Surgery for retinal detachment

If you have a retinal detachment, your physician likely recommended a surgical procedure to repair it.  There are several options for repair of retinal detachment, and the one we recommend changes based on factors such as your age, whether you have had cataract surgery, the location of the retinal detachment, and if any scar tissue is already present in your eye.

A retinal detachment occurs when the layers of the retina separate from the choroid, or inner lining of the eye.  The goal of retinal detachment repair is to get the retina to "stick" to the back wall again.  This can be accomplished with several different options.

The first option is a pneumatic retinopexy.  This is an in office procedure where a gas bubble is placed in the eye.  The gas bubble pushes against the detached retina and holds it in place, allowing the retina to scar down.  The gas bubble is either preceded by cryo, which freezes around the tear causing the detachment, or followed later by laser, which seals around the tear that caused the detachment.  Only certain people are candidates for pneumatic retinopexy.  The tears causing the detachment must be close to one another, and must be near the top or the sides of the eye.  This is so the bubble, which floats, can press against the tear. Also, the patient must be able to hold a specific position for 5-7 days which can be difficult for the elderly and patients with neck or back problems. The gas bubble dissolves over time leaving the retina attached in about 70- 75 % of cases.

The second option for repair is a scleral buckle.  In a scleral buckle, the tear, or tears, are frozen with cryo, and a silicone band is placed around the eye and sutured in place. This is done in the operating room. The buckle stays in place for life in most cases.  A gas bubble may be used as well that will dissolve over a 3-6 week period.  Scleral buckles are excellent choices for young patients who have not yet had cataract surgery.

The third option for repair is a pars plana vitrectomy with oil or gas (the vitrectomy can be combined with a scleral buckle as well).  This is the most common procedure to repair a retinal detachment today and is also performed in the operating room.  In a pars plana vitrectomy, three small incisions are made in the eye.  The vitreous gel is removed and laser or cryo is used to seal around the causative holes or tears. A  gas bubble or oil bubble is then placed in the eye.  The gas bubble will dissolve over time (3-6 weeks).  The oil bubble will not dissolve and must be removed in the operating room at a later date.  In some cases, the oil may remain in for life. The decision between gas and oil is made by your surgeon depending on the type of retinal detachment you have and whether you have scar tissue that requires a long term solution like oil. As mentioned, in some cases, we do a scleral buckle and vitrectomy in the same procedure.

Each person's retinal detachment requires a thorough evaluation before the decision is made as to which surgery is appropriate.

This blog is for informational purposes only and is not medical advice. Please seek the advice of a qualified medical personnel.

Choroidal Nevus: what is it and what do you need to do for it?

A choroidal nevus is a freckle found in your eye. It is caused by a growth of melanocytes in the choroid, or the layer of the eye between the retina and the sclera. Choroidal nevi are relatively common- studies estimate that 4-8% of Caucasian people have a choroidal nevus.

A choroidal nevus can only be detected on dilated eye exam.  They rarely have symptoms and cannot be seen by the patient.  Nevi need to be monitored by an eye care professional, often yearly or more frequently, because a nevus can become a choroidal melanoma.  1 out of every 250,000 people will develop a choroidal melanoma.  Like a melonoma of the skin, these can metastasize and can lead to death. Therefore, it is very important to maintain follow-up if you have been diagnosed with a choroidal nevus.

Your eye doctor will follow the nevus with exams and photos.  There are several characteristics of nevi that are worrisome: Proximity to your optic nerve, orange pigment (lipofuscin) on the nevus, fluid surrounding the nevus, symptoms such as flashing lights, and greater than 2mm of thickness of the nevus.  These characteristics make it more likely that your nevus may grow or become a melanoma. The nevi will be followed more closely by your doctor.

A choroidal nevus does not require any treatment.  But, since it can become a melanoma, it is important for you to have it checked by your eye doctor regularly.



This blog is for informational purposes only and is not intended to be medical advice. Please consult an eye care professional for medical advice.

Macular Hole

A macular hole is a small defect in the macula, the center of the vision that is responsible for fine, detailed vision.  It is most common in women and in patients over the age of sixty, but can present in people of all ages.  Macular holes are caused by pulling of the vitreous on the center of the vision.  The vitreous can physically pull a hole in the macula or can lead to tension on the macula that creates a hole.

When patients develop a macular hole, they will often notice blurred vision in the eye or a missing area of their vision.  Sometimes, however, patients do not notice the symptoms of the macular hole and are instead discovered on routine eye exams.

There are different stages of macular holes. Stage 1 macular holes have a 50% chance of resolving without any intervention. Stage 2, 3, and 4 macular holes require treatment for resolution.

There are 2 treatment options available to fix a macular hole.  The first is an injection of a medication called ocriplasmin into the eye.  This medication can dissolve the adhesion of the vitreous from the hole and lead to closure.  It only works in some macular holes that have specific criteria, so it is not an option for all patients.  The second option for macular hole repair is surgery.  The surgery is a vitrectomy, or removal of the vitreous fluid from the eye, followed by an ILM peel and gas placement.  The ILM is a very thin sheet of tissue that we peel away to help relieve tension on the macular hole and allow it to close.  The gas bubble is then placed into the eye to help with the healing process and dissolves on its own over a period of weeks.  After the surgery, patients must maintain face-down positioning for the best chance of achieving hole closure.

Face-down positioning is often the most dreaded part of macular hole surgery.  Physicians recommend different lengths of face-down positioning, and it can vary from 3-7 days depending on the patient, the macular hole, and the physician.  There are positioning devices that your physician can recommend that can help with face-down positioning to make the process easier and more tolerable.

The success rate of macular hole surgery varies depending upon chronicity and size of the hole, but in many studies is greater than 90%.   However, even with closure, patients often notice that their vision is never "quite right" again.  Patients with macular holes of more than 6 months duration are less likely to have a successful treatment and less likely to regain significant vision after treatment.

This blog is not intended to be medical advice.  Please see a qualified medical professional for medical advice.

Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSCR) is a condition where fluid accumulates under the retina. The fluid often accumulates under the center of the macula, which is the center of vision.  It leads to decreased visual acuity or distortion of images. Patients often report a central blur or a grey spot that is blocking their central vision. It presents most frequently in males age 20-50, but it can present in patients of any age or gender.

CSCR is often described as an idiopathic disease, which means that we don't know what causes it. However, in some patients, episodes of CSCR are triggered by the use of steroids.  Oral steroids, topical steroids, inhaled steroids, or even steroids injected into joints can lead to the development of the disease.  If a patient presents with CSCR, we always do a detailed medical history looking for any exposure to steroids. Stress is also thought to be an exacerbating factor for CSCR, so stress management techniques are emphasized as well.

CSCR is diagnosed by a combination of a dilated eye exam, OCT, and fluorescein angiography (a dye test where we inject dye in your vein and take pictures as it enters the circulation of the eye).  The dilated exam reveals swelling of the macula and the OCT quantifies the amount of fluid, which provides detailed information about improvement for follow up examinations. The angiogram allows us to pinpoint the "hot spot", or the area of leakage that is creating the swelling if present, which can be a target for treatment. Some patients have a discrete leakage point that leads to the fluid accumulation whereas others have no such spot.

CSCR most often resolves without any treatment in 3-4 months.  If it persists past 3-4 months, there are treatment options such as laser, PDT (a form of laser as well), and oral medications.

In 20-30% of patients, CSCR will recur in the same or the other eye.  Therefore, after an episode of CSCR, we educate patients about avoiding oral steroids (if possible), as well as monitoring their vision at home for changes.  Many patients report having no visual sequelae of an episode of CSCR, but some patients do report having blurred, dimmed, or distorted vision after the resolution of the fluid.


This blog is for informational purposes only and is not intended to be medical advice.

At Home Macular Degeneration Monitoring

Macular degeneration is the leading cause of blindness in the United States.  While dry macular degeneration has no treatment, wet macular degeneration can be treated with injection of medications into the eye. Unfortunately, may patients realize too late that their macular degeneration has converted from the dry form to the wet form.  We recommend Amsler grid usage at home, but often patients do not notice the early, subtle changes of newly converted macular degeneration.

Untreated wet macular degeneration can create scarring in the central vision that can be difficult, if not impossible for us to reverse.  Early detection seems to lead to improved vision outcomes in our patients. Until now, however, only the Amsler grid was available for detection.

A new device, called the ForeseeHome, monitors patients with macular degeneration by using preferential hyperacuity perimetry to detect early changes that can be associated with wet macular degeneration. The testing takes three minutes per eye and is done several times per week.  The device then transmits the data to a center that compares your results to previous results.  If there is a change, the device alerts your physician who can then contact you and recommend an evaluation.

Not every patient with macular degeneration qualifies for the use of the ForeseeHome.   We at NC Retina are prescribers of ForseeHome, so if you are interested in learning more about at home macular degeneration testing, your physician can discuss this with you at your next visit and write a prescription for the device if appropriate.




This is not intended to be medical advice.  Please consult your physician for medical advice.

Your first visit with us: What to expect

If you have been referred to us by another eye care or other health professional, you might be wondering what to expect on your first visit.  As retina specialists, we evaluate and treat diseases in the back part of the eye- the vitreous, retina, and choroid.  There are many such diseases that we evaluate and treat, but some of the most common include macular degeneration, diabetic eye disease, macular hole, epiretinal membrane, vitreous hemorrhage, retinal tears or holes, and retinal detachments.

On your first visit, you will first have your vision checked, you intraocular pressure measured, and your eyes dilated.  Often, people ask if it is necessary to dilate their pupils.  The answer is yes, it is necessary.  The way we see the retina is through the pupil, so it must be dilated for us to perform a complete exam.

Once your pupils are dilated, we will begin the testing process.  Most patients will have an OCT, a test that looks at the layers of your macula, or center of your vision.  And, most patients will have color photos taken of your retina.  These tests are usually very quick and easy for the patient.  Some patients will also require a fluorescein angiography.  This is a dye test that looks at the circulation and structures of the retina and choroid.  This dye is inserted into a vein in your arm or hand, and the photos are taken over a period of approximately 10 minutes.  Fluorescein angiography is usually very well tolerated by the patient but can leave your vision blurry for a few minutes.  Rarely, people have an allergic reaction to the dye, but before any test is done, the technician will discuss things that you should be aware of during the test.

After the testing is completed, you will then see the doctor.  He or she will perform an examination as well as go over all of your testing with you.  If treatment is necessary, you will receive a thorough description of the treatments available including risks, benefits, and alternatives to these treatments. Some of the various treatments that we perform include injections into the eye, lasers, and surgeries. Often, the first treatment is given or scheduled that day!

Overall, your first visit to any retina specialist will most likely be different than any eye examination you have had in the past due to the different tests that we perform.  The first visit can last anywhere from 1-3 hours depending on your eye disease and treatment requirements.

This blog is for informational purposes only and is not intended to be medical advice.  Please seek the advice of a health care professional.

How many injections will I get for macular degeneration?

One of the most common questions we get asked by patients receiving injections for exudative (wet) macular degeneration is how many injections that they will have to receive.  Understandably, most patients are anxious to decrease or even stop their injections all together.  The answer, however, is variable depending on the patient.

Exudative macular degeneration is a chronic disease where the blood vessels in the choroid (the back of the eye) grow through a barrier called Bruch's membrane and bleed.  This bleeding leads to fluid in the macula which is what leads to decreased vision.  Chronic fluid and blood can lead to scarring and eventually markedly decreased central vision. The primary driving force between these blood vessels is a protein called vascular endothelial growth factor (VEGF).  The medications that we currently use to treat macular degeneration-  including Avastin, Lucentis, and Eylea-block this protein (anti-VEGF medications).

When the anti-VEGF medications are injected into the eye they only have an effect for about 28 days. After the medications wear off, the VEGF proteins made in the eye rise again and cause the vessels to leak or grow.  That is why the medications have to be injected at regular intervals.  I often compare this to having to take your blood pressure medication every day to keep your pressure under control.  The medications aren't a cure, but a treatment.

In the initial trials for anti-VEGF medications, the injections were continued every 28 days for 2 years regardless of the patient's vision or amount of fluid in the retina.  The results were excellent- stabilization of vision in most patients and increased vision in many patients.  In the years since the initial trials, a few different approaches have been tried to decrease the number of injections including treating only as needed when fluid returns, and a treatment called treat and extend where we gradually increase the time between injections. One medication, Eylea, is often used very 8 weeks after a 3 to 6 month initiation with monthly injections with good success.

One recent trial, HORIZON, examined the use of as needed injections and revealed that patients lost some vision that they had initially gained when only receiving the injections as needed (when fluid returned in the macula) instead of on a strict schedule.  So, many retina physicians concluded that either monthly treatments or a slow treat and extend regimen is more beneficial to the patient.  And, we know that if we stop the injections all together, the blood often returns and leads to severe central vision loss.

As cumbersome as monthly injections seem to you as a patient, it is important to realize the benefit you are likely receiving from your injections.  The anti-VEGF medications have revolutionized the treatment of this blinding disease and have given hope to many patients who did not have a good visual prognosis in the past.

Researchers are working to develop longer acting medications and other methods that could help avoid these monthly or ever other month injections, so some day in the future you may be able to decrease your visits to the retina physician for macular degeneration treatment.

Each patient is different and is evaluated by his or her physician to determine the best course of treatment.

This blog is for informational purposes only and is not intended to be medical advice.  Please consult your physician for any medical advice.