Age Related Macula Degeneration – AMD

 

Age related macula degeneration (AMD) is a very common cause of blindness amongst the elderly population. Utilizing US census data physicians have estimated by 2020 almost 3 million people were likely to develop AMD. Constant research is occurring to search for more advanced therapies to treat this condition.

AMD is often divided into wet and dry. Dry macula degeneration is far more common. Its presence is dedicated by a dilated eye exam. Wear and tear changes build up in the very metabolically active macula (the center part of your vision) at the back of the eye in patients over 50 years of age. Some AMD patients have genetic predispositions to developing their disease. Other patients have modifiable risk factors that they can control to help slow the progression of their condition. The most important of these is smoking, as smoking is known to accelerate disease progression. Other factors in your control include maintaining good blood pressure and exercise.

Wet AMD occurs when new blood vessels grow underneath the retina. These leak fluid and bleed potentially causing rapid changes in central vision. Thankfully treatment of this condition has been revolutionized by injections delivered inside the eye painlessly. In many cases sight can be preserved with prompt treatment.
Historically, only destructive laser treatments were available that attempted to limit disease progression of wet AMD. Research showed that immature new vessel networks like those found in wet AMD need a biochemical called vascular endothelial growth factor (VEGF) to grow and thrive. Originally used for colon cancer, Avastin was one of the first anti-VEGF to be injected into eyes. The results were a dramatic reduction in activity of the new blood vessels networks, limiting their bleeding and fluid leakage and either restoring or preserving vision in a lot of patients. Now there are 2 other anti-VEGF medications available to use in addition to Avastin. Choice is physician dependent and good arguments can be made to select all three.

If you are identified as having wet AMD you will typically be recommended to receive monthly treatments by your retina doctor until your disease is under control. At this point many physicians extend treatment, this attempts to reduce treatment burden whilst keeping the eye safe. A lot of patients can be safely extended, some have new vessel networks that need more medication to treat, and cannot safely be extended. In the future sustained release medications may become available reducing treatment burden for many patients.
Developments in AMD are occurring all the time, new ways to monitor for progression (including home monitoring), new technology to detect wet AMD earlier, and in the future surgical intervention with stem cell therapies are all in progress. If you are older than 50 and have a family history of AMD talk to your eye care provider about getting screened for AMD.

 

Henry Holt, M.D.

1801 N. H. Medical Park Drive

Wilmington, N.C. 28403

Myopia and the Macula

Nearsighted individuals can develop problems in the center part of the vision. Very nearsighted individuals can develop thinning in the macula which is the center part of the retina. The macula is necessary for our finest detailed vision. Sometimes the thinning can disturb one of the layers of the retina which functions as a barrier between the underlying blood vessels in the choroid and the retina itself. Just like cracks in a pavement these thin areas can grow ‘weeds’ (new blood vessels). In fact a lot of pathologies in the macula that we treat have as there common path new blood vessel formation. Wet macular degeneration patients being the obvious example, here new blood vessel formation results from progressive degenerative change where age is the greatest risk factor.

The good news for myopic individuals is oftentimes their prognosis is better for their macula degeneration compared with their wet AMD counterparts. Patients with myopic choroidal neovascularization (new blood vessel formation or cnv) may experience distortion or a blur in their central vision. Oftentimes patients in this situation are extremely sensitive to any changes in their vision. If a patient has myopic CNV the standard of care is intravitreal medications (medications delivered inside the eye). Thankfully myopic patients often respond very well to treatment and can continue to enjoy good central vision for a long period of time. If you are extremely nearsighted it is important to get regular eye checks and if your ophthalmologist suspects myopic macular degeneration a retina specialist evaluation is always reasonable.

Henry Holt, MD
1801 N.H. Medical Park Drive
Wilmington, N.C. 28403

Hurricane Florence Aftermath

Offices of Retina of Coastal Carolina have reopened and phone service is restored.  Please note that only calls to our main numbers, 910 254 2023 or 910 355 0896 are routed to our answering service when the office is closed.  We continue to reschedule patients not seen during the storm closing.

You may also message us through your Patient Portal.

Myopia – Retina Pathologies and Treatments

 

 

Should everybody with peripheral retinal pathology be treated?

This is controversial. The best data that we have would indicate it is reasonable to observe a lot of peripheral retinal pathology as the amount of subsequent retinal detachments are infrequent therefore one would have to treat a lot of patients to prevent one retinal detachment. However if you ask any retinal surgeon which they would prefer to treat; an atrophic hole with laser in the office or a retinal detachment in the operating room I know which one they would opt for!

So how do we decide?

I tend to treat patients that are symptomatic with flashing lights, or who have had a retinal detachment in the other eye, or who have a strong family history of retinal detachment. The risk of laser is minimal so I also offer each patient with peripheral pathology the option of prophylactic laser. Regardless of the decision to treat or observe nearsighted individuals should follow regularly with an ophthalmologist. And those that have peripheral retinal pathology should see a retina specialist once a year.

Henry Holt, MD
1801 N.H. Medical Park Drive
Wilmington, N.C. 28403

Myopia and the Retina

Myopia is a refractive state where the light entering the eye is focused naturally before the retina. It can either be refractive which is often due to the shape of the cornea, or it can be axial which is related to the length of the eye. Most people in a retinal office have axial myopia. Their eye is longer than average. As a consequence the retina is thinner than average. This can cause a number of different issues.

In the periphery degenerative holes or thin areas in the retina (lattice degeneration) can form leading to chronic retinal detachment. In the center of the retina, the macula, degenerative changes and thinning of the retina can lead to new blood vessel formation which can cause irreversible central loss of vision.

Who is at risk?

Although there is no definitive cutoff pathological myopia is defined as a prescription of greater than minus 8D. In practice anyone with myopia and a family history of retina issues should get screened by an ophthalmologist to ensure their eye is healthy.

Henry Holt, MD
1801 N.H. Medical Park Drive
Wilmington, N.C. 28403

Employee of the Quarter

Our most recent employee of the quarter is Noelle, our Executive Assistant. Noelle joined our practice 18 months ago.  She is a jack (or jill) of many trades.  Noelle has become that smiling face to go to for other staff from arranging meetings with other practices to helping address project needs in the office.  That might be purging charts, moving boxes of files, unclogging toilets, repairing crates used to transport items between locations or running errands.   That is in addition to her more routine report preparation and data entry duties.  Thank you Noelle for what you do and for your positive demeanor and contribution to the ROCC team!

Solar Eclipse Eye Safety

 

 

Solar Eclipse Eye Safety
Written by: Kierstan Boyd
Information provided by American Astronomical Society
Reviewed by: Russell N Van Gelder MD PhD

Mar. 06, 2017

A truly awe-inspiring event, a solar eclipse is when the moon blocks any part of the sun from our view. The bright face of the sun is covered gradually by the moon during a partial eclipse, lasting a few hours. During the brief period of a total eclipse when the moon fully covers the sun (only a couple of minutes), the light of day gives way to a deep twilight sky. The sun’s outer atmosphere (called the solar corona) gradually appears, glowing like a halo around the moon in front of it. Bright stars and planets become more visible in the sky.
Watching a solar eclipse is a memorable experience, but looking directly at the sun can seriously damage your eyes. Staring at the sun for even a short time without wearing the right eye protection can damage your retina permanently. It can even cause blindness, called solar retinopathy.
There is only one safe way to look directly at the sun, whether during an eclipse or not: through special-purpose solar filters. These solar filters are used in “eclipse glasses” or in hand-held solar viewers. They must meet a very specific worldwide standard known as ISO 12312-2.
Keep in mind that ordinary sunglasses, even very dark ones, or homemade filters are not safe for looking at the sun.
Steps to follow for safely watching a solar eclipse:
Carefully look at your solar filter or eclipse glasses before using them. If you see any scratches or damage, do not use them.
Always read and follow all directions that come with the solar filter or eclipse glasses. Help children to be sure they use handheld solar viewers and eclipse glasses correctly.
Before looking up at the bright sun, stand still and cover your eyes with your eclipse glasses or solar viewer. After glancing at the sun, turn away and remove your filter—do not remove it while looking at the sun.
The only time that you can look at the sun without a solar viewer is during a total eclipse. When the moon completely covers the sun’s bright face and it suddenly gets dark, you can remove your solar filter to watch this unique experience. Then, as soon as the bright sun begins to reappear very slightly, immediately use your solar viewer again to watch the remaining partial phase of the eclipse.
Never look at the uneclipsed or partially eclipsed sun through an unfiltered camera, telescope, binoculars or other similar devices. This is important even if you are wearing eclipse glasses or holding a solar viewer at the same time. The intense solar rays coming through these devices will damage the solar filter and your eyes.
Talk with an expert astronomer if you want to use a special solar filter with a camera, a telescope, binoculars or any other optical device.
For information about where to get the proper eyewear or handheld viewers, check out the American Astronomical Society.

The Next Total Solar Eclipse: Aug. 21, 2017 across North America
On Monday, Aug. 21, 2017, a solar eclipse will be visible across North America (weather permitting). The whole continent will experience a partial eclipse lasting 2 to 3 hours. Halfway through the event, anyone within a roughly 70-mile-wide path from Oregon to South Carolina will experience a brief total eclipse. At that point, the moon will completely cover the face of the sun for up to 2 minutes 40 seconds.

The last solar eclipse with a path of totality (area where a full eclipse could be seen) was in March, 2016 in Indonesia and some small islands in Micronesia.
After the Aug. 2017 eclipse across North America, the next total solar eclipse will be in South America on July 2, 2019.

A Flash of Light

A flash of light

Erik van Rens, MD
Last week, I was asked to see a patient as an emergency work-in. She experienced

sudden bright light flashes and floaters.

Once she was in my office I had a chance to listen to her symptoms in more detail.

She had a sudden onset of bright stroboscopic light sensations, followed by seeing

dark spots. These lasted for about 15 minutes, after which they disappeared.

Her symptoms turned out to be related to a fairly common phenomenon called

ophthalmic migraines.

Most people associate migraines with severe headaches, but often eye symptoms are

the only manifestation of a migraine attack.

These are often very elaborate and can be very frightening, but are harmless.

Patients often see kaleidoscopic patterns with bright colors in a strobe-like fashion.

Sometimes these are followed by blind spots, usually starting in the periphery, but

these can move to the center, blocking vision temporarily. Most attacks last less than

30 minutes, after which vision returns to normal.

This patient could be reassured and she was glad it was not serious.

These flashes are quite different from the symptoms of a more dangerous

phenomenon called vitreous detachment, when the vitreous gel that fills the eye cavity

shrinks and pulls away from the adjacent retina.

This is a process we all will go through, usually as we age, but often earlier in near

sighted eyes.

These light flashes are very brief, like a shooting star, and are mostly seen in dim or

dark conditions upon eye movements. Ultimately they are followed by the sudden

appearance of floaters, some of which are permanent.

A vitreous detachment happens only once, and is benign in most cases. Sometimes,

however, it is the beginning of a bigger problem, when the gel cannot separate from

the retina and tears it. This will lead to a progressive accumulation of fluid under the

retina, forming a retinal detachment. Usually, the patient is aware of a progressive area

of vision loss, that will get worse until all vision is lost.

A tear in the retina can be treated with laser, and often will prevent the retina from

detachment.

So, if a sudden onset of bright and brief light flashes, and floaters occur,

visit an eye specialist as soon as possible, preferably with 24 hrs.

Melanoma

Just a Freckle?

 

Igor Westra, MD

Retina of Coastal Carolina

1801 N.H Medical Park Dr.

Wilmington, NC 28403

910-254-2023

 

Time flies! I didn’t realize that I hadn’t seen Mr. K for about five years. He had been seeing me annually for many years because he had a freckle in his left eye. Recently he had noticed a shadow in his vision. I had a sick feeling in the pit of my stomach when the technician told me of his symptoms.  I felt even worse when I saw the photos that he had taken of his left retina. I told the technician to go ahead and do an ultrasound of the eye.

 

Freckles of the retina are quite common. The medical term is “choroidal nevus” and these are composed of the pigmented cells that grow underneath the retina. The vast majority of these freckles are not dangerous but they may grow slightly and can become darker with age. A small minority, however, become malignant and invade the eye and metastasize to other parts of the body to eventually kill the patient.  This is called malignant melanoma and treatment is not very successful.

 

When a nevus is discovered in a patient’s eye, the doctor typically will get photographs and follow the patient on a regular basis, usually getting photographs each time. If there is any suspicious aspect to the nevus, the patient is referred to the retina specialist. I usually recommend follow up every four months when a nevus is first detected and then after a year, annual exams. In addition to photographs, we may do analysis with ultrasound and sometimes with angiography.

 

My office usually calls patients to remind them of their appointments. Mr. K had moved and his phone number had changed so he never received the call.  He knew that he had missed his appointments but felt that after all these years of follow up his lesion must be benign. Unfortunately it was not.

 

One option for treatment is radiation to the eye using a special holder that is attached to the eye for two to three days. Pre-radiation a biopsy can be done and sent for analysis and prognostic information. Another option is to cut the tumor out from between the layers of the retina. In Mr. K’s situation the tumor was too large and the eye had to be removed. The tissue showed highly invasive cells and the DNA was consistent with cells that were inclined to metastasize.  Nine months later tumors were discovered in his liver and six months later he died.

 

I tell my patients not to lose sleep over the nevus in their eye but make sure that they keep it checked out. Freckles on the skin that can be watched pretty easily and cut off and sent for testing. The choroidal nevus needs specialized equipment to monitor it and cannot be removed without causing eye damage. Fortunately this is a relatively rare cancer and with early detection the prognosis is good.

17th Annual ASRS Meeting

Members of our Management Team had the opportunity to attend the 17th Annual ASRS Business of Retina meeting in Dallas, Texas.  Kim, Janie and Martha took advantage of this yearly opportunity to attend sessions and have discussions with other practices devoted solely to the diagnosis and treatment of issues related to the Retina subspecialty.  The American Society of Retina Specialists sponsors this one and a half day session every spring, utilizing members’ expertise as well as those of various outside experts.   It provides the opportunity to remain up to date, as well as network with other retina leadership.  We learn together, commiserate together over constantly changing governmental regulations, anguish over obstacles to patient care by insurers as well as deal with the ongoing challenges of running a business.  Thanks to our physicians for this opportunity.