April 2, 2014
Your retina is the light sensitive lining in the back of your eye. It contains millions of special nerve cells that react to light and send electrical impulses to your optic nerve, which your brain converts into the images you see. The retina collects images and passes them on to the brain. Retinal disorders interrupt this transfer of images. They include age-related macular degeneration, diabetic retinopathy, and retinal detachment.
Most people never give their eyes—let alone their retinas—a second thought until something goes wrong. Yet, retinal diseases are the leading cause of blindness in adults in the United States. Fortunately, early diagnosis of retinal disease leads to earlier effective treatment of the condition.
About the Speaker
Alex Yuan, MD, PhD is an associate staff physician at Cleveland Clinic’s Cole Eye Institute. His specialty interests include the medical and surgical diagnosis and treatment of retinal disorders.
Dr. Yuan completed a vitreoretinal surgery fellowship at Cleveland Clinic’s Cole Eye Institute, in Cleveland, Ohio. He completed his ophthalmology residency at Jules Stein Eye Institute, University of California School of Medicine in Los Angeles, in Los Angeles, and an internship at Forest Park Hospital in St. Louis, Mo. Dr. Yuan earned his medical degree from Washington University School of Medicine in St. Louis, Missouri.
Let’s Chat About Ask a Retina Specialist
Moderator: Welcome to our chat today with Cleveland Clinic expert Dr. Alex Yuan. We are thrilled to have him here with us to share his knowledge about retinal conditions. Let's begin with the questions.
Floaters, Flashes and Spots
7135David: My eye doctor said the floaters in my vision are caused by a separation of the internal gel from my retina. He also said there was nothing that could be done unless it got very bad. Why has it suddenly started happening after no eye problems my whole life? I am 69 years old. Are there things I could do to prevent any more of these floaters?
Alex_Yuan,_MD._PhD: The gel (vitreous) degenerates with age. It is a natural process, which unfortunately causes floaters. Sometimes these floaters can be debilitating, but the brain usually learns how to adapt and ignore the floaters over time. Sometimes the floaters get better as the vitreous degenerates more.
wswan: Just recently I have been seeing some floaters in my right eye and occasionally see moving black spots or dots. I understand this is could mean I have a detached retina. What can be done to either fix the detached retina or to eliminate or minimize the floaters and black spots? Are there any recommended eye drops?
Alex_Yuan,_MD._PhD: If you have not had a thorough dilated eye exam, then I recommend you make an appointment to rule out retinal tears or bleeding inside your eye. If you do have a detached retina, you need surgical repair. There are multiple ways to repair a retina but it depends on your specific situation so I would recommend an evaluation. Floaters and black spots can only be removed by surgery. No eye drops will help unfortunately.
Hallie: Several months ago I began having flashes in my right eye. I saw retina doctors at a top clinic, who saw no retina tear. The top retina physician said he didn't know why I am having flashes and to consult a neurologist. I have lupus and Raynaud disease but do not take medications for these conditions. One of the retina doctors told me lupus patients often have flashes. A few years ago, when my thyroid medicine was increased, I suddenly got many floaters, which still bother me. I subsequently lowered my thyroid medication, but the floaters didn't go away. Before the beginning of the flashes a few months ago, my doctor had slowly been raising my Synthroid® (levothyroxine) again. I think there is a correlation between the raising of the thyroid medication and the onset of floaters and flashes. What do you think? I feel much better on the higher Synthroid® dose and blood tests say this is the right dose for me, but I backed down again. I still see flashes at night or in dark. What should I do about the flashes and Synthroid®?
Alex_Yuan,_MD._PhD: I think it is a coincidence that your Synthroid® has been associated with your symptoms. Flashes and floaters are usually caused from degenerating vitreous (gel) in your eye. It is associated with aging. Inflammatory disorders such as lupus can cause flashes in the eye. I would recommend being evaluated by a uveitis specialist, like Sunil Srivastava, MD, Careen Lowder, MD, PhD, or Daniel Martin, MD at Cleveland Clinic, to see if your lupus may be causing the flashes of light?
Moderator: We are having a lupus webchat on May 7. If you are interested check it out at: http://chat.clevelandclinic.org/chatpage.aspx?chatid=1604. Questions can always be submitted early.
noble: Is there a YAG laser treatment for central floaters that produces good results? If it is not recommended, then what is? Are there options?
Alex_Yuan,_MD._PhD: I would not recommend YAG laser treatment for floaters. YAG laser in the vitreous causes lots of movement in the vitreous. The vitreous is attached to the retina in many places. The YAG laser can cause retinal tears, which can then lead to a retinal detachment.
If the floaters are debilitating then surgery (vitrectomy) is the only option. In 99 percent of patients, the brain will adapt to the floaters and learn to ignore them under most circumstances. It is similar to the rims of your eyeglasses or your nose. They are present and you can see them only if you concentrate on it, otherwise the brain tunes it out. Vitrectomy has risks so I would only advise surgery if absolutely necessary.
Retina Conditions and Blindness
sadiegrey: Is it always the retina problems that cause blindness? My sister who is 78 years old has been having less vision continually for about six months with burning and watering of the eye. An ophthalmologist told her she is going blind in that eye, but not due to cataracts or macular degeneration, according to what she tells me. What can she do to save her sight? She only sees shadows now with that eye. Do you have any suggestions?
Alex_Yuan,_MD._PhD: Retina problems are not the only disorders that can cause blindness. It is not clear what diagnosis was given to your sister. I suggest you have her make an appointment with one of our ophthalmologists who can evaluate her.
Epiretinal Membranes (Macular Pucker)
Mtclimber: In idiopathic cases of macular pucker, does the pucker ever resolve on its own? Does the management protocol change in cases of unknown etiology? What are the specific indications for surgical intervention?
Alex_Yuan,_MD._PhD: Usually macular pucker will not resolve on its own, but I have seen maybe one or two cases where I was convinced it resolved. It is extremely rare. Idiopathic macular puckers are the majority of cases, and these are the cases where surgery is usually anatomically successful. Decreased vision or distortion that affects your activities of daily living is indications for surgery. Progression and worsening vision are also indications.
ccligal: Can you address watch-and-wait as it relates to macular pucker? I have macular pucker, and have been advised to watch-and-wait. The pucker has not changed over the last two years. By the numbers my sight is good, but not perfect. However, I feel unsteady when out in public. I struggle to find a sweet spot.
Alex_Yuan,_MD._PhD: If your vision is good, then I agree that waiting is recommended. Your pucker sounds like it has been stable for the past two years, and it is likely to remain stable. Make sure you have an updated refraction to help with using both eyes together. However, if you are having lots of difficulty due to distortion or a larger image in that eye, then surgery may be worth the potential risks.
Mtclimber: A retina specialist originally attributed my macular pucker to retinal vein occlusion, but now believes the cause of the pucker to be idiopathic. Does knowing the cause change how and when the problem is addressed?
Alex_Yuan,_MD._PhD: It depends on what your primary visual problem is and the timing of the vein occlusion relative to the pucker. Both retinal vein occlusion and pucker can cause retinal edema. If you have retinal edema as the main cause for vision loss, then I would want to try to address the edema due to the vein occlusion first. Any residual edema can then be addressed by surgery. With a vein occlusion, macular ischemia can also occur (loss of blood flow). If this is present, then fixing the pucker may not improve your vision.
Mtclimber: How is a macular pucker surgically addressed? Is surgical removal of macular pucker in the hands of a retina expert considered routine? Is improvement to vision somewhat immediate?
Alex_Yuan,_MD._PhD: All surgeries carry some level of risk, even the most routine cases. With that said, it is considered a routine retina procedure. A vitrectomy is performed followed by removal of the epiretinal membrane and sometimes the internal limiting membrane as well. Improvement in vision is gradual because the retina takes time to recover and flatten back out. I have seen patients with visual gain even one year out from surgery, but most of the vision improvement occurs within the first two to three months.
ccligal: I had cataract surgery in prep for epiretinal membrane peel to better see the macula that never happened because of macular pucker. But a friend had epiretinal membrane peel and was advised to do the cataract surgery after the peel. Which is correct and when?
Alex_Yuan,_MD._PhD: There are three different ways to approach this. Some will advise cataract surgery before vitrectomy and others will advise vitrectomy before cataract surgery. A lot will have to do with your pre-existing cataract and how dense it is. I usually perform cataract surgery at the same time as my vitrectomy.
Dillard: I have recently been diagnosed as having epiretinal membranes. What is the surgical success rate at Cleveland Clinic for epiretinal membranes and complication rate?
Alex_Yuan_MD-PhD: In 2012, our average visual acuity gain after surgery was 11.2 letters (which is over a two-line gain in vision). Twenty two percent of patients actually had a three line or more gain in vision. There were no intraoperative complications reported out of 111 cases.
Dillard: Can epiretinal membranes recur? What replaces the vitreous?
Alex_Yuan_MD-PhD: Yes, they can recur. Naturally made fluid in your eye eventually replaces all of the vitreous.
Dillard: On average what is the recuperation time from surgery? Is the patient still required to lie on his stomach for weeks?
Alex_Yuan_MD-PhD: Two to three weeks. Lying on your back to recuperate is not for an epiretinal membrane repair.
Dillard: How many procedures should the surgeon have performed before I have confidence in her or him?
Alex_Yuan_MD-PhD: I have utmost confidence in any Cleveland Clinic retina specialist. However, any surgeon with retina training from a respectable program should be qualified.
Dillard: I have been told to have an intraocular lens (IOL) placed before the epiretinal membrane surgery. Since I have blurred vision, how does the ophthalmologist determine correct IOL for me?
Alex_Yuan_MD-PhD: IOL calculations are based off of objective measurements. Unless you have a very thick retina with retinal edema, your IOL calculations should be correct.
Terry Lee: They have not found macular degeneration in any tests, but have found a rippling in the macula. They mentioned having it surgically pulled to stop the waviness in my vision.
Alex_Yuan,_MD._PhD: If your primary vision problem is distortion of your vision (such as wavy lines) or a larger or smaller image in that eye, then having surgery can help with the distortion. However, blank spots in your vision that come and go do not sound like epiretinal membrane or macular pucker (which is what I think you are referring to as "rippling"). If your primary issue is blank spots in your vision that come and go, then you should have that evaluated by a neuro-ophthalmologist especially with a diagnosis of multiple sclerosis.
PHendrick: I am 74 years old, diagnosed with one wet and one dry macular degeneration at 70 years old. The dry macular degeneration became wet, and then developed pucker. After four years of Avastin® (bevacizumab) injections, supplements, and eating a consistent dark green vegetable diet, my left eye is maintaining at 20/30 and 20/40. My right eye pucker, responded to Avastin® four months ago, but only once. Ten days ago, my left eye showed a hemorrhage "dot." The retina specialist said it was probably due to heavy lifting and injected, and; gave it Avastin®. As I rely on my left eye, when should I consider vitrectomy? Do puckers usually get thicker, and harder to remove? Do you have any suggestions for me?
Alex_Yuan,_MD._PhD: Your retina specialist can monitor your macular pucker to see if it is getting worse. As long as your vision does not drop, I think it is safe to wait because your left eye is your good eye. It would not be more difficult to remove the epiretinal membrane, but results could be worse if you waited too long.
Wet and Dry Age-related Macular Degeneration
Amydee53: Does being diagnosed with age-related macular degeneration (AMD) guarantee that you will lose most of your sight?
Alex_Yuan,_MD._PhD: No, it does not guarantee vision loss. Some patients with dry AMD can have only very mild vision loss or no vision loss for a very long time. Some patients with wet AMD on treatment also maintain good vision.
deltonfarm: I have failing vision and have visited two different ophthalmologists for eye exams in the past several years. They both noted some macular degeneration, but only prescribed stronger glasses and ICaps MV, and gave me no further advice. Where can I go to obtain treatment that might actually help me?
Alex_Yuan,_MD._PhD: Did they perform studies such as an optical coherence tomography (OCT) and/or fluorescein angiography (FA)? (These studies help confirm you do not have wet macular degeneration.) If not, perhaps you can make an appointment with one of our retina specialists to be evaluated. If you have dry macular degeneration, then there may not be treatment available to restore lost vision. The AREDS vitamins help to slow the progression of macular degeneration. There are other treatments currently in clinical trials for the treatment of dry macular degeneration, so perhaps some of these will be available in a few years.
Amydee53: I have been diagnosed with moderate age-related dry macular degeneration (AMD) at 59 years old. My mother was diagnosed with wet macular degeneration at 57 years old. Is this young to have this disease?
Alex_Yuan,_MD._PhD: Although it is young to have AMD in your mid to late 50s, it is possible—especially if you have a strong family history.
blinky: Is there a permanent cure for wet age-related macular degeneration (AMD) or just the shots to slow the progression?
Alex_Yuan,_MD._PhD: There is currently no permanent cure. The shots do a good job at preventing progression and can sometimes restore some vision.
fz4h4d: When dealing with wet macular degeneration, does getting an injection in an eye that is currently dry help to keep it from getting wet again? Does most of the damage occur when there is fluid in the eye?
Alex_Yuan,_MD._PhD: Over the past two to three years, there have been multiple studies looking at this question. A little bit of fluid is well tolerated. Some retina specialists inject patients monthly, and this is the method to obtain the best anatomic result. However, there really was no difference between monthly injections and “as needed” injections. In an “as needed” regimen, you get an injection if there are signs of leakage on ocular coherence tomography (OCT).
Terry Lee: I am a 51-year-old female who has had multiple sclerosis for 15 years. I have been seeing two retinal specialists for two years. I have blank spots of vision in both eyes. It is acting like macular degeneration. I have had vitreous veil and cataracts for four years. I have had several optical coherence tomographies (OCT's). Why do I keep losing my sight? Sight in my left eye slowly came back, but now it is slowly decreasing and is now starting in both eyes.
Alex_Yuan,_MD._PhD: Do you have signs of macular degeneration on examination? You are rather young for macular degeneration. Multiple sclerosis can also cause vision loss. I would recommend having a neuro-ophthalmologist examine you also.
whiskey74: I wanted to know if dry macular degeneration could be confused with some other deterioration that may present in cases of CREST syndrome or high sedimentation rates? I would also like to know if Metformin or other medications may increase deterioration as quickly or instead of type 2 diabetes—not necessarily the effective ingredient in the drugs, but whatever else is used in the process of making it?
Alex_Yuan,_MD._PhD: CREST syndrome or systemic sclerosis, usually does not have retinal manifestations. High sedimentation rate is nonspecific and by itself would not be diagnostic. There have been case reports of CREST syndrome causing retinal artery occlusion. Metformin has not been shown to cause worsening diabetic retinopathy or worsening macular degeneration.
dixon: What, if any, treatment is available or on the horizon for dry macular degeneration? What percentage of cases of dry macular degeneration become wet macular degeneration? How effective are Ocuvite® 50+ vitamins?
Alex_Yuan,_MD._PhD: Currently the only treatment for dry macular degeneration is implantation of a telescopic lens into an eye with end-stage dry macular degeneration. The lens serves as a magnifier for the eye. Not everyone is a candidate for this type of surgery. To slow the progression of dry macular degeneration, we recommend AREDS (age-related eye disease study) vitamins. (There are different brands.) The AREDS formulation includes the following: 500 milligrams of vitamin C, 400 International Units of vitamin E, 15 milligrams of beta-carotene (often labeled as equivalent to 25,000 International Units of vitamin A), 80 milligrams of zinc as zinc oxide, and two milligrams of copper as cupric oxide. Copper was added to the AREDS formulations containing zinc to prevent copper deficiency anemia, a condition associated with high levels of zinc intake. A new study, AREDS II, found that beta-carotene (vitamin A) can be substituted with lutein and zeaxanthin. Since vitamin A was linked with lung cancer in active smokers, this is a good alternative. Ocuvite® 50+ does not fulfill the AREDS formula given above. I recommend sticking with supplements that have the AREDS formula (perhaps substituting vitamin A with lutein and zeaxanthin).
sam500016: I am a 72- year-old male. I have been a diabetic for about eight years with good glycemic control. I have an annual eye examination which has not revealed anything wrong. However, I am noticing that for the last year, straight lines in print or on a computer screen appear wavy. When I asked the doctor, he mentioned that it was due to age-related macular degeneration for which there was no specific treatment. Is there nothing to be done? What is the prognosis for the future?
Alex_Yuan,_MD._PhD: If an optical coherence tomography (OCT) and fluorescein angiography (FA) has been done to rule out wet macular degeneration, then I would recommend taking AREDS formula vitamins. If you have dry AMD, then progression is usually slow. There may be new treatments on the horizon for dry AMD.
MoR: Does your recommendation on AREDS apply to early stages of dry macular degeneration as well as more advanced age-related macular degeneration (AMD)?
Alex_Yuan,_MD._PhD: The AREDS study only showed a benefit in patients with intermediate or advanced stages of AMD. Patients with only a few small drusen did not benefit.
caldas: Can you kindly shed some light as to the current best treatments for wet and dry age-related macular degeneration (AMD)? My mother has both types and has been receiving monthly eye injections of Avastin® (bevacizumab) for the wet type for over a year with no signs of improvement except maybe for a slight retardation in the creation of new blood vessels. Can you comment on whatever happened to the promise of RNAi gene therapy and why Merck would subsequently shut down their RNAi division (after acquiring Sirna Pharmaceuticals)—especially after the apparent successful treatment of a patient in the clinical trial sponsored by Sirna several years ago? If the patient demonstrated initial improvement but later regressed, are we then to conclude that this form of therapy is not longer feasible and/or being explored by other biotech/pharmaceutical companies? And if that's the case, is Eylea® (afilbercept) then the best treatment for the foreseeable future?
Alex_Yuan,_MD._PhD: Anti-VEGF (vascular endothelial growth factor) therapy is currently the best treatment for wet AMD. This includes Avastin®, Lucentis® (ranibizumab) and Eylea®. Prior to these therapies, patients would continue to lose vision with wet AMD. Now with treatment, we are at least able to stabilize vision in most patients. Some patients even gain some vision back.
RNAi was one method of inhibiting VEGF. Avastin®, Lucentis®, and Eylea® all perform similar functions using proteins instead of RNA to do so. Unfortunately, due to the way RNAi was targeting cells, it is believed that its activity was through a nonspecific pathway (and not directly inhibiting VEGF). There is animal evidence that this nonspecific pathway causes atrophy of the retina. The RNAi studies did not meet their endpoint goals and our current treatments were shown to be superior. This is the main reason why those studies were halted.
Laurie: I was diagnosed with Stargardt disease two years ago and was told there is no treatment for it. Has there been any news in regards to this disease recently? Also, I get flashes, usually in the evenings, in my eyes. Do you have any idea what that means. I go to my eye doctor every six months and nothing has changed.
Alex_Yuan,_MD._PhD: There are no approved treatments for Stargardt disease that I am aware of. However, there may be some gene therapy trials that are promising in the future. Flashes in the eyes are a nonspecific symptom. Many things can cause flashes including migraines, retinal tears/holes, trauma, and inflammatory disease (uveitis) to name just a few. You should make sure you get a thorough examination and mention to your eye doctor you are experiencing flashes of light.
tlcope: My daughter was diagnosed at 12 years old with Stargardt disease and received a plethora of assistance from the State of Ohio with visual aids, etc. She is now 31 years old and is a certified social worker with a master's degree from Case Western Reserve University and is able to drive with a telescopic lens. The problem is there are some states that prohibit driving with assistive lenses, which limits her flexibility to reside or travel outside of her residence state of Ohio. Where do you see the research going for a potential cure? Is there a future possibility in the works for all states permitting driving with telescopic lenses?
Alex_Yuan,_MD._PhD: That is terrific to hear your daughter doing so well with the telescopic lens! I think research into Stargardt disease is very exciting. There are ongoing gene therapy trials, which may someday lead to an effective treatment. I don't know the answer to your question regarding states permitting driving with visual aids and telescopic lenses specifically.
Relish: My husband who is 67 years old was diagnosed about 10 years ago with retinal dystrophy. To date we have no treatments for this condition and have been told that there is nothing on the horizon to treat or cure this disease. Do you have any treatments or cures that you are either investigating, experimenting with or using at the Cleveland Clinic that may reverse his condition or even improve it? If so, we would be very interested in finding out more information from you.
Alex_Yuan,_MD._PhD: Retinal dystrophy is a very broad term. Dystrophies can include conditions such as cone dystrophy, Stargardt dystrophy, etc. Currently we do not have any clinical trials running for retinal dystrophies but nationwide there are some gene therapy trials for specific retinal dystrophies. What kind of dystrophy does your husband have?
mcraebhr: I am a 57-year-old female with Parkinson disease. I saw an ophthalmologist in December for blurred vision. I was diagnosed with thinning retina in my left eye and a retina tear in my right eye. Retinopexy was performed in both eyes. Are there any steps I can take to prevent retinal tears in the future? Also, does this procedure cause increased dryness in the eyes?
Alex_Yuan,_MD._PhD: Retinal thinning, or lattice degeneration and retinal tears, is treated with laser retinopexy as you have had. Laser helps prevent retinal detachment from tears. There is unfortunately no way to prevent tears in the future. Remember to look for new symptoms such as flashes of light, floaters, or a shade or curtain in your vision. If you notice new symptoms, contact your retina specialist. Laser does not cause dryness in the eyes. It may cause irritation the first day after treatment.
perplexed: What causes a macular hole? I was being treated for a viral syndrome causing extensive coughing episodes. Also was using a prednisone inhaler very minimally. I read that steroid use can increase possibility of a hole. My physician discounts the coughing episodes as a cause. I was 60 years old at the time of occurrence.
Alex_Yuan,_MD._PhD: Vitreomacular adhesion causes macular holes. Trauma can also cause macular holes. I doubt coughing would cause a hole unless you had some pre-existing traction on the macula and the coughing caused violent head movement. Steroid use can cause elevated pressures and central serous retinopathy, but not macular holes.
dingyrider: What special care or precautions is needed 18 months after vitrectomy to correct macular hole and six months after cataract surgery? The eye that had the vitrectomy and cataract surgery has occasional slight tightness and discomfort vs. the other eye that had only cataract and no discomfort at any time. Will the tightness and discomfort go away in due time?
Alex_Yuan,_MD._PhD: No special precautions should be needed that far out from surgery. Have a thorough exam to make sure there are no sutures causing irritation and no eye inflammation.
Shahkalla: I had a macular hole, followed by surgery. I have poor vision in that eye now. Previous to the macular hole, I had glaucoma. Since the macular hole I have developed age-related macular degeneration (AMD). Did the macular hole predispose me to the AMD?
Alex_Yuan,_MD._PhD: No, macular holes and AMD are unrelated.
perplexed: What is the statistical risk of a macular hole recurring or happening in the other eye?
Alex_Yuan,_MD._PhD: There is approximately a five to 10 percent risk of macular hole recurrence after surgery. I am not sure what the rate of macular hole is in the contralateral eye, but usually there are vitreomacular adhesion disorders in the contralateral eye (just not necessarily a hole).
flrp: I have been diagnosed with macular pseudohole, and the hole is continuing to grow in size. A doctor has told me that it is treatable, but not the treatment success rate or the degree of vision that will be achieved after the treatment. Will the hole be reduced in size and will I regain normal vision? Today I have difficultly reading because the printed lines won't sync. Therefore, when I read I shut the eye with the pseudohole and try to read with just one eye. What is the best treatment for this type of issue? Will the pseudohole recur after the treatment?
Alex_Yuan,_MD._PhD: There is no proven treatment for a pseudohole and it will depend on other factors such as the presence of an epiretinal membrane or macular pucker. If you have vitreomacular traction associated with the pseudohole, then surgery and perhaps a drug called Jetrea® (ocriplasmin) may help. If a pseudohole is growing in size, I suspect there is some traction on the retina. There is no guarantee treatment will improve your vision. It is difficult to determine a success rate since surgery is usually not performed on pseudoholes. Distortion after surgery is usually improved, but your vision may not.
Trauma and Retinal Scar
derekl: I was hit in the eye as a child 30 years ago, resulting in a torn retina and subsequent scar, leaving a large center blind spot. Have there been any advancements to deal with retina scar tissue, such as laser surgery, stem cell implantation, retina transplants, etc.?
Alex_Yuan,_MD._PhD: Unfortunately, there are no new advancements. My laboratory is looking at retinal scar tissue formation and how we may be able to manipulate scar formation into regeneration. Hopefully, we will be able to develop some treatment in the future.
BETHELMOM: In 1995 my son "caught" a golf ball with his right eye. He and his friends were playing homerun derby, found a golf ball, and decided to hit it with the bat. Unfortunately, my son was pitching and when the ball was hit it went right into his eye. The orbit was fractured, and just missed his temple. Thank God there was no brain damage, but there was a lot of damage to his eye. It caused a hole in the center of the retina. He had surgery to try and close the hole, draining vitreous, etc., but it was not successful. Today he has no vision in the center of that eye—only peripheral. His current doctor said there is nothing they can do to help improve his vision due to the fact that too much time has elapsed, but that had it happened now, they would have been able to. Is this correct?
Alex_Yuan,_MD._PhD: Traumatic macular holes are often difficult to repair even today. Although surgery for macular holes has progressed since 1995, and he may have had a better chance at successful closure today, it is not a guarantee. Idiopathic macular holes have a much higher surgical success rate.
ptone26: What kinds of signs or symptoms would be experienced with retinal detachment?
Alex_Yuan,_MD._PhD: Floaters, especially a "shower" of floaters, flashes of light that are persistent, a curtain or shadow over your vision, and sometimes also loss of central vision. Each eye should be checked individually (with covering one eye at a time). There is no pain usually unless the retinal detachment is very chronic.
robtoby: Is there a relationship between posterior vitreous detachments (PVDs) and retinal detachments? If you have the former, what’s the likelihood of having the retina detach at some point?
Alex_Yuan,_MD._PhD: Yes, patients with PVD have a higher risk of retinal detachment. Approximately seven to 15 percent of patients with symptomatic PVD will have a retinal tear. The chance is higher if hemorrhage is found on exam and lower if it is not. Retinal tears are precursors to retinal detachment. Left untreated up to half of retinal tears may lead to retinal detachment. Retinal tears can be prophylactically treated with laser to prevent retinal detachment.
ptone26: What are complications of surgery for retinal detachment, and what is the recovery like?
Alex_Yuan,_MD._PhD: Risks can include infection, bleeding, need for more surgery, glaucoma or high eye pressure, damage to the retina or eye, and even loss of vision. However, left untreated, most retinal detachment will lead to permanent and irreversible loss of vision. Given the risk/benefit ratio for retinal detachment repair, it is advisable to treat retinal detachments. Sometimes laser can be added to avoid surgery. Recovery depends on the approach to surgery. Scleral buckle usually has the longest recovery. It also depends on what type of gas is used or if oil is used instead.
janophelia: I had an operation to remove an epiretinal cyst or macula pucker. When the gas bubble finally disappeared after 7 weeks, it took my retina with it. Is this very unusual? My retina has been reattached and now, I have silicon oil in my eye. How long before it should be removed and what are the odds that I will regain much sight in this eye? (Now at two weeks since the second surgery, I am just seeing shapes and light.)
Alex_Yuan,_MD._PhD: There are risks associated with all surgeries and unfortunately, retinal detachment is a risk for retinal procedures. It is rare, but it does happen. There is no set date for removal, but I usually wait two to three months. Without knowing more details about your vision, surgery, and nature of detachment, I can’t address your question regarding your visual prognosis.
janophelia: I had a detached retina reattached recently. The doctor changed my lens to make it compatible with silicone oil during the same operation. Since the operation the doctors and ophthalmic technicians have not been able to get a clear view of my retina. They theorize that there might be a lot of blood blocking their view, and say that my eye may need to heal for a couple more weeks before they get a clear view. Is this very unusual?
Alex_Yuan,_MD._PhD: Bleeding during vitrectomy may occur depending on what type of surgery was performed. With a lens exchange, bleeding may occur. I think it is reasonable to wait for the blood to clear. If it is blood, it can be visualized. An ultrasound can be done to make sure the retina is attached.
Retinal Artery Occlusion
whiskey74: What is a retinal artery occlusion?
Alex_Yuan,_MD._PhD: A retinal artery occlusion is blockage of the blood supply feeding the retina (central retinal artery occlusion) or parts of the retina (branch retinal artery occlusion). They result in vision loss and scotomas (blind spots). Complications from artery occlusions can occur including glaucoma, bleeding inside the eye, and even retinal detachments.
Cystoid Macular Edema and Macular Edema with Branch Vein Occlusion
bren4: My 13-year-old daughter has been diagnosed with cystoid macular edema. The fluid was noticed last March when she mentioned that her glasses were not helping and through a vision test, changing the lenses was not improving her vision. She has been tested for the genetic disease X-linked juvenile retinoschisis, which was negative. She was put on dorzolamide, one drop twice daily for three months, and had a significant decrease in the fluid as shown through the optical coherence tomographic (OCT) scan. On her four month follow-up, her fluid had slightly increased and vision in one eye slightly decreased, so her drops were increased to one drop three times daily. Her eye pressure has been about 19. They still do not know what is causing this fluid. Is there another form of treatment or possible causes or disease that she should be tested for?
Alex_Yuan,_MD._PhD: The differential for cystoid macular edema is broad and can include uveitis, vein occlusion, medication/supplement induced, retinal dystrophies, etc. I recommend you come in for a thorough examination by one of our retina specialists.
jttk44: My wife is suffering from a branch retinal vein issue. She is receiving Avastin® (bevacizumab) injections monthly or bi-monthly. I am trying to find an alternative drug that would be covered by my medical provider. Lucentis® (ranibizumab) and Eylea® (afilbercept) are not covered either. Are there other treatments I could look into?
Alex_Yuan,_MD._PhD: It is surprising that Avastin® is not covered for macular edema with branch vein occlusion. Other treatment options are intravitreal steroids and laser. You may want to ask your provider to see if Avastin® is accepted if macular edema is present.
Marie14: If an individual in his mid 50s, has degenerative myopia (-21, -17) and has had lacquer cracks that have been successfully treated with Visudyne® (verteporfin), is there anything that the individual can do to prevent further deterioration?
Alex_Yuan,_MD._PhD: As long as no choroidal neovascularization develops, then frequent monitoring is all that is necessary.
Idiopathic Juxtafoveal Telangiectasia (IJFT)
jobajua2: I have been diagnosed with idiopathic juxtafoveal telangiectasis OS>OD. There are several intraretinal cysts on the OCT, but no significant thickening on the optical coherence tomography (OCT). Although my vision is decreasing in my left eye, my doctor has told me that there is nothing short of surgery that can be done to stop or slow the loss of vision. Because of the location of the cysts in my retina, my doctor has told me that surgery is too dangerous. Is there anything in your opinion that can be done to save my eye sight?
Alex_Yuan,_MD._PhD: Laser therapy can help in cases of idiopathic juxtafoveal telangiectasia (IJFT) type I. If both eyes are affected, you probably have type II, which does not benefit from laser. Your ophthalmologist will monitor you to make sure you do not develop choroidal neovascularization (CNV). If you do develop CNV, then treatment is available. However, without CNV, there are not proven treatments for IJFT type II. If you are losing vision quickly, I would ask your ophthalmologist to make sure you do not have CNV. Usually vision remains fairly stable for a long time in patients with IJFT.
ccligal: Under what circumstances, surgery or condition is lying on the stomach necessary?
Alex_Yuan,_MD._PhD: When a gas bubble or oil is necessary, then special positioning may be required. Gas and oil floats inside an eye. The macula is responsible for the central vision and in order to keep gas or oil buoyant on the macula, you must lie on your stomach and face down. Surgeries for retinal detachment, macular hole usually require some type of face down positioning.
PriscillaHendrick: I have wet macular degeneration in both eyes and a pucker in one. Avastin® (bevacizumab) injections keep my non-puckered eye stable at 20/30. One Avastin® shot helped the leakage in the eye that is puckered, but my vision unchanged (20/100) after two more injections. Does a pucker get thicker without a vitrectomy? How successful is this operation? How can I tell when or if I should have a vitrectomy?
Alex_Yuan,_MD._PhD: It is difficult to know for certain if your vision loss is attributed to macular degeneration or your pucker. Your retina specialist should be able to help guide you to make the right decision. In the absence of macular degeneration, the operation is anatomically very successful (well over 90 percent). However, the vision may return to completely normal. Distortion caused by macular pucker is usually greatly improved after surgery.
Dillard: I have glaucoma and take Xalatan® (latanoprost 0.005 percent OP one drop daily at bedtime) and type 2 diabetes (A1c of 6.1) controlled with Glucotrol® (glipizide) 5 mg oral tablet twice daily. I understand that a vitrectomy may cause elevated pressure inside the eye (intraocular pressure, or IOP), especially in people who have glaucoma. Can I still consider this surgery to be safe?
Alex_Yuan,_MD._PhD: During vitrectomy, the eye pressure is modulated and can be controlled by the surgeon. If there is significant bleeding during vitrectomy, the pressure is usually elevated for very brief periods of time to control the bleeding. Usually, these brief spikes in pressure do not cause permanent damage. After vitrectomy, steroid drops are used to control inflammation, and those steroid drops may cause your pressure to be elevated. As long as you are monitored, then your doctor should be able to manage your pressure. Sometimes a gas bubble or silicone oil is used after vitrectomy to repair a detached retina, and your pressure could be elevated from the gas bubble as well. Your retina doctor will see you after surgery to see if your pressure spikes. Although it is a risk, with careful monitoring vitrectomy is safe in glaucoma patients.
ccligal: How common is infection after vitrectomy? How common is retinal detachment one month after vitrectomy?
Alex_Yuan,_MD._PhD: Infection is very rare probably less than 1:1000 cases. Retinal detachment one month after vitrectomy is usually due to proliferative vitreoretinopathy (scar tissue formation). After retinal detachment surgery, proliferative vitreoretinopathy occurs about five percent of the time. After other types of vitrectomies, it is rare to have retinal detachment and probably occurs 1:100 times or less.
perplexed: I had a vitrectomy for a macular hole in February 2013 with a lens replacement roughly six months later. Aside from a small blacked out area in the very center of my vision, I could see clearly up until about two months ago. My distance vision is not as clear and I can no longer read with my glasses with that eye. The vision actually seems hazy. I have been told the hole is flat and sealed. What happened to my vision and can anything be done to improve my vision again?
Alex_Yuan,_MD._PhD: There are many possible causes for hazy vision. You will need an evaluation to see what is causing this. Approximately one third of patients can develop a posterior capsular opacity after cataract surgery and this is just one common cause of hazy vision that can be treated. I recommend you make an appointment for an evaluation.
Cataract Surgery After Scleral Buckle Surgery
liesel: In January 2012 I had surgery for a detached retina where I got the scleral buckle (sponge). I had an extremely long, painful recovery. I had extreme double vision in that eye immediately. In February 2012 I had eye muscle surgery to help with left hypotropia. That surgery was not successful. I had a second eye muscle surgery in September 2012 with a different surgeon. That surgery helped the double vision a lot for a few months and then it got worse again. I still see double looking up and first thing in the morning the eye is in a somewhat locked down position for about two hours. Toward the evening that eye gets really tired and things get very blurry. I did not like the prism glasses. I needed a 5 prism. I do wear glasses with left upper 3 prism for evening TV watching only.
Is there anything more I can do? I am also worried that in the future if I have to have cataracts eye surgery on that eye, how difficult that would be? I am 75 years old.
Alex_Yuan,_MD._PhD: I am sorry to hear about your many difficulties after surgery. Cataract surgery should not be any more difficult after scleral buckle surgery and muscle surgery. What did your strabismus doctor recommend as far as further correcting your double vision with surgery? Sometimes, the buckle can also be removed and this might help.
Cataract Surgery After Vitreous Detachment
slizzy: I am very nearsighted and have recently been diagnosed with vitreous detachment. I am scheduled for cataract surgery in May, and am wondering if it is safe to move forward with surgery while I have this condition?
Alex_Yuan,_MD._PhD: Yes, it is safe to have cataract surgery with a vitreous detachment. Sometimes cataract surgery can precipitate vitreous detachments. If you have new symptoms such as new floaters or flashes of light after surgery, let your ophthalmologist know so a thorough dilated exam can be performed.
Cataracts Following Macular Pucker Surgery
Mtclimber: Following removal of scar tissue in macular pucker cases, what percentage of patients develops cataracts, and after what period of time does this occur?
Alex_Yuan,_MD._PhD: A very large number of patients over the age of 55 years old will develop a cataract within two years. In some studies, the percentage is as high as 80 to 90 percent.
xdwl: I am a 56-year-old female. I lose small parts (15 to 20 percent) of my visual field intermittently, usually in bilateral temporal areas (upper corners). In the affected small area, I can still feel the light twinkling, but have no clear picture. The rest parts of my visual field seem OK, but my eyes could not focus when this happened. These symptoms initially started six months ago, and occur every one to two weeks. The symptom usually last for a few hours. I have no clue how it happened and how it can be relieved. I have no history of eye or head trauma, no smoking, no hypertension, and my blood sugar and lipids are normal. The ophthalmologist examined my eyes with mydriatic agent, and could not find the reasons for my problem. My vision acuity is 1.0 in both eyes, and eye pressure is normal. I appreciate your advice on what may be my problem and whether there are any treatment options?
Alex_Yuan,_MD._PhD: Bilateral symptoms such as you are describing are rarely due to the retina. It would be a big coincidence to have similar problems present in both eyes simultaneously in such a symmetrical pattern. I would recommend you have an evaluation with one of our neuro-ophthalmologists (Gregory Kosmorsky, DO or Lisa Lystad, MD). It could be something simple like migraines, but other problems involving the visual pathway will need to be ruled out. Those would require a good exam and perhaps some testing.
Lifestyle, Diet and Supplementation
MoR: Are there any lifestyle or dietary changes that show promise for slowing dry age-related macular degeneration (AMD)?
Alex_Yuan,_MD._PhD: Absolutely! Smoking is a huge independent risk factor and quitting will help. Also, diets rich in colorful vegetables and fruits are helpful. The AREDS study showed micronutrients helped slow the progression of dry AMD by 25 percent.
ccligal: Are there vitamins or other preventions to stem the progression of macular pucker?
Alex_Yuan,_MD._PhD: I am not aware of any vitamins or supplements that can prevent the progression of macular pucker.
SusieQ52: What can be done to prevent further retina damage? Does a vitamin D deficiency affect the health of the retina?
Alex_Yuan,_MD._PhD: It depends on what type of damage. If a patient has a macular hole for example, then repair is recommended to prevent further damage. Not all retinal damage is the same. I am not aware of the effects of vitamin D on the health of the retina.
Stem Cell Therapy
Carol D: I have wet age-related macular degeneration (AMD) in both eyes and an epiretinal membrane in one eye. I receive Avastin® (bevacizumab) in my left eye and Eylea® (afilbercept) in my right eye every five weeks. I just read about a stem cell procedure in Florida that is in a clinical trial now. Can you tell me more about it or about other clinical trials available—preferably in the area of Columbus, Oh?
Alex_Yuan,_MD._PhD: I am not familiar with any stem cell trials that look promising. There is active basic science research in this area, but I have not seen convincing results published thus far. Unfortunately, having prior treatment in your eye would make you ineligible for many clinical trials. Most trials recruit patients who have not been treated previously. I would recommend steering away from trials that ask for payment beyond what your insurance should already cover.
icarch: When do you anticipate the availability of stem cell injections to restore clarity of vision for patients that have lost portions of color sensitivity in the retina? My retina is restored to a normal shape, but the firing of the nerve cells has not returned as I had hoped. I can see large to medium objects but can't read with the eye that was repaired. Are there options other than stem cell therapy?
Alex_Yuan,_MD._PhD: Stem cell therapy has not yet been proven for the retina. More research is necessary at this point.
Cleveland Clinic and Insurance Plans
Dillard: I am located in the mid-south. Would Cleveland Clinic accept me as a patient? I have Medicare with a supplemental Plan G.
Moderator: If you have questions regarding insurance or information for covered treatments, you may contact one of our financial representatives at: my.clevelandclinic.org/patients-visitors/billing-insurance/financial-review-services.aspx.
Moderator: I am sorry to say that our time with Dr. Alex Yuan is now over. Dr. Yuan, I would like to thank you for sharing your time to answer questions today.
Alex_Yuan,_MD._PhD: I want to take this opportunity to thank everyone for participating in our retina chat. It was a pleasure to chat with all of you.
To make an appointment with Dr. Yuan or any of the other specialists at the Cole Eye Institute, please call 216.444.2020 or call toll-free at 800.223.2273, ext. 42020. You can also visit us online at www.clevelandclinic.org/eye.
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