Retina Diseases and Procedures

The clinic has been relying on the expertise of world renowned retina specialists for all its medical and surgical retina. They specialize in the treatment of retinal detachment, proliferative vitreoretinopathy, macular holes, diabetic retinopathy, age-related macular degeneration, epimacular membranes, retinopathy of prematurity, as well as other macular and vitreous problems

We have recently started a Saturday Retina clinic to better serve you.  The clinic offers the latest diagnostic technologies - the Heidelberg Retina Camera and Heidelberg Optical Coherence Tomography OCT.  We also have the newest technology for Age Related Macular Degeneration and other sight threatening retina diseases called the Iridex IQ 577 Micropulse Laser.  For an appointment call any one of offices for a consultation.

 

Diabetic Retinopathy

Diabetes is a disease characterized by a disturbance in blood sugar metabolism. Diabetes can affect multiple organ systems in the body including the eye. The primary determinants of eye disease are the length of time a patient is diabetic, blood sugar control, blood pressure control and blood lipid levels.

Diabetic Retinopathy can be divided into two stages, nonproliferative and proliferative disease.

Nonproliferative retinopathy (an early stage of diabetic retinopathy) is characterized by small blood vessel damage which may result in fluid leaking into the retina and/or bleeding. Chronic fluid within the retina may lead to progressive vision loss and requires prompt treatment to stabilize the fluid and reduce the risk of progressive vision loss.

Proliferative retinopathy (a more advanced stage of diabetic retinopathy) is caused by progressive blood vessel damage which results in reduced blood flow to the retina. Chemical signals are then released by the retina which results in abnormal blood vessel development. If left untreated, these abnormal vessels can rupture, bleed and scar which can lead to profound vision loss and even blindness. This condition requires urgent evaluation and treatment in order to preserve vision.

New Laser for Diabetic Macular Edema - MicroPulse Laser - First and Only in Tennessee

Historically laser therapy was considered to be the "gold standard" of therapy for diabetic macular edema. It's use has declined in recent years in part due to the collateral damage created to normal tissue when laser is utilized. In conventional laser therapy, a laser beam is fired in a continuous wave to areas of swelling in the retina. The thought was that by destroying the leaking blood vessels, leakage would stop and swelling would resolve. Although the laser was effective in accomplishing that goal, it had the unwanted effect of burning healthy retina around those vessels which risked damage to the patient's vision.
Injectable therapies like Ozurdex and the anti-vegF mediations (to be discussed in a future post) were developed to treat diabetic macular edema without risking healthy tissue. These injections have become wildly popular amongst the retina community due to their effectiveness. The disadvantage however involves the invasiveness of the treatment and potential risks of infection and in the case of anti-VegF therapies, the risk, though small, of heart attack and stroke. In addition, injectable medications must often be frequently repeated to maintain their benefits. As such, attention over the last few years has turned back to lasers and research and design improvements have led to a technology called micropulse therapy.
With micropulse laser, the continuous laser beam is broken up into a series of short or "micro" pulses that are then applied to the areas of swelling. The interval between pulses allows the retina being treated to cool down between the pulses which eliminates the negative effect of damage to healthy tissue. Thus patients can enjoy the benefits of laser without the risk to their vision. Practitioners have been slow to adopt the technology due to a lack of understanding or familiarity with the principles  behind it as well as the comfort level that has developed over the last decade with the use of injectables.   Toyos clinic has been treating diabetic patients with the micropulse laser achieving excellent outcomes and in many patients, avoiding the need for injections. If you have diabetic eye disease we invite you to schedule an appointment at Toyos Clinic to see whether you are a candidate to receive micropulse laser technology.

Macular Hole

A macular hole is a full thickness loss of central retina tissue which results in a spontaneous decrease in central vision. Macular holes may result from traumatic injuries but are more commonly linked to the aging process. As a person ages, the clear vitreous gel within the eye liquefies and shrinks which may cause traction on the central retina. If this traction is strong enough, a hole may be pulled open resulting in decreased vision. Fortunately, macular holes are generally treatable with surgical intervention if performed within a timely manner. Any loss of central vision should therefore be promptly reported to one’s eye physician.

Retinal Detachment

The retina is a layer of nerve tissue that lines the back wall of the eye. The retina functions like the film in a camera and sends light to the brain in order to be processed into an image. In order for the retina to function properly, it must remain attached to the back wall of the eye and receive nourishment from the choroid layer underneath it. The retina is a very delicate structure and damage generally results in some loss of vision

A retinal detachment generally occurs due to a tear in the retina with subsequent fluid accumulation which may be rapid. As a person ages, the vitreous gel within the eye begins to liquefy and shrink. At some point this shrinkage becomes significant enough that the vitreous gel pulls away from the retina. Rarely, this results in a tear in the retina which can then lead to retinal detachment. Peripheral retinal degenerations may also occasionally lead to holes or tears in the retina which may lead to retinal detachment.

Retinal detachments are a very serious condition which generally requires prompt evaluation and management by a retina specialist. This condition is generally treated with surgery but in rare cases it can be repaired in the office. Only a qualified retinal specialist would be able to determine which treatment option is best.

Surgery for Retinal Detachment

Retinal detachment is a very serious eye condition where the retina separates away from the back wall of the eye. When this occurs the retina no longer is in contact with the blood vessels that nourish it and as a result loses function. If the detachment is not repaired quickly, permanent loss of vision can occur.

Retinal detachments often start from either a hole or tear in the retina that allows fluid to move from the middle of the eye to the space underneath the retina. As this fluid accumulates, the retina further separates and detaches. Retinal tears or holes by themselves can be easily repaired in the office by an experienced retina specialist but what happens when the retina detaches? Historically patients are taken to the operating room and undergo incisional surgery to remove the fluid and seal the retinal tear or hole. Although highly effective in reattaching the retina, patients are subjected to a lengthy procedure with a long recovery process in addition to the costs associated with hospital and anesthesia care.

Fortunately for many patients, an alternative therapy exists in which the retinal detachment can be repaired in the office. The procedure, called pneumatic retinopexy, involves two steps. The first utilizes a cryotherapy device to transiently freeze the area of the eye where the retina is torn. This freezing treatment seals the retinal tear by fusing all the layers of the eye together. Once that has occurred a small gas bubble is placed within the eye to push the fluid out from behind the retina thereby reattaching it to the critical structures that nourish it. By utilizing this technique, patients are given the opportunity to save their vision without incurring exuberant hospital costs or enduring a lengthy recovery process.  This procedure is very effective but requires a great deal of skill by the physician performing it.

Our retina specialist has extensive experience utilizing the pneumatic retinopexy technique and offers this service as an alternative to traditional surgery. If you have signs and symptoms of a retinal tear or detachment including flashing lights, floating spots or veils over your vision, we invite you to schedule an urgent appointment with retina specialist to be evaluated and to determine whether pneumatic retinopexy is the right choice for you.    

Epiretinal Membrane

An epiretinal membrane or macular pucker is a layer of superficial scar tissue that rests on the surface of the central retina. This scar tissue may contract with time resulting in distortion or blurring of the vision. This distortion may make it difficult to perform daily tasks such as reading or driving. Epiretinal membranes usually occur in older individuals when the vitreous gel within the eye liquefies and shrinks. It may also follow trauma or be associated with certain conditions such as inflammation, retinal tears or diabetes.

Epiretinal membranes are diagnosed using a combination of physical examinations and imaging tests called optical coherence tomography and sometimes fluorescein angiography.

Mild epiretinal membranes that cause little or no distortion can often be monitored. More advanced cases may be treated with surgery to remove the scar tissue from the central retina. A qualified retina specialist can determine whether surgery would be a good option for cases where distortion interferes with daily activities.

Macular Degeneration

Age-related macular degeneration (AMD) is a common condition which results in damage to the central retina which may cause distortion and loss of central vision. Fortunately, macular degeneration does not result in total blindness as the peripheral undamaged portions of the retina provide some degree of vision. Macular degeneration is diagnosed by physical examination as well as diagnostic imaging tests performed by an ophthalmologist or optometrist.

AMD may be divided into two categories, nonexudative or “dry” disease and exudative or “wet” disease. Dry macular degeneration generally causes a slow but progressive damage to the central retina and accounts for 80% of all cases of macular degeneration. The current goal of treatment involves nutritional and lifestyle modifications in an effort to slow the progression of the damage. Wet macular degeneration accounts for 20% of all cases. It can result in rapid deterioration of central vision and results from abnormal blood vessel growth underneath the retina. This condition is generally treatable if detected early. Various treatment options exist, our retinal physician can help determine which treatment is best for each individual case.

Eye Injections: All the Benefit. None of the Pain

Intraocular drug injections to treat blood vessel disease and inflammation have constituted a therapeutic advancement of unprecedented scale in the history of ophthalmology and have revolutionized the way patients are treated. These injections have given physicians the ability to prevent vision loss in a majority of patients suffering from macular degeneration, diabetes and other blood vessels diseases. An estimated four million people each year receive injections for a variety of eye disorders.

As effective as these treatments are, one difficulty patients often face is the pain associated with the injection. Intravitreal (injections in the eye) are performed by placing a tiny needle into the eye and injecting medication into the center of the globe. These treatments do not cure the underlying disease but help control it. Unfortunately, however they need to be administered in 1-2 month intervals for maximum effectiveness. The frequency associated with the pain of the injections places a burden on patients and creates high levels of fear and anxiety when going to get treatment. The pain associated with injections often results in patients deferring treatment or under treating their condition can reduce the effectiveness and ability to preserve vision.

At the Toyos Clinic, our retina specialist performs intravitreal injections to treat macular degeneration, diabetes, inflammation and a host of other retinal conditions. Our retina specialist has been performing eye injections for nearly a decade and has continually assessed and evolved the local and topical anesthetic protocol.
By utilizing these evolved methods, patients at the Toyos Clinic are able to receive the benefits of these injections with nearly a complete absence of pain or discomfort.  We have developed a technique and special medications that numb the area of treatment.  The protocol helps with the treatment because patients are less apt to move during the injection.  We have also found that patients are more compliant with receiving the treatments because they don’t have the fear of pain.   Our cancellation rate has decreased since we have been able to control pain.   In fact, after the procedure, patients often ask whether the injection had been given not realizing the needle had already been in and out of the eye.

Eye injections have truly changed the face of eye care and now patients have the ability to reap the benefits without experiencing the anxiety or fear that often comes with those injections. Our retina specialist is currently accepting patients at the Toyos Clinic in Franklin, Tn and invites all patients undergoing eye injections to come and see the difference the Toyos Clinic can make in their lives.  We have clinics in Green Hills, Skyline Medical Center, and Cool Springs.

Can Laser Therapy Reduce Risk in Macular Degeneration?

Age related macular degeneration (ARMD) is a common eye condition seen in people over 50 years old. It is a degenerative process that affects the macula, the portion of the retina involved in central vision. In ARMD, a toxic material known as drusen accumulates within the macula and damages central vision over time making it difficult to read, drive and enjoy quality of life. Although modifiable risk factors such as smoking and diet do exist, the biggest factor in development and progression of the process involves our genetic make up which cannot be altered.

To date, when patients are diagnosed with macular degeneration, they are often given vitamin supplements and counseled to stop smoking in order to reduce their risk of progression to what is known as neovascular disease or wet macular degeneration. Once this progression has occurred, however, patients are often relegated to a lifetime of eye injections in an effort to control the disease and maintain vision. As such, there has been a great deal of interest in trying to figure out ways to reduce the risk of progression to this advanced stage.

Recently, there has been evidence that laser therapy using the Iridex 577-nm subthreshold micropulse laser may be able to reduce the amount of drusen present in ARMD thereby slowing the progression of the disease and maintaining vision. Modern laser technologies and recent protocols have already shown that the 577 micropulse laser can benefit patients with a wide range of macular diseases however this is the first time we have evidence that it might be beneficial in slowing down the progression of ARMD.

The procedure involves an office visit to diagnose what stage of ARMD the patient is in. Once it has been determined that they are at high risk of progression, the laser therapy can be applied directly to the drusen present in the macula. The procedure is painless and takes only minutes to perform. Patients are then observed over the next 12 months to determine whether the treatment was indeed successful. In one study, partial resolution of the drusen material was noted in 70% of treated patients with no identifiable damage to healthy structures. Larger studies and longer follow up are needed, but the data demonstrates that treatment with the 577-nm laser may be useful in slowing or even preventing the progression of ARMD in high risk patients.

The Toyos Clinic is the only facility in the greater Nashville area that provides treatments using the 577-nm laser for a wide variety of macular diseases. We welcome you to schedule an appointment to see how we can help preserve your vision and your quality of life.

Floaters

Many individuals note small specks in their vision that move around as they move their eyes. These are called vitreous floaters and are generally the result of the vitreous gel within the eye liquefying as one ages. This is a very common disorder which is usually well tolerated. Rarely, vitreous floaters may be a sign of retinal damage and the sudden onset of floaters, especially when associated with flashing lights or peripheral vision loss, should prompt an examination by a qualified eye professional. Visually disabling floaters may also rarely occur, and if significant enough, they may be removed in an outpatient surgical procedure known as the Pure Path Vision Procedures: 1. Laser for Floaters 2. FOV - Floater Only Vitrectomy (some have called it Floaterectomy). We are able to perform either surgery at Toyos Clinic.  Dr. Toyos has been performing laser for floaters for the last 10 years.  Our retina surgeon has the ability to perform Floaterectomy which has been shown in various studies including one published in the Journal of Ophthalmology demonstrating that the procedure is safe and effective.  

Central Serous Chorioretinopathy

Central Serous Chorioretinopathy (CSCR) is a condition where fluid builds up underneath the retina due to a dysfunction in the layers underlying the retina itself. This build up of fluid may causes blurring and distortion of the vision. CSCR is often associated with “Type A” personalities or the use of steroid medications.

In the vast majority of patients this condition self-resolves and the vision recovers, although in rare circumstances blurred vision may persist. In these cases, various treatment options exist and an evaluation with a retinal specialist may help determine which treatment is the best option.

Retinal Vein Occlusions

The retina contains arteries and veins like all other tissues in the body. These blood vessels may develop disruptions in their blood flow and this condition is known as a vascular occlusion. Retinal vein occlusions are the second most common retinal vascular disease following diabetes. They are generally related to the aging process but can be associated with a number of different vascular, coagulation and inflammatory disorders.

Retinal vein occlusions can range from mild to severe and may result in significant damage to the underlying blood vessel. This damage may cause fluid to leak into the retina resulting in a condition known as macular edema. Macular edema causes progressive damage to the retina which can lead to a decrease in vision. When severe, vein occlusions may also disrupt the flow of blood into the retina which can lead to a condition known as ischemia. Significant ischemia may cause the growth of abnormal blood vessels which in turn can lead to bleeding and loss of vision.

Several treatment options exist and vein occlusions should be evaluated by our retinal specialist to determine the severity of the condition and to provide the correct treatments to reduce the risk of permanent vision loss.