Age-related macular degeneration — also called macular degeneration, AMD or ARMD is deterioration of the macula, which is the small central area of the retina of the eye that controls visual acuity.
The health of the macula determines our ability to read, recognize faces, drive, watch television, use a computer, and perform any other visual task that requires us to see fine detail.
Macular degeneration is the leading cause of vision loss among older Americans, and due to the aging of the U.S. population, the number of people affected by AMD is expected to increase significantly in the years ahead.
Astigmatism is probably the most misunderstood vision problem.
Astigmatism usually causes vision to be blurred or distorted to some degree at all distances.
Symptoms of uncorrected astigmatism are eye strain and headaches, especially after reading or other prolonged visual tasks.
Squinting also is a very common symptom.
Astigmatism usually is caused by an irregularly shaped cornea. Instead of the cornea having a symmetrically round shape (like a baseball), it is shaped more like an American football, with one meridian being significantly more curved than the meridian perpendicular to it.
(To understand what meridians are, think of the front of the eye like the face of a clock. A line connecting the 12 and 6 is one meridian; a line connecting the 3 and 9 is another.)
The steepest and flattest meridians of an eye with astigmatism are called the principal meridians.
In some cases, astigmatism is caused by the shape of the lens inside the eye. This is called lenticular astigmatism, to differentiate it from the more common corneal astigmatism.
There are three primary types of astigmatism:
Myopic astigmatism. One or both principal meridians of the eye are nearsighted. (If both meridians are nearsighted, they are myopic in differing degree.)
Hyperopic astigmatism. One or both principal meridians are farsighted. (If both are farsighted, they are hyperopic in differing degree.)
Mixed astigmatism. One principal meridian is nearsighted, and the other is farsighted.
Astigmatism also is classified as regular or irregular. In regular astigmatism, the principal meridians are 90 degrees apart (perpendicular to each other). In irregular astigmatism, the principal meridians are not perpendicular. Most astigmatism is regular corneal astigmatism, which gives the front surface of the eye an oval shape.
Irregular astigmatism can result from an eye injury that has caused scarring on the cornea, from certain types of eye surgery or from keratoconus, a disease that causes a gradual thinning of the cornea.
Blepharitis is inflammation of the eyelids. It’s a common cause of sore, red eyelids and crusty eyelashes.
Eyelid inflammation is very common: In a recent survey of American ophthalmologists (eye MDs) and optometrists (ODs), these eye doctors reported that 37 percent and 47 percent of their patients, respectively, have had blepharitis symptoms at some point.
This survey also found that younger people reported more (and more frequent) blepharitis symptoms than older people, which contradicts conventional wisdom about eyelid inflammation.
Thankfully, your eye doctor can prescribe effective blepharitis treatment that can limit the eyelid inflammation before serious damage occurs to your eyes or eyelids.
There are several possible causes of blepharitis, including:
Bacterial eyelid infection
Meibomian gland dysfunction (MGD)
Fungal eyelid infection
Parasites (Demodex eyelash mites)
Blepharitis and dry eyes often occur at the same time, causing confusion whether dry eye causes blepharitis or blepharitis causes dry eye.
This happens so often that some researchers and eye doctors now believe these two conditions may be part of a single chronic eye problem called dry eye blepharitis syndrome (DEBS).
According to supporters of this theory, dry eye is simply the late manifestation of blepharitis, and treating blepharitis also will prevent, reduce or eliminate dry eye symptoms.
Blepharitis usually is associated with an overgrowth of bacteria that live along the margins of the eyelids and at the base of the eyelashes. Over time, these bacteria multiply and create a structure called a biofilm.
This biofilm becomes a toxic environment — like the plaque that forms on your teeth. Parasitic eyelash mites called Demodex feed on the biofilm, which in turn leads to an overgrowth of these mites that causes a worsening of the eyelid inflammation.
Bacteria in the eyelid biofilm also produce substances called exotoxins that cause inflammation of oil-secreting glands in the eyelids called meibomian glands. This causes a condition called meibomian gland dysfunction, which causes (and worsens) dry eye discomfort.
The most common symptoms of blepharitis are:
Burning or stinging eyes
Crusty debris at the base of eyelashes
Irritated, watery eyes
Grittiness or a foreign body sensation
Depending on the severity of blepharitis, you may have some or all of these symptoms, and blepharitis symptoms may be intermittent or constant. In some cases, blepharitis also causes loss of eyelashes (madarosis).
Blepharitis also is a common cause of contact lens discomfort, forcing many people to give up wearing contacts.
Treatment of blepharitis should begin with a visit with your eye doctor to determine the cause of your eyelid inflammation. Your doctor will examine your eyes and eyelids to evaluate whether you have blepharitis and determine what type of blepharitis treatment is most appropriate.
Typically, blepharitis treatment includes:
Eyelid scrubs. Gently scrubbing your eyelids removes the buildup of biofilm and excess bacteria from your lid margins. Your eye doctor typically will recommend a daily regimen of warm compresses and lid scrubs to clean your eyelids and reduce the amount of bacteria and Demodex mites on your lids. Cleaning agents may include prescription eyelid cleansers (Avenova), non-prescription eyelid cleansing pads (Ocusoft; Systane), or diluted baby shampoo.
In-office procedures. Though eyelid scrubs at home are helpful, in-office eyelid hygiene procedures often are recommended for more effective blepharitis treatment. Possible procedures include:
1. Electromechanical lid margin debridement (such as BlephEx treatment) to efficiently remove bacteria, biofilm and Demodex mites from your eyelids and open clogged meibomian glands.
2. Thermal pulsation treatment (Lipiflow, for example) to melt and express material obstructing the meibomian glands.
3. Intense pulsed light (IPL) therapy to open clogged eyelid glands and resume normal flow of oils into the tear film.
Medicated eye drops and/or ointments. Your doctor also may prescribe topical medicines to destroy excess blepharitis-causing bacteria or other microbes on the eyelids — particularly if there is a risk of eye infection or it appears you have pink eye or some other type of eye infection as well as blepharitis.
Eyelid hygiene tips
Eyelid hygiene is very helpful to treat and control blepharitis, but only if performed properly.
To begin, use a clean, warm compress to melt any blocked residue in the oil-secreting meibomian glands in your eyelids. Here’s how:
Wash your hands, then dampen a clean washcloth with warm (nearly hot) water.
Place the washcloth over your closed eyelids for several minutes.
Then gently rub your eyelid margin with the washcloth before opening your eyes. (Don’t press hard on your eye.)
Follow your eye doctor’s recommendations regarding how often to use a warm compress and how long to keep it in place. When you first begin treatment, you may be instructed to do this several times daily, for about five minutes each time. Later on, you might only need to apply the compress once daily.
Cleaning your eyelids
Cleaning your eyelids is the next essential step. Your doctor will recommend what to use for the cleaning agent. Options include warm water, diluted baby shampoo or an over-the-counter or prescription eyelid cleanser.
To clean your eyelids:
Wash your hands, then moisten a clean washcloth, cotton swab or gauze pad with the cleaning solution.
Gently wipe your eyelashes and lid margin.
Rinse with warm water.
Repeat the process for your other eye, using a different washcloth, swab or pad.
Your eye doctor may have you clean your eyelids several times daily to start, and then once daily thereafter.
It’s a good idea to minimize use of eye makeup when you have blepharitis, because mascara and other makeup can interfere with eyelid hygiene.
If your doctor recommends an anti-dandruff shampoo for your scalp and eyebrows, make sure you keep the shampoo out of your eyes to avoid irritation.
Cataracts are the most common cause of vision loss in people over age 40 and is the principal cause of blindness in the world. In fact, there are more cases of cataracts worldwide than there are of glaucoma, macular degeneration and diabetic retinopathy combined, according to Prevent Blindness America (PBA).
Today, cataracts affect more than 22 million Americans age 40 and older. And as the U.S. population ages, more than 30 million Americans are expected to have cataracts by the year 2020, PBA says.
Types of cataracts include:
A cataract starts out small and at first has little effect on your vision. You may notice that your vision is blurred a little, like looking through a cloudy piece of glass or viewing an impressionist painting.
A cataract may make light from the sun or a lamp seem too bright or glaring. Or you may notice when you drive at night that the oncoming headlights cause more glare than before. Colors may not appear as bright as they once did.
The type of cataract you have will affect exactly which symptoms you experience and how soon they will occur. When a nuclear cataract first develops, it can bring about a temporary improvement in your near vision, called “second sight.”
Unfortunately, the improved vision is short-lived and will disappear as the cataract worsens. On the other hand, a subcapsular cataract may not produce any symptoms until it’s well-developed.
If you think you have a cataract, see an eye doctor for an exam to find out for sure.
The lens is mostly made of water and protein. The protein is arranged in a precise way that keeps the lens clear and let’s light pass through it.
But as we age, some of the protein may clump together and start to cloud a small area of the lens. This is a cataract, and over time, it may grow larger and cloud more of the lens, making it harder to see.
No one knows for sure why the eye’s lens changes as we age, forming cataracts. But researchers worldwide have identified factors that may cause cataracts or are associated with cataract development. Besides advancing age, cataract risk factors include:
One theory of cataract formation that’s gaining favor is that many cataracts are caused by oxidative changes in the human lens. This is supported by nutrition studies that show fruits and vegetables high in antioxidants may help prevent certain types of cataracts (see below).
Though there is significant controversy about whether cataracts can be prevented, a number of studies suggest certain nutrients and nutritional supplements may reduce your risk of cataracts.
One large, 10-year study of female health professionals found that higher dietary intakes of vitamin E and the carotenoids lutein and zeaxanthin from food and supplements were associated with significantly decreased risks of cataract.
Good food sources of vitamin E include sunflower seeds, almonds and spinach. Good sources of lutein and zeaxanthin include spinach, kale and other green, leafy vegetables.
Other studies have shown antioxidant vitamins such as vitamin C and foods containing omega-3 fatty acids may reduce cataract risk.
Another step you can take to reduce your risk of cataracts is to wear protective sunglasses that block 100 percent of the sun’s UV rays when you are outdoors.
When symptoms begin to appear, you may be able to improve your vision for a while using new glasses, strong bifocals, magnification, appropriate lighting or other visual aids.
Think about surgery when your cataracts have progressed enough to seriously impair your vision and affect your daily life.
Many people consider poor vision an inevitable fact of aging, but cataract surgery is a simple, relatively painless procedure to regain vision.
Cataract surgery is very successful in restoring vision. In fact, it is the most frequently performed surgery in the United States, with more than 3 million Americans undergoing cataract surgery each year, according to PBA.
Nine out of 10 people who have cataract surgery regain very good vision, somewhere between 20/20 and 20/40.
During surgery, the surgeon will remove your clouded lens and in most cases replace it with a clear, plastic intraocular lens (IOL).
New IOLs are being developed all the time to make the surgery less complicated for surgeons and the lenses more helpful to patients. Presbyopia-correcting IOLs potentially help you see at all distances, not just one. Another new type of IOL blocks both ultraviolet and blue light rays, which research indicates may damage the retina.
Read more on this website about what to expect if you have cataract surgery and how to deal with rare cataract surgery complications.
Also, men should be aware that certain prostate drugs can cause intraoperative floppy iris syndrome (IFIS) during a cataract procedure.
In most cases, unless you choose presbyopia-correcting IOLs, you will still need reading glasses after cataract surgery. You may also need progressive lenses to correct mild residual refractive errors as well as presbyopia.
A chalazion is a benign, painless bump or nodule inside the upper or lower eyelid.
Chalazia (plural for chalazion) result from healed internal styes that no longer are infectious. These cyst-like nodules form around an oil gland (meibomian) within the eyelid, resulting in red, swollen eyelids.
The contents of a chalazion include pus and blocked fatty secretions (lipids) that normally help lubricate the eye but can no longer drain out.
Many chalazia drain, resolving on their own, especially if you facilitate the process with periodic warm compresses and gentle massage of the eyelid.
However, some chalazia persist for more than several weeks and grow large enough to become cosmetically unappealing.
It is not always possible to identify a cause for a chalazion. However, chalazia are more common in those with blepharitis (eye inflammation) and rosacea.
People with rosacea, characterized by facial redness and swollen bumps under the skin (papules and pustules), are prone to have certain eye problems such as blepharitis and chalazia.
These manifestations of rosacea on the eye collectively are referred to as ocular rosacea. Causes of rosacea itself can be difficult to pinpoint, although environment and inherited tendencies are likely factors.
Certain microorganisms living in or near eyelash roots also may exacerbate inflammation around the eye.
If you are prone to developing chalazia, your doctor can prescribe preventative regimens, such as cleaning your eyelids, applying medicine on your eyelid and even using oral medication for underlying conditions.
The most commonly prescribed oral medicine for blepharitis and meibomian gland dysfunction is doxycycline (antibiotic). Sometimes tetracycline and minocycline, both of which are in the same drug family of antibiotics, are prescribed. However, doxycycline tends to be better tolerated.
Topical and oral antibiotics usually are ineffective as direct treatments for chalazia, which have no active infectious component that would require this kind of approach.
If you develop a chalazion, your eye doctor may have you regularly apply a warm, moist compress on the outside of your closed eyelid to promote drainage from the eye’s blocked oil gland.
Small, inconspicuous chalazia may require no treatment at all. However, some blockages causing chalazia do not clear up on their own. These may remain indefinitely or even grow larger.
In the case of a bothersome and persistent chalazion, you may undergo a simple in-office surgery to excise it.
An eye surgeon will use local anesthesia to numb the area before making a small incision, typically from underneath the eyelid to clear the contents of the lesion without visible scarring.
An alternate procedure involves injecting the chalazion with corticosteroid to allow better drainage. A potential side effect of steroid injection is lightening of the surrounding skin, which can be more problematic in dark-skinned people.
In cases where a chalazion recurs in the same part of the eyelid or has a suspicious appearance, the removed tissue may be sent to a laboratory to rule out tumorous growth.
Fortunately, most chalazia are relatively harmless.
Conjunctivitis is a common condition which causes the surface of your eye to go red and, often, sticky or watery and your eye becomes sore.
Conjunctivitis can be caused by infection from bacteria, viruses or other organisms, and also by allergy or inflammation.
Viral conjunctivitis tends to cause a watery red eye and can last for two to three weeks even with the correct treatment. In most cases viral conjunctivitis does not affect your vision but rarely you might notice your vision becomes blurry or you may see glare when looking at lights. This is due to an inflammatory reaction causing small white dots on the cornea, the transparent window at the front of the eye. These usually fade with time, but it can take a few weeks or even months.
Bacterial conjunctivitis is more likely to cause a red eye with a sticky yellow discharge.
There is no antiviral medication for viral conjunctivitis and it does not respond to antibiotic drops as it is not caused by bacteria. The best treatment for viral conjunctivitis is to use artificial tears and simple painkillers, with regular lid cleaning and cold compresses. The conjunctivitis disappears when your body becomes immune to the virus and fights the germs off, just as in a cold or ‘flu. Very rarely, steroid drops are given for severe cases of viral conjunctivitis or when the cornea is affected.
Antibiotic drops can be helpful in cases of bacterial conjunctivitis and are often prescribed for a one or two-week course.
Contact lenses should not be worn during any type of conjunctivitis.
Conjunctivitis is contagious and spreads very easily by water droplets (coughing, sneezing) or contact with tissues, flannels, towels, pillowcases and so on. For that reason, it’s really important to wash your hands frequently and dispose of tissues after use to prevent the condition from spreading to other family members or work colleagues.
Corneal abrasions are a small scratch on the cornea, the clear window at the front of the eye. They are generally a result of trauma (injury) to the surface of the eye. Common causes include a fingernail scratching the eye, walking into something, and getting grit in the eye, particularly if the eye is then rubbed. Injuries can also be caused by contact lens insertion and removal.
Abrasions are very painful because there are many nerves that supply the cornea.The pain gets better as your eye heals, but this can take between 24 and 48 hours.If the abrasion involves the central part of your cornea, your vision could also be temporarily affected.Apart from the pain, your eye might be watery, red and sensitive to light.
Treatment generally involves a thorough examination of your eye and lids, to check for any trapped foreign body or grit and ensure there is no serious eye injury, followed by drops or ointment and, sometimes, an eye pad. If you are given an eye pad, you will need to keep it on for between 12 and 24 hours; if you find this uncomfortable, you can take it off and use sunglasses instead.
You should also note the following:
You may take ordinary pain killers, such as paracetamol, to help with the pain
Avoid rubbing or touching your eye
If you wear contact lenses, don’t use them until your eye is completely healed; you need to see your contact lens practitioner after finishing treatment for your abrasion before you wear your contact lenses again
If you are asked to use drops or ointments, please follow these steps:
Lie down, or lean your head back, and look up
Use a clean finger to gently pull down your lower eyelid to create a pocket
If you are using eye drops, gently squeeze them into the pocket you have created,not directly onto your eye
If you are using ointment, apply a small strip into the pocket
Blink to spread the medication over your eye.
Millions of Americans each year face vision loss related to diabetes. In fact, according to recent data from the U.S. Centers for Disease Control and Prevention (CDC), nearly 26 million Americans — roughly 8.3 percent of the U.S. population — have diabetes, and more than 28 percent of diabetics age 40 or older in the U.S. have diabetic retinopathy (DR) and related diabetic eye disease.
To make matters worse, a significant number of cases of diabetes and diabetic eye disease go undetected or untreated because people fail to have routine comprehensive eye exams as recommended by their optometrist or ophthalmologist.
Most laser and non-laser treatments for diabetic eye disease depend on the severity of the eye changes and type of vision problems you have.
Diabetic retinopathy is diabetes-related damage to the light-sensitive retina in the back of the eye. As diabetes progresses, chronic high blood sugar levels cause changes that damage the tiny blood vessels in the retina, which makes them leak fluid or hemorrhage (bleed). Eventually, this leads to vision problems that cannot be corrected with eyeglasses or contact lenses.
The appearance of diabetic retinopathy is associated with the proliferation of a protein called vascular endothelial growth factor (VEGF) in the retina. VEGF stimulates the production of new blood vessels in the retina to bring more oxygen to the tissue because retinal blood circulation is inadequate due to diabetes.
Unfortunately, these tiny new blood vessels that form in the retina in response to VEGF are fragile and increase in number, leading to additional fluid leakage, bleeding and scarring in the retina and progressive vision loss.
Blood vessel leakage from diabetic retinopathy can cause fluid to accumulate in the macula, which is the most sensitive part of the retina that is responsible for central vision and color vision.
This condition — called diabetic macular edema (DME) — is the primary cause of vision loss associated with diabetic retinopathy and is the leading cause of new cases of blindness in adults ages 20 to 74 in the United States, according to CDC.
Laser treatment of diabetic eye disease generally targets the damaged eye tissue. Some lasers treat leaking blood vessels directly by “spot welding” and sealing the area of leakage (photocoagulation). Other lasers eliminate abnormal blood vessels that form from neovascularization.
Lasers also may be used to intentionally destroy tissue in the periphery of the retina that is not required for functional vision. This is done to improve blood supply to the more essential central portion of the retina to maintain sight.
The peripheral retina is thought to be involved in formation of VEGF responsible for abnormal blood vessel formation. When cells in the peripheral retina are destroyed through panretinal photocoagulation (see below), the amount of VEGF is reduced, along with the potential to produce abnormal retinal blood vessels.
After laser treatment of the peripheral retina, some blood flow bypasses this region and instead provides extra nourishment to the central portion of the retina. The resulting boost of nutrients and oxygen helps maintain the health of cells in the macula that are essential for detailed vision and color perception. However, some peripheral vision could be lost due to this treatment.
The two types of laser treatments commonly used to treat significant diabetic eye disease are:
Treatment of clinically significant DME also entails using fluorescein angiography to provide images of the eye’s interior. These images accurately guide application of laser energy, which helps “dry up” the localized swelling in the macula. A fluorescein angiogram also can identify the location of blood vessel leakage caused by proliferative diabetic retinopathy.
While laser treatment for diabetic retinopathy usually does not improve vision, the therapy is designed to prevent further vision loss. Even people with 20/20 vision who meet treatment guidelines should be considered for laser therapy to prevent eventual vision loss related to diabetes.
Laser treatment typically requires no overnight hospital stay, so you will be treated on an outpatient basis in a clinic or in the eye doctor’s office.
Make sure you have someone drive you to and from the office or clinic on the day you have the procedure. Also, you’ll need to wear sunglasses afterward because your eyes will be temporarily dilated and light sensitive.
Before the procedure, you will receive a topical anesthetic or possibly an injection adjacent to the eye to numb it and prevent it from moving during the laser treatment.
Your eye doctor will make these types of adjustments to the laser beam before it is aimed into the eye:
A laser treatment typically lasts at least several minutes, but more time may be required depending on the extent of your eye condition.
During laser treatment, you might experience some discomfort, but you should feel no pain. Right after a treatment, you should be able to resume normal activities. You might have some discomfort and blurry vision for a day or two after each laser treatment.
The number of treatments you need will depend on your eye condition and extent of damage. People with clinically significant diabetic macular edema may require three to four different laser sessions at two- to four-month intervals to stop the macular swelling.
Though the specific mechanism by which laser photocoagulation reduces diabetic macular edema is not fully understood, a landmark study called the Early Treatment Diabetic Retinopathy Study (ETDRS) showed that focal (direct/grid) photocoagulation reduces moderate vision loss caused by DME by 50 percent or more.
In December 2011, Iridex Corporation announced the results of a 10-year study of the company’s MicroPulse laser therapy for treating DME. The study data showed the new micropulse technology was at least as effective as conventional laser photocoagulation in the treatment of macular edema, with less risk of thermal damage and scarring to the surrounding retinal tissue.
If you have proliferative diabetic retinopathy (PDR) — meaning that leakage of fluid has begun in the retina — the laser treatment should take from 30 to 45 minutes per session, and you may require up to three or four sessions.
Your chance of preserving your remaining vision when you have PDR improves if you receive scatter laser photocoagulation as soon as possible following diagnosis.
Early treatment of PDR particularly is effective when macular edema also is present.
Injection of corticosteroids or other medications into the eye — either directly or in the form of an injectable implant — is often recommended over laser procedures for the treatment of diabetic macular edema. Or in some cases, a combination of drug injections and laser treatment may be recommended.
As diabetic retinopathy worsens, in addition to VEGF, other small “signal” proteins (cytokines) are released by cells, causing additional inflammation in the retina that can cause or worsen DME. Corticosteroids have been shown to have a beneficial effect by decreasing the amount of VEGF and other inflammatory cytokines produced by cells (a process called “downregulation”), which can lead to a reduction of diabetes-related macular edema.
Though the following medications reduce levels of several proteins associated with inflammation, they are generally classified as “anti-VEGF” medicines.
Anti-VEGF drugs or drug-releasing implants that are FDA-approved for injection into the eye for treatment of DME in the United States include:
Iluvien is a tiny implant that delivers a sustained, slow release of a corticosteroid (fluocinolone acetonide) to treat diabetic macular edema. It is prescribed for patients who previously have been treated with corticosteroids and did not have a clinically significant rise in intraocular pressure (a potential side effect of corticosteroid use).
Iluvien received FDA approval in September 2014, based on clinical trial data that showed that patients receiving the implant demonstrated a statistically significant improvement in visual acuity within three weeks of the procedure, compared with a control group; and at 24 months after the procedure, 28.7 percent of patients showed an improvement in visual acuity of 15 letters or more on a standardized eye compared to baseline (prior to undergoing the procedure).
According to Alimera Sciences, a significant advantage of Iluvien over other treatments for DME is the longevity of its effect: Iluvien is designed to provide a sustained release of corticosteroid medication for 36 months (three years), compared with other treatments that last only a month or two.
Ozurdex, another FDA-approved implant for DME treatment, releases a sustained dose of dexamethasone (a corticosteroid) to the retina. In September 2014, Ozurdex received approval for all patients with diabetic macular edema. Previously, the device was approved to treat DME only among adult patients who also previously had or were scheduled to have cataract surgery with intraocular lens (IOL) implantation.
The Ozurdex implant also is FDA-approved for treatment of posterior uveitis and for macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) — two types of eye strokes.
Lucentis (ranibizumab), marketed by Genentech, gained FDA approval for the treatment of diabetic macular edema in 2012 and was approved for the treatment of diabetic retinopathy (with or without DME) in April 2017.
Approval of Lucentis to treat DME was based on clinical trials that showed up to 42.5 percent of patients who were given monthly eye injections of the drug gained at least 15 letters in best corrected visual acuity (BCVA) on a standard eye chart two years after initiation of the treatment, compared with 15.2 percent of patients in a control group.
Another study found that Lucentis injections and Lucentis injections combined with laser photocoagulation both were significantly more effective than laser treatment alone for the treatment of DME.
Approval of Lucentis for the treatment of diabetic retinopathy with or without DME was based on results of multiple clinical studies that showed the drug demonstrated a significant improvement of patients’ diabetic retinopathy, according to Genentech.
Eylea (aflibercept) is another anti-VEGF drug that is FDA-approved for the treatment of DME. It is also approved for treatment of advanced age-related macular degeneration (AMD) and macular edema following retinal vein occlusion.
The FDA’s approval of Eylea for DME treatment was based on one-year data from two studies of 862 patients, which evaluated eye injections of 2 mg of Eylea administered either monthly or every two months (after five initial monthly injections). Results were compared with patients who were treated solely with laser photocoagulation (once at the beginning of the study and then as needed).
The two Eylea treatment protocols produced similar outcomes, which were significantly better than those produced by laser treatment. Patients in both Eylea treatment groups gained, on average, the ability to read approximately two additional lines on an eye chart, compared with almost no change in visual acuity in the control group.
The recommended dose for Eylea is 2 mg administered by injection into the eye every two months (following five initial monthly injections).
Retisert (Bausch + Lomb) is another intraocular implant that delivers long-term, sustained release of a corticosteroid (fluocinolone acetonide). Currently, Retisert is FDA-approved for the treatment of posterior uveitis, but some eye surgeons also use the device “off label” for the treatment of DME.
Retisert is designed to deliver corticosteroid therapy inside the eye for up to 2.5 years, according to Bausch + Lomb. The device is implanted into the eye through a surgical incision in the sclera.
Risks associated with intraocular steroid treatment for DME include steroid-induced cataracts and glaucoma. Vision loss from cataracts usually can be restored with cataract surgery. To reduce the risk of glaucoma, your eye doctor might recommend preventive use of glaucoma eye drops or even glaucoma surgery.
In some people who have proliferative diabetic retinopathy, bleeding into the vitreous (vitreous hemorrhage) makes laser photocoagulation treatment impossible because the blood obscures the surgeon’s view of the retina.
If the vitreous hemorrhage fails to clear within a few weeks or months, a vitrectomy surgery may be performed to mechanically remove the hemorrhage — after which, laser photocoagulation can be applied. The laser procedure is performed either at the time of the vitrectomy or shortly thereafter.
Retinal bleeding and vitreous hemorrhage also can cause bands of scar tissue to form. These bands of scar tissue can shrink and — if attached to the retina — can cause the retina to pull away from its base to create traction.
This traction may lead to retinal tears or possible retinal detachments.
If you experience a fractional detached retina as part of PDR and shrinking scar tissue that tugs at the retina, you usually will be scheduled promptly for a procedure to reattach the retina.
ETDRS guidelines show that type 2 diabetics in particular can reduce their chance of severe vision loss and the need for vitrectomy surgery by about 50 percent when proliferative diabetic retinopathy is treated before it reaches a high-risk stage.
Some individuals with diabetic macular edema may experience reduced symptoms and improved vision after treatment with corticosteroid medication delivered to the eye via eye drops rather than an intraocular implant.
In a study published in Acta Ophthalmologica in November 2012, researchers found that patients with diffuse DME who used Durezol emulsion eye drops (Alcon) four times a day for one month had reduced retinal swelling and a significant improvement in visual acuity, compared with similar DME patients who did not use the eye drops.
Durezol is a corticosteroid eye drop used primarily for the treatment of inflammation and pain associated with eye surgery.
The study authors concluded that use of Durezol eye drops is a useful and effective treatment for diffuse DME without surgical intervention and the associated risk of potentially severe side effects.
People who are most vulnerable to diabetic retinopathy, including the elderly and certain minorities, may not receive appropriate eye care because of lack of health insurance or access even to primary care physicians.
For these reasons, make sure you promptly advocate for your own eye health and that of affected family members or friends when any kind of diabetes is present.
Generally, diabetics don’t develop diabetic retinopathy until they have had diabetes for at least 10 years. But it is unwise to wait that long for an eye exam.
With any diagnosis of diabetes, your primary care physician should refer you to an eye doctor (optometrist or ophthalmologist) for a dilated eye exam at least once a year.
Diabetes mellitus (DM) causes abnormal changes in the blood sugar (glucose) that your body ordinarily converts into energy to fuel different bodily functions.
Uncontrolled diabetes allows unusually high levels of blood sugar (hyperglycemia) to accumulate in blood vessels, causing damage that hampers or alters blood flow to your body’s organs — including your eyes.
Diabetes generally is classified as two types:
With both types of diabetes, abnormal spikes in blood sugar increase your risk of diabetic retinopathy.
Eye damage occurs when chronically high amounts of blood sugar begin to clog or damage blood vessels within the eye’s retina, which contains light-sensitive cells (photoreceptors) necessary for good vision.
You first may notice diabetic retinopathy (DR) or other eye problems related to diabetes when you have symptoms such as:
During an eye examination, your eye doctor will look for other signs of diabetic retinopathy and diabetic eye disease. Signs of eye damage found in the retina can include swelling, deposits and evidence of bleeding or leakage of fluids from blood vessels.
Your eye doctor will use a special camera or other imaging device to photograph the retina and look for telltale signs of diabetes-related damage. In some cases, he or she may refer you to a retinal specialist for additional testing and possible treatment.
For a definitive diagnosis, you may need to undergo a test called a fluorescein angiography. In this test, a dye is injected into your arm intravenously and gradually appears in the blood vessels of the retina, where it is illuminated to detect diabetes-related blood vessel changes and blood leakage in the retina.
One sometimes overlooked symptom of diabetic eye disease is nerve damage (neuropathy) affecting ocular muscles that control eye movements. Symptoms can include involuntary eye movement (nystagmus) and double vision.
Once high blood sugar damages blood vessels in the retina, they can leak fluid or bleed. This causes the retina to swell and form deposits in early stages of diabetic retinopathy.
If you want to avoid diabetic retinopathy or control its progress, try these tips:
Above all, make sure you have regular eye exams!
In later stages, leakage from blood vessels into the eye’s clear, jelly-like vitreous can cause serious vision problems and eventually lead to blindness.
Clinically significant macular edema (CSME). This swelling of the macula more commonly is associated with type 2 diabetes. Macular edema may cause reduced or distorted vision.
Diabetic macular edema (DME) typically is classified in two ways:
If you have CSME, you typically are advised to undergo laser photocoagulation.
Non-proliferative diabetic retinopathy (NPDR). This early stage of DR — identified by deposits forming in the retina — can occur at any time after the onset of diabetes.
Often no visual symptoms are present, but examination of the retina can reveal tiny dot and blot hemorrhages known as microaneurysms, which are a type of out-pouching of tiny blood vessels.
In type 1 diabetes, these early symptoms rarely are present earlier than three to four years after diagnosis. In type 2 diabetes, NPDR can be present even upon diagnosis.
Proliferative diabetic retinopathy (PDR). Of the diabetic eye diseases, proliferative diabetic retinopathy has the greatest risk of visual loss.
The condition is characterized by these signs:
These abnormal blood vessels formed from neovascularization tend to break and bleed into the vitreous humor of the eye. Besides sudden vision loss, more permanent complications can include tractional retinal detachment and neovascular glaucoma.
Macular edema may occur separately from or in addition to NPDR or PDR.
You should be monitored regularly, but you typically don’t require laser treatment for diabetic eye disease until the condition is advanced.
Beyond the presence of diabetes, how well your blood sugar is controlled is a major factor determining how likely you are to develop diabetic retinopathy with accompanying vision loss.
Uncontrolled high blood pressure (hypertension) has been associated with eye damage related to diabetes. Also, studies have shown a greater rate of progression of diabetic retinopathy in diabetic women when they become pregnant.
Of course, the longer you have diabetes the more likely you are to have vision loss.
The American Academy of Ophthalmology (AAO) notes that all diabetics who have the disease long enough eventually will develop at least some degree of diabetic retinopathy, though less advanced forms of the eye disease may not lead to vision loss.
In the United States, minorities appear particularly vulnerable to vision loss caused by diabetic eye disease.
According to the National Eye Institute (NEI), more than 13 percent of African-American adults have been diagnosed with diabetes, and at least 825,000 have diabetic retinopathy. NEI expects the number of black Americans with diabetic retinopathy will increase to more than 1 million by 2030 and to nearly 2 million by 2050.
Also, a recent study conducted at the University of Alabama at Birmingham and Wills Eye Hospital in Philadelphia found that African-Americans with diabetes are among those at highest risk for diabetic retinopathy and have one of the lowest rates of eye care use.
Hispanics with diabetes also are at higher-than-average risk of developing diabetic retinopathy and vision loss.
Results of the NEI-sponsored Los Angeles Latino Eye Study show that 42 percent of Hispanics who have had diabetes for more than 15 years also will develop diabetic retinopathy, compared with 15 percent for all individuals with diabetes of similar duration.
Native Americans also are at high risk of developing diabetes and related diabetic eye disease. Pima Indians, for example, have a 35 percent prevalence of diabetes compared with 9.4 percent among the general U.S. population.
You must make every effort through medical intervention and other remedies to address diabetes and diabetic retinopathy before you qualify for special considerations under the Americans with Disabilities Act (ADA).
A disability basically means that you are substantially limited in the way you function in daily activity. When you are disabled, you are entitled to certain reasonable accommodations at the workplace and at public places such as schools.
ADA amendments added in 2008 further clarify that diabetics in particular have certain protections under the law, such as needed breaks at the workplace for insulin injections or lunches at set times to maintain blood sugar levels.
You cannot be fired from your job or denied employment strictly because you are diabetic, as long as you are able to handle the basics of your work tasks.
As an example, the American Diabetes Association says that a person with mild diabetic retinopathy easily might perform daytime tasks but could have difficulty with night vision. In this case, special accommodation such as appropriate lighting might be needed at the workplace.
If questions arise, you may need a letter from your physician that advises an employer regarding how well you will be able to perform certain work tasks. Any special accommodations you might need, such as extra lighting, also could be explained by your doctor(s).
State regulations governing disability differ, so you also should check guidelines established by the state in which you reside.