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In diabetes, the retinal blood vessels can develop tiny leaks. Blood and fluid seep from the retinal blood vessels, and fatty material, called exudate, may deposit in the retina. This may be associated with swelling of the retina, and it is called nonproliferative diabetic retinopathy (NPDR). When the swelling occurs in the central part of the retina (the macula), it is called macular edema and vision may be reduced or blurred. Leakage elsewhere in the retina will usually have no effect on vision.

It is important that patients be aware of what they are seeing with each eye. If a patient can detect a problem with vision very early, the chance of saving eyesight with laser surgery is much greater. Once the macula has been damaged, laser surgery is generally not as helpful. For this reason, everyone should test the vision in each eye, separately, each day.

One way to test vision in order to detect even small changes when they first appear is to use the Amsler grid. Follow these instructions:

In PDR, retinal blood vessels close off, and large areas of retina lose their source of nutrition. When this happens, peripheral or side vision is usually reduced, and the patient’s ability to see at night and to adjust from light to dark is often diminished.

As a result of this loss of nourishing blood flow, the retina responds by developing new blood vessels that are abnormal and are called neovascularization. The development of neovascularization is the retina’s method of coping with the closing of its own blood vessels and the loss of nourishment. Many people with diabetes have some closing of retinal blood vessels without ever developing neovascularization. But the problem is that when neovascularization develops, it is never always a problem. It is, in fact, dangerous to the eye. Neovascularization does not nourish the retina properly, and it may cause other problems. One problem is bleeding into the vitreous cavity (called vitreous hemorrhage). A second problem that occurs when neovascularization develops is the growth of scar tissue on the retina; the scar tissue can pull the retina off the back wall of the eye (called a traction retinal detachment). Either of these serious problems, vitreous hemorrhage or traction retinal detachment, can lead to severe loss of vision or even total blindness.

Because vitreous hemorrhage is not necessarily associated with any specific activity (although it can be associated with strenuous physical activity), people with diabetes are encouraged to have regular eye exams, and your doctor will help advise you. When a person does notice the sudden appearance of floaters, spider webs, spots in front of the eye, or blurred vision, they should immediately call their eye doctor. Vitreous hemorrhage in a diabetic is most often associated with the stage known as proliferative diabetic retinopathy (PDR).

The most common variety of retinal detachment results from a hole or tear, usually but not always in the periphery, which allows fluid to migrate under the edges of the break, and detach the retina. A limited detachment may be treated by laser surgery if the macula is not theatened. More extensive fluid build-up will require gas bubble, or Scleral Buckling, and/or vitrectomy surgery with fluid-air exchange. More complicated cases especially re-operations for the same condition may require silicone oil.

In proliferative diabetic retinopathy (PDR), the neovascularization may cause scar tissue to develop. The neovascularization and the scar tissue grow along the surface of the retina and attach firmly to the back surface of the vitreous gel. The vitreous gel pulls on the blood vessels and scar tissue and lifts them up. Because the neovascularization and scar tissue are attached to the retina, the retina is also lifted up. When the retina separates from the back surface of the eye, it is called a retinal detachment. Because the retina is pulled off, it is called a traction retinal detachment. The scar tissue can also tear the retina and cause a retinal detachment. Vitreous hemorrhage may also accompany the tractional process.

Scleral Buckling is generally performed in the operating room under local anesthesia but, in some cases, may be performed under general anesthesia. The surgeon first treats the retinal tear with cryotherapy, first looking into the eye using a cryoprobe placed on the outside part of the eye (the sclera). The surgeon then places the cryoprobe in the correct position and the retinal tear is treated. A piece of silicone plastic or sponge is then sewn onto the outside wall of the eye (sclera) over the site of the retinal tear. This pushes the sclera in toward the retinal tear and holds the retina against the sclera until scarring from the cryotherapy seals the tear. This surgery is called scleral buckling because the sclera is buckled (pushed) in by the silicone. The silicone buckle is left on the eye permanently.

Cryotherapy or laser treatment can be performed to seal the retinal tear. The surgeon injects a gas bubble inside the vitreous cavity of the eye using a needle. The patient is instructed to keep his head in a specific position so that the gas bubble pushes the detached retina against the back wall of the eye to seal the retinal tear. The patient is then asked to remain in this position for various periods of time until the retinal tear is sealed against the back wall of the eye. The surgeon will tell you how long special positioning is necessary.

The gas bubble in the vitreous cavity of the eye expands for several days and will take six to eight weeks to disappear. During this time, airplane travel or travel to a high altitude must be avoided because high altitudes can result in an expansion of gas and an increase in pressure that can damage the eye. Your surgeon will tell you when it is safe to travel. It is also important for a patient with a gas bubble not to lie face up, as the air bubble may come to rest against the lens of the eye and cause a cataract or high pressure in the eye.

Proliferative vitreoretinopathy (PVR) involves the growth of scar tissue around the vitreous and retina of the eye. It is typically a complication of retinal detachment, a disorder that occurs when the retina is pulled away from the underlying tissue to which it is normally attached. The scar tissue cells of PVR form in the area of the injury and may continue to expand even after a surgeon has corrected the detachment. This results in a tugging on the retina that can cause another detachment in either the same area as the initial problem or elsewhere along the retina. The patient may have symptoms such as visual disturbances and loss of vision.

Macular degeneration is most often related to aging. There are some unusual types of macular degeneration that start very early in life, however, most patients with macular degeneration begin to notice problems with eyesight sometimes after age 50. Macular degeneration may be hereditary and therefore may run in families. Macular degeneration usually starts with the appearance of spots called drusen on the retina. Drusen are like age spots and do not usually change vision very much themselves. Most patients with drusen never have a serious loss of vision and only a few develop severe macular degeneration with loss of vision.

Instructions on using the Amsler grid:

Drusen are considered to be a dry form of macular degeneration. When drusen are present for a long time, the macula may thin and stop working. This is referred to as atrophy or atrophic macular degeneration and it often causes a slow and progressive loss of vision.

Although there is no medical or surgical treatment for this form of macular degeneration, eyesight may be helped somewhat with the use of special low vision lenses: Magnifying lenses for close-up and telescopic lenses for distance. With counseling, people can learn to use some of their peripheral vision to help them see more clearly, and to cope more effectively with the practical tasks of every day life. Because the dry form of macular degeneration with drusen or atrophy can change into the wet form, it is important for anyone with the dry form to monitor vision (with the Amsler grid, for example) and report any new changes to their eye doctor.

In the wet form of macular degeneration, abnormal blood vessels grow under the retina and lift the retina up, very much like the roots of a tree growing under a sidewalk, these abnormal blood vessels are called sub retinal choroidal neovascularization, or CRNV. The abnormal blood vessels located under the retina may leak fluid, bleed, and lift up the retina. When this happens, vision is reduced.

The longer the abnormal blood vessels continue to leak, bleed, and grow, the more detail vision will be lost. An eye with the wet form of macular degeneration will usually lose its ability to see detail. In some cases, laser treatment done promptly may stop or minimize loss of vision but laser treatment does not guarantee that vision won’t be lost. In addition, if the abnormal blood vessels occur in one eye, there is about a one in ten chance per year that they will occur in the other eye.

The earlier that abnormal blood vessels are discovered, the more likely that some or much of the central (detail) vision can be saved. The later abnormal vessels are discovered, the less likely laser treatment can be done. In other words, pay close attention to your eyesight and see your eye doctor promptly if there is any type of change in your vision. fluorescein angiography and OCT are used to diagnose and characterize this condition.

There is a third form of macular degeneration that is called pigment epithelial detachment (PED). In this form of macular degeneration a blister (PED) can form in the macula, with or without hemorrhage, causing blurring or distortion of vision. Diagnosis is greatly facilitated using Fluorescein angiography and OCT. Intra-vitreal anti-VEGF injections are usually indicated. Laser treatment is not usually recommended unless abnormal blood vessels are also present, and located away from the fovea. If you have a PED, you will want to have your eyes examined regularly to see that the condition does not worsen.

The photographs show what changes have occurred in the retina and where those changes are located. Fluorescein angiography is necessary if the doctor thinks there is a chance that the patient could benefit from laser treatment. The photographs provide a kind of map that the doctor uses during laser treatment. Fluorescein angiography is also usually done a few weeks following laser treatment to be sure that the laser has destroyed the abnormal blood vessels.

There is another photographic test called indocyanine green angiography. This test may give additional information that may be helpful if laser treatment is to be done.

Treatment for wet age related macular degeneration is undergoing major shift from primary laser therapy to pharmacologic therapy with intraocular injection of drugs that counteract VEGF. VEGF (vascular endothelial growth factor) is a natural chemical in the body necessary for growth of new blood vessels especially for healing. Unfortunately, VEGF appears to be a major factor in the development of wet ARMD. New agents have been developed to counteract VEGF. These agents are injected into the eye at regular intervals, usually about 4 to 6 weeks apart. The results so far have been very exciting.

Treatment for macular degeneration with thermal laser or photodynamic therapy (PDT) with Visudyne combined with the injection of a steroid called Kenalog directly into the eye is still used by many retinal specialists for selected cases. This technique of the so called “cold laser” does not cause a retinal scar. Argon or “hot, thermal laser” is still used in selected cases of wet AMD. When the vessels are under the center of the macula, PDT can be used. Some retinal surgeons are using PDT combined with Avastin in an attempt to limit the number of injections required to stabilize wet ARMD.

Up to now, most cases of age related macular degeneration (ARMD) ended up with loss of vision over time with or without therapy. However, with therapy, the final vision plateaus far above what the vision would have been without therapy. With these new anti-VEGF therapies, vision in some cases may actually improve. Clinical trials with Avastin, Lucentis, and Eyelea resulted in 95% of patients staying the same or getting better, while about 40% actually improved with treatment.

The Argon laser beam is a high energy light that turns to heat when it hits the parts of the retina to be treated. This heat destroys the abnormal blood vessels, causing the wet macular degeneration and stops them from growing, leaking and bleeding. A scar forms as a result of the treatment.

Even when laser treatment is considered successful, and the abnormal blood vessels have been destroyed, additional abnormal blood vessels can appear later and further damage vision. The patient who is treated with laser should continually check the vision in the treated eye and tell the doctor immediately if there are new changes, such as a return of distortion or blurriness; in some cases additional laser treatment may be helpful.

Although prevention of AMD (age related macular degeneration) is a goal not yet reached by medical research, recent studies (The Age Related Eye Disease Study) have shown that if you have early macular degeneration, taking special vitamins can help reduce the risk of severe vision loss.

The retina is a thin sheet of nerve tissue in the back of the eye where light rays are focused and transmitted to the brain. Tiny blood vessels supply the retina with oxygen and other nutrients. Arteries deliver the blood, and the retinal veins carry it out. Sometimes one of these arteries hardens or swells and presses on a nearby vein. The vein can then become blocked, or occluded, making it difficult for blood to leave the eye. This is called a retinal vein occlusion (RVO). It is also known as venous stasis retinopathy or hemorrhagic retinopathy. The blocked circulation can lead to swelling, bleeding, growth of abnormal blood vessels, and partial or total vision loss.

Occasionally, a retinal detachment is so complicated and severe that it cannot be treated with either standard scleral buckling surgery or pneumatic retinopexy. In such cases, vitreous surgery to reattach the retina may be necessary.

Vitreous surgery is performed in an operating room usually under local anesthesia. The vitreous is removed and, therefore, this procedure is called vitrectomy. The surgeon uses a fiber optic light to illuminate the inside of the eye and other instruments inside the eye, such as forceps, and scissors, to do the surgery. The vitreous is replaced during the operation with either clear fluid that is compatible with the eye, or with gas that completely fills the eye. Over time, the fluid (or gas) is absorbed by the eye and replaced by the eye’s own fluid; the eye does not replace the vitreous itself. The lack of vitreous does not affect the functioning of the eye.

In a vitrectomy, instruments are passed through the sclera into the vitreous cavity. A variety of instruments can be used to remove the vitreous gel and any scar tissue that may be growing on the surface of the retina. A laser probe can be inserted into the eye so that laser treatment can be done during surgery.

Recent advancements in technology have led to smaller instrumentation for vitrectomy surgery. Standard size for vitrectomy was 20-gauge until recently when much smaller 25-gauge instrumentation became available. No suturing is required in most cases. Healing is quicker, pain is less, and the overall experience of vitrectomy surgery is much more comfortable for the patient.

Vitrectomy can be combined with the placement of a scleral buckle. Usually, air, gas, or silicone oil is place in the vitreous cavity. These materials hold the retina in place against the back wall of the eye while the laser scars are forming. After this surgery, it may be important for the patient to maintain a certain position of the head, which is often a face-down (prone) position.

Eventually, the gas is absorbed and replaced by fluid produced by the eye. If silicone oil has been used, it frequently must be removed at a later time with another surgical procedure.

Vitreous surgery usually lasts one to two hours but, with very severe and difficult problems, may take longer.

Following surgery, the patient may experience some discomfort and a scratchy sensation in the eye, but significant pain is unusual. If it occurs, the surgeon should be told promptly.

When a retinal tear occurs, retinal blood vessels may also be torn. When this happens, blood enters the vitreous cavity; this is called a vitreous hemorrhage. Because there is a tear in the retina, a retinal detachment may also occur. The combination of a vitreous hemorrhage and retinal detachment is difficult to treat because the hemorrhage prevents the surgeon from seeing the retina and finding the tears. In such a case, a special technique called ultrasonography is necessary to help make the diagnosis of retinal detachment beneath the hemorrhage.

Ultrasonography is a harmless and painless test. It is like the sonar on a submarine. Sound waves are sent into the eye. They travel through the hemorrhage and bounce off of the retina. The returning sound waves make an image on a monitor and allow the doctor to see whether the retina is attached or detached.

If a patient has a combined vitreous hemorrhage and retinal detachment, a vitrectomy must be performed to remove the blood so that the surgeon can see the retina. Also, a scleral buckle is placed around the eye. The combination of retinal detachment and vitreous hemorrhage puts the eye at high risk for developing proliferative vitreoretinopathy.

Vitrectomy is a microsurgical procedure in which specialized instruments and techniques are used to repair various retinal disorders. The initial step in this procedure is the removal of the "vitreous gel" through a very small micro-incision in the wall of the eye, hence the name "vitrectomy". The vitreous is removed with a miniature cutting device and replaced with a special saline solution similar to the fluid being removed from the eye. An endoilluminator provides the light source used to illuminate the inside of the eye for the surgeon to visualize the internal structures as the surgery is being performed. The surgeon uses a specialized operating microscope and contact lenses, which allow a clear view of the vitreous cavity and retina at various magnifications. The procedure is performed in an operating room under local or (occasionally) general anesthesia. It can, and is often done as an ambulatory procedure. This means that barring complications, a patient is discharged and can leave the hospital or surgical facility within 23 hours. With most of our cases the patients are usually discharged and leave the hospital within 3 to 4 hours of completion of the procedure. Although vitrectomy procedures are sometimes performed through incisions made near the front of the eye, most vitreo-retinal surgeons enter the globe through a part of the eye known as the pars plana. This is why the procedure is often referred to as a pars plana vitrectomy (PPV). Entering the eye through this location avoids damage to the retina and the crystalline lens.