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Common Eye Diseases

 

Other Eye Diseases

ARMD

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 2020.

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 pressure etc.

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 races.

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.

Since ARMD 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 the glasses.

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 others.

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.

Other common 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 retina specialist.

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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Blepharitis

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.

Anterior 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.

Posterior 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 population.

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 for Blepharitis?
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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Childhood Eye Diseases

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 syndrome.

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 abnormal.

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Dermatochalasis

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 Dermatochalasis?
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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Dry Eyes

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 Acne rosacea.

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 Eyes?
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 the computer.

What is the treatment for dry eyes?
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 prolonged use.

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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Ectropion

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 the cornea.

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 for Ectropion?
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 underlying cause.

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 tissues.

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 the ear.

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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Entropion

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 ‘spastic’ entropion.

How common is Entropion?
Entropion is most commonly found in the elderly. The exact frequency has not been reported.

What are 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 eye ointments.

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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Epiretinal Membrane

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.

Most 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 membrane formation.

How common is an Epiretinal Membrane?
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 .

What 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 membrane.

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Eyelid and Orbital Tumors

What is a Tumor of the Eye?
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.

Malignant Melanoma 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.

Malignant melanoma 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.

Orbital tumors 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.

How 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 year.

What is the treatment for Eyelid and Orbital Tumors?
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 chemotherapy.

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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).

In rare 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.

A retinal 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 obstructed.

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 time.

There is no medical treatment for floaters. In rare cases, a retinal specialist can remove very large persistent symptomatic floaters by performing a vitrectomy.

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 operating room.

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Fuch’s Dystrophy

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 vision blurs.

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.

How common is Fuch’s dystrophy?
Fuch’s dystrophy is found in approximately 1 to 4% of the world population.

What are the symptoms of Fuch’s dystrophy?
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.

Surgical 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 sutures.

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 cornea.

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 astigmatism.

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 infections.

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 50.

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).

What 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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Iritis

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 visual loss.

The following list includes some of the causes of iritis listed by category.

Inflammatory or Autoimmune disorders:

  • Ankylosing Spondylitis
  • Rheumatoid Arthritis
  • Behcet’s disease
  • Crohn’s disease
  • Lupus
  • Chronic Psorias
  • Psoriatic arthritis
  • Scleroderma
  • Ulcerative Colitis
  • Gout

Infections:

  • Tuberculosis
  • Lyme Disease
  • Syphilis
  • Toxoplasmosis
  • Toxocariasis
  • Herpes Simplex
  • Herpes Zoster Virus

Cancers:

  • Leukemia
  • Lymphoma
  • Malignant Melanoma
  • Trauma

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 systemic illness.

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.

What 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 glaucoma.

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 usually disappear.

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Macular Hole

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.

Macular holes 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.

What 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.

What 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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Myasthenia Gravis

What is Myasthenia Gravis?
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.

The 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 muscle.

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 gravis?
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 breathing.

What is the treatment of Myasthenia gravis?
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.

Treatment 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 removed surgically.

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Optic Neuropathy

What is optic Neuropathy?
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 sedentary lifestyle.

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 blindness.

How common is optic neuropathy?
NAION is found in approximately 2.52-11.8 cases per 100,000 men aged >= 50 years of age.

What are the symptoms of optic neuropathy?
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 neuropathy?
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 through exercise.

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Pink Eye

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.

How 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 worsened.

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Retinal Detachment

What is a retinal detachment?
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.

A 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 possible.

How common is a Retinal Detachment?
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 eye.

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 surgery.

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 Detachment?
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 nearsightedness.

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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.

What is Hyperopia?
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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Shingles 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 life.

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 nerve.

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.

What 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 the eye?
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 recurrence.

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.

Pain is 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 Chalazion)

What is a Hordeolum?
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.

What 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 hordeolum.

How common are Styes (Hordeolum and Chalazia)?
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 and Chalazia)?
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.

In rare 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.

Patients that 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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Subconjunctival Hemorrhage

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.

As we 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 conjunctiva.

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 SCH.

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 vision.

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 blood tests.

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The material contained on this site is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Always seek the advice of your physician or other qualified health care provider.