Tag: Ophthalmology

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“Other” Eye Conditions Retinal Detachments

Retinal Tears and Vitreous Hemorrhage

Vitrectomy for Retinal Tear to Remove Vitreous HemorrhageA vitreous hemorrhage may be caused by a retinal tear.  Sometimes there is so much blood in the eye that direct examination is impossible and we can only guess at the most likely cause.  It is the most difficult situation for me to handle as a doctor.

Patients lose significant vision as the blood in the middle of the eye physically blocks all light from hitting the retina.  While this is usually not permanent visual loss, the blood makes it difficult to make a definitive diagnosis as it can be impossible to see the retina.

Normally, without blood in the eye, a retinal tear may be easily diagnosed and treated with laser.

While there are other causes of vitreous hemorrhage, such as diabetic retinopathy, retinal vascular disease and others.  Still, a retinal tear causing the vitreous bleeding is quite likely.

Retinal Tears Cause Retinal Detachments

A retinal tear can cause a retinal detachment.  A retinal detachment is potentially blinding.

In cases of vitreous hemorrhage, the patient cant’ see “out” and I can’t see “in.”  My ability to examine the eye is hindered.

Options at this point are to observe (i.e. do nothing).  Observing the eye is okay as the blood is doing no harm.  But what if there is a retinal tear?  A retinal detachment could occur if there is an undiagnosed retinal tear.

Other tests, such as an ultrasound can often detect a large tear, but it is not as good as directly examining the eye.  Operating to remove the blood to facilitate proper examination is an option, too.

What Does This Mean?

I am getting older, more aggressive, but smarter.

As I have aged, i.e. gained more experience, I have become more comfortable operating in these cases.  When I was younger, I would often hesitate because I was uncomfortable offering surgery in a situation where surgery might not be necessary, but I’ve learned (through experience) that watching a waiting can be more problematic.

Most of the time I recommend operating to at least remove the blood and confirm a diagnosis.  The risks of modern vitrectomy are quite low, while the risk of a retinal detachment occurring while we are waiting is quite possible.

Vitrectomy surgery is usually performed as an outpatient.  If a tear is indeed present, it can be treated simultaneously.

At the very least, a diagnosis can be made and a potentially blinding condition avoided.

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Retina Treatments Video

Vitrectomy Eye Surgery for Macular Pucker

This is my first patient education video.  I uploaded this last evening to YouTube.  It is one of the best I’ve seen for a super niche like eye surgery.

Vitrectomy Surgery

As I state in the video, vitrectomy surgery is performed by retina specialists.  I completed extra training to specialize and to perform retinal surgery.

A vitrectomy is the core operation for many of the surgical diseases we treat.  For instance, a vitrectomy is used to remove an epiretinal membrane (ERM), fix a macular hole or repair a retinal detachment.  A vitrectomy can remove floaters.

It is very similar to arthroscopic surgery or laparoscopic surgery in that all the systems are “closed.”

Patient is Awake and Comfortable

Most of my procedures are performed while the patient is awake.  Before surgery, the patient receives a sedative, putting them to sleep for a few minutes while the entire eye is numbed.

This “IV sedation” or “twilight” form of anesthesia is quite popular in most outpatient surgical settings.  It avoids the rigors of general anesthesia.

By the way, the operation is completely painless!  I am usually able to talk to my patients while operating.

25 Gauge Instrumentation:  No Stitches!

The instruments used have revolutionized vitrectomy surgery.  The instruments are so thin, that we no longer have to take time to stitch the eye.  This improves efficiency (shortens operating times), but also causes less tissue damage and greatly speeds up healing time (fewer office visits).

What Does This Mean?

You’ve probably noticed that you see more and more video.  It’s a great medium, it captures your attention via audio and video, the costs of equipment are miniscule and the video quality is exeptional.

I produced this entire video at home using iMovie (Apple).  The operation took about 16 minutes in real time.  Many thanks to Meredith Maclauchlan for her skill in adding the special effects and background!

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Treatments

Your Eye Treatments

Eye drops are the most common form of medication for your eyes.  There are also ointments (aka salves), pills and injectable medicines.  The eye is unique in the many ways.  It can be treated directly with medicines.  Eye drops and ointments are the most common.  Medications given by mouth or intravenous usually don’t get into the eye well, due to the blood brain barrier.  Direct injection of medicine into the eye is probably the best for treating problems inside the eye (e.g. the retina).

Eye Drops

The skin is the only other organ in the body where the medication is placed directly upon it.  We use lotions and creams to treat ailments and diseases of the skin.

Eye drops, too, are placed right where we want them.  These drops commonly treat infections, fight glaucoma, lubricate, reduce inflammation, etc.  Eye drops are best suited for problems that develop outside, that is, on the surface, of the eye.  They aren’t so useful for treating diseases in side the eye as the drops do not penetrate the eye very well.

Each eye drop has a volume of about 32 microliters.  The volume of the surface of the eye is about 28 microliters.  These are approximations, but my point is that for most eye drop medications, the volume of one drop exceeds the amount of liquid that can be “held” by the surface of the eye.

This means that whatever the medication, never use more than one drop, or, the excess will roll down your cheek…it is a waste.  I have always recommended that if the directions recommend the use of more than one drop at a time, don’t buy it.  The manufacturer knowingly advises you waste a portion of the product.

A  more practical view?  Often patients are directed to use more than one different type of eye drop.  Separate the drops by a minute or two to prevent the first being washed away (and down your cheek) by the second drop.  Give the first drop time to be absorbed.

Ointments

There are fewer medications available in ointment form.  The advantage of an ointment, or salve, is the effects may last a bit longer.  Once applied, the ointment heats up.  As it nears body temperature, the ointment melts and releases the medicine over the ocular surface.

Ointments; however, are somewhat greasy, difficult to apply and, most of all, generally blur the vision.  Patients don’t like to use them, they are messy and they can’t see.

Eye ointments are great for eye lid problems and for cases where lubricating the eye requires more than just drops (e.g. just before you go to bed).

Intravenous Medications

Rarely used in the office setting, intravenous medications can be used when there are eye and systemic complications that need to be treated.  Beyond the scope of this article, intravenous medications may be used to treat certain infections, bacterial and viral, that are out of control (e.g. herpes, CMV, syphilis).  Still not much drug finds its way into the eye even whe given I.V.  The “blood-brain-barrier” prevents many drugs from getting inside the eye.  This is a unique problem of the eye and the brain.

Pills

Tablets and pills are sometimes used to treat certain types of inflammation, occasionally eye pressure and only a few types of infections.  This route, too, fails to get large quantities of medicine inside the eye, again, due to the blood brain barrier.

Intravitreal Eye  Injections

Most of the advances in treatment for macular degeneration and diabetic retinopathy involve intravitreal injections.  Injecting anti-VEGF medications and steroids have given us new ways to treat these two common retinal diseases.  This circumvents the the “blood brain barrier.”

Sustained Release Drug Delivery

This category is really a subset of intravitreal injections.  These devices will be injected into the eye and release drug over many months (bypasses the blood brain barrier).  Right now, Ozurdex, is the only FDA approved system.  It releases steroid for the treatment of retinal vascular occlusions.  Other sustained release systems are in the pipeline.

What Does This Mean?

Depending on the malady, topical eye drops and ointments are probably best suited to treat disease outside the eye.  They have the advantage of being applied directly to the target tissue.

Similarly, by directly injecting medicine into the eye to treat retinal disease, intravitreal injections share the same advantage; namely, directly applying the medication to the target.

While the main thrust of this web site focuses on retinal disease, don’t forget that eye drops were really the first time we could apply medicine directly to the eye.  History has taught us that this is a very effective method.  This makes for an exciting future for the treatment of retinal disease.

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Retina Treatments

Eye Drops to Help You Heal

After eye surgery, there are several eye drops to help you recuperate, and heal, quickly.  These eye drops usually include an antibiotic, anti-inflammatory, and sometimes, an eye drop to keep  you dilated for comfort.

There are many types of eye surgery; cataract, glaucoma, corneal, retina, etc.  In general, the post-operative medications/drops that we use are about the same.

Antibiotics

These usually come packaged in a bottle with a tan colored top.  It may be used 4 times a day.  The drop is clear and may be prescribed to be used 4 times per day.

Remember that eye drops do not penetrate the eye very well, so it is probable that the antibiotics really help the outside of the eye and the actual incision (i.e. place where your surgeon “cut” into your eye) from becoming infected.

One of the unfortunate complications of any intraocular surgery is endophthalmitis, an infection of the contents of the eye.  I doubt the topical drops actually fight any infection inside the eye per se.

Anti-Inflammatory Drops

These usually come in a white or pink capped bottle.  I prefer a steroid called prednisolone acetate 1% (e.g. Pred Forte, Omni Pred).  It is milky white.  This drop must be shaken prior to instillation.  It is really a suspension, that is, the drop contains microscopic particles of drug that settle out.

Other anti-inflammatories included Xibrom or Acular.  These are not steroids and probably not as strong.

Anti-inflammatory drops help the eye keep comfortable during the healing.  If we limit the post-operative inflammation, there should be less discomfort.

Dilating Drops

Some operations and some docs require dilating drops after the operation.  These are in a bright red topped dropper.  These are very similar to what is used in the office to dilate your eyes for examination.

Occasionally, it is helpful to keep the pupil dilated during the recovery period.  I like to use these drops at the end of an operation.  The drops I use will keep the pupil dilated for a day or two, but I don’t have to wait for dilation the next day for the follow-up exam.

Certain dilating drops can also cause “cycloplegia” in addition to simple pupillary dilation.  One of muscles inside the eye, the ciliary muscle, can sometimes spasm, causing severe pain and discomfort.  “Cycloplegia” prevents this from occurring and helps keep the eye comfortable.  The ciliary muscle also helps focus, so vision become blurry.

What Does This Mean? Most of the post-operative medicines we use are topical drops.  Oral medicines usually aren’t necessary.   Most of the drops are really used to promote smooth, comfortable healing, the antibiotics being the exception.

Oral pain relievers generally are not required.  I rarely have to prescribe anything by mouth regardless of the procedures I performed.  The operation I perform requiring the most tissue manipulation is a scleral buckle.  Even with this procedure, oral pain relievers are not necessary.  (Of course, this is surgeon dependent and reflects the way I practice only.)

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