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

Diabetic Macular Edema

What is Diabetic Macular Edema

 Macular edema is defined as an abnormal macular thickening and excess fluid in the extracellular space of the retina. It is considered the leading cause of vision loss in the developed world in the working age population.

Current trends in the treatment of Diabetic Macular Edema

The Diabetic Retinopathy Clinical Research Network study in the USA, investigated ranibizumab (Lucentis) vs. Triamcinolone (an steroid) with laser treatment (Prompt versus deferred) and laser alone. It showed that the patients treated with ranibizumab had superior visual acuity results compared with the other groups.

Another randomized clinical study was the RIDE / RISE study (USA and Europe), comparing two different doses of ranibizumab versus a sham treatment for diabetic macular edema. Those with the ranibizumab gained on average 12 letters of visual acuity versus only four letters in the sham treatment group.

Also these studies demonstrated that the eyes that were treated with anti- VEGF agents as ranibizumab were more likely to have an improvement in their Diabetic Retinopathy Severity Scale and reduced the risk of Proliferative Diabetic Retinopathy (PDR) or the the end stage of diabetic retinopathy.

The eyes that received ranibizumab, less than 15% progressed to PDR at 3 years compared to 40% in the sham study eyes, significantly reduced the risk of severe vision loss.

In the United Kingdom, the BOLT study involved 80 eyes using bevacizumab or Avastin, an off-label treatment originally approved in the USA for colon rectal cancer and breast cancer. It showed that bevacizumab was superior to laser treatment.

Also the VIVID and Vista studies evaluated aflibercept or Eylea versus laser treatment. It showed that eyes that received Eylea gained on average 10 letters of visual acuity versus only one letter in the laser treatment group

What is the Newest Treatment for Diabetic Macular Edema?

In conclusion, the most recent data suggest that anti vascular endothelial growth factor agents previously discussed are becoming the first-line of treatment for macular edema and if the patient does not respond to these then we can add or combine them with laser treatment and steroids.

 Where To Get Treatment For Diabetic Macular Edema

All these agents are available at Sarasota Retina Institute and are performed routinely by Dr. Torres. If you have been diagnosed with diabetes, it is important to have at least a yearly exam of the retina to appropriately rule out, diagnosed and/ or treat diabetic retinopathy by a vitreo-retinal specialist.

Dr. Waldemar Torres, is a board certified and fellowship trained vitreo-retinal surgeon / sub- specialist that is available for the diagnosis and treatment of vitreo-retinal diseases such as diabetic retinopathy, age related macular degeneration, retinal detachment and acquired and congenital conditions. Call 941-921-5335  to schedule an appointment.

 

Waldemar Torres, MD 

Vitreo-retinal Surgeon

Sarasota Retina Institute

Sarasota, Florida

 

 

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

The Telescope Makes National News

On Friday the Implantable Miniature Telescope was featured on NBC Nightly News. As many of you know this is a new hope for our patients with dry macular degeneration. Dr. Levy is currently the only  physician in the southwest Florida area who is offering this amazing options to patients. He was involved in the original trial for the telescope over 10 years ago. Since the approval of the telescope by the FDA last year he has placed many of these incredible devices, improving patients lives. He was even asked to present information on the telescope at a prestigious ophthalmology meeting in Ft. Lauderdale this weekend.

If you or a loved one has dry macular degeneration and would like to learn more about this possible life changing device please call our office at 941-921-5335.

 

 

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

The Latest on Vitamins for Macular Degeneration and Cataracts

AREDS2: Most Recent Results on the Use of Vitamins and Their Effect on Cataract and Age-relate Macular Degeneration

This study was proposed because of the increasing prevalence of both age-related macular degeneration (AMD) and cataracts in the United States.  Both conditions have become major health issues impacting the overall cost of medical care. There has been a lot of hype to find out what vitamins help for these patients to possible reduce the prevalence of these diseases.

What is AREDS 2?

On May 5, 2013 the AREDS2 results were reported in Seattle, Washington at the Association for Research in Vision and Ophthalmology (ARVO) by The National Eye Institute.  This 5 year study looked at the effects of adding omega-3 and the antioxidants, lutein and zeaxanthin, in different combinations with the original ingredients of the AREDS formula currently recommended for high risk AMD.  The objective of the study was to determine if a new formulary could be found that would be more beneficial for AMD and whether the new ingredients, or different combination of ingredients, could be beneficial against the development or progression of cataract.  Additionally, there were some adjustments within the AREDS formula to determine if there was a difference in the absorption of ingredients in the presence of others.

Do Vitamins Help ?

The final results showed that the addition of omega-3 did not improve the results of the AREDS formula for AMD; neither did the addition of lutein and zeaxanthin.  Further, the use of or non-use of lutein and zeaxanthin did not have any effect on the development and/or progression of cataract in the study group as a whole.  However, it was pointed out that in the original AREDS and another randomized study the use of multivitamins did appear to retard cataract formation, particularly in the less well-nourished population.

There was also noted in AREDS2 that the absorption of lutein and zeaxanthin was reduced in the presence of beta carotene.

The Final Word On Vitamins (For Now)

From the AREDS2 the final conclusion is that the AREDS formula continues to be the nutritional supplement of choice for those with high risk AMD, and that there has yet to be a good nutritional recommendation for the prevent of or retardation of age-related cataract. Smokers can not take beta carotene since it can increase their risk of lung cancer, there was some indication that these patients should take lutein as it might help in these patients.

If you would like more information on this study or about getting vitamins made to these new findings please contact one of our doctors at Sarasota Retina Institute at 941-921-5335.

 

Mel Chen, MD

Vitreo-retinal Surgeon 

Sarasota Retina Institute

Sarasota, Florida 

Vitreous: The Jelly Filling of the Eye

What is the Vitreous?

The vitreous is a jelly-like material that resides in the large cavity of the eye located behind the lens.  It is 98% water and 2% solid, and during the early part of life, it is very uniform and clear.  It has a surface which is in direct contact with the retina.  This contact is more than just surface to surface, but a molecular bond early in life, which weakens over time, at least in most places.  This bonding is relatively tight at the optic nerve, at the macula and at the anterior border of the retina several millimeters just behind the junction where the white part of the eye meets the colored part.  Other areas where the vitreous is more tightly adherent to the retinal is at blood vessel crossings and where there is scarring or thinning of the retina due to some pathology.   The vitreous is important only in the very early stages of the formation and development of the eye.  Its presence later in life is only to occupy space thus helping to maintain the shape of the eye.

 

What Are Floaters In The Eye?

As a person ages, so does the vitreous.  Some of the vitreous condenses and some of it liquefies.  Condensed vitreous will cast shadows on the retina which are perceived as a “floaters.” Floaters, in turn are described as dots, spots, lines, hair, cobweb, etc.  There is one floater that can be particularly annoying, in that it is rather large. It is called a Weiss ring and it is a ring of connective tissue which attaches the vitreous to the retina around the optic nerve.  If it comes off intact, it is often described as a “smoke ring” and if it is incomplete it is described as “C-shaped.”  Liquid vitreous results in a collapse of the vitreous surface away from the retina.  As this occurs the vitreous will pull on the retina before it pulls completely free.  This pulling mechanically stimulates the retina which is perceived as a light flash, occurring in the far periphery of the visual field.  This aging of the vitreous, if it only involves floaters and light flashes is benign and requires no intervention.

 

What Happens to Floaters and Light Flashes?

Over time, one either gets used to the floaters, or more commonly, as the vitreous continues to degenerate the floaters will appear to disappear.  In reality, they are still present.  The condensed particles that caused the floaters have actually fallen below the line of sight and more anteriorly within the eye.

Light flashes, which are only seen in subdued lighting or in the dark, eventually stop, but this may take several weeks to months. Fortunately, their frequency decreases rather rapidly.

 

Are Floaters and Light Flashes Ever an Indication of a Problem?

The onset of floaters and light flashes should always require an examination to rule out a retinal tear and/or an early retinal detachment.  This is particular true if the floaters are reddish and numerous (100’s to 1000’s) or described as large vertical blobs or strands.  In this case, it is usually blood and there is often a decrease in vision.  Additionally, if one perceives a “curtain” over their field of vision, this and a decrease in vision would be ominous signs of a retinal detachment and require an urgent eye examination.

 

Mel Chen, MD

Vitreo-Retinal Surgeon

Sarasota Retina Institute

Sarasota Florida 

 

 

 

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

 

 

 

 

Near sightedness and The Retina

Even though you might not have diabetes or macular degeneration, if you are near sighted you might need normal exams with a retinal specialist.

What is Myopia?

Myopia is the eye condition where one has the ability to see well at near but without correction objects in the distance are blurred.  This is normally called near sightedness. In the United States, 10 to 20% of the population suffers from myopia.  Patients are classified as being mildly myopic if their correction is less the -3.00 diopters, moderate if the correction is between -3.00 and -6.00 diopters, and high if the correction is -6.00 diopters or above.  Mild and moderate myopes generally have no retinal problems and their vision can be corrected with glasses.  High myopes, which make up 30% of those with myopia, can also have corrected vision with glasses but frequently, have retinal problems.

Why are People Myopic?

Myopia occurs when the image being observed is not focused exactly on the surface of the center of vision, i.e. the macula. There are three reasons this occurs.  A refractive cause occurs when the curvature of the cornea and/or the lens result in the focal point being in front of the macula.  The second cause is due to a long axial length of the eye (which means the eye is longer then normal from front to back), and the third cause is metabolic, due to either a systemic disease like diabetes or a drug side effect.  Of these causes, the first is by far the most common.

What Retinal Problems Are Associated With High Myopia?

High myopes with long axial length eyes are those who have the most risk of retinal problems.  The cause results from either an unusually large eye or a bulge in the back of the eye, i.e. staphyloma.  In both cases all layers of the eye are stretched.  Stretching of retina in the back of the eye leads to not only thinning of the retina, but may also result in a splitting of the retina tissue called “macular schisis”, which results in decreased vision.  Thinning of the retina peripherally manifests itself as lattice degeneration, atrophic holes and retinal tears, which increase the risk of retinal detachments.  The latter condition is an ocular emergency and may occur suddenly, particularly after trauma.

Thinning of the inner lining of the eye, particularly under the macula, results in breaks in the continuity of the involved tissue.  This leads to decreased vision and may also result in the ingrowth of abnormal blood vessels under the retinal.  In turn, these abnormal blood vessels can rupture causing subretinal hemorrhaging similar to that found in wet age-related macular degeneration.

If the sclera, the thick outer wall of the eye, is thinned, it presents a potential complicating condition should there be a retinal detachment.  Since retinal detachments are not uncommonly treated with a scleral buckle, the creation of scleral tunnels or the placement of sutures through the sclera used to secure the buckle in place, become risky.  Either of these maneuvers could result in further thinning of the sclera and/or uncontrolled perforation of the inner lining of the eye.  Should the latter occur there would be uncontrolled drainage of subretinal fluid resulting in incarceration of retina in the perforation site and/or, since the inner layer is also vascular, bleeding into the subretinal space.

 What Precautions Should a High Myope Take?

Patients who have high myopia should get regular check-ups, which should include a careful evaluation of the macula and the peripheral retina.  This would best be performed by a retinal specialist who would be looking for peripheral retina pathology, which would increase the risks of a retinal tear and/or detachment.  If significant pathology is noted a recommendation for prophylactic treatment may be made.  If macular schisis is present, it is possible to repair the condition with a vitrectomy and injection of gas.

If you are very near sighted (a high myopia) and would like your eyes evaluated by our retinal specialist, Dr. Chen or Dr. Torres, please call 941-921-5335 to make and appointment.

 

Mel Chen, MD

Vitreo-retinal surgeon

Sarasota Retina Institute

Sarasota, Florida  

 

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

Twinkle Twinkle Little Star

Common Light Flashes

The most common cause of light flashes (photopsia) is due to vitreous degeneration, a benign condition that occurs over time, but is accelerated in patients who are myopic or have sustained eye trauma.  There are several other less common conditions which are associated with early vitreous degeneration.

Light flashes due to vitreous degeneration are characteristically seen in the far peripheral visual field and last less than a second and may be repetitive, but not continuous.  They are arcuate in configuration, and they are often associated with either head or eye movement.  Because of their low intensity they are observed only in the dark or subdued lighting.  (see Floaters and Light Flashes) These symptoms need to be evaluated by an eye doctor, often a retina specialist.

Ocular Migraines

Another type “light flashes” are those associated with ocular migraine.  These “light flashes” are called “scintillating scotomas”, and are persistent, lasting 20 -40 minutes.  Classically they are jagged, in a ring-like figure, begin centrally and expand outwardly.  They are not associated with a headache, but can be visually troublesome until they resolve. Often these ocular migraines are not associated with any systemic problem, but if they start to get worse it is a good idea to see a neuro-ophthalmologist.

Less Common Causes of Light Flashes

Occasionally, patients with Age-related Macular Degeneration (AMD) will also complain of “light flashes”.  These occur centrally and are described as “sparkling”.  Invariably, these patients have advanced AMD, and the source of “sparkling” occurs due to extraneous stimulation of the damaged retina.  In some patients this extraneous stimulation of the damaged retina does more than cause “sparkling”, it can cause the perception of well formed hallucinations, described as “trees, flowers, buildings, people, etc”.  This condition has been well described and is called Charles-Bonet Syndrome.

If you start to suddenly notice any new flashes of light it is a good idea to contact your eye doctor for further evaluation.

 

Mel Chen, MD

Retina Specialist

Sarasota Retina Institute

Sarasota Florida

 

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