This section is an on-going posting of unusual or clinically interesting patients that I have recently seen in my practice.
09/15/09 This patient knew his diabetes wasn't well controlled but he thought his eyes were OK still.
This patient is a 46 year old caucasion male. His chief complaint was blurred vision with his reading glasses. He had seen several physicians regarding his diabetic medications over the last two years, but the glucose level was still elevated. A dilated eye examination was unremarkable in both eyes.
However digital photographs revealed some new evidence that was not noted in the traditional examination. Digital photographs can be easily enlarged many time allowing detection of very small findings that might not be seen with traditional examination techniques. He has early Non-Proliferative Diabetic Retinopathy (NPDR).
If the digital photographs were not taken those findings would probably not have been seen untill the condition worsened. Now that he knows that his vision is threatened he will be more motivated to control the diabetes better.
Enlarged view:
07/17/2009 This young women was at risk for a stroke.
A 35 year hispanic women presents for a routine eye examination. She wears contact lenses and simply needed more lenses. General health was good. She was not taking any medications and felt great. The left eye was unremarkable.
This is a photograph of her right eye: The white spot half way between her optic nerve and her macula is a "cotton-wool" spot. This is a retinal infarction (an area of dead tissue from an inadequate blood supply - like a heart attack). At it's top edge there are a few dots of blood.
Cotton-wool spots are sometimes seen in collagen vascular diseases, cardiac valve disease and carotid artery disease. A clot, plaque or emboli, break free and become lodged in the smaller blood vessels. When the vessel becomes occluded, blood leaks out to create a retinal hemorrhage. Poorly controlled diabetes can also lead to cotton-wool spots. As the sugar level surges up and down, the vessel walls expand and become leaky. Hypertension is another main cause of cotton-wool spots. If the blood pressure is high enough, it will blow a hole in the blood vessel producing a hemorrhage. The patient's blood pressure was 185/102. This is hypertensive retinopathy.
Another interesting finding here is the dark band above the macula arcing through the cotton-wool spot to the optic nerve. This is a neve-fiber defect caused by the hemorrhage. Note the white lines below the macula arcing over to the optic nerve. This is normal. The dark band above are dead nerve fibers.
If the patient had the same event in her brain it would have lead to a stroke. She is now on hypertension medications and is very glad she had an eye exam that day.
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07/06/2009 This patient almost became blind in both eyes.
A 64 year old Caucasian male presents for an examination only because he wife insists on it. She wants him to get a new look in glasses. His last eye examinastion was 5 years ago.
Apparently the left eye can only see outlines. He cannot see anything straight ahead with the left eye. He can see the outline of my head but cannot see my face. He says that his last eye doctor told him that he was blind in that eye and that nothing further could be done. He has not had an eye examination in the 5 years since then.
See the top photograph: This is his left eye. Note the central whitish round area. This is a scar following a hemorrhage in the macula. Apparently, at some time in the past, he had developed Age Related Macular Degeneration (ARMD). There is a "Dry" form of ARMD which is much more serious than the "Wet" form of ARMD. He had the "Wet" form of ARMD in this eye. In the "Wet" form of the disease, a blood vessel below the surface grows into the macular area and then leaks blood there. When the blood is re-absorbed, a large fibrotic scar forms. This eye is legally blind and nothing can be done to improve central, straight ahead vision.
See bottom photograph: This is his right eye. The central whitish spots are called drusen. Drusen often are seen in peripheral areas of the retina without problem. When they are seen within that central macular area it is often a case of "Dry" ARMD. The most common type of drusen is called "Hard drusen" because of their sharp demarcations. As more and more drusen develop in the macula they begin to coaless into larger more fluffy drusen called "Soft drusen". Soft drusen are often associated with "Wet" ARMD. These drusen are soft drusen.
This patient was at risk of hemorrhaging in the left macula, probably leading to legal blindness in both eyes. He was immediately sent to a retinal specialist for further testing. By injecting a dye into his arm while looking in his eye, the retinal specialist was able to detect a blood vessel that was below the retinal surface and not normally visible. A laser treatment was performed to destroy the blood vessel. The patient will need on-going injections of a drug in his eye to slow or stop new blood vessels from growing. So far, vision remains good in his right eye.
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06/18/2009 This patient was at risk for a possibly serious stroke
A 45 year Hispanic male came in for an eye examination. He had no eye or vision complaints. He wears reading glasses without problem. Examination was uneventful until I looked inside his eyes.
His left eye reveals a very small retinal hemorrhage at the bottom of the picture. There is also a small whitish area near the top of the picture. This is referred to as cotton wool spots, and indicates a disruption of the adjacent tissues from a now resolving hemorrhage. Both of these findings were first detected in this digital photograph of his eye. Digital photographs can be enlarged to reveal small details that might not be noticed in standard examination techniques.
Further questioning revealed that he had stopped taking his blood pressure medicine about a month ago because he did not think he needed it. He felt fine. His blood pressure measured 220/115. He was at risk of having a stroke. He was sent to an Urgent Care Center immediately. We might have saved his life with that photograph.
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06/05/09 Dry Age Related Macular Degeneration (ARMD) about to become Wet ARMD
A 76 year old Caucasion presents for examination with a chief complaint of blurred vision in his left eye. He was noted to have mild macular pigmentary changes (dry ARMD) 5 years ago that had not changed much since then.
The top photograph is his right eye. Their are soft drusen in the macula. The bottom photograph is the left eye and it also has soft drusen, but it also has some small hemorrhages in the macula. Both eyes are at risk of developing wet ARMD. He was referred to a retinal specialist who confirmed the presence of neovascularization below the surface of the macula.
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Untill recently there were few options for treatment for this patient:
Laser surgery. This procedure uses a laser to destroy the fragile, leaky blood vessels. A high energy beam of light is aimed directly onto the new blood vessels and destroys them, preventing further loss of vision. However, laser treatment may also destroy some surrounding healthy tissue and some vision. Only a small percentage of people with wet AMD can be treated with laser surgery. Laser surgery is more effective if the leaky blood vessels have developed away from the fovea, the central part of the macula. The risk of new blood vessels developing after laser treatment is high. Repeated treatments may be necessary. In some cases, vision loss may progress despite repeated treatments.
Photodynamic therapy. A drug called verteporfin is injected into your arm. It travels throughout the body, including the new blood vessels in your eye. The drug tends to "stick" to the surface of new blood vessels. Next, a light is shined into your eye for about 90 seconds. The light activates the drug. The activated drug destroys the new blood vessels and leads to a slower rate of vision decline. Unlike laser surgery, this drug does not destroy surrounding healthy tissue. Because the drug is activated by light, you must avoid exposing your skin or eyes to direct sunlight or bright indoor light for five days after treatment. Photodynamic therapy is relatively painless. It takes about 20 minutes and can be performed in a doctor's office. Photodynamic therapy slows the rate of vision loss. It does not stop vision loss or restore vision in eyes already damaged by advanced AMD. Treatment results often are temporary. You may need to be treated again.
Now there is a much better treatment option:
Injections. Wet AMD can now be treated with new drugs that are injected into the eye (anti-VEGF therapy). Abnormally high levels of a specific growth factor occur in eyes with wet AMD and promote the growth of abnormal new blood vessels. This drug treatment blocks the effects of the growth factor. You will need multiple injections that may be given as often as monthly. The eye is numbed before each injection. This drug treatment can help slow down vision loss from AMD and in some cases improve sight.
This patient is scheduled for an injection in his right eye in a few days. Hopefully the treatments will help preserve his vision.