Craig Blackwell, MD
Ophthalmology

Santa Cruz, CA
Diplomate: American Board of Ophthalmology
Fellow: American Academy of Ophthalmology

Welcome to the Website of Craig Blackwell, MD

An Ophthalmology Practice in Santa Cruz, CA

Eye Photo Gallery

The following photos were taken of our patients showing a variety of common eye conditions.

Front of the Eye with Contact Lens

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View of the front of the eye through the slit lamp microscope. The arrow points to the edge of a soft contact lens, extending about a millimeter beyond the edge of the cornea.

Corneal Arcus

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The arrows point to a white ring around the edge of the cornea that commonly appears in the later decades of life. The white ring is a deposit of lipid. In people over age 50 it is not related to serum cholesterol or lipid levels. It usually remains peripheral and does not interfere with vision.

If this occurs in a young person it is called arcus juvenalis. Specifically, in men under age 50 there is a correlation with heart disease and lipids should be tested.

Laser Iridotomy

The white arrow points to a small opening in the iris made with a YAG laser. This is an iridotomy, made in order to prevent angle closure type of glaucoma.

Lens through a Dilated Pupil

Slit lamp view through a dilated pupil. The slip beam, coming at an angle from the left, first cuts through the cornea (broken arrows), followed by a dark gap for the anterior chamber, then it lights up a large section through the lens (solid arrows). This lens is average clarity for a person of 50 years of age.

Exfoliation Syndrome

White deposits are visible in rings on the surface of the lens. This is associated with increased risk of glaucoma, more difficulty with cataract surgery and possible systemic conditions.

For more on this surprisingly interesting subject see Dr. Robert Rich’s site: www.glaucoma.net/nygri/education/exfosyn.html.

Dense Cataract

Lens Implant

Through the dilated pupil a lens implant (IOL) is visible. It is tricky to see because it is clear. The solid arrows point to the edge of the circular optic of the IOL. The end of one of the stabilizing arms can be seen embedded in the clear optic at about 6 o’clock position.

The diagram below shows an IOL oriented at the same angle.

At cataract surgery the main cloudy part of the lens is removed leaving the back part of the lens (the capsule) in place to support the lens implant (IOL). Picture an avacodo as the lens. Surgery involves removing the pit and the meat, leaving the skin in place. The IOL is inserted into the capsule like a sandwich in a sandwich bag.

Months to years after surgery, the capsule may become cloudy and interfere with vision much like the original cataract.

Capsule Opacity

The white ring shown by the broken arrow is the part of the capsule in front of the IOL. The IOL is clear. The hazy area indicated by the solid arrow is clouding of the posterior capsule behind the lens. My mental picture is of a sheet of wax paper behind the lens. See the diagram below.

Diagram, side view of the IOL within the lens capsule.

At surgery an opening is made in the front of the capsule so the cloudy lens material (cataract) can be removed. The IOL is inserted into the capsule with the arms (haptics) keeping the lens positioned in the center. Within weeks the capsule contracts around the IOL holding it securely in position.

Months to years later the back part of the capsule may become clouded, obscuring vision. Using a YAG laser an opening can be made in the clouded back capsule to restore vision to the postop level of clarity.

Capsule Opened with Laser

The picture shows a clouded capsule opened with a YAG laser. Compare with the previous picture where there was a cloudy area behind the lens, now there is a clear opening.

Retina of a Young Person

The white areas are reflections off the glossy surface of a young retina. Compare to the middle-aged retina in the photo below.

Retina in Middle Age

Macular Degeneration, Moderate Dry

The yellow spots in the center of the retina are called “drusen.” They are waste products that have built up in the cells under the retina causing gradual decrease in vision. This is one of the two types of the “dry” form. See the sections on Macular Degeneration and AREDS for information about the effect of vitamin and mineral supplement slowing progress.

Macular Degeneration, Atrophic, Dry

Instead of drusen this form of AMD is characterized by gradual wasting away of the pigment layer, outlined by the white arrows. This is still “dry,” but vision is significantly reduced.

Macular Degeneration with Hemorrhage

The large hemorrhage signifies a change from the dry to the “wet” form, with an accompanying large decrease in vision.

Diabetic Retinopathy, Mild

In diabetes the high blood sugar damages the fine capillary vessels making them leaky. First they leak serum, the clear part of the blood. The white arrow is pointing at a ring of “exudates.” The yellow spots are the lipid part of the leaking serum and mark the edge of an area of edema.

Later, red blood cells leak out into the retina. The black arrow is pointing at a small hemorrhage.

Diabetic Retinopathy, Moderate

Diabetic Retinopathy. Moderate severity.

Compared to the first photo there is an increased number and density of exudates and hemorrhages.

Macular Hole, OCT Image

OCT is an instrument that uses light to scan the layers of the retina revealing more detail than we can get by looking.

The gentle slope and valley in the right eye (left picture) is the normal contour of the fovea, the area of central vision. Vision in this eye is 20/20.

The left eye (right picture) shows a flattening of the contour and a full thickness hole in the sensory layer of the fovea. Vision is reduced to 20/200. Retinal surgery is planned for this person, but it may be too late for much improvement.

OCT stands for Ocular Coherence Tomography.

Epiretinal Membrane, OCT Image

This image shows flattening of the normal contour of the fovea. This is a relatively common condition whereby extra free floating cells within the eye join together to form a membrane on the surface of the retina. As the membrane contracts it causes the underlying retina to wrinkle, which reduces and distorts vision.

The above image is from a 57 year old man with vision still at 20/25. If vision worsens then retinal surgery can be done to remove the membrane and overlying vitreous. If it is done in a timely fashion vision there is a good chance vision would improve. Because vision is good now, we will wait and watch.

Macular Edema, OCT Image

Sometimes vision is blurred because of edema (extra fluid) in the retina. But small amounts of clear fluid can be difficult for us to see on exam. In this case the OCT test shows us something we could not see.

On the printout, in the upper box, the white arrow points to the elevated area of retina. The black hole is a pocket of edema.

In the lower box, the black line represents the surface contour of this retina, which is elevated well above the green zone, the range where normal should be.

Blockage of a Branch Retinal Vein

The small cluster of hemorrhages and white patches is the result of the blockage of a small branch vein in the lower part of the retina. Because the blockage was in the lower retina this person was lucky that central vision was not affected. The hemorrhage gradually absorbed without problems.

Blockage of the Central Retinal Vein

With blockage of the central vein blood backs up into the eye causing widespread hemorrhages and edema. Vision is usually severely reduced and there are more possible complications.The hemorrhages make the normal structures difficult to make out in the photo. For reference, the white arrow is pointing to the optic nerve.

Choroidal Nevus

The dark oval area in the photo represents a nevus, composed of melanin containing cells similar to a mole on the skin. The risk is that this could change into a melanoma, a particularly invasive type of tumor.

Appearance can vary, with some characteristics considered as indicators of greater risk of malignant transformation. Increasing size has long been considered the most important warning sign.

(Other risk indicators include: visual symptoms, greater tumor thickness and diameter, presence of orange pigment, absence of drusen, absence of adjacent RPE changes, tumor near disc and subretinal fluid. See COMS)

A recent population study estimates that, among the Caucasian population, between 5 to 8% harbor a choroidal nevus. Using the number of cases of melanoma reported in the US, the estimated chance of a nevus turning into a melanoma is 1 in 8,845 per year.

[Ophthalmology,112;10, pp 1784 – 1789]

Uveal Melanoma

The pale area in the whole lower half of the photo is an elevation of the retina caused by a melanoma growing beneath it. This person had minimal vision symptoms and this was found on a routine annual exam. It was successfully treated by radiation.

Optic Nerve, Normal

The photo on the left shows a normal optic nerve head. Approximately one million nerve fibers are bundled together into the optic nerve. The veins are dark red, while the arterioles are narrower and orange.

A detailed look at the contour of the surface shows an even rim of nerve tissue with a depression in the center, called the “cup.”

Optic Nerve, “Tilted”

A common finding in a person with moderate to high myopia is the optic nerve head appears to be “tilted,” with a pale crescent of atrophy. May be more vulnerable to glaucoma.

Optic Nerve with Glaucoma Damage

The photo shows an example of an optic nerve where there is advanced thinning of the rim of nerve tissue. Compare to the photo of a normal nerve with a full rim of nerve tissue. See Glaucoma for more explanation.

HRT Contour Map of Nerve Head Showing Glaucoma Damage

This is part of a printout from a computerized map of the optic nerve head shown in the previous photo.

On the left is a contour map. The blue-green is the rim. The red is the central cup.

On the right, the computer has divided the nerve into six sections and compared each section to the expected normal range. The green checks mean that section is within normal range. The yellow exclamation mark means borderline. The red X’s mean out of the normal range.

We always double check to confirm that the computer’s interpretation agrees with what we see. See Glaucoma section for more explanation.

Optic Nerve Swelling

Compare the optic nerve head in this photo to the photos above. In this photo the sharp margin of the nerve is lost. In 3-D you could see the nerve head is swollen and bulging forward. The congestion has also caused small hemorrhages around the nerve. In this case the swelling was caused by inflammation of the nerve. It looks the same as if there was raised intracranial pressure.