After discussing with you any concerns or problems you may have with your eyes, a thorough medical history will be obtained, including a review of your current medications and previous surgical information. Your vision will be checked and if needed, your glasses and/or contact lens prescription will be updated. Through a series of tests and measurements, your eye health will be assessed and your eyes will be checked for diseases such as dry eye, glaucoma, cataracts and macular degeneration. In order to fully assess your eye health, eye drops will be used to check the eye pressure and to dilate the pupils. It takes an average of 20 minutes for the pupils to get big enough for the physician to be able to thoroughly examine the retina and optic nerve.
Your pupils will remain dilated after the exam for approximately 4 hours. Dilation can last longer for some individuals, especially children and those with light colored eyes. Since the dilation process affects people differently, it is difficult to know if a patient is going to feel comfortable driving home after being dilated. Pupil dilation makes the eyes more sensitive to light and can make vision blurry up close and in some cases blurry at a distance. For that reason, we usually recommend that you have someone available to drive you home and consider scheduling your appointment on a day when you will not need to do a lot of near work after the examination.
The lens of the eye, which is normally clear and focuses light onto the retina in the back of the eye, becomes a cataract when it is no longer clear. Cataracts generally occur with age and ultraviolet (UV) light exposure. However, some individuals are born with cataracts or develop them earlier in life because of trauma, disease or certain genetic or environmental factors. The lens imperfections cause the vision to seem blurry, hazy or less colorful. Some cataracts also cause double vision and can increase light sensitivity. Individuals with cataracts also frequently have difficulty seeing well at night and also experience glare or halos around lights.
Normal cataract development can be slowed by use of sunglasses or prescription eyeglasses with UV protection. If cataracts progress to the point that it is affecting the vision, cataract surgery will likely be recommended. People perceive the quality of their vision differently and have different visual demands. Surgery is recommended when the patient's daily activities are affected.
Cataract surgery is performed under sterile conditions, usually with the patient awake. A very small incision is made and an instrument is inserted that breaks up and removes the natural lens that has formed the cataract. The physician then inserts an intraocular lens (IOL) implant to replace the natural lens. This lens is held in place by the same membrane that holds the natural lens in place and is intended to last for the rest of the patient's life. Cataracts can not grow back, but occasionally the membrane holding the IOL in place can become cloudy due to the formation of scar tissue. This scar tissue can be removed by use of a laser as an in-office procedure.
Glaucoma is a condition that damages the optic nerve in the back of the eye. The optic nerve takes light messages from the retina and sends it to the brain for interpretation, like a fiber-optic cable. With Glaucoma, the nerve fibers are damaged. The peripheral vision is lost first and end-stage glaucoma leads to blindness. Any damage at all that occurs, is irreversible. Usually this damage is caused by uncontrolled eye pressure but about one third of the population have nerve damage even with normal eye pressure. Glaucoma has no symptoms in its early stages so early detection by an eye physician is key to preventing damage. This is why it is so important to have regular eye examinations. Half the people who have Glaucoma have no idea they have it and it is the leading cause of blindness in people over 60 years of age.
Once the signs of Glaucoma are detected by the physician (via eye pressure measurements, anatomical inspection of the drainage angles in the eyes, examination of the optic nerve, visual field testing and Optical Coherence Tomography imaging), the first line of treatment is generally eye drops. The goal with the eye drops is to decrease the intraocular eye pressure (IOP) by increasing the rate it flows out of the eye or reducing the amount of fluid the eye makes. There are many different types and combinations of eye drops available but if they are found to be insufficient in keeping the damage from progressing, laser surgery or more invasive surgery with drainage shunts are necessary.
There are two types of Macular Degeneration (AMD), Wet AMD and Dry AMD. Macular Degeneration happens when the central part of the retina (the macula) is damaged, resulting in the loss of central vision and the loss of fine details. This damage occurs usually as an aging process and is the leading cause of visual impairments in people over the age of 50. AMD is more prevalent in Caucasian populations, smokers (or former smokers) and those who have a family history of AMD. Having heart disease and/or high cholesterol are other risk factors for Macular Degeneration.
Dry AMD is the most common (about 90% of AMD is in the dry form) and occurs when drusen (white or yellow particles that form under the retina) grow and parts of the macula get thinner. At this point in time, there is no treatment for dry AMD, only the hope to slow down the process with nutritional supplements that include Vitamin C, Vitamin E, Lutein, Zeaxanthin, Zinc and Copper.
Wet AMD is much less common than the dry form but is much more serious and aggressive. Wet AMD occurs when new, abnormal blood vessels grow under the retina and leak blood or other fluids, causing a rapid decline in the vision due to scarring of the macula. There are medications called anti-VEGF drugs that help to treat Wet AMD by causing the abnormal vessels to regress. These medications are administered through and injection into the eye and often require multiple treatments. Sometimes laser surgery is required, but has become less common after the advancements of the anti-VEGF medications.
High blood sugar levels can lead to vision loss by affecting the macula and the retina. This is a condition called Diabetic Retinopathy, which occurs when the blood sugar damages the small blood vessels (capillaries) in the retina, causing them to leak or close up, stopping the blood flow. Sometimes Diabetes can cause the retina can grow new blood vessels, a process called neovascularization, but these new vessels are very fragile and often bleed into the vitreous (the jelly-like fluid inside the eye), blocking the vision. The abnormal vessels can also form scar tissue which can lead to a retinal detachment.
It is also common for high blood sugar to cause changes in the lens inside the eye, making vision blurry. This often slowly returns to normal after normal blood sugars are restored but can accelerate the growth of cataracts when it happens repeatedly. Since this is a temporary change, it is always good to make sure the blood sugar levels are stable before getting a new prescription for eyeglasses.
Macular Edema is the most common cause of vision loss in Diabetics. Treatments for Diabetic Retinopathy and Macular Edema include Anti-VEGF medication administered via injection into the eye, laser surgery to seal the leaking blood vessels or Vitrectomy, where the vitreous gel and blood are removed from the eye. Prevention is the best line of treatment, however. Controlling the blood sugar and blood pressure can stop vision loss and sometimes bring back some of the vision once it is better controlled, depending on how much and what type of damage has occurred.
Floaters are usually made from little clumps of gel or condensations in the jelly part of the eye (the vitreous). We see small specks, dots/circles or lines or cobwebs or tadpole looking objects in our field of vision as a result of the light casting a shadow of these on the retina. Since this is a shadow that we are seeing, it is most common to notice floaters when looking at something like a white piece of paper, a blank wall in a brightly lit room or when looking up at a bright sky.
Floaters are formed as the vitreous liquefies and starts to separate from the retina, which happens at any given point in our lives. Sometimes the vitreous can pull on the retina or rub against it, causing flashes of light. Under normal circumstances, floaters are benign. Occasionally, however, the vitreous can adhere to the retina and create a tear in it, potentially leading to a detached retina. For this reason, medical attention should be sought (by having a dilated exam from an eye doctor) if there is a sudden onset of floaters/flashes or a sudden increase in the amount of floaters one already has, especially if accompanied by a change in vision, or if an area of the vision becomes obscured or shadowed or appears to have a curtain coming down over it.
Most commonly, watering is actually a sign of dryness. When the eyes get dry, reactive tears are produced, the same tears as when we cry that lack the oil and mucus that are present in lubricating tears. These reactive tears aren't regulated at a slow and steady flow like lubricating tears are regulated. Instead it's an overproduction of tears that floods the eye(s) and sometimes spills over the lids onto the cheeks.
Another less common cause of watering eyes is the blockage of the tear ducts. This problem can be determined by a test in the office.
Dry eye occurs when your eyes do not produce enough tears or the right type of tears. Tears are necessary to keep the eyes healthy and comfortable and play an integral role in how well we see. Tears are comprised of three layers: an oily layer that keeps tears from evaporating too quickly, a watery layer that cleans the eye, and a mucus layer that keeps the tears slippery and helps the tears spread over the eye's surface.
Symptoms of dry eye include burning, stinging, scratchy or gritty feeling or the sensation like something is in the eye. Dry eye can create strings of mucus in the eyes, make the eyes red or irritated and cause contact lens wear to be uncomfortable.
Dry eye can be caused by many things and is more common as we age, affecting women more often than men, especially women who have gone through menopause. Systemic diseases like Sjogren's, arthritis, lupus or thyroid disease can predispose someone to dry eye more, as can having had a history of refractive eye surgery, such as LASIK. Environmental factors can create a dry eye problem like looking at a computer or reading for long periods of time (due to reduced blinking), being in smoke, wind or a dry climate. People who have used contact lenses for a long time or are taking certain medicines such as antihistamines, water pills for high blood pressure, beta-blockers for heart or blood pressure problems, sleeping pills, and anxiety medications are more affected by dry eye quite commonly.
There are many types of treatments available for dry eye, depending on the severity of a patient's symptoms they exhibit and on the findings that the doctor sees in the patient's tear film and ocular surface.
People who smoke have an increased risk of developing Cataracts, which leads to multiple vision problems and ultimately, Cataract Surgery (see Q and A for Cataracts for more information). It can also increase the likelihood of acquiring Macular Degeneration, permanently damaging the central part of the retina and therefore affecting the center of the vision. See the Q and A on Macular Degeneration for more information.
Smoking damages the small blood vessels throughout the body. The retina has an abundance of these small blood vessels, which are crucial for keeping the retina healthy by means of proper blood-flow. Diabetics who smoke are at a particularly high risk level for this damage to occur (see Diabetic Retinopathy).
Smoking can also damage the optic nerve, especially in those with Grave's Disease (a thyroid problem) or in those who have a poor diet and drink alcohol excessively.
It is not news that smoking during pregnancy is known to cause several problems for the unborn child, including prematurity. Premature infants sometimes require oxygen therapy to survive, which can cause Retinopathy of Prematurity (ROP), leading to permanent vision loss or blindness in some cases.