Online Health Chat with Justis P. Ehlers, MD
April 22, 2016
Your retina is the light sensitive lining in the back of your eye. It contains millions of special nerve cells that react to light. These photoreceptors send electrical impulses to your optic nerve. Your brain converts these impulses into the images you see. Most people never give their eyes – let alone their retinas – a second thought until something goes wrong. Yet, retinal diseases are the leading causes of blindness in adults in the United States.
At Cleveland Clinic’s Cole Eye Institute, our retina staff has the expertise to accurately diagnose and offer world class treatment for retinal diseases, including age-related macular degeneration (AMD), diabetic retinopathy, macular diseases and retinal detachment, as well as more uncommon conditions such as retinal inflammatory diseases and retinitis pigmentosa. Cole Eye Institute is among the world’s most advanced eye institutes, and is ranked Number 6 nationally by U.S. News & World Report (2015-2016).
Seeking treatment as soon as possible is often critical when it comes to many retinal diseases. In many cases, early diagnosis and treatment can help stop vision loss.
About the Speakers
Justis P. Ehlers, MD, is a staff physician on the vitreoretinal service of the Cole Eye Institute in the Department of Ophthalmology at Cleveland Clinic. He was appointed in 2010. Dr. Ehlers received his undergraduate degree summa cum laude at the University of Notre Dame. He completed his medical degree at the Washington University School of Medicine in St. Louis, Missouri. Following medical school, he did an internship at St. Luke’s Hospital in Chesterfield, Missouri. He completed his ophthalmology residency at the Wills Eye Institute in Philadelphia, Pennsylvania and served as chief resident from 2004 to 2005. From the Wills Eye Institute, Dr. Ehlers then completed a vitreoretinal surgery and disease fellowship at the Duke Eye Institute in Durham, North Carolina.
Let’s Chat About Retinal Conditions
RayMC: In 2010, I had a branch retinal artery occlusion (BRAO) and have lost eyesight in the upper hemisphere of my right eye. In 2014, I had a stent implant in my coronary artery. Here are my questions. Thanks for answering them.
- What is the likelihood, statistically, of another BRAO?
- In the absence of any bleeding, does it make sense for me to remain on Plavix plus 81 mg aspirin forever?
- Are there any new procedures on the horizon that could restore the lost vision to my right eye?
Justis_Ehlers,_MD: The risk of a subsequent retinal artery occlusion depends on the underlying condition that may have contributed to its formation. For example, if someone has an underlying inflammatory condition that contributed to the artery occlusion, the risk may be higher of a second event than in someone in whom the occlusion occurred without other risk factors. Regarding the use of Plavix or other anticoagulants:. The evidence has not supported a clear use of these medicines for the treatment or prevention of BRAO. However, often there are other systemic conditions that may benefit from these medicines (such as having a stent). This decision should be guided by a primary care physician or cardiologist. There is ongoing investigation into ways to deal with the occlusion. To date, studies have generally had results that showed limited benefits of agents, such as clot-busting drugs (e.g., tPA), and potential systemic risks. New potential surgical procedures and targeted delivery of therapeutics may offer some hope in these cases in the future.
TheCeladon: Two years ago I had a transient ischemic attack (TIA). Several days after the event, a spot formed in my right eye. It is a grey area near the center of my vision that blocks a portion of my vision. I saw an eye doctor soon after and was told that it should resolve itself within a few months. I was given eye drops, which didn't help. Two years later, the spot is still there. I saw another eye doctor recently (not a retina specialist). I was told that it is most likely permanently damaged. My eye was scanned, and I was shown a computer image of the damaged area. My question: Is the damage permanent and are there any new procedures available for this problem? Thank you.
Justis_Ehlers,_MD: It is difficult to determine what the specific condition is without evaluating the scans and performing a clinical examination. Generally speaking, if there is retinal damage that persists for more than several months, it often does not completely resolve. Sometimes, it can improve over time, but other times it does remain. I would suggest asking your doctor where the damage is located (e.g., retina, nerve) and potentially inquire about a referral to see an appropriate specialist to better answer your questions.
Discovering Wet AMD
Grannyscott: I have been diagnosed with the following:
- "PRIMARY” new neovascular age-related macular degeneration (AMD)
- Findings consistent with drusen and RPE changes
- No evidence of macular edema
- No evidence of subretinal fluid
I would like to know whether this diagnosis means I am developing wet macular degeneration, which will lead to blindness. I am scheduled to have shots in both eyes every four weeks.
Justis_Ehlers,_MD: If the findings of your exam showed only drusen and RPE changes without any evidence of choroidal neovascularization activity (such as macular edema, subretinal fluid, retinal hemorrhage), this suggests that your wet AMD is being well controlled with your injections. You should clarify with your doctor your exact diagnosis. Neovascular AMD and "wet macular degeneration" are synonyms.
BETHELMOM: In 1995, my son had an eye injury. He and his friends were playing "homerun derby" when they found a golf ball on the town field and decided to hit it with a bat. Unfortunately, my son was pitching and tried to catch the ball. It hit him in the eye, causing major damage (whole in the center of retina, orbital fracture, pushed the eye back a little). He ended up having surgery, removing vitreous fluid and attempting to close the hole, which wasn't very successful. As a result, today he only has peripheral vision; the center vision is entirely dead. My question is: Eleven years later, is there any surgery that can reverse the damage and possibly give him some vision back in that eye through the retina? Retina replacement, etc.?
Justis_Ehlers,_MD: When a macular hole does not close, additional surgical repair can be attempted. However, this is usually preferred in the near future following the first surgery. If the hole has been there for several years, the potential benefit from trying to close that hole is minimal. Additionally, in trauma, the retina can be damaged such that even if the hole is closed, we do not see return of function. There are significant efforts in research toward regenerative therapy (e.g., stem cells, potential partial transplantation), but all of these studies are either still in animal models or very early on in clinical studies.
liesel: In 2012, I had surgery for a detached retina where I got the scleral buckle (sponge). I had extreme double vision in that eye immediately; and two months later, I had eye muscle surgery to help with left hypotropia. That surgery was not successful. I had a second eye muscle surgery on September 17, 2012, with a different surgeon. That surgery helped the double vision a lot for a few months, and then it got worse again. My body makes too much scar tissue. I still have double vision, but I have gotten used to it.
Is there anything more I can do? I am also worried about the future when I have to have cataract eye surgery on that eye. How difficult that would be? I am a 77-year-old female.
Justis_Ehlers,_MD: Significant double vision after scleral buckle surgery is a known potential risk. In many cases, it resolves over time, but in other cases, it requires more significant interventions. It is often challenging to manage. Scleral buckle removal and muscle surgeries are both potential options. I would not expect the double vision issue to complicate the cataract surgery, but unfortunately cataract surgery won't likely improve the double vision. Given that it has been almost four years since your last surgery, it is also tough to know if additional surgery would be helpful given the level of scarring. I always think that second opinions can be helpful in these situations with both a retina specialist and a strabismus specialist (muscle-surgeon, often a pediatric ophthalmologist).
SusQ: Are there any negative implication to having cataract surgery on the progression or other issues with early, dry AMD?
Justis_Ehlers,_MD: There is no evidence that having cataract surgery results in progression of early, dry AMD. Depending on the level of AMD, it is always important to consider the potential impact of the AMD on overall vision and that it may impact the overall visual outcome.
CassiO: Is there a link between cataract surgery and macular holes?
Justis_Ehlers,_MD: There has not been a clear link established between cataract surgery and macular hole. The development of a macular hole is associated with the vitreous jelly pulling on the center of the retina (macula). This can result in the development of a hole.
During cataract surgery, there can be some normal shifts in the vitreous jelly that could theoretically pull more on the retina. However, it is not clear whether a macular hole specifically resulted from cataract surgery or that the macular hole would have developed regardless of cataract surgery.
Carol D: I have wet AMD in both eyes and have been receiving injections for 10 years. I also have an epiretinal membrane in my right eye, which causes a lot of blurring and distortion. My retina specialist thinks the risks may outweigh the benefits of surgery to remove the membrane and suggests that the problems may stem from a small cataract. My ophthalmologist said that the cataract is not causing the problems and that the epiretinal membrane is the culprit. I am 76 years old and in excellent health. Please advise as to the next steps. Thank you.
Justis_Ehlers,_MD: When a patient has two retinal issues (such as wet AMD and an epiretinal membrane), it is always challenging to discern which process is primarily responsible for the visual symptoms. For example, both the epiretinal membrane and the wet AMD can result in blurring and distortion. I always suggest that having the wet AMD under complete control is really important prior to considering surgical intervention. I also always feel that when it is unclear whether surgery is helpful that a second opinion can be really useful.
jjsjjs: I am 78 years old, and four years ago, I had retina surgery for removal of an epiretinal membrane, which has left me with poor vision in the affected eye. What causes the formation of these membranes, and how likely is it that I will get another one.
Justis_Ehlers,_MD: These membranes can form due to multiple causes. Most frequently, we are not able to identify a specific cause. In these cases, they are thought to result from the abnormal interaction of the vitreous jelly in the back of the eye and the retinal surface. Other potential associated causes include retinal tears, retinal vascular occlusions, inflammatory eye disease, diabetic retinopathy and others.
Once it has been removed during surgery, depending on the surgical technique and approach, the risk of significant recurrence is between one percent and 10 percent.
jjsjjs: I also was wondering if I was more likely to get an epiretinal membrane formation in my left eye since I already had one in my right?
Justis_Ehlers,_MD: There is probably a small increased risk for developing an epiretinal membrane. However, if your doctor has performed scans and examined the back of your other eye, and there is no evidence of any significant membrane at this time, the risk of needing surgery in your other eye is probably pretty small.
A Unique Disorder
flrp: I am 77 years old and in excellent health, but I have been diagnosed with a lamellar macular hole in my left eye. I appear to be at level two on the cataract scale of four. I have been told the hole is about the size of a pin head. The condition was detected three years ago, and the retina specialist believes the best course of action is to monitor the hole. At this time, most of my reading is done via my right eye, with the left eye closed. When trying to use both eyes, the printed line becomes distorted. Straight lines that define the lanes on highways become distorted and wavy. Here are my questions:
- What caused the condition?
- Will the hole continue to grow and the vision deteriorate?
- Will the macular hole spread to the other eye?
- Is there treatment for this condition? A) To stop the growth of the hole? B) Or to correct the problem?
- If surgery is required to contain and/or minimize the size of the hole, what is the success rate of the surgery? What is involved in the surgery?
Justis_Ehlers,_MD: Lamellar macular holes are typically caused by the growth of a membrane on the surface of the retina or loss of a portion of the macular tissue. Generally speaking, they can be symptomatic but the vision loss is not severe. The only potential treatment for lamellar macular holes is surgery. However, this is controversial. The results are quite variable, and if the symptoms are mild and the vision remains fairly good, many retinal surgeons will recommend observation alone. Lamellar macular holes usually do not progress significantly or progress slowly. There is likely a higher risk of developing it in your other eye, but there are no specific preventive measures.
Grannyscott: I have been diagnosed with macular degeneration and begun a routine of shots in my eyes every four weeks for the foreseeable future. Are these shots an attempt to prevent dry macular from turning into wet, or do they indicate that my condition is already the wet kind and the drops may help to keep me from losing my vision?
Justis_Ehlers,_MD: The only approved therapies for macular degeneration that involve shots are for the wet macular degeneration. Many physicians initiate treatment every four weeks, but often spread the shots out if the patient is doing well and responds well to the therapy over time. There are now medications that are under investigation (e.g., clinical trials) for dry macular degeneration that involve shots as well. I would suggest clarifying with your physician what specific condition you have.
Dynamo56: One thing has puzzled me about Lucentis injections as a treatment for age-related macular degeneration. My layman's understanding is that the optimum treatment cycle is an injection every 30 days, but there seems to be a focus on reducing the number of shots through "trial and (unfortunately) error." In my case, my AMD had stabilized until the interval reached seven months. There seems to be more focus on cost containment and reduction of patient discomfort than on positive outcomes. Should patients have more of a say in establishing the treatment timetable? If AMD develops in my other eye, I would like to be able to insist on monthly injections.
Justis_Ehlers,_MD: My personal belief is that all patients should have a major say in the treatment timetable. I actually discuss the evidence for a few different approaches to the management of macular degeneration and let them choose. Generally speaking, very few retinal specialists perform long-term monthly therapy. Several studies have shown that more personalized approaches may also have excellent outcomes while reducing overall treatment and visit burden for the patient.
Although injections are well-tolerated and generally low-risk, there is a small but real risk of a major problem with every injection (e.g., infection, retinal detachment). These complications can be devastating. Studies have shown that more frequent injections (e.g., monthly) may be associated with higher risk of infection. Generally speaking, the risk of progression of untreated wet AMD is dramatically higher than the risk of infection, but individualizing care may help to optimally modify all those risks.
One approach is an "as needed" approach. Evidence suggests that these patients need to be followed every month and are treated if there is any sign of activity. If there is no activity, there is no injection. This minimizes injection frequency, but still requires frequent visits. When patients are not followed that frequently, there is significant risk of subsequent vision loss.
The current most popular approach is something called "treat-and-extend." In this approach, a patient is treated at every visit, but the treatments are slowly spread out. Once a small amount of activity is seen, the optimal treatment interval is determined as just shorter than that time period. For example, at 10 weeks in between shots a patient may have a little activity, but at eight weeks everything looks perfect. Treatment would then be maintained every eight weeks.
Other factors that may also play a role in deciding the best treatment approach includes the status of the other eye (such as visual acuity, severity of macular degeneration), the severity of the initial activity of the wet macular degeneration) and the ability of the patient to come in for frequent visits.
All of these options should be discussed with your doctor, and any patient should have a voice in their treatment regimen.
On the Horizon
Curevase: I understand there is a new treatment and hope for those who suffer with macular degeneration. If so, can you tell me if there is any new treatment or breakthrough regarding myopic degeneration. Is there a way to slow down the progression to avoid retina damage and or hemorrhaging?
Justis_Ehlers,_MD: Over the last several years, multiple new medications have emerged for the treatment of wet age-related macular degeneration. Many of these treatments are used by retina specialists for the management of myopic degeneration when choroidal neovascularization occurs. This is an abnormal growth of blood vessels, similar to wet macular degeneration, that may result in retinal swelling or hemorrhage. Although these medications are not specifically approved for myopic degeneration, multiple small studies have shown that they can be effective in treating the abnormal blood vessels when they occur. There is a lot of research on how to slow down "dry" myopic degeneration, but there are no currently approved treatments.
That is all the time we have for questions today. Thank you, Dr. Ehlers, for taking time to educate us about retinal conditions.
On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.
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For More Information
Cleveland Clinic’s Cole Eye Institute is ranked among the top 10 ophthalmology programs in the country by U.S. News & World Report, making it the top-ranked program in Ohio. We are among an elite group of dedicated, comprehensive eye institutes. Our fully integrated model helps us provide patients with quick and easy access to specialty and sub-specialty care for a wide spectrum of eye conditions -- from the routine to the complex. Cole Eye Institute has extended its quality ophthalmic care to several locations throughout Northeast Ohio, allowing patient access to ophthalmologists closer to their homes. To learn more, visit http://my.clevelandclinic.org/eye.
Cleveland Clinic Health Information
Learn more about retinal conditions:
Retinal Detachment: http://my.clevelandclinic.org/services/cole-eye/diseases-conditions/hic-retinal-detachment
Retinal Vein Occlusion: http://my.clevelandclinic.org/services/cole-eye/diseases-conditions/hic-retinal-vein-occlusion
Retinitis Pigmentosa: http://my.clevelandclinic.org/services/cole-eye/diseases-conditions/retinitis-pigmentosa
Retinopathy of Prematurity: http://my.clevelandclinic.org/health/diseases_conditions/retinopathy_of_prematurity
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For additional information about clinical trials, visit: ClinicalTrials.gov.
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