Eye floaters are a common problem in the retina clinic.  Below is an eye floaters video that will help you understand what is occurring inside of your eye.

With aging, the vitreous gel inside the eye begins to shrink and break down. In every human, the vitreous will separate from the retina.  This process is called a PVD or posterior vitreous detachment. The retina is the delicate brain tissue that you use to see.

When the vitreous detaches, it can pull so hard coming off the retina that it causes a retinal tear. Sometimes there is bleeding within the retina (retinal hemorrhage) or bleeding into the vitreous (vitreous hemorrhage). Untreated, retinal tears will progress to retinal detachments which are what cause blindness or severe vision loss.

A good retina specialist should be consulted to determine the extent of injury with any new eye floater.

Retina specialists are often asked by general ophthalmologists or optometrists to treat the eye complications of diabetes.  One of the most common complications is diabetic macular edema or DME.  Retina specialists use clinical examination in the office to determine if the edema (or swelling) is “clinically significant.”  Signs of clinically significant macular edema are blurred vision, trouble seeing during the day, difficulties reading, and (less commonly) eye floaters.

Clinically significant macular edema (CSME) is present if any of the three exam findings are seen by your ophthalmologist.

• Any retinal edema within 500 microns of the center of the fovea (the most central part of your vision)
• Hard exudates (fats) within 500 microns of the center of the fovea if associated with retinal thickening
• Retinal edema greater than one optic nerve disc in size and within one disc diameter of the center of the fovea

My eye doctor found macular edema.  How can I be treated?

Patients with clinically significant macular edema may benefit from eye laser or eye injections.  Common eye injections include Avastin, Lucentis, and Eylea.  Eye injections of steroids can be helpful in some cases.  Steroids are used sparingly as they can cause cataracts and glaucoma over time and with repeated use.  Good control of blood sugars and blood pressure is critical in the treatment of macular edema.

How can I be tested for macular edema?

A dilated eye exam is the most useful test to determine if you have macular edema.  Your retina specialist may take OCT images (showing the retina in cross section) to show the degree of retinal edema and your improvement over time with repeated eye injections.  A fluorescein angiogram (FA) may be helpful to determine the degree and severity of the retinal swelling.

Without treatment, your vision may become blurred over time since macular edema involves the part of the retina responsible for central vision.

If you are interested, here is some additional reading about macular edema from EyeWiki.

If you are diabetic and think you may have diabetic macular edema, call Dr. Stelton today or contact him here.

Patients are often concerned about the possibility of a retinal detachment when they experience blurred vision.  In the eye clinic, I discuss the symptoms of retinal detachment on a daily basis.  This is for good reason, as a retinal detachment is an eye emergency that requires immediate diagnosis and treatment by a skilled ophthalmologist.  The retina is the sensitive and delicate brain tissue which lines the eyeball and allows you use to see.  If you can imagine, the retina is only about 0.2-0.3 mm thick!  This thin tissue is critical for sight.

If a break in the retina occurs, fluid from within the center of the eyeball can move under the retina and cause a retinal detachment.  I like the analogy of wallpaper being stripped from a wall when speaking to patients about retinal detachment.  First, a small bubble or break may form in the wallpaper.  Slowly over time, humidity and moisture cause the wallpaper to strip from the hard surface underneath it.  When a retina detaches, fluid forms underneath it and damages the cells we use for vision within the retina (photoreceptors).  Damage to the photoreceptors is the reason for vision loss and blindness; this sometimes still happens even after a retina detachment is repaired.

Who is at risk for a retinal detachment?

Risk factors for retinal detachment include high nearsightedness (myopia), recent cataract surgery, trauma, and a family history of retinal detachment.  Patients with known “weak areas” in the retina such as lattice degeneration or retinal hole are also at increased risk.

Retinal detachments are painless and often occur suddenly.  Typically a patient experiences new floaters or cobwebs in the vision which are accompanied by flashes of light.  The vision may become blurred.  More advanced findings are the loss of peripheral visual field and blindness.  Some people describe it as a “shade” or “curtain” that expands over time toward the central vision.  Hopefully, a patient will seek care before this “shade” or visual field loss is noted as these are more serious symptoms.

What are the warning signs of a retinal detachment?

Remember to call your ophthalmologist immediately if you are experiencing any of the following:

• new flashes in your eye
• new or worsening eye floaters
• blurred vision in one eye
• loss of peripheral vision
• a “curtain-like” shadow in your vision

Fortunately, most retinal detachments can be fixed with eye surgery.  The key to a good visual prognosis is early detection and treatment.  If you feel you may be experiencing a retinal detachment, call 941-777-5000 today or schedule a consultation here.

Ophthalmologists and retina specialists often use a simple macular degeneration test to document and detect changes in their patients’ central vision.  The test is called an Amsler grid (named after Swiss ophthalmologist Marc Amsler).  The test can detect changes in a patient’s central 10 degrees of visual field which is commonly affected by macular degeneration.

Patients who have been diagnosed with macular degeneration can use this test to monitor for any potential worsening on a daily basis in the comfort of their home.  Detecting changes is particularly important as this often signals a change from the dry macular degeneration to wet macular degeneration.  The Amsler grid is not perfect and is not a substitute for a comprehensive eye exam by an ophthalmologist or retina specialist.

Download this printable Amsler grid to test for macular degeneration.

How to Perform the Amsler Grid Test

• Sit comfortably in a well-lit room.
• If you normally wear glasses, Make sure you are wearing the eyeglasses you use for reading.
• Hold the test approximately 14-16 inches from your face.
• Cover one eye.  Only one eye is tested at a time so you can compare the difference between the two eyes.
• Fixate on the black dot in the center of the square.
• Stay fixated on the black dot in the middle of the square and ask yourself a few questions.  This is very important.  You must keep your fixation on the black dot in the middle of the square.  Don’t move your eyes around – stay focused on the black dot.
  • Do I see the black dot?
  • Can I see all four corners of the square?
  • Are all the lines straight or are they blurred, distorted, or wavy?
  • Are there are any missing areas or holes?
• Repeat with your other eye.

If you are experiencing any changes on the macular degeneration test, please call today to schedule an eye exam.  Early diagnosis can help preserve and save vision.

Call our office today at 941-777-5000.

The macula is a critical portion of the retina responsible for our central vision and fine focus. We use the macula to read, look at our iPhones, and recognize familiar faces. Rarely, a hole can develop directly in the macula, which immediately causes a blind spot in the central vision. Patients who develop a macular hole can suddenly experience a decrease in their central visual acuity. Other times, the symptoms of blurred, wavy, or distorted vision can occur more slowly. Macular holes sometimes are accompanied by eye floaters. Macular holes are sometimes diagnosed on routine eye exams when the fellow “good” eye is covered during vision testing at the eye doctor.

How is a macular hole diagnosed?

Macular holes typically occur later in life and happen more often in women. They occur about 5-10% of the time in both eyes, but usually not at the same time. General ophthalmologists and retinal specialists use clinical examination in the eye clinic to diagnose macular holes. Optical coherence tomography (OCT) testing is a new technology at the retina specialist’s office which can help determine the size of the macular hole as well as reveal any areas of tension on the edges of the macular hole. This helps to determine the stage of the hole, which is important. The stage of the macular hole influences which cases may benefit from vitrectomy surgery.

How can my macular hole be fixed?

It is amazing to think that macular holes were considered untreatable until as recently as 1991! Now, retina specialists perform vitrectomy, membrane peeling, and introduce intraocular gas to fix macular holes with great success. A vitrectomy removes the vitreous jelly from the back part of the eye and replaces it with a clear solution. This step removes the pulling forces from the edge of the hole. Surgeons then peel the inner-most lining of the retina around the edges of the hole to remove any additional tension around the edges of the hole.  Intraocular gas is then used to fill the eye to act as a “bridge” to allow the retina to heal and close the gap from the macular hole. The gas will dissolve naturally over a period of time as the eye fills with a clear fluid that is naturally made by your eye. Success rates after vitrectomy are very high and range from 85-95% depending on pre-operative factors such as the size of the macular hole and the length of time prior to vitrectomy surgery. After surgery, some retinal specialists recommend a period of face-down positioning depending on their practice pattern and the characteristics of the macular hole. This is an important question to discuss with your retinal specialist.

If you think you are experiencing symptoms of a macular hole, call today – 941-777-5000.

Eye floaters are a visual phenomenon caused by opacities and light scattering in the vitreous gel at the back part of the eye that cast shadows onto the surface of the retina.  These opacities cause annoying linear shadows or dark spots that move with eye and head movement.  Eye floaters can come on suddenly or gradually.  Due to their proximity to the retina, the brain can interpret the floaters as being quite large.  Each patient will perceive eye floaters differently and will be bothered by them by varying degrees.  The Latin origin of the word floaters is “muscae volitantes” or “flying flies,” a description that many patients that suffer from floaters find particularly fitting.

Why do floaters occur?

To understand why floaters tend to affect older patients, it is important to understand what the vitreous gel is and how it ages over time.  The vitreous gel is 98% water and other molecules, mostly collagens and hyaluronan.  These components form a “jelly-like” pattern that is amazingly clear.  When we are born, the vitreous jelly has the consistency of a thick gel.  Over time, in a process called liquefaction, the components that form the vitreous jelly break down.  The vitreous jelly becomes less like a gel and more liquid in consistency.  The liquefaction process doesn’t only affect the consistency of the vitreous jelly.  It also alters the interactions within the vitreous, which can result in eye floaters and other retinal concerns.

What is a posterior vitreous detachment or PVD?

In particular, the gradual breakdown of the vitreous gel through liquefaction can cause a posterior vitreous detachment or PVD.  This is because the vitreous gel has a very close relationship and a delicate attachment to the adjacent retinal tissue.  With enough time and aging, the vitreous breaks down enough to cause a PVD, which occurs when the back edge of the vitreous jelly separates naturally from the retina. When this occurs, the patient often becomes very symptomatic and notes a worsening of floaters and occasionally flashing lights.  Nearsightedness, or myopia, is a risk factor for a PVD at an earlier age than expected.    A PVD can sometimes be a harbinger of a serious eye complication called a retinal tear or retinal detachment.  Read more about the sudden onset of eye floaters here.

I have diabetic retinopathy.  Could my eye floaters be bleeding in my eye?

Other types of floaters can be due to bleeding (vitreous hemorrhage), inflammation (uveitis or lymphoma), calcium spheres (asteroid), and sometimes even injected medications for macular degeneration.

In other words, floaters are more than a mere annoyance, like flying flies.  They can be a warning sign of a PVD or other serious retinal injuries.  If you notice a floater, it is important to be seen by a retinal specialist who can check on the health of your retina and continue to observe your retinal health over time.  Read more about eye floaters at the American Academy of Ophthalmology.

What should I do if I am experiencing a new eye floater?

Call your retina specialist today!

Retinal vein occlusion is a common eye problem.  A major cause of retinal vein occlusions is arteriolosclerosis or the thickening of the blood vessel walls.  Thickening of the walls of your blood vessels occurs in response to increased blood pressure.  This arteriolosclerosis leads to a compression of the ocular veins which course under the arteries.  This compression leads to partial occlusion of the vein, development of a blood clot, and damage to the blood vessel wall.  When blood cannot drain properly, it leads to bleeding and leakage of fluid from blocked blood vessels.  Oxygen delivery to the retina is reduced and problems such as blurred vision, blind spots, bleeding in the eye, or a painful type of glaucoma can ensue.

What causes a retinal vein occlusion?

Risk factors for retinal vein occlusion include age (your risk increases 10-fold from age 40 to age 65), hypertension, high cholesterol, diabetes, or elevated eye pressure. In the rare cases where retinal vein occlusion is not explained by these factors, lab work must be done to search for other, uncommon medical conditions that lead to an increased tendency for blood to clot.

What does RVO mean?

Ophthalmologists use different terminology to describe retinal vein occlusions, depending on where the blockage in the eye occurred.  A BRVO, or branch retinal vein occlusion, occurs in one of the smaller veins in the eye.   A BRVO may only affect one-quarter or one-half of the retina, leaving other parts of the retina to function normally. In contrast, a CRVO, or central retinal vein occlusion, affects the main venous drainage of the eye.  Typically, a central retinal vein occlusion is more severe than a BRVO, and patients experience worse vision and develop more complications due to the poor blood flow patterns that result due to the blockage of the main drainage of the eye.

What is your ophthalmologist looking for?

When a retinal specialist looks inside your eye, he can see vessels which are wider and curvier than normal.  This finding indicates your vessels may have increased pressure due to an outflow problem which occurs in any vein occlusion.  The doctor will see many hemorrhages occurring within the retinal layers.  In addition, a swollen optic nerve and swelling in the central retina are often found.  Additional testing (e.g. optical coherence tomography and fluorescein angiogram) done by your retinal specialist can further determine the level of retinal swelling and show how the vein occlusion has affected the blood flow to the eye.

Here is a patient who has suffered a branch retinal vein occlusion.

It’s not unusual for me to spend the last few hours of my day reading on my iPad or iPhone.  It helps me unwind from a long day and keeps me up-to-date on the latest news.  I wouldn’t be surprised if many of you do the same thing before heading to bed.  Have you ever wondered whether this habit could be making it harder for you to fall asleep and stay asleep through the night? 

A lot has changed in light technology over the last few years.  Gone are the days of the Edison light bulb you learned about in grade school.  Americans have become dependent on smartphones, tablets, and other techie gadgets which utilize light emitting diodes (LEDs) to allow you to view their content.  This technology has led to the increase in light emitting devices in the bedroom.  If you are like me, most of your reading is now done on a tablet rather than a physical book.  Below, we will discuss if all this light prior to bedtime is good for your sleep.

Let’s first discuss light more generally.  Although humans perceive visible light as predominantly white, remember that light can be broken down into its component colors of red, orange, yellow, green, blue, indigo, and violet.  This is the phenomenon that explains rainbows.  The different colors correspond to varying wavelengths of light.  Violet light has the shortest wavelength and red light has the longest.  Scientists and ophthalmologists think that perhaps the blue wavelength of light emitted by electronic devices may be the culprit in the disruption of normal sleeping patterns [1].  Your eye detects the blue wavelength of light through small cells in your retina called ganglion cells.  A pigment in some of your ganglion cells called melanopsin is particularly sensitive at absorbing this specific blue wavelength of light [1].

The theory is that smartphones and tablets, both of which emit blue light, can confuse our brains and decrease the body’s natural production of melatonin.  Melatonin is a hormone produced by the pineal gland in the brain that helps regulate a person’s circadian rhythm or sleep-wake cycle.  It is normally low in the mornings and elevated in the evenings- which helps us to fall asleep.  A decrease in the body’s production of melatonin can make it difficult to both fall asleep and stay asleep during the night.  This, in turn, can result in decreased cognition, worsened mood, and depression.  Some people are very sensitive to alterations in their sleep cycles.

Despite what we know about the relationship between melatonin and sleep, the relationship between your iPhone and your circadian rhythms is less clear.  There has been debate among scientists, particularly ophthalmologists, about how blue light (or light in general) really affects patients and normal sleep rhythms.

It does seem clear to me that heavy use of electronic devices, in general, is associated with poor sleep.  A large study in 2012 in Norway looked at 9846 adolescents between the ages of 16-19.  The study looked at many variables including bedtime, time in bed, sleep duration, and sleep onset latency.  Nearly all children reported using an electronic device in the hour prior to sleep.  The most common devices were personal computers and cell phones.  The use of any electronic devices at bedtime was associated with increased odds of sleep onset latency, or the period of time from full wakefulness to sleep.  Total screen time above 4 hours per day was associated with an increased risk of sleeping less than 5 hours per night.  The authors concluded that there was a negative relationship between the use of technology and sleep and suggested that recommendations for healthy media use needed updating [2].

Another study in 2015 specifically looked at the blue light issue.  The study authors used blue light filtering glasses in 15-17-year-old adolescent boys.  The glasses proved helpful in blunting the melatonin suppression that occurs when looking at a computer screen.  Wearing blue filtering lenses allowed the boys to feel sleepier and less vigilant prior to bed [3].

After reading these studies, I decided to make a couple of changes to my nightly reading ritual.  In addition to trying to read print books rather than e-books prior to bed, I have begun to use the “Night Shift” feature on my iPhone, which adjusts the display and causes the iPhone to emit less blue light.  This feature was included in the iOS 9.3 software update for the iPhone and iPad.  Similar applications are now available on the Android line of phones.

The jury is certainly still out on blue light and its effects on the retina and your sleep. Although scientists do not yet know definitively whether blue light negatively impacts sleep, reducing the amount of blue light reaching the retina at night may be beneficial.  If you have been having difficulty falling asleep or staying asleep throughout the night, consider making a change to your nighttime routine and avoid using electronic devices close to bedtime.

Note:  Here are instructions on how to set up the Night Shift feature on your iPhone.  Get this app if you have an Android device.  I have no financial interests in either product.

Now, time for a nap.

Hogg, R. E., Woodside, J. V., Mcgrath, A., Young, I. S., Vioque, J. L., Chakravarthy, U., . . . Fletcher, A. E. (2016). Mediterranean Diet Score and Its Association with Age-Related Macular Degeneration. Ophthalmology. doi:10.1016/j.ophtha.2016.09.019

This recently published study reminded me of how diet can influence the progression of macular degeneration (AMD), and it also made me think twice about the soda I was drinking at the time.  Patients often ask me what vitamins or supplements I recommend to help prevent the vision loss that can occur in macular degeneration. This study looked at 5060 randomly selected people, aged 65 or older from 7 different countries in Europe (Norway, Estonia, United Kingdom, France, Italy, Greece, and Spain).

Macular degeneration is a complex eye disease with numerous contributing factors- some of these include age, genetics, environment, smoking, degree of pigmentation, sunlight exposure, and diet. We know that high-dose multivitamin supplements can help prevent the progression of AMD. I recommend the AREDS2 (Age-Related Eye Disease Study) formulation of vitamins to all my patients along with a standard multivitamin. It is well recognized among doctors (and patients) that a diet high in antioxidants can have numerous beneficial effects on one’s health. These benefits are hard to hash out in clinical studies, as dietary patterns are so different from person-to-person and country-to-country. This was a nice study as it enrolled people from many countries and with widely different cultural diets.

Participants in the study took a questionnaire about their habitual consumption of foods including variety and portion size. Each patient was given a score (ranging from 0-9) based on their consumption of key foods. They got points for certain food goals (shown below).  The key foods were part of a Mediterranean diet which is inspired by the eating habits of people from Italy, Spain, and Greece.  This diet is high in olive oil, legumes, fruits, vegetables, wine, and fish.  The diet is low in red meat and heavily processed carbohydrates.   There has been evidence that it lowers the risk of heart disease.

Important note: Remember this list as it gives some good dietary goals for you to follow.

Eat more:

≥ 1 spoon/day of olive oil
≥ 1 glass of wine per day
≥ 1 serving of fruit/day
≥ 1 serving of vegetables or salad/day
≥ 3 servings of fish/week
≥ 2 servings of legumes/week
≥ 5 servings of whole-grain bread/week
+ extra point given if daily serving of both fruits and vegetables

Eat less:

≤ 1 serving of meat/day
≤ 1 serving of rice/day
≤ 1 serving of white bread/day

Each patient then had color retinal photographs taken and sent to a reading center for evaluation. This was a feature of the study that was nice – the person reading the photo had no idea about the dietary patterns of the person in the picture, hence eliminating bias. The photograph was given a grade of 0, 1, 2, 3, or 4. As the number increased, so did the degree of severity of the macular degeneration. Grade 4 were patients with “wet” macular degeneration or geographic atrophy. Both are bad and can cause severe vision loss. Many patients with “wet” macular degeneration require injections of medications like Avastin, Eylea, or Lucentis into the eye to reduce the risks of severe vision loss. “Wet” denotes the presence of scar, blood, or fluid under the retina due to abnormal blood vessel growth. “Geographic atrophy” are patches of thin retina where vision can be very poor. Blood samples were also collected and sent to test for antioxidants like retinol, beta-carotene, lutein, zeaxanthin, and lycopene.

The results of the study showed that increased adherence to a Mediterranean Diet was associated with reduced odds of having “wet” macular degeneration. Scoring a 6 or more (remember the goals above) was associated with about a 50% reduction in odds ratio of developing “wet” macular degeneration compared to those scoring ≤ 4.

I think the results of this study will make my wife and I think twice about our habitual “Friday Burger Night.” I plan to mention this study to my patients looking to adopt dietary changes after being diagnosed with macular degeneration.

All the best,

Chris Stelton MD

Diabetic retinopathy is a serious public health issue.  

Diabetic retinopathy is the leading cause of blindness in people of working age in developed countries.  In 2012, nearly 30 million Americans were diagnosed with diabetes per the American Diabetes Association.

Diabetic retinopathy is the visible manifestation of longstanding diabetes in the retina.  

Changes in the eye caused by diabetes are due to a combination of the longevity of disease duration and degree of blood sugar control.  Diabetes will affect the eyes of nearly all patients with sufficient duration of uncontrolled disease.  If left untreated, diabetic retinopathy can result in eye pain over time and can even result in permanent vision loss or blindness.

As with many eye problems, symptoms may not manifest until late in the disease.  Common symptoms include:

• Decreased vision
• Floaters
• Blind spots
• Distortion
• Eye pain
• Loss of vision
• Poor color vision
• Poor night vision

The number one risk factor for the development of diabetic retinopathy is the duration of diabetes.

In short, the longer you have diabetes, the more likely you are to develop bleeding in the retina.  Other factors include poor blood sugar control, poor blood pressure control, high cholesterol, pregnancy, and barriers to healthcare access.

Diabetes causes damage to the small blood vessels in the eye.  

This leads to poor blood flow in the eye.  A low oxygen state triggers a series of biochemical and cellular events that can cause damage to the eye over time.

Diabetic retinopathy progresses through a series of very predictable stages. 

Diabetic retinopathy begins as a “non-proliferative” disease, meaning that hemorrhages begin to form in the retina and small vascular abnormalities form within the retina.  If left untreated, the diabetic retinopathy becomes increasingly more severe, until it eventually enters a proliferative stage.

This proliferative stage is identified by the development of abnormal, new blood vessels.  These blood vessels can lead to hemorrhaging with the gel in the middle of the eye (vitreous hemorrhage), scar tissue formation on the retina, retinal detachment, or a painful type of glaucoma (neovascular glaucoma).  The abnormal vessels can be treated with a laser procedure called pan-retinal photocoagulation (PRP).  If left untreated, an eye will become blind and painful over time. Ophthalmologists and retina specialists like to identify and treat the disease before it gets to the “proliferative” stage.

Patients can help prevent diabetic retinopathy by getting a yearly dilated eye exam. 

Eye exams help with early detection and prevention.  The American Academy of Ophthalmology recommends an eye exam at the time of diagnosis of diabetes then yearly for Type 2 diabetics.  Intensive blood sugar control both reduces the risk of progression and slows progression in most patients.

Treatment options include close observation, laser, or injections of medications like Avastin, Lucentis, and Eylea into the eye.  Ophthalmologists commonly work with primary care doctors and endocrinologists in patients at high risk for vision loss.

For further reading, check out the American Academy of Ophthalmology’s Preferred Practice Patterns regarding diabetic retinopathy.

It is very important for diabetics to have their eyes checked annually for any signs of diabetic retinopathy.  Call today if you are due for your yearly eye exam – 941-777-5000.