Your retinal surgeon may order diagnostic tests in the office to determine the degree of diabetic swelling and damage to the retina. Optical coherence tomography (OCT) is a scan of the retina that locates and measures swelling. Fluorescein angiograph identifies poor blood flow and fluid leakage in the retina.

Treatment of diabetic macular edema involves good control of blood sugar, good control of blood pressure, and not smoking. Without controlling these, the success rate of any treatment is reduced. Treatments for diabetic macular edema include laser as well as injections. In many cases, treatment involves a combination of these therapies. Your retinal surgeon is trained in the most effective use of these treatments and will tailor the treatment to your individual eyes.

It is important to understand that the first goal of treatment is the prevention of further vision loss, which is likely to happen without treatment. The second goal of treatment is improvement of the vision. Modern treatments are very effective at both of these goals, particularly when diabetes and high blood pressure are well controlled.

With a combination of the best treatments available, we reduce the risk of further vision loss by at least half. The chance of visual improvement is about 15% with laser treatment. The chance of visual improvement is higher with injections of steroids or Avastin but repeated injections are usually needed to maintain these improvements. The longer the retinal swelling has been present, the harder it is to improve vision, since some degree of vision loss may become permanent over time.

Diabetic retinopathy begins long before the vision is affected. Regular examination of the retina is important to identify and treat diabetic retinopathy before vision loss occurs. Once the vision is affected, treatments can often improve the vision, but it may never return to normal even with treatment.

Diabetic retinopathy causes vision loss in three main ways:

• Blood vessels begin to leak fluid, like a garden hose with holes in the side. This fluid collects in the retina and causes swelling, called diabetic macular edema. Central vision may be reduced.
• Abnormal blood vessels grow out of the retina into the middle of the eye. These blood vessels may break and bleed into the middle of the eye, or they may continue growing and start pulling the retina off the wall of the eye. This is called proliferative diabetic retinopathy.
• Blood vessels may become blocked and starve the retina of oxygen. If this process, called ischemic retinopathy, continues long enough, the retina may permanently lose function.

Controlling blood sugars and high blood pressure is critical to the treatment of all forms of diabetic retinopathy. Without good control of blood sugar and blood pressure, all other treatments are less likely to have positive outcomes. Diabetic macular edema is treated with laser or injections of medicine into the eye in order to stop the leakage of fluid. In some cases, surgery may help as well. Proliferative diabetic retinopathy is treated with laser photocoagulation. In some cases, surgery may be required to remove blood in the eye or to remove scar tissue pulling the retina away from the wall of the eye (retinal detachment).

Diagnostic imaging is sometimes needed. This testing may include fluorescein angiography (a yellow dye is injected into a vein in your arm and rapid sequence photos are taken of your eye), ocular ultrasound (a probe is placed on your eyelid and reflected sound waves produce images on a screen) and optical coherence tomography (light beams are sent into your eye and the reflected light is then processed by a computer). All of these tests have almost no side effects and are essentially painless.

There are various methods of treating proliferative diabetic retinopathy. These methods may be employed individually or together.
Laser Treatment: Panretinal photocoagulation (PRP) laser treatment creates hundreds of small laser burns throughout the peripheral retina, thereby improving the flow of oxygen to the central retina, which is most important for everyday vision. The application of laser also decreases the stimulus for new blood vessel growth. This treatment may be done in one or more sessions. This treatment is highly effective and has saved vision in millions of patients.

Vitrectomy surgery: This procedure is recommended in cases of advanced bleeding or scarring inside the eye. Vitrectomy surgery is performed in an operating room. Tiny needle-sized incisions are made in the eye. The surgeon views the interior of the eye through a microscope while using fine instruments to remove blood, clear out scar tissue, repair the retina and perform laser treatment.

Anti-VEGF therapy: This new form of therapy causes stabilization and temporary shrinkage of the new blood vessel formations, thus decreasing the likelihood of bleeding. The medicine is injected into the eye in the office after numbing medicines are given. The anti-VEGF medication has a temporary effect and may need to be repeated periodically depending on the response to treatment. This treatment is sometimes used prior to vitrectomy surgery or in combination with laser.

The development of diabetic retinopathy is related to the severity and length of time with diabetes. Control of blood sugar and blood pressure are of paramount importance in preventing diabetic retinopathy. Additionally, it is extremely important to avoid cigarette smoking. Smoking significantly increases the risk that a diabetic patient will develop diabetic retinopathy. Finally periodic eye exams by an eye care professional are the best way to preserve vision. Early detection of retinopathy followed by appropriate treatment reduces the chance of blindness.

Your retinal surgeon may order diagnostic tests in the office to determine the degree of damage caused by the vein occlusion. Blood flow in the affected area may be permanently reduced. Swelling may occur in the central part of the retina (the macula) resulting in decreased vision. In some cases, the eye may grow abnormal blood vessels. These complications of BRVO can be detected by a combination of clinical examination and imaging tests. Optical coherence tomography (OCT) is a fast, non-invasive scan of the retina which measures and locates swelling in the retina. Fluorescein angiography (FA) evaluates blood flow in the retina with a series of photographs taken after intravenous injection of a dye (fluorescein).

If swelling is present, your retinal surgeon may recommend one or more treatments including laser or injection of medicine into the eye. If the eye is growing abnormal blood vessels (neovascularization), your surgeon may recommend laser treatment. In some cases, surgery is recommended. In all cases, treatment of underlying medical conditions such as high blood pressure is critical to preventing another retinal vein occlusion in the future.

Blood flow in the retina may be damaged permanently to some degree. Swelling may occur in the central part of the retina (macular edema). In some cases, the eye may grow abnormal blood vessels. Abnormal blood vessels in the front of the eye may cause elevated eye pressure, or neovascular glaucoma. Imaging tests may be helpful in identifying these complications of CRVO. Optical coherence tomography (OCT) is a non-invasive scan of the retina which measures and locates swelling in the retina. Fluorescein angiography (FA) evaluates blood flow in the retina with a series of photographs taken after intravenous injection of a dye (fluorescein).

Treatment of CRVO depends on the findings on examination and diagnostic imaging. If swelling is present in the macula (macular edema), your retinal surgeon may recommend injection of one or more medicines into the eye. If the eye is growing abnormal blood vessels (neovascularization), your surgeon may recommend laser treatment. In some cases, surgery is recommended to remove blood from the eye or to treat macular edema that has not responded to any other treatments. In all cases, treatment of underlying medical conditions such as high blood pressure or diabetes is critical to preventing another retinal vein occlusion in the future.

Your retinal surgeon may order diagnostic tests in the office to determine the degree of damage caused by the artery occlusion. Blood flow in the affected area may be permanently reduced. In some cases, the eye may grow abnormal blood vessels. These complications of BRAO or CRAO can be detected by a combination of clinical examination and imaging tests. Fluorescein angiography (FA) evaluates blood flow in the retina with a series of photographs taken after intravenous injection of a synthetic dye (fluorescein) which contains no iodine. Carotid studies, magnetic resonance angiogram, echocardiogram, and blood tests may be ordered to look for medical problems which may be life-threatening if untreated.

While it is important to identify and treat the underlying cause of a retinal arterial occlusion, there are no well-established medical or surgical techniques for treating the actual occlusion. Massage of the eye may be attempted to increase blood flow, decrease eye pressure, and dislodge emboli. Fluid may be taken from the front of the eye to lower eye pressure quickly. Sublingual nitroglycerin (nitroglycerin tablet placed under the tongue) has been tried with variable success.

If new vessels grow in the front of the eye, they may cause glaucoma, sometimes with pain and loss of vision. These abnormal new blood vessels can be treated with laser and injections of medicine into the eye, but these treatments do not restore vision.
In all cases, treatment of underlying medical conditions (such as diabetes or high blood pressure) is critical to prevent stroke or blood vessel blockage elsewhere in the body.

Like many conditions, cystoid macular edema can range from mild to severe. In most cases, CME is visible during detailed examination of the macula by an eye specialist. Additional testing is often indicated to determine the cause and severity of CME. Common tests include optical coherence tomography (OCT) and fluorescein angiography (FA). OCT is a laser scan of the retina which measures the degree of swelling and shows your doctor a cross section of the swollen area. Fluorescein angiography involves a small intravenous injection of dye (fluorescein) followed by a series of photographs of the retina. The images show blood flow and any leakage from blood vessels in the retina, and the patterns seen in these images are often necessary to diagnose the cause of cystoid macular edema.

The treatment of CME depends on the underlying cause. In some cases, such as after cataract surgery, eye drops may be an appropriate first treatment. In many cases, swelling is reduced by an injection of medicine in the eye after the eye is numbed. Several different medicines can be injected into the eye depending on the cause of CME, and your retina specialist will discuss these options in detail if such treatment is deemed appropriate. In some diseases, such as branch retinal vein occlusion or diabetic macular edema, the treatment regimen may include one or more sessions of laser. If an epiretinal membrane is pulling on the retina and causing CME, surgery may be recommended to remove the membrane. Surgery is sometimes recommended in other conditions as well depending on the response to first line therapies.

Macular holes are frequently identified by an eye care professional using a slit lamp biomicroscope. Fluorescein angiography (a dye test to evaluate blood flow) is often performed to evaluate a macular hole and rule out other conditions. Optical coherent tomography (OCT) is a type of imaging test used to produce high resolution cross sectional images of the macula in order to confirm the diagnosis, exclude other conditions, and monitor the macular hole before and after surgical repair.

Macular holes can be repaired by a surgical procedure called vitrectomy with membrane peeling and fluid gas exchange. This operation is performed in a hospital or surgery center on an outpatient basis. During surgery, the retinal surgeon removes the vitreous gel and then releases all forms of traction by separating the back of the vitreous from the retina and peeling any membranes surrounding the macular hole. The eye is filled with a bubble of sterile air mixed with a long acting gas. After surgery, the patient must stay in a face down position so that the gas bubble is positioned over the macular hole at the back of the eye.

Patients may sit upright for meals and in order to shower and use the bathroom but should otherwise stay and sleep in the face down position for a period of time determined by the surgeon, usually several days to a week. Eighty to ninety percent of macular holes can be successfully repaired with this technique. The majority of patients will enjoy relief of distortion and an improvement of two or more lines of visual acuity. There are no medications that will repair a macular hole. With a gas bubble in the eye, one should never travel to a higher elevation or fly in an airplane until the gas bubble has disappeared. Otherwise, the gas bubble may expand in the eye at the higher altitude causing acute glaucoma and permanent blindness. Rare complications of surgery include bleeding, the development of a retinal tear or detachment, and infection. These complications occur in 1 out of several thousand patients. More commonly, a cataract may develop following macular hole surgery if cataract surgery was not previously performed.

A visually significant ERM is usually first identified on clinical examination of the eye. An ERM may cause only a slight wrinkle in the retina, or it may pull on the retina and cause swelling or distortion with decreased vision. Imaging tests such as optical coherence tomography (OCT) and fluorescein angiography (FA) can be helpful in demonstrating the degree to which an ERM is distorting or damaging the underlying retina.

Vitrectomy is the surgical removal of the gel in the eye, or vitreous. Membrane peeling, or removal of the scar tissue, is then performed using microscopic instruments such as picks and forceps. Vitrecomy with membrane peeling is an outpatient procedure that usually takes less than an hour. Surgery is most often performed under local anesthesia, but can be done under general anesthesia as well.

Visual improvement after surgery for epiretinal membrane is gradual, since the retina does not immediately snap back into its normal configuration after surgery. Significant visual improvement is usually seen by 6-8 weeks after surgery, but vision may continue to improve for 6 months or more. Vitrectomy with membrane peeling can lead to visual improvement in 75-90% of eyes with enough distortion and blur to warrant surgery. The average postoperative acuity is half way between preoperative vision and 20/20. It is important to consider that postoperative vision may not be perfect, but most eyes that undergo this surgery have a decrease in distortion. Eyes that have had a prior retinal detachment in the macula are less likely to have return of fine vision. Rare complications after vitrectomy surgery include bleeding, infection, retinal tear and retinal detachment.

These complications occur in 1 out of several thousand patients. More commonly, cataract may advance at a faster pace following vitrectomy. Patients who have not previously undergone cataract surgery should expect to need cataract surgery within 1-2 years of vitrectomy surgery.

The blister of fluid under the retina is usually visible on clinical examination by an eye professional, but additional testing is helpful to confirm the diagnosis (other conditions may also cause fluid collections) and monitor change over time. Optical coherence tomography (OCT) is a non-invasive scan of the retina which measures and illustrates the subretinal fluid in cross-section. Fluorescein angiography involves a small intravenous injection of dye (fluorescein) followed by a series of photographs of the retina. The images can differentiate between various causes of subretinal fluid and can also identify the precise source of fluid leakage.

Initially, the pocket of subretinal fluid in CSCR is measured and usually observed, since the fluid reabsorbs spontaneously in the vast majority of cases. If imaging shows improvement, continued observation is usually most appropriate.

In some cases, particularly those in which the fluid fails to reabsorb within three to six months, treatment may be recommended in order to facilitate resolution of the fluid. Current treatment options include thermal laser, photodynamic therapy and intravitreal injection. Thermal laser treats the source of leakage with a “hot” laser, while photodynamic therapy treats the source of leakage with a “cold” laser after intravenous injection of a medication called Verteporfin. Intravitreal injection involves the injection of a medicine into the eye after numbing drops are given in the office. If treatment is advised, your retina specialist will discuss the various options and make recommendations based on your particular case.

While most cases of CSCR resolve without treatment, and those cases that require treatment tend to resolve as well, it is important to understand that CSCR is often a chronic disease. Repeat episodes are common and may occur in the same eye or the other eye. Even after the fluid reabsorbs, vision may not return to normal due to damage in the retinal tissue. When a trigger such as steroids is identified, avoiding that trigger in the future will help reduce the chance of a recurrence.

As the vitreous gel pulls away from the retina, the gel may tear a blood vessel on the retinal surface. A few drops of blood may leak out of the blood vessel into the gel and be seen as new floaters. While these floaters may be annoying, the blood generally does not cause any damage to the eye tissues. Hemorrhagic PVD is concerning because in the presence of blood there is a high likelihood of a retinal tear. If a tear is present, the blood may obscure it, and so frequent careful retinal examinations are appropriate in order to identify a retinal tear as early as possible and prevent a vision-threatening retinal detachment. In cases of dense hemorrhage that does not clear quickly on its own, surgery may be recommended to remove the blood and identify and treat the underlying source of bleeding.

When a PVD occurs with flashes or floaters, there is about a 10% chance of developing a retinal tear. Most of these tears occur within 6 weeks of the initial symptoms. Tears occur because of the traction at the leading edge of the gel separating from the retina. An untreated retinal tear may lead to retinal detachment with severe vision loss.

What to expect after a PVD occurs. Detailed examination by a retinal specialist may be necessary after a PVD, depending on the findings at the time of examination. The primary purpose of examination is the detection of a retinal tear, which would be treated without delay in order to prevent severe vision loss.

In most cases, the new floaters from a PVD will not go away entirely. However, the brain often learns to ignore the new floaters, and the floaters may become more mobile and move away from the central vision as the vitreous gel continues to liquefy with time. In cases of hemorrhagic PVD, the floaters may decrease over time as the blood breaks down and disappears. Flashes usually decrease and stop as the process of vitreous separation completes itself. This may take days, weeks or even months depending on the characteristics of the gel. If you experience a sudden increase in flashes, the onset of additional new floaters, or a shadow in the vision, contact your eye care provider immediately, as these may be symptoms of a retinal tear or detachment.

Laser treatment is delivered through the front of the eye using either a head-mounted apparatus or a laser apparatus connected to a slit lamp in conjunction with a contact lens. While this treatment is generally not painful, there are sensory nerves that run through the back of the eye which may be stimulated by the treatment. Some patients may have a mild headache after treatment, which is usually easily remedied with over-the-counter acetominophen.

Cryotherapy involves the application of a probe to the outer wall of the eye corresponding to the location of the retinal tear. A freeze is created at the tip of the probe, extending inwards to the retina. Cryotherapy is usually experienced as an “ice cream headache” most of which resolves within minutes. Some patients have a headache or eye ache afterwards, which can be treated with over-the-counter acetominophen.

Many patients with retinal tears initially present with symptoms such as flashes of light or new floaters. It is important to understand that treatment is not meant to get rid of these symptoms. The flashes occur because the vitreous gel is pulling on the retina. This process usually resolves spontaneously within days or weeks but in some cases will last much longer. The continuation of intermittent flashes after treatment is usually not concerning unless the flashes increase in frequency or are associated with new floaters or other vision changes.

Floaters in the setting of a retinal tear may occur for two reasons. When the vitreous gel pulls away from the back of the eye (a normal, age-related process), small condensations in the gel will appear as floaters. While these floaters are annoying, they do not cause problems on their own. These floaters will be more noticeable when looking at a clear blue sky or a white wall. In some cases, the floaters are due to blood that was released when the retina tore. This blood eventually breaks down and disappears, but the rate of disappearance is unpredictable and may vary from days to months.

Scleral buckling entails sewing a piece of silicone to the outside wall of the eye. This material may be sewn to a section of the outside eye wall, or it may go around the eye for 360 degrees forming a “belt” around the eye. The silicone material indents the wall of the eye (buckles) and pushes the wall of the eye closer to the retinal tear. The tear is treated with freezing therapy which causes local tissue damage and controlled scarring which seals the tear. The fluid already under the retina is either absorbed by the body or actively drained from under the retina and the retina is thereby reattached.

Vitrectomy is a type of surgery that takes place primarily inside the eye. The surgery takes place through three very small openings in the white part of the eye. The surgeon uses fine instruments and an operating microscope to remove the vitreous gel inside the eye and drain the fluid out from under the retina. The surgeon may use a laser to seal the retinal tears or holes. A bubble of gas is commonly placed inside the eye in order to hold the retina in place while it heals. The patient may be asked to maintain a specific head position for several days after surgery in order to position the gas bubble correctly.

Unlike scleral buckling and vitrectomy, which are performed in the operating room, pneumatic retinopexy is performed in the office with only local anesthesia. The surgeon will determine whether this is a good option based on the characteristics of the retinal detachment. Pneumatic retinopexy consist of at least three parts:

1. The tear in the retina needs to be sealed to the eye wall. This is usually done with cryotherapy, a freezing treatment applied to the outside of the eye after numbing medications are given.
2. Gas is injected into the back part of the eye (vitreous cavity). When the head is later positioned appropriately, this bubble pushes the fluid out from under the retina and pushes the retinal tear closed. Proper positioning by the patient immediately after this procedure is critical.
3. Fluid is removed from the eye in order to make place for the gas. This can be done before the gas is injected, after the gas is injected, or both before and after.

In selected cases it may be advisable to “wall off” the detachment to prevent the retinal detachment from spreading within the eye. In cases such as these, a barrier of scar tissue forms as a result of laser (or freezing treatment) and the detachment remains fixed in its position. This technique is most often used when the area of detachment is very small and located at the far edge of the retina so that vision is not significantly affected. This technique is also sometimes used for patients who cannot safely undergo any other procedure due to severe medical illness.

Results of retinal reattachment surgery are divided into two categories: anatomic results and visual results. The overall anatomic success rate of retinal detachment repair is greater than 90%. This means that the surgeon can successfully put the retina back into place 9 out of 10 times. Sometimes more than one procedure is required to achieve anatomic success. The visual result depends on the patient’s pre-operative vision as well as the body’s ability to heal. If the center of the retina is attached prior to the surgery, then post-operative vision tends to be similar to pre-operative vision. However, if the central retina is detached prior to the surgery, there may be some degree of permanent vision loss even after successful reattachment. Some procedures will accelerate cataract formation, in which case cataract surgery is needed later in order to achieve the best possible vision.

Mild lattice does not interfere with vision and does not present a high risk for future retinal detachment. Prophylactic treatment is indicated only in specific circumstances. Lattice degeneration complicated by retinal tear or an increasing cuff of fluid under the retina constitutes an urgent indication for treatment with laser retinopexy or cryoretinopexy. Both of these techniques create a controlled scar around the tear in order to seal it and prevent a vision-threatening retinal detachment from occurring. Lattice lesions in fellow eyes of patients who have retinal detachment in the other eye may be treated prophylactically, but there is still a small chance of retinal detachment even after treatment.

Patients with significant lattice lesions may be at slightly increased risk for vision loss due to retinal detachment. These high risk patients should have regular follow-up examinations of the retina. Patients with lattice degeneration should be aware of the signs and symptoms of retinal tear or detachment and seek urgent ophthalmic care when needed.