Privileged Sight

Understanding disorders of the retina.

He admits he might be biased, but to Nandesh N. Patel, MD, the retina is the most important part of the eyeball. The retina is a thin layer of specialized tissue that lines the back of the eye. It senses light as it enters the eye and sends it to the brain to process as images.

Photo by Fred Bellet.

Dr. Kohlhepp consults with a patient at the Ruskin location.

Dr. Patel is a board-certified ophthalmologist and fellowship-trained retina surgeon at Florida Eye Specialists & Cataract Institute. To him, the retina is a rare, privileged site, unlike any other part of the body, and it merits special care.
“Think of the eyeball as a camera,” he describes. “There are two crucial elements: the lens to focus the light and the film to register the light that comes in. The retina is the film. Any disease that compromises the quality of the film creates problems with the pictures processed by the eye, resulting in a reduction of vision.
“The retina is a critical structure, and as I tell my patients, with every body part, there’s a disorder to go with it. Unfortunately, there are many disorders that affect the retina.”
The two most common disorders are diabetic retinopathy and macular degeneration, which are the two leading causes of blindness in adults. Dr. Patel and his colleague, board-certified ophthalmologist and fellowship-trained retina surgeon Marguerite Kohlhepp, MD, have expertise in treating these retinal diseases and more.

Diabetic Retinopathy

Diabetic retinopathy is the most common eye disease associated with diabetes, and is caused by changes in the blood vessels of the retina. In some cases, abnormal blood vessels develop on the surface of the retina, and in others, blood vessels begin to bleed or leak fluid.
“Anyone who has diabetes is at risk for developing diabetic retinopathy,” stresses Dr. Kohlhepp, “and the risk increases with the duration of having the disease. The main reason: High glucose levels affect the blood vessels and make them unhealthy.
“Diabetic retinopathy generally has no symptoms in its early stages, so screening and early diagnosis are of incredible importance. We have treatments that will overturn poor visual outcomes, but they require early detection.”
There are two main types of diabetic retinopathy, non-proliferative and proliferative.

“Think of the eyeball as a camera. There are two crucial elements: the lens to focus the light and the film to register the light that comes in. The retina is the film.” – Dr. Patel

“The non-proliferative type is an early stage of diabetic retinopathy characterized by microaneurysms and retinal hemorrhages,” explains Dr. Kohlhepp. “Small swellings, called microaneurysms, begin to form on the sides of tiny retinal blood vessels.
“When these small swellings begin to bleed or leak fluid into the retina, causing noticeable vision problems, a retinal hemorrhage occurs. The abnormal bleeding may cause the appearance of floating spots in the patients’ vision, which may go away on their own.
“If the fluid and blood proceed to leak into the macula, the central area of the retina, leading it to swell and thicken, a macular edema develops. Vision then becomes blurrier, and rapid vision loss can occur.
“Non-proliferative is the more manageable form of diabetic retinopathy,” she adds. “If a patient works to control the underlying diabetes with a primary care doctor, then it’s possible to reverse some of the findings.”
In the proliferative type of diabetic retinopathy, the patient experiences an advanced form of the disease marked by an extensive closure of retinal blood vessels. As a result, the retina begins to grow new, leaky blood vessels in an effort to re-supply blood to the area where the original blood vessels closed. Partial or total vision loss may occur.
Photo by Jordan Pysz.“Unfortunately, these new vessels are abnormal and are not able to supply the retina with normal blood flow,” informs Dr. Kohlhepp. “Instead, fluid leaks into the vitreous, the gel that lies in front of the retina and behind the eye’s lens, causing a vitreous hemorrhage. Small scars also begin to develop on the retina and the vitreous, causing the retina to pull away from the back of the eyeball, resulting in a retinal tear or retinal detachment.
“Once you get into the proliferative states, aggressive treatment is necessary. Some patients will undergo regular treatments such as laser surgery, monthly injections of medication directly into the eye or, in extreme cases, surgery.”

Macular Degeneration

Another serious threat to sight that can occur as people age is macular degeneration. It is a disease of the central vision with which the main images in the vision become less discernible.
“Think of the retina as being ten layers thick with many blood vessels nourishing it,” elaborates Dr. Patel. “Macular degeneration is a disease in which some of those layers essentially become diseased and waste away. As a consequence, some of the blood vessels pop and leak.
“The first situation I described, where the layers waste away, is what we consider dry macular degeneration. When blood vessels start popping and leaking, that’s what’s called wet macular degeneration. This type does considerable damage that translates into poor vision.”
Dry macular degeneration is the more prevalent form, accounting for approximately 90 percent of cases. Macular degeneration is more common in people age 55 and older. It generally has no signs or symptoms in its early stages.

“Anyone who has diabetes is at risk for developing diabetic retinopathy, and the risk increases with the duration of having the disease.” – Dr. Kohlhepp

“Macular degeneration progresses like a slow-moving conveyor belt,” notes Dr. Patel. “Every case of wet macular degeneration was at one time the dry form. Patients may have had the dry form for a long time without being aware of it. They are often shocked by the diagnosis because they had no corresponding symptoms.”
When there are symptoms, people might notice a gradual loss of their ability to see objects clearly, especially noticing a blurring of areas of type on a page of print, or dark or empty spaces that may block the center of their field of vision.
Some patients may notice that straight lines in the landscape – such as telephone poles, the sides of buildings or streetlight posts – appear wavy, crooked or distorted. Some may notice the need for brighter light when reading or a gradual loss of color intensity in everything around them.
“For intermediate-level dry macular degeneration, specific vitamin supplements can help slow down the conveyor belt,” reports Dr. Patel. “They don’t halt progression of the disease and they certainly don’t reverse it, but they can buy the patients more time. For example, if they would normally turn wet in five years, this treatment may give them ten to fifteen years, which is substantial.
“With the wet form, which is an end stage of the disease, we have a variety of medications that are injected directly into the eye on a monthly basis. These can help contain the amount of leakage and bleeding and can often result in a stabilization of the eye, but not improvement.”
Patients with macular degeneration should also monitor their vision daily with a specially designed tool called an Amsler grid and notify their eye doctors about any changes as soon as possible.

Surgical Disorders

Dr. Patel and Dr. Kohlhepp treat both medical and surgical retinal disorders. Diabetic retinopathy and macular degeneration are two examples of medical retinal disorders.Photo by Jordan Pysz.
“Of the surgical disorders, some of the more common are retinal tears and retinal detachments,” states Dr. Patel. “Then there are other disorders called macular puckers and macular holes.
“Macular pucker and macular hole are not as catastrophic as retinal detachment or vitreous hemorrhage, where there’s complete loss of vision that evolves very quickly, sometimes within hours or days. Macular pucker and macular hole are conditions that come on somewhat slowly and involve a disruption in the normal architecture of the macula.”
If a person develops a macular hole, then all of a sudden, he or she has a hole in the middle of their vision, and they literally don’t see anything. There’s a blank spot dead center, which is very discomforting for the patient.
“The macular pucker is like a scar tissue that develops on the macula and creates wrinkles,” comments Dr. Patel. “This is due to the normal aging process. A wrinkled macula will make images appear wrinkled or distorted. Straight lines that look wavy is a common descriptor that naturally has repercussions if you are driving and want to stay within the lines.”
“We suspect a retinal tear as soon as we hear a patient report flashing lights or floaters, which are common complaints,” relates Dr. Kohlhepp. “Flashing lights and floaters can be due to normal changes of the eye, but one of five who presents with those symptoms will likely have a retinal tear to explain them.
“A retinal tear is an unwanted consequence of a normal, age-related process where the vitreous is liquefied, but that process is complicated by the vitreous inadvertently pulling at the retina. That’s how a retinal tear is formed.”
If a retinal tear does occur, it is critical that it is treated right away. If not treated immediately with laser or freezing, a tear lends itself to developing into a retinal detachment.
“The big, gaping hole in the retina allows fluid to pass through it,” educates Dr. Kohlhepp. “You find the fluid on the undersurface of the proverbial wallpaper, and the next thing you know, the wallpaper is falling off of the wall, and that’s a retinal detachment.”
Macular pucker and macular hole are corrected during a same-day surgery. The procedure, called a vitrectomy, removes the vitreous gel between the lens and retina, replacing it with a bubble of gas or air. Over a short time, the bubble will help to smooth out the retina and close the hole.

Under One Roof

Florida Eye Specialists & Cataract Institute offers a complete range of eye care services for residents in the region. Its location in Brandon and its clinics in Sun City and Ruskin help make quality eye care available to more people closer to their homes.
“Florida Eye Specialists and Cataract Institute’s Sun City location is a multispecialty practice that takes care of various ocular diseases,” observes Dr. Patel, “whether the problem is cataracts, glaucoma, dry eye, a disorder of the optic nerve or a disorder of the retina or macula. We have specialists in many subspecialties of ophthalmology.
“I’m happy to be a part of the center because often some of these diseases co-exist. A cornea specialist will see a disease in the setting of a macular disease and vice-versa. It’s nice to have that collegiality amongst ourselves where if I’m treating one part of the eyeball but there’s something wrong with another part, I’ve got the relevant specialists to whom I can turn to examine the patient and treat them accordingly.”
The Sun City location also provides comprehensive eye care examinations, as well as the diagnosis, treatment and management of a number of eye-rated health problems and conditions.
“Our large facility enables us to add additional subspecialists and offer even more services in the future,” expounds Dr. Patel. “The facility also provides a comfortable environment for our patients.”

Through the Continuum

The eye clinic in Ruskin, another Florida Eye Specialists & Cataract Institute eye care center, offers complete eye care close to home for residents of the Ruskin area.
“Here, we provide a wide range of eye care services for the entire family, from school-age children through geriatric patients,” points out Dr. Kohlhepp, who practices at the clinic.
“When patients consider eye care centers, I urge them to select one with skilled eye care professionals who can handle not only their general eye care needs, but also the many changes and diseases that can affect vision throughout a lifetime. It is that very thorough approach to eye care that we offer at our Ruskin clinic.”
Available services include comprehensive eye exams that test not only for vision but also for general eye health, including eye conditions relating to diabetes, high blood pressure and thyroid disorders. The Ruskin clinic also offers management of serious eye diseases such as glaucoma, dry eye syndrome and macular degeneration.
“Our patients have access to the physicians in sub-specialties who practice under the umbrella of Florida Eye Specialists and Cataract Institute,” assures Dr. Kohlhepp. “Several of them come to our Ruskin office throughout the month, and we can also make specialized treatments and surgeries available without the delays patients might experience trying to schedule first-time appointments with unaffiliated practices.”
The eye centers in Ruskin and Sun City are united with Florida Eye Specialists & Cataract Institute in one family of quality, dedicated eye care facilities.
“Being part of such a well-respected eye care consortium has important advantages for our patients,” says Dr. Kohlhepp. “It means fewer transportation worries for the patients, and immediate referrals, which are especially important in emergency situations such as retinal detachments. This increased access to care helps preserve vision in our communities.”

 

For more information about retina issues or to book an appointment at
Florida Eye Specialists & Cataract Institute please visit
https://floridaeye.org/our-services/specialty-eye-care/retina/

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