Articles - Nader Moinfar, MD, MPH, FACS, FASRS

What is the Vitreous?

The vitreous, also known as the vitreous humor, is a gel-like substance that fills the inside of the eye, occupying the space between the lens and the retina. It plays a crucial role in the development of the eye and in supporting the overall structure of the eye after we are born.

Composed mainly of water, the vitreous humor is a transparent, colorless gel that consists of a network of collagen fibers and various other molecules. It is synthesized during the early stages of development and persists throughout life. It is not renewed.

Function

The primary function of the gel is to provide mechanical support to the eyeball. It helps maintain the spherical shape of the eye, which is essential for proper focusing of light onto the retina. Additionally, the vitreous acts as a shock absorber, protecting the delicate structures within the eye from external forces or impact.

Moreover, this clear gel plays a role in the optical system of the eye. By virtue of its transparency, it transmits light, allowing it be focused on the retina. The retina converts light into electrical signals that are then transmitted to the brain, thus creating “vision.” The smooth, uniform consistency of the vitreous helps to ensure that light rays are not scattered or distorted as they travel through the eye.

Posterior Vitreous Detachment

While the vitreous is mostly a stable, gel-like substance, it can undergo changes that can impact vision. With age, the vitreous may gradually shrink and develop small pockets of fluid. This is known as a posterior vitreous detachment (PVD). This can lead to the formation of floaters, which are perceived as tiny specks or threads that seem to float across the field of vision. Although floaters are usually harmless, a sudden onset of numerous floaters or flashes of light may be a sign of a retinal tear. A retinal tear can cause a retinal detachment, which requires immediate medical attention. Sudden onset of floaters should always be checked by your eye doctor.

The vitreous is most important for normal development of the eye. Once we are born, it indirectly maintains various functions of the retina and the lens. Understanding the role of the vitreous can help appreciate its importance in maintaining healthy vision and identifying potential eye problems.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

What is the Retina?

The retina is the light sensitive tissue that translates light into electrical signals for the brain. That’s how we see.

The retina is a highly specialized layer of tissue that lines the inside of the eye. As part of the central nervous system, it serves as a crucial component of the visual system. Its primary function is to convert light into electrical signals that can be translated to “vision” by our brain.

It consists of several layers of cells, each with a specific role in the process of vision. The outermost layer contains the photoreceptor cells, known as rods and cones. Rods are responsible for vision in low-light conditions and are highly sensitive to light, while cones are responsible for color vision and visual acuity in brighter light conditions. Cones are further classified into three types: red, green, and blue cones, allowing us to perceive a wide range of colors.

Converts Light to Electrical Signals

When light enters the eye, it passes through the cornea and lens, which help focus the light onto the retina. The rods and cones in the retina absorb the light and convert it into electrical signals. This process involves the activation of light-sensitive pigments within the photoreceptor cells, triggering a cascade of chemical reactions that generate electrical signals.

The electrical signals produced by the rods and cones are then processed by several layers of cells within the retina. Bipolar cells receive the signals from the photoreceptor cells and transmit them to ganglion cells, which are the final layer of cells in the retina. The ganglion cells collect the signals and their axons form the optic nerve, which carries the visual information from the retina to the brain.

Highly Specialized Cells Sharpen Vision

Within the retina, there are also other types of cells, such as horizontal cells and amacrine cells, which help refine and modulate the visual signals. These cells play a role in enhancing contrast, adjusting sensitivity to light, and facilitating communication between different parts of the retina.

The central region of the retina is known as the macula, which contains a high concentration of cones. At the center of the macula is a small depression called the fovea, where visual acuity is highest. The fovea contains a high density of cones, allowing for detailed and sharp central vision.

For us to see, all layers of the retina must be healthy, maintain normal blood supply and remain attached.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

What is Macular Pucker?

Macular pucker, also known as an epiretinal membrane or cellophane maculopathy, is a condition that affects the macula, a small area located in the center of the retina at the back of the eye. The macula is responsible for central vision, which allows us to see fine details and perform tasks such as reading, driving, and recognizing faces.

Causes of Macular Pucker

Macular pucker occurs when a thin, transparent layer of scar tissue forms on the surface of the macula. This scar tissue can cause the macula to wrinkle or pucker, leading to distorted and blurred vision. The most common cause of epiretinal membrane development is aging, as the vitreous gel inside the eye shrinks and pulls on the macula, causing the formation of scar tissue. However, other factors such as eye trauma, inflammation, and certain eye conditions can also contribute to its development.

Symptoms of Macular Pucker

Symptoms of macular pucker can vary from mild to severe and typically affect only one eye. Common symptoms include blurred or distorted central vision, difficulty reading or performing tasks that require good vision, and the appearance of straight lines as wavy or bent. In some cases, individuals may also experience a gray or cloudy area in their central vision.

While macular pucker can cause significant visual impairment, it can vary in severity. In mild cases, no treatment may be necessary, and individuals can adapt to their vision changes. However, in more severe cases where vision loss significantly affects daily activities, surgical intervention may be recommended.

Treatment Options

The most common surgical procedure for macular pucker is called vitrectomy with membrane peeling. During this procedure, the vitreous is removed from the eye and the scar tissue on the macula is carefully peeled away. Following surgery, visual recovery may take several weeks to months, but not all individuals will regain normal vision.

Regular eye examinations are important for the early detection of macular pucker or other eye conditions. If you experience any changes in your vision, I recommend you inform your own doctor to provide a proper diagnosis and recommend appropriate treatment options after examining you.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

Syfovre™ for Geographic Atrophy

Syfovre™ is the first available FDA approved treatment for geographic atrophy, an advanced form of macular degeneration.

Syfovre™ is a novel treatment for an advanced stage macular degeneration called geographic atrophy.

The FDA has approved Syfovre™ (pegcetocplan) for the treatment of GA, a leading cause of in developed countries. Syfovre™ is the first treatment for this advanced stage of macular degeneration. Treatment for wet macular degeneration has been available for over a decade.

Administration of Syfovre™

As with many retinal therpies, Syfovre™ is administered as an intravitreal injection into the eye. Because eye drops, ointments, oral meds and intravenous medications have difficulty penetrating the eye, intravitreal injections are necessary to deliver the right amount of drug to the retina.

Injections may be given monthly or every other month and will need to be repeated. The exact frequency of dosing will be determined by your doctor.

How Does Syfovre™ Work?

Pegcetocoplan is a unique inhibitor of C3, a protein involved in the complement system. The complement system is a major factor in our immune system and helps prevent infection from bacteria, viruses, regulates inflammation and aids the body get rid other pathogens.

Left unchecked, C3 may be involved in the death of healthy cells of the retina called retinal pigment epithelial (RPE) cells. RPE cells are responsible for the health and maintenance of photoreceptors, such as rods and cones. Without healthy photoreceptors, we can not see.

Syfovre™ binds C3 much like an antibody and prevents C3 from causing cell death to the retinal RPE cells.

Geographic Atrophy

Areas of RPE cell loss can be detected during a retinal examination. Usually these so-called “atrophic lesions” arise near the macula. With time the lesions enlarge to involve the central macula.

Visual acuity, your central vision, is usually spared early in the disease, but visual function may be compromised depending upon the size, number and location with respect to the central macula.

Unlike wet macular degeneration where abnormal blood vessels develop within the layers of the retina, geographic atrophy is causes by death of the RPE cells.

Symptoms of Geographic Atrophy

Symptoms of macular degeneration include: blurry vision, distortion and loss of central vision. Geographic atrophy can also cause decline in visual function such as poor contrast, decreased reading speed, poor color perception etc.

If you or your family member is concerned, please call your eye care provider. The earlier this is detected and possibly treated, the better.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

Floaters from Vitreous Hemorrhage

Vitreous hemorrhage from various causes can cause floaters.

Vitreous hemorrhage can cause floaters in the eye. Bleeding inside the eye is called vitreous hemorrhage. Symptoms of this type of bleeding range from a showere of floaters to incomplete darkness (lots of blood).

Floaters due to blood can not be distinguished by other types of floaters based upon appearance. Often floaters from hemorrhage have appeared suddenly and don’t necessarily last as long as chronic (long-lasting) floaters, but they can.

Causes of Vitreous Hemorrhage

Any bleeding into the vitreous is called vitreous hemorrhage. Hence, there are a variety of causes of bleeding into the vitreous;

Retinal tears
Retinal Detachments
Trauma
Diseases of the retina (eg. proliferative diabetic retinopathy)
Complications of retinal vascular disorders
Posterior Vitreous Detachment

Treatments

For all intents and purposes, blood in the vitreous does not cause long-lasting damage. It is most important to establish the underlying cause of the bleeding and treat that disorder whenever possible.

For dense vitreous hemorrhages, it may indeed be prudent to consider a vitrectomy to remove the blood to restore vision, but more importantly, and to allow the retina specialist to perform a thorough examination of the eye with the blood removed.

Retinal Tears and Bleeding

As an example, a retinal tear can cause a vitreous hemorrhage if the tear rips across a retinal blood vessel and causes bleeding. There may be too much blood to actually visualize a retinal tear. Keep in mind, retinal tears can lead to retinal detachments.

Retinal detachments can be potentially blinding and, in cases of all retinal tears, we would like to treat the tear before a retinal detachment develops.

Vitreous Hemorrhage Can Resolve

Blood in the vitreous usually absorbs and can clear on with a vitrectomy. There is no specific timing of this and it can take weeks or even months. Sometimes, blood does not clear on its own and vitrectomy may be necessary.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

Treatment of Diabetic Macular Edema (DME)

Diabetic macular edema is a common complication of diabetic retinopathy where fluid accumulates in the macula and blurs the vision.

Diabetic macular edema (DME) is a condition characterized by the accumulation of fluid in the macula, the central part of the retina responsible for sharp, detailed vision. It is a common complication of diabetic retinopathy, a disease affecting the blood vessels of the retina. The management of diabetic macular edema (DME) involves various treatment approaches aimed at reducing macular edema and preserving vision.

Anti-VEGF Injections – Treatment of Diabetic Macular Edema

One of the primary treatment options for DME is intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) medications. Drugs like ranibizumab, bevacizumab, and aflibercept are commonly used to inhibit the abnormal growth of blood vessels and reduce leakage, thus decreasing macular edema. These injections are typically administered on a monthly or as-needed basis, with the aim of improving visual acuity and reducing central retinal thickness.

Steroids for Diabetic Macular Edema

Another treatment modality for DME is the use of corticosteroids. Intravitreal injections of triamcinolone acetonide or dexamethasone implants can help suppress inflammation and reduce fluid accumulation in the macula. These steroid injections are usually performed at longer intervals compared to anti-VEGF agents due to their sustained-release properties.

In some cases, laser photocoagulation may be employed to treat DME. Focal laser treatment can be used to seal leaking blood vessels and reduce fluid accumulation. However, this approach is typically reserved for cases where the edema is away from the central macula to avoid damaging central vision.

New Treatments

Recently, a new class of medications called integrin receptor antagonists has shown promise in the treatment of DME. These drugs, such as pegpleranib and abicipar, target specific proteins involved in the pathogenesis of macular edema and are administered via intravitreal injections.

In addition to these specific treatments, managing the underlying diabetes is crucial in preventing and managing DME. Maintaining optimal blood sugar control, blood pressure, and cholesterol levels can help reduce the risk and progression of DME.

Regular eye examinations and early detection of DME are essential for timely intervention and optimal outcomes. Treatment options should be individualized based on the severity of the edema, visual impairment, and patient characteristics. By employing a combination of these treatment modalities and a comprehensive approach to diabetes management, healthcare professionals can improve visual outcomes and enhance the quality of life for individuals living with DME.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

What is Geographic Atrophy?

Geographic atrophy is an advanced form of macular degeneration. Vision loss is irreversible.

Geographic atrophy (GA) is a progressive and irreversible form of advanced age-related macular degeneration (AMD) that affects the central portion of the retina, known as the macula. It is a leading cause of severe vision loss and visual impairment among older adults.

The macula is responsible for providing sharp, detailed, and central vision, which is essential for tasks such as reading, driving, and recognizing faces. In GA, the cells in the macula begin to degenerate and die, leading to the loss of these critical visual functions.

The term “geographic atrophy” refers to the characteristic appearance of the damaged areas in the macula. As the disease progresses, patches of atrophy develop, giving the appearance of irregularly shaped, well-demarcated lesions. These lesions can vary in size, shape, and location, and they can gradually expand and merge together over time.

The exact cause of GA is not fully understood, but it is believed to involve a combination of genetic, environmental, and lifestyle factors. The risk of developing GA increases with age, and individuals with a family history of AMD are also at higher risk.

Currently, there is no cure for GA, and treatment options are limited. However, researchers are actively investigating potential therapies to slow down the progression of the disease and preserve vision. Some experimental treatments include anti-inflammatory drugs, antioxidants, and cellular therapies.

Early detection and regular eye examinations are crucial for managing GA. High-resolution imaging techniques, such as optical coherence tomography (OCT), can help identify the presence and progression of GA. Additionally, lifestyle modifications, such as eating a healthy diet rich in fruits and vegetables, not smoking, and maintaining regular exercise, may help reduce the risk or slow down the progression of GA.

Living with GA can be challenging, as it can significantly impact an individual’s quality of life and independence. Therefore, it is important for individuals with GA to seek support from low vision specialists, who can provide assistance in adapting to vision loss and recommend visual aids and devices to enhance remaining vision.

In conclusion, geographic atrophy is a severe and irreversible form of AMD that leads to progressive vision loss. While there is no cure, ongoing research offers hope for potential treatments. Early detection, regular eye examinations, and lifestyle modifications are essential for managing GA and minimizing its impact on daily life.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

What is FOV?

FOV stands for Floater Only Vitrectomy. In my experience, this is the common name of the basic operation performed by a retina specialist called vitrectomy.

Vitrectomy and FOV, therefore, are synonyms. Vitrectomy is the standard operation performed by all retina specialists (for all reasons) whereas FOV refers to a vitrectomy performed for the removal of only (just) floaters.

Vitrectomy

Vitrectomy is the operation to remove the vitreous. The vitreous is the gel-like substance that fills the back of the eye.

The vitreous may be removed;

To remove a vitreous hemorrhage (blood)
Remove a foreign body
Repair
- Retinal detachment
- Macular hole
- Epiretinal membrane
Remove floaters

Types of FOV or Vitrectomy

All modern types of FOV are basically the same. They involve the creation of 3 holes in the eye:

Left hand
Right hand
Infusion port to keep the eye filled with saline during the operation

There are slight changes in nomenclature to distinguish the size or thickness of the instruments used to enter the eye. The size of the sclerotomies (holes) the instruments create naturally vary in size. The thicker instruments create large holes and vice versa. 20 gauge instruments are the thickest and require sutures to close the sclerotomies. 23 and 25 gauge instrumentation create tinier sclerotomies and suture closure is up to the discretion of the retina specialist.

What Replaces the Vitreous?

The vitreous is cut away rapidly in very tiny miniscule pieces and is replaced by artificial saline solution. As the operation is proceeding, a tube is constantly infusing saline into the eye. After the operation is complete, your eye replaces the saline with aqueous humor in a matter of a couple days.

How is FOV Different than Vitrectomy

It’s not. It’s exactly the same. After the vitreous is removed, the operation is essentially over. FOV for floaters is exactly the same as FOV for vitreous hemorrhage – the goal of both is to simply clear opacities from the vitreous to create a clear path for vision.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

What are Eye Floaters?

Vitreous floaters, eye floaters or just floaters can be annoying or a dangerous threat to your vision.

Eye floaters, or vitreous opacities, are common but not always benign. They also affect us all differently, from a mere annoyance to visually impressive.

Floaters are the common name for dark specks or spots which move to and fro in your vision. They move with eye movement in your field of vision. They may or may not be associated with clumps or strands of protein floating in your vitreous. These clumps or strands may represent “cob-webs” also seen in your vision.

There are many causes of floaters.

What is the Vitreous?

The vitreous is the substance that fills the vitreous cavity. The vitreous cavity, or posterior chamber, is the largest compartment of the eye and is located between the lens and the retina. The retina is the inside lining of the eye.

Normally, the vitreous is optically clear, color-less and has the consistency of a gel. The vitreous is composed mostly of water, but has about 5% protein.

The vitreous is essential for normal embryologic development of the eye. Once we are born, we are not sure of any true functions of the vitreous although many believe it is essential in oxygenation of the tissues of eye, such as the lens.

The vitreous may absorb energy. For instance when you are engaged in sports, running, or suffer a head injury, the vitreous may be absorbing shock waves. This is unproven.

What are floaters?

The vitreous is never regenerated. While the fluid component does renew (aqueous humor), the proteins do not. With time and normal aging, the proteins can denature or breakdown and the vitreous becomes more water-like.

The thinner, more fluid, vitreous means that the vitreous changes from a thicker gel to a more watery substance. The proteins can more easily coalesce and clump together casting shadows on the retina…more commonly known as floaters.

Floaters can also be a result of retinal disease, blood or inflammation. Floaters from any cause are indistinguishable from one another (i.e. you can’t tell the difference between floaters due to blood vs. inflammation). Only your eye doctor can tell the difference after a thorough dilated examination of your eye.

It is recommended that you alert your eye care professional should you ever experience a sudden increase in floaters. New floaters could be a sign of a potentially blinding condition.

Treatment of Floaters

In general, the best treatment for floaters is to treat the underlying disease. Persistent floaters can be bothersome. Removal via vitrectomy may be the only solution for clearing the floaters from your vision.

Some doctors may offer Nd:Yag laser for the treatment of floaters. There are limitations to this type of treatment and not all retina specialists view this treatment equally.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL

7 Reasons You Need a Retina Specialist

A retina specialist has undergone expert training to deal with diseases and surgery of the retina and vitreous such as these disorders or situations.

A retina specialist is an ophthalmologist who has extra-training in diseases and surgery of the retina. Additional training years are required to focus attention in this special area.

Here are 7 more common reasons why you may be referred to a retina specialist.

Retinal Tear, Retinal Detachment, Retina Specialist

Retinal tears can cause a retinal detachment. Retinal tears may be asymptomatic, but often are associated with the sudden onset of new floaters or flashes usually due to a posterior vitreous detachment.

While most new floaters and flashes are NOT associated with a retinal tear, the only way to make sure you are not at risk for developing a retinal detachment is have a complete dilated eye exam.

Retinal tears can be treated with either cryotherapy or laser. Retinal detachments will often require surgery.

Foreign Body Inside the Eye

While not commonplace, intraocular foreign bodies may occur with any penetrating eye injury. Glass, metals and organic material need to be removed by performing a vitrectomy, the principal operation performed by a retina specialist.

Retina Specialist and Endophthalmitis

Endophthalmitis is infection inside the eye. This usually occurs following recent eye surgery, but can also follow penetrating eye injury.

Prompt referral to a retina specialist is paramount in preventing loss of vision from infection. Intraocular antibiotics, anti-fungals and/or vitrectomy surgery may be necessary to prevent catastrophic vision loss.

Advanced Diabetic Retinopathy

Diabetic retinopathy can cause blurry vision and blindness. A retina specialist is adept at treating the two most common causes of vision loss from diabetes: diabetic macular edema and proliferative diabetic retinopathy.

Common treatments used by retina specialists include: anti-VEFG injections, steroids, laser and surgery. In most scenarios, these are procedures only offered by a retina specialist.

Macular Degeneration

Macular degeneration (AMD) comes in two forms: dry AMD and wet AMD. The “wet” form is also called neovascular AMD (nAMD).

Both types of macular degeneration affect both eyes and are progressive, but the wet form can steal vision quickly, is associated with leaky abnormal blood vessels and bleeding. Treatment usually involves intravitreal injections of anit-VEGF.

There is presently no treatment for dry macular degeneration approved by the FDA.

Retinal Vascular Occlusions

Periodically the retinal vessels can become occluded or blocked. Both arteries and veins can be blocked retinal vascular occlusions. Vision loss is usually sudden and treatments may be required in an attempt to improve vision and/or to prevent total blindness from complications of the vascular occlusions.

If you would like to schedule an appointment, please call us (877) 245.2020.

Nader Moinfar, M.D., M.P.H.
Retina Specialist
Orlando, FL