular comfort in those with dry eye syndrome. These factors include heating, air conditioning, windy, dusty, or dry surroundings. Working on computers and extended reading plays a role in dry eye syndrome due to the decrease in blinking that occurs with these tasks. Insufficient blinking affects the spreading of the tear film across the eye, causing symptoms of dryness and irritation.

Signs and Symptoms of Dry Eye Syndrome

Diagnostic Testing

Treatment and Management

  1. Mild
    • Libricating artificial tears 4X/day
  2. Moderate
    • Lubricating artificial tears 6-8X/day
    • Lubricating gels 4-6X/day and at bedtime
    • Humidifier
  3. Severe
    • Lubricating gels every hour and at bedtime
    • Punctal plugs
    • Prescription ocular medication including Restasis or mild steriods



Conjunctivitis

What is a Conjunctivitis?

The conjunctiva is a thin clear membrane that lies on top of the white (sclera) of the eye and houses blood vessels. When this membrane becomes inflamed or infected, it is referred to as a conjunctivitis. There are several forms of ocular conjunctivitis, many of which cause dilation of the blood vessels within the conjunctiva, causing the eye to appear pink or red. This is where the term "pink-eye" originated.

What Types of Conjunctivitis Should I Be Aware Of?

There are three main types of conjunctivitis that are most common to the general public. These types are allergic, bacterial, and viral conjunctivitis. All forms of conjunctivitis should be viewed as serious, and are subject to further analysis, diagnosis, and treatment by your eye care professional.

 
Allegric Conjunctivitis
Bacterial Conjunctivitis
Viral Conjunctivitis
Cause Due to seasonal allergies or irritating allergens Various offending bacteria such as
  • Staphylococcus (most common)
  • Haemophilus
  • Pseudomonas
  • Streptococcus
  • Moraxella
 Recent upper respiratory infection
Common cold
Near someone with an eye infection
Onset Within hours to days after contact, one eye or both eyes Within hours after contact, one eye or both eyes Within hours to days, one eye with prospect of spreading to fellow eye
Signs & Symptoms
  • Severely itchy eyes
  • Ocular redness
  • Tearing, watery eyes
  • Mild clear mucous discharge
  • Eyelid swelling is possible
  • Thick yellow or green colored discharge that persists throughout the day
  • Severe ocular redness
  • Markedly swollen eyes
  • Crusted eyelashes upon awakening
  • Ocular redness
  • Mild watery discharge
  • Ocular discomfort, irritation, and burning
  • Swollen eyelids
Duration *** NEED INFORMATION *** Days to weeks, depending upon severity Days to weeks, depending upon severity
Treatment & Management
  • Cold compress
  • Artificial tears
  • Prescription antihistamine, mast cell stabilizer, or steriod eye drops
  • Eye wash
  • Cold compresses
  • Prescription antibacterial eye drops
  • Artificial tears
  • Cold compress
  • Prescription antihistamine, non-steriodial anti-inflammatory, or antibacterial eye drops
Nature Not contagious Contagious
  • Do not share towels, clothes, and makeup
  • Wash hands frequently
  • Refrain from touching eyes and face
 Contagious
  • Do not share towels, clothes, and makeup
  • Wash hands frequently
  • Refrain from touching eyes and face




Cataracts

What is a Cataract?

A cataract is the clouding of the crystalline lens within the eye. The crystalline lens serves to aid in focusing at near, and over time begins to opacify due to age-related changes and exposure to ultraviolet sunlight. Cataracts begin as a slight clouding or discoloration, and slowly accumulate over time. Once a cataract has reached a certain density, it will impede natural light from entering the eye, causing symptoms of glare, decreased contrast, and blur.

Different Types of Cataracts

More than half the population over 65 will have some degree of cataract formation. There are several forms of cataracts, the most common being age-related cataracts. Other cataracts can form due to trauma, long term steroid use, medical conditions such as diabetes, and congenital formation.

What are the Symptoms of a Cataract? How is a Cataract Diagnosed?

The diagnosis of a cataract takes place during a comprehensive eye examination by your eye care professional. Several tests are performed to evaluate your ocular health status, with the most important test being pupillary dilation. In the course of this test, the pupil is temporarily expanded with eye drops, allowing the practitioner to view and assess the extent of the cataract formation.

What is the Treatment for Cataracts?

Treatment of a cataract is dependent upon the size of the opacity, along with the degree of symptoms the patient is experiencing. The doctor and patient together will assess if the patient’s quality of life has been affected by the reduction of clarity due to the cataract.

With early cataracts, symptoms are often mild and are best treated with a current eyeglass prescription, strong sunglasses for glare, and a bright light when reading.

Moderate and dense cataracts cause more impeding symptoms that are not as easily relieved with a change in the glasses prescription, and sunglasses. The treatment that will diminish symptoms and improve vision will be cataract surgery.

What is entailed in Cataract Surgery?

Removal of a cataract is performed by a cataract surgeon, who specializes in this type of ocular surgery. The first visit with the surgeon allows the doctor to take special measurements necessary for the surgery, allows the patient and surgeon to discuss exactly what the surgery will entail, and schedule a surgical date and time. One eye is performed at a time, and once that eye has begun to heal, the next eye will undergo surgery when ready.

Phacoemulsification Cataract Extraction

During the surgery, the patient’s eye will be anesthetized in such a way that the patient will remain comfortable, and need not worry about an accidental blink or movement of the eye. Dilating eye drops are used to allow complete access to the cataract during the surgery. A very small incision is made into the cornea, and a small aperture is made on the front surface of the lens capsule. A state-of-the-art instrument, called a phacoemulsification probe, uses ultrasound waves to dissolve the cataract. The remnants are then gently vacuumed up, and the area is irrigated. A clear lens implant called an intraocular lens, that contains your prescription, is placed within the eye where the cataract once was. Some surgeries require one stitch in the cornea to close the incision, but most incisions are small enough that they don’t require this. Antibiotic medication is placed on the eye, along with a drop of anti-inflammatory medication. An eye shield is placed over the eye, and the patient is sent to the recovery area, and will go home that day.

Postoperative Examination

The patient will be given a package with eye drop medications and a schedule of when to use them. The patient is to see the surgeon one day after surgery, and your co-managing eye doctor one week and one month after surgery. Glasses which may hold a small distance prescription with mainly a reading prescription, will be given once the eye is completely healed. Under the optimum conditions, patients may only need to wear reading glasses! This usually occurs at the one month visit, but can vary due to your individual healing rate.




Astigmatism

What is Astigmatism?

Astigmatism is a type of refractive error or glasses prescription. Those with astigmatism have difficulty seeing clearly both at distance and up close. Anatomically, astigmatism is when the cornea, the clear front surface of the eye, has an irregular shape causing the image to be focused at two different places in the eye. This is perceived as blur or distortion when the proper correction is not being worn.

Signs and Symptoms of Astigmatism
a) Squinting to see
b) Eyestrain & headaches with distance and up close reading
c) Shadow images when viewing objects at distance
Diagnostic Testing
a) Visual Acuity
b) Refraction
c) Corneal Topography
Treatment and Management Options

There are several options to treat and manage astigmatism. It is best to discuss with your eye care professional what treatment modality best suits you and your needs.
a) Glasses
b) Contact lenses
           -Soft contact lenses (inc Disposable lenses)
           -Aspheric
           -Spherical
           -Toric
           - Rigid gas permeable lenses
c) Corneal refractive therapy
           Specialty contact lenses worn at night to eliminate myopia & astigmatism
d) Refractive surgery
           Laser procedure to eliminate myopia & astigmatism