What is Age Related Macular Degeneration (ARMD)?
Age related Macular Degeneration, often called AMD or
ARMD, is a disease that affects the central part of the
retina called the macula. The macula is responsible for
reading, viewing tv, reading street signs, and
identifying the features of an approaching face. Loss of
vision in ARMD is generally quite slow in the ‘dry’ type
of the disease, but can sometimes be sudden in the ‘wet’
type. People affected by the disease are generally fair
skinned and older than the age of 65. ARMD is the
leading cause of vision loss and legal blindness in the
US with approximately 1.75 million individuals affected
in 2010 and is expected to climb to nearly 3 million by
ARMD can be diagnosed by your Eye doctor during
a routine eye exam. In the ‘dry’ form yellow or white
spots begin to appear in the macula. With time these
deposits lead to damage which is demonstrated by
increased pigmentation. Over many years the visual cells
in the retina can begin to die leaving large areas of
atrophy. The ‘wet’ form of the disease occurs when the
eye tries to slow the disease through recruiting new
blood vessels. Unfortunately, these vessels are fragile
and are associated with scar tissue that can lead to
sudden bleeding and permanent scarring.
The process of
ARMD is not fully understood. Interestingly, ARMD is not
primarily a disease of the retina. The degenerative
changes that occur take place in the ‘nurse made’ of the
retina called the RPE (Retinal Pigment Epithelium). The
RPE is the pigmented eye tissue beneath the retina that
creates ‘red eye’ in many of our photographs. In order
to transform light energy into chemical signals that
travel to the brain, the retina must be transparent. It
therefore lacks the pigmented machinery to produce its
own energy and break down waste products such as the
outer segments of the rods and cones. This is the job of
the retinal pigment epithelium. As the breakdown
products of the rods and cones begin to accumulate, the
pigment epithelium slowly loses its ability to care for
the retina leading to loss of vision.
The causes of
ARMD are not fully understood. Studies have shown that
high blood pressure, smoking, UV light exposure, certain
medications, and heredity all play a role. It is
therefore important for high risk groups to eliminate
causative factors that can be controlled such as blood
How common is ARMD?
ARMD is the number one cause of new visual loss and
legal blindness in the US. It is estimated that 1.75
million people are currently affected by AMD and that
number will rise to nearly 3 million by 2020. This
increase is a consequence of an aging population and
increased longevity. It primarily affects fair skinned
What are the Symptoms of ARMD?
ARMD generally leads to a slow but rarely a rapid
decrease in the central vision. This loss affects
activities of daily living such as reading, watching TV,
and driving to mention a few. Dry ARMD patients describe
the vision as blurry often associated with mild
distortion. In addition, blind spots can require eye
movements to see small images. In later stages, these
blind spots can progress to large areas of blanked out
vision that make central viewing impossible. The ‘wet’
form of the disease is associated with a sudden drop in
central vision from the leakage of fluid or blood
blocking the vision. The distortion with the wet form
can be quite sudden and severe as the fluid and blood
cause a blister to form. As the disease progresses, scar
tissue can slowly worsen the distortion.
can affect one eye more than the other it is important
that patients with ARMD check the eye sight in the eyes
separately every day. Many patients miss a profound loss
of vision in one eye because the other eye continues to
see normally. Subtle changes in distortion can be
monitored using a special chart called an Amsler grid.
This grid is viewed up close using the near portion of
What are the treatments for ARMD?
There is no cure for ARMD, but some treatments may slow
the progression or in some cases even improve the
vision. As the diseases progresses it may be necessary
to use visual devices to aid in reading, writing, and
viewing the TV.
Dry ARMD Treatments
Dry ARMD can be slowed by taking antioxidants. This was
proven by a phase one study that concluded in 2001
called AREDS (Age-related eye disease study). This study
demonstrated that antioxidants can slow the progressive
visual loss of ARMD by stopping the free radical damage
caused by UV light and aging. Antioxidants are vitamins
A, C, & E; micronutrients zinc and selenium; along with
lutein and zeaxanthin. Antioxidants are agents found
naturally in dark green leafy vegetables such as swiss
chard, kale, beat greens, spinach, collard greens, and
Omega-3’s are currently being studied as a source of
strong antioxidant activity. Omega 3’s are found in high
concentrations in the flesh of cold saltwater fish such
as Atlantic Mackerel, Shad Fillet, Halibut, and Herring.
These fish are not good sources because their bodies
manufacture omega-3 fats, but because they eat large
quantities saltwater seaweed which is very high in
omega-3’s. An even more concentrated source is found in
Flaxseed/linseed oil, English walnuts, Canola oil, Black
walnuts, and Wheat germ oil. Phase 2 of the AREDS trial
began in 2005 and is looking at the antioxidant effects
of omega-3’s, lutein, and zeaxanthin.
sources of antioxidant activity are blue berries, bill
berries, chocolate, and green tea.
Wet ARMD Treatments
New treatments for wet ARMD have emerged in the last few
years. These treatments are an improvement over
‘thermal’ laser because the destructive effects can be
applied to the harmful new vessels without damaging
healthy retina. These therapies include FDA-approved
Lucentis, Macugen, and Visudyne, along with the off
label use of Avastin. Avastin is very widely used
because of its prolonged duration of action and low
cost. Avastin and other therapies for ARMD are currently
being investigated. Photodynamic Therapy or PDT is a
therapy that uses cool laser to target the abnormal
vessels while leaving the healthy retina untouched. Each
of these therapies has its place and the effectiveness
of their use for a particular patient is directed by a
Low Vision Treatments
In the event that the central vision has been profoundly
affected by ARMD, the low vision specialist has many
devices that can be useful. These devices help in
writing, viewing the TV, and in reading. Low vision
examinations are covered by insurance, but like glasses,
the devices generally are not.
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What is Blepharitis?
The basic definition of blepharitis is any condition
that causes inflammation of the eyelids. This
inflammation leads to chronic redness of the eyelids and
a continual feeling of irritation. Generally it is
divided into anterior and posterior depending upon the
part of the lid that is most affected.
blepharitis is most often associated with Seborrheic
dermatitis. Dry, flaky, red, itchy skin is present over
the areas of the body with sebaceous glands including
the scalp, face, and trunk and is usually treated by a
dermatologist. The treatment includes the use of lotions
and topical steroids.
The second cause of anterior
blepharitis is the Staphylococcal bacteria. As this
chronic infection progresses it leads to foreign body
sensation, mattering of the lashes and burning. Many
general doctors treat this condition with topical
antibiotics that do not usually help.
blepharitis is a disease affecting the meibomian glands
that drain posterior to the eye lashes. The common name
is Meibomian Gland Dysfunction (MGD). MGD is often
associated with acne Rosacea.
How common is Blepharitis?
Blepharitis is one of the most common disorders and is
the most frequent cause of redness, eye discomfort, and
tearing of the eyes. Patients with staphylococcal
blepharitis are affected at an average age of 42 with a
short duration of illness of about 2 years. Seborrhea
and MGD are more chronic in nature and in an older
What are the Symptoms of Blepharitis?
All three forms of blepharitis share symptoms such as
vague eye discomfort, redness, tearing, burning,
itching, light sensitivity, sandy, gritty sensation that
is worse upon awakening.
What is the treatment
The deposits along the lashes and the lid margin along
with the plugging of the meibomian glands are all
benefitted by warm compresses. This home remedy is the
mainstay of treatment. A wash cloth is heated in tap
water, wrung out, and applied to the closed eye lids
directing the heat to the base of the lashes. This
allows for the loosening of the deposits as well as
softening of the meibomian glands. The warmth is applied
for approximately 2-3 minutes followed by a scrubbing
and massaging of the lids to further remove deposits and
open plugged glands.
Oral antibiotics taken in low
dose for months such as Doxycycline can promote a return
to normal meibomian gland function. Azasite, a new
topical Azithromycin can be taken topically 2 times a
day for 4 days and then 1 time a day for another week
with FDA trial data showing long term relief of the
symptoms of blepharitis. Topical artificial tears as
well as short courses of antibiotic/steroid drops or
ointment can decrease symptoms while the chronic
treatment becomes effective.
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What are Childhood Eye Diseases?
Amblyopia is classically known as a “lazy eye” because
often it is seen to wander. Amblyopia is defined as an
eye that is healthy but does not develop sight normally
because the eyes are crossed, develops unbalanced focus,
or the eye is covered by a cataract or droopy lid.
High myopia or hyperopia may be difficult to diagnose
when a child is very young. A potential tip off that the
child has blurry vision is when a child holds objects
very close to view them, or the eyes cross when focusing
on near objects. Amblyopia may develop in one or both
eyes depending on the nature of the focusing problem.
Ptosis (droopy eye lid) can lead to a weak eye caused by
the blocking of the vision. It is rarely associated with
a neurological disease called Congenital Horner’s
Congenital nasolacrimal duct obstruction is
a common cause of tearing. It can be associated with
swelling and redness between the eye and the nose, and
generally resolves itself by 9 months of age. It is
important to see your eye doctor to rule out other
causes of tearing such as congenital glaucoma.
Congenital Glaucoma is a rare blinding condition that
generally involves one eye and can be difficult to
diagnose. Clinical signs include tearing, enlargement of
the eye (buphthalmos), or blue discoloration of the
cornea (the window over the color part of the eye).
Retinoblastoma is a rare tumor of the retina that can
sometimes involve both eyes, and may be fatal. It is
often diagnosed in 1-3 year olds by a family member, or
the Pediatrician by noticing leukocoria. Leukocoria is a
whitening of the red reflex in the pupil seen in photos
or on examination.
Rhabdomyosarcoma is a tumor that
can involve the muscles that move the eyes. It is
generally diagnosed in children less than 10 years of
age by noting swelling of the lid, bulging of the eye,
or paralysis in eye movement.
It is important as a
parent to be observant and have a high level of
suspicion when it comes to your child’s eye health.
Infants are unable to communicate verbally, and young
children will accept even serious vision problems as
‘normal’. Parents are the best ‘doctors’ when it comes
to observing your child. See your pediatrician or eye
doctor if your child’s vision or eye movements seem
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What is Dermatochalasis?
Dermatochalasis is a term to describe the progressive
drooping of the upper eyelid skin. The description of a
‘heavy’ or ‘tired’ feeling of the upper lid begins in
the early 40’s and affects the peripheral vision in the
late 50’s and beyond. Progressive age seems to be the
main risk factor, but excessive sun exposure, smoking,
as well as a family history also increase the risk.
How common is Dermatochalasis?
Drooping of the upper lids is nearly universal in the 70
+ age group.
What are the symptoms of
The earliest complaints regarding excess eyelid skin
include a ‘tired’ or ‘heavy’ feeling of the eyes. With
time the complaints include an impairment of side vision
affecting driving etc., as well as a decrease in the
ability to read. As the droopiness progresses, it can
ultimately cause an obstruction of the central vision as
the skin droops over the pupil.
What is the
treatment for Dermatochalasis?
Eyelid surgery called a blepharoplasty is the only
treatment. A blepharoplasty is an outpatient surgery
that lasts between 1-2 hours. The excess skin is
excised, prolapsed fat is removed and smoothed, and the
incision is closed with sutures. The eyelids are
bandaged for the first 24 hours, sutures removed at 1
week, and the bruising is gone at around 2 weeks. The
final healing occurs over the following 2-3 months.
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What is Dry Eye Syndrome?
Dry eye syndrome is caused by poor quality or inadequate
volume of tears. It is very common as we age and is
related to certain disease states and medications. It is
estimated that nearly 70% of the office visits to an Eye
doctor are in some way related to dry eyes. It generally
worsens over time and can make contact lenses difficult
or impossible to wear, and affect the stability and
quality of vision.
The normal tear film is composed of
three layers. The thin inner layer that coats the eye is
the mucin layer produced by glands at the junction of
the white and color part of the eye. It is this layer
that can harden in the inner corner of the eye while
sleeping called ‘sleepy dirt’. This layer can be
disrupted in severe vitamin A deficiency states and
after a chemical burn.
The thickest layer is the aqueous layer which serves
to lubricate, wash, smooth, and protect the eye with
antibodies. It is produced by about 70 glands in the
white part of the eye (conjunctiva) that are distributed
under the upper and lower eyelids. This layer decreases
in quantity and quality with age, and is affected by
medications such antihistamines, beta-blockers,
antidepressants, diuretrics, and birth control pills.
Systemic diseases such as Rhuematoid arthritis, Sjogrens,
and Lupus can cause inflammation of the surface of the
eyes and severe dry eyes. Menopause can also cause a
dramatic increase in dry eye symptoms. In addition,
Lasik and post Blepharoplasty patients can experience
worsening of dry eye symptoms. When the volume of the
aqueous layer of tears begins to decrease the lacrimal
gland produces large amount of tears as if one is
crying. This is why many people misunderstand that a
common symptom of dry eyes is tearing.
The outer layer
of the tear film is the fatty layer that is produced at
the margin of the upper and lower lids at the lash line
from special glands called meibomian glands. This fatty
layer causes a decrease in surface tension of the tears
so that the tear film is smooth. It also keeps the tear
layer form breaking up between blinks or in dry windy
conditions. The Meibomian glands begin to plug up in a
condition called blepharitis that is caused by increased
bacteria on the eyelids. The bacteria that are most
responsible are Staph epidermidis, Staph aureus, and
How common is Dry Eye?
20.7 million Americans are currently diagnosed with dry
eyes and this number is rising. It is estimated that
nearly 40% of all Americans are affected by dry eye
symptoms at one time or another. In fact, more than 70%
of all visits to the eye doctor are related to dry eyes.
The prevalence increases with age and the group most
commonly affected is post menopausal women. Of those
diagnosed with dry eyes, nearly 67% experience
progression over time.
What are the symptoms of
Dry eye symptoms are generally foreign body sensation,
fluctuating vision, burning, itching, crusting, and
tearing. These symptoms are mediated by the inflammation
cascade generally causing associated redness of the
conjunctiva. Patients generally report inability to read
for extended periods of time and worsening dry eyes at
What is the treatment for dry
The goal of dry eye therapy is to increase the quantity
and quality of the tear film. In the past this has been
accomplished exclusively with the use of artificial
tears. Artificial tears are an effective therapy for
many dry eye patients, but the more serious cases find
little relief with this alone. Recently, researchers
have shown that the symptoms of dry eyes are mediated by
inflammation. Topical steroids therefore can and do
relieve dry eye symptoms. Unfortunately, the side
effects such as glaucoma and cataracts prevent their
Restasis is a cyclosporine derivative that not only
treats the symptoms of dry eyes but increase tear
production over time. It is instilled in the eye twice a
day for months to years with excellent results.
Punctal plugs decrease symptoms by blocking the outflow
of tears to the nose through the nasolacrimal system.
Punctal plugs are painlessly inserted at the slit lamp
in the office in a matter of minutes and most can be
removed if necessary.
Many other methods of dry eye
treatment may also help. Your Eye doctor can discuss
with your primary doctor if you can stop medications
that worsen dry eyes. A humidifier can help dry eye
symptoms, especially at night. Sunglasses are available
that seal around the eyes preventing dryness from the
wind. Systemic autoimmune diseases such as Rhuematoid
arthritis, Lupus, and Sjogrens can be treated
systemically decreasing the associated dry eyes.
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What is an Ectropion?
Ectropion is an outwardly turned or sagging lower
eyelid. The droopiness of the lower eyelid leads to
exposure of the surface of the eye and inside of the lid
to the air. Ectropion can be serious if the exposure of
the eye, and the failure of the lids to close properly
leads to dryness, abrasion, and ultimately ulceration of
Ectropion is most common with aging. Other
conditions such as Bell’s palsy, trauma, tightening of
the skin associated with sun or radiation exposure, or
following lower eyelid blepharoplasty account for some
of the cases.
What are the symptoms of Ectropion?
Symptoms of ectropion include irritation, burning, a
gritty sandy feeling, excessive tearing, visible outward
turning of the eyelid, and redness and thickening of the
eyelid and conjunctiva.
What is the treatment
The irritation from an ectropion can be temporarily
relieved with artificial tears and ointments to
lubricate the eye. In more advanced cases, surgery is
the only option and the exact technique depends upon the
Ectropian related to aging is
treated by tightening the lower lid at the outer corner
in a surgery called a Tarsal Strip. This procedure
involves detaching the lower eyelid, shortening the lid
to remove the laxity, creating a new tarsal tendon or
‘strip’, and reattaching the lid to the deep eyelid
Sometimes, the skin below the lid is
tightened following trauma, eyelid surgery for tumors,
or radiation exposure. Surgery generally involves
relaxing the tightened skin by making an incision and
releasing the tension. The space that is created is
filled with a skin graft usually taken from the back of
Surgery for ectropion is outpatient, and
healing is generally over 1-2 months. During this time
antibiotic ointments may be used to help prevent
infection, and cover the lower lid with a protective
layer during healing.
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What is Entropion?
Entropion is a condition in which the lower eyelid is
loose and rotates inward against the eye. It is more
common with increasing age, after trauma, following eye
surgery, and as a consequence of a severe eye infection
or burn. Generally, the symptoms are related to the
irritation of the eye lashes rubbing against the surface
of the eye. Entropion can be intermittently caused by
tightly squeezing the eyelid in a condition called
How common is Entropion?
Entropion is most commonly found in the elderly. The
exact frequency has not been reported.
the symptoms of Entropion?
Entropian can cause many symptoms related to the
irritation caused by the lashes rubbing against the
surface of the eye. Redness, irritation, sensitivity to
light, excessive tearing, and mucous discharge and
crusting are common with entropian. In more serious
cases the constant irritation from the lashes can lead
to a corneal abrasion or ulceration.
What is the
treatment for Entropion?
Prior to surgery, the eye can be protected by taping the
lower lid away from the surface of the eye and applying
Surgical techniques vary, but the basic approach is
to tighten the lower lid to prevent it from rotating
against the surface of the eye. In cases where the
eyelid surgery must be delayed, an in office surgery
called a Quickert procedure can provide temporary
relief. In this technique, under local anesthesia, two
or three well placed sutures can evert the lid away from
the eye surface.
Surgery for entropion is an
outpatient surgery using light sedation. The eye is
patched overnight and eye ointments are generally used
for one to two weeks.
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What is an Epiretinal Membrane?
An epiretinal membrane develops on the surface of the
retina in the macular area. It is formed by a collection
of cells that produce scar tissue. As the scar tissue
progresses, it leads to distortion and swelling in the
macula. If left untreated, an epiretinal membrane can
lead to irreparable disruption of the macular
architecture and a permanent loss of vision.
macular holes, nearly 80%, are idiopathic; meaning that
the cause is unknown. Retinal holes or tears, bleeding
in the eye, inflammation in the eye, retinal detachment,
or eye trauma are all associated with epiretinal
How common is an Epiretinal
Epiretinal membranes occur in about 7% of the general
population. The incidence of ERM increase from about 2%
at age 50 to about 20% at 75 years of age .
are the symptoms of an Epiretinal Membrane?
Usually the loss of vision is very slowly progressive
over years. The decrease of vision affects the ability
to read and is associated with metamorphopsia, or
distortion, that causes bowing of straight lines and
micropsia (images appear smaller in the affected eye).
What is the treatment for an Epiretinal Membrane?
An epiretinal membrane can be treated in a retinal
surgery called a vitrectomy. After removing the vitreous
of the eye, the retinal specialist uses extremely
delicate instruments to remove or ‘peal’ the scar tissue
off the surface of the retina.
Generally, the vision of the eye is improved
considerably after successful surgery. Most patients
will develop progressive cataract formation after
surgery. Cataract surgery can be performed safely to
improve the vision after surgery for an epiretinal
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What is a Tumor of the
A tumor is either benign or malignant. Benign tumors
often remain localized and grow slowly while malignant
tumors invade surrounding structures, grow more rapidly,
and can invade the vascular system and spread to
distance locations in a process called metastases.
Tumors of the eye can involve the lids, muscles,
retina/choroid, and orbit.
Basal cell carcinomas are
the most common eye tumor accounting for 85-90% of all
malignant tumors of the eyelid. Basal cell carcinomas
are most often located on the inner lower lid in the
lash area, grow slowly, invade the eyelid with pearly
borders and necrotic centers (scaly skin with ulceration
and scab), and rarely spread through metastases.
Squamous cell carcinoma is the second most common cancer
of the eyelids accounting for approximately 5% of all
cases. The most common location is the lower eyelid.
This cancer is located at the lash line, will grow and
develop ulceration and occasional bleeding, and can
metastasize to the lymph nodes of the head and neck.
Sebaceous cell carcinoma accounts for about 1-5% of all
malignant eyelid tumors. This highly malignant tumor
involves the upper or lower lids and creates subtle
crusting, redness, loss of lashes, and pigment change
making it difficult to diagnose. Because sebaceous cell
carcinoma is often missed it causes many of the deaths
from eyelid tumors through spread into the tissues
around and to the lymph nodes.
comprises 1% of all eyelid tumors. It can be pigmented
or lack pigment and should be watched if it is growing
or changing color. Malignant melanoma shows less damage
to the eyelid than other malignant tumors but has a high
rate of distant metastases if allowed to invade deeply
into the skin. The diagnoses must be made early and the
treatment prompt and aggressive.
can also affect the back of the eye at a layer called
the choroid. This layer supplies the outer part of the
retina with blood. Generally this condition is diagnosed
by your eye doctor because the signs and symptoms are
few. Initially the lesion can look like a pigmented
freckle but it can begin to grow, increase in pigment,
and cause a localized retinal detachment leading the
diagnoses of choroidal melanoma.
involve the orbit (bony socket around the eye), the eye
muscles, optic nerve, and nerves and blood vessels.
Signs and symptoms of an orbital tumor include bulging
of the eye, loss of vision, double vision and pain. The
most common orbital tumors include optic nerve glioma,
meningioma, hemangioma, lymphangioma, neurofibroma, and
metastases from another part of the body.
common are Eyelid and orbital tumors?
Eyelid tumors affect approximately 20 per 100,000 males
and 13 per 100,000 females in the United States each
What is the treatment for Eyelid and
Most tumors of the eyelid and orbit, if diagnosed early,
are removed surgically. If the symptoms have been
ignored, or the diagnoses missed surgery is often more
involved and can sometimes include removal of the eye.
Additional treatments include radiation and
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Flashes and Floaters
What are flashes and floaters?
The human eye is divided into two main chambers. The
anterior chamber is the space between the cornea (the
clear window on the front of the eye), and the Iris (the
color part of the eye). This is the part of the eye
which regulates the eye pressure. Behind the lens is the
larger chamber called the vitreous cavity that spans
from the lens of the eye to the retina, and is filled
with the vitreous. The vitreous is a gelatinous
substance that begins to become liquefied generally
beginning in our 30’s to 40’s. With time, the liquid
vitreous can flow out of the eye through the channels
that regulate the eye pressure. Since the gelatinous
vitreous no longer fills the entire vitreous cavity, the
vitreous collapses and pulls away from the retina. This
collapse often causes many floaters including a ‘C’ or
oval shaped floater called a Weiss Ring in process
called a Posterior Vitreous detachment (PVD).
instances, more commonly in near sighted people, the
vitreous is abnormally attached to the retina in a
disease called lattice degeneration. As the vitreous
pulls with force on the retina it causes spontaneous
arcing flashes in the peripheral vision of the eye, seen
generally in the dark with eye movements.
detachment can occur if the vitreous creates a hole or
tear in the retina during traumatic separation. This is
generally associated with thousands of tiny dot floaters
made of red blood cells and or pigment. If the liquefied
vitreous is able to enter the hole or tear in the retina
it can cause a retinal detachment. This generally looks
like a dome shaped shade in the side vision with the
convex side oriented toward the center of vision. The
dome shape spreads toward the center of the vision most
commonly from below until the central vision is
How common are flashes and floaters?
Most people experience floaters beginning in their 30’s
to 40’s. These mild floaters rarely cause significant
visual symptoms. However, the process of a posterior
vitreous detachment (PVD) generally occurs approximately
50% of the time in 50’s and nearly 100% by the time a
person reaches 80.
What are the treatments for
Flashes and Floaters?
Flashes and floaters generally spontaneously disappear.
This can often take weeks to months. Flashes that are
new or are becoming more frequent should be evaluated by
your eye doctor. If the flashes are associated with many
dot floaters you should contact your doctor immediately.
A retinal hole or tear is present when associated with
flashes and many dot floaters approximately 70% of the
There is no medical treatment for floaters. In
rare cases, a retinal specialist can remove very large
persistent symptomatic floaters by performing a
A retinal hole or tear is treated with
laser to scar down the retina and prevent a retinal
detachment. Retinal detachments can sometimes be treated
in the office, but are generally treated in the
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What is Fuch’s dystrophy?
Fuch’s dystrophy is a disease of the inner layer of the
cornea of the eye. The cornea is on the front of the eye
overlying the iris (color part of the eye). The inner
layer of the cornea is called the endothelium and is
responsible for maintaining the fluid balance in the
cornea. In other words, the endothelial cells are
‘pumping’ cells that pump the fluid back into the eye to
maintain the clarity of the cornea.
Endothelial cells normally decline in number each
year of life. In Fuch’s dystrophy this loss of
endothelial cells is accelerated to the point that the
cornea can no longer pump the fluid out of the cornea.
As the cornea begins to swell, clarity is lost, and the
Fuch’s dystrophy is inherited as an autosomal
dominantly inherited trait. It is found more commonly in
females than males, and the visual effects generally
become noticeable by age 60 and older.
common is Fuch’s dystrophy?
Fuch’s dystrophy is found in approximately 1 to 4% of
the world population.
What are the symptoms of
As the loss of endothelial cells progresses the cornea
will become cloudy. At first, the vision will be blurry
only upon awakening and gradually clear during the day.
This is because the cornea is able to clear when the
eyes are open through a process called evaporation. As
the disease worsens the cornea progressively swells and
the vision can remain blurry throughout the day.
Ultimately the cornea continually swells until the
surface of the eye develops cysts or blisters that cause
a foreign body sensation and pain. Vision continues to
blur until activities such as reading, driving, and
watching TV are severely impaired.
What is the
treatment for Fuch’s dystrophy?
The symptoms of morning blurring and mild foreign
sensation are initially treated with hypertonic eye
drops such as Muro 128. The ‘saltiness’ of the drops
creates an osmotic force that draws the fluid out of the
eye much like the process of evaporation.
management is necessary when the vision is poor and
medical treatments no longer are effective. Penetrating
Keratoplasty (PKP) is an outpatient surgery in which the
cornea is removed and a donor cornea is sutured into
place. The eye heals slowly over about a year as eye
drops are instilled and the eye doctor slowly removes
PKP replaces the cornea with healthy tissue
that allows the cornea to clear. The potential risks of
surgery are infection, high astigmatism, need for
chronic eye drops, and potential rejection of the donor
A new outpatient procedure called a Descemet
Stripping Endothelial Keratoplasty (DSEK) has been
performed for the last 4-5 years. This procedure
involves removing the endothelial cells and descemet’s
membrane from the eye, and replacing the diseased cells
with healthy cells from a donor cornea. The advantages
include a recovery time of 2-3 months, minimal suturing,
maintenance of the integrity of the cornea, and less
The apparent advantages of DSEK over PKP has lead to
ongoing long term studies to compare the overall success
of each surgery.
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Giant Cell Arteritis
What is Giant Cell Arteritis?
Giant cell arteritis can cause blindness in both eyes
and is therefore a medical emergency. Giant Cell
arteritis is named by the characteristic ‘giant cell’
seen on biopsy of the involved blood vessel. It is a
condition that causes inflammation of the arteries and
can affect any artery including the main artery to the
eye called the ophthalmic artery. GCA has multiple names
that are used interchangeably including “temporal
arteritis”, “cranial arteritis”, and “Horton’s disease”.
GCA is associated with a systemic condition called
polmyalgia rhuematica (PMR) in ¼th of all cases. PMR is
characterized by muscles pains and stiffness upon
awakening. Other conditions that occur more commonly are
lupus erythematosus, rheumatoid arthritis, and severe
The diagnosis is made by the history, a
blood test called a sedimentation rate, 3D MRI, and
biopsy of the involved artery.
How common is Giant Cell Arteritis?
The exact incidence of GCA is not known, but it is more
common in females than males in a 3:1 ratio. The mean
age is around 70 years, and it is rare under the age of
What are the Symptoms of GCA?
Symptoms are varied depending upon the arteries that are
involved. Symptoms include: fever, headache, tenderness
and sensitivity of the scalp, jaw claudication (pain in
jaw when chewing), reduced vision, sudden visual loss
(blindness), double vision, tinnitus (ringing in the
ears), and photophobia (light sensitivity).
is the treatment for Giant Cell Arteritis?
The most important aspect of treatment is to make the
diagnoses early and treat aggressively. Oral prednisone
in high dose is used to treat this condition. In cases
of acute vision loss, IV steroids may be beneficial.
Treatment generally involves high dose prednisone for
2-4 weeks, followed by a slow taper over 9-12 months.
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What is Iritis?
Iritis is a form of anterior uveitis that refers to the
inflammation of the iris of the eye. The iris is the
part of the eye that gives it its color. Iritis can be
divided into acute and chronic. Acute is often self
limited and responds rapidly to treatment. Chronic
iritis can last for months to years and may be very
difficult to control. Chronic iritis can lead to serious
The following list includes some of the
causes of iritis listed by category.
or Autoimmune disorders:
- Ankylosing Spondylitis
- Rheumatoid Arthritis
- Behcet’s disease
- Crohn’s disease
- Chronic Psorias
- Psoriatic arthritis
- Ulcerative Colitis
- Lyme Disease
- Herpes Simplex
- Herpes Zoster Virus
- Malignant Melanoma
How common is Iritis?
Iritis can occur at any age. In acute irits
there is generally no association with any
diseases like those listed above. Chronic
cases more commonly are related to a
What are the
symptoms of Iritis?
The signs and symptoms of iritis are related
to the inflammation of the internal
structures of the eye, and the irritation of
the internal eye muscles. Ocular and
periocular pain, photophobia (severe light
sensitivity), blurred or cloudy vision,
redness of the eye especially near the iris,
white blood cells and protein floating in
the anterior chamber termed cell and flare,
synechiae (sticking of the iris to the lens
or cornea, and glaucoma can occur with
varying frequencies in iritis.
is the treatment of Iritis?
The inflammation that causes the signs and
symptoms of iritis is generally treated with
topical steroids and dilating drops. The
topical steroids decrease the inflammation,
while the dilating drops control the pain
and decrease the likelihood of synechiae
(sticking of the iris to the cornea or lens)
and glaucoma. Care must be taken with the
use of topical steroids because of the
possibility of worsening certain eye
infections as well as causing cataracts and
Chronic or recurrent cases of iritis, in
which a systemic disease is found, are
treated with oral medications along with
topical. When the systemic disease is
treated and controlled the iritis will
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What is a Macular Hole?
The area of the retina that is responsible
for central vision is called the macula. The
most acute part of the central vision comes
from a thin area within the macula called
the fovea. Here, the concentration of cones
(color vision pixels) is the highest in the
retina and allows for our high definition
view of the world.
As described in the
section on flashes and floaters and retinal
detachment, the vitreous gel of the eye
begins to liquefy and contract over a
lifetime. The vitreous is attached to the
retina at the blood vessels, optic nerve,
and at the fovea. Because the area of the
fovea is so thin, it is vulnerable to the
development of a tear or a hole. This
microscopic hole often allows the liquid
vitreous to detach the retina in the macula
creating a macular hole.
generally occur as a process of vitreous
degeneration and separation associated with
aging. Other causes of macular hole include
diabetic eye disease, high near sightedness,
epiretinal membrane, and eye trauma.
How common is a Macular Hole?
Macular holes are more common in people over
60 and affect females more frequently than
males in a ratio of 3.3:1. Overall, the
incidence of macular holes in an age- and
sex- adjusted incidence is 7.8 and 8.7 eyes
per 100,000 per year. Nearly 12% of patients
with macular holes can develop this
condition in the second eye.
are the symptoms of a Macular Hole?
Macular holes cause a decrease and
distortion of the central vision of the eye.
The loss of vision is from a defect in the
retina, and is not the same as macular
degeneration which is primarily a disease of
the retinal pigment epithelium. A macular
hole usually develops suddenly without
warning. In some cases it can be preceded by
mild blurring and missing letters in words
while reading if the condition stops at
thinning or a partial-thickness hole. Most
frequently, progression occurs in 70% of
cases and is associated with vision of the
‘big E’ only on the eye chart.
is the treatment for a Macular Hole?
The doctors who pioneered the surgical
treatment for macular hole still practice in
the Sacramento area and now have an office
in Grass Valley. This technique involves
removing the vitreous of the eye in a
surgery called a vitrectomy. Any fine
strands of vitreous that may be left on the
surface of the macula are also removed. The
hole is closed by injecting a gas bubble
that lasts for two weeks. The patient must
keep a head down position for up to 2 weeks
to keep the bubble against the macular hole
in order to seal it. The gas bubble will
expand at higher elevations causing a
dangerous rise in eye pressure, therefore
flying and even traveling to the mountains
is restricted while the bubble is in the
eye. The success of the surgery is high.
The procedure is safe, but will cause a
cataract in all eyes usually within 1 year
after surgery. When this occurs, cataract
surgery can safely be performed and most
often will improve the vision.
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What is Myasthenia
Myasthenia gravis (MG) is a neuromuscular
disorder that causes muscle weakness and
fatiguability. The word is Latin: Myasthenia
(muscle weakness) and gravis (serious). The
weakness is caused by circulating antibodies
to the acetylcholine receptors at the post
synaptic neuromuscular junction.
electrical signal travels along the nerve
toward the neuromuscular junction at the
muscle. In order for the electrical signal
to get to the muscle, the electrical signal
must cross the neuromuscular junction on a
neurotransmitter called acetylcholine.
Acetylcholine crosses the neuromuscular
junction and docks at the muscle on a
special receptor called the acetylcholine
receptor leading to stimulation of the
MG is an autoimmune disease that
creates antibodies to the acetylcholine
receptor. These antibodies block the ability
of acetylcholine to work, and cause the
muscle to weaken with continued use.
How common is Myasthenia gravis?
Approximately 200-400 cases per million
occur each year making MG one of the rarer
autoimmune diseases. Most of these cases are
diagnosed because of eye involvement.
What are the symptoms of Myasthenia
The hallmark of myasthenia gravis is
fatiguability. Muscles become progressively
weaker during periods of activity. Symptoms
include drooping of one or both eyelids,
intermittent double vision, weakness of the
face, and difficulty chewing talking and
swallowing. The most serious symptom is loss
of control of the muscles that control
What is the treatment of
Myasthenia gravis is normally diagnosed by
the classic clinical history of weakness
that develops with use of the affected
muscle group. A blood test for acetylcholine
receptor antibodies is used to confirm the
diagnoses, but the results can sometimes be
unequivocal. A chest x-ray, CT, or MRI are
sometimes performed looking for an alternate
diagnoses or for an enlargement of the
thymus gland called a thymoma.
includes the use of immunosuppressant drugs
such as prednisone to decrease the
antibodies. Acetylcholinesterase inhibitors
such as Tensilon decrease the breakdown of
acetylcholine, and increase the nerve
transmission and improve muscle function.
Plasmapharesis and intravenous
immunoglobulins are used in cases of
respiratory failure. Surgical removal of a
thymus gland has shown varied outcomes from
improvement to severe exacerbations. Because
of the neoplastic effects, a thymoma is
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What is optic
Optic neuropathy describes damage to the
optic nerve, the conduit that carries
signals from the eye to the brain, from
disruption of blood flow (ischemia), trauma,
or toxic exposures. Ischemic optic
neuropathy is generally divided into cases
associated with temporal arteritis (TA), and
those that are not (nonarteritic ischemic
optic neuropathy--NAION). Ischemic optic
neuropathy associated with TA is generally
in the under 55 age group, where as cases
not associated are over 55 years of age, and
generally over age 65.
The causes for
NAION include those disease that cause
atherosclerosis. Risk factors include high
blood pressure, diabetes, elevated lipids
and triglycerides, stress, obesity, and a
Optic neuropathy is
considered a medical emergency. If TA is the
cause, the other eye can be involved within
hours, and if affected, can result in total
How common is optic
NAION is found in approximately 2.52-11.8
cases per 100,000 men aged >= 50 years of
What are the symptoms of optic
NAION is associated with painless loss of
vision in one eye. The symptoms of those
case associated with temporal arteritis (TA)
are quite different and reviewed in the
section titled Temporal arteritis).
The vision loss in NAION is generally
slowly progressive and associated with
central vision blurring, and loss of the
peripheral field usually in the lower half.
The loss of vision is typically permanent.
What is the treatment for optic
There is no effective treatment for NAION.
In some cases, IV steroids will be tried in
an attempt to decrease the associated
swelling, and limit the vision loss.
Attention is usually directed at limiting
the systemic risk factors. This includes
lowering the blood pressure, controlling the
blood sugar, decreasing the lipids and
triglycerides, eliminating stress, weight
loss, and improving cardiopulmonary health
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What is Pink Eye?
Pink eye is a term used by the public to
describe a viral infection of the eye. This
term is really not very descriptive as most
any condition of the eye is generally
associated with ‘pink’ or red eyes. A few
examples of causes of a red eye include
bacterial conjunctivitis, viral
conjunctivitis, allergic conjunctivitis,
iritis, subconjunctival hemorrhage, dry eye,
blepharitis, elevated intraocular pressure,
and episcleritis to name a few.
common is Pink Eye?
Pink eye associated with a viral infection
generally occurs in mini epidemics. Out
breaks are found in schools and with day
care providers. Most begin as an upper
respiratory condition that spreads rapidly
by direct and indirect contact. All other
forms of red eye are random and occur more
predicatably in the population based on age,
sex, race etc.
What are the symptoms
of Pink Eye?
The classic history for a patient with viral
conjunctivitis includes a recent upper
respiratory infection in the patient,
relative, coworker, or acquaintance. The
virus is spread to the eyes causing redness,
tearing, enlarged lymph nodes, and often a
progression from one eye to both in a matter
of 3-5 days.
What is the treatment
of Pink Eye?
Viral infections of the eye are self limited
meaning that the body will fight the
infection and it will resolve on its own. It
is important for the infected person to try
and prevent spread to the second eye or to
friends, family, or coworkers. This can be
accomplished by limited contact, copious
hand washing, and avoiding touching the eye.
Many times viral infections are treated
with an antibiotic/steroid to protect from a
secondary infection and to decrease the
inflammation and swelling. Steroids must be
used with caution in any infection because
dependence can develop, and some rare viral
infections such as Herpes Simplex can be
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What is a retinal
A retinal detachment is a potentially sight
threatening condition of the eye caused by
the separation of the retina from the back
of the eye. This can happen spontaneously,
especially in highly near sighted people or
those with a strong family history of
retinal detachment. Other causes include
intraocular tumors, systemic diseases such
as diabetes, and after trauma to the eye.
Spontaneous retinal detachments can occur
suddenly with minimal warning. Generally,
however, a retinal detachment is preceded by
symptoms. See the section of flashes and
floaters. Flashes and floaters occur when
the vitreous begins to collapse and
separates from the back of the eye. This
separation is called a posterior vitreous
detachment or PVD. A PVD occurs
approximately 50% of the time around age 50
up to nearly 100% of the time by the age of
80. When the vitreous collapses, it pulls
away from the retina and can in rare
instances cause a retinal hole or tear. This
damage can lead to a retinal detachment.
retinal detachment can lead to permanent
blurring or distortion of the vision. The
retina has two sources of nourishment. The
outer layers, which include the rods and
cones, are supplied by the choriocapillaris,
while the central retinal artery supplies
the inner layers through arteroles within
the retina itself. It is therefore important
to repair a retinal detachment as quickly as
How common is a Retinal
The risk of retinal detachment in otherwise
healthy eyes is around 5 in 100,000 per
year. In the middle age and elderly, this
rate increase to around 20 in 100,000 per
year. The lifetime risk in a normal eye is
around 1 in 300. After having a retinal
detachment, there is a 15% chance of
developing a retinal detachment in the other
Retinal detachments are more common
in certain individuals Highly near sighted
people (>5-6 diopters) account for 67% of
all retinal detachments. The lifetime rate
of retinal detachment increases to about 1
in 20 in this population. This rate
increases to about 1 in 15 after cataract
The estimated risk of retinal
detachment after cataract surgery is about 5
to 16 per 1000 cataract surgeries. Younger
people seem to have an increased risk as
compared to the older population. The
lifetime risk of retinal detachment
following uncomplicated phacoemulsification
cataract surgery appears to be 0.36% at 2
years, 0.77% at 5 years, and 1.29% at 10
years following cataract surgery.
What are the symptoms of retinal detachment?
Generally, a retinal detachment is preceded
by flashes and floaters. The flashes are
generally best seen in the dark and are more
frequent with head movement. Most often the
flashes are described as a transient arcing
flicker of light in the side vision.
Floaters associated with a retinal
detachment are often 1000’s of small dots as
opposed to the lines or cobwebs that many
people see normally.
The most common sign
of a retinal detachment is a dome shaped
shade in the side vision. The convex side is
oriented toward the center of vision and
moves from the lower nasal part of the eye
up into the vision 67% of the time. It can
begin from any quadrant of the eye. This is
a medical emergency. Call your eye doctor or
go the emergency room immediately.
What is the treatment for Retinal
Retinal detachments are most often treated
surgically. The process is to move the
retina into place, and seal the hole or tear
with laser. This can sometimes be
accomplished in the office, but most often
requires surgery in the operating room.
The treatment in the office is called a
laser retinopexy. This surgery involves
injecting a slowly absorbing gas into the
eye to move the retina into place a sealing
the hole or tear with laser or freezing.
A sclera buckling surgery is performed in
the operating room. A band is placed around
the eye and the retina is repositioned using
a gas bubble. This is followed by laser or
freezing to seal the hole. Generally, a
sclera buckle leads to increased
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Refractive errors and Presbyopia
What is Myopia?
Myopia (near sightedness) is a 1st order
refractive condition of the eye in which the
incoming light is focused short of the
retina. Reading vision is good in myopia but
the distance vision must be focused with
glasses, contact lenses, refractive surgery,
or cataract surgery.
Hyperopia (farsightedness) is a 1st order
refractive condition of the eye in which the
light rays are focused beyond the retina.
Most babies are born far sighted. Far
sightedness increases until the age of 9 and
then begins to decrease through the teen
years. Far sightedness can be brought into
focus without glasses or contact lenses as
the lens of the eye increases its shape in
the same action that allows the eye to
adjust its focus from far to near.
What is Astigmatism?
Astigmatism is a 2nd order refractive
condition of the eye which creates two focal
points. In astigmatism, the eye is shaped
like a football instead of a basketball.
Special glasses, contact lenses, cataract
surgery, or Lasik can correct astigmatism.
What is Presbyopia?
Presbyopia is a condition that generally
begins in the mid forties and slowly worsens
until the early sixties. Most people
describe this condition in terms of their
arms becoming shorter. The lens of the eye
stiffens and is no longer able to increase
its shape to focus on objects up close.
Multifocal lenses such as bifocals,
trifocals, progressives, monovision and
bifocal contacts lenses, and cataract
surgery can correct presbyopia.
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of the Eye
What is shingles
of the eye?
Shingles is caused by the varicella-zoster
virus that also chicken pox virus.
Chickenpox usually develops in the young,
causing a fever and a characteristic rash
which normally resolves in a few weeks.
Unfortunately, the virus remains dormant in
the nerve tissue of the body throughout
Shingles often occurs later in life
when the immune system becomes weakened
allowing the virus to reactivate. The
eruptions are characteristically limited to
one side of the face or body, can range from
mild to severe necrosis of the skin, and are
often associated with pain that can be
severe and permanent in a condition called
postherpetic neuralgia. Postherpetic
neuralgia is the most common complication
occurring in approximately 7.9% of cases.
If the area of skin eruption involves the
forehead and or the upper cheek, the eye can
be affected. Involvement of the eye can
manifest in any of the eye tissues including
the lids, cornea, anterior chamber, iris,
lens vitreous, retina, and even the optic
How common is shingles of the eye?
Shingles affects 1 in 544 or 500,000 people
in the US each year. It is more common over
the age of 60, and the lifetime risk is 2 in
10. Data shows that 1.6% of cases of
shingles can affect the eye.
are the symptoms of shingles in the eye?
When the skin eruption involves the forehead
and upper cheek, the eye can be affected.
Symptoms include a scratchy or foreign body
sensation, light sensitivity, achiness or
pain, and rarely loss of vision. It is
usually best to see your eye doctor if the
skin eruption involves the upper face.
What are the treatments for shingles of
Antiviral medications such as Acyclovir (Zovirax),
Valacyclovir (Valtrex), and Famciclovir (Famvir)
have been shown to decrease the duration and
severity of shingles including shingles of
the eye, and to significantly reduce the
number of cases of post herpetic neuralgia.
These antiviral medications are used for one
week in shingles, or until the involvement
of the eye is gone. Rarely these antiviral
are necessary long term to prevent
Topical steroids are used to
decrease iritis (inflammation of the inside
of the eye). Treatment can last from weeks
to months, and rarely for life.
difficult to control. Medications such as
narcotics, antidepressants, anticonvulsants,
and topical numbing agents (Capsaicin) have
all been tried with varying success.
In 2006, the FDA approved a vaccine for
shingles in adults age 60 or older. The
vaccine has proven to be 60% effective in
reducing the symptoms of shingles and the
incidence of postherpetic neuralgia.
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Stye (Hordeolum and
What is a
Each lash follicle of the eyelid has
associated oily glands called the sebaceous
glands of Zeiss and the apocrine glands of
Moll. Similar oil glands are found
associated with every hair follicle on the
body. These glands serve to nourish and
protect the hair follicle and hair shaft.
The oil that is secreted is the cause of the
oily feeling of our hair when we have not
showered for a few days.
The oily liquid
that is secreted by theses glands is
normally thin and runny. Sometimes, however,
the secreted material can become thick
forming a ‘plug’ in the gland that results
in swelling. This is thought to be caused by
bacteria, hormonal increase or decreases, or
contamination of the eyelids.
is a Chalazia?
The eye lid produces a fatty substance
called meibom that smooths the tears by
decreasing the surface tension and helps
prevent evaporation between blinks, when
staring, or in windy conditions. These
glands drain from the lids onto the surface
of the eye through tiny openings behind the
lashes. It is thought that the same
mechanisms cause the meibomien glands to
plug leading to similar symptoms as a
How common are Styes (Hordeolum
Eye Styes are fairly common. They occur
frequently during puberty and again near
menopause. Certain people seemed to be more
proned to having styes than others. This
undoubtedly has something to do with the
genetic factors such as general skin type
along with environmental factors such as
contamination of the lids, frequent touching
and rubbing, and possibly high fat diet.
What are the symptoms of a Stye (Hordeolum
Generally eye styes are manifested by
redness, very tender swelling, and pain. The
lid generally feels like it is more swollen
than it actually is. A hordeolum is
generally smaller and closer to the margin
of the lid while the chalazion can be quite
large with swelling involving more of the
eyelid. Tearing, discharge, and swelling of
the eyelid can lead to transient blurring of
the vision. However, eye styes are generally
most bothersome because of the cosmetic
appearance of the lid.
What are the
treatments for a Stye(Hordeolum Chalazia)?
Most eye styes will disappear without
treatment. Many will resolve more quickly
with supportive care such a warm wash
clothes applied to the lids for 5 minutes
3-4 times a day. Antibiotics are usually
prescribed in recurrent cases and in the
rare stye that leads to an infection of the
skin called cellulitis. Signs of cellulits
include increasing warmth, swelling, and
redness of the skin surrounding the stye. It
is important to see your eye doctor right
away if this occurs. Never attempt to ‘pop’
a stye with a pin or by squeezing.
instances when styes do not drain on the
own, your eye doctor may need to perform a
surgery called an I&D (incision and
drainage). This involves injecting an
anesthetic, creating an incision, and
curetting out the plugged up gland. Healing
time is generally 2-3 days.
suffer from chronically recurrent styes may
be treated long term with a low dose
antibiotic related to tetracycline, and
ongoing lid hygiene using warm soaks scrubs.
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What is a Subconjunctival Hemorrhage?
The conjunctiva is the white skin that
overlies the wall of the eye called the
sclera. It is continuous from the color part
of the eye to the eyelids covering the
muscles of the eye and preventing foreign
objects from getting behind the eye.
Generally, the conjunctiva is loosely
attached to the surface of the eye.
age, the protective skin around the blood
vessels begins to thin. Generally, it is
this thinning that leads to multiple bruises
caused by minimal or no trauma. This same
process affects the blood vessels of the eye
leading to hemorrhages under the
How common is a
Subconjunctival Hemorrhage (SCH)?
Subconjunctival hemorrhages are seen
commonly as we age. Most occur over night
presumably from inadvertently rubbing the
eye. Trauma to the eye, extremely high blood
pressure, excessive aspirin use, an
increased INR with Coumadin use, and rarely
clotting factor deficiencies can all cause a
What are the symptoms of a
Subconjunctival Hemorrhage (SCH)?
A SCH is most commonly asymptomatic and
recognized in a mirror, by a family member,
or friend. The swelling of the conjunctiva
caused by the blood can lead to a foreign
body sensation but rarely pain.
Infrequently, the hemorrhage can be severe
enough to cause the conjunctiva to protrude
out between the lids causing drying of the
eye surface, double vision, or blurred
What is the treatment for a
Subconjunctival Hemorrhage (SCH)?
Generally, SCHs are merely cosmetic in
nature and will disappear without treatment
in 5-10 days. Treatment is supportive
including artificial tears and patching. In
the event that aspirin containing agents,
Coumadin, or high blood pressure are
present, it is important to see your eye in
order to rule out one of these unusual
causes. Rarely, a clotting disorder can be
detected with a clotting factor work up and
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