Eyelid Problems
Macular Degeneration
Diabetic Retinopathy
Tearing Problems
Glaucoma
EYELID PROBLEMS
Eyelid Surgery
Complete eye health includes having healthy eyes and healthy eyelids. Common eyelid problems include excess eyelid skin, droopy eyelids, or eyelids that turn inward or outward. They cause eye discomfort and can limit vision and affect appearance. Fortunately, such eyelid problems can be corrected with surgery.
Ptosis: Upper Eyelid Drooping
Ptosis (pronounced “toe-sis”) can either be apparent at birth (congenital) or develop with age (involutional).
Ptosis is a condition in which the upper eyelid droops
Surgery restores the upper eyelid to its normal position.
A child with congenital ptosis may tilt his or her head backward in order to see, so the condition does not always lead to poor vision. However, children with ptosis should be examined by an ophthalmologist [Eye M.D.] because they can have other associated eye problems.
Surgery to correct ptosis is commonly recommended in the preschool years to improve appearance and make it easier for the child to see. The type of surgery varies, depending upon how much the eyelids droop.
Involutional ptosis develops with aging. It may worsen after other types of eye surgery or eyelid swelling. Ptosis may limit your side or even your central vision. If ptosis occurs in one eye, it may create an uneven appearance. Surgical shortening of the muscle that opens the eyelid will often lead to better vision and improved appearance.
Excess Eyelid Skin
Over time, many people develop excess eyelid skin. Eyelid skin is the thinnest skin of the body, so it tends to stretch.
In the upper eyelid, this stretched skin may limit your side vision. The same problem causes “bags” to form in the lower eyelids.
The excess skin in the upper eyelids can be removed surgically by a procedure called blepharoplasty. It improves side vision and other symptoms. Removal of the excess skin in either the upper or lower eyelids may improve appearance. If excess fatty tissue is present, it may be removed at the same time.
Excess eyelid skin may produce a heavy sensation as well as limit side vision.
Ectropion: Outward Turning of the Lower Eyelid
Stretching of the lower eyelid from age may cause the eyelid to droop downward and turn outward. This condition is called ectropion. Eyelid burns or skin disease may also cause this problem. Ectropion can cause dryness of the eyes, excessive tearing, redness and sensitivity to light and wind. Surgery usually restores the normal position of the eyelid, improving these symptoms.
Entropion: Inward Turning of the lower eyelid
Entropion also occurs most commonly as a result of aging. Infection and scarring inside the eyelid are other causes of entropion. When the eyelid turns inward, the eyelashes and skin rub against the eye, making it red, irritated, watery and sensitive to light and wind. If entropion is not treated, an infection may develop on the clear surface of the eye called the cornea.
With surgery, the eyelid can be turned outward to its normal position, protecting the eye and improving these symptoms.
In these drawings, the eyelid is cut away to show the appearance of the normal eyelid (left), and the eyelid turning outward (center) and inward (right).
Eyelid Plastic Surgery
Eyelid plastic surgery is almost always performed on an outpatient basis using local anesthesia.
Before surgery, your ophthalmologist will perform an eye examination and make recommendations.
Photographs and peripheral vision testing are often required by insurance companies before blepharoplasty and ptosis surgery.
If you are planning to have surgery, be sure to tell your ophthalmologist if you are taking aspirin or aspirin-containing drugs, blood thinners, or if you have a bleeding problem.
This surgery is generally safe; however, as with any surgery, there are some risks:
• The ophthalmic surgeon will attempt to make both eyes look similar, but differences in healing between the eyes may cause some unevenness in appearance following surgery.
• A “black eye” is common, but will go away quickly.
• The eye may feel dry after surgery, because it may be more difficult to close your eyes completely. This irritation can be treated and generally disappears as the eyelids heal.
• Serious complications are rare. The risk of losing vision is estimated to be less than one in 5000 surgeries. Infections and excessive scarring occur infrequently.
Eyelid plastic surgery procedures can be done safely in an outpatient setting by your ophthalmologist. The improvement in vision, comfort and appearance can be very gratifying.
MACULAR DEGENERATION
Age-Related Macular Degeneration
Age-related macular degeneration (AMD) is a common eye disease associated with aging that gradually destroys sharp, central vision. It is one of the leading causes of legal blindness and vision impairment in older Americans.
The Macula
The progression of AMD can be slow or rapid, but the deterioration of central vision generally occurs over a period of a few years. If you experience the following, see your Eye M.D. right away:
• Straight lines appear wavy
• Difficulty seeing at a distance
• Decreased ability to distinguish colors
• Inability to see details, such as faces or words in a book
• Dark or empty spots block the center of your vision
Although the exact cause of macular degeneration is unknown, several studies have shown the following individuals may be at risk:
• People over age 60
• People with hypertension
• People that smoke
• People with a family history of AMD
Dry AMD
The “dry” form of macular degeneration affects approximately 90 percent of those with AMD. Studies have found that high levels of zinc and antioxidants play a key role in slowing the progression of dry macular degeneration in advanced cases.
Wet AMD
The “wet” form affects only 10 percent of those with AMD, but it accounts for 90 percent of all severe vision loss from the disease. For these individuals, conventional laser treatment and photodynamic therapy (PDT) treatment is used. PDT is used to reduce the risk of moderate to severe vision loss in patients with a few very specific forms of “wet” macular degeneration. Other experimental treatments that are being investigated include, intraocular antineovascular injections and the insertion of a “retinal chip” to restore vision loss.
Standard Laser Therapy
Early detection and treatment is the best defense against losing your vision. If you are at risk for macular degeneration, see your Eye M.D. for a complete eye exam at least every one to two years. If your vision has been reduced, low vision rehabilitation resources can help you maintain an excellent quality of life.
PDT
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DIABETIC RETINOPATHY
Diabetes Can Affect Sight
If you have diabetes mellitus, your body does not use and store sugar properly. High blood-sugar levels can damage blood vessels in the retina, the nerve layer at the back of the eye that senses light and helps to send images to the brain. The damage to retinal vessels is referred to as diabetic retinopathy.
normal eye
Types of Diabetic Retinopathy
There are two types of diabetic retinopathy: nonproliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR).
NPDR
NPDR, commonly known as background retinopathy, is an early stage of diabetic retinopathy. In this stage, tiny blood vessels within the retina leak blood or fluid. The leaking fluid causes the retina to swell or to form deposits called exudates.
close-up of retina with diabetic retinopathy
Many people with diabetes have mild NPDR, which usually does not affect their vision. When vision is affected it is the result of macular edema and/or macular ischemia.
Laser for Macular Edema
• Macular edema is swelling or thickening of the macula, a small area in the center of the retina that allows us to see fine details clearly. The swelling is caused by fluid leaking from retinal blood vessels. It is the most common cause of visual loss in diabetes. Vision loss may be mild to severe, but even in the worst cases, peripheral vision continues to function.
Macular Edema-Ischemia
• Macular ischemia occurs when small blood vessels (capillaries) close. Vision blurs because the macula no longer receives sufficient blood supply to work properly.
PDR
PDR is present when abnormal new vessels (neovascularization) begin growing on the surface of the retina or optic nerve. The main cause of PDR is widespread closure of retinal blood vessels, preventing adequate blood flow. The retina responds by growing new blood vessels in an attempt to supply blood to the area where the original vessels closed.
Unfortunately, the new, abnormal blood vessels do not resupply the retina with normal blood flow. The new vessels are often accompanied by scar tissue that may cause wrinkling or detachment of the retina.
PDR may cause more severe vision loss than NPDR because it can affect both central and peripheral vision.
Proliferative diabetic retinopathy causes visual loss in the following ways:
Vitreous Hemorrhage
Vitreous hemorrhage: The fragile new vessels may bleed into the vitreous, a clear, gel-like substance that fills the center of the eye. If the vitreous hemorrhage is small, a person might see only a few new dark floaters. A very large hemorrhage might block out all vision.
Floaters and Flashes
It may take days, months, or even years to resorb the blood, depending on the amount of blood present. If the eye does not clear the vitreous blood adequately within a reasonable time, vitrectomy surgery may be recommended.
Vitreous hemorrhage alone does not cause permanent vision loss. When the blood clears, vision may return to its former level unless the macula is damaged.
Traction retinal detachment: When PDR is present, scar tissue associated with neovascularization can shrink, wrinkling and pulling the retina from its normal position. Macular wrinkling can cause visual distortion. More severe vision loss can occur if the macula or large areas of the retina are detached.
Neovascular glaucoma: Occasionally, extensive retinal vessel closure will cause new, abnormal blood vessels to grow on the iris (colored part of the eye) and block the normal flow of fluid out of the eye. Pressure in the eye builds up, resulting in neovascular glaucoma, a severe eye disease that causes damage to the optic nerve.
How is diabetic retinopathy diagnosed?
A medical eye examination is the only way to detect changes inside your eye. An ophthalmologist [Eye M.D.] can often diagnose and treat serious retinopathy before you are aware of any vision problems. The ophthalmologist dilates your pupil and looks inside of the eye with an ophthalmoscope.
If your ophthalmologist finds diabetic retinopathy, he or she may order color photographs of the retina or a special test called fluorescein angiography to find out if you need treatment. In this test a dye is injected into your arm and photos of your eye are taken to detect where fluid is leaking.
How is diabetic retinopathy treated?
The best treatment is to prevent the development of retinopathy as much as possible. Strict control of your blood sugar will significantly reduce the long-term risk of vision loss from diabetic retinopathy. If high blood pressure and kidney problems are present, they need to be treated.
Laser surgery: Laser surgery is often recommended for people with macular edema, PDR, and neovascular glaucoma.
laser beam in the treatment of diabetic retinopathy
For macular edema, the laser is focused on the damaged retina near the macula to decrease the fluid leakage. The main goal of treatment is to prevent further loss of vision. It is uncommon for people who have blurred vision from macular edema to recover normal vision, although some may experience partial improvement. A few people may see the laser spots near the center of their vision following treatment. The spots usually fade with time but may not disappear.
Laser Procedure for PDR
For PDR, the laser is focused on all parts of the retina except the macula. This panretinal photocoagulation treatment causes abnormal new vessels to shrink and often prevents them from growing in the future. It also decreases the chance that vitreous bleeding or retinal distortion will occur.
Multiple laser treatments over time are sometimes necessary. Laser surgery does not cure diabetic retinopathy and does not always prevent further loss of vision.
Vitrectomy
Vitrectomy: In advanced PDR, the ophthalmologist may recommend a vitrectomy. During this microsurgical procedure, which is performed in the operating room, the blood-filled vitreous is removed and replaced with a clear solution. The ophthalmologist may wait for several months or up to a year to see if the blood clears on its own before performing a vitrectomy.
vitrectomy surgery
Vitrectomy often prevents further bleeding by removing the abnormal vessels that caused the bleeding. If the retina is detached, it can be repaired during the vitrectomy surgery. Surgery should usually be done early because macular distortion or traction retinal detachment will cause permanent visual loss. The longer the macula is distorted or out of place, the more serious the vision loss will be.
Vision Loss Is Largely Preventable
If you have diabetes, it is important to know that today, with improved methods of diagnosis and treatment, only a small percentage of people who develop retinopathy have serious vision problems. Early detection of diabetic retinopathy is the best protection against loss of vision.
You can significantly lower your risk of vision loss by maintaining strict control of your blood sugar and visiting your ophthalmologist regularly.
When to Schedule an Examination
People with diabetes should schedule examinations at least once a year. More frequent medical eye examinations may be necessary after a diagnosis of diabetic retinopathy.
Pregnant women with diabetes should schedule an appointment in the first trimester because retinopathy can progress quickly during pregnancy.
If you need to be examined for eyeglasses, it is important that your blood sugar be consistently under control for several days when you see your ophthalmologist. Eyeglasses that work well when the blood sugar is out of control will not work well when the blood sugar is stable.
Rapid changes in blood sugar can cause fluctuating vision in both eyes even if retinopathy is not present.
You should have your eyes checked promptly if you have visual changes that:
• affect only one eye;
• last more than a few days;
• are not associated with a change in blood sugar.
When you are first diagnosed with diabetes, you should have your eyes checked:
• within five years of the diagnosis if you are 29 years old or younger;
• within a few months of the diagnosis if you are 30 years old and older.
Click here for additional information about the retina and retina specialists.
TEARING PROBLEMS
Tear Production
The lacrimal gland and other small glands located inside the eyelid and on the white part of the eye constantly produce tears to keep the eye moist, lubricated and healthy.
How Do Tears Drain From the Eye?
As new tears are produced, old tears drain from the eye through two small openings called the upper and lower puncta, which are located at the inside corner of the upper and lower eyelids near the nose. The tears then move through a passage called the canaliculus and into the lacrimal sac.
From the sac, the tears then drop down the tear duct, called the nasolacrimal duct, and drain into the back of the nose and throat. That is why your nose runs when you cry.
Excessive Tearing May Occur From the Following:
• Dry eyes
• Injury, birth defects, infection or other blockage of the lacrimal (tear) drainage system
• Eyelid or eyelash disorders
• Infection in the eye
• Wind, smoke, fumes or other environmental irritants
• Glaucoma
• Certain medications
• Allergic reaction
• Eyestrain
• Foreign material in the eye
• Scratch on the eye
How Is the Cause of Excessive Tearing Determined?
A thorough eye examination by an ophthalmologist (Eye M.D.) is necessary to determine the cause of excessive tearing. He or she also may:
• Irrigate your tear drainage system with fluid to make sure the pathway is open
• Measure tear production
• Measure eye pressure
• Illuminate the tear drain with a fluorescent dye test
• Perform computerized tomography (CT) scanning
How Is Excessive Tearing Treated?
Once your ophthalmologist determines the cause, treatment may include one or more of the following:
• Use of lubricating eyedrops or ointment
• Surgical opening of the blocked drainage system
• Surgery to repair an injured drainage system
• Removal of an inturned eyelash or foreign body in the eye
• Adding a new opening from the lacrimal sac into the nose, a procedure known as dacryocystorhinostomy (DCR)
• Insertion of an artificial tear duct implant
Your ophthalmologist will discuss the most appropriate form of treatment with you based on the cause of your tearing.
GLAUCOMA
What is Glaucoma?
Glaucoma is a disease of the optic nerve — the part of the eye that carries the images collected by the retina (film) to the brain. The optic nerve is made up of many nerve fibers, like an electric cable containing numerous wires. When damage to the optic nerve fibers occurs, blind spots develop. These blind spots are usually not apparent to the person until the optic nerve is significantly damaged. If the entire nerve is destroyed, blindness results.
How the Eye Sees
Early detection and treatment of glaucoma by your ophthalmologist (Eye M.D.) are the keys to preventing significant optic nerve damage and blindness from glaucoma.
Vision Loss in Glaucoma
Glaucoma is a leading cause of blindness in the United States, especially for older people. But loss of sight from glaucoma can often be prevented with early treatment.
What causes glaucoma?
A clear liquid called aqueous humor circulates inside the front portion of the eye. To maintain a healthy level of pressure within the eye, a small amount of this fluid is produced constantly while an equal amount flows out of the eye through a microscopic drainage system (fig. a). (This liquid is not part of the tears on the outer surface of the eye.) Because the eye is a closed structure, if the drainage area for the aqueous humor — called the drainage angle — is blocked, the excess fluid cannot flow out of the eye (fig. b). A build up of fluid within the eye causes the eye pressure to increase, damaging the optic nerve.
Optic Nerve Damage
What are the different types of glaucoma?
Primary open-angle glaucoma: This is the most common form of glaucoma in the United States. The risk of developing primary open-angle glaucoma increases with age. The drainage angle of the eye becomes less efficient over time, and pressure within the eye gradually increases, which can damage the optic nerve. In some patients, optic nerve damage occurs at “normal” eye pressure. Half of the people with glaucoma never have “elevated” eye pressure. Their eye pressure, though in the “normal range” is too high for their optic nerve. Treatment is designed to lower the eye pressure. This is accomplished with prescription eye drops, laser, and/or surgery.
Open-angle Glaucoma
Typically, open-angle glaucoma has no symptoms in its early stages and vision remains normal. As the optic nerve becomes more damaged, blank spots begin to appear in the field of vision. You typically won’t notice these blank spots in your day-to-day activities until the optic nerve is significantly damaged and these spots become large. If all the optic nerve fibers die, blindness results.
Closed-angle Glaucoma
Closed-angle glaucoma: Some eyes are formed with the iris (the colored part of the eye) too close to the drainage angle. In these eyes, which are often small and farsighted, the iris blocks the aqueous humor’s access to the drainage angle, resulting in elevated eye pressure.
Symptoms of angle closure may include:
• blurred vision;
• severe eye pain;
• headache;
• rainbow-colored halos around lights
• nausea and vomiting
This is a true eye emergency. If you have any of these symptoms, call your ophthalmologist immediately. Unless this type of glaucoma is treated quickly, blindness can result.
Unfortunately, two-thirds of those with closed-angle glaucoma develop it slowly without any symptoms prior to an attack.
Who is at risk for glaucoma?
Your ophthalmologist considers different factors in determining your risk for developing glaucoma.
The most important risk factors include:
• elderly;
• elevated eye pressure;
• family history of glaucoma;
• African or Spanish-American ancestry;
• farsightedness or nearsightedness;
• past eye injuries;
• thinner central corneal thickness;
• systemic health problems, including diabetes, migraine headaches, and poor circulation.
Your ophthalmologist will weigh all of these factors before deciding whether you need treatment for glaucoma, or whether you should be monitored closely as a glaucoma suspect. This means your risk of developing glaucoma is higher than normal, and you need to have regular examinations to detect the early signs of damage to the optic nerve.
How is glaucoma detected?
Regular eye examinations by your ophthalmologist are the best way to detect glaucoma. A glaucoma screening that checks only the pressure of the eye is not sufficient to determine if you have glaucoma. The only sure way to detect glaucoma is to have a complete eye examination.
During your glaucoma evaluation, your ophthalmologist may:
• measure your intraocular pressure (tonometry);
• inspect the drainage angle of your eye (gonioscopy);
• evaluate whether or not there is any optic nerve damage (ophthalmoscopy);
• test the peripheral vision of each eye (visual field testing, or perimetry).
How is glaucoma treated?
As a rule, damage caused by glaucoma cannot be reversed. Eyedrops, laser surgery and surgery in the operating room are used to lower eye pressure to help prevent further optic nerve damage. Treatment of glaucoma requires a partnership between the physician and the patient. The patient must use medications regularly to maintain lower eye pressure and continue follow up visits. The physician must monitor each patient to ensure the pressure is low enough to stabilize the disease.
Medications
Glaucoma is usually controlled with eyedrops taken daily. These medications lower eye pressure, either by decreasing the amount of aqueous fluid produced within the eye or by improving the outflow of aqueous through the drainage angle.
Never change or stop taking your medications without consulting your ophthalmologist. All medications can have side effects or can interact with other medications. Therefore, it is important that you make a list of the medications you regularly take and share this list with each doctor you see.
Laser Surgery
Laser surgery treatments may be recommended for different types of glaucoma. In open-angle glaucoma, the drain itself is treated. The laser is used to modify the drain (trabeculoplasty) to help control eye pressure.
SLT (Selective Laser Trabeculectomy)
ALT-SLC
In closed-angle glaucoma, the laser creates a hole in the iris (iridotomy) to improve the flow of aqueous fluid to the drain.
Iridotomy
Setons
What is your part in treatment?
Treatment for glaucoma requires teamwork between you and your doctor. Your ophthalmologist can prescribe treatment for glaucoma, but only you can make sure that you follow your doctor’s instructions and take your eyedrops. Once you are taking medications for glaucoma, your ophthalmologist will want to see you more frequently. Typically, you can expect to visit your ophthalmologist every three to four months. This will vary depending on your treatment needs.
Loss of vision can be prevented
Regular medical eye exams may help prevent unnecessary vision loss. Recommended intervals for eye exams are:
Age 20-29: Individuals of African descent or with a family history of glaucoma should have an eye examination every three to five years. Others should have an eye exam at least once during this period.
Age 30 -39: Individuals of African descent or with a family history of glaucoma should have an eye examination every two to four years. Others should have an eye exam at least twice during this period.
Age 40-64: Every two to four years.
Age 65 or older: Every one to two years.