Cure Eye Floaters Naturally

Eye Floaters No More

Eye Floaters (Also known as Eye Flashes) are deposits of various sizes and shapes that float within the eye. They are caused by degenerative changes of the vitreous humour the clear gel that fills the eyeball. Eye infections, inflammation, wounds and damage to the eye can lead to eye floaters. A sudden increase in floaters can be one of the first signs of retinal detachment or other severe eye conditions. In Eye Floaters No More, you'll discover: How to finally get rid of your stressful eye floaters, blocks of vision, the flashing lights using a safe, natural and easy system. Eliminate your annoying eye floaters from the comfort of your home. How to prevent more eye floaters from forming. How to find out if your eye floaters are a sign of other eye conditions. Easy, natural ways to drastically improve your vision. More here...

Eye Floaters No More Overview

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Mechanism of Rhegmatogenous Retinal Detachment

Once a retinal tear forms as a result of abnormal vitreous traction following PVD, the fluid from within the vitreous cavity can gain access to the subretinal space through the retinal tear. The progressive accumulation of fluid in the subretinal space eventually causes the retina to separate from the underlying RPE, similar to wallpaper being stripped off a wall. This inward separation of the retina from the RPE through the recruitment of fluid via a retinal break is the basis for rhegmatogenous retinal detachment, which is the most common form of retinal detachment.

Rhegmatogenous Retinal Detachment Associated with Trauma

Most rhegmatogenous retinal detachments occur as a result of spontaneous PVD-induced retinal breaks. However, retinal tears can also occur as a result of trauma. A perforating injury of the eye can produce a tear at any point in the retina, but contusion injuries commonly produce tears in the extreme retinal periphery and in the lower temporal quadrant or the superior nasal quadrant. This is because the lower temporal quadrant of the globe is most exposed to injury from a flying missile, such as a squash ball. The threatened eye makes an upward movement as the lids attempt to close. Tears of this kind often take the form of a dialysis, the retina being torn away in an arc from the ora serrata. Warning symptoms in these patients are usually masked by the symptoms of the original injury and they tend to present some months, or occasionally years, after the original injury with the symptoms of a retinal detachment. This is unfortunate because the tear can be treated if it is located...

Tractional Retinal Detachment

In tractional retinal detachment, the retina can be pulled away by the contraction of fibrous bands in the vitreous. Photopsiae and floaters are usually absent but a slowly progressive visual field defect is noticeable. The detached retina is usually concave and immobile. Advanced proliferative diabetic retinopathy can be complicated by tractional retinal detachment of the retina when a contracting band tents up the retina by direct traction. Not infrequently such a diabetic patient experiences further sudden loss of vision in the eye, when the traction exerted by the contracting vitreous pulls a hole in the area of tractional retinal detachment, resulting in a combined rhegmatogenous and tractional retinal detachment.

Exudative Retinal Detachment

In such detachments, there are no photopsiae but floaters can occur from associated vitritis or vitreous haemorrhage. A visual field defect is usual. Exudative detachments are usually convex shaped and associated with shifting fluid. A malignant melanoma of the choroid might present as a retinal detachment. Often the melanoma is evident as a black lump with an adjacent area of detached retina. If the retina is extensively detached over the tumour, the diagnosis can become difficult. It is important to avoid performing retinal surgery on such a case because of the risk of disseminating the tumour. Suspicion should be raised by a balloon detachment without any visible tears, and the diagnosis can be confirmed by transilluminating the eye to reveal the tumour. Retinal detachments secondary to inflammatory exudates are not common. One example is Harada's disease, which is the constellation of exudative uveitis with retinal detachment, patchy depigmentation of the skin, meningitis and...

Retinal Detachment Proliferative Vitreoretinopathy

Retinal detachment is a condition in which fluid exists in the subretinal space and causes separation of the neural retina from the underlying retinal pigment epithelium. Proliferative vitreoretinopathy is the proliferation of avascular fibrocellular retinal membranes associated with rhegmatogenous retinal detachment, a retina detached as a result of a retinal break or tear, which causes severe damage to the neural retina and retinal pigment epithelium. Contact between the retinal pigment epithelium and the vitreous fluid through retinal breakage may change the content of glycosaminoglycans in the fluid. The glycosaminoglycans in the subretinal fluid of rhegmatogenous retinal detachment were characterized (52). The results revealed that hyaluronan alone (HA type) was present in 50 of the eyes. A combination of chondroitin sulfate (chSA) and hyaluronan (chSA type) was present in 15 of the eyes. A combination of dermatan sulfate (DS) and hyaluronan (DS type) was present in 35 of the...

Agerelated Macular Degeneration

Older patients with macular degeneration complain of blurring of their vision and inability Figure 19.2. Dry macular degeneration.03 Figure 19.2. Dry macular degeneration.03 In the wet type of macular degeneration a fan of new vessels arises from the choroid -choroidal neovascularisation (CNV). The growth of these new vessels seems to be important because they invade the breaks in Bruch's membrane. Serous or haemorrhagic exudate tends to occur and this can be either under the RPE or subretinal (Figure 19.3). A sudden loss of central vision might be experienced as the result of such an episode. Subsequently,healing of the leaking vascular complex results in scar tissue formation, which further destroys the central vision permanently.

CAIs In Macular Edema Macular Degeneration And Related Ocular Pathologies

Optic nerve blood flow is diminished in the eyes of primary open-angle glaucoma suspects and patients (Pilts-Seymour et al. 2001). Because sulfonamides with CAI properties act as vasodilators (Supuran and Scozzafava 2000), this might explain the use of such drugs for treating retinal edema and age-related macular degeneration. In consequence, these pharmacological agents represent a new approach for improving visual function. Retinal edema (also referred to as cystoid macular edema) consists of a swelling process within the critically important central visual zone, and might develop in association with a variety of ocular conditions, such as diabetic retinopathy, ischemic retinopathies, intraocular surgery (such as cataract procedures) or laser photocoagulation (Cox et al. 1988 Grover et al. 1997 Sponsel et al. 1997 Barnes et al. 2000). It is also common in patients affected by retinitis pigmentosa, a hereditary disorder leading to total blindness (Orzalesi et al. 1993). The precise...

Age Related Macular Degeneration

Experimental disease models for AMD attempt to mimic what are thought to be important disease-contributing conditions in the retina, but they suffer from one major limitation AMD is a chronic disease that takes years to develop, while the existing cellular and animal models produce morphological and functional characteristics on a weeks to months timescale. Largely this is out of necessity for timely evaluation of new chemical entities (NCEs), but partly this is due to the difficulty of efficient disease phenotype generation with a weak but long-lasting stimulus, which probably more accurately reflects pathology in man. As with most diseases, in vitro AMD models provide convenient screening tools and frequently use RPE cells, while being limited by the lack of heterogeneous, dynamically interacting components (e.g., RPE, photoreceptors, and Bruch's membrane) that an animal model provides. Nonhuman primates would constitute the preferred in vivo model however, rodent models are mostly...

Retinal Detachment

Although the condition is relatively rare in the general population, it is important for several reasons. First, it is a blinding condition that can be treated effectively and often dramatically by surgery. Second, retinal detachment can on occasions be the first sign of malignant disease in the eye. Finally, nowadays the condition can often be prevented by prophylaxis in predisposed eyes.

Floaters

Flashes and floaters appear because the vitreous has tugged on the retina, producing the sensation of light, and often when the tear appears there is a slight bleeding into the vitreous, causing the black spots. When clear-cut symptoms of this kind appear, they must not be overlooked. The eyes must be examined fully until the tear in the retina is found. Sometimes, a small tear in the retina is accompanied by a large vitreous haemorrhage and thus sudden loss of vision.

How to Find Out What a Patient Can

The camera around to the relevant views and allows the camera (or macula) to make sense of the scene. If the macula area is damaged by, for example, age-related macular degeneration, the patient might be unable to see even the largest print on the test type and yet have no difficulty in walking about the room. Navigational vision is largely dependent on the peripheral field of vision. On the other side of the coin, the patient with marked constriction of the peripheral field of vision but preservation of the central field might behave as though blind. The same patient could read the test chart down to the bottom once he has found it. This situation sometimes arises in patients with advanced chronic simple glaucoma.

Long Sight Short Sight

Hypermetropia is associated with certain eye conditions, notably narrow-angle glaucoma and childhood amblyopia of disuse. Myopia is associated with other conditions, particularly retinal detachment, cataract and myopic retinal degeneration. You must be aware, though, that whereas Retinal detachment Retinal detachment with seeing flashes of light, he may be about to have a retinal detachment.

When the Fundus Is Abnormal

Quite a proportion of patients who complain of loss of vision with eyes that look normal on superficial inspection show changes on ophthalmoscopy. The three important potentially blinding but eminently treatable ophthalmological conditions must be borne in mind cataract, chronic glaucoma and retinal detachment. It is an unfortunate fact that the commonest cause of visual loss in the elderly is usually untreatable at the present time. It is known as age-related macular degeneration and forms part of the sensory deprivation, which is an increasing scourge in elderly people. These diseases are limited to the eye itself, but disease elsewhere in the body can often first present as a visual problem. In this context, we must remember what has been the commonest cause of blindness in young people - diabetic retinopathy, as well as the occasional case of severe hypertension. Intracranial causes of visual loss are perhaps less common in general practice and, for this reason, are easily missed....

Treatable Causes of Failing Vision

Nobody can deny that the practice of ophthalmology is highly effective. Many eye diseases can be cured or arrested, and it is possible to restore the sight fully from total blindness. Many of the commoner causes of blindness, especially in the third world, are treatable. The most important treatable cause of visual failure in the UK is cataract, and, of course, no patient should be allowed to go blind from this cause, although this does occasionally happen (Figure 8.1). Retinal detachment is less common than cataract but it provides a situation where the sight could be lost completely and then be fully restored. For the best results, surgery must be carried out as soon as possible, before the retina becomes degenerate, whereas delay before cataract surgery does not usually affect the outcome of the operation. Acute glaucoma is another instance where the sight could be lost but restored by prompt treatment. The treatment of chronic glaucoma has less impression on the patient because it...

Untreatable Causes of Failing Vision

Ophthalmologists are sometimes asked if the sight can be restored to a blind eye and, as a general rule, one can say that if there is no perception of light in the eye, it is unlikely that the sight can be improved, irrespective of the cause. There are several ophthalmological conditions for which there is no known effective treatment and it is sometimes important that the patient is made aware of this at an early stage in order to avoid unnecessary anxiety, and perhaps unnecessary visits to the doctor. Most degenerative diseases of the retina fail to respond to treatment. If the retina is out of place, it can be replaced, but old retinae cannot be replaced with new. So far, there has been no firm evidence that any drug can alter the course of inherited retinal degenerations, such as retinitis pigmentosa, although useful information is beginning to appear about the biochemistry and genetics of these conditions. Age-related macular degeneration tends to run a progressive course in...

Other Important Signs

Certain other important signs need to be carefully elicited in a patient with cataracts. The pupil reaction is a particularly useful index of retinal function and it is not impaired by the densest of cataracts. A poor reaction might lead one to suspect age-related macular degeneration or chronic glaucoma, but a brisk pupil with a mature cataract might be described as a surgeon's delight because it indicates the

Introduction Ocular Anatomy and Diseases

Most information about our surroundings is gathered by the eye, which is literally a 'window' for the brain. With an aging population, the prevalence of sight-threatening ocular diseases continues to increase. Thus, for instance, more than 70 million people suffer from glaucoma worldwide.1-3 Visual impairment caused by diabetes affects up to 90 of diabetics over 10 years of age. Likewise, pathological dry eye and ocular allergic conditions afflict > 100 million patients worldwide, and age-related macular degeneration (AMD) is the leading cause of blindness among the elderly, affecting up to 28 of patients after the seventh decade of life.2 Consequently, the discovery and development of therapeutic products for the treatment of these various ocular diseases is of paramount importance, and is being actively pursued within the pharmaceutical industry.1-3

Disease Basis 61231 Glaucoma

When considering potential causes and treatments of macular degeneration, it is informative to consider the normal vision process from a functional and morphological standpoint. Light that is transmitted through the surface and the anterior chamber of the eye is absorbed in the outer retina by opsin-bound (as a Schiff base) retinaldehyde, which is present in specialized light-gathering cells called photoreceptors. There are two types of photoreceptors rods, which are used primarily for low light vision, and cones, which are responsible for color perception and visual acuity. Light-induced isomerization of the retinaldehyde Schiff base position 11 olefin from cis to trans geometry generates a signal, which is converted to a nerve impulse for eventual relay to RGCs in the inner retina (Figure 2). RGCs transmit this signal through the optic nerve head (ONH) and into the brain, where the signal is integrated.

Figure 2 11cis and 11fransretinaldehyde

A likely functionally important component of lipofuscin is the amphiphilic pyridinium ion A2E19 (Figure 3), that is believed to be formed in vivo from the condensation of one equivalent of phosphatidylethanolamine with two equivalents of 11-trans-retinaldehyde, followed by phospholipase-D-catalyzed dephosphorylation. A2E might be the major component of lipofuscin, producing reactive oxygen species (ROS).20 A2E is thought to be the major component of lipofucsin producing ROS in the presence of light and oxygen.20 Enhanced production of A2E can occur as the result of the dysfunctional transport of photobleached 11-trans retinal phosphatidyethanolamine Schiff base (NRPE) through the photoreceptor disk membrane resulting in the accumulation of RPE cell lysosomes. BNRPE transport ossurs via an ABCR (ATP-binding cassette transporter) mechanism. Individuals null for the ABCR gene suffer from Stardgardt's macular dystrophy, an early-onset macular degeneration-like disease.21 Individuals with...

Posterior Vitreous Detachment

Vitreous floaters are commonplace and tend to increase in number as the years pass. But the vitreous undergoes a more dramatic change with age. Often in the late 50s, it becomes more fluid and collapses from above, separating from its normal position against the retina and eventually lying as a contracted mobile gel in the inferior and anterior part of the cavity of the globe. The rest of the globe is occupied by clear fluid. This then is the process known as posterior vitreous detachment (PVD).

Figure 7 The structures of 5fluoruracil and mitomycin C

The disadvantages to pegaptanib therapy arise from drug specific and drug class considerations. Pegaptanib is administered by intravitreal injection, which is inconvenient, requires highly skilled delivery by an ophthalmologist, and in clinical trials has demonstrated a higher rate of intraocular infection (endophthalmitis) and retinal detachment than in controls.67 It is not known if pegaptanib's lack of binding to other VEGF isoforms lessens its effectiveness as compared with pan-isoform binders like the anti-VEGFantibody ranibizumab (see Section 6.12.5.2.2). Pegaptanib does not improve visual acuity or arrest its degradation, which would be ultimately desirable.

Other Diseases of the Retina

Diabetic retinopathy (DR) occurs in 27 of diabetics after 5-10 years of contracting diabetes and up to 90 have DR after more than 10 years of diabetes. DR essentially stems from retinal ischemia due to thickening of retinal capillary basement membranes when capillary pericytes start to die off. The ensuing ischemia causes the overexpression of VEGF, which in turn causes capillaries to leak and cause edema. VEGF also stimulates the growth of new blood vessels. This neovascularization could be perceived as a compensatory mechanism, but it is actually detrimental, since the new blood vessels disrupt retinal function. Deterioration of vision in DR is due to macular edema and proliferation of fibrovascular membranes that can lead to retinal detachment. Current treatments for DR are limited to laser photocoagulation of the leaky blood vessels, but this unfortunately destroys the underlying and surrounding retinal tissue. A much more specific approach is the use of photodynamic therapy,...

Reduction of Proliferative Vitreoretinopathy

On the other hand, the maximum tolerated dose of enoxaparin, a low-molecular-weight heparin, during vitrectomy for rhegmatogenous retinal detachment with proliferative vitreoretinopathy and severe diabetic retinopathy was determined (103). The study was able to achieve the 6.0 IU ml maximum dose in the infusion fluid, and enoxaparin dose escalation did not result in a dose-dependent increase in acute side effects.

Testing Visual Acuity

Measuring the visual acuity means measuring the function of the macula, which is of course only a small part of the whole retina. A patient might have grossly impaired visual acuity and yet have a normal visual field, enabling him to walk about and lead a normal life apart from being unable to read. This state of affairs is seen in patients with age-related macular degeneration and can be compared with the situation in which a patient has grossly constricted visual fields but normal macular function, as is sometimes seen in retinitis pigmentosa or advanced primary open-angle glaucoma. Here, the patient

Pars Planitis Intermediate Uveitis

This refers to a low-grade inflammatory response,which is seen in young adults. It affects both eyes in up to 80 of cases, although the severity can be asymmetrical. There is minimal evidence of anterior uveitis and the patient complains of floating spots in front of the vision. Inspection of the fundus reveals vitreous opacities and careful inspection of the peripheral retina shows whitish exudates in the overlying vitreous. A mild-to-moderate peripheral retinal phlebitis can occur. The condition runs a chronic course and occasionally can be complicated by cataract, cystoid macular oedema and tractional retinal detachment. The cause is unknown in the majority of cases, although there is a known association with sarcoidosis.

Viscosurgery A Viscosurgical Use in the

The concept and the early experiments using elastoviscous hyaluronan, and the development of the first purified preparation to replace the vitreus after surgery and to be used as a 'soft tool' to manipulate the retina in retinal detachment surgery as well as to be used as a viscoelastic protector of the corneal endothelium in corneal transplantation, were the work of the author and his co-investigators (7,8) and a group of eye surgeons, who carried out the first clinical trials in the late 1960s and early 1970s (9-12). By the end of the 1970s the use of the first highly purified, non-inflammatory fraction of Na-hyaluronan, NIF-NaHA (manufactured under the trade name Healon , Biotrics, Inc., Arlington, MA) in retinal surgery and to protect the corneal endothelium during corneal transplantation was well established (13). At the same time the increasing use of intraocular plastic lenses to replace cataractous lenses was slowed down by the problem presented by accidental contact of the...

Viscoaugmentation A Hyaluronan Gels

Tissue engineering with viscoelastic hyaluronan focused first on its use as a tissue filler or tissue augmentator (viscoaugmentation). Unlike collagen and non-biological tissue fillers, hyaluronan is an extremely elastic molecule and as such provides elasticity to the intercellular spaces into which it is injected. Hylan B gel was first used for viscoaugmentation of the vitreus after retinal detachment surgery, and later for correcting facial wrinkles and depressed scars for vocal cord augmentation in glottal insufficiency and augmentation of the connective tissue in sphincter muscles to treat urinary incontinence.

Retinopathy of Prematurity

Realized that the retinopathy seen in premature children was caused by this treatment. During the course of oxygen therapy in a premature infant, the retinal vessels become narrowed and the optic disc becomes pale. When the oxygen treatment is stopped, the retinal vessels become engorged and new vessels grow from the peripheral arcades in the extreme periphery of the fundus. This growth of abnormal vessels leads to vitreous haemorrhage, retinal detachment and fibrosis of the retina. The infant can rapidly become blind, although some are minimally affected. The management of the condition now involves screening of those children at risk and monitoring of blood oxygen levels. When the condition occurs, treatment with cryotherapy to the peripheral retina has been shown to be beneficial. Now that children are being born at an earlier and earlier stage, it seems that extreme prematurity runs the risk of blindness from this cause even in the absence of supplementary oxygen.

Associated Manifestations Of Hvs Retinal findings

Among the first clinical signs of HV is the appearance of peripheral and mid-peripheral dot- and blot-like hemorrhages in the retina, which are best appreciated with indirect ophthalmoscopy and scleral depression.3031 In more severe cases of HVS, dot, blot, and flame-shaped hemorrhages can appear in the macular area, and may be accompanied by retinal edema and visual disturbance. Although visual acuity usually improves with plasmapheresis treatment, irreversible visual loss has been reported.32 Some patients with HVS show papilledema and markedly dilated and tortuous veins with focal constrictions, predominantly at the arterio-venous junctions (i.e., venous sausaging). Other clinical findings associated with HVS can include intraretinal exudates resulting from more severe leakage from retinal vessels and retinal detachments.33 Fluorescein angiography may be helpful in cases of intraretinal exudates in identifying areas of leakage.

Proliferative Retinopathy

Proliferative diabetic retinopathy is characterised by the development of new blood vessels (neovascularisation) on the optic nerve head or the retina (Figure 21.4). These occur as a response to retinal ischaemia. These new vessels can appear as small tufts, which ramify irregularly. They might be flat initially but enlarge and move forward into the vitreous cavity as they grow. Once the new vessels form and grow, there is increased risk of an acute pre retinal or vitreous haemorrhage. This is a significant threat to vision because the vitreous haemorrhages can become recurrent or dense, preventing any meaningful examination and treatment. Retinal fibrosis, traction retinal detachment and neovascular glaucoma can occur at a later stage.

Ophthalmic Viscosurgery A Development

The contents of this report, published in the following years (1-7), established that hyaluronan solutions, after being purified from proteins, nucleic acids, endotoxin, and other inflammatory agents, can be used in various surgical procedures, provided the solution has certain viscous and elastic properties. The report was the result of a decade of laboratory research (Boston Biomedical Research Institute), industrial development (Biotrics, Inc., Arlington, MA), and clinical studies in academic ophthalmology departments (Boston, Stockholm, Essen, Paris, Zurich). The biocompatibility of this product produced from human umbilical cord and rooster comb was tested in nearly 500 owl monkey eyes. Owl monkeys were used because their viscous vitreous is liquid, and half of it (1 ml) can be replaced by test solutions without causing traumatic injury to the eye. The clinical studies established the usefulness of the highly elastoviscous hya-luronan solutions as...

Vitreoretinal Surgery

That it is now possible to remove a persistent vitreous haemorrhage and to divide or remove fibrous tissue, even from the surface of the retina, and relieve traction retinal detachment. Vitrectomy for vitreous haemorrhage tends to be performed sooner these days because of the relative safety of the technique. It can be combined with intraoperative laser photocoagulation.

Fluorescein angiography of the fundus

Hyperfluoresence is the term used whenever fluorescence is increased in an area either due to leakage, as in macular oedema, or due to a window defect that allows the choroidal fluorescence to show through an atrophic retina, as in macular degeneration. It can show as an area of pooling, as in pigment epithelial detachment (Rabb et al. 1978 Gass 1997).

Abnormalities of the Pupil

Miosis refers to a small pupil, mydriasis to a large pupil (big word, big pupil). The pupil grows smaller with age, as does reactivity. In young children the pupils are relatively large and sometimes anxious parents bring up their children because they are concerned about this. During sleep, the pupils become small. When examining the eye with the ophthalmoscope, it is evident that the pupil constricts more vigorously when the macula is examined than when the more peripheral fundus is stimulated with the ophthalmoscope light. When an eye is totally blind, usually there is no light pupil reaction,but as a general rule,the pupils remain of equal size. It should be apparent from Figure 22.7 that the patient with cortical blindness (lesion within the occipital cortex) might have a normal pupil reaction. We must also remember that a pupil might not react to light because it is mechanically bound down to the lens by adhesions (posterior synechiae). When both maculae are damaged by senile...

Drops That Constrict the Pupil

To constrict the pupil and open up the closed drainage angle. Sometimes it is necessary to constrict the pupil rapidly during the course of intraocular surgery and this is achieved by instilling acetylcholine directly into the anterior chamber. Strong meiotics run the risk of causing retinal detachment in susceptible individuals. Meiotics have been used to reverse the effect of mydriatic drops used for fundus examination, but this practice is no longer recommended as a routine because it is unnecessary and the symptoms of meiosis may make matters worse.

Antiangiogenic Drugs and the

Uncontrolled angiogenesis (growth of new blood vessels) is a common finding in many potentially blinding conditions, such as prolif-erative diabetic retinopathy, central retinal vein occlusion, wet age-related macular degeneration (ARMD) and retinopathy of prematurity. Inhibiting their growth offers us the hope of dramatically reducing the number of patients going blind each year. It is thought that the angiogenic response is caused by elevated levels of a cytokine called vascular endothelial growth factor (VEGF) produced by abnormal or ischaemic cells within the eye. Attempts to reduce the levels of VEGF and hence turn off the angiogenic drive have involved intravitreal

Incidence and Causes of Blindness

In England and Wales, the prevalence of blindness in 1980 for children under five years was 9 100,000. This figure increased to 2324 100,000 for adults over 75 years. In the western world, blindness in children is largely because of inherited genetic disease and birth trauma. In adults aged 20-60 years, the major causes are diseases of the retina, including diabetic retinopathy and optic atrophy. Over the age of 60 years, macular degeneration, glaucoma and cataract are the important problems.

As Sources Of Distress

The advent of HAART therapy has altered the natural progression of HIV and has changed the incidence, natural history, management, and sequelae of HIV-associated retinopathy, especially CMV-associated retinopathy. Before use of HAART, CMV retinitis was common, occurring in 20 -40 of seropositive patients. Patients were relegated to indefinite intravenous therapy, and between 25 and 50 suffered retinal detachment. Survival after development of CMV retinitis was 6-10 months. The incidence of CMV retinitis declined by approximately 80 after the advent of HAART therapy, and mean survival has increased to over 1 year from time ofdiagnosis (Holbrook et al., 2003 Goldberg et al., 2005). However, visual loss and blindness from multiple etiologies are still significant causes for concern and sources of distress for patients with HIV (Ng et al., 2000 Kestelyn and Cunningham 2001 Hill and Dubey 2002 Oette et al., 2005). Specific studies examining the quality of life and distress experienced by...

Multiple sclerosis

The eye is a key part of the CNS connecting to the brain via the second cranial or optic nerve. Many other receptors and signal transduction process in the eye recapitulate those present in the CNS proper although the cellular architecture of the eye and its function are unique (see 6.12 Ophthalmic Agents). The anterior pole of the eye, composed of the cornea, iris, and lens, serves to focus light onto the photoreceptors of the retina. The retina is a layered structure composed of retinal ganglion cells, amacrine cells, horizontal cells, and photoreceptors that transduces, processes, and integrates visual stimuli. The ganglion cells are the output neurons of the retina, sending axons to the lateral geniculate nucleus by way of the optic nerve. This highly evolved complex system allows for accurate processing of visual stimuli with an exceptional dynamic range. However, it is susceptible to multiple disorders including glaucomas and macular degeneration that ultimately can produce...

Applications

Injectables are very attractive systems for delivery of pharmaceutical agents into the eye, since the current delivery devices suffer from drawbacks such as the need of a surgery for implantation (bulk preshaped devices) or the migration of injectable microparticles into the visual axis or into adjacent tissue sites.6 Although these disadvantages are also present when the implantation occurs in other sites of the body, they are particularly dangerous in a delicate region such as the eye. Moreover, degradable injectables present advantages over conventional implants because repeated intraocular injections can increase the risk of infection, cataract, vitreous hemorrhage, or retinal detachment. The peak and valley effect of conventional administration could result in direct toxicity to ocular tissues followed by a rapid clearance of the drug.

Failing Vision

Failing vision means that the sight, as measured by the standard test type, is worsening. The patient might say I can't see so well doctor or they might feel that their spectacles need changing. Some patients might not notice visual loss, especially if it is in one eye. Sometimes, more specific symptoms are given the vision might be blurred, for example in a patient with cataract, or objects might appear distorted or straight lines bent if there is disease of the macular region of the retina. Disease of the macular can also make objects look larger or smaller. Double vision is an important symptom because it can be the result of a cranial nerve palsy,but if monocular, it could be caused by cataract. Patients quite often complain of floating black spots. If these move slowly with eye movement, they might be caused by some disturbance of the vitreous gel in the centre of the eye. If they are accompanied by seeing flashing lights, the possibility of damage to the retina needs to be kept...

Symptoms

Many patients complain of blurred vision, which is usually worse when viewing distant objects. If the patient is unable to read small print, the surgeon might suspect that other pathology, such as macular degeneration, could be present. One must bear in mind that some elderly patients say that they cannot read when it is found that they can read small print if carefully tested. It is a curious fact that when the cataract is unilateral, the patient can claim that the loss of vision has been quite sudden. Elucidation of the history in these cases sometimes reveals that the visual loss was noted when washing and observing the face in the mirror. When one hand is lowered before the other, the unilateral visual loss is noticed for the first time and interpreted as a sudden event. The history in cataract cases might be further confused by a natural tendency for patients to project their symptoms into the spectacles, and several pairs might be obtained before the true cause of the problem is...

When to Operate

Even though the decision to operate on a cataract must be made by the ophthalmic surgeon, optometrists and the nonspecialist general practitioner need to understand the reasoning behind this decision. Elderly patients tend to forget what they have been told in the clinic and might not, for example, understand why cataract surgery is being delayed when macular degeneration is the main cause of visual loss. An operation is usually not required if the patient has not noticed any problem, although sometimes the patient can deny the problem through some unexpressed fear. The requirements of the patient need to be considered those of the chairbound arthritic 80-year-old subject who can still read small print quite easily are different from the younger business person who needs to be able to see a car number plate at 20.5 m in order to drive. The visual acuity by itself is not always a reliable guide. Some patients who have marked glare might need surgery with

Intracranial Injury

Retinal hemorrhages are strongly suggestive of abuse when accompanied by intracranial injuries and in the absence of a confirmed history of severe accidental injury. Unilateral or bilateral retinal hemorrhages are present in 7590 of cases of shaken baby syndrome (36). Retinal hemorrhages can also be found after severe closed chest injury, asphyxia, coagulation disorders, carbon monoxide poisoning, acute hypertension, sepsis, meningitis, and normal birth (usually disappearing by 2 weeks, rarely persisting to 6 weeks). When shaking injuries are suspected, retinal examination is essential and should include direct and indirect ophthalmoscopy preferably by an ophthalmologist. Subhyaloid hemorrhages and local retinal detachment occur earliest, are often peripheral, and are found only by indirect ophthalmology. When intraocular injury is present, subdural hemorrhage is likely, and the presence of retinal detachment and multiple hemorrhages may indicate additional cerebral lacerations or...

Incidence

Retinal detachment is rare in the general population but an eye unit serving a population of 500,000 might expect to be looking after three or four cases a week. It can be seen, therefore, that a doctor in general practice might see a case once in every two or three years, especially if we consider that some retinal detachment patients go directly to eye casualty departments without seeking nonspecialist advice. Although children are sometimes affected, the incidence increases with age and reaches a maximum in the 50-60-

Pathogenesis

There is an embryological explanation for retinal detachment in that the separating layers open up a potential space that existed during the early development of the eye, as described previously (Chapter 2). The inner lining of the eye develops as two layers. In its earliest stages of development, the eye is seen as an outgrowth of the forebrain, the optic vesicle, the cavity of which is continuous with that of the forebrain. The vesicle becomes invaginated to form the optic cup, and the two-layered cup becomes the two-layered lining of the adult eye. Anteriorly in the eye, the two layers line the inner surface of the iris and ciliary body. Posterior to the ciliary body, the outer of the two layers remains as a single layer of pigmented cells, known as the Figure 13.1. Histology of retinal detachment showing the location of subretinal fluid.This eye has an underlying choroidal melanoma. CO pigment epithelium. The inner of the two layers becomes many cells thick and develops into the...

The Vitreous

The vitreous is usually perfectly transparent but most people become aware of small particles of cellular debris, which can be observed against a clear background such as a blue sky or an X-ray screen (vitreous floaters). These particles can be seen to move slowly with eye movement and appear to have momentum,just as one would expect if one considers the way the vitreous moves.

Shadow

Once a retinal tear has appeared, the patient might seek medical attention, and effective treatment of the tear can ensue. Unfortunately, some patients do not seek attention, or, if they do, the symptoms might be disregarded. Indeed, in time the symptoms might become less, but

Prophylaxis

Retinal tears without significant subretinal fluid can be sealed by means of light coagulation. A powerful light beam from a laser is directed at the surrounds of the tear (Figure 13.2). This produces blanching of the retina around the edges of the hole and, after some days, migration and proliferation of pigment cells occurs from the RPE into the neuroretina and the blanched area becomes pigmented. A bond is formed across the potential space and a retinal detachment is prevented. This procedure can be carried out, with the aid of a contact lens, in a few minutes. Figure 13.2. Laser photocoagulation of retinal tear (with acknowledgement to Mr R. Gregson). CD Figure 13.2. Laser photocoagulation of retinal tear (with acknowledgement to Mr R. Gregson). CD

Retinal Surgery

In the early part of the twentieth century, it was generally accepted that there was no known effective treatment for retinal detachment. It was realised that a period of bedrest resulted in flattening of the retina in many instances. This entailed a prolonged period of complete immobilisation, with the patient lying flat with both eyes padded. This treatment can restore the sight but only temporarily because the retina redetaches when the patient is mobilised. It was also dangerous for the patient in view of the risk of venous thrombosis and pulmonary embolism. In the 1920s, it began to be realised that effective treatment of retinal detachment depends on sealing the small holes in the retina (Figure 13.3). It was already known by then that the fluid under the retina could be drained off externally simply by puncturing the globe, but up till then no serious attempt had been made to associate this with some form of cautery to the site of the tear. Once it became apparent that Figure...

Vitrectomy

The detached retina can also be reattached from within the vitreous cavity. This involves the use of fine-calibre instruments inserted through the pars plana into the vitreous cavity. A light probe is used to illuminate the operative field, while a vitrectomy cutter is used to remove the vitreous, hence relieving the abnormal vitreous adhesions that produced the retinal tear in the first instance (Figure 13.5). The detached retina is pushed back into place from within and temporarily supported by an internal tamponade agent (air, gas or silicone oil) while the retina heals. The retinal breaks are identified and treated by either laser photocoagulation or cryopexy at the same time. Vitrectomy can also be combined with a silicone strap encirclement if further support of the peripheral retina is needed. Historically, vitrectomy is reserved for the more difficult and complex cases of rheg-matogenous retinal detachment, where multiple tears and posteriorly located tears are present, or as...

Intraocular Lymphoma

When intraocular lymphoma (IOL) is present at diagnosis, there is usually concomitant cerebral involvement. If WBXRT is being used in the primary treatment, the eyes should also be included in the irradiation field. The long term side-effects of orbital irradiation include the development of cataracts, retinal detachment, and optic nerve atrophy. High-dose intravenous MTX alone can achieve therapeutic concentrations in the vitreous humour.65 One study reported a complete response in four of five patients with IOL treated with this approach.66 This suggests that orbital XRT can be deferred in patients with stable visual findings who receive MTX. One approach is to assess for persistent disease after four cycles of chemotherapy. If IOL is still detected, then orbital irradiation can be administered.

Introduction

A large number of investigations have revealed limitless functional contributions of glycosaminoglycans, the most characteristic carbohydrates, to ocular systems. Here, we focus on the roles of glycosaminoglycans in ocular pathogenic conditions and the clinical applications of glycosaminoglycans for eye diseases, and attempt to review them for both health professionals and general readers. We deal with macular corneal dystrophy, glaucoma, cataract, diabetic retinopathy, retinal detachment pro-liferative vitreoretinopathy, myopia, thyroid eye disease, and pseudoexfoliation syndrome in the eye disease section, and heparin, hyaluronan, and chondroitin sulfate in the clinical application section. Figure 1 shows a schematic diagram of the eye in cross section indicating each ocular component. The candidate glycosaminoglycans involved in the ocular components of each eye disease described in this chapter are summarized in both the legend for Fig. 1 and Table 1.

Perforation

The outcome of a perforating injury is dependent on the depth of penetration and the care with which the wound is cleaned and sutured. If the cornea alone is damaged, excellent results can be obtained by careful suturing under general anaesthesia using the operating microscope. If the lens has been damaged, early cataract surgery might be needed and deeper penetration can result in the need for retinal detachment surgery.

Ophthalmology

The original development of HA as a product to be used in clinical medicine is entirely due to Endre Balazs. He derived the main concepts and was the first to prepare HA samples that were of sufficient purity to be tolerated. During the 1950s Balazs concentrated his research on the composition of the vitreous body and started to experiment with vitreous substitutes to be used in surgery of retinal detachment. He introduced the term viscosurgery for these medical applications. One of the crucial obstacles for using HA in implants was to prepare HA free of impurities that could cause inflammatory reactions. Balazs solved this problem, and his final preparation was called NIF-NaHA (noninflammatory fraction of sodium hyaluronate). In 1970 Rydell and Balazs injected HA in the arthritic joints of racehorses with a dramatic positive effect on the clinical symptoms. Two years later, Balazs convinced Pharmacia AB in Uppsala to start production of HA for veterinary and human use. Ten years...

Diet Healthy Eyes

To maintain good eyesight foods rich in vitamins A, C, E, riboflavin, selenium, and zinc should be consumed. All these nutrients are important for vision and are supplied by a balanced diet with generous amounts of fruits and vegetables, such as carrots, cantaloupe, oranges, and broccoli. Generous intake of antioxidant nutrients (see pp. 115) over a lifetime may help prevent cataract, the most common cause of impaired vision in older adults.1 Age-related macular degeneration (AMD) is a common cause of vision impairment in older people, and the risk of AMD can be reduced by a diet high in antioxidants, ca-rotenoids, and zinc.2 3 Nutrient supplementation may help correct minor eye troubles such as dry, burning, itchy eyes and eyestrain.

Other Causes

A wide variety of infective agents have been shown to cause posterior uveitis on rare occasions. The leprosy bacillus and the coxsackie group of viruses are two examples chosen from many. Sympathetic ophthalmia has already been mentioned as a specific form of uveitis following injury. An especially rare but intriguing form of uveitis is known as the Vogt-Koyanagi-Harada syndrome, in which is seen the combination of vitiligo, poliosis, meningo-encephalitis, uveitis and exudative retinal detachments.

Congenital Cataract

The lens can be partially or completely opaque at birth. Congenital cataract is often inherited and can be seen appearing in a dominant manner together with a number of other congenital abnormalities elsewhere in the body. The condition might also be acquired in utero, the best known example of this being the cataract caused by rubella infection during the first trimester of pregnancy remember the triad of congenital heart disease, cataract and deafness in this respect. Minor degrees of congenital cataract are sometimes seen as an incidental finding in an otherwise normal and symptom-less eye. The nature of the cataract usually helps with the diagnosis. The lens fibres are laid down from the outside of the lens throughout life. If the opaque lens fibres are laid down in utero, this opaque region can remain in the centre of the lens. Only when the cataract is thick does it present as a white appearance in the pupil and often it is difficult to detect it. It is important to examine the...

The Snellen chart

Number of letters, as compared with earlier charts with only one or two letters for the 6 60 and 6 36 visual acuity lines, and a large number of letters for the 6 6 and smaller visual acuity lines. Third, the spacing between letters is proportional to the letter size, while the older acuity charts had unequal spacing between letters. Finally, the change in visual acuity from one line to another is in equal logarithmic steps, where there were very small changes for different lines at the small-letter end and rather large changes for the big-letter end of the older charts. This new eye chart permits more precise definition of visual acuity, especially at levels of diminished visual acuity. It is thus used in the current UK national study of photodynamic therapy in age related macular degeneration (TAP study group 1999 Bames et al. 2004). In addition, new methods of scoring responses to this type of visual acuity chart can provide greater sensitivity and reliability of measure. The ETDRS...

At Protein Level

Of interest is that with use of a combination of techniques (separation of serum proteins with LC and 2D-gels and identification with MALDI TOF and ion-trap MS) several inflammation related proteins, including protein factors C4 and C3 and factor H, a cofactor for inactivation of activated C3, are found upregulated in serum of AD compared to controls 121,314 . Polymorphism (Y402H) in Factor H has been associated with age-related macular degeneration, and recently also with AD 310 , the pathologies of which are both associated with Ap deposition 133 and APOE polymorphism 16 .

Choroidal Melanoma

Be an associated exudative retinal detachment or, less often, secondary glaucoma. Other associated features might include choroidal haemorrhage and serial photography might be needed to confirm the growth. The usual presentation is with decreased vision or a visual field defect. Diagnosis is confirmed with careful clinical examination, including indirect ophthalmo-scopy and slit-lamp biomicroscopy (contact lens or volk lens examination), fluorescein angiography, ultrasonography and transvitreal fine-needle aspiration in equivocal cases. The most common site for metastases is the liver, so abdominal ultrasound, serum liver function tests, and chest X-ray should be performed at regular intervals. The appearance of liver metastases can be delayed for several years and can occur even if the eye has been removed, signifying micrometastases at the time of presentation. Approximately 40 of patients develop liver metastases within ten years of the initial diagnosis, while the estimated...

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