Retina

AGE RELATED MACULAR DEGENERATION (AMD)
Age related macular degeneration (AMD) is an important cause of vision loss in people over 50 years or older. It involves damage to the macula which is a small but extremely important area located at the center of the retina responsible for the ability to see fine details clearly. A person with AMD loses the ability to perceive fine details clearly both up close and at a distance.

There are two common types of AMD. Most people (about 90%) have a form of AMD called ‘atrophic’ or ‘dry’ AMD, which develops when the tissues of macula get thinner with age. Dry AMD usually causes a slow loss of vision.

A second, smaller group of people (about 10%) have a more serious condition called ‘exudative’ or ‘wet’ AMD. Wet AMD occurs when abnormal blood vessels grow underneath the retina, Choroidal neovascular membrane (CNVM). These unhealthy vessels leak blood and fluid, which can scar the macula. For patients with wet AMD, vision loss may be rapid and severe.


Dr-kothari-eye-amrd

Symptoms
• Blurring of central vision despite using glasses
• Difficulty in reading books/newspapers
• Difficulty in recognizing faces

Diagnosis
Detailed examination includes a dilated fundus examination, slit lamp biomicroscopy besides recording the visual acuity and intraocular pressure. Following tests are commonly done as indicated

• Optical Coherence Tomography (OCT) – It a non-invasive technique for obtaining cross sectional images of the retina indicating any leakage or thickness changes in the retina. At Retina Foundation we have one of the most advanced OCT system (Heidelberg Spectralis) having ultra high resolution to detect any thickness change at the earliest.

• Fundus fluorescein angiography (FFA) – It involves injection of a dye into the veins and photographing the retina to look for perfusion changes. At Retina Foundation we have one of the most advanced FFA system (Heidelberg Spectralis & Topcon). In some case another similar test using a more sensitive dye Indocyanine Green(ICG) is also carried out to locate leakage underlying a blood collection.

Treatment
1) Intra vitreal injections – Anti VEGF injections are the mainstay of treatment for Wet AMD.

LUCENTIS, an Anti VEGF injection is the most commonly used approved injection for this condition and is very effective in regressing the oedema

Another drug which is commonly used, although unapproved by FDA is AVASTIN

These injections are usually given as a loading dose of 3 consecutive monthly injections and may need to be repeated in case of a persistence or recurrence of leakage. The timing and usage would be decided and recommended by the surgeon. Follow up schedule would be recommended on a monthly basis initially and then reduced once the condition is stable.

Low vision aids such as magnifying glasses etc. may be helpful in patients who have a severe degree of visual impairment. The idea is to magnify whatever one is trying to read. TABLETS such a IPADS, Galaxy tabs etc are also used to achieve the purpose of magnifying text related to various daily activities of reading related to books or news items

THE OTHER EYE : Remember this is a bilateral condition and a similar pathology might occur in the other eye also. Best visual recovery is achieved if the condition is detected at the earliest and timely injections are given. Hence always call for an early check up in case you have any symptoms related to blurring or distortion in the other eye also.

Other measures

• Stop smoking
• Balanced diet & especially green leafy vegetables
• Nutritional supplements: Your eye surgeon may prescribe some nutritional supplements in the form of anti oxidants, vitamin combinations etc to reduce the risk of progression of this condition.

NON AMD RELATED CHOROIDAL NEOVASCULAR MEMBRANES

Some other conditions such as Juxtafoveal Telengiactasia (JXT), Idiopathic Polypoidal Chorio Vasculopathy (IPCV), Myopic CNVM, CNVM in Angioid Streaks, Post Inflammatory CNVMs or Idiopathic CNVM may require similar treatments in the form of multiple injections

RETINAL DETACHMENT
Normally the retina is firmly attached to the back of the eyeball. If it becomes detached, the eye loses vision. The immediate cause is usually a hole in the retina. It may occur spontaneously or due to injury or underlying weakness of the retina.

Once there is a Retinal Detachment the only treatment is in the form of a surgery to reattach it. Retinal Detachment cannot be treated with only medicines or eye drops. Hence surgery should be planned at the earliest so that the eye can regain maximum possible vision. The longer it remains detached the lesser vision it would recover after surgery.

ecDetachment Kotharieye

The surgery carried out for this procedure could be a Vitrectomy, buckling or a combination of these two procedures and the choice would be determined by the surgeon based on the type of your detachment.

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TYPE OF SURGERY
1. Vitrectomy is a very delicate operation performed with an operating microscope and special needle-sized instruments wherein the vitreous gel, which is pulling on the retina, is removed from the eye and is usually replaced with silicone oil or gas bubble. Endo laser is carried out to seal the breaks causing the detachment. In Retina Foundation this procedure can done using the state of the art Micro Incision Vitrectomy System (MIVS)

2. Scleral buckling surgery
A flexible band scleral buckle is placed around the eye to counteract the force pulling the retina out of place. Fluid under the detached retina is drained, pulling the retina to its normal position against the back of the wall of the eye.

Sometimes a combination of the above 2 procedures could also be done if the surgeon finds that necessary

Following surgery the surgeon would guide you about the post operative care and also specific positioning of the head for some time in the immediate post operative period to achieve better tamponade to keep the retina attached. Necessary postoperative medications would also be explained to you. In case if silicon oil is injected it would need removal by a procedure after 6 months. In case a gas bubble is injected then the patient needs to avoid air travel for 3 weeks post surgery to avoid any inadvertent increase in the pressure of the eye. Due care and guidance would be explained to you in these situations.

Recovery
With a successful retinal attachment, vision usually takes a few months to improve. Change in the power of your glasses may also enhance the quality of vision at this stage.

The Other eye
In case there is a weakness in the retina which caused the detachment, the other eye also may have a predisposition to getting the same in the future. In case any specific weak area or tear is detected, then the surgeon would guide you to undertake a laser procedure to seal these area s and thus reduce the incidence of detachment. Most retinal tears if detected early can be successfully treated with laser, thereby preventing retinal detachment. At Retina Foundation laser treatment is carried out with the most advanced Pattern scanning laser systems.

DIABETIC RETINOPATHY
An increasing incidence of diabetes mellitus poses a major health problem in India.

Diabetes may affect both the young (type I) and the old (type II). The latter type is far more common.

Any person with diabetes can potentially develop diabetic retinopathy, irrespective of type of diabetes; however it is observed that nearly half of all people with diabetes develop some degree of diabetic retinopathy during their lifetime.

 

How does diabetes affect the eye?
Diabetes causes weakening of the blood vessels in the body. The tiny, delicate retinal blood vessels are particularly susceptible. This deterioration of retinal blood vessels, accompanied by structural changes in the retina, is termed diabetic retinopathy and leads to loss of vision which can be permanent in case it is not treated in time.

Diabetic retinopathy is gradual in onset and is related to the duration of diabetes. High blood glucose levels, high blood pressure and genetics influence the development and progression of diabetic retinopathy.

Causes of vision loss in diabetic retinopathy:
The vision loss in diabetic retinopathy can be due to Macular Oedema, Haemorrhage (Vitreous / subhyaloid) or Tractional Retinal detachment

Diagnosis
Detailed examination includes a dilated fundus examination, slit lamp biomicroscopy besides recording the visual acuity and intraocular pressure. Following tests are commonly done as indicated

Optical Coherence Tomography (OCT) – It a non-invasive technique for obtaining cross sectional images of the retina indicating any leakage or thickness changes in the retina. At Retina Foundation we have one of the most advanced OCT system (Heidelberg Spectralis) having ultra high resolution to detect any thickness change at the earliest.

Fundus fluorescein angiography (FFA) – It involves injection of a dye into the veins and photographing the retina to look for perfusion changes. At Retina Foundation we have one of the most advanced FFA system (Heidelberg Spectralis & Topcon)

Ultrasonography (B Scan) – It involves doing sonography of the eye to know about the anatomic status of retinal attachment in cases where visibility is compromised due to vitreous haemorrhage

Depending on the clinical findings as well as those from the above mentioned tests one of the following treatment options would be suggested

1) Laser photocoagulation – the purpose of this treatment is to arrest the progress of the changes within the retina and help to retain existing vision. By deliberately destroying some parts of the retina, photocoagulation helps regression of abnormal new blood vessels, thereby reducing the risk of vitreous hemorrhage/tractional retinal detachment. PROCEDURE – Laser treatment is usually performed as an outpatient procedure. The patient is given topical anesthesia to prevent any discomfort and is then positioned before a slit lamp. The ophthalmologist directs the laser beam precisely on the target with the aid of the slit lamp and a special contact lens. It is usually done in 2 sittings. However, additional sittings may be required in the future according to the patient’s condition. The type of treatment (PRP/Focal) depends on the extent and location of damaged capillaries. At Retina Foundation we use one of the most advanced Pattern Scan Laser systems for the same.

2) Intra vitreal injections – Intra vitreal injections may be given to treat macular oedema and also regress the leaking vessels. Along with laser they play a great role in stabilizing the condition of the retinopathy.

LUCENTIS, an Anti VEGF injection is the most commonly used approved indication for this condition and is very effective in regressing the oedema

OZURDEX implant, a slow release (long acting) steroid is also used to reduce oedema.

Other drugs which are commonly used are AVASTIN and TRIAMCINOLONE

These injections are sometimes used in conjunction with laser or Vitrectomy as well as a preparatory drug to be given a few days before surgery to reduce bleeding during surgery.

The timing and usage would be decided and recommended by the surgeon. They may need to be given for a few months in continuity or repeated in case of a recurrence of oedema

3) Vitrectomy – In case there is a vitreous or subhyaloid haemorrhage blocking the view or a tractional detachment detected clinically or on OCT or Ultrasound, then a surgery in the form of Vitrectomy is indicated. Vitrectomy is a very delicate operation performed with an operating microscope and special needle-sized instruments wherein the haemorrhage is cleaned or the retina is reattached. Endo laser is carried out to regress the retinopathy. In Retina Foundation this procedure can done using the state of the art Micro Incision Vitrectomy System (MIVS)

FOLLOW UP

Diabetes is a lifelong disease and periodic eye examination with dilated pupils is the only way to detect the changes early and prevent further deterioration of vision. Follow up schedule would be suggested to you as per your ocular condition.

RETINAL VEIN OCCLUSION (BRVO/CRVO)
Retinal Vein Occlusion (RVO) is a blockage of the small veins that carry blood away from the retina.. It is the 2nd most common vascular disorder of the retina, next only to diabetic retinopathy.

Causes
Retinal vein occlusion is most often caused by hardening of the arteries (atherosclerosis) and the formation of a blood clot due to following risk factors

  • High blood pressure (hypertension)
  • Atherosclerosis
  • Diabetes
  • Glaucoma

Dr-kothari-eye-amrd

Symptoms
Due to blockage there is accumulation of retinal haemorrhages and oedema leading to visual loss. It leads to sudden vision loss in all or partial loss of field of vision

Diagnosis
Detailed examination includes a dilated fundus examination, slit lamp biomicroscopy besides recording the visual acuity and intraocular pressure. Following tests are commonly done as indicated

Optical Coherence Tomography (OCT) – It a non-invasive technique for obtaining cross sectional images of the retina indicating any leakage or thickness changes in the retina. At Retina Foundation we have one of the most advanced OCT system (Heidelberg Spectralis) having ultra high resolution to detect any thickness change at the earliest.

• Fundus fluorescein angiography (FFA) – It involves injection of a dye into the veins and photographing the retina to look for perfusion changes. At Retina Foundation we have one of the most advanced FFA system (Heidelberg Spectralis & Topcon)

• Blood tests – Apart from these tests you may need to get some blood tests done as recommended

Treatment
1) Intra vitreal injections – Intra vitreal injections may be given to treat macular oedema and also regress the leaking vessels. Along with laser they play a great role in stabilizing the condition of the retinopathy.

LUCENTIS, an Anti VEGF injection is the most commonly used approved injection for this condition and is very effective in regressing the oedema

OZURDEX implant, a slow release (long acting) steroid is also used to reduce oedema.

Other drugs which are commonly used are AVASTIN and TRIAMCINOLONE

These injections are sometimes used in conjunction with Laser or Vitrectomy as well as a preparatory drug to be given a few days before surgery to reduce bleeding during surgery.

The timing and usage would be decided and recommended by the surgeon. They usually given as a loading dose of 3 consecutive monthly injections and may need to be repeated in case of a persistence or recurrence of oedema

2) Laser photocoagulation – The purpose of this treatment is to arrest the progress of the changes within the retina and help to retain existing vision. By deliberately destroying some parts of the retina, photocoagulation helps regression of abnormal new blood vessels, thereby reducing the risk of vitreous hemorrhage/tractional retinal detachment.

Laser treatment is usually performed as an outpatient procedure. The patient is given topical anesthesia to prevent any discomfort and is then positioned before a slit lamp. The ophthalmologist directs the laser beam precisely on the target with the aid of the slit lamp and a special contact lens. Initially 1 or 2 sittings of laser are required to accomplish the task. However, additional sittings may be required in the future according to the patient’s condition. The type of treatment (PRP/Focal) depends on the extent and location of damaged capillaries. At Retina Foundation we use one of the most advanced Pattern Scan Laser systems for the same.

3) Vitrectomy – In case there is a vitreous or subhyaloid haemorrhage blocking the view or a tractional detachment, then a surgery in the form of Vitrectomy is indicated. Vitrectomy is a very delicate operation performed with an operating microscope and special needle-sized instruments wherein the haemorrhage is cleaned or the retina is reattached . Endo laser is carried out to regress the bleeders. In Retina Foundation this procedure can done using the state of the art Micro Incision Vitrectomy System (MIVS)

Prevention
Retinal vein occlusion is a sign of a general blood vessel (vascular) disease. The same measures used to prevent other blood vessel diseases, such as coronary artery disease, may decrease the risk of retinal vein occlusion.

These measures include:

• Eating a low-fat diet
• Getting regular exercise
• Maintaining an ideal weight
• Not smoking

Controlling co existing systemic conditions such as diabetes and hypertension would be helpful in preventing retinal vein occlusion.