Photo Gallery 2
This is the left eye of a 40 year old man who presented with a red eye, blurred vision and aching pain beginning one week before. Looking inside the front of the eye the aqueous of the anterior chamber was filled with white cells and fibrin, like the inside of a snow globe. This is inflammation in the front of the eye called “iritis.” There was so much inflammation the rim of the pupil was stuck to the front surface of the lens. Treatment consisted of frequent cortisone drops to calm the inflammation and a dilating drop to relax the focusing muscles, thereby reducing pain. After two days the pupil dilated, but left the ring of pigment from the edge of the iris stuck to the lens. It is unlikely to affect vision.
Central Serous Retinopathy on OCT
There are times when we can look into the eye and not be able to see what is wrong. A good example is when there is edema in the retina, which amounts to clear fluid in clear nerve tissue. Like finding glass in a bowl of water. Before OCT (Ocular Coherence Tomography) was available the only way to identify this kind of fluid was with a retinal angiogram. Now we have OCT which uses light to visualize the fine details of retinal structure.
Patient 1. Right Eye. Normal. VA 20/20. Patient 1. Left Eye. Subretinal Fluid. VA 20/70.
Patient 2. Right Eye. Subretinal Fluid. VA 20/60.
Upper Row. These are the OCT images from a 53 year old woman who had noticed blurred vision in the left eye for one month. The OCT on the left (her right eye) shows the normal appearance of the central retina. The hill and valley contour is the location of central vision. Note the contour is smooth and the retinal layers are even. The OCT on the right (her left eye) shows a dark gap underneath the retina which represents an accumulation of fluid. Vision in this eye is 20/70. This is called central serous retinopathy. An angiogram was done to be sure the fluid did not come from invading new vessels. Most of these cases resolve on their own with time. And indeed 6 weeks later vision had improved to 20/25.
Lower Image. This is the OCT image from the right eye of a 51 year old woman who came in for blurred vision. Vision measured 20/60 in this eye. The OCT shows a large fluid-filled gap under the retina. An angiogram showed no new vessels, so we waited and two months later vision had improved to 20/25.
Disc Hemorrhage in Glaucoma
This is the right optic nerve of a 53 year old woman with elevated intraocular pressures, but no disc or visual field defect. The arrow at 7:00 points to a the red streak which is a hemorrhage in the nerve fiber layer of the retina. It suggests an increment of damage to the optic nerve telling us we need to get her pressure lower.
This is a very common problem. Sometimes associated with injury, sometimes from eye rubbing and sometimes for unknown reasons a blood vessel on the outside of the eye will break. The blood collects in the space between the wall of the eye and the covering layer, the conjunctiva which is essentially clear. If there was any kind of injury we need to carefully check the eye for penetration. If there are multiple recurrences associated with easy bleeding and bruising then you are either on aspirin or anticoagulants or need to have your clotting mechanisms checked. But most of the time the hemorrhage just looks dramatic without causing any harm. Depending on the amount of hemorrhage it can take from a couple of days to over a week to absorb.
Diabetic Retinopathy: Before and After Laser Treatment
This is a case of moderate Diabetic Retinopathy in a 55 year old woman who was overweight and not paying attention to her blood sugar levels. In the photo on the left the red patches are hemorrhages and the white rings are edema.Vision in this eye was reduced to 20/40.
An angiogram was done to locate the leaking areas, which were then treated with laser. The dark spots on the right are scars from the laser. Note that all the blood and edema has cleared. Vision has improved to nearly 20/20.
Progressively worsening retinopathy and accompanying blurred vision had this lady concerned that she was in danger of losing her vision. With that as motivation she lost 35 pounds and got her A1c score down to 5.4. By keeping her A1c scores under 6, and blood pressure under control, her retinopathy has stayed stable through her last visit in 2011.
Diabetic Retinopathy: Recurring
This is the first of a series of photos of Mr. S., a 57 year old gentleman who was diagnosed with Diabetes at age 25. He admitted that he did not always pay attention to keeping blood sugar under control, with A1c values up to 11 in the last few years. The dark and light spots are scars of previous laser treatment, which covers just about everything. This much laser treatment means he had retinopathy in the past which had advanced to the ominous proliferative stage.
One day Mr. S called in noting vision in the right eye was a little fuzzy. On the vision chart readings were the same, but here is what was happening inside that eye. The dark red crescent is blood in front of the Retina, behind the Vitreous. There is also a small hemorrhage at the top of the Optic Nerve. The retina consultant found new vessel growth on the angiogram so more laser treatment was added. The hemorrhage gradually cleared.
At his 2011 visit Mr. S reported his last A1c was 10. He complained that vision in the left eye seemed blurred. On the chart vision measured 20/30 in the right eye and 20/40 in the left. This is an OCT scan of the left eye showing the normal contour is gone and the black spaces represent fluid within the retinal layers. That is macular edema which is affecting his vision. The retinal consultant is currently treating this with a series of injections of Avastin into the eye. It remains to be seen how vision will do.
The lesson of Mr. S is that although there are a number of tools available to treat diabetic retinopathy, the problems will continue to recur if the blood sugar and blood pressure are not adequately controlled. As retinal damage advances vision may not be recoverable.
Diabetic Retinopathy: Extensive Laser Treatment
Since we were looking at extensive laser treatment, here is a photo montage to show how extensive the treatment is. This is called “Pan-Retinal Photocoagulation,” or “PRP,” for short. This is reserved for the case in which there is the ominous new vessel growth. There are usually on the order of 1,000 laser spots administered. Note that there are no spots inside the Macula, that is to spare vision. While this results in a decrease in peripheral and night vision, that is the trade off made to save central vision which is needed to function.
This is a photo of the inside of a left eye. Not only does the Optic Nerve have an irregular outline, but if you could see it in 3 dimensions you would also note it is abnormally raised. Sometimes a elevated nerve is from swelling, but in this case it is from Drusen, which are calcium deposits that are embedded in the Optic Nerve. They can damage the nerve and cause vision loss like in Glaucoma. Unfortunately, there is nothing that can be done to remove them.