RETINA SERVICES



Retina is the light sensitive layer of cells at the back of the eye. It converts light into electrical signals which are sent to the brain through the optic nerve and the brain interprets them to produce the images that we see. A healthy retina is necessary for good vision.

To examine the retina, the ophthalmologist will dilate your eyes by using dilating drops. A retina specialist then uses a special magnifying lenses to examine your retina. The dilatation will reverse after 4-5 hours.

Diabetic retinopathy

Diabetes can cause blood vessels to leak, causing fluid accumulation in the inner layers of the retina and thus affecting the vision. Abnormal blood vessels can also grow and possibly bleed. The damage and changes seen in the retina due to diabetes is called diabetic retinopathy.

  • The earliest form of diabetic retinal damage is called “background diabetic retinopathy”. About 50% of patients with diabetes for 10-15 years have some signs of this such as bleeding, or swollen pockets within the retina. If these swollen areas affect the macula, dim or blurry vision may result.
  • If the eye disease worsens, areas of the retina may not get enough blood. The eye responds by growing thin new vessels. This is called “proliferative diabetic retinopathy”. Unfortunately, these new vessels frequently break open and bleed, filling the eye with blood and stimulating scar tissue to grow, sometimes leading to retinal detachment.

 

Points to remember

  • Severity of diabetic retinopathy runs parallel to the duration of diabetes mellitus.
  • 50 % of diabetics have diabetic retinopathy after 10 years of diabetes mellitus.
  • 90 % of diabetics have diabetic retinopathy after 20 years of diabetes mellitus.
  • A regular checkup every 6 – 12 months can detect early changes and prevent blindness.

Diagnosis

A dilated retinal examination can reveal macular edema and proliferative diabetic retinopathy. Fluorescein angiogram and ocular coherence tomography (OCT) are useful in detecting subtle changes.

Treatment and Drugs:

In mild cases, treatment for diabetic retinopathy is not necessary. Regular eye exams are critical for monitoring progression of the disease. Strict control of blood sugar and blood pressure levels can greatly reduce or prevent diabetic retinopathy. In more advanced cases, treatment is recommended to stop the damage due to diabetic retinopathy, prevent vision loss and restore vision.

Treatment options include:

  • Anti-VEGF therapy (Avastin, Lucentis, Ozurdex)
  • Intraocular steroid injection
  • Laser surgery
  • Vitrectomy

Retinal vein occlusion

Retinal vein occlusion occurs when one of the tiny retinal veins becomes blocked by a blood clot. Risk factors, apart from advanced age and genetic factors, are smoking, obesity, high blood pressure, diabetes and high cholesterol levels. The occlusion of the vein prevents the drainage of blood which results in hemorrhages and a swelling of the surrounding retina. In the long run the retina is irreversibly damaged.

Types

  • Branch retinal vein occlusion
  • Central retinal vein occlusion

Treatment is aimed at preventing and treating any complications of the vein occlusion and control of risk factors. There is currently no treatment that can reverse the blocked vein.

Treatment of any complications

Someone with retinal vein occlusion needs close follow-up so that any complications can be picked up early and treated where possible. Anti VEGF therapy in the form of injections needs to be given in case there are complications like neovascularization. Recurrence is real risk hence control of the underlying risk factors if of great importance.

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Age-related macular degeneration

Age-related macular degeneration (AMD or ARMD) is one of the most common causes of vision loss in those aged over 50 years. AMD is a condition that occurs when cells in the macula degenerate and die. Damage to the macula affects the central vision which is needed for reading, writing, driving, recognizing people’s faces and doing other fine tasks. The disease does not lead to complete blindness. Visual loss can occur within months, or over many years, depending on the type and severity of AMD.

Types of Age-related macular degeneration

 

Dry AMD

In this type the cells in the RPE of the macula gradually become thin (they ‘atrophy’) and degenerate. This layer of cells is crucial for the function of the rods and cones which then also degenerate and die. Typically, dry AMD is a very gradual process and patients may not totally lose their reading vision.

Wet AMD

Wet AMD may also be called neovascular or exudative AMD. It may cause severe visual loss within a short period – sometimes just months. Rarely if there is a bleed (hemorrhage) from a new blood vessel, this visual loss can occur suddenly, within hours or days. In wet AMD the retinal pigment cells degenerate and new tiny blood vessels grow from the tiny blood vessels in the choroid. This is called choroidal neovascularization. These vessels are fragile and tend to leak blood and fluid. This can damage the rods and cones, and cause scarring in the macula, causing severe vision loss.

Certain risk factors can lead to the development of AMD. These include:

  • Smoking tobacco.
  • Possibly, high blood pressure (inconclusive evidence).
  • A family history of AMD.
  • Sunlight. (Ultraviolet rays).

AMD is painless. When there is blurred vision even with the best corrected glasses further evaluation of the retina is needed. As the disease progresses slowly, the symptoms go unnoticed by the patients. Symptoms of dry AMD tend to take 5-10 years to become severe. However, severe visual loss due to wet AMD can develop more quickly.

Diagnosis

ARMD is usually diagnosed after an eye specialist (an ophthalmologist) examines the retina at the back of the eye, using an ophthalmoscope. The retina at the back of your eye has a typical appearance in ARMD.

Special investigations may be performed to evaluate the extent of damage and this include:

  • Fundus photographs
  • Fluorescein angiography
  • Optical coherence tomography

Treatment

Preventing further visual loss is the main goal of treatment. A healthy balanced diet rich in antioxidants and the addition of dietary supplements containing lutein, zeaxanthin and other ingredients like bilberry extract is beneficial. Stopping smoking and protecting the eyes from the sun’s rays by wearing sunglasses are important. Low vision aids can be prescribed for individuals who cannot see well.

For the less common wet AMD, treatment may halt or delay the progression of visual loss in some people. Newer treatments may even be able to reverse some of the visual loss. Treatments which may be considered include treatment with anti-vascular endothelial growth factor (anti-VEGF), photodynamic therapy and laser photocoagulation.



Uveitis

Uveitis is the inflammation of the Uvea which is made up of iris, ciliary body and choroid. If we think of the eye as a hollow, fluid-filled, 3-layered ball, then the outer most layer is the sclera (a tough coat), the inner-most is the retina, (the thin light-gathering layer), and the middle layer is the Uvea (the vascular layer).

Clinical presentation

  • Anterior Uveitis is associated with eye pain, redness, blurring of vision and light sensitivity.
  • Intermediate and Posterior forms of Uveitis may more typically be associated with floaters, flashes of light and blurred vision.

Treatment for uveitis will depend on which areas of the eye are affected and what has caused the condition. Medication through drops and injections is the main treatment, but surgery can be used in particularly severe cases. Most of cases of uveitis are idiopathic. This means that the process occurs without a specific identifiable cause or an associated health problem elsewhere in the body.

Treatment of Uveitis

The findings may be very similar, but the Treatment of Uveitis varies significantly depending on the type and cause of the Uveitis.

  • In the case of autoimmune Uveitis, the treatment may involve the use of corticosteroids and/or immunosuppressive drugs.
  • Treatment of Uveitis that stems from an infection, targets the treatment of the underlying infection.
  • Likewise, Uveitis may be a manifestation of a malignant condition. In this case, it is managed along with treating the underlying malignancy.

The treatment of some forms of Uveitis may involve collaboration between ophthalmologists and other specialists such as rheumatologists, infectious disease specialists or oncologists. Most patients with acute Uveitis do not lose vision and treatment is aimed at controlling the inflammation to prevent any visual loss. The main causes of visual loss in patients with chronic Uveitis are cataract, glaucoma or damage to the back of the eye from high pressure inside the eye, and macular edema or ‘waterlogging’ of the retina due to the chronic inflammation.


Frequently Asked Questions

Most people with diabetic retinopathy do not have any symptoms or visual loss due to their retinopathy. Initial symptoms that may occur include blurred vision, seeing floaters and flashes, or even having a sudden loss of vision. Without treatment, diabetic retinopathy can gradually become worse and lead to visual loss or even blindness.

As many patients are not aware of the disease even when advanced damage is present, it is very important for diabetics to have a regular, complete eye and retinal examination with dilation of the pupil. Treatment for diabetic eye disease is better at preventing and controlling the diabetic retinopathy than at reversing it once it is well established.

Laser seals leaking blood vessels to reduce macular edema, helping to prevent further vision loss. It also slows or stops growth of abnormal blood vessels, decreasing the chance of bleeding in the eye.

Retinal vein occlusion is a common cause of vision loss. It is most common in people over the age of 60 and it seems to affect both sexes equally.

The exact reason why a blood clot may form in one of the retinal veins is not clear. However, there are some things that are thought to increase your risk of developing retinal vein occlusion. They include the following

  • High blood pressure
  • Diabetes
  • Smoking
  • Cardiac diseases (heart related diseases)
  • Raised intraocular pressure (glaucoma)

Macular edema is swelling at the center of the retina. Neovascularization or abnormal new blood vessel formation at the back of the eye. About one third of patients with retinal vein occlusion can develop this problem which can lead to increased pressure in the eye and glaucoma. Bleeding is common with these new vessels.

Painless decrease in vision in one eye or blind spot in one eye of sudden onset is the commonest presentation of retinal vein occlusion. Visual loss could be mild or severe depending on the extent of occlusion and subsequent damage.

Retinal vein occlusion is usually diagnosed by an ophthalmologist on examination of the retina using an ophthalmoscope. The retina at the back of your eye has a typical appearance in retinal vein occlusion. Your specialist may advise some other tests or examinations to help to see how much damage has occurred to your retina. The tests may include:

  • Fundus photographs
  • Fluorescein angiography
  • Optical coherence tomography

Currently, there is no treatment that can reverse the blocked vein. The aims of treatment are to detect and treat any underlying risk factors and detect and treat any complications where possible.

Eye drops and tablets do not deliver enough amount of medication to the retina. The only way to ensure adequate concentration of medication to the retina is by intraocular ( intravitreal) injection especially for wet macular degeneration.

Drops are put in the eye to numb the eye and reduce discomfort. The eye is carefully cleaned with an iodine solution to reduce the risk of infection. The injection is given using a tiny needle that enters through the white part of the eye (sclera) close to the front of the eye. The procedure is done in operation theatre to reduce the chances of infection.

An intraocular injection is a very safe procedure. Occasionally minor side effects can occur. Commonly, a spot of bleeding may develop on the surface of the eye at the site of the injection. The bleeding is painless and usually causes no symptoms at all, resolving over a few days. There is a very small risk of infection which may happen in about 1 out of every 3,000 injections.

  • The earliest symptom is blurring of central vision despite using your usual glasses.
  • One specific early symptom is visual distortion. Typically, straight lines appear wavy or crooked.
  • A ‘blind spot’ then develops in the middle of your visual field. This tends to become larger over time as more and more rods and cones degenerate in the macula.