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(what you feel) and
disorders.

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Eye Symptoms

Redness PainBlurred VisionLoss of VisionFloaters/Distortion
Itching/BurningTearing/DischargeSomething in Eye Eyelid Problems
Double VisionHeadacheContact LensMedical Conditions

Eye Disorders

Abnormal Color Vision

Acute Glaucoma

Acute Iritis

Allergic Problems

Amaurosis Fugax

Bifocal Contact Lenses

Blepharitis

Brow Ptosis

Calcifications

Cataract

Cellulitis - eyelid

Cellulitis orbit

Central Serous Maculop

Chalazion Stye

Cicatricial Pemphigoid

Cluster Headache

Conjunctivitis

Contact Lens Allergy

Contact Lens Problems

Convergence Insufficiency

Corneal Abrasion

Corneal Edema

Corneal Foreign Body

Corneal Ulcer

Corneal Warpage

Dacryocystitis

Diabetes

Diabetic Retinopathy

Disposable Contact Lens

Distorted Vision

Dry Eye

Duane's Syndrome

Eales' Disease

Ectropion

Entopic Phenomenon

Entropion

Episcleritis

 

 

Esotropia

Exotropia

Extended Wear Contact

Eye and Orbital Cancer

Eye Muscle Paralysis

Eye Redness

Eyelid Tumor

Eyelid Twitching

Floaters/Flashing Lights

Focusing Spasm

Foreign Body

Giant Papillary Conjunct

Glaucoma

Glaucoma Suspect

Granulomas

Headache

Herpes Zoster (Shingles)

Inclusion Cysts

Iritis

Keratoconus

Lyme Disease

Macular Degeneration

Macular Edema

Macular Hole

Medication Toxicity

Migraine Headache

Molluscum Contagious.

Monovision

Myasthenia Gravis

Nerve Paralysis

Obstructed Tear Duct

Ocular Cicatricial Pemphi

Ophthalmic Migraine

Optic Neuritis

Optic Neuropathy

Orbital Fracture

Paralysis Fourth CN

 

Paralysis Sixth CN

Paralysis Third CN

Phlyctenulosis

Pingueculum

Pterygium

Ptosis

Rainbow Vision

Readers w Contacts

Rec. Corneal Erosion

Refractive Error

Retinal Artery Occlus.

Retinal Detachment

Retinal Tear

Retinal Vein Occlusion

Retinitis Pigmentosa

Sarcoidosis

Scleritis

Seborrheic Keratoses

Shingles

Sickle-Cell Disease

Sinus disease

Skin tags

Strabismus

Stroke

Subconj Hemorrhage

Temporal Arteritis

Thyroid Disease

Tight lens syndrome

TMJ Disease

Trichiasis

Tunnel Vision

Uveitis

Valsalva

Viral Papilloma

Vision prob w Contacts

Vitreous Detachment

Vitreous Hemorrhage

 

 

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Introduction: The Red Eye

There are numerous conditions which can cause eye redness, and nearly any condition causing symptoms of discomfort will also lead to eye redness. Redness usually specifically refers to the "white of the eye." Redness here can be due to engorged blood vessels on the surface of the eye, or due to hemorrhage on the surface. The location and pattern of redness may be important to making a diagnosis, as may be any associated symptoms and findings. This page discusses a few causes of eye redness which are not discussed elsewhere. There are also links to other Symptom and Diagnosis pages based on other symptoms in addition to the redness.

Conditions Discussed in this Section:

Conjunctivitis

Subconjunctival hemorrhage

Episcleritis

Medication (eye drop) toxicity

Pterygium

A Listing of other Conditions causing eye redness found in other sections:

 

  For eye anatomy explanations, go to ANATOMY

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Conjunctivitis

Conjunctivitis is an infection or inflammation of the lining over the sclera (the "white of the eye"). This lining is the conjunctiva, and it also lines the inside of the eyelids. The infection or inflammation may caused by a virus, allergy, bacteria or numerous other causes.

Viral conjunctivitis is common in adults, and is extremely contagious (even with indirect contact). Sometimes it may occur with the common cold. The eyes become injected and itch. There may be a watery or mucoid discharge, and the lids may swell. Both eyes are usually affected. Treatment is to reduce symptoms, since antivirals are not available. It usually runs its course in about 2 weeks. Care must be taken to wash the hands after touching the eyes.

 Bacterial conjunctivitis is more common in children. While also contagious, it requires more direct contact for spread than a viral infection. Eye redness, lid swelling, and a heavy pus-like discharge are common. Treatment with antibiotic eye drops, ointments, and sometimes even pills by mouth are necessary for treatment. Cultures may be taken to determine the bacteria involved and appropriate antibiotics.

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Subconjunctival hemorrhage

A subconjunctival hemorrhage usually appears as a sudden, spontaneous, bright red patch on the surface of the eye. This occurs when a small blood vessel breaks in the lining over the eye (the conjunctiva). It is usually otherwise painless, and the vision is not affected. The redness can be quite dramatic. This can occur spontaneously, or after direct trauma such as sneezing, throwing up, coughing, or straining. It often happens overnight. High blood pressure is a rare cause. The redness usually disappears over a one to two week period.

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Episcleritis

Episcleritis is an inflammation of the episclera, which is a fibrous layer between the white wall of the eye (the sclera) and the lining of the eye (the conjunctiva). With this condition, there is a patch of injected blood vessels on the surface of the eye (only a part of the eye is red). It may be associated with mild irritation, or sometimes iritis. The condition may resolve without treatment, but it also can recur, and may affect both eyes. It sometimes is associated with gout.

 

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Medication (eye drop) toxicity

 Many prescription and non-prescription eye drops can create ocular irritation or allergy, especially if used for a long period of time. Over-the-counter eye drops such as artificial tears, allergy eye drops, and contact lens solutions all contain preservatives unless the bottle specifically states "preservative free". These preservatives can commonly cause eye irritation and redness, if the user is sensitive to that preservative.

Prescription antibiotic eye drops can be effective at treating infection, but they can also be quite irritating to the eye and may cause prolonged irritation and redness. This may lead to confusion as to whether or not the infection has really been treated. Steroid eye drops usually are not particularly irritating. A few prescription allergy eye drops are known to cause some eye redness and burning on installation.

Vasoconstricting or decongestant eye drops ("get the red out" drops) simply blanch out blood vessels on the eye surface, concealing redness. If these eye drops are used frequently to mask redness, there may be a rebound redness when the drops are discontinued. This may lead to more usage of the eyedrop to conceal the worsening redness. 

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Pterygium /Pingueculum

A pterygium is a non-cancerous growth from the conjunctiva onto the cornea. It may start as a "pingueculum" (photo at right), which is a small lump of tissue located on either side of the cornea on the sclera. A pterygium has a "head", which may progressively cover the cornea, and a "body" which extends toward the corner of the eye (usually the inside corner). Often the "body" of a pterygium may appear red, with noticeable blood vessels.

A pterygium which progressively moves toward the pupil may need to be surgically removed in order to prevent the vision from being affected. Redness and irritation from a pterygium can be managed with artificial tears, and with other prescription eye drops. Pterygia seem to occur more frequently in people who spent much time outside, and is especially common in the southern latitudes. If they need to be removed, there is a possibility of recurrence.

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Other Conditions causing ocular redness found in other sections:

Allergic Problems - usually with itching and irritation.

Blepharitis - itching, burning, eyelid irritation.

Cellulitis (Infection) of Eyelid Skin - eyelid swelling, tenderness.

Contact Lens Related Problems - may have pain, scratchy sensation.

Corneal Abrasion - pain, tearing, sensation that something is in eye.

Dry Eye - irritation, scratchy sensation, sometimes tearing.

Ectropion (Out-Turning) of Eyelid - scratchy sensation, pain, tearing.

Entropion (In-Turning) of Eyelid - scratchy sensation, pain, tearing and discharge.

Glaucoma Acute - pain, blurred vision.

Iritis - pain, sensitivity to light, blurred vision.

Phlyctenulosis - sensation that something is in eye, burning, itching.

Scleritis - pain, blurred vision.

Thyroid Related Eye Disease - scratchy sensation, double or blurred vision, protruding eyes.

Trichiasis (In-Turning of Eyelashes) - scratchy sensation, pain, tearing.

Ocular Cicatricial Pemphigoid - an autoimmune disorder that leads to conjunctival scarring with inturning of the eyelids and lashes.

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Introduction: Eye Pain

Eye pain can originate from many different places within the eye, orbit (the bony eye socket), and around the orbit. Almost any eye problem that causes some discomfort can also cause eye pain, if the condition is bad enough. (For example, a dry eye problem usually causes a gritty eye sensation. But severe dry eye will cause eye pain.) This page discusses four conditions that are known to cause severe eye pain. Many of the conditions causing severe eye pain are associated with underlying medical conditions.

Other conditions capable of causing eye pain that are discussed on other pages of this Symptom and Diagnosis section are listed below with possible distinguishing features.

Conditions Discussed in this Section:

Acute Iritis

Corneal ulcer (infection)

Acute glaucoma

Scleritis

Other Conditions causing eye pain found in other sections:

 

For eye anatomy explanations, go ANATOMY

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Acute Iritis

Iritis usually refers to a group of ocular inflammatory diseases affecting the iris, ciliary body, and choroid. This is the "uveal tract," and another term for iritis is "uveitis." In acute iritis, the structures near the front of the eye become inflamed. This inflammation is similar to arthritis, except that in arthritis a joint is inflamed. Inflammation affecting the iris and ciliary body usually lead to symptoms of eye pain, sensitivity to light, pain with focusing, blurred vision, eye redness, and sometimes floaters. These symptoms occur because the iris and ciliary body both contain muscles which act to control the pupil size and focusing. Anything causing these muscles to work will cause pain. One, or both eyes can be affected.

There are several symptoms of iritis which are fairly specific to it. One is "contralateral photosensitivity." This means that the eye with iritis will feel pain even if light is shined into the OTHER eye only. Furthermore, the eye redness in iritis is usually a "flush" of redness in a ring around the cornea.

The ophthalmologist can diagnose iritis because inflammatory cells can actually be seen floating around in the front part of the eye. Treatment is with ocular steroids, usually in the form of eye drops. It is important to shake most steroid eyedrop bottles well, since the medication can often sink to the bottom of the bottle. It is also important not to stop these eye drops suddenly without "tapering off" of the medication. A sudden stoppage of the medication when there is still low-grade (but asymptomatic) iritis can result in a severe flare up of the disease. Thus follow-up visits are important. Oral steroids and other medications (such as dilating eye drops) are sometimes used as well.

Iritis can be associated with several medical conditions. Cases of recurrent iritis, especially severe iritis, and iritis involving both eyes may indicate reason to search for an underlying medical condition. Sarcoidosis is a commonly found cause of iritis in adults, especially in African-American women. In men, arthritic conditions such as ankylosing spondylitis (a back arthritis) and Reiter's syndrome may be found. Some infectious diseases such as syphilis, herpes, and toxoplasmosis can cause iritis. Iritis can be associated with inflammatory bowel disease and with arthritis associated with psoriasis.

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Corneal ulcer (infection)

Corneal ulcer (or ulcerative keratitis) can cause severe eye pain. A corneal infection occurs when bacteria are able to gain entry to the cornea through a scratch or breakdown in the corneal surface. With the use of extended wear disposable contact lenses, corneal ulcers have become more and more common. Symptoms include eye pain, redness, tearing, foreign body sensation, sensitivity to light, and blurred vision. In some contact lens users, the cornea may become somewhat insensitive to pain, and only symptoms of redness and irritation may appear.

A corneal ulcer is a serious, vision threatening problem. Some bacteria can be extremely aggressive, and the cornea can actually perforate (leading to endophthalmitis, or infection within the eye.) Treatment may include culturing of the corneal infection, and antibiotic eye drops are used very frequently (sometimes every 1/2 hour.) The eye may need to be re-examined on a daily basis to insure that the treatment is being successful. Contact lenses should not be used during this time. The photo above and right shows a small hypopyon (white cells) that resulted from the severe inflammation.

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Acute glaucoma

Most people with glaucoma have "open-angle glaucoma". This type of glaucoma causes no symptoms except for a gradual loss of vision. Acute angle-closure glaucoma is a rare, but severe form of glaucoma.

In this condition the eye pressure becomes extremely high rapidly. This can lead to symptoms of eye pain, redness, tearing, seeing rainbows around lights, blurred or lost vision (black-out), nausea, and vomiting. Treatment to break the attack of glaucoma includes eye drops to lower the pressure, and often oral medication as well. In some cases, IV medication has to be used. A laser surgical procedure can often break the attack and prevent future attacks.

For more information on glaucoma and acute angle-closure glaucoma, see the section on Glaucoma.

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Scleritis

Scleritis is a fairly rare disorder involving inflammation of the wall of the eye (the sclera). It is often associated with serious medical problems, usually auto-immune or vascular problems (rheumatoid arthritis, polyarteritis nodosa, lupus). In scleritis, symptoms of severe, "boring" eye pain occur. The white part of the eye may appear red, swollen, and there may be a nodule present which is painful to touch. Scleritis can be associated with iritis, and in some cases with swelling under the retina leading to visual loss. Treatment is usually with oral medication, and eye drop medication as needed. Treatment of the underlying medical problem may be necessary.

Other Conditions causing eye pain found in other sections:

Cellulitis (Infection) of Eyelid Skin - eyelid swelling, tenderness.

Cellulitis (Infection) of the Orbit - eye pain, protrusion, double vision, redness.

Corneal Problems - dry eye, corneal abrasion, corneal foreign body, and foreign body under the eyelid.

Dacryocystitis - infection of the tear drainage system leading to pain and tearing.

Ectropion (Out-Turning) of Eyelid - scratchy sensation, pain, tearing.

Entropion (In-Turning) of Eyelid - scratchy sensation, pain, tearing and discharge.

Headache - may be interpreted as eye pain.

Optic Neuritis - may lead to pain with eye movement.

Thyroid Related Eye Disease - scratchy sensation, double or blurred vision, protruding eyes.

Trichiasis (In-Turning of Eyelashes) - scratchy sensation, pain, tearing.

 

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Introduction: Blurred vision

Blurred vision can come about from any disturbance in the pathway of light from the front of the eye (the cornea) to the retina. Disorders of the optic nerves which transmit visual information to the brain can also be a source of blurred vision. A change in vision can be as simple as a need for glasses, but in some cases more complicated reasons for blurred vision can be present, and a complete eye examination may be necessary to determine the cause.

This page discusses causes of blurred vision that normally have very few other symptoms. Some of these conditions can cause more than just blurred vision, they may cause a loss of vision. Conditions which usually cause a more severe loss of vision are discussed on the Loss of Vision section. Many other eye problems can cause blurred vision along with numerous other symptoms. Links to these Symptom and Diagnosis pages based on these other symptoms are included as well.

Conditions Discussed in this Section:

Refractive Error (glasses change)

Cataract

Macular Degeneration

Macular Edema (swelling)

Central Serous Chorioretinopathy

Diabetes

Corneal Edema (swelling)

Keratoconus (a corneal degeneration)

Optic Neuritis

Optic Neuropathy

Other conditions causing blurred vision found in other sections:

 

For eye anatomy explanations, go to ANATOMY

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Refractive Error (glasses change)

 A need for glasses leads to blurred vision. With nearsightedness and astigmatism, the distance vision is blurry, but the near vision may be clear. Sometimes this blurring comes out more at night, and there may be the impression of double vision or ghost images. Farsightedness leads to blurry near vision, but the distance may be blurry as well. The need for reading glasses develops especially in the mid-forty's.

For more detailed information on the need for glasses and contact lenses, see the section on Optics.

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Cataract

Cataract is a common cause of blurred vision. Cataract occurs commonly in people over 50 years old, but may occur in younger people as well. Usually, with cataract there is a gradual blurring of vision. In some cases, cataract can lead to a change in glasses prescription. There are often other symptoms along with blurring with cataract, including glare problems, problems with night vision, and disturbances in color vision. Cataract does not cause pain or the sensation that something is in the eye. For more information on cataract, see the section Cataract.

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Macular Degeneration

Macular degeneration is a retinal disease that is a common cause of visual loss in the older population, and especially in Caucasians. With mild forms of macular degeneration there may be a blurring of the central vision. In more severe cases, the entire central visual area (for reading, etc.) may be gone. In some cases, distortion in the vision may precede a loss of vision. Distortion in the vision can be recognized when straight lines appear bent, or crooked. A person experiencing this symptom should seek evaluation by an ophthalmologist immediately. Usually, the term "macular degeneration" refers to "age-related macular degeneration", or a retinal disorder occurring primarily in the elderly. Similar conditions occur with ocular histoplasmosis and high degrees of nearsightedness (myopic macular degeneration).

For a more detailed discussion, go the section on Macular Degeneration.

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Macular Edema (swelling)

The "macula" is the central part of the retina that perceives our central, or reading, vision. A number of disorders can cause swelling, or edema, of this part of the retina. With macular edema, the vision is usually blurred. Things may appear washed out, and color vision may be reduced.

There may be some distortion of the vision as well. In the photos at the right, you can see the actual appearance of macular edema as well as schematics and early and late phase fluorescein angiograms that show the characteristics of macular edema.

Some conditions leading to macular edema include:

Diabetes - diabetic macular edema is a common problem in diabetes that can lead to permanent visual loss if it is left untreated. For more information on this, go to the section on Diabetic eye disease.

• Cystoid Macular Edema - this condition, abbreviated CME, is a cystic accumulation of fluid in the macula, which can lead to blurred vision. This occurs sometimes after eye surgery (especially cataract or glaucoma surgery). Sometimes it occurs with inflammatory conditions of the eye (iritis). In a few cases, it occurs spontaneously. Often, CME goes away on its own. An eye drop may help, and treating any underlying cause (if one can be found) may help as well. It can be a frustrating condition to treat.

Venous Obstruction Macular edema can occur with blockages of veins in the eye. If the main vein that drains the retinal blood circulation becomes blocked (central retinal vein occlusion), the macula may become severely swollen. There may be no effective treatment for this. If only a branch of a vein is blocked (branch retinal vein occlusion), the macula may also become swollen. This problem is treatable by laser, if the vision is sufficiently blurred to need treatment. Usually a generous time period is waited before treating this condition (months), since often it goes away on its own.

Central Serous Maculopathy - this condition is common in the younger population (30's to 50's), and can cause variable visual effects. This condition is a dome-like swelling of the retina due to a leakage of fluid from beneath the retina. Some people experience blurred vision, and some distorted vision. Some people describe a circular gray spot in their vision, and some people have disturbed color vision. This condition usually goes away spontaneously with little permanent loss of vision. Some times a laser surgery can help to speed the resolution. Many cases recur.

 

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Diabetes Mellitus

Aside from the diabetic effects on the retina, a sudden rise in the blood sugar can cause the lens in the eye to become swollen. This usually causes a sometimes severe shift in the glasses prescription toward farsightedness. Thus, a normally nearsighted person may see an improvement in their vision without glasses. However, a person not using glasses, or who is already farsighted, will see a worsening in prescription. Some people find that their distance vision is clearer when viewed through their bifocal! Once the blood sugar is controlled, the glasses prescription will revert back to normal over a period of weeks. Usually both eyes are affected at the same time. For more details, see the section on Diabetic Eye Disease.

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Corneal Edema (swelling)

Edema, or swelling, of the cornea occurs when the cornea is unable to keep itself clear, and fluid begins to accumulate within it. The inside lining of the cornea is responsible for keeping it clear, and if this layer is becomes damaged, symptoms of corneal edema may occur. When mild, corneal edema may cause fluctuating or occasionally blurred vision. This may be worst when first opening the eyes after sleeping. One may see rainbows around headlights or streetlights. When severe, corneal edema can substantially blur the vision. Occasionally blisters may form on the surface of the eye (bullae), which can rupture and cause pain, like a corneal abrasion.

Causes of corneal edema include:

·  A disorder of the inside layer of the cornea (Fuchs' endothelial dystrophy) can lead to progressively worsening corneal edema over years. This usually affects both eyes.

· Prior eye surgery, such as cataract surgery, can lead to temporary corneal edema. If the cornea was not healthy prior to surgery, an intraocular procedure can cause the cornea to fail, and severe edema can result. Certain types of lens implants (no longer used) are known to cause corneal edema and failure. If the vitreous gel within the eye is allowed to come forward into the front part of the eye (anterior chamber), it can cause corneal edema as well. Severe corneal edema resulting from these causes is often termed "bullous keratopathy".

·  Eye trauma can cause corneal damage and edema.

·  Acute Glaucoma, with very high eye pressure, can cause corneal edema as well as pain. Chronic glaucoma (much more common) usually does not cause this.

·  Contact lens Overuse can lead to corneal edema, and is a risk factor for infection.

Treatment of corneal edema sometimes depends on its cause. Mild edema can be treated with hypertonic eye drops and ointment (Muro 128, available over-the-counter). This draws fluid out of the cornea and into the tears, and helps to clear the cornea. More severe edema, especially with blister (bullae) formation, may require corneal transplant to correct. Sometimes a corneal transplant is combined with cataract extraction, a lens implant exchange, or removal of vitreous material, if these are also problems.

 

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Keratoconus

 

Keratoconus is a disease of the cornea where there is a progressive thinning and bulging of the cornea so that it eventually takes on a cone shape. This generally is not a visible change to the naked eye, but the distortion in the shape of the cornea leads to worsening astigmatism and blurring of vision. Both eyes are usually affected, although one may be much worse than the other. There is no known cause of the disorder, and there is no clear hereditary pattern in most cases. The condition usually stabilizes in early adulthood, although there may be further worsening possible. Both photos show keratoconus, but the right eye also shows corneal scarring.

There is no cure for the disorder, nor any means to stop its progression. However, the eye is generally otherwise healthy, and glasses (mild disease) and later contact lenses (more severe disease) can greatly improve the vision. In the presence of keratoconus, refractive surgery is contraindicated (not done). In cases where the vision cannot be improved with correction, or if contact lens use is not possible, a corneal transplant is an option. Corneal transplants are generally highly successful after keratoconus, although contact lenses may sometimes still be needed to fully correct the vision. Keratoconus does not recur in a transplant.

An unusual complication of keratoconus is "acute hydrops". When this happens the central cornea suddenly becomes swollen, and the vision becomes blurred and the eye may be painful. With medical treatment, the condition subsides over a period of a few weeks.

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Optic Neuritis

Optic neuritis is an inflammatory condition of the optic nerve. Usually one eye is involved at a time. The vision can become progressively more blurred over a period of hours or days. Sometimes, a blind spot erases the central vision. There may be pain with eye movement. After the vision reaches a low point, it usually gradually recovers over a period of weeks to months. There may be some residual blurred vision, blind spots, loss of color vision, or dimming of vision which persists. Treatment is controversial.

It is currently recommended to have an MRI of the head done with an episode of optic neuritis. This may demonstrate findings which could show risk for development of multiple sclerosis, in the non-pediatric age range. If these findings are found, high dose IV steroids given at the time of an episode of optic neuritis may not only speed the visual recovery, but also delay onset of MS. There are studies being done with other medications which may help as well.

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Optic Neuropathy

The optic nerve is subject to losing its blood supply, as is any part of the brain. In the brain, this is called a stroke, or Cerebrovascular Accident (CVA). In the optic nerve, this is called "ischemic optic neuropathy", or ION. Symptoms of this disorder, which usually occurs in the elderly, is a sudden, painless blurring or loss of vision in one eye. After the initial event, there may be some recovery of vision over a period of weeks. The visual loss can range from mild blurring of vision, to severe loss of vision. Color vision may be affected, and there may be blind spots in the peripheral (side) vision. Some people experience an entire loss of the upper or lower field of vision in one eye. There is an association of this disorder with vascular disease, and it is important to exclude one possible cause of ION, called Temporal Arteritis. Diagnosis and treatment of temporal arteritis may prevent loss of vision in the other eye. Otherwise, there is no effective treatment for ION, except treating any underlying medical problems.

A number of medications have been associated with the development of an optic neuropathy, leading to reduced visual acuity, blind spots in the peripheral vision, or reduced color vision. Some medications associated with an optic neuropathy include amiodarone, chlorpropamide, ethambutal, and isoniazide. Go to the section on Drugs and the Eye for more information about this. This section also discusses a nutritional optic neuropathy which can develop with alcohol and tobacco use.

Other Conditions causing blurred vision found in other sections:

Blepharitis - itching, burning, eyelid irritation. Can lead to corneal irritation and blurred vision.

Contact Lens Related Problems - vision may be related to lens condition, infection and allergy.

Corneal Abrasion - pain, tearing, sensation that something is in eye.

Corneal Ulcer - an infected cornea can sometimes cause blurred vision along with pain and redness.

Chalazion (Stye) - a stye can cause astigmatism pressing on the eye and blur the vision.

Conjunctivitis - vision sometimes blurs due to discharge or mucous.

Dry Eye - irritation, scratchy sensation, sometimes tearing and blurred vision.

Glaucoma (Acute) - pain, blurred vision, rainbows around lights.

Iritis - pain, sensitivity to light, blurred vision.

Orbital Cellulitis - infection of the orbit behind the eye can lead to blurred vision and pain.

Scleritis - pain, blurred vision, redness.

Temporal Arteritis - headache with blurring or loss of vision, usually in the elderly.

Thyroid Related Eye Disease - scratchy sensation, double or blurred vision, protruding eyes.

Uveitis - inflammation within the eye can lead to floaters, pain, and blurred vision.

Vitreous Hemorrhage - bleeding into the vitreous jell of the eye can cause blurred vision, or loss of vision.

 

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Introduction: Loss of vision

A loss of vision can be a frightening experience, and all people with a sudden loss of vision should be seen by an ophthalmologist as an emergency. Here, loss of vision refers to a severe blurring of the vision in one or both eyes often to the point that almost no detail can be made out. There may be large blind spots in the vision, or the appearance that something is blocking the vision. With these symptoms, there is almost always a cause for the visual loss other than a simple change in glasses.

Many things that cause blurred vision can also cause a loss of vision, if the condition is severe enough. These conditions are discussed in the Blurred Vision section. Many other eye problems can cause a loss of vision along with other symptoms. Links to Symptom and Diagnosis pages based on these other symptoms are included as well.

Conditions Discussed in this Section:

Amaurosis Fugax

Retinal Artery Occlusion

Retinal Vein Occlusion

Stroke (Cerebrovascular Accident or CVA

Macular Hole

Retinal Detachment

Vitreous Hemorrhage

Other conditions causing loss of vision found in other sections:

 

For eye anatomy explanations, go to ANATOMY

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Amaurosis Fugax

Amaurosis fugax refers to a temporary black-out of vision. This is usually affects one eye, is painless, and is often described like a "shade coming down over the vision" of that eye. The black-out may last minutes, and then the vision returns. The problem can recur in the future, and could affect either eye. Most commonly, this happens in older people with arteriosclerosis and possibly vascular disease, and is due to small clots breaking off of the walls of arteries and then lodging in the vessels of the eye. The clot obstructs the blood flow to the retina, and the vision blacks-out.

When the clot breaks up, the blood flow returns, as does the vision. The source of the clot (or embolus) is usually from the carotid arteries leading up the neck to the brain, or from the heart. The embolus may be a cholesterol crystal, a calcium deposit, or a true blood clot. This problem falls into the same category as "transient ischemic attacks" (or TIA's), which may herald a stroke. Vascular evaluation and possibly anticoagulation (use of blood thinners) is indicated for this problem.

Other problems which cause a temporary loss of vision include:

 

Obstruction of the vertebral arteries, which course up the back of the neck and supply the visual part of  the brain. People which this problem may notice temporary dimming of vision affecting both eyes, and possibly imbalance.

Increased intra-cranial pressure (the pressure of the fluid around the brain) can cause momentary lapses of vision especially when moving, such as standing from a sitting position. Sometimes even eye movements are enough to induce a temporary loss of vision.

Retinal migraine is a spasm of the artery leading into the eye which supplies the retina. This spasm can lead to a temporary black-out of vision on one side, and is fairly rare. 

 

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Retinal Artery Occlusion

 

If a clot (embolus) breaks free from the wall of a blood vessel leading up the neck or to the eye, it can lodge in the retinal arteries causing an obstruction of blood flow to the eye, and a loss of vision. In some cases, the clot will rapidly dislodge, and the vision will return (Amaurosis Fugax, discussed above). However, if the clot is large and does not dislodge, the vision remains blacked-out. Usually this is painless, and the loss of vision is severe. If the blood flow to the retina is interrupted for more than 1 1/2 hours (approximately), the vision may not return even if the clot breaks free and the circulation is restored. This condition may indicate risk for cardiac disease, and stroke. You can see the central retinal pallor and the reddish fovea in the photo at the right (the latter is also known as a "cherry red spot").

If a person with this condition rapidly seeks the medical help by an ophthalmologist, things may be able to be done to dislodge the clot before permanent damage occurs. No ophthalmologist will turn a patient away with this condition.

 

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Retinal Vein Occlusion

The retinal blood circulation is drained by a single vein, called the central retinal vein. If this vein becomes obstructed, various problems can occur in the eye, depending on the severity of the obstruction. A person with this condition will notice blurring of vision, dimming of vision, and possibly blind spots and floaters in the vision. It usually starts fairly suddenly, but the vision may worsen over a period of time (hours to days). Rarely does this happen in both eyes at the same time. The problem is usually caused by underlying vascular disease, and sometimes abnormal clotting or blood thickness. It is not caused by clots breaking off of arteries, like an artery obstruction is. The photo on the left is a branch retinal vein occlusion while the photo on the right is a central retinal vein occlusion.

There is no effective treatment to reverse the blockage of the vein, except to treat any underlying medical condition (diabetes, hypertension, increased cholesterol, etc.), and hope that the vein opens back up on its own. About 1/3 of cases will completely resolve with little damage to the vision. About 1/3 stay the same with some loss of vision, and 1/3 of cases worsen and develop more severe loss of vision. The worst cases may need to be treated by a laser to prevent a dangerous form of glaucoma (neovascular glaucoma), but the laser treatment will not help the vision. Studies are being done to evaluate possible medication or laser treatments which may help people with this condition. (For a related topic, see Macular Edema.)

 

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Stroke (Cerebrovascular Accident or CVA)

 

A stroke is an obstruction of blood flow leading to a part of the brain. If the part of the brain affected serves the vision, there may be a loss of vision with the stroke. If a small area of brain is affected, there may be a blind spot in the vision corresponding to that area. However, with more substantial stroke, an entire side of vision can be lost. The visual part of the brain has a left and right side. The left side serves the right half of the vision from both eyes, and right side serves the left half. Thus if there is a stroke of one side of the brain, the person may lose the corresponding half of vision of both eyes. Most people notice this more from the eye that lost the outside field of vision. For example, a stroke of the left side of the brain would cause the right half of vision to be lost from both eyes. This would be the inside half of vision of the left eye, and the outside half of vision of the right eye.

Strokes affecting the visual part of the brain are treated as any stroke of the brain, and usually the problem is evaluated by internal medicine physicians, or neurologists. 

 

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Macular Hole

 

Some people develop a degeneration of the part of the retina that serves the central vision (reading vision), which is called the macula. Unlike macular degeneration, where there is gradual deterioration of the macula possibly associated with hemorrhage under the retina, a macular hole is a sharply outlined loss of retina in the center of the macula. It is not fully understood why this happens. There may be some risk for the second eye being affected as well. Usually there is a fairly severe loss of reading vision (central vision), with a blind spot appearing centrally. The peripheral vision remains normal. There is a surgical procedure which may help some macular holes to fill back in, with some return of vision.

 

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Retinal Detachment

A retinal detachment occurs when fluid in the eye gets behind the retina, and lifts it off of the wall of the eye on the inside. Normally the fluid in the eye has no way to get under the retina, but if a tear in the retina occurs, a detachment could follow. A retinal detachment is usually perceived as a dark area encroaching on, or covering, the central vision from the outside. The symptoms may seem to occur suddenly, or may worsen over a short period of time. A retinal detachment including the macula (the central visual part of the retina) will cause a substantial loss of vision. Retinal detachments can be repaired surgically with usually good results, depending on the severity of the detachment, how long it has been present, and if the macula is involved or not.

People who are highly nearsighted may be at increased risk for retinal detachment, as are people who have had eye trauma. There are certain conditions of the retina which lead to detachment in the future, and sometimes these are treated prophylactically. The most common of these is a retinal tear, and symptoms of retina tear usually precede a detachment (floaters and flashing lights). A person with these symptoms should be examined promptly by an ophthalmologist. (See Retinal Tear for more information.)

 

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Vitreous Hemorrhage

Bleeding into the eye can cause substantial loss of vision, since the blood clot obstructs light images from reaching the retina. The main cavity of the eye is filled with a gel-like substance called vitreous, and bleeding into this is a "vitreous hemorrhage". Blood becomes trapped in this gel, and does not immediately sink to the bottom of the eye or dissolve. Thus, symptoms usually include seeing floaters or spots in the vision which increase with time (and possibly flashing lights). With more severe hemorrhages, a dark, reddish blob which seems to move, may cover the vision. Most vitreous hemorrhages will resolve spontaneously with time, although some need to be removed surgically. The most important thing is determining the cause of the hemorrhage.

The bleeding can occur with the following conditions, some of which are discussed elsewhere:

 

Retinal Tears

Vitreous Detachment - a separation of the gel-like vitreous from the retina inside the eye.

Diabetes - as a complication of vascular growth within the eye.

Macular Degeneration - with a severe hemorrhage under the macula breaking through the

  retina, and bleeding into the vitreous.

Retinal Vein Obstruction - with bleeding from abnormal blood vessels growing in response

  to the vein obstruction

Sickle-Cell Disease - this blood disorder can cause retinal vascular problems which may lead to vitreous hemorrhage. See the abnormal vascular sea-fan in the photo to the right.

Valsalva related vitreous hemorrhage - severe straining with coughing, emesis, and holding your breath can raise the venous pressure around the eye high enough to cause a vitreous hemorrhage. This can also occur with trauma.

 

Other Conditions causing a loss of vision found in other sections:

Cataract - a severe cataract can cause more than just blurred vision. Some cataracts cause a loss of vision under glare circumstances.

Corneal Abrasion - A centrally located abrasion can cause a loss of vision. Others symptoms are pain, tearing, redness, and a sensation that something is in eye.

Corneal Ulcer - an infected cornea can sometimes cause a loss of vision along with pain and redness.

Glaucoma (Acute) - pain, blurred vision, rainbows around lights. Severe chronic glaucoma can also cause a loss of vision over time.

Iritis- pain, sensitivity to light, blurred vision or a loss of vision.

Macular Degeneration - severe macular degeneration leaves a scar or hemorrhage in the retina, causing a loss of vision.

Optic Neuritis - this can cause sudden blurred or lost vision, and sometimes pain on eye movement.

Orbital Cellulitis (Infection) - infection of the orbit behind the eye can lead to blurred or double vision, pain, and eye protrusion.

Scleritis - pain, blurred vision, redness.

Temporal Arteritis - headache with blurring or loss of vision, usually in the elderly.

Thyroid Related Eye Disease - scratchy sensation, double or blurred vision, protruding eyes.

Uveitis - inflammation within the eye can lead to floaters, pain, and blurred vision. Severe inflammation can cause a loss of vision due to retinal swelling and inflammatory debris within the eye.

 

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Introduction: Floaters, Flashing lights, Rainbows,
Abnormal Color Vision, Distorted Vision

This section discusses unusual visual phenomenon such as floaters and different types of flashing lights. Other visual abnormalities such as seeing rainbows around lights, abnormal color vision, and distorted vision are discussed as well

The first grouping of abnormalities give symptoms of floaters or flashing lights. Separate sections on Rainbows, Abnormal Color Vision, Distorted Vision, and Tunnel Vision follow.

Conditions Discussed in this Section:

Floaters and Flashing Lights

Vitreous Detachment

Retinal Tear

Uveitis (inflammation in the eye)

Entopic Phenomenon

Eales' Disease

Ophthalmic Migraine

Rainbow Vision

Abnormal Color Vision

Distorted Vision

Tunnel Vision

Retinitis Pigmentosa

 

For eye anatomy explanations, go to ANATOMY

 

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Floaters and Flashing Lights

Vitreous Detachment

 

The vitreous is a gel-like fluid which fills most of the eye. As people age, this vitreous becomes more and more liquefied. The vitreous has loose attachments to the retina, and more firm attachments to the optic nerve. At some point in a person's life, the vitreous liquefies enough to shift position in the eye. When this occurs, usually between age 50 and 70, the back edge of the vitreous will pull forward away from the retina, leading to a "vitreous detachment". This is generally a normal process, although it may happen abnormally early in cases of high nearsightedness or trauma. As the vitreous detaches, it tugs on the retina. This is perceived as a flash of light, similar to a lightning flash in the corner of the vision. It may occur especially with eye movement, since the vitreous moves in the eye. Debris pulled off of the optic nerve and retina are then seen as floaters, suspended in the vitreous above the retina. Sometimes this is described as a cobweb, a net, a string, or a fly over the vision.

These symptoms usually resolve over a period of days to weeks, although some people will continue to see the floaters for a longer period of time. The important thing is to determine that the retina is healthy as the vitreous detaches. This requires a careful dilated examination of the retina to look for tears, or other areas which may be at risk for tearing. A retinal tear can then lead to retinal detachment, if not treated. Thus, people experiencing these symptoms should be examined by an ophthalmologist as soon as possible. (Note, only about 1 in 10,000 cases of vitreous detachment lead to retinal detachment, but it still is one of the most common causes of retinal detachment.) 

 

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Retinal Tear

 

A tear in the retina can occur with vitreous detachment (see discussion above), with trauma or eye injury, or in areas at risk for a retinal tear, such as "lattice degeneration". The symptoms of a retinal tear usually are of a flash of light in the peripheral vision followed by floaters. The floaters may be debris, but may also be blood, if the tear extends through a retinal blood vessel.

Symptomatic retinal tears should be treated by laser to prevent retinal detachment. Sometimes a retinal tear is discovered incidentally as part of an eye examination. These usually need to be treated prophylactically.

 

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Uveitis

 

Uveitis refers to a large group of disorders which cause inflammation within the eye. A similar condition, iritis, usually refers to an inflammation involving the front structures of the eye associated with pain, redness, and sensitivity to light. In this discussion, uveitis could have these symptoms, but mainly consists of inflammation involving the back structures of the eye (the retina, choroid, and optic nerve). Inflammatory debris liberated into the vitreous leads to the visualization of floaters. If this liberation continues, the vision may become substantially hazy and blurred.

There are numerous conditions leading to uveitis, and many have floaters and blurred vision as predominant symptoms: sarcoidosis, toxoplasmosis chorioretinitis, ocular histoplasmosis, multifocal choroiditis, pars planitis, endophthalmitis, syphilis, candidiasis, viral uveitis, Vogt-Koyanagi-Harada syndrome, and HIV related uveitis.

 

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Eales' Disease

Eales' Disease is a rare disorder primarily affecting young adult males in their 30's to 50's. 80% of those affected are male, and usually both eyes are affected. There is no known cause for the disease, and no known association with any medical disorder (although one study noted balance dysfunction and hearing loss in 24% of patients).

In Eales' Disease, there is inflammation of the retinal vessels, where there is visible sheathing of the vessels and inflammation of the vessels. This can lead to obstruction of the vessels, hemorrhages into the retina and vitreous, and occasionally retinal detachment (in severe cases). There may be no symptoms of this disease, or one may see floaters, or develop a loss of vision if vitreous hemorrhage or retinal detachment occur.

Treatment is usually aimed at eliminating the risk of hemorrhage through retinal laser treatments. Oral anti-inflammatory agents may also be helpful. 

 

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Entopic Phenomenon

The entopic phenomenon is a normal phenomenon that some people may become suddenly aware of. This sudden awareness may lead to the idea that there is a problem with the eyes, when actually there is not. The entopic phenomenon can be seen especially when looking at a bright blue sky. Small, rapid pin-point sparks of light can be seen darting about in the central vision. Some people may think that these sparks are floaters. In reality, they represent white blood cells moving through the blood capillaries of the retina. This is a normal finding, and actually may indicate normal retinal function.

 

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Other Visual Phenomena

Ophthalmic Migraine

 

Migraine headaches may be preceded by a visual "aura", lasting for 20 to 30 minutes, and then may or may not proceed to the headache.

What does an ocular migraine aura look like?

These phrases sum up some of the many visual perceptions migraine sufferers may experience.

lightning bolts like jagged “Z” patterns – most common
psychedelic patterns of bright colors
sparkling zigzag lines that rotate
random patterns of curved and straight lines
spider webs in front of the eyes
lattice work, grids, or mini-blinds in front of the eyes
a spiraling tunnel
kaleidoscopes of changing colors and patterns
objects seeming to be larger, smaller, nearer, or farther away
objects seeming to be tilted
double vision – seeing two of everything
stationary objects appearing to move
heat waves or rain falling
picket fences or shooting stars

Some people, however, experience the aura but do not have a headache. This visual aura can be very dramatic. Classically, a small blind spot appears in the central vision with a shimmering, zig-zag light inside of it. This enlarges, and moves to one side or the other of the vision, over a 20 to 30 minute period. When it is large, this crescent shaped blind spot containing this brightly flashing light can be difficult to ignore, and some people fear that they are having a stroke. In reality, it is generally a harmless phenomenon, except in people who subsequently get the headache of migraine. Since migraine originates in the brain, the visual effect typically involves the same side of vision in each eye, although it may seem more prominent in one eye or the other.

Some people get different variations of this phenomenon, with the central vision being involved, or with the visual effect similar to "heat rising off of a car". Some people describe a "kaleidoscope" effect, with pieces of the vision being missing. All of these variations are consistent with ophthalmic migraine. Please also see the Simulations page and Migraine Headache.

 

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Rainbow Vision

 

Seeing rainbows around lights, especially at night, usually indicates swelling of the cornea. This may occur from a variety of causes which are discussed under Corneal Edema. Cataract can sometimes cause this also.

 

Abnormal Color Vision

Color vision is perceived mainly by the macula, which is the central vision portion of the retina. Thus any disorder affecting the macula may cause a disturbance in color vision. However, about 8% of males and 0.5% of females have some version of "color blindness" from birth. Usually this is an genetically inherited trait, and is of the "red-green confusion" variety. The reds, browns, olives, and golds may be confused.

Purple may be confused with blue, and pastel pinks, oranges, yellows, and greens look similar. Usually both eyes are affected equally.

There are many obscure macular retinal disorders that can lead to a loss of color vision, and many of these syndromes are inherited as well. There may also be a problem with a generalized loss of vision with these problems as well. Other retinal problems can lead to a temporary disturbance of color vision, such as Central Serous Chorioretinopathy,Macular Edema of different causes, and Macular Degeneration.

Certain types of cataract can gradually affect the color vision, but this is usually not noticed until one cataract is removed. The cataract seems to filter out the color blue, and everything seems more blue after cataract extraction. Optic nerve disorders such as Optic Neuritis can greatly affect color vision, with colors seeming washed out during or after an episode.

 

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Distorted Vision

Distortion of vision refers to straight lines not appearing straight, but instead bent, crooked, or wavy. Usually this is caused by distortion of the retina itself. This distortion can herald a loss of vision in macular degeneration, so anyone with distorted vision should seek medical attention by an ophthalmologist promptly. Other conditions leading to swelling of the retina can cause this distortion, such as Macular edema and Central Serous Chorioretinopathy.

An "Amsler grid" (see the Resources Page Self-Testing Vision section) can be supplied by an ophthalmologist so that the vision can be monitored for distortion in people who may be predisposed to this problem. 

 

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Tunnel Vision

"Tunnel vision" implies that the peripheral vision, or side vision, is lost, while the central vision remains. Thus, the vision is like looking through a tunnel, or through a paper towel roll. Some disorders that can cause this include:

Glaucoma - severe glaucoma can result in loss of nearly all of the peripheral vision, with a small "island" of central vision remaining. Sometimes even this island of vision can be lost as well. Please also seeGlaucoma.

 

Retinitis Pigmentosa - This is usually a hereditary disorder which can be part of numerous syndromes. It is more common in males. The peripheral retina develops pigmentary deposits (see photo at right), and the peripheral vision gradually becomes worse and worse. The central vision can be affected eventually as well. People with this problem may have trouble getting around in the dark. Cataract can be a complication as well. There is no known treatment for this disorder, and supplements of Vitamin A have not been proven to help.

Stroke - a stroke involving both sides of the visual part of the brain may wipe out nearly all of the peripheral vision. Fortunately, this is a very rare occurrence.

 

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Introduction: Ocular burning and itching

Symptoms of ocular itching and burning are very common. The eye is susceptible to allergies and irritations due to the fact that it is a moist surface constantly in contact with the air, and all of its pollutants. Furthermore, bacteria thrive on moist surfaces, and can cause substantial irritation as well. Some of these bacteria related conditions can progress beyond simple itching, and can lead to a scratchy sensation or even pain. Other conditions capable of causing eye itching and burning that are discussed on other pages of this Symptom and Diagnosis section are listed below with possible distinguishing features.

Conditions Discussed in this Section:

Blepharitis

Ocular allergy

Phlyctenulosis

Other Conditions causing ocular itching and burning found in other sections:

 

For eye anatomy explanations, go to ANATOMY

 

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Blepharitis

Blepharitis is a non-specific term signifying infection or inflammation of the eyelids. It is a extremely common cause of ocular redness, itching, burning, and generalized irritation. Other symptoms include discharge (especially in the mornings), a scratchy sensation, tearing, and temporary blurred vision. The condition tends to involve both eyes. The third photo shows angular blepharitis..

Blepharitis occurs when bacteria begin to excessively grow at the edge of the eyelid. This is a moist surface with plenty substances for bacteria to thrive on, including exfoliated skin and oil secretions. People tend to avoid cleaning near the eye, further aggravating this problem. Bacteria at the edge of the lids create irritating toxins which irritate the eye, and the glands of the eyelids themselves can become infected.

There are about 30 glands which open at the edge of each eyelid, and these are oil producing glands. Some people have a dysfunction of these glands where the secretion is abnormally thick and becomes trapped in the gland. This creates further irritation and can lead to stye formation. People with the skin condition known as "rosacea" tend to have blepharitis and dysfunction of these oil glands.

Treatment of blepharitis involves foremost cleaning of the eyelids. Warm compress can be used to help loosen up debris. There are commercially available kits for eyelid cleansing ("Eyescrub", "Occu-cleanse") which also contain a mild soapy solution and small gauze pads. Some physicians recommend using diluted baby shampoo to clean the eyelid, although this can cause irritation in some people, and care has to be taken not to get soap in the eyes. Artificial tears during the day may help to relieve irritation. Antibiotic ointment can be used on the lids at bedtime to reduce the bacterial load. Sometimes antibiotics my mouth are needed. This condition tends to have relapses, but continued efforts at eyelid cleaning may help to prevent problems. 

 

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Ocular allergy

 

The eyes are commonly affected by allergy, due to their constant contact with the air. Symptoms include itching, redness, lid itching and swelling, mucoid discharge, and eyelid matting in the mornings. Acute allergic conjunctival swelling is called chemosis (see photo at right). There may be an association with hay fever or pollen allergies, with nasal congestion, itching, and running. Oral antihistamines can often relieve ocular symptoms as well. Over-the-counter allergy eye drops can be effective, although eye drops which are purely decongestants simply blanche out blood vessels on the surface of the eye. Prescription eye antihistamines may be more effective. Three eye drop medications (Crolom, Alomide, and Patanol) block the release of histamine in the first place, but take some time to become effective. Cold compresses on the eyes may help to ease symptoms.

The eyes can commonly develop allergies to make-up applied on or near the lids. Any change in eye make-up followed by allergy symptoms may point to this as a cause. Some medications taken by mouth can cause an allergic reaction first seen around the eyes, with swelling and redness of the lids and skin around the eyes. Some eye medications, antibiotics, and glaucoma eye drops can cause allergic reactions as well, some very commonly.

Some younger people can develop a variant of ocular allergy called "vernal conjunctivitis". This tends to be seasonal, and large lumps develop under the eyelids and can create severe symptoms of itching, lid swelling and droopiness, and discharge. A similar syndrome occurs with contact lens use (see Contact Lens for more information about this).

 

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Phlyctenulosis

 

Phlyctenulosis (flick-ten-u-low-sis) is a blepharitis related complication of the cornea and conjunctiva. Bacteria at the edge of the eyelids (blepharitis) liberate toxins which get into the tears and irritate the eyes. In this complication, a hypersensitivity reaction, or allergic reaction develops on the cornea or conjunctiva.

Symptoms include ocular redness, itching, burning, tearing, and the sensation that something is in the eye, especially with blinking. Sometimes a white spot can be seen near the edge of the cornea. This spot represents a sterile (non-infected) breakdown of the corneal surface, and can be very irritating.

Treatment is aimed at treating the underlying blepharitis, and at helping the cornea to heal. This condition is very responsive to steroid eye medication. Preventive measures include cleaning of the eyelid in order to prevent the hypersensitivity reaction.

 

Other Conditions causing ocular itching and burning found in other sections:

Conjunctivitis- redness, discharge, lid swelling.

Contact Lens Problems- contact lens use can cause itching and irritation, due to allergy soaking solutions.

Episcleritis- localized eye injection with mild to moderate symptoms.

Medication toxicity- ocular irritation related to eye drop usage.

 

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Introduction: Tearing and discharge

Tearing can be caused by two basic mechanisms: overproduction of tears, and a blockage of tear drainage away from the eye. Sometimes a combination of the two can coexist. The tears are produced by numerous glands present on the insides of the eyelids. Tears drain away from the eye through two small openings (lacrimal puncta) present at the edge of the eyelid near the inside corner (upper and lower lids). When the eyelids blink, tears are milked into these openings, and drain through narrow tubes to a sac under the skin at the inside corner of the eye (lacrimal sac). Tears then drain into the nasal cavity.

Two conditions leading to obstruction of this tear drainage system are discussed here. Other conditions capable of causing tearing and discharge that are discussed on other pages of this Symptom and Diagnosis section are listed below with possible distinguishing features.

 

Conditions Discussed in this Section:

Obstructed tear drainage system

Dacryocystitis

Other conditions causing tearing and discharge found in other sections:

 

For eye anatomy explanations, go to ANATOMY

 

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Obstructed tear drainage system

 

Blockage of the tear drainage system is a common cause of painless and spontaneous tearing. The affected eye or eyes have to be frequently wiped throughout the day as the tears drain onto the skin. Often the skin itself becomes irritated and red from the wiping. Sometimes the tears can drain out at very inappropriate times during social encounters. 

Why obstruction of the tear drainage system occurs is not well understood. There can be an association with sinus problems, and low grade infection of the system can lead to scarring and blockage. Some people have a problem with the eyelid not being flush against the eye (ectropion of the eyelid), and tears thus have no way to enter the lacrimal puncta to drain away. Certain medications can lead to scarring to the tear drainage symptoms. Rarely, tumor can obstruct the system.

Treatment is aimed at establishing a diagnosis and a probable cause for the obstruction. Fluid irrigation of the system using a smooth tube can help to determine exactly where the system is blocked. Sometimes the nasal cavity needs to be examined to see if any blockage is present there. In some cases the use of steroid-antibiotic eye drops with oral decongestants may help to open the system and relieve the tearing. Warm compresses applied to the inside corner of the eye may help as well. In cases where nothing seems to work, surgery can create a new opening for tears to drain into the nasal cavity. 

 

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Dacryocystitis

 

Dacryocystitis (dak-reo-sis-stitis) is an infection of the lacrimal sac, or the sac into which tears drain from the eyes. Usually this appears as a painful, tender swelling present at the inside corner of the eye under the skin. There may be redness which can even extend onto the cheek. Tearing and discharge occur since tears have no way to drain beyond the infected sac. Treatment is by oral and eye drop antibiotics. After a severe or recurrent infection, surgery may need to be done to create a new opening for tears to drain into the nasal cavity, preventing further infections.

 

Other Conditions causing tearing and discharge found in other sections:

Conjunctivitis - redness, discharge, lid swelling.

Corneal Conditions - corneal irritation (dry eye, corneal abrasion, inturned eyelashes, corneal foreign body, etc.) can lead to tearing with foreign body sensation or pain.

Ectropion (Out-Turning) of Eyelid - tearing due to eye drying and improper position of tear duct.

Entropion (In-Turning) of Eyelid - eye irritation, redness, discharge.

Cluster Headache - tearing, nasal congestion usually on side of headache.

 

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Introduction: "Foreign body sensation"

The sensation that something is in the eye commonly brings people to the ophthalmologist. This is referred to as a "foreign body sensation", as if a foreign object were scratching the eye. Usually this sensation originates from the cornea, which is the clear part of the eye through which we see. The cornea has a large number of nerve fibers that are normally covered by a lining. If this lining is breached, the sensation that something is in the eye results, whether or not anything is actually there.

Any condition which can cause a scratch on the cornea can lead to this symptom. Some causes are detailed on this page. There are also links to other Symptom and Diagnosis pages based on other symptoms in addition to the foreign body sensation.

 

Conditions Discussed in this Section:

Dry Eye

Corneal Abrasion - scratched eye

Inturned Eyelash - Trichiasis

Corneal Foreign Body

Foreign Body Under Eyelid

Recurrent Corneal Erosion

Other conditions causing the sensation that something is in eye eye found in other sections:

 

For eye anatomy explanations, go to ANATOMY

 

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Dry Eye

 

"Dry eye" is a common ocular problem, as is evidenced by the large number of artificial tear preparations available over-the-counter. There may be a tendency for tear production to decrease with aging, and dry eye problems may be associated with certain arthritis syndromes, such as Sjogren's syndrome and rheumatoid arthritis. However, many people can develop a problem with ocular dryness with no apparent underlying cause.

Symptoms of dry eye include a sensation of dryness or grittiness, foreign body sensation, burning, redness, and generalized eye fatigue. The vision may blur or fluctuate. The eyes may seem sensitive to changes in temperature and to wind. Paradoxically, tearing may be a symptom of ocular dryness. Tearing can occur because the glands that produce tears in large quantities are not usually involved much in the minute to minute lubrication of the eyes. If the eye reach a certain level of dryness, this large tear gland becomes activated and produces excessive tears.

Symptoms of dry eye can have other causes than just reduced tear production. Oil producing glands in the eyelids provide a layer of oil on the surface of the eye which helps to prevent tears from evaporating. If this oil layer is deficient, as in certain types of blepharitis, the eyes can become dry much too quickly. Similarly, mucous helps to lubricate the eye, and if this is deficient, dry eye symptoms can result. Oral antihistamines may dry the eyes in this way. The ophthalmologist can determine the principle cause of the dryness symptoms, and direct therapy in the right direction.

Supplemental lubrication of the eye is the main treatment for dry eye. There are numerous artificial tears available. Generally, preservative free eye drops are recommended in people who have to use eye drops frequently and on a daily basis. Some preparations, such as Celluvisc and Refresh Liquigel, are thicker than most other artificial tears, and may provide more long lasting relief in some cases. Lubricant ointments are also available (such as Refresh, GenTeal or Systane P.M.). These are generally used at bedtime (since the vision is extremely blurred for a period of time after their use), but may give substantial relief.

Newer over the counter options for dry eye include Systane, which improves the ability of natural tears or other artificial tears to remain on the ocular surface, and Soothe, which reduces the evaporation of tears from the eye.

Other options for treating dry eye include treating any other problems, such as blepharitis. Sometimes oral antibiotics may help. In severe cases, occlusion of the tear drainage system may help the tears to stay longer on the eye itself. Restasis is prescription eye drop which has been found to improve tear production when used over a period of weeks to months.

Often the treatment of dry eye requires a combination of different types of eye drops to promote healing of the ocular surface and to maintain lubrication.

 

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Corneal Abrasion (scratched eye)

 

A corneal abrasion is a break in the surface layer of the cornea, which is the clear part of the eye through which we see. This usually follows obvious trauma, although an abrasion may occur from other causes, such as an inturned eyelash or from an eyelid infection (blepharitis) 

Symptoms include pain, redness, tearing, sensitivity to light, and blurred vision. The "foreign body" sensation can be severe, and often people describe symptoms of a "rock were rolling around under the eyelid". What is actually being felt is this extremely sensitive exposed part of the cornea touching the inside of the lid as the eye blinks.

Diagnosis and treatment should be made by an ophthalmologist. If trauma is involved, the eye must be thoroughly examined to rule out and other injury. Treatment is usually by patching of the eye with antibiotic ointment, or frequent use of antibiotic ointment or lubricating medication 

There is risk of infection (corneal ulcer) and internal ocular inflammation (iritis) with this condition. Fortunately, under good circumstances, the cornea can heal rapidly, sometimes even overnight. 

 

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Inturned Eyelash (Trichiasis)

 

Trichiasis refers to misdirected eyelashes, where they point backwards and irritate the eye surface. Symptoms are usually of a foreign body sensation, but more severe symptoms of redness, pain, tearing, and light sensitivity are not uncommon. Treatment is by removing the offending eyelash (epilation), and by providing protective treatment for any corneal injury which may have occurred. With recurrent inturned eyelashes, electrolysis may permanently remove the eyelash, although more than one treatment may be necessary.

 

Corneal foreign body

 

A foreign object can lodge itself onto the cornea and cause significant symptoms of pain, tearing, light sensitivity, and blurred vision. Except in cases of obvious trauma where debris strikes the eyes, the most common corneal foreign body is a rusted metallic particle. Small shards of metal seem to have an almost magnetic attraction to the corneal surface, where they rapidly rust and become embedded. The use of safety goggles with any type of drilling, hammering, etc. can be preventative. As the rusted particle sits on the cornea, the eye becomes progressively more irritated over a period of days with redness, pain, light sensitivity, and tearing. Often the particle is visible on the eye, but it may be nearly microscopic. The ophthalmologist has the equipment necessary in the office to remove these foreign bodies. Usually a scar remains, and there is risk of infection.

 

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Foreign body under eyelid

 

Debris which gets into the eyes can become trapped under the upper eyelid. This will lead to worsening symptoms of foreign body sensation, pain, tearing, and redness. The debris can be nearly anything, and plant material (wood) is not uncommon. A large foreign body under the lid rapidly becomes intolerable, with a corneal scratch occurring every time the eye blinks. Obviously, removal of the foreign body is curative.

 

Recurrent Corneal Erosion

 

After the cornea is scratched, it can heal superficially very rapidly to cover the defect. However, a longer period of time (months) is required for this area of healing to become firmly bonded in place. In some people, an area of corneal injury may be permanently weakened. In this situation, minimal trauma to the eye may be enough to cause this area of weakening to slough off, leading to a corneal abrasion again. This "minimal trauma" can include things as simple as eye rubbing or the eye opening for the first time in the morning.

This second situation is the most common. Typically, people with a recurrent corneal erosion problem experience ocular pain upon awakening. The eye may tear and have foreign body sensation. The corneal defect rapidly heals over in most cases, and the symptoms resolve in minutes to hours. However, the process may repeat itself the next morning. Some people may have an underlying weakness of the cornea (map-dot-fingerprint dystrophy), and can develop these symptoms with no history of trauma in the past.

Treatment is first to diagnose the problem, and then initially to try using lubricating ointments on the eye at bedtime. Sometimes these have to be used for weeks to months. Commonly used lubricants include Refresh P.M. and Muro 128. These lubricants help to prevent the eyelid from pulling open the corneal scratch upon awakening in the morning. In cases where the problem continues in spite of treatment, there are procedures which can be done in the ophthalmologist's office to reinforce the weakened area.

 

Other Conditions causing the sensation that something is in the eye found in other sections:leads t

Blepharitis - itching, burning, eyelid irritation.

Conjunctivitis - eye redness, itching, discharge.

Contact Lens Related Problems - may have pain, scratchy sensation, redness, lens intolerance.

Ectropion (Out-Turning) of Eyelid - scratchy sensation, pain, tearing.

Entropion (In-Turning) of Eyelid - scratchy sensation, pain, tearing and discharge.

Eye Medication Toxicity - corneal irritation from eyedrops can lead to scratchiness.

Phlyctenulosis - sensation that something is in eye, burning, itching, blepharitis.

Pterygium - a growth on the surface of the eye, often with redness.

Ocular Cicatricial Phemphigoid - an autoimmune disorder that leads to conjunctival scarring and dry eye symptoms.

 

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Introduction: Eyelid Problems

 

The eyelids have many functions, including protecting and lubricating the eye, producing oil secretions for the eye, and helping to drain away tears. This page includes a variety of eyelid problems ranging from lumps and bumps of the eyelid to twitching of the lid. Eyelid malpositions (in-turning and out-turning) and drooping eyelids (ptosis) are discussed as well.

Other eyelid related problems that are discussed on other pages of this Symptom and Diagnosis section are listed below with possible distinguishing features.

 

Conditions Discussed in this Section:

Chalazion (Stye)

Eyelid Cellulitis (Infection)

Eyelid Ectropion (Out Turning)

Eyelid Entropion (In-Turning)

Eyelid Tumor

Eyelid Twitching

Eyelid Drooping (Ptosis)

Other conditions causing Eyelid Problems found on other pages:

 

For eye anatomy explanations, go to ANATOMY

 

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Chalazion (Stye)

 

A chalazion, or stye, appears as a well defined lump within the eyelid. The upper and lower eyelids each contain about 30 oil secreting glands that open at the edge of the lid, and travel deep within the tarsal plate of the eyelid. If one or more of these glands becomes blocked, the gland continues to make the secretion, but this is trapped within the lid and eventually forms a rounded lump within the lid. There may be mild soreness initially since the trapped material creates some inflammation in the eyelid. The swelling may protrude toward the eye, toward the outside and appear to be just under the skin, or protrude at the edge of the eyelid. Conditions such as blepharitis and rosacea may lead to chalazion formation.

In most cases, the chalazion will drain spontaneously if hot compresses are applied to the eyelid a few times a day for a few days to a week. Sometimes an antibiotic ointment or an oral antibiotic may help. In cases where the chalazion does not drain, it can be drained surgically under local anesthesia in the office. This procedure should not be overdone, since it may lead to the loss of numerous glands in the eyelid, which could lead to a dry eye problem in some people.

Sometimes a chalazion leads to the formation of a "granuloma", which is a reactive fleshy growth on the inside of the eyelid. This too can be removed if necessary. Lumps in the eyelid can put pressure on the eye which can temporarily cause astigmatism, or a change in the shape of the eye. 

 

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Eyelid Cellulitis (infection)

 

Cellulitis is an infection of the eyelid, and is more severe than the more low-grade "blepharitis", which usually causes only itching or burning symptoms. Cellulitis causes diffuse swelling of the entire eyelid, which is usually tender, hot, and red. The swelling may extend onto the face, and there may be discharge present. Cellulitis of the lower eyelid can mimic infection of the tear drainage sac (dacryocystitis). It is important to distinguish infection involving only the eyelid from infection extending from behind the eye, or the orbit (orbital cellulitis), which is usually more severe and causes eye protrusion and double vision.

Eyelid cellulitis is treated with oral antibiotics, and sometimes with IV antibiotics in more severe cases. It is important to watch for extension of the infection into the orbit. 

 

Eyelid Ectropion (out-turning)

 

Ectropion, or out-turning, of the eyelid usually involves the lower eyelid. The lower eyelid pulls away from the eye and visibly appears to sag down. Symptoms include irritation, swelling, and redness of the eyelid, tearing, and irritation and redness of the eye. The lower eyelid is usually pressed flush against the eye and keeps the eye bathed in lubricating tears. When the eyelid sags away, so do the tears, and the eye can become severely dry. Tearing occurs if the opening in the eyelid which drains tears away becomes separated from the eye. Thus, tears have no way to drain away except onto the face. Dryness of the cornea can lead to a scratchy sensation, redness of the eye, pain, and blurred vision. Sometimes the cornea can become infected.

Most of the time, ectropion occurs along with the general aging changes in the skin. The lower eyelid can become looser, and eventually pull away from the eye by gravity. Bell's Palsy, or a temporary paralysis of the side of the face, can suddenly make these normal aging changes much worse, and the eye can become severely dry due to ectropion. Other conditions lead to scarring of the skin under the eyelid, which pulls the eyelid away from the eye. 

Treatment of ectropion in some cases is merely to lubricate the eye as best as possible, with artificial tears during the day and ointment at night. In more severe cases, or if the cornea is at risk due to severe dryness, the eyelid out-turning can be corrected surgically under local anesthesia.

 

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Eyelid Entropion (in-turning)

 

Entropion, or in-turning, of the eyelid can involve the upper or lower eyelid. Symptoms occur due to the scratching of the eye by the inwardly pointing eyelashes (trichiasis). Usually numerous eyelashes are involved, and it is impractical to pull all of them. This condition can occur due to generalized aging changing in the eyelid with a gradual rotation inward. Other cases are caused by scarring, either from trauma, infection, or an inflammatory condition such as shingles of the eyelid.

In cases where the eye is being severely scratched by the entropion, surgery can be performed emergently to reposition the lid. Other less severe cases might be able to be managed using lubricating eye drops and ointments on the eye, but usually surgery will need to be performed. 

 

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Eyelid Tumor

 

This discussion of eyelid tumors includes growths present on the skin, the edge, or the inside surface of the eyelid. A chalazion, or stye, which is a lump within the eyelid, is covered in a section above.

Skin cancer of the eyelid appears usually as a slowly enlarging lump usually on the lower eyelid. The most common type is "basal cell" cancer, which usually is a firm, pearly nodule which is non-tender. If present at the edge of the eyelid, there may be a loss of eyelashes. Another type of skin cancer of the eyelid resembles a chronic infection of the lid, or blepharitis, with redness of the lid. Melanoma can involve the outside or inside of the eyelid, and usually is a changing, darkly pigmented growth. Sometimes melanomas have no pigment. 

Treatment of suspicious growths is by excisional biopsy with examination in the laboratory to determine if the growth is cancerous, and if it has been removed completely.

 

Non-cancerous growths of the eyelid include:

Skin tags or horns , which are fleshy growths of skin on a stalk. These can be removed if necessary.

Seborrheic keratoses , which are "stuck-on appearing" growths on the skin. These are more of a cosmetic problem and rarely have to be removed.

Inclusion cysts , which are round, bubble-like swellings on the eyelid which may come and go. If simply drained, they usually recur.

Viral papilloma , or wart-like growths, are fleshy growths usually on the edge of the eyelid. These can be removed if necessary. See B photo to the right.

Granulomas are inflammatory growths on the inside or outside of the eyelid, and can occur after a stye, or chalazion.

Molluscum contagiosum is a small viral growth of the eyelid or skin which can spread. Usually it is a tiny, round, white lump on the lid. Viral particles shed from this can irritate the eye and lead to itching and redness. Treatment is by excision. See A photo above.

Calcifications , or "concretions" can occur on the inside of the eyelids. If the eyelid is flipped over, a small, very white particle or cluster of particles may be seen on the inside surface. Usually these are covered over by a transparent membrane that lines the inside of the eyelid. Rarely do they erode and scratch the eye, and rarely do they ever have to be removed.

 

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Eyelid Twitching

 

Twitching of the eyelid is a common, and annoying problem. Usually a tiny piece of muscle beneath the skin of the upper or lower eyelid seems to rhythmically and uncontrollably twitch. Often it is barely visible to other people observing the eyes. The muscle fibers beneath the skin of the eyelid run in a circle around the eye, so the twitch seems to also pull toward the inside or outside.

Causes include local eye irritation such as dry eye and blepharitis, and artificial tears may help. Fatigue, stress, and lack of sleep are other known causes. Stimulants such as caffeine and decongestants may also lead to twitching. Rarely, pulsation of an artery on a nerve controlling the muscle causes twitching.

Usually the eyelid twitching will resolve with time spontaneously. A more severe version of this, called blepharospasm, leads to severe, uncontrollable squeezing of the eyelids closed. This problem can be treated if necessary by medication such as Botox injections. This problem usually needs evaluation by an ophthalmologist.

 

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Eyelid Drooping (Ptosis)

 

Several problems can lead to drooping of the upper eyelids, called ptosis (toe-sis). Some people are born with this condition, and live their lives with no complaints or symptoms. This may not even be a cosmetic problem, if it is symmetrical between the two eyes (as in some photos of Marilyn Monroe). However, for people who develop worsening ptosis in one eye or the other, it can become a battle to keep the eyes open. Significant ptosis of the upper lids can block the upper field of vision. Causes include:

Aging changes - in some people the muscle that lifts the upper eyelid slips back with time and the eyelid droops.

Trauma - a blow to the eye or a laceration can damage or disinsert the muscle controlling the height of the eyelid.

Eye surgery - For an unknown reason, some people will develop ptosis after cataract surgery, or other eye surgeries.

Myasthenia gravis - This unusual disorder leads to a temporary, often severe, drooping of one or both eyelids. At other times, the height of the lids can be completely normal. This may be associated with muscle weakness and fatigue, as well as a variable double vision. It is treatable with medication.

Nerve paralysis - one of the nerves that control eye movement also controls the muscle which lifts the eyelid. If the affected eyelid is raised, usually the person will have double vision. This is discussed more in the section on nerve paralysis. Another condition called "Horner's syndrome" can cause this also, along with a small pupil on one side. Both of these conditions need prompt evaluation by a ophthalmologist.

Brow ptosis - In this condition, common in men, the entire brow area drops down. If folds of skin then block the vision, surgical correction can be done. Photos show pre- and post-op views.

Dermatochalasis - Some people develop loose overhanging skin of the eyelids, or develop pockets of fat which protrude and bulge in the eyelids. This can be corrected surgically if necessary or desired.

Ptosis which encroaches on the pupil and is blocking the upper field of vision can be surgically corrected. Less severe ptosis can be corrected with cosmetic surgery.

 

Other Eyelid Conditions found in other sections:

Thyroid Eye Disease - can cause eyelid swelling and "retraction" (a wide-open eye appearance)

Myasthenia Gravis - can cause drooping of one or both upper eyelids, often worse at the end of the day or when tired.

Dacryocystitis - infection of the tear drainage system can cause eyelid swelling and pain.

Trichiasis (Inturned Eyelashes) - an eyelid problem leading to a scratchy eye sensation, redness, and tearing.

Orbital Infection - infection behind the eye can lead to eye swelling.

Ocular Cicatricial Phemphigoid - an autoimmune disorder that leads to conjunctival scarring with inturning of the eyelids and lashes.

 

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Introduction: Double Vision

Double vision can have many different causes, but it is important to distinguish between double vision seen with one eye alone, as opposed to that seen with both eyes at the same time. In other words, if the double vision disappears when one or the other eye is closed, it is due to a misalignment between the two eyes.

Most of the topics on this page discuss these misalignment problems. When the double vision is present even with one eye closed, it may be due to optical problems with the eye, or refractive problems. This can come from improper glasses prescriptions, cataract, or corneal scars.

 

Conditions Discussed in this Section:

Strabismus

Orbital Infection (Cellulitis)

Eye Muscle Paralysis

Thyroid Disease

Orbital Fracture

Refractive Error (glasses prescription)

Other Conditions causing Double Vision found in other sections:

 

For eye anatomy explanations, go to ANATOMY

 

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Strabismus

 

Strabismus is a term that can be used to describe any ocular misalignment, but most commonly it refers to a group of conditions of ocular misalignment not due to any specific cause. Instead, the eyes turn in or out on their own, not due to muscle paralysis, trauma, or other cause. Usually these conditions occur in childhood, and can signal or lead to the development of a "lazy eye", or amblyopia. During the early years of development of the visual system (from birth to around age 8 to 9), anything which interferes with a clear image being received by an eye can lead to subnormal development of the entire visual system serving that eye. If this problem is not corrected, irreversible visual loss can occur (amblyopia). While many things can cause amblyopia (need for glasses prescription, childhood cataract, retinal disorders, etc.), misalignment of the eyes is a common cause or associated condition. Thus, it is important to have a child of any age promptly examined by an ophthalmologist if their is any evidence of visual problem.

There are numerous types of strabismus. Some occur constantly, and some are evident only occasionally (intermittent). Some misalignments of the eyes occur mainly during times of fatigue, daydreaming, or speaking. Strangely enough, strabismus does not commonly lead to complaints of double vision. In young children, the visual system has mechanisms to avoid double vision. If one eye turns in the wrong direction, the central visual area of that eye is simply turned off (suppression). In some conditions, a peculiar head position may be adopted by a person that minimizes double vision. Some common types of strabismus include:

 

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Esotropia - or In-Turning of the Eyes . This condition may occur in very young infants (less than 1 year-old), or may develop later in childhood. In some cases farsightedness may lead to esotropia, and in other cases the inturning may only occur with reading. In these situations, the use of glasses, and possibly bifocals may alleviate the problem. Amblyopia (lazy eye) must be constantly searched for, and treated aggressively if found (patching of the dominant eye). Sometimes eye muscle surgery can re-align the eyes if other therapies are not effective.

Exotropia - or Out-Turning of the Eyes . This condition can occur in children, and may initially only be present occasionally (during fatigue or daydreaming). It may progress to being present at distance or near, and may become more constant. If not treated, it can continue into adulthood, and the person's eye may continue to wander out at times unknowingly. In children, any uncorrected glasses prescription or amblyopia is treated prior to muscle realignment surgery (if needed).

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Duane's Syndrome is a fairly common ocular misalignment present from birth. Usually, one eye or the other cannot turn outward, away from the nose, all of the way. On inturning of the eye, the eyelid opening seems to narrow, and the affected eye appears to pull back into the orbit. Double vision can develop in certain positions of gaze. People with this condition often adopt a head turn toward the affected eye. Thus, the affected eye is usually turned toward the nose, and the eyes stay properly aligned, and double vision is avoided.

 

Convergence Insufficiency indicates a problem with the natural inturning of the eyes that occurs with reading. People with this problem have to struggle to keep the eyes aligned when looking at something close. Often the eyes will separate apart at some point, the text will seem to run together, and the reading must be temporarily stopped. This is a common cause of "eyestrain", and can also be seen in people with certain neurological problems, such as Parkinson's disease. Treatment can sometimes involve glasses, holding reading material further away, and possibly "eye exercises". This is one condition that can be helped by orthoptics, or vision training, since the ability of the eyes to turn in can be improved. 

 

Orbital Infection (cellulitis)

 

An infection of the orbit, or boney eye socket, can lead to severe symptoms, one of which is double vision. Usually orbital infection spreads from adjacent sinuses, and sometimes from a skin or eyelid infection. Symptoms include pain, eyelid swelling and possibly a lump behind the eyelids that can be felt, eye and eyelid redness, discharge, blurred vision, eye displacement or protrusion, and double vision. The double vision comes from the infection preventing normal movement of the eye, and a misalignment may occur in certain positions of gaze. People with this condition are usually treated in the hospital with IV antibiotics. Diabetics are subject to a particularly severe and destructive fungal orbital cellulitis. 

NOTE: A tumor of the orbit can cause similar symptoms, although usually with less pain, redness, and discharge. A condition known as orbital pseudotumor ("like a tumor") is an inflammatory condition which can simulate tumor or infection, but usually responds to steroids. A CT scan or MRI is usually done in cases of orbital infection, tumor, or pseudotumor to help make the diagnosis and guide treatment.

 

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Eye Muscle Paralysis

 

There are three nerves which control the six "extra-ocular muscles" of each eye, or the muscles that control eye movement. These nerves are called "cranial nerves", since they come directly from the brain rather than the spinal cord. There are twelve cranial nerves, and they are often named by a number 1 through 12. (Note: the optic nerve is cranial nerve number two). These nerves pass under the brain to enter the orbit on each side, until they reach the muscles that they control. Damage to these nerves leads to paralysis of the muscles that they control. There are four muscles which control the movement of the eye roughly up, down, left, and right, although it is really more complicated than that. Two additional muscles (the "oblique" muscles, control some up and down movement, as well as the twisting or tilting movement of the eyes).

 

Paralysis of the 3rd Cranial Nerve: The third cranial nerve controls four of the six eye muscles, as well as the ability of the eye to focus and pupil to constrict. The muscle that is controls turn the eye up, down, and in. Paralysis of this nerve leads to the affected eye being unable to turn in, and it is often turned out and down. The pupil may or may not be dilated as well. Causes of this condition can be serious, such as an expanding aneurysm on an artery at the base of the brain, or tumor. Stroke can also cause dysfunction of this nerve. In some cases, people with diabetes and other vascular disease can develop a temporary paralysis of this nerve that resolves over a period of a few months. Often the pupil is not affected in the diabetic type of paralysis. A third cranial nerve paralysis is usually treated an an emergency. The tape in the photo is used to be able to see the eye as there is otherwise a total ptosis of the left upper eyelid.

 

Paralysis of the 4th Cranial Nerve: The forth cranial nerve controls only one eye muscle, the "superior oblique muscle". This muscle is involved in the twisting or rotation of the eye, and somewhat in downgaze (especially when also looking in). Paralysis of this nerve can give variable symptoms. Sometimes people will notice double vision on in some extreme position of gaze. Others may develop a more severe vertical double vision (things separated up and down), often with a tilted effect as well. This nerve is particularly prone to damage from head trauma, sometimes even just a bad bump on the head. Vascular problems such as diabetes can rarely cause this as well. Prisms placed in glasses can usually reduce double vision until the nerve function returns. The photo shows the elevation of the left eye.

 

Paralysis of the 6th Cranial Nerve: The sixth cranial nerve controls the muscle that turns the eye outward. Thus, is paralyzed, the eye will turn inward, and often cannot often cross the midline back toward the outside. This leads to severe horizontal double vision (side to side), usually bad enough to require patching of one eye to prevent the double vision. This is commonly caused by vascular problems such as diabetes, and the nerve function returns in 1 to 3 months. Other problems such as tumor, temporal arteritis, and stroke can cause this as well.

 

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Thyroid Disease

 

Thyroid dysfunction can affect the tissues around the eye and in the orbit in a condition called "thyroid related orbitopathy". Usually this is associated with hyperthyroidism (over-acting thyroid) as in "Grave's disease", although it can occur in a normal or even under-acting thyroid. It is felt to be an auto-immune problem where the immune system attacks the tissues around the eye, and possibly also the thyroid gland. This leads to a variety of eye symptoms.

Swelling of the eyelids and tissues around the eyes.

Eyelid "retraction", or excessive opening. This leads to a wide-open eye staring appearance. The white of the eye is often visible above and below the iris.

Eye protrusion, where swelling of the tissues in the orbit behind the eye literally push the eye outward.

Corneal drying and breakdown can occur from exposure of the cornea due to the eye protrusion and eyelid opening.

Double vision can occur due to swelling and dysfunction of the eye muscles. Especially involved are the muscle the turn the eye downward. Thus, the eye becomes tethered and has difficulty looking upward, especially when turned out also. Double vision due to misalignment of the eyes occurs in certain positions of gaze, and it usually is a vertical double vision. It may be highly variable.

Compression of the optic nerve in the orbit due to the swelling of the eye muscles can lead to visual loss, blind spots in the vision, loss of color vision, and swelling of the optic nerve. This can be an ophthalmic emergency and may take high dose steroids or surgery to reverse.

Thyroid related eye problems tend to come and go, and the eyes may remain unaffected for long periods of time between attacks. Supportive treatment during symptomatic periods such as eye lubrication and steroids to reduce swelling may help.

 

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Orbital Fracture

 

Blunt trauma to the eye and bones around the eye (such as by a fist) can lead to a fracture in the thin bones of the orbit behind the eye. Anyone with such injury should seek out a complete eye examination to rule out any other eye injury promptly. The floor and inside wall of the orbit are especially thin, and sinuses are on the other side of the bone. Blunt trauma can cause what is termed a "blow-out fracture", where the sudden rise in pressure in the orbit literally blows a fracture through the bone and into the sinus. If this involves the floor of the orbit, the cheek below the eye and upper gums in the mouth can often become numb due to damage to a sensory nerve that runs in the floor of the orbit 

If the fracture of large enough, the contents of the orbit can start to slip into the sinus, and the eye will appear to sink backwards. Sometimes an eye muscle can get trapped in an orbital fracture and become stuck. This leads to double vision especially if looking up, with pain. A CT scan of the orbit can diagnose fractures and entrapment of muscles. Entrapped muscles often have to be released surgically. Antibiotics are usually given after an orbital fracture, due to risk of infection from the sinus into the orbit.

 

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Refractive Error

 

An uncorrected glass prescription, especially if nearsighted or with astigmatism, can lead to ghost images or slight double vision. Unlike double vision caused by misalignment of the eyes, this type of double vision remains if one eye is closed. It is often worse at night when the pupil dilates some.

Irregular astigmatism, or an uneven curvature of the cornea, can lead to ghost images which may only be treatable using a contact lens.

Certain types of cataract can lead to double vision due to distortion of images passing through the lens of the eye, and from glare. Intraocular lens implants can cause double vision if they slip out of position (rare), and the edge of the lens comes close to the pupil center. Some people after glaucoma or cataract surgery have an iridectomy done at the time of surgery. This is a hole cut into the iris usually hidden by the upper eyelid. In some with an iridectomy, double vision may occur with light passing through this opening.

 

Other Conditions causing double vision found in other sections:

Myasthenia Gravis - can cause drooping of one or both upper eyelids, often worse atthe end of the day or when tired.

 

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Introduction: Headache

 

Headaches often appear centered around the eyes or behind the eyes. There are many ocular disorders which can cause headache, from eyestrain focusing problems, to glaucoma and inflammatory conditions of the eye. There are other problems which cause headache where findings of that problem can be seen with a complete eye examination. Finally, there are many conditions where the eyes are not involved with the cause of the headache, but the area around the eyes seem to ache because of "referred pain" to that area.

Patients will often be referred to an ophthalmologist in order to determine if an ocular condition could be causing headache. Unfortunately, most of the time, the eyes are not the cause. However, many conditions of the eyes which cause headache are easily treatable, making the eye evaluation worthwhile.

This page is divided into a group of disorders causing headache which also can affect the eyes. The next section discusses "other causes" of headache which cause pain around the eyes, but there is no ocular abnormality. The last section contains links to ocular problems known to cause headache.

 

Conditions Discussed in this Section:

Focusing Spasm (eyestrain)

Migraine Headache

Cluster Headache

Temporal Arteritis

Sinus Disease

Shingles (Herpes Zoster)

Other causes for headaches near the eyes

Other conditions causing headache found on other pages:

 

For eye anatomy explanations, go to ANATOMY 

 

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Focusing Spasm (Eyestrain)

 

"Eyestrain" refers to overworking of the focusing muscle within the eye. To read at a close distance (within arm's length), the lens within the eye must change shape in order to bring images into focus. The closer an object is held, the more focusing that has to be done. Furthermore, the focusing ability of the eye diminishes with age, and noticeable problems with focusing can appear usually between age 38 and 48. If the eye is forced to focus more intensely and for a longer duration than it is comfortable with, eyestrain symptoms can result. These symptoms include:

Headache, usually a brow ache or an ache behind the eyes.

Fluctuating vision, with trouble in changing focusing between near and distance.

Inability to focus at close range, or blurred distance vision occurring after a period of close work.

A burning, uncomfortable eye sensation.

 

  Eyestrain symptoms can be relieved by taking a few steps:

Limit the amount of time spent focusing at one fixed distance, and take periodic breaks for a few minutes every 15 to 20 minutes. During this break time, focus at a distant object, not at a near one.

Vary the distance that you hold reading material, and avoid getting closer and closer to what you are reading.

Consider using reading glasses, after an eye examination has been performed to determine the proper power of the glasses. 

 

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Migraine Headache

 

Migraine is a vascular type of headache, and is caused by a change in vascular tone in the brain. It is a common cause of headache surrounding one or both eyes or other parts of your head. Migraine headache may be difficult to localize in some cases. It is often preceded by a visual "aura" in an ophthalmic migraine, which typically is a jagged zigzag pattern of shimmering lights in the side vision lasting up to 30 minutes. There are many other ophthalmic aura patterns including heat waves, picket fences, shooting stars, kaleidoscope and crystal glass. The aura may be in one or both eyes. Some people experience this aura and may or not have a headache. This is commonly referred to as Ophthalmic Migraine. However, you may have an aura that effects smell, hearing, sensation in your hands or feet, gastrointestinal pain, hearing and taste. Some people experience neurological changes during this period, such as tingling or numbness on one side. After the aura clears, the headache begins, and may be associated with nausea, vomiting, and sensitivity to light and sounds.

There are many medications that can be used to treat migraine. There are also numerous factors which may set off a migraine. Some of these can be identified as a factor in some people:

 

Foods containing tyramine (cheese, bananas, yogurt), phenylethylamine (chocolate, wine, cheese), nitrates (food coloring, preservatives, processed meats), MSG, alcohol, caffeine, and artificial sweeteners.

Medications such as estrogen and oral contraceptives. Some women may be sensitive to hormonal changes.

Factors such as fatigue, stress, depression, and exertion can play a role in some people.

Bright lights, glare, loud noises, and flickering lights may trigger some migraines.

    Also see Ophthalmic Migraine.

 

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Cluster Headache

 

Cluster headache is a severe one-sided headache especially involving the area around the eye. It lasts for up to 2 hours at a time, several times a day, for up to 6 to 8 weeks (thus, a cluster of headaches). Associated symptoms include tearing and nasal drainage (on the affected side), eye redness, and a temporary smaller pupil on the affected side.

Treatment is similar to the treatment of migraine headache, and steroids and other medications may be needed as well.

 

Temporal Arteritis

 

Temporal arteritis, or "giant cell arteritis", is a serious condition usually affecting the elderly. This is an immune disorder where medium sized arteries becomes tender and inflamed. The condition is named after the "temporal artery", which runs from in front of the ear and up the scalp along the hairline. This artery is commonly involved, and the headache associated with this is a constant, throbbing pain in the temples. Associated symptoms are weight loss, fatigue, arthritis (especially of the shoulders), fever, and pain or fatigue with chewing. Visual symptoms occur due to a loss of blood supply to the optic nerve, or due to a loss of retinal blood supply. Both of these conditions can cause either a temporary (Amaurosis fugax) or permanent loss of vision, usually in one eye first (see Optic nerve stroke or Retinal artery occlusion.)

Most people with this condition have an elevated lab test, called a "sed rate." Diagnosis, however, is made by taking a biopsy of the temporal artery. Steroids can treat the condition, and the vision is the unaffected eye can often be saved. Untreated, temporal arteritis can often cause visual loss in both eyes.

 

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Sinus Disease

 

The eye socket, or orbit, is surrounded by sinuses, except on the outside wall. Infection of the sinuses can lead to pain over the affected area, often radiating to the eye and face. The headache is usually dull, aching, and throbbing. Bending or stooping may worsen the headache. Fluid retention within the sinuses around the eyes can cause similar symptoms, but less severe. Sometimes sinus congestion or infection can be associated with obstruction of the tear drainage system. This leads to frequent tearing of the affected side, and possible infection of the tear duct.

It is possible for sinus infection to spread into the skin around the eyes (Eyelid Cellulitis), or even spread into the orbit behind the eyes (Orbital Cellulitis), especially in children. These conditions require aggressive antibiotic therapy, often given IV. 

 

Shingles (Herpes Zoster)

 

Shingles refers to a reactivation of the chicken pox virus along the distribution of a nerve. Once a person has had chicken pox, the virus lies dormant in nerve cells. Sometimes the virus becomes reactivated (often during a period of stress of illness), and a rash of blisters will appear on the skin along the distribution of that nerve. The nerve that supplies sensation to the scalp, upper eyelid, eye, and nose is commonly involved, and the rash may appear in this area. Note that the rash never crosses the midline of the forehead, and this gives a very obvious appearance. The area involved is usually painful, with a burning aching. This pain may precede the rash. Antiviral medications given promptly by mouth may shorten the duration and intensity of the flare up.

The eye can also be involved with shingles if the trigeminal nerve is involved. Almost any part of the eye can be affected and seeing an ophthalmologist is important to prevent problems.

 

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Other Causes for Headache Near the Eyes

 

There are many other conditions which can cause headache around the eyes that do not directly involve the eyes themselves. The eye and orbits are frequent areas of "referred pain", that is, pain coming from another source. Some of these conditions include:

 

Ear and tooth pain can radiate to the eyes and orbits.

TMJ Disease (temporo-mandibular joint) can cause eye, tooth, ear, neck, or sinus pain. The photo at the right shows the areas of involvement with a temporal mandibular joint disorder.

Degeneration of the cervical (neck) spine can cause pain which
can radiate to the eye and orbits.


Trigeminal Neuralgia (tic douloureaux) is a brief attack of severe pain affecting one side of the face, often near the eye. The pain is can be very severe, sharp, and cutting. There are different treatment options available for this problem.

 

Other Conditions causing headache found in other Sections:

Contact lens related problems - headache may come from a poorly fitting, tight lens, corneal infection or swelling, or from a lack of oxygen in the cornea.

Corneal Abrasion - pain, tearing, redness, and a sensation that something is in eye.

Corneal Ulcer - an infected cornea can cause pain, headache, blurred vision, and redness.

Conjunctivitis - swelling of the conjunctiva and eyelids can cause headache, along with the itching, redness, and discharge.

Dacryocystitis - an infected tear drainage sac (inside corner of the eye) can lead to pain and headache, as well as tearing.

Dry Eye - irritation, scratchy sensation, sometimes tearing and blurred vision.

Glaucoma (Acute) - pain, blurred vision, rainbows around lights, and headache.

Iritis - pain, sensitivity to light, blurred vision.

Paralysis of the Eye Muscles - when caused by a nerve paralysis, there may be significant headache as well.

Optic Neuritis - inflammation of the optic nerve can cause headache and pain on eye movement along with blurred vision.

Orbital Cellulitis (Infection) - infection of the orbit behind the eye can lead to blurred or double vision, pain, and eye protrusion.

Scleritis- pain, blurred vision, redness.

Thyroid related eye disease - scratchy sensation, double or blurred vision, protruding eyes.

 

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Introduction: Contact Lens Related Problems

 

Contact lenses provide an excellent alternative to glasses for correction of refractive errors, and the technology of lenses continues to improve. However, contact lens use is not without risk, and the potential for vision threatening problems is present, especially in those who abuse the use of contacts. On this page can be found discussion about contact lenses in general and contact lens related problems.

 

Conditions Discussed in this Section:

Contact lens related problems

Lens comfort problems

Wearing time problems

Vision problems

Contact lens allergy

Lens deposits

Contact lens complications

Tight lens syndrome

Corneal Ulcer (infection)

Corneal Warpage

Corneal swelling (edema)

Giant Papillary Conjunctivitis

Eye Redness

Options for the bifocal user

Reasons for Disposable Lens Use

Should contact lenses be used extended wear?

 

For eye anatomy explanations, go to ANATOMY 

 

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Contact Lens Related Problems and Lens Comfort Problems

 

There are many reasons why a contact lens may be uncomfortable to wear, including underlying eye disease and other contact lens complications discussed on this page. In cases where the eyes are healthy and the contact lenses are new, there is always the possibility that a lens is defective. Generally, if a lens of a given brand and curvature has been worn successfully in the past without problem, a new and uncomfortable lens makes one strongly suspicious of an abnormally curved lens, or a lens with a scratch or other defect. Since most manufacturers (and online contact lens providers) offer a warrantee for defective lenses, it may be reasonable to return the lens for replacement or refund. Usually the lens must be returned in the bottle in which it was sent in order to get credit. In cases of new gas permeable or hard lenses, sometimes the lens can be smoothed or polished to improve the comfort.

If a new lens of a different brand than has been worn before is uncomfortable, the problem may be with the fit (tightness) of the lens, the thickness of the lens, and the edge design of the lens. Some soft contact lenses have a very high oxygen permeability (extended wear type lenses), and these may be more comfortable for some people. However, these lenses also demand more ocular lubrication to keep them hydrated and moist, so eyes which are somewhat dry may not be comfortable with this type of lens. If a lens is too tight, the cornea may become starved for oxygen, leading to discomfort (see Tight Lens Syndrome below). On the other hand, a lens that is too loose may irritate the eye due to excessive movement with blinking. Finally, certain characteristics of lenses (thickness and edge design) may be simply uncomfortable for some people. It may take a follow-up examination by the lens prescriber to distinguish between these problems.

An old lens that becomes uncomfortable may be developing deposits on the lens, scratches or nicks in the lens, or problems with the tears lubricating the surface of the lens. People are different with how long a given lens will remain comfortable, and good care of lenses will usually extend the life of a lens. Having to replace lenses frequently due to rapid protein deposit formation or other problems is a good reason to consider disposable lenses.

As mentioned above, the development of an underlying eye disorder not related to the contact lenses can make their use uncomfortable. Some conditions include eye allergy, dry eye, blepharitis, conjunctivitis, eyelid problems, iritis, phlyctenulosis, and pterygium. These conditions are discussed in other Ocular Symptoms and Diseases Sections listed at the top of this page. Pregnancy or hormonal changes are known to cause difficulty in contact lens use in women. Finally, other contact lens complications discussed below can cause discomfort with lens use. 

 

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Wearing Time Problems

 

People can develop problems with being unable to wear a lens as long as they would like. Sometimes this problem is simply related to external problems such as a high pollen count or being in an environment with poor air quality or low humidity. In cases where it becomes increasingly difficult to wear an older lens as long as previously, the lens may be developing protein deposits or other defects. Hard or gas-permeable lenses can often be polished, and will be comfortable to wear again, while soft lenses usually have to be replaced.

Some people are unable to wear any type of lens for the entire day, but can only wear the lens for a limited period of time. In cases where the eyes are somewhat dry, the use of rewetting drops (preferably preservative-free) can extend the time that the lenses can be used. Some people need to remove the lenses at some point during the day, such as lunchtime, and can then subsequently wear them longer during the afternoon. If one is having a problem with the wearing time of lenses, it is usually a good idea to have an eye examination to rule out any other potential problem such as infection or allergy. A lens case with solution should be carried if the lenses need to be removed during the day, since wearing a lens longer than it is comfortable can lead to disaster. One should never put a contact lens in tap water, or in solutions not designed for lens storage or disinfection.

 

Vision Problems

 

Contact lenses are better at correcting certain types of vision problems than others. Simple nearsightedness or farsightedness is usually easily corrected using contact lenses, but astigmatism can be more challenging to correct, especially with soft lenses. Contact lenses have varying success in correcting the need for reading glasses, with bifocal contact lenses being successful in only about 50% of people.

Toric soft lenses have an astigmatism correction built into the lens, but rotation of the lens can lead to a shifting of the astigmatism correction, and temporarily blurred vision. For people with severe or irregular astigmatism, gas-permeable lenses or hard lenses may offer better visual results. Irregular astigmatism is a situation where the cornea is distorted due to a scar or underlying disorder. Sometimes rigid contact lenses are the only way to correct the vision in these cases, as even glasses will not help (as in keratoconus).

Many people who use contact lenses may experience halos around lights at night, and sometimes ghost images. This probably is a normal phenomenon in most people, and occurs when the pupil is larger (or more dilated) than the optical area of a soft lens, or of the lens itself in cases of rigid lenses. However, seeing a rainbow around lights indicates swelling of the cornea (corneal edema), and indicates that the lenses have been in too long and should be removed.

Blurred vision in one eye or the other with a contact lens that was previously clear could indicate a more serious eye problem, and should be checked by the lens prescriber. Of course, it is possible that lenses can become switched between the eyes, but usually this is fairly obvious. An older lens can develop deposits and other surface problems which can make the vision not only blurry, but also can make the lens uncomfortable to wear. 

 

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Contact Lens Allergy

 

The fact that a contact lens is constantly touching the eye leads to the possibility of an allergy developing to the lens material, deposits on the lens, or to solutions used with the lens. The conjunctiva is a thin membrane which lines the white surface of the eye and the inside of the eyelids. Soft lenses usually extend somewhat onto the conjunctiva outside of the cornea. The inside of the eyelids are also in contact with lenses especially during blinking. The conjunctiva contains cells which can rapidly respond to allergens, leading to redness, itching, tearing or discharge, and a general inability to wear a contact lens.

A common source of allergy is a preservative found in the contact lens solutions. Thimerasol was used frequently as a preservative in the past, but severe allergic problems developed. Now, benzalkonium chloride and EDTA are common preservatives found in contact lens solutions. If one develops an allergy or sensitivity to these preservatives, symptoms of allergy (redness, itching, discharge) frequently develop especially when the lens is first inserted, or when rewetting drops containing these preservatives are used. Solutions marked as being for "sensitive eyes" usually contain no less preservatives than other solutions. If a lens solution allergy is suspected, switching to a preservative free lens disinfection system may help.

Developing an allergy to protein deposits on lenses is common, and this may lead to a condition called "giant papillary conjunctivitis". (see below) Regular enzyme cleaning may help prevent this complication, but often lenses with deposits need to be replaced. Rarely, one can develop an allergy to lens material itself, and trying a different brand, or switching to a rigid type of lens may help.

A more unusual but common allergy problem is the development of an allergy to bacteria present on the edge of the eyelid. These bacteria produce toxins which become trapped in the tears, especially beneath a contact lens. For more information on this condition, see Phlyctenulosis.

 

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Lens Deposits

 

Protein deposits can frequently form on both soft and rigid types of lenses. With soft lenses, the regular use of enzyme cleaners as well as proper disinfection and daily cleaning of lenses can help prevent the protein deposition, but they are never as effective as traditional hand rubbing with a cleaner. Rigid lenses may develop deposits especially during seasons with high pollen counts, and polishing the lenses usually will buff off any deposits. When a lens develops deposits, the eye can become irritated, itchy, and red. Wearing time may be decreased, and the vision may be somewhat blurred. Complications such as "giant papillary conjunctivitis (GPC)" may occur, which can limit the use of contact lenses for an extended period of time. Once deposits form on a soft lens, the lens usually has to be replaced. Rapid development of deposits on lenses is a valid reason to consider disposable lenses. Some contact lenses (Aquaflex and CSI) are resistant to deposit formation. 

 

Contact Lens Complications

Tight Lens Syndrome

 

Normally a contact lens should move slightly on the surface of the eye with blinking or eye movement. Soft lenses usually move a few millimeters with a blink, while rigid lenses (gas permeable or hard lenses) move more. This movement allows tears to circulate across the surface of the eye, helping to provide oxygen to the cornea. Of course, some oxygen can diffuse directly through a contact lens also (more so in soft lenses and disposable extended wear lenses). For different reasons, a contact lens during the course of the day may begin to fit more tightly onto the surface of the eye. This may be because the lens was too tight fitting to begin with, or it may be related to increasing drying of the lens and eye as the day proceeds. If the lens reaches a point where it stops moving on the eye, several things may happen. The oxygen transmission to the cornea will begin to drop, and the cornea may begin to swell (corneal edema). This leads to further tightening of the lens on the eye, with a further worsening of swelling. Symptoms during this period may include redness, eye irritation or burning, and a dry sensation. The vision may begin to blur, and halos or rainbows may be seen around sources of light.

The use of rewetting drops may help prevent this cycle of lens tightening onto the eye, and may help to prevent complications. The fit of the lens may need to be checked as well, and sometimes a new lens is needed. Once the lens has tightened onto the eye enough to cause symptoms, the lens should be carefully removed. Lubricating drops should be placed several times to help loosen the lens before removal. Sometimes removal of a tight lens can lead to a painful corneal abrasion, which would require further treatment by an ophthalmologist. Another risk of the tight contact lens syndrome is of infection (corneal ulcer).

 

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Corneal Ulcer

 

The development of a corneal ulcer (an infection of the cornea) unfortunately is a common complication of contact lens use. Soft contact lenses have a higher risk of corneal ulcer than rigid lenses, but all lenses have some risk. Disposable contact lenses worn extended wear were found to have a much higher risk of corneal ulcer than any other type of lens, for reasons that are not fully understood. A corneal ulcer starts when a bacteria (or rarely a fungus or parasite) infects an area of breakdown in the corneal surface. The surface may break down, forming a small corneal abrasion, due to routine lens use. Overwear of lenses, improper cleaning of lenses, extended wear use of lenses, and overly tight lenses may increase the risk of developing this surface breakdown. Normally, a corneal abrasion, even if tiny, is uncomfortable. However, a contact lens can act as a bandage on the eye masking symptoms, and some contact users develop a lack of sensitivity of the cornea.

Once an infection begins, most people experience severe symptoms. The eye typically becomes red and painful. There may be tearing or discharge and sensitivity to light. The vision may be variably blurred. There are other disorders which can cause these symptoms, but the risk of corneal ulcer in contact lens users is such that the most important thing to do initially is to remove the contact lens. An appointment should be arranged immediately with an ophthalmologist to determine if an infection is present. A corneal ulcer needs to be treated intensively with antibiotic eye drops, and often a culture of the infected cornea, or of the lens or lens case is performed. Frequent follow-up appointments will help the ophthalmologist determine if the infection is being adequately treated with the antibiotics. Usually a week or two of antibiotic eye drops is needed, and contact lenses cannot be worn during this time.

A successfully treated corneal ulcer may still leave a scar which could affect the vision. It is important to avoid situations which can lead to corneal ulcer, such as overwear of lenses, poor disinfection techniques, swimming with contact lenses in, and ignoring symptoms of pain or redness. 

 

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Corneal Warpage

 

"Warpage" of the cornea refers to a distortion in the shape of the cornea, usually due to the use of rigid contact lenses, and especially poorly fitting rigid lenses. The type of lens most notorious for this is the "hard" type of lens, which is a non-gas-permeable lens made of a plastic called PMMA. This type of lens is still used today successfully by many people. However, the lens is known to flatten out the cornea, often reducing or eliminating astigmatism. When lens use is discontinued, the cornea will try to spring back to its original shape. Thus, it may be impossible to find a glasses prescription that will consistently give clear vision for times when the contact lens is not in. Often only the contact lens itself can give clear vision. A condition known as "irregular astigmatism" refers to an irregular curvature of the cornea, usually caused by poorly fitting rigid lenses.

It may take several weeks of not using a contact lens for the cornea to return to its normal curvature. At this time, the proper fitting measurements can be made to determine the shape of a contact lens needed which will not distort the shape of the cornea.

 

Corneal Swelling (edema)

 

Corneal edema, or swelling, occurs when there is an inadequate supply of oxygen reaching the cornea due to contact lens wear. Essentially, the cornea becomes smothered by the lens. Sleeping in contact lenses, as with extended wear lenses, greatly increases the risk of corneal edema. In this situation, even less oxygen reaches the cornea because the eyelid is closed over it. Also, the normal blinking of the eye is not present, which helps tears and oxygen to circulate under the lens.

Symptoms of corneal edema included blurred or foggy vision, seeing rainbows around lights, redness, and possibly irritation or pain. Complications of corneal edema include corneal abrasion, a tight lens syndrome (see above), and corneal ulcer or infection. Generally, a lens should not be worn if symptoms of corneal edema are occurring. 

 

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Giant Papillary Conjunctivitis (GPC)

 

Giant Papillary Conjunctivitis (GPC) is a type of allergic reaction, usually to protein deposits on contact lenses. Since these deposits are more common with soft contact lens use, GPC is more common with soft lenses also. Sometimes GPC can occur as a reaction to the presence of a lens itself, or in reaction to lens solutions used. GPC is visible as large lumps beneath the upper eyelid (usually). These lumps can interfere with lens use, as they may "grab" the lens when the upper eyelid blinks over the lens. Other symptoms include itching, discharge, and redness. Regular enzyme treatments and proper contact lens cleaning techniques may reduce the chance of GPC. The use of preservative-free solutions can help as well. However, once GPC develops, the use of contact lenses often must be temporarily discontinued while the condition resolves. Anti-inflammatory and anti-allergy eye medications may help to speed resolution and to ease symptoms. Frequent cases of GPC due to protein deposits on lenses may be prevented by using disposable lenses, since these do not have a chance to build up the deposits.

 

Eye Redness

 

The development of eye redness with contact lens use is always a warning sign. At the least, it may mean that the lenses have been in too long, and should be removed. Many conditions can cause eye redness (see the Eye Redness section), but contact lens use makes certain problems more likely. Often, a red eye with contact lens use is treated like a case of conjunctivitis (pink eye), when actually the redness may be due to a contact lens related allergy or infection. Some common causes of a red eye with contact lens use include:

Lens Allergy, lens solution allergy, or allergy to protein build-up on lenses.

Lens Overwear with corneal edema, with corneal drying or a tight contact lens syndrome.

Interaction of Bacterial Toxins (from the eyelids) trapped beneath the contact

    lens leading to corneal irritation such as with Phlyctenulosis.

Corneal Ulcer.

Giant Papillary Conjunctivitis.

Poorly Fitting or defective contact lenses.

Eye redness associated with contact lens use should not be ignored, and the eye should be examined by an ophthalmologist to determine the cause. 

 

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Other Contact Lens Considerations:

 

Options for the Bifocal User

Contact lenses are generally designed to correct the distance vision, leaving the eye itself to focus additionally for near vision. However, as people age, the focusing ability of the eye gradually declines. Usually in the early forties, this becomes noticeable, and reading material has to be held further away to be able to focus on it. Eyestrain symptoms and headache can occur. In people who do not use contact lenses, a bifocal prescribed in glasses can eliminate any problems with reading. However, what options are available for contact lens users?

Reading Glasses –

This is the simplest option for reading with contact lenses in: using reading glasses over top of the lenses. However, most contact lens users prefer to avoid glasses use, and it may be difficult to keep up with a pair of reading glasses when the distance vision is clear with contact lenses.

Monovision

This refers to using one eye for distance vision, and one eye for near vision. Usually the nondominant eye is set for reading (usually the left eye). Advantages of this system include the ability to read and see at distance without glasses using relatively inexpensive contact lenses. Disadvantages include a loss of depth perception and the possibility of eyestrain symptoms. Some people are simply not comfortable with this arrangement.

Bifocal Contact Lenses

A bifocal contact lens can be used in one or both eyes to maximize both near and distance vision. Unfortunately, sometimes clear reading vision comes with some sacrifice of clear distance vision. Probably on 50% of people successfully use bifocal contact lenses, and they are among the most expensive of contact lenses. See our newsletter about bifocal contacts.

 

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Disposable Contact Lens Use

Disposable contact lenses can be a useful option for some contact lens users, and there seems to be a trend toward increased use of this type of lens. Even disposable lenses that are discarded on a daily basis are available, although most people use the type of lens that is discarded after one month. Some reasons and situations for which disposable lenses may be useful include:

Rapid deposit formation on lenses, with or without the development of giant papillary conjunctivitis.

Having to replace contact lenses frequently, whether it be because of lens deterioration, damage, or the losing of lenses.

Sensitivity to solutions used to clean or disinfect lenses.

Difficulty in finding another type of lens that is equally comfortable for an individual. Some problems associated with disposable lenses include:

A higher risk of infection (corneal ulcer), whether or not the lenses are used extended wear.

A higher cost than most lenses. At wholesale cost, the 8 six-pack boxes needed to replace a lens every two weeks costs about $150 a year. One may be able to buy 4 sets of daily wear lenses at this cost.

A tendency to abuse the use of the lenses, such as wearing a lens for more than two weeks, an absence of lens disinfection, and wearing the lenses in situations not usually recommended, such as swimming. (These factors may lead to the increased risk of infection).

Poorer vision with disposable lenses. These lenses are very thin, and correct very little astigmatism. If an eye has borderline astigmatism, a more substantial lens may correct the vision better.

Problems using the lens with dry eye. Disposable lenses require more eye fluid to keep them hydrated.

There are definite situations where disposable lenses are appropriate, and some situations where they should be avoided. Exercising caution with the use of any contact lens helps to prevent complications. Check our disposable contact lens Newsletter.

 

Extended Wear Contact Lens Use

Many people are able to wear lenses continuously for many days with no apparent problem or complication. However, sleeping in contact lenses, while convenient, substantially increases the risk for infection and other complications. The oxygen supply to the cornea drops overnight while wearing a contact lens. This can lead to swelling of the cornea (giving blurred vision or the visualization of rainbows around lights), breakdown of the corneal surface, and ultimately infection of the cornea (ulcer). This risk is high enough that many eyecare providers discourage against the use of contact lenses on an extended wear basis. If the lenses are used this way, extreme caution should be taken, and the lenses should be removed with any sign of trouble (eye redness, pain, blurred vision, sensitivity to light, etc.) In fact, it may be reasonable to consider refractive surgery as an alternative to extended wear contact lens use.

 

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Introduction: Medical Disorders Causing Eye Problems

 

This section discusses a selection of medical disorders which are known to lead to a variety of eye problems. Links to other pages discussing medical conditions causing eye problems are provided as well. There are many medical disorders where eye complications are found as part of a larger symptom complex. In some cases, several different parts of the eye, orbit, or visual system can be affected by the condition, which is why they are discussed on this page rather than on a specific symptom category page. One example is thyroid related ocular problems, which is discussed on the Double Vision section. This condition not only causes double vision due to eye muscle involvement, but also can cause dry eye problems, eyelid problems, and potential loss of vision. Since the eye muscle problems are relatively common with thyroid dysfunction, it is discussed in that section. In some cases, a medical physician may request an eye examination to determine if the eyes are being affected by the medical condition. There are numerous conditions which potentially have eye complications, and only a few are discussed here.

This page is divided into a group of medical disorders which also can affect the eyes. The next section discusses other medical disorders discussed elsewhere that have ocular complications.

 

Conditions Discussed in this Section:

Cicatricial Pemphigoid

Myasthenia Gravis

Sarcoidosis

Lyme Disease

Eye and Orbital Cancer

Other medical condtions causing eye problems found in other sections, such as thyroid related eye disorders, temporal arteritis, and stroke.

 

For eye anatomy explanations, go to ANATOMY

 

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Cicatricial Pemphigoid

 

Cicatricial Pemphigoid (also known as ocular cicatricial pemphigoid and benign mucous membrane pemphigoid) is a relatively rare chronic inflammatory disease mainly affecting mucous membranes, such as the conjunctiva and inside of the mouth. Sometimes the throat, esophagus, and other areas are affected as well. In 25% of cases, the skin itself is involved. Patients most commonly affected are females under the age of 60.

 

When the eyes are involved (75% of the time), the condition usually begins as a chronic conjunctivitis, followed by scarring of the conjunctiva. One, or more commonly both, eyes can be affected. Over time, this leads to bands of scar tissue connecting the surface of the eye to the inside of the eyelid (symblepharon), with a loss of the space between the eyelid and the eye (the conjuctival fornix). This can lead to inturning of the eyelid (entropion), and inturning of eyelashes (trichiasis) which can scratch the eye. The scarring of the conjunctiva can lead to a loss of mucous secreting cells which help to lubricate the eye, as well as closure of tear glands (lacrimal ducts). This leads to drying of the corneal and ocular surface, which potentially can cause symptoms of dry eye (gritty sensation, burning, light sensitivity, and loss of vision), as well as more severe corneal ulceration, scarring, and neovascularization (growth of blood vessels on the corneal surface). Blindness from these problems occurs in 25% to 33% of patients with the disorder. Other areas of the body can be involved as well, requiring care from dermatologists, gastroenterologists, and ENT specialists. A rheumatologist or internist may coordinate treatment of the patient.

The diagnosis of the disorder is usually based on clinical findings. However, biopsy of the conjunctiva, or other involved mucous membranes or skin, can give a definitive diagnosis 80% of the time. Immunopathologic techniques, such as direct immunofluorescence or direct immunoelecton microscopy can identify linear immune deposits at the level of the epithelial basement membrane of the examined tissue. Other disorders which can simulate ocular cicatricial pemphigoid include:

 

Acne rosacea

Drug induced pseudo-pemphigoid

Infectious disorders, such as fungal infections

Chemical burns

Sarcoidosis

Squamous cell carcinoma of the conjunctiva

Stevens-Johnson syndrome

Trachoma

Epidermal bullosa

Atopic keratoconjunctivitis

 

The disorder requires systemic treatment (oral medication) rather than simply local treatment to the eye. Immunosuppressive agents, such as steroids and dapsone (a sulfa derivative), are used, but can have side effects. Dapsone has showed improvement in the ocular and oral condition in up to 88% of cases. Laboratory testing is required while dapsone is used to rule out hemolytic anemia. In more severe cases, cyclophosphamide, steroids, and azathioprine in combination can be used.

 Supportive ocular care involves dealing with complications of the conjunctival scarring, and restoring the ocular surface lubrication. Preservative free lubricating ointments and drops need to be used frequently. Treatment of eyelid malpositions and inturning eyelashes can prevent corneal scarring. In some cases, corneal transplant may be necessary to restore corneal clarity, but the results are often disappointing even when the underlying disease can be controlled.

 

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Myasthenia Gravis

 

Myasthenia Gravis is an autoimmune disease of the muscles leading to weakness and easy fatigability. Commonly (80% to 90% of cases), the disorder presents itself with drooping upper eyelids (ptosis) and double vision. The symptoms are typically highly variable, intermittent, and may be asymmetrical between the two eyes. There may also be speech and swallowing difficulties, problems with facial expression, and weakness of the muscles of the arms and legs. The symptoms tend to improve after rest and in the morning, and tend to be worse later in the day and after exercise. The underlying problem is the development of antibodies to neuromuscular receptors present in all muscles (acetylcholine receptors). There is some relationship with the thymus gland, and there is a positive family history in about 5% of cases. Symptoms tend to appear in the middle age years for men and women. Some cases have occurred after bone marrow transplantation.

Patients with prominent ocular symptoms often develop a fairly severe drooping of one or both upper eyelids, worse when tired, that may interfere with vision. The double vision associated with myasthenia can be variable, and does not usually fit into a typical pattern of any one specific eye muscle being involved. Two recent tests that can be suggestive of myasthenia are the sleep test, and the ice pack test. In the sleep test, the degree of eyelid drooping and double vision lessens after the patient sleeps, or rests in a quiet, darkened room, for 30 minutes. In the ice pack test, the ice is placed over the droopy eyelid for 2 minutes. If the drooping lessens by 2 millimeters or more, myasthenia may be a cause. There are other office tests that can be performed to aid in diagnosis (Tensilon test).

Treatment of the disorder has typically been with drugs that block the enzyme that degrades the neurotransmitter acetylcholine at the neuromuscular junction. Thus, the neurotransmitter will stay in the junction longer, and is better able to stimulate the muscle to contract. However, these drugs seem to be less effective in reducing the ocular symptoms than those related to other parts of the body. Steroids and other immunosuppressants such as azathioprine have been successful in reducing ocular symptoms, and in slowing the worsening of the disease over time. These medications are not without side effects, and need to be closely monitored by the treating physician. In some cases, removal of the thymus gland may help the disorder. 

 

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Sarcoidosis

 

Sarcoidosis is an inflammatory disease of the body which commonly affects the eyes (25% to 50% of patients). It is more frequently seen in African-Americans at a rate of 10:1 compared to Caucasians. Females tend to be more commonly affected. Multiple systems throughout the body can show symptoms. Granulomas, or inflammatory nodules, develop in organs and throughout the body. They lungs are commonly affected (90% of cases), and pulmonary function may be reduced. Chest X-rays are commonly monitored in sarcoidosis, since nodules in and around the lungs can be visualized. You can see the difference in the chest X-rays above with the clouding around the heart in the second X-ray compared to the clear film to its left. Skin nodules can occur, as well as muscle aches, generalized fatigue, and low grade fever.

Less commonly, neurological and central nervous system involvement can occur, potentially affecting the visual system. An inflammatory neuropathy of the optic nerve (photo on the far right) of one or both eyes can lead to a loss of vision, or blind spots in the vision. The fourth photo from the left shows several small sarcoid retinal lesions. Involvement of the brain itself can cause visual loss. Paralysis of the third cranial nerve has been reported, leading to double vision, as well as the facial nerve (seventh cranial  nerve), leading to a paralysis of the facial muscles. The most common ocular complication of sarcoid is inflammation within the eye, known as iritis or uveitis. In fact, sarcoidosis is one of the most common identifiable causes of uveitis in adults. Symptoms of uveitis can range from ocular redness, aching, and sensitivity to light, to blurred vision and floaters in the vision.

Eyelid nodules (middle photo above) and orbital nodules can affect ocular movement, and in some cases, cause protrusion of the eye itself. If the tear gland (lacrimal gland) is involved, tear production may stop, and a significant dry eye problem can ensue. In some cases, nodules of the conjunctiva can occur. Biopsy of conjunctival or lacrimal gland nodules can be useful for diagnosis. The cause of sarcoidosis is unknown. Diagnosis is by clinical findings as well as laboratory testing (elevation of the ACE level, or angiotensin converting enzyme level), chest X-ray, biopsy of nodules, and in some cases, Gallium scan of the head and neck. Treatment is by anti-inflammatory agents, most commonly steroids by mouth. Since the disorder tends to be chronically recurrent, the amount of steroid is titrated to the level of disease activity. In some cases, sarcoid has only a mild, self-limited course. In more severe cases, or in those affecting the central nervous system, stronger anti-inflammatory agents such as cyclophosphamide may be needed. Ocular steroids, usually in the form of eye drops, can control inflammation, but may lead to complications of cataract and glaucoma. 

 

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Lyme Disease

 

Lyme disease is a multi-system disorder caused by an immune reaction to the spirochete Borelia burgdorferi transmitted by the Dear tick (Ixodes dammini). There are common ocular complications during all stages of Lyme disease. The disease is most common in the Northeast and upper Midwest United States. It involves joint pain and dermatological and ophthalmic findings, as well as neurological and cardiac abnormalities. Three stages of Lyme disease have been described, which may overlap:

Stage 1: The earliest stage includes a flu-like illness with a typical expanding "bull's-eye" rash. This may or may not be associated with a known tick bite. Some patients can develop conjunctivitis during this stage.

Stage 2: The second stage of the disease (after weeks to months of the disease) includes cardiac involvement (8%) and neurological involvement (15%). This can include meningitis and paralysis of cranial nerves. Paralysis of the third or sixth cranial nerves affect eye movement, and lead to double vision. Paralysis of the seventh cranial nerve causes Bell's palsy, or drooping of one side of the face. During this stage inflammatory ocular disorders such as iritis, retinal vasculitis, chorioretinitis, and optic disc edema can occur. These conditions can cause a loss of vision.

Stage 3: The last stage of the disease, starting within 2 weeks to 2 years of the infection, include arthritis and chronic neurological syndromes. This includes fatigue syndromes and focal central nervous system disorders. Ocular findings in this stage include corneal inflammation (keratitis) and double vision.

Treatment of Lyme disease is by commonly available antibiotics. Longer treatment is required for cases with neurological involvement, and intravenous antibiotics are required for severe neurological involvement and arthritis. 

 

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Eye and Orbital Cancer

 

There are numerous malignancies that can affect virtually any part of the eye, eyelids, orbit, and optic nerve. Fortunately, these conditions are very rare. Due to the wide scope of information concerning ocular and orbital malignancies, I recommend the following site for further information on this subject: eyecancer.com. This site contains an excellent review of ocular, orbital, and eyelid malignancies, including photographs, case histories, and treatment options. The site is written by a prominent specialist in the field of ocular cancer.

 

Other Medical Conditions causing eye problems found in other sections:

Temporal Arteritis - Giant Cell Arteritis- a medical condition of the elderly associated with headache, arthritis, and visual loss.

CVA - Cerebrovascular Accident - Stroke- a stroke involving the brain or the visual pathways from the eye to the brain can lead to blind spots in the vision.

Thyroid related eye disease - scratchy sensation, double or blurred vision, protruding eyes.

Diabetes Mellitus - can cause retinal problems, glaucoma, and cataract.

 

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Introduction: CATARACT

 

Cataract is a common condition affecting the adult eye. One study found visually significant cataract to be present in 14% of men and 24% women aged 65 to 74, and in 39% of men and 46% of women aged 75 years and older.

It has been found to be the leading cause of blindness (although curable) in people over 40 years, and millions of cataract procedures are needed to be performed in this country annually. However, not all cataracts need to be removed. This section discusses adult cataract and cataract extraction.

 

Topics Include:

What is a cataract?

What causes a cataract?

When does acataract need to be removed?

How is a cataract removed and what are the risks?

 

For eye anatomy explanations, go to ANATOMY 

 

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What is Cataract?

 

Cataract is a clouding of the natural lens within the eye. It can be congenital or age-related (see photos at the right). Usually both eyes are affected, although one may be more severe than the other. Nearly everyone will develop some clouding of the lens by age 60, but the vision may not be affected. 

Since light must pass through the lens to reach the retina, visual disturbances are the main symptoms of cataract. Cataract within the lens of the eye distorts and blurs visual images. Possible symptoms include:

A usually gradual blurring of the vision at distance or near which may not be correctable with glasses.

A shift in the eye's refractive error (or glasses prescription) toward nearsightedness. Some people experience "second sight", or the ability to read without glasses at near due to nearsightedness.

Glare symptoms, sometimes worse at night (headlights), other times worse during the day. Sensitivity to light, but not pain.

Halos around lights and double vision (through one eye - double vision can also be caused by misalignment of the eyes, but if one eye is closed the double image disappears).

Worsening color vision, although this may be so gradual that it is not appreciated. Cataract does not cause pain (except is very advanced cases), redness, scratchy feelings, and cataract is not a "skim growing on the surface of the eye".

 

Different types of cataract include:

"Nuclear" cataract - this is a gradually worsening haziness in the nucleus, or center of the lens. This tends to change very slowly, and my cause a change in glasses prescription.

"Cortical" cataract - this is a clouding just inside the lens, and may cause glare symptoms. 

"Posterior subcapsular" cataract - this is a crust-like formation near the back surface of the lens. This tends to affect the vision more rapidly, and is more common in younger eyes (under 60 especially).

Many cataracts may have varying degrees of all of the above types mixed together.

 

What causes a cataract?

 

It is not fully understood what causes cataract in most cases, why one eye is often worse than the other, and what can be done to slow the worsening of cataract.

Ongoing research is being directed in these areas. Some known causes of cataract include:

A change in the lens due to normal aging processes. By a certain age, it may be normal to develop some cataract in the lens, although the vision may not always be affected. There may be a family tendency to develop certain types of cataract at certain ages. Association with certain medical problems, especially diabetes. Association with certain medications, such as long term or high dose steroids. There has been established an increase risk for cataract in men who smoke, and an increase risk for cataract extraction in women who smoke. Cataract can occur after ocular trauma (sometimes very rapidly in severe trauma), and after intraocular inflammatory problems (iritis).

 

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When does a cataract need to be removed?

 

A cataract does not need to be removed just because it is present; there needs to be a visual impairment present to warrant surgery. Less emphasis now is being placed on a required loss of visual acuity (20/50 vision or worse, in the past), and instead more emphasis is being placed on a loss of functional ability related to visual loss. A cataract does not have to be "ripe" before is can be removed. In other words, one does not have to wait until they have a complete loss of vision before a cataract can be removed. It is important to have a complete, dilated eye examination, preferably by the operating ophthalmologist, in order to determine if cataract is present, and if it is causing any loss of vision.

The examining physician will ask vision related questions regarding daily activities, such as difficulty driving, reading, working, enjoying hobbies, or trouble with glare. These questions help the ophthalmologist to understand the exact nature of any visual problems that the patient is having.

In many instances, a simple change in glasses prescription can substantially improve the vision, and cataract surgery can be deferred. However, quality of vision problems, such as glare, may remain in spite of new glasses 

After the complete examination, if there is an uncorrectable (with glasses) loss of vision, the ophthalmologist should have a good idea as to whether or not cataract is the cause, and whether or not removing the cataract would help to restore the vision. Other eye problems such as corneal disease, glaucoma, retinal problems, or optic nerve problems may limit a full recovery of vision. Sometimes, other tests are needed to help to sort this out.

Cataract surgery is considered if a loss of vision is caused by the cataract, and if it seems that improvement would occur in vision with surgery. Generally, if a loss of vision, or other cataract related visual side effects (such as glare) are interfering with a person's lifestyle, cataract surgery is considered. A careful explanation of the risks and potential benefits need to be explained to the patient by the surgeon prior to surgery.

 

How are cataracts removed and what are the risks?

 

Cataract extraction is a highly refined and successful surgical procedure using state-of-the-art technology. The goal of the surgery is to allow a return of vision as fast as possible and without restricting a person's lifestyle during the recovery period. Cataract surgery is done as an outpatient operation in a operating room. A person has dilating drops placed in the eye prior to surgery. Anesthesia is a combination of sedation with local anesthesia. A person does not have to be "put to sleep" for the operation, but many patients will fall asleep during the operation.

The operation usually takes about 30 minutes to perform. The cloudy portion of the lens (the cataract) is removed from the eye using a technique known as phacoemulsification (1st photo). This uses ultrasound to break apart the lens, which is then aspirated using fluid suction. Lasers are not used to remove a cataract at this point. A lens implant is then placed back into the eye where the old lens used to rest (photo at the right). This implant is a plastic lens of a particular power to help to minimize the need for glasses after the operation. The implant does not need to be exchanged or removed, except in extremely rare circumstances. The opening through which the surgery is done (millimeters in size) may or may not need to be closed with fine dissolvable sutures.

The patient usually returns home within one to two hours after the completion of surgery, usually with a patch covering the eye. This is removed the next day in the office, and eye drops are then prescribed to help with the healing process. These eye drops are tapered over a period of time. At about a month after the operation, glasses can be prescribed, if needed. If the second eye needs to be operated on, this is usually done 2-4 weeks at the earliest after the first operation.

 

Generally, cataract surgery is highly successful. However, there are some risks:

With any surgery, there is risk of infection and bleeding. This is very rare with cataract surgery.

There is risk that the eye may not be able to see as well as predicted, due to an addition problem with the eye not previously seen.

There is risk that an unexpected glasses prescription will result, although this is becoming rarer with improved equipment used to determine the power of the lens implant.

There is a chance that the membrane that the lens implant rests on in the eye may become cloudy with time. If this cloudiness begins to affect vision, this membrane can be opened using a laser in a 10 minute procedure done outside of the operating room.

There is a low (about 1%) risk of retinal detachment after cataract surgery. There is also a slight risk of a usually temporary swelling of the retina after surgery. There may be other risks in people with diabetes, glaucoma, macular degeneration, and other eye conditions. These need to be discussed by the ophthalmologist.

 

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Introduction: Diabetic Eye Disease

 

Diabetes mellitus is the leading cause of new cases of legal blindness in working age Americans. It is estimated that 14 million Americans have diabetes, but that only one half of these are aware of it. This page discusses ocular complications of diabetes, and their treatment.

 

Topics Include:

Retinal Complications of Diabetes

Background diabetic retinopathy

Diabetic macular edema

Proliferative diabetic retinopathy

Evaluation and Treatment of Diabetic Retinal Disease

Other Ocular Complications of Diabetes

Fluctuations in vision

Cataract

Glaucoma

Prevention of Complications

 

For eye anatomy explanations, go to ANATOMY

 

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Retinal Complications of Diabetes Mellitus:

 

Diabetes Mellitus is more than just a problem with the control of the blood sugar. It is a vascular disease: a disease of the blood vessels. Diabetes can lead to complications throughout the body, including blood vessel problems in the kidneys, heart, brain, and eyes. The retina lines the inside surface of the eye and receives and processes visual information for their transmission to the brain via the optic nerve. The primary source of blood supply to the retina comes from a single artery, the central retinal artery, which enters the eye through the optic nerve. Once inside the eye, the artery branches on the surface of the retina into smaller and smaller vessels to supply all of the retina 

An especially critical part of the retina is the "macula" which serves the central vision of the eye, or the reading vision. There is a pin-point spot of the macula called the "fovea" which has the sharpest vision.

The eye is unique in that living blood vessels in the retina can be observed by the examining physician. A number of problems can arise in the retina as complications of diabetes. Risk factors for the development of these complications include:

 

The type of the diabetes: Type 1 diabetics generally are younger at onset, and require insulin for survival. Type 2 diabetics are usually older at onset, and the diabetes may or may not require oral medication or insulin for control.

The control of the diabetes: It has been found that very tight control of the blood sugar (and associated hypertension) can reduce the risk of retinal complications (in both Type 1 and Type 2 diabetics).

The presence of other medical problems such as increased blood pressure or cholesterol. The duration of having diabetes.

It has been found that the longer one has diabetes, that there is more risk for developing retinal complications:

After 5 years, 25% of insulin-dependent diabetics have some retinopathy. After 10 years, 60% have retinopathy. After 15 years of insulin-dependent diabetes, 80% have retinopathy, with 25% having the more severe "proliferative diabetic retinopathy".

 

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Background Diabetic Retinopathy (Non-proliferative Retinopathy)

 

The earliest or mildest diabetic effect on the retina is called "background diabetic retinopathy". This condition can occur in one or both eyes in people with diabetes. When the ophthalmologist examines the retina (usually after dilation), small hemorrhages can be seen scattered within the retina. Irregularity of blood vessels, and mild blockage of blood vessels also can occur. Small dilated blood vessels called "microaneurysms" commonly occur, and appear as tiny red dots in the retina.

 

 

Clear fluid can leak from these microaneurysms and from abnormal damaged blood vessels into the retina. When this occurs, the retina will swell in thickness like a sponge, and white deposits, or exudates, can form. This is seen in the two top photos. This swelling can damage the vision, if present for a long enough time.Background diabetic retinopathy can occur in people who are not even aware that they have diabetes. An ophthalmologist observing such incidental findings during a retinal examination might suggest an evaluation to look for diabetes being present.

 

Background diabetic retinopathy itself does not usually damage the vision, but it does indicate that diabetes is affecting the vascular system of the eye and probably of the entire body. People with background diabetic retinopathy are usually re-examined within 6 months. In the two photos above, the yellow appearing (actually white) "cotton wool patches" in the photo on the right are areas of retinal death followed by acute swelling. You can see the areas in the schematic and also in the fluorescein angiogram as filling defects where the blood no longer flows. This is a sign of significant diabetic damage.

 

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Diabetic Macular Edema

 

A complication of background diabetic retinopathy, and also of more severe forms of diabetic retinopathy, is diabetic macular edema. Edema is swelling of the retina. The macula, as discussed above, is responsible for the sharpest, central vision that a person has. In diabetic macular edema, clear fluid leaking from damaged blood vessels in the retina and from microaneurysms causes the retina to swell and thicken. When this occurs in the macula, the reading or central vision is at risk, and can be lost. Extensive studies have been undertaken to determine when diabetic macular edema should be treated, and when it can just be monitored. Sometimes an additional test called a "fluorescein angiogram" can be done to help to determine the source and extent of fluid leakage.

Proliferative Diabetic Retinopathy

 

A more severe retinal complication of diabetic eye disease is "proliferative diabetic retinopathy". Fortunately, only a small number of diabetics will develop this complication, but it is still treatable. Here, the vascular damage to the retina worsens, with more extensive hemorrhages, abnormal blood vessels, areas of blocked off blood vessels, and fluid leakage into the retina. The closure of small retinal blood vessels can become so severe that parts of the retina begin to produce a chemical (recently identified) that stimulates the growth of NEW blood vessels. This chemical spreads into the jelly-like material that fills the eye, and can affect many different parts of the eye.

The new blood vessels which form in response to this chemical are abnormal, frail, and tend to grow out off of the retinal surface into the vitreous body, which is a gel-like material that fills most of the eye. They tend to break and bleed, causing large hemorrhages inside of the eye, and can become scarred, leading to retinal detachments. In a detachment, the retinal is tented off of the wall of the eye, being pulled up by these abnormal blood vessels

This complication of diabetes requires more extensive treatment, and sometimes intra-ocular surgery done in the operating room. Sometimes blood vessels can block off supplying the central vision itself. If this occurs, the central vision is lost and cannot be regained.

 

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Evaluation and Treatment of Diabetic Eye Disease:

 

The diagnosis of diabetic eye disease requires dilated retinal eye examinations at periodic intervals. If there is no retinal complications of diabetes, an annual examination is suggested. If there are retinal changes present, follow-up examinations ranging from 1 to 6 months may be necessary. In cases of more severe retinal complications, an additional test if often done:

 

Fluorescein Angiogram

 

A fluorescein angiogram is a test done in the office where a yellow-pigmented dye is photographed as it passes through the retinal blood vessels. For this test, the eyes are dilated, and initial color photographs are taken of the retina by the photographer. Then, the fluorescein dye is injected into an arm vein by a physician. This is similar to having blood drawn. Once the dye is in, the needle is removed, and the photographs are taken. The dye reaches the eye in a matter of seconds. About 30 photographs are taken between the two eyes over a 10 minute time span. The film is then developed, and the ophthalmologist studies the results. Important information about the leakage and blockage of blood vessels can be gained from this test, as well as the presence of abnormal blood vessels.

 

Treatment of diabetic retinal disease:

 

Very careful control of blood sugar is the hallmark of the basic treatment for all types of Diabetes Mellitus. If background diabetic retinopathy occurs, it  is usually observed closely unless progressive changes occur. Many diabetic retinal problems are treated using a laser. The laser casts a tiny spot of light onto the retina in order to seal leaking blood vessels or to prevent the formation of abnormal blood vessels. Laser treatment is done as an outpatient operation, and usually only eyedrop anesthesia is needed. The patient is seated at the laser, and treatments usually range from 5 to 20 minutes. Occasionally, repeat treatments are required.

For diabetic macular edema, the laser is used to seal leaking blood vessels which are causing the retina to swell dangerously. This procedure is called "focal" or "grid photocoagulation". Studies have identified precise situations when this condition should be treated. The vision does not need to be reduced before treatment is done, since the goal of the surgery is to maintain the vision at least at where it is.

For proliferative diabetic retinal disease, the source of the chemical causing abnormal blood vessels to grow within the eye must be eliminated. The laser is used to diffusely treat retinal areas which have lost their blood supply to allow the abnormal blood vessels to stop growing and shrink down. Sometimes this laser surgery is broken up into several "sittings". In cases where extensive bleeding has occurred inside of the eye, or if retinal detachments have formed, intra-ocular microsurgery is needed to correct the problem. This is termed a "vitrectomy", and is usually performed by a retinal specialist in the operating room.

 

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Other Complications of Diabetes:

 

Fluctuations of Vision

 

If the blood sugar in diabetes becomes elevated to a very high level (usually over 300) the natural lens inside of the eye can become affected. The high levels of sugar leach into the lens, and cause it to begin to swell with fluid. This can cause a shift in a glasses prescription, often toward farsightedness. Vision can become progressively blurrier for both reading and distance vision, and usually both eyes are affected. After the blood sugar is brought under control, the lens may remain swollen for weeks! It may take up to 6 weeks for the glasses prescription to return to normal in some cases. A person may have to go through several temporary pairs of glasses in order to function during this transition.

 

Cataract 

 

Diabetes is a risk factor for developing cataract, which is a clouding of the lens within the eye. If this occurs, the vision may become permanently blurred and not improved with a change in glasses. Sometimes, cataracts associated with diabetes can be more rapid to develop and can have more severe glare symptoms. Cataract extraction can cure the problem, but there is some risk of a flare up of diabetic retinal disease immediately after surgery. The reason for this is not well understood. Sometimes, cataract can be so severe that the retina cannot even be examined by the ophthalmologist, and the cataract may have to be removed just to be able to see or treat the retina. Please see the full section on Cataracts for more information.

 

Glaucoma

 

Diabetes may increase the risk of glaucoma, a disease where usually increased pressure in the eye damages the optic nerve carrying visual signals from the eye. A more severe form of glaucoma can occur also, called "neovascular glaucoma". Here, abnormal blood vessels begin to grow on the iris near the front of the eye. This can occur with proliferative diabetic retinopathy. If laser surgery is not done to force regression of the blood vessels, they can continue to grow and can rapidly damage the outflow channels of the eye. Once these channels are scarred closed, the pressure in the eye can skyrocket in a form of glaucoma that is very difficult to treat. Please see the separate section on Glaucoma for more information.

 

Prevention of Diabetic Complications

 

Early detection of diabetic eye complications is the key to successful treatment. The patient with diabetes should watch out for any changes in vision, and keep regular appointments with an ophthalmologist knowledgeable in the diagnosis and treatment of diabetic eye disease.

A person recently diagnosed with diabetes should have a complete eye examination. If the retina is free of any diabetic complications, the eye exam should be repeated annually.

If there is a blurring of vision, this may indicate that the blood sugar is elevated. If the blurred vision continues, or if floaters or other symptoms are experienced, the eyes should be re-examined.

With active diabetic retinopathy, even if mild, the eyes should be examined at 1 to 6 month intervals.

Tight control of the blood glucose and associated hypertension is essential to preventing retinal complications of diabetes. This is true for all types of diabetics, from diet controlled diabetics to insulin dependent.

If a patient's medical physician desires to intensively control the diabetes, it may be necessary to have a retinal examination prior to this change in medical treatment. Some patients can develop "early worsening" of diabetic retinopathy when very tight control is begun (and for the first 1 to 2 years). Especially in cases with pre-existing retinopathy, examinations every 3 months may be necessary to prevent complications from diabetic retinopathy during this transition.

 

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Introduction: Age-Related Macular Degeneration

Topics Include:

What is the Macula?
What is macular degeneration?
What are the symptoms of macular degeneration?
How is macular degeneration diagnosed?
What are the current treatment options for macular degeneration?
What about smoking?
Do vitamins have an impact on the development of macular degeneration?
What are Lucentis and Avastin?
What about macular degeneration research?

 

What is the macula?  

The normal macula (seen at the right) is an oval area in the retina on the back of the eye where the photoreceptors are most dense and where the light is focused. The center of the macula is called the fovea. The macula is responsible for the central (or reading) vision. The macula has the greatest concentration of photoreceptor cells, and when the eye is directed at an object, the part of the image that is focused on the fovea is the image most accurately seen.

 

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What is macular degeneration?

In the western world, age-related macular degeneration (AMD or ARMD) is the leading cause of legal, irreversible blindness among people 50 years of age and older.

There are two types of macular degeneration: Dry and Wet:

Dry macular degeneration (atrophic AMD) is the most common form of macular degeneration (seen at the right) and can progress to cause severe central vision loss. This disease progresses slowly and most people usually maintain some central vision in at least one eye. The condition always starts as "dry" AMD. "Dry" AMD refers to the slow degenerative process that occurs without any formation of abnormal blood vessels. The recent Age-Related Eye Disease Study (AREDS) demonstrated that the progression of "dry" AMD could be slowed with vitamin supplementation. This study demonstrated the benefits of taking Vitamin C, Vitamin E, beta carotene, and zinc along with copper. Several vitamin preparations containing the appropriate amounts of these vitamins are currently available and we encourage patients with AMD to discuss these various vitamin preparations with their eye care specialist. Previous studies have also suggested that green leafy vegetables may be beneficial and smoking may be detrimental to patients with AMD.

 

"Wet" macular degeneration (exudative or neovascular AMD), as seen to the right, is caused by blood vessels growing under the retina in the macula. "Wet" AMD always arises from pre-existing "dry" AMD. These blood vessels leak fluid, protein, lipid and blood. Eventually, if untreated, scar tissue forms under the macula and central vision is destroyed. Current treatments approved for "wet" macular degeneration include thermal laser therapy and photodynamic therapy with Visudyne®.

 

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What are the symptoms of macular degeneration?

There is no pain associated with dry or wet AMD. The most common symptom of dry AMD is slightly blurred or fuzzy vision requiring greater illumination to see greater details. Also, an inability to recognize faces at a distance may develop.

As dry AMD progresses, a blurred spot develops in the center of vision (see photos below). With time, the spot may get bigger and darker, reducing central vision. Often, when dry AMD is limited to one eye, patients do not complain of visual changes because of the ability of the other healthy eye to see clearly, allowing for driving, reading, recognizing faces and seeing fine details.

    Symptoms of wet AMD may be that straight lines, such as sentences on a page, appear wavy as seen in the first image on the right, or progress to rapid loss of central vision as seen in the far right image with a blurred or blind spot in the center of vision.

How is macular degeneration diagnosed?

If an ophthalmologist suspects a patient of having AMD, they will

perform a visual acuity test to measure vision at a distance

perform a dilated pupil examination to see the inside of the eye with an ophthalmoscope to check for drusen (tiny yellow deposits on the retina which are the most common early signs of AMD)

ask the patient to look at an Amsler grid with a pattern of straight horizontal and vertical lines. To the person with AMD, the lines appear wavy, distorted or missing or a black spot may appear in the center of the grid.

perform a fluorescein angiography. During this test, a dye is injected into the arm and quickly travels throughout the blood system. Once the dye reaches the blood vessels in the back of the eye, photographs are taken of the eye. The dye allows the ophthalmologist to detect blood vessels that are abnormal and leaking dye.

 

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What are the current treatment options for macular degeneration?

Currently, treatments for macular degeneration are rapidly advancing and changing approximately every three months. It is anticipated that for the next three to five years, the treatment will be changing all the time. Various treatments are currently available, but most of these treatments are directed at the early stage of wet AMD. Regardless of the treatment therapy followed, patients with advanced dry macular degeneration should check the vision in each eye, one at a time, at least once a week. By staring at the central point on an Amsler grid (see printable copy on the Vision Tests page), patients can help monitor their vision regularly and can detect distortions in vision. These distortions represent the earliest stages of dry or wet macular degeneration.

Promising treatments for wet AMD are drugs recently approved by the FDA, Lucentis and Avastin.. Patients with wet AMD have high levels of the vascular endothelial growth factor (VEGF) protein in their affected eyes. VEGF is a protein that causes the abnormal blood vessels to grow, leak, bleed, and damage a part of the retina known as the macula resulting in loss of central vision and interfering with driving, reading and other everyday tasks. Studies published in the New England Journal of Medicine showed that levels of VEGF protein were increased in eyes that developed abnormal new blood vessels, and that VEGF-blocking drugs (Lucentis and Avastin) were able to prevent the growth of these abnormal blood vessels.  These drugs are administered by injection into the eye every six weeks in an ophthalmologist's office.  They are the first drugs to be approved in a new class of ophthalmic drugs that specifically target the VEGF protein.

Despite all these advances, we still do not have effective therapies for the majority of patients with dry AMD. For this reason, the best option for many of our patients is to receive low vision training. Whether it is vision loss for conditions such as AMD, glaucoma or diabetes, low vision aids help patients perform normal activities of daily living and lead independent lives.

 

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Do vitamins have an impact on the development of macular degeneration?

The National Eye Institute, one of the federal governments National Institutes of Health, sponsored a major clinical trial called the Age-Related Eye Disease Study (AREDS) whose results were published in the October 2001 issue of Archives of Ophthalmology. Scientists found that high levels of antioxidants and zinc may reduce the risk of losing vision in the future from age-related macular degeneration.

What is the dosage of the AREDS formulation?

The specific daily amounts of antioxidants and zinc used by the study researchers were:

500 milligrams of vitamin C

400 International Units of vitamin E

15 milligrams of beta-carotene (often labeled as equivalent to 25,000 International Units of vitamin A)

80 milligrams of zinc as zinc oxide; and

2 milligrams of copper as cupric oxide.

Copper was added to the AREDS formulations containing zinc to prevent copper deficiency anemia, a condition associated with high levels of zinc intake.

 

 What if I currently smoke or recently stopped?

In general, current or former smokers should not use these vitamins because they contain beta-carotene, which may increase the risk of lung cancer in smokers. (If you stopped smoking more than 10 years ago, your risk of lung cancer should be lower.) If you currently smoke, we recommend that you stop smoking. If you cannot, or if you only recently stopped smoking, then another vitamin preparation may be beneficial, although there is less scientific evidence. Look for vitamin preparations that do not include beta-carotene, but have lutein instead.

• In fact, it is generally recommended that the AREDS formulation should include the use of Lutein for anyone at risk or who already has evidence of macular degeneration.

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What about macular degeneration research?

There is much more that needs to be done to slow the progression of both dry and wet AMD, and even restore vision in patients with this disease. For those patients with wet AMD, there is significant hope in the very near future. Ongoing clinical research is investigating new treatment strategies using photodynamic therapy in the hope of saving much more vision in many more patients. These studies are underway and the preliminary results are very encouraging.

One of the newest strategies that holds promise is the use of new drugs that stop blood vessels in wet AMD and can cause existing blood vessels to regress. This new class of drugs is known as anti-angiogenic agents.

Lucentis • Avastin • Anecortave acetate

The most promising anti-angiogenic drugs are being investigated in patients with wet AMD. These drugs are injected either around or into the eye. The names of these drugs are rhuFab V2 (Genentech, Inc.), Avastin (Genentech, Inc.) and Anecortave acetate (Alcon Research Ltd.). We are optimistic about the preliminary results using these drugs, but it is important to understand that these drugs are only available to patients participating in a clinical study.

Recently, Avastin™ was shown to substantially reduce the leakage from abnormal blood vessels in eyes of patients with neovascular (wet) age-related macular degeneration (AMD).  Within 1 week, vision improvement occurred in patients treated with Avastin™, a drug designed to inhibit angiogenesis, the body’s process of making new blood vessels. Avastin™ is given through an intravenous infusion.

In addition to the improved vision, Avastin™ causes a reduction in leakage from the abnormal blood vessels, and a restoration of normal macular anatomy was observed. Avastin™, also known as bevacizumab, is presently approved by the FDA for the treatment of patients with metastatic cancer of the colon or rectum when used in conjunction with 5-FU based chemotherapy.

Patients with macular degeneration are thought to have elevated levels of vascular endothelial growth factor (VEGF) in their affected eyes.  VEGF is a protein that causes abnormal blood vessels to grow, leak, bleed, and damage the macula resulting in vision loss.  New anti-VEGF drugs work by blocking this protein and the formation of abnormal blood vessels that grow in the eye.

This isn’t a cure and it’s not the right treatment for everyone with wet AMD.  Some people would rather have an injection in the eye than worry about the risks from a systemic drug.  What this offers us is a new potential option for patients with wet AMD.  It also provides us with additional evidence that VEGF is the major factor responsible for blood vessel growth and vision loss in wet AMD.

Treatment for AMD traditionally included thermal laser photocoagulation therapy and photodynamic therapy.  Although neither treatment is a cure for wet AMD each treatment may slow the progression of vision decline or stop future vision loss.  While these therapies are effective for certain types of wet AMD, pharmacotherapy (drug therapies) represents the new era in macular degeneration treatment.

While Avastin™, approved by the FDA in February 2004, was the first drug that targets the VEGF protein, the FDA approval was for the treatment of metastatic colorectal cancer. Avastin™ is not approved for the treatment of macular degeneration. Macugen®, approved by the FDA in December 2004, is the first ophthalmic drug approved for the treatment of macular degeneration that specifically targets the VEGF protein.

We don’t know how many treatments will be needed. In this study, patients were treated twice or three times over a twelve week period.  As most patients commonly get wet AMD in both eyes, an added advantage of this therapy is that both eyes can be treated with a single infusion into the arm.

Other treatments and experimental therapies currently in development for AMD require an injection into the eye while Avastin™ is given systemically.  As a result, there are no apparent intraocular complications that arise from treatment with Avastin™ therapy.  However, there is a potential disadvantage of Avastin™ in that it is a systemic therapy with the risk of systemic side-effects.  The most significant risk we observed was the risk of elevated blood pressure, but this was easily controlled with medication.”  However, the FDA has issued an updated warning for Avastin™ in cancer patients receiving chemotherapy plus Avastin™. In these patients, there was an increased risk of thromboembolic diseases such as stroke and heart attack.  The risk of thromboembolic events in cancer patients was approximately two-fold higher in patients receiving infusions of 5-fluorouracil based chemotherapy plus Avastin™ compared with patients receiving chemotherapy alone, with an estimated overall rate of up to 4.4%.  Also, cancer patients receive Avastin™ every 2 weeks for many months while our patients initially received only 2 or 3 doses of Avastin™ given 2 weeks apart.  Only 2 treatments were sufficient to dry up the leakage in the eyes of wet AMD patients and the treatment benefit lasted for at least 3 months.

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IMT

For those patients who have experienced vision loss and are stable, there is a new low vision device that is undergoing clinical investigation. This device is known as an intraocular miniature telescope (IMT) and is inserted into the eye at the time of cataract surgery. While this device may not help all patients with AMD, there is a very good chance that the IMT could improve the ability to read and watch television. To determine if you are a candidate, you should contact your ophthalmologist.

The Future

All of our treatments, so far, are designed to treat the vision loss associated with wet AMD and slow the progression of the disease. None of the therapies really treat the underlying cause of AMD. While we do not yet know the cause, we do know this is a disease with a strong genetic basis. We are years away from developing a successful therapy based on genetic information, but the basis for this therapy begins with the genetic research currently underway and the help of families with AMD.

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Introduction: GLAUCOMA

 

Glaucoma is a common eye disease, with an estimated 2 million Americans being affected. It is the second most common cause of legal blindness in this country, and the first among African Americans. To make the situation even worse, glaucoma usually offers no symptoms until it is very advanced. Vision lost from glaucoma cannot be regained. 

 

This section discusses adult onset glaucoma, its diagnosis, and treatment.

 

Topics Include:

What is glaucoma?
What are the different types of glaucoma?
Who is at risk for glaucoma, and how is it diagnosed?
How is glaucoma controlled?
What about glaucoma surgery?

 

For eye anatomy explanations, go to ANATOMY

 

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What is glaucoma?

 

Glaucoma is an eye disorder where the nerve containing visual information from the eye (the optic nerve) back to the brain is damaged over time. Usually, a high pressure inside of the eye leads to a gradual loss of nerve fibers contained within the optic nerve. This leads to a loss of vision, usually involving the peripheral vision first. The relationship between the pressure inside of the eye and the risk of glaucoma is complicated.

The optic nerves shown in A show only minimal cups. Cups are a depression in the surface of the optic nerve. They are similar to a donut hole. If optic nerve tissue is damaged, the cup enlarges.

The nerves in B show moderately sized cups with normal and pink rims. If these cups had been smaller previously and had become larger due to a loss of optic nerve tissue, that would be glaucoma damage.

The optic nerve on the left in C to the right is normal. The optic nerve on the right shows a similarly sized cup, but damage is present. The rim tissue is pale due to a loss of blood and the retina shows zones of thinning due to the loss of nerve fibers. This optic nerve damage with the tissue loss results in a loss of part of this patient's field of vision. See series of photos below.

This optic nerve shows almost total loss of the neuroretinal rim with what is called a total cup. There is severe loss in the field of vision in this patient's eye

The normal eye pressure usually ranges between 10 and 21, with an average of 16, when measured by an eye doctor. The eye pressure (or IOP, for intra-ocular pressure) can vary throughout the day, and is not affected by blood pressure, reading, sinus problems, or eye-strain.

 

The series of photos here show, in order: a normal visual field, an abnormal glaucomatous visual field, a normal optic nerve with a moderate"cup"in its center, anormal optic nerve with a small cup in its center,and a glaucomatous optic nerve with both a large cup and a very narrowed rim of optic nerve tissue at the lower border of the optic nerve. The loss of rim tissue inferiorly (the lower portion of the nerve) causes the field loss (dark area) superiorly (the upper portion of the field) in the visual field test.

Some people can have a high eye pressure (over 21) consistently, and yet never suffer any optic nerve damage from the pressure.

Most people with elevated eye pressure will eventually get damage to the optic nerve. If the pressure approaches 30 or higher, the damage may come faster and be more severe. Some people can get optic nerve damage with even what is considered to be a NORMAL pressure (under 22, even as low as 14). This type of glaucoma is termed "low tension glaucoma". If the optic nerve becomes damaged by glaucoma, blind spots in the vision will occur. Usually this affects the peripheral vision first (the side vision). If it is untreated, the central vision can be lost from glaucoma as well. Usually both eyes are affected by glaucoma if it is present, but one eye may be affected more severely.

 

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What are the different types of glaucoma?

 

There are many different types of glaucoma, but basically they fall into two categories: open-angle and closed-angle glaucoma. The "angle" of the eye is an area where fluid drains from the eye back into the blood circulation. The eye produces fluid on the inside in order to maintain its shape and for nourishing structures within the eye. This fluid is drained by an area located at the junction of the cornea and the iris inside of the eye.

In "open-angle" glaucoma, this drainage area appears to be unobstructed when viewed by the physician. This is the most common form of glaucoma, and it is not fully understood why the pressure within the eye becomes elevated. It is also known as "primary open-angle glaucoma" (POAG) or as "chronic open-angle glaucoma" (COAG). In "closed-angle" glaucoma, the drainage angle is physically blocked, and is not visible to the physician.

 

Open-angle glaucoma

 

 Open-angle glaucoma is the most common form of glaucoma by far. It rarely offers any physical symptoms: there is no pain, no pressure sensation, no blurring of vision. The intra-ocular pressure is often only mildly elevated, and the optic nerve is gradually damaged over a period of months and years. Other, less common types of open-angle glaucoma include:

 

Pigmentary glaucoma

 

Here, pigment granules liberated by the iris and other structures within the eye are thought to clog the outflow channels. This variety tends to occur in younger individuals, and may be worsened by vigorous physical activity, which may disperse more pigment. This type of glaucoma can give symptoms because the pressure may spike to very high levels at times (over 40). This may cause eye discomfort, blurred vision, rainbows or halos around lights, or headache.

 

Low tension glaucoma (or normal pressure glaucoma)

 

This sub-category of open-angle glaucoma is characterized by optic nerve damage occurring at normal or even low intra-ocular pressures. This may be common in the very elderly (over 80). Other tests need to be done to diagnose this condition.

 

Closed-angle glaucoma

 

Closed-angle glaucoma is more rare, but also more severe in symptoms. During an attack of "angle-closure", the iris rotates toward the cornea and blocks the outflow channels suddenly and completely. Intra-ocular pressures over 60 are not uncommon, which can cause severe eye pain, nausea, vomiting, redness, blurred vision with rainbows around lights, and sudden loss of vision. This requires emergency treatment to cure, and usually requires a laser procedure to be done to break an attack or prevent future attacks. Often, the other eye, if at risk of an attack, is treated prophylactally by laser.

 

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Who is at risk for glaucoma, and how is it diagnosed?

 

Glaucoma can affect people of all races, background, and age, and can occur in people who are otherwise completely healthy. However, there are certain groups of people who are especially at risk for glaucoma. These include:

People over 60 years old

African-Americans

People with a family history of glaucoma

People with vascular diseases such as diabetes

People who are very nearsighted

 

It is recommended to have a complete eye examination for glaucoma:

At age 35 and 40

Every two to three years after age 40

Every one to two years after age 60

Every one to two years after age 35 if there are any special risk factors, as listed above

 

The diagnosis of glaucoma cannot be accomplished by a brief screening examination. While free pressure screenings done at health fairs can help to detect people with a high eye pressure, a normal pressure found does not rule out that glaucoma is present. This is because the pressure can fluctuate throughout the day, and because some people with glaucoma never have an elevated pressure. The examination to determine whether or not glaucoma is present includes the following:

 A complete eye examination, including checking the vision, pupil reaction, biomicroscopic examination of the structures of the eye, the intraocular pressure (tonometry), and an examination of the optic nerve and retina.

The eye pressure can be checked in different ways. The standard method is called "applanation tonometry". In this method, anesthetic drops are placed in the eyes and a device using a blue light gently touches the eye. Another method is "air-puff" tonometry. Special attention needs to be paid to the appearance of the iris, and of the drainage angle of the eye.

The optic nerve needs to be evaluated closely for evidence of damage from glaucoma. If there is suspicion for glaucoma, a "visual field" test can be done. This test is usually scheduled separately, and is run by a technician. This test usually lasts about 20 minutes, and the peripheral, or side, vision of each eye is tested for any blind spots. The ophthalmologist will then review the results of the test.

 

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 The "glaucoma suspect"

 

A person is considered a "glaucoma suspect" if there are risk factors present for glaucoma, but not any evidence of damage to the peripheral vision. Some cases of "glaucoma suspect" could include:

A person with a high eye pressure, but normal nerve appearance and normal visual field testing. (Also known as "ocular hypertension". 

A person with glaucoma in the family, and a suspicious appearance to the optic nerve, but normal visual field testing.

An African-American with a borderline high eye pressure and a family history of glaucoma. Usually, cases suspicious for glaucoma are followed more closely, with follow-up visits coming every 4 to 6 months.

 

The diagnosis of "glaucoma" itself

A diagnosis of glaucoma can be made if there is suitable evidence for glaucoma based on the eye examination performed by an ophthalmologist. Usually to diagnose glaucoma, there are blind spots in the field of vision. Other situations where glaucoma may be diagnosed include:

 

There is a very high eye pressure (over 30) or evidence of angle-closure glaucoma.

If there are repeatedly high eye pressures approaching 30 even in spite of a normal visual field test. Damage may be imminent in these cases.

If there is progressive worsening of the appearance of the optic nerve or worsening of blind spots on the visual field test.

Once diagnosed with glaucoma and treatment is initiated, follow-up examinations are usually at least every 3 to 6 months.

 

 How is glaucoma controlled?

 

Open-angle glaucoma usually cannot be cured, only controlled. Damage done to the optic nerve, and loss of peripheral or central (reading) vision usually cannot be restored, only prevented.

Proper use of medication by the patient, and consistent follow-up examinations are of the utmost importance in controlling glaucoma.

Once glaucoma is diagnosed, the main goal of treatment is to lower the pressure within the eye to the point that damage will not continue. Usually, initial treatment is in the form of eye drop medications.

In some cases more than one eye drop, and even oral medications can be used to control the pressure. Repeated follow-up examinations are needed to determine the effectiveness of any medication used to lower the pressure.

 

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Some important points about glaucoma medications include:

 

Eye drops (see photo to the right) used for glaucoma are administered at different times depending on the medication. Some are only once a day, while others are used up to four times a day. It is important to fully understand the physician's instructions about how often to use the medication.

If a medication is to be used more than once a day, it is important to spread out the dosages as much as possible. (Example: If an eye drop is to be used twice a day, and the first dosage is given at 7:00 AM, use the second dosage around 7:00 PM, not midnight.) Once the eye drop is administered, hold the eyes closed for a few minutes and apply pressure to the inside corner of the eye. This helps to prevent drainage of the eye drop immediately into the tear drainage system (and away from the eye) 

Since some of the eye drop will inevitably get into the tear drainage system, some of the medication could be absorbed into the general circulation. Glaucoma eye drops can cause physical symptoms in some people. Your physician will discuss this with you. Once the eye pressure has been lowered sufficiently with medication, the glaucoma is usually monitored about every 3 to 6 months. Once a year, the optic nerve is re-evaluated, and the visual field test is repeated. If damage still seems to be occurring, the eye pressure may have to be lowered further. Each individual eye has its own optimal pressure.

 

Surgical treatment of glaucoma

 

In cases where medication alone cannot control glaucoma, there are surgical options. Each carries its own potential risks and benefits.

Laser surgery: Angle-close glaucoma can be cured by a procedurecalled a "peripheral iridectomy" (1st photo). In thisprocedure, a laser makes small hole in the iris to redirect fluid flow within the eye. Open-angle glaucoma can be treated by a procedure called "argon laser, diode laser, or selective trabeculoplasty" (2nd photo). Here, the drainage angle of the eye is treated precisely by a laser to help open the drainage channels. With both procedures, recovery time is almost immediate.

Filtering surgery: This is a micro-surgical procedure done in the operating room under local anesthesia. A new drainage channel is made for fluid to exit the eye and form a bubble (or "bleb") under the conjunctiva, which is a thin membrane lining the white part of the eye. Usually, this bleb is hidden by the upper eyelid. Recovery time is usually 2 to 4 weeks after the procedure.

There are other options for the treatment of glaucoma, and new medications and procedures are frequently made available.

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Disclaimer. Please read this important information.

These sections are not intended to replace the professional examination and diagnosis by a physician, and they are presented here purely for informational purposes. All possible diagnoses and treatment options are not covered, and the information discussed should not be taken as a recommendation to self-diagnose and self-treat a condition. A misdiagnosed or improperly treated eye condition can result in a permanent loss of vision, or a permanent loss of function of the eye or visual system. In the case of any eye problem, seek medical attention promptly. This can include emergency room treatment, as well as treatment by a medical physician or eyecare provider.