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.

New Opportunity for Dry Macular Degeneration Patients

Over the last year we have talked about an incredible device that can be used for patients with dry macular degeneration. The implantable miniature telescope (IMT) has been placed in numerous patients around the country giving them increased independence. In the past the patients had to have advanced dry macular degeneration, not had cataract surgery yet, and be over the age of 75. Well needless to say that was a very limited group of patients with macular degeneration.

The Government Changes

Just recently the rules for who can get a implantable miniature telescope has changed. The patient still has to have advanced dry macular degeneration, have not had cataract surgery, but now the age limit is 65 and older. Dr Levy is very excited with this change in the rules. This now allows him to offer the treatment to a much larger group of patients that previously had little options for improvement in their vision

What is the Implantable Miniature Telescope?

In patients with dry macular degeneration they lose their central vision. The center of the back of the eye is damaged, but the side or peripheral areas is usually left untouched. Regular glasses focus light on the center part of the eye, and  with macular degeneration the light information can not be used no mater how good the glasses. The implantable miniature telescope is placed inside the eye during cataract surgery. This specially designed lens then enlarges the image in front of the patient and projects it onto areas of the peripheral retina. This can have significant improvement in the patients overall vision.

Where Can Patients Get Evaluated For a Telescope Procedure?

If you or a loved one has advanced dry macular degeneration, has not had cataract surgery in at least one eye, and is over the age of 65 there are a limited number of centers in the country that can offer you some hope by putting in an implantable miniature telescope into the eye. We are lucky in the western coast of Florida to have Dr. Marc Levy performing this procedure. Dr. Levy has been involved with the telescope and its surgical procedure since the original FDA trials since 2002.  He is currently the only physician in this area who it qualified to preform this life altering procedure.

Please watch the below videos for more information on the telescope.

Sarasota Florida ABC7 News WWSB (may be slow to load) 11/5/14

Detroit Michigan Local4 News WDIV 11/6/14

South Bend Indiana / Notre Dame NBC16 WNDU 11/6/14

Flint Michigan ABC12 WJRT aired 11/5/14

Beaumont Texas CBS 6 Nov 7, 2014 KFDM

If you notice Dr Levy is presented in these videos from around the country. This is due to his long experience and expertise with the IMT.

If you or a loved one wants to learn more about what the implantable miniature telescope can do for people with dry macular degeneration, please call 941-921-5335 to make an appointment with Dr Levy.

 

 

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

Snoring May Blind You

Eyelid Problems with Sleep Apnea

When I was an Ophthalmology resident at LSU, I was taught about a certain eyelid condition, called Floppy Eyelids, associated with sleep apnea.

This is a condition where the lids become loose against the eyeball which in turn causes dry eyes, excessive tearing, foreign bodies (e.g. hairs and fibers), exposure of the surface and corneal scarring.

People with sleep apnea may rub their eyes a lot when trying to start breathing again and the chronic rubbing causes the tissue to become chronically stretched.  Over the years, I have been able to diagnosis sleep apnea on some patients by just examining their eyelids.  Once the sleep apnea is treated the eyelids can be fixed by an outpatient surgical procedure to tighten them.

Optic Nerve Problems and Sleep Apnea

When I finished training 7 years ago, sleep apnea was not associated with vision loss, but that has since changed.

A new emerging area for neuro-ophthalmology is damage to the optic nerve caused by sleep apnea.  I see many patients referred for problems of the optic nerve not explained by normal causes such as glaucoma.  Often the patient will have a “negative workup,” meaning tests like MRIs and blood tests are normal.

Until recently, there was no further workup, yet we’d have no idea about the cause of the vision loss.  Now I am sending many of our patients for sleep testing looking for evidence of sleep apnea.  I do this for all patients in whom I suspect sleep apnea and not just the typical overweight patients who have sleep apnea.    I diagnose optic nerve damage due to sleep apnea in all shapes and sizes and old and young.

Why Does Sleep Apnea Damage the Eye

In short, I’m not exactly sure how sleep apnea causes optic nerve damage, but there are some very convincing theories.

During sleep apnea the oxygen level in the blood decreases since the person is not breathing normally.  Perhaps this decreased oxygen level is damaging to the optic nerve, a tissue highly sensitive to variation in oxygen levels.

The optic nerve is a very active part of the body and such it needs a lot of oxygen. When the oxygen level decreases this causes stress and damage to the nerve which over time can cause vision loss.  Sleep apnea also causes changes in the blood vessels which can also decrease the oxygen delivered to the eye.

If the thought of high blood pressure, strokes and or heart attacks is not enough to get you checked for sleep apnea, then possible blindness might be.  To learn more about this call 941-921-5335 and make and appointment to talk with one of our doctors.

 

 

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

The Advantage of Small Incision Vitreo-retinal Surgery

The Early Days of Vitreo-Retinal Surgery

A vitrectomy is an ophthalmologic surgery preformed by a retinal surgeon to remove the vitreous (the jelly in the back of the eye). The surgery was introduced by Dr. Robert Machemer about 40 years ago using very large and, by today’s standards, very crude instruments.

During the 1990s, 20 gauge vitrectomy became the standard. Gauge refers to the size of the instruments (needles are listed in gauge). The higher the gauge number the smaller the instrument in circumference. The 20 gauge instruments where inserted into the eye through an 1.1 mm incision. While this is small, the wounds still need a suture at the end of the surgery

Modern Vitreo-Retinal Surgery Technique

In 2002  a new age of vitreo-retinal surgery was introduced to the world. The 25 gauge vitrectomy soon became the new choice for retinal surgeons. The incision is just 0.5 mm and does not usually require a suture. Like modern day cataract surgery, the small incision vitreo-retinal surgery offers many advantages to the patient. There is decreased post surgical inflammation, less visual distortion after the surgery, less risk of infection, a faster visual recovery and improved comfort for the patient.  On less complex surgeries such as a vitrectomy for floaters, the risk of serious complications is around the same as modern cataract surgery. This is why today we can offer surgery for floaters, where in the past the risk was thought to be  too high.

How is Retinal Surgery Done

The surgery is often done on an outpatient basis with the patient awake. The eye is numbed with local anesthetic so that  the patient is comfortable. The patient goes home with a patch and is seen in the clinic the next day. Usually drops are given after the surgery to be used for a week or so. With the new 25 gauge systems,the down time for the patient is much less then in the past.

Sarasota Retina Institute Retinal Surgeons

Dr. Waldemar Torres and Dr. Melvin Chen both offer this cutting edge eye surgery for our patients. This procedure is preformed at Sarasota Memorial Hospital or St. Andrews Surgery center. Both places offer the newest, most advanced systems for 25 gauge vitrectomy. This enables us to offer patients the chance for the best possible outcome.

If you would like to be evaluated by one of our retinal surgeons for your retinal problems, or to talk about possible having those pesky floaters removed, please call 941-921-5335.

 

Waldemar Torres, MD

Vitreo-Retinal Surgeon

Sarasota Retina Institute

Sarasota, Florida 

 

Dr. Levy’s Board Presentation

Last week Dr. Levy gave a presentation to the Sarasota County Public Hospital board on the implantable minature telescope. The meeting is going to be rebroadcast-ed on Access Sarasota (Channel 19 on Comcast and Channel 32/34 on Verizon) tonight at 730. Other show times are scheduled through out the week and can be found on Access Sarasota. We are delighted that the telescope has been meet with such enthusiasm. It has given hope to patients with a terrible disease where none existed before.

 

 

Getting The Bugs Out of Your Vision

Many people start to experience visual floaters as they age.  These are due to changes in the vitreous (the jelly in the eye) that lead to small shadows being cast on the retina. People will often come into the office complaining about thinking there is a small bug flying around their head.

What To Do If You Notice Floaters

These floaters can come on gradually or can be a sudden onset. It is a good idea to have a retina physician examine your eye to make sure there are no retinal tears or retinal detachments. If these are present and treated early the vision can be saved from severe loss.

Do Floaters Cause Visual Loss

Most people will only occasionally notice the floaters and there is not much of a complaint from them. Others however have a lot of problems with their floaters. The vision can be 20/20 and still have significant visual disturbance that is hard to test with our current technology. But we have all had patients whose lives are affected by the floaters.

What Can Be Done For Floaters

Until recently we told patients that there was no safe way to treat floaters. A few doctors have used a special laser (called a YAG laser) to treat the floaters, but this has a increased risk level of causing severe visual loss. It was known for sometime that retinal surgery called a vitrectomy can remove the floaters but there was risk associated with it. That was the thought until recent technology changes.

 Surgical Treatment For Floaters

Today our retinal doctors can use an advanced technique called 25 gauge vitrectomy to safely treat floaters. Unlike previous techniques the risk of this surgery is similarly to the most common ophthalmic surgery, cataract surgery.  The use of 25 gauge vitrectomy is now becoming a recognized treatment for floaters in patients who are symptomatic.

 

In the next few weeks we will be presenting articles on 25 gauge vitrectomy and the procedures used to treating floaters. Dr. Chen and Torres are proud to bring this treatment to the Sarasota area and look forward to helping patients who previously had little hope.

 

If your floaters are bothering you, call Dr. Chen or Torres at 941-921-5335 to schedule and appointment for evaluation.

 

Dr. Chen and Torres

Retinal Surgeons 

Sarasota Retina Institute

Sarasota, Florida 

 

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

New Treatment For a Pulling Problem: Jetrea

JETREA

The first non-surgical alternative to eye surgery (vitrectomy) for a vision-threatening problem that affects approximately 250,000 people a year in the United States, is now available, Jetrea.

The FDA recently approved (October 2012) this injectable drug, Jetrea,  that is specifically indicated for the condition known as vitreo-macular adhesion (VMA) or vitreo-macular traction syndrome (VMT).

 Vitreo-Macular Adhesion and Vitreo-Macular traction

VMT and VMA occurs when the vitreous humor, or the clear gel in the back of the eyeball,fails to  separates from the retina, or more specifically the macula, causing distorted and blurred visual acuity instead of normal floaters. Sometime this can lead to a macular pucker (think of a wrinkle on the retina) or a full thickness macular hole. These are often conditions that often need to be repaired with a surgical procedure in a hospital or outpatient surgical center under anesthesia, with the risk of anesthesia, plus post operative recovery and limitations of at least one to two weeks.

What can be done for Vitreo-Macular Adhesion or Vitreo-Macular Traction Instead of Surgery?

The Sarasota Retina Institute and Dr. Waldemar Torres are  pleased to offer this new breakthrough that will alleviate these vision threatening condition with the convenience of a outpatient office visit. Jetrea is a new medication that can be injected into the vitreous and cause release of the tractions. Using the latest technology in retinal imaging known as Spectralis Optical coherence tomography that produces a cross section and three dimensional view of the retina, patients can be identified with this problem and often treated all in the same office visit. Intra vitreal injection or injections into the eye are everyday procedures in the armamentarium of our retinal doctors for  conditions as retinal detachment, diabetic retinopathy, inflammation and age related macular degeneration.

The effects and safety of Jetrea (Ocriplasmin) by ThromboGenics, were based on the MIVI and TRUST clinical studies that were published in the New England Journal of Medicine in 2012. Sarasota Retina Institute was proud to be part of this research leading to a better understanding of Jetrea.

Dr Torres is  happy to be able to treat these challenging retinal conditions in the office, which were previously only treatable with laser and or retinal surgery. This has greatly improved patient care and visual recovery.

Why Are Dilated Eye Exams Important ?

“ The key is to have a retinal exam early before vision acuity is affected or lost by these macular conditions that often do not cause total blindness but a definitive distorted and blurred central visual acuity leading to a decrease in the quality of life as to not being able to read the newspaper, drive a car or play golf as others” I stress this to my patients daily.

If you have visual distortion related to retinal disease call Sarasota Retina Institute at 941-921-5335 for an appointment.

Waldo Torres, MD

Retina Specialist

Sarasota Retina Institute

Sarasota, Florida

 

 

 

 

Half Mast Eyes

Eyelids can look closed or droopy from either dermatochalasis or true droopiness of the eyelid, called ptosis. Ptosis is a downward deviation of any part of the body, but in this case the upper eyelids. These are the the eyes that appear to be half closed and the person has to really struggle to lift them up.

How the Upper Eyelid Works

The upper eyelid is made of a combination of skin on the front side, 3  muscles, fat  and a supporting structure called the tarsal plate in the middle, and the smooth wet layer on the back side called the conjunctiva. The front and back layers protect the eyelid structures and the eyeball behind it. There has to be enough extra of both for the eye to open and close for blinking to keep the eye healthy and protected. The orbicularis muscle is just under the skin and helps close the eye. Behind it is some fat and then the levator muscle. This is the main muscle responsible for lifting the eyelid. It attaches to the tarsal plate and when it contract it lifts the eyelid. Behind the levator and in front of the conjunctiva is Mueller’s muscle. This is a small muscle that give a small amount of lift to the eyelid.

Causes of Droopy Lids

There are multiple causes of the lids drooping. One of the main causes is aging. Often the levator muscle can slip off the tarsal plate so it can not grasp the lid as well and lift it. This can occur from natural aging and stretching of tissue. This can also be seen in patients with long term contact lens use or recent eye surgery since both of these can stretch the muscle and pull it off the tarsal plate. There are neurologic causes of droopy lids such as myasthenia gravis, brain strokes, cranial nerve 3 damage,  other neuromuscular disorders.It is important to see your eye doctor for evaluation of droopy eyes to rule out some of these causes.

When to treat Droopy Lids

I see patients all the time with droopy eyelids, and they usually ask when is it time to have the lids raised. Well this is a questions the patient must actually answer. I tell the patient that when they are watching to lift their lids with a finger and see if this makes a difference. Often the patient is amazed at how much this improves the light coming in and opens up their visual field area. If there is no improvement then raising the lids is more of a cosmetic procedure (not covered by insurance)  not a functional procedure (covered by insurance). That is why we often ask if the lids are noticeable in the patients vision and test this with visual fields. Once it is determined to do lid surgery the two most common procedures are a blephroplasty or a levator advancement.

Droopy Eyelid Surgery

In a levator advancment the eyelid itself is actually raised by moving the muscle forward and giving it a stronger pull on the tarsal plate. The surgery is done with the patient awake but the eyelid is numbed up with a local injection. The patient is then covered to keep the area clean, and an incision is made through the skin. Both the tarsal plate and levator muscle are exposed. A suture is then passed through both to pull the muscle onto the plate. After this is done on both sides the patient is then sat up and asked to open the eyes. This allows adjustments to be made for both lid height and contour for adequate elevation and symmetry. Once this is accomplished the sutures are tied in place and the skin is then closed. The patient is then sent home to use ointment and ice. There is often bruising for about 1-2 weeks and some swelling that can last up to 1-2 months. The sutures are often removed in 2 weeks in the clinic.

 

Droopy eyelids can be a cause of significant loss of a patients visual field. It is important to have a trained eye care specialist evaluate them and recommend the proper fix. This is often done with surgery but even then there are multiple ways to fix it and each fix needs to be right for that patient.

 

Jody Abrams, MD 

Oculoplastics/Neuro-ophthalmologist

Sarasota Retina Institute

Sarasota, Florida 

 

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

Dermatochalasis (extra eyelid skin)

Dermatochalasis refers to the redundant or extra skin of the eyelid. This is often a normal occurrence in aging and can also be brought on by lots of weight loss, recurrent swelling of the eyelids.  Gravity is usually the main cause of the stretching of the skin as we age.  Dermatochalasis is most often seen in the upper eyelids but can be seen in the lower eyelid.

Patients often complain of :

  • Decreased vision in the upper fields
  • Decreased peripheral vision
  • Having to lift their lids to read
  • Chronic irritation of the upper eyelid skin
  • Heaviness of the upper eyelids

Treatment

The treatment of dermatochalasis is surgical, called a blepharoplasty. This is most often preformed in an outpatient surgical center but occasionally be done in the office. The patient is given some IV medications to help them drift of into a twilight sleep and during this time the lids are injected with a numbing agent. The patient is then allowed to remain awake during the procedure, but can be given medications in the IV to help remain relaxed throughout the surgery. In the operating room towels and covers are placed around the face after it is washed to keep the area sterile. Measurements and marks are then made to determine the incision areas and the skin to be removed. The skin is then incised with no pain to the patient only the slight feel of pressure. During this time the fat pad on the inside corner of the eyelid can often be thinned out to give less bulk to the eyelid. Once the skin is removed it is then reapporximated with suture. After both sides are done the patient is then sent to recovery and then home. During the post operative period it is important to use ice and ointment as prescribed. The eyelids will be black and blue looking for about a week and the swelling can be present for a month or more, but this all varies by the patient and most heal quickly. The sutures are often removed in one to two weeks.  It is important to have a trained oculoplastic surgeon preform the surgery to prevent too much skin from being removed and the eye being damaged.

Who pays for the surgery. insurance or the patient?

Most people believe that a blepharoplasty is a cosmetic surgery, and while this can be the case, most of the time the surgery is functional and is covered by insurance. This is true for most insurance plans including Medicare. To prove that the eyelids are indeed causing visual problems and functional nature special test must be done including extensive photos and visual fields.

 

Jody Abrams, MD

Oculoplastic Surgeon/ Neuro-Ophthalmologist 

Sarasota Retina Institute

Sarasota, Florida

 

 

Vitreous Surgery: Vitrectomy

Vitreous surgery, vitrectomy, is a surgical procedure where the jelly-like material within the eye is removed.  Its removal is not 100%, due to its structure in relation to the retina near the front part of the eye, and also due to the presence of the natural lens within the eye.

The removal of the vitreous is necessary in order to approach the back of the eye to repair macular holes and macular puckers, resolve vitreo-macular traction syndrome, and remove sub-macular blood.  Vitrectomies are also used to clear blood in the eye and other vitreous opacities, and certain types of retinal detachments, especially those detachments associated with scar tissue formation.  It is also necessary in many cases involving intraocular foreign bodies and eye trauma.

How are Vitrectomies Performed?

In order to perform a vitrectomy,  three to four small stab incisions,  sclerotomies, are made into the eye through a save zone approximately 3-4  mm away from the colored part of the eye.  These small openings may be kept open with small cannulas and are the entry sites for the several instruments which are placed into the eye in order to perform the surgery.  The first opening is used to infuse fluid into the eye.  If this were not done the eye would collapse as vitreous is removed from within the eye. The other 2 or 3 openings are for a light source and working instruments.  One of the instruments is a vitrector, which cuts and aspirates the vitreous out of the eye. It can do the same for scar tissue and any other soft material, which may be in the eye and require removal.   Other instruments include tissue manipulators, aspirators, injectors, diathermy/cautery devices, scissors and forceps.

Using the vitrector, the vitreous is removed, and with the other instruments scar tissue is dissected off the retina and removed.   Large foreign bodies are removed with forceps though enlarged sclerotomies.

In the past it was routinely necessary to close the sclerotomies with sutures, but instrumentation has become more refined resulting in very small sclerotomies, which close spontaneously.  This has also resulted in less trauma to the eye and shorter recovery time.

What Complications Can Occur With Vitrectomy Eye Surgery?

Like all surgery, there is a potential for unexpected bleeding or infection. With regard to the eye, the bleeding can occur in different locations and different degrees of severity. check domain owner . Hemorrhages on the surface of the retina are controlled by increasing the infusion pressure and/or with diathermy/cautery.   Hemorrhaging under the retina is much more ominous and may require heroic measures to salvage the eye.  Infections are initially treated prophylactically with antibiotics around the eye, but intraocular post vitrectomy infections require injections of antibiotics into the eye, and occasionally, repeat vitrectomy.

Specific to the eye, there is the potential for a retinal detachment, an exacerbation scar tissue formation, increase in eye pressure, and inadvertent retina damage.  Each of these problems is handled as they occur in the manner appropriate to the problem.

The complications mentioned above are the major ones which may result in significant loss of vision.  Although the complication rate for vitrectomies is less than a 5%, compared to cataract surgery, which is less than .01%, this is high by a factor of 500.   Considering that without vitreous surgery, most eyes would be lost, this success rate is very favorable.

 

 

 

 

 

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