Tumors of the Eye | Ocular Tumors

As a neuro-ophthalmologist/oculoplastic specialist,  I treat patients with various tumors around their eye.

Tumors of the eye can occur on the eyelids, the eyeball itself, the tissue around the eye (the orbital area) or even the optic nerve.

Any tissue can develop a tumor.  Different types of tumors in various tissues often have characteristic behaviors.  These tendencies help us decide the appropriate treatment.  These articles are to help you understand some of the tumors that are seen around the eye.

Tumor and Cancer NOT Synonyms

Most people use the term tumor and cancer interchangeably but these do not mean the same thing. A tumor or neoplasm is an abnormal growth of tissue.  This can be any tissue in the body. Some tumors are benign and some are malignant.  The difference is based on the way the tissue act.

Benign tumors are tumors which do not spread, or metastasize, to other parts of the body.  Though a benign tumor does not spread, it can still cause damage.  For instance, large benign tumors of the optic nerve can cause loss of vision by compressing the nerve.

Depending upon the size, rate of growth and potential to blind, these tumors may be watched (i.e. left alone) or removed surgically.

Malignant Tumors

Malignant tumors can spread to other parts of the body.  There are different ways for the tumors to spread.  Parts of the tumor can spread through blood, lymphatic system, or directly invade surrounding tissue.  Often, malignant tumors are difficult to treat because they spread by multiple ways; not just one.

Treatment for malignant tumors can include surgery, chemotherapy and/or radiation.

Tumors Affecting the Eye

There can be either malignant or benign tumors around the eye. The tumor can be formed from local tissue (called a primary tumor) or have spread from other areas (called a metastasis). Sometimes in office examination , radiology imaging, or surgical biopsy with pathologic examination is needed to help determine the origin, type of tumor and then treatment course.

In our next article we will discuss some of the specific tumors we see around the eye and ways to diagnosis and or treat them.

The doctors here at Sarasota Retina Institute have special training dealing with tumors around the eye. Drs. Abrams, Spoor and Levy are part of a small group of surgeons in the country who work both on tumors of the eyelids and orbits. Using state of the  art techniques and equipment they are able to offer our patients care the rivals large academic centers around the country.

Getting Your Bell Rung

What Is A Concussion

A concussion is a complex pathophysiological process which results in an injury to the brain. The process starts with direct or indirect trauma to the head.

In more general terms is it an injury to the nerves that make up our brain. Direct trauma or force to the head is not needed. This can be from rotational, acceleration or deceleration of the head.

How Common Are Concussions

Concussions are very common injuries in motor vehicle accidents, athletic injuries, and even falls. In the past few years concussion are becoming a hot medical topic as we learn more of their immediate and long term effects.

It is unknown how many concussions occur every year. Most concussion go unreported. Loss of consciousness occurs only about 10%. The medical community is working to raise awareness by educating the public to recognize concussions.

This will help people get tested and treated to help limit long term effects.

 What Are Indications Of A Concussion

Signs and Symptoms of a concussion include:

  • Memory loss
  • Confusion
  • Loss of coordination
  • Double vision
  • Blurred vision
  • New onset of problems reading
  • New Headaches
  • Dizzy feeling
  • Sadness
  • Difficulty with concentration

Diagnosing A Concussion

It is important to recognize a concussion to prevent repeat damage. If a second concussion occurs while healing from the first incident, this can lead to swelling of the brain. If this is not treated quickly death can occur.

There is no specific test to diagnose a concussion. Diagnosing a concussion can be challenging. A lot of times in medicine we rely on a specific test such as blood work or MRIs.  There is no blood test or imaging (like MRI or CT ) that will show when a concussion occurs.

There are neuro-psychological tests that can be used to help diagnose a concussion. These specialized tests compares pre-concussion brain speed with post-concussion brain speed.

The problem is with this is you need a baseline of how the brain was working prior to the concussion to see the change. This type of testing is fast becoming the standard for most contact sports. For example, “pre-concussion” baseline testing is obtained prior to the start of the season. Any suspected concussion compares the athletes ability to perform the same baseline exam. Results can indicate concussion.

This is great for activities like sports where test can be done prior to the season. In patients without baseline testing neuro-psychological testing can help often have to be more extensive.

 How Do The Eyes Help Diagnosis a Concussion

Neuro-ophthalmologists can perform additional tests like visual field testing, ocular motility testing, and even VEPs to aid in making a diagnosis.

 

So when a concussion is diagnosed treatments include rest, retraining of the brain, and limiting reoccurrence of injury. Each time the brain sustains an injury cells are lost. After loosing enough cells (which varies with each person) disease such as Alzheimer’s can develop earlier in life then normal.

 

If you or someone you know has suffered a concussion and are experiencing visual problems call our office at 941-921-5335 to come in for an evaluation.

Jody Abrams, MD, FACS
Oculoplastics/Neuro-ophthalmology
Sarasota Retina Institute
Sarasota, Florida 34239

Who Needs an ERG or VEP?

Sarasota Retina Institute is proud to announce we now have Diopsys – a brand new, state of the art, diagnostic machine to help us diagnose diseases of the retina and optic nerve!

With Diopsys, we are one of the few practices in the state which can now perform VEP and ERG testing for our patients.  These are very specialized tests allowing us to evaluate and diagnose diseases aof the retina and optic nerve.

These tests are not new and have been the mainstay of neurologists and retina specialists, but until now, have been difficult to administer and took hours to perform.

With the acquisition of the Diopsys system, we are able to stay true to our mission of providing the best, state of the art care for our patients.

What is a VEP?

Visual evoked potential (VEP) tests the optic nerve.  The optic nerve connects the eye to the brain. The retina of the eye is stimulated by light and converts this to an electrical signal that runs through the optic nerve and then to the back of the brain.

Many diseases affect the speed at which signals travel along the optic nerve to the brain.  This may translate to decreased vision.  With the VEP we can actually measure the speed of the signal as it goes from the eye to the brain.

The Diopsys machine stimulates the eye by projecting a black and white checkerboard pattern on the retina and then with small electrodes on the skin it can detect the electrical impulse.

The test is painless and all the patient has to do is look at a screen.

We can then compare the transmission time between the two eyes and also to what is considered normal (around 100 milliseconds). The VEP test can actually give us information of the function of the nerve. This is useful in disease such as multiple sclerosis, ischemic optic neuropathy, glaucoma, and other disorders of the optic nerve.

It can even be helpful in patient with closed head injuries or concussions.  Often we will get a baseline to establish where the nerves are and then compare that at a later time. This way we can detect small changes in the nerve function much earlier then the patient will ever notice.

What is an ERG

In contrast, the electroretinography (ERG) is a way to test the function of the retinal cells. This includes the photoreceptors, inner retinal cells and gangional cells. Previously we were able to look at the structure of the retina with test like OCT, but the ERG has given us the ability to look at the function of the retina.

This test can be used in patients with macular degeneration, diabetic retinopathy, and especially useful in patients on plaquinel. The ERG and the OCT are becoming the new standard to test for early changes from Plaquinel toxicity.

We can detect changes in the retina prior to them causing vision changes that the patient notices.

Once again the test is done with a small electrode around the lower lid, and then on the head. The patient will look at a screen and that is about as hard as the test is.

Who Needs an ERG or VEP

  • Multiple Sclerosis patients
  • Patients on Plaquinel or other medications that can affect the optic nerve or retina
  • Patients with unexplained vision loss
  • Patients with macular degeneration
  • Patients with closed head injuries

We are constantly strive to offer our patients with the best technology and the best care.  The new VEP and ERG machine opens a new world of diagnostic testing for you, our patients.   This will enable us to detect disease earlier and reduce the effect on your vision.

If you or a loved one could benefit from this testing please call us to schedule an appointment at 941-921-5335.

 

Jody Abrams, MD, FACS
Oculoplastics/Neuro-ophthalmology
Sarasota Retina Institute
Sarasota, Florida 34239

Concussion and Vision Changes Part 3

Concussion and your vision (part 3): double vision

       Last time I discussed what happens to you ability to see after a concussive head injury.  When your head hits a stationary object or is struck by a concussive blow the brain is jolted around the cranial cavity and is injured by smooth and sharp bones (fig 1).   The three nerves that innervate the muscles that move your eyes exit the brain stem and travel along the base of the skull, coming together behind the eye and enter the orbit thru a narrow canal to innervate their respective muscles that move the eye (fig 2).   These nerves are susceptible to injury anywhere along the route from the brain stem to the eye muscles.   Injury to any or all of these nerves results in a distinct pattern of double vision.   With this knowledge a neuro-ophthalmologist can determine which nerve is involved and how and when to treat the patient.

   

Thomas Spoor MD

Fig 1 (Click to enlarge)

Closed Head Injuries 01 d002

Fig 2 (Click to enlarge)

 

      

 

 

Double Vision: 6th Nerve Palsy

The patient in figure 3 has a sixth nerve palsy.  This nerve only moves one muscle, the lateral rectus that moves the eye to the side.   Due to its long passage from the brainstem to the lateral rectus muscle, damage to this nerve is the most common squeal of concussive injuries (fig 3a).  These patients complain of horizontal or side-by-side double vision and cannot move their eye to the side.  The double vision is very bothersome and there is no immediate treatment except to patch either eye.   This will resolve the double vision as long as the eye is covered.  Now begins the waiting game.  You really must wait 6 months to see the extent of spontaneous recovery.  If partial recovery occurs continue to wait until the amount of misalignment is stable.  Appropriate surgery is then very effective resolving the double vision.

Closed Head Injuries 01 d025

Fig 3a (Click to Enlarge)

Fig 3(Click to enlarge) Patient looking to her Right

Fig 3 (Click to enlarge) Patient looking to her Right

If there is no improvement, surgery is still helpful but less successful.  There is always residual double vision when the patient looks to the side but you can usually resolve the double vision straight ahead and in most other gazes.

I will talk about other cranial nerve injuries that can cause double vision from closed head injuries. If you our some one you know is suffering from any of these ocular problems please contact us for evaluation and treatment.

Tom Spoor, MD
Oculoplastics and Neuro-ophthalmology
Sarasota, Florida

Tom Spoor,MD
Oculoplastics and Neuro-ophthalmology
Warren, Michigan

The Back Of The Normal Eye

Normal retinal anatomyThis is the second of two articles on the normal anatomy of the eye.  This post describes the retina and associated problems.

Pars plana:

This is a flat area extending from the pars plana to the ora serrata.  It does not have a particular function, however, it is an area of the eye through which needles and other instruments can be placed into the eye without causing complications or damaging other parts to the eye.  At times it can be involved in inflammatory problems in the eye.

Ora serrata:

This is the junction between the pars plana and the periphery edge of the retina.  It is significant because straddling this area is the vitreous base, where the vitreous is tightly adherent to the retina.  Because of this tight attachment, significant trauma on the eye can tear the retina away from the wall of the eye causing a dialysis and retinal detachment.

Vitreous cavity:

This is the large space behind the lens, like the air space in a basketball. But instead of air, it is filled with a jelly-like matter call vitreous.  Vitreous is homogenous and clear, normally in early life.  With aging, the vitreous degenerates leading most commonly to symptoms of light flashes and floaters.

However, with the degeneration of the vitreous more serious conditions can occur such as retinal tears, retinal detachments, vitreo-macular traction syndrome, macular pucker, etc.  The vitreous may also be involved in inflammatory conditions, diabetes and cancers.

Retina:

This is the sensory part of the eye, picking up light stimuli and transporting that signal to the brain to be interpreted into sight. It covers the entire inner surface of the eye from the ora serrata to the optic nerve.  It is a very thin layer of tissue which contains the photo receptors and nerve fibers, which carry all the light impulses to the brain.

Any pathology of the retina such as retinitis pigmentosa, myopic degeneration, macular degeneration, trauma, etc. will result in decreased vision.  Any damage to the integrity to the retina such as a hole or tear could lead to a retinal detachment.

Macula:

This is part of the retina, but it is centrally located in the back of the eye.  It is the area of the retina responsible for your best vision.  It gives you your best reading and color vision.  It is a small area measuring about 3 mm in diameter with its center accounting for the most precise vision.

Any image focused outside this area results in decreasing clarity and the further out, the poorer the vision.  The periphery of the retina does not have any photo receptors which can distinguish color, but is adapt for night vision.  Therefore, loss of the peripheral photo receptors results in loss of night vision.

Retinal arteries and veins:

There is only one main artery, the central retinal artery that enters the eye through the optic nerve.  As soon as it enters the eye it divides into an upper (superior) branch and a lower (inferior) branch.  From there, progressively smaller vessel branch off until they become capillaries.

The capillaries eventually combine to become progressively larger veins, and finally the upper (superior) vein joins the lower (inferior) vein, to exit the eye as the central retinal vein. Blood entering the eye through the central retinal artery supply oxygen and nutrients to the inner ⅔ of the retina, which does not include the photoreceptors.  Any obstruction of these vessels would be called a occlusion, which be the result of an embolus or a clot formation.

Choroid:

This is a vascular layer lying just below the retina; it supplies the blood circulation to the outer third of the retina which includes the photoreceptors.  The sources of the vessels which make up the choroid come from branches of the optic artery in back of the eye which penetrates through the sclera.  This layer is like a thin, dry sponge which expands when wet.

Any trauma to the choroidal vessels can cause either seepage of serum into the extravascular space or frank blood.  This would cause expansion inwards into the eye rather than outwards because the sclera prevents any outward expansion.  If the eye is closed, meaning that there is normal pressure within the eye, the expansion would be relative minimal.

However, if there is  and opening like a filtering bleb or valve in glaucoma  patients, or the eye is open during cataract or vitreous surgery, the expansion of the choroid could be massive and result in extensive damage and loss of vision.  Primary malignant melanoma and metastatic can also arise from the choroid.

Optic nerve:

This is the accumulation of all the nerve fibers from the retina which exit the eye.  The exact area at which they exit is the optic disc, which is also where the central retinal artery enters and the central retinal vein exits the eye.  In observing the optic disc and the nerves as they exit the eye, it common to see a small dimple in the center, which is normal.  However, if it is large or asymmetric as compared to the fellow eye, it may suggest the presence of glaucoma.  If the disc appears pale, it indicates optic atrophy; and if it is red and/or swollen, it may indicate local inflammation or pressure in the optic nerve or further back in the brain.

Sclera:

This is the thick, tough outer layer of the eye, which, along with the cornea, maintains the shape of the eye as long as there is pressure within it.  It is whitish in color as observed from the front.  In reality one is seeing it through a transparent layer of tissue called the conjunctiva.

It is within the conjunctiva where all the blood vessels are seen.  Occasionally, the sclera may not keep the eye as round as it normally does due to either weakness or thinning.  This may then result in elongation of the eye, which makes the cornea and lens incapable of focusing an image clearly on the back of the eye.  This results in a condition of myopia (near sightedness).

Thinning on the sides of the eye can be seen as dark areas because the darker choroid layer is   partially exposed.  In contrast to an elongated eye, if the eye is short, sharp focusing may also be impossible, resulting in the condition of hyperopia (far sightedness).  In the very back of the eye the sclera is connected to the optic sheath which is wrapped around the optic nerve as it extends back into the brain.

Dr. Mel Chen
Vitreo-retinal surgeon
Sarasota Retina Institute
Sarasota, Florida

 

 

Parkinson’s Disease and the Eye

What an incredible weekend. Saturday October 12 I had the honor of presenting at the Neuro Challenge Foundation conference on how Parkinson’s disease affects the eyes. I was amazed at the turn out, over 200 people. I presented a power point presentation (the one shown below) and then was able to answer audience questions.  What a wonderful conference. Dr. Sutherland and the entire staff of Neuro Challenge Foundation should be given a standing round of applause for the work they do.

I hope you enjoy the power point presentation.

If you or a loved one are affected by Parkinson’s disease and would like to learn more about it affects your eyes please call 941-921-5335 and schedule and appointment to speak with one our or doctors.

In the next few days I will send out what Drs. Levy, Torres and Rivero presented over the weekend.

 

 

Jody Abrams, MD, FACS
Oculoplastics/Neuro-ophthalmology
Sarasota Retina Institute
Sarasota, Florida 34239

Sarasota Retina Institute Doctors’ Lecture Locally

Our doctors will be speaking at several meetings this weekend.

Macular Degeneration and Telescope

We have been asked to speak at two separate events this upcoming weekend. Drs. Levy, Torres and Rivero will be speaking at the Macular Degeneration Awareness Society meeting in Sarasota.

This is a wonderful event to help provide information on macular degeneration, the current therapies for it and what might be coming out in the future. Our doctors will be presenting information on the miniature implantable telescope that is giving so many of our patients a new outlook on life.

If you would like to attend call 1-800-253-0985, or  email danielle@maculardegenerationassociation.org to reserve your seat.

Parkinson’s Disease and the Eye

Dr. Abrams will be presenting at the the Neuro Challenge Foundation Meeting at the  Sarasota Memorial Institute for Advanced Medicine. The talk is about the Non-Motor Aspects of Parkinson’s disease.  Dr. Abrams will be talking about how Parkinson’s disease affects the eyes and visual system.

Dr. Andy Keegan from the Roskamp Institute will be talking about memory loss and dementia in Parkinson. This will be a very informative morning for both patients and their family/caregivers on aspects of the disease they might not often think of.

Registration is online at the Neuro Challenge Foundation website.

Doctors Reaching Out to Community

We hope that be going out to these lectures we can help educate the community. Our goal is not only to help our patients, but to help people understand what is going on with their diseases.

If you would like one of our doctors to talk at a local group on any of the disease we treat, please contact us at 941-921-5335 and we will be happy to help.

If you can not make the lectures do not fear. We will be posting our PowerPoint lectures online this week for everyone to view.

 

Jody Abrams, MD, FACS
Oculoplastics/Neuro-ophthalmology
Sarasota Retina Institute
Sarasota, Florida 34239

Botox For Migraines

Botox is the only drug currently FDA approved for the treatment of migraine headaches.  All other medications previously have been used “off-label” (meaning with out the FDA approval).

What Is Botox?

Botox is botulinum toxin A. It is a toxin produced from a bacteria. It is a very powerful toxin that causes weakness and paralysis of muscles. It is seen in food that was not properly canned and could cause severe medical problems for the person who consumed it.

Scientists have known about the toxin for over a 100 years. It was in the late 70s that an ophthalmologist, Dr. Alan Scott, figured out that in small doses the toxin could be used to treat strabismus or spasms of the face.

He sold Botox to Allergan and he discovered how useful the medication was for treating wrinkles.  And in the early 90s cosmetic Botox was introduced and the explosion began.  Coincidentally, after injecting the medication for years doctors started to notice patients with migraines commented they had improvement in their headaches when they got the injections (either for spasms or cosmetic).

This was proven true and approved by the FDA about 3 years ago for the treatment of chronic migraines.

Is Botox Safe?

Botox is safe.  True Botox is the same toxin that causes botulism, but the doses that we use are significantly smaller.  In fact it has been reported that the company that makes Botox, Allergan, can produce enough product to supply the entire world with only a gram of toxin.

What this means is that the doses we use are very small in comparison to what is found in poisoning cases. Botox used properly is a safe and effective drug.

Botox For Migraines

Botox is injected into the neck, back of the head, temples and the forehead when treating for migraines. The FDA approved dose is 155 units given in approximately 33 different locations.

The injections take less then 5 minutes to give, and often last 3 months. Most insurance companies, including medicare, now cover the injections. We will see the patient for an initial evaluation, preform some testing, and then submit the information to the insurance if needed for approval. Often we can do the injections a few days or so after the first visit. Most patients start to get relief about 4-5 days after the injections.

No one really knows why the Botox improves the migraines, this dose and location areas works best.  It is thought that maybe there are micro spasms of the muscles that cause the migraine and the Botox relaxes the muscle enough to help limit their occurrence.

If you or someone you know suffers from chronic migraines, call 941-921-5335 for help.

Jody Abrams, MD

Oculoplastics/Neuro-ophthalmology

Sarasota Retina Institute

Sarasota, Florida

 

 

Giant Cell Arteritis: Test and Treatment

Last time I talked about what are some of the signs and symptoms of  giant cell/temporal arteritis. Remember vision loss, headaches, jaw pain, fevers, and unexplained weight loss can all be warning signs. So now that you have recognized these symptoms as a problem what is the next step?

Test For Giant Cell Arteritis

I tell patients if they start to notice these problems they should be calling their eye doctor immediately. The appointment is usually made that day if there is enough worry. We preform a complete exam including:

These are the test that we will often preform in the office. While no one test above gives the diagnosis of giant cell, they all help aid in making the decision for further workup. This can take a few hours to get through all these test so please be patient and know that this is all important to help preserve your vision.

Giant Cell/Temporal Arteritis Labs

If your workup is suspicous for giant cell/temporal arteritis then we will send you out for some labs. There are 3 main labs that will ordered. Sedmenation rate (sed rate), C Reactive protein (CRP), and a platelet count, are all used to help. These test show signs of inflammation in the body. While they can be very sensitive to inflammation they are not specific. What this means is that if they are normal for your age then there is almost no chance the problem is giant cell/temporal arteritis. If how ever the labs are high (one or more) then there is a chance this is giant cell/temporal arteritis but it also can be other causeses of inflammation. These are what we call highly sensitive but low specificty test.

If the office workup is suspcious for giant cell/temporal arteritis and the labs look elevated then it is time to start therapy imediatly and proceed with a slightly more invasive test for diagnosis. That is what we will discuss next time.

If this sounds like a problem you are having please call our office at 941-921-5335 for immediate assistance.

 

Jody Abrams, MD

Oculoplastics and Neuro-ophthalmology

Sarasota Retina Institute

Sarasota, Florida

 

Stop The Burn

Treating dry eye

I never thought I would be involved in treating patients with dry eye problems.  I am an oculoplastic surgeon and neuro-ophthalmologist.  Treating tearing ok, but dry eye symptoms belong to the cornea and external disease specialists. However these patients present to the neuro-ophthalmologist with undiagnosed complaints ranging from pain in the eyes to fluctuating or decreased vision.  These symptoms are very often undiagnosed and subsequently the patients suffer for a prolonged period of time when help should be readily available.

As I have mentioned in previous articles, the key to accurate diagnosis and treatment is the use of a vital stain (Lissamine green) at the beginning of the examination.  Vital stains (which lissamine is) stain devitalized tissue.  Dry eyes stain with speckled spots of  lissamine green stain.  If the conjunctiva stains you have moderate dry eye, if the conjunctiva and cornea stain you have severe dry eye.  It is really that simple.

Artificial Tears

Conventional wisdom and the party line is treat mild dry eye with some artificial tear preparation.  This sound good and cost effective but artificial tears are not real tears.  Your tears are composed of a very complex mixture of proteins, antibodies, enzymes and lubricants.  You can’t find these in a bottle of tears.  After a trial of tears most patients are not happy.  Tears are expensive and have to be dropped in the eyes many times during the day.  This is especially hard for seniors who may have some arthritis problems and difficulty using eye drops.

Alternative Options for Dry Eyes

Why not keep your own tears around longer?  This is easily accomplished by partially occluding the tear drainage system with a punctual plug.  These are tiny devices that are eventually dissolved by the body that delay the drainage of tears from around the eye.  This keeps the tears with all their valuable ingredients in contact with the eyes longer and very effectively and conveniently alleviates dry eye symptoms.  They can be placed in the office during the examination with little or no discomfort.   The effects can be amazing.

How Important is Dry Eye Treatment

Early in my dry eye career a patient was referred to me for an unrelated surgical procedure.  During her complete examination I noted significant lissamine green staining of her eye indicative of severe dry eye.  I placed plugs in all four of her drainage holes (puncta) and scheduled her for her unrelated surgery.  When I saw her in the pre-operative holding area she gave me a huge, tearful hug stating that she felt so much better and why could not the 6 previous ophthalmologists do what I had done for her.  This is the value of lissamine green and punctual occlusion.  This scenario plays s out in the office almost every day.  Dry eye is common and usually easily treatable with simple office procedures.

If these symptoms sound familiar to you please call 941-921-5335 to see one of our dry eye specialist.Tom Spoor, MD

Oculoplastics and Neuro-ophthalmology
Sarasota, Florida

Tom Spoor,MD
Oculoplastics and Neuro-ophthalmology
Warren, Michigan