Articles

Lattice Degeneration

Many people are told they have “thinning of the retina,” but it’s real name is lattice degeneration and it could cause a retinal detachment.

Lattice degeneration is a fairly common, but abnormal, “thinning of the retina” that can cause a retinal detachment.  This type of degeneration affects the peripheral retina, and for reasons poorly understood, increases the chances of developing retinal tears or retinal holes that can lead to a retinal detachment

Lattice degeneration may be found in 8-10% of the population and seems to be found more frequently in families with this peripheral degeneration, myopia and a few rare diseases:

“Lattice” has characteristic findings, but only the presence of retinal holes is concerning.  Not all areas of lattice develop retinal holes.  When found, your retina specialist may feel treatment is necessary to prophylax against a retinal detachment.

Symptoms of Lattice Degeneration

There are no symptoms, but the condition may predispose you to retinal tears or retinal detachment, hence, patients should be on the lookout for symptoms of retinal tears or detachment including:

  • Flashes
  • Floaters
  • Blurred vision
  • Progressive loss of peripheral vision

Patients experiencing any of these symptoms should alert their eye doctor. 

Treatment of Lattice Degeneration

The majority of patients never require treatment and can be safely monitored.  There is absolutely no threat to the vision if a tear or retinal detachment do not ensue.  

The chance of developing a retinal detachment is quite small.  Still, it is recommended that patients with this peripheral thinning be monitored regularly.  Though progression is unlikely, retinal holes can develop over time.  Retinal holes develop slowly and gradually, whereas, a retinal tear can happen suddenly.

Retinal holes from lattice degeneration are treated and managed exactly the same way as treating a retinal tear.  Not all retinal holes from lattice degeneration require treatment. 

Laser treatment is the preferred treatment, however, cryotherapy and endolaser photocoagulation with vitrectomy are viable options as well.

In short…

In summary, lattice degeneration is usually a benign “thinning” of the retina that increases your chances of developing a retinal detachment over your lifetime.  Tell your doctor if you develop sudden flashes and/or floaters or if you experience loss of your peripheral 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

Treatment of Retinal Tears

Here are common ways a retina specialist can treat a retinal tear to prevent a retinal detachment.

Retinal tears can lead to a retinal detachment.  A retinal detachment can cause permanent vision loss and possible blindness.

Successful treatment of a retinal tear or retinal hole can prevent a retinal detachment from occurring. 

Posterior Vitreous Detachment

Also known as a PVD, a posterior vitreous detachment is the most common cause of a retinal tear.  The most common symptoms of a PVD are sudden flashes and floaters.

Any acute flashes or floaters require a complete dilated examination of the retina looking specifically for a retinal tear.  

Retinal Holes

Retinal holes are usually not caused by a posterior vitreous detachment, trauma or other eye surgery.  Most retinal tears are associated/caused by lattice degeneration, a common “normal” finding in many near-sighted patients. 

For the purposes of this article, both retinal tears and retinal holes are treated using the same techniques. 

Laser Treatment for Retinal Tears

The preferred treatment of a retinal tear is with laser treatment.  Laser light is used to create scarring around the retinal tear to prevent fluid from migrating underneath the retina.  This does not really fix the retinal tear, but it does prevent a retinal detachment from occurring. 

Laser treatment can be performed easily in the office setting and usually does not require any aftercare.  Most retinal specialists will recheck the retina a few weeks after laser treatment. 

Laser treatment usually does not cause pain when applied.  There are no nerves in the retina, but there are some deeper nerves in certain locations of the eye that can cause “discomfort.”

Cryotherapy for Retinal Tears

Not all tears can be treated with the laser.  Cryotherapy, an older treatment, can be equally effective.

For laser treatment to succeed, your retinal specialist must be able to see the entire retinal tear.  Some tears can not be completely visualized due to:

  • Vitreous hemorrhage (blood)
  • Cataract
  • Anterior location (hard to “see” the entire retina without special techniques/instruments)
  • Intraocular implants

Cryotherapy treats retinal tears by freezing them from the outside of the eye.  Because cryotherapy requires manipulation and indentation of the eye, more tears can be treated that otherwise could not be fixed with laser. 

Vitrectomy

As a last resort, intraocular surgery called vitrectomy can be used to treat a retinal tear.  In this situation, a laser probe is introduced inside the eye at the time of surgery to treat the tear.  Using the endolaser, the tear or hole is treated from the inside of the eye.  While virtually any tear can be treated in this fashion, it does require an invasive procedure and must be performed in the operating room. 

Regardless of the modality of treatment, the results are the same.  The goal is to prevent retinal detachments from occurring. 

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

Symptoms of a PVD

These symptoms may prevent a retinal detachment and here’s why.

PVD stands for “posterior vitreous detachment.” It’s a normal event that increases your risk for developing a retinal tear which can lead to a retinal detachment. Everyone will eventually get a PVD.

New flashes and new floaters should be reported to your eye doctor or retina specialist. Not all floaters are benign. Only a full dilated exam will determine if your new symptoms are related to a posterior vitreous detachment, retinal tear or something else.

Symptoms of Posterior Vitreous Detachment

The most common symptoms of a PVD:

  • Flashes
  • Floaters
  • Nothing (Asymptomatic, no flashes or floaters)

There are two ways to stimulate the retina: normal light and physical manipulation. Usually, light enters the eye and is captured by the rods and cones of the retina which eventually produce vision. The other mechanism occurs when you rub your eyes so hard you actually see patterns in your vision. This rubbing, or physical manipulation, also produces “light.”

After a PVD has occurred, only the back, or posterior portion, of the vitreous separates from the retina. The anterior portion remains fixed to the surface of the retina. As the newly separated vitreous cleaves from the retinal surface in the back, it can move to and fro in the eye. This transmits energy to the portion of the vitreous still attached to the retina in the anterior part of the eye…causing flashes.

What are Floaters?

Floaters can be a result of cellular debris from underneath the retina in cases of a retinal tear, blood or just opacities which have formed in the otherwise clear vitreous gel.

Not all posterior vitreous detachments cause flashes or floaters. Thus, follow up is always recommended so your retina specialist can look for asymptomatic retinal tears.

What if I have a Retinal Tear?

First of all new flashes and floaters should be reported to your eye doctor. In the case of a PVD, it’s important to look for a retinal tear. A retinal tear is most likely to occur during the first 6 weeks after a PVD has occurred.

The goal of examination is to find a retinal tear before it turns into a retinal detachment. Retinal tears can usually be treated with laser whereas a retinal detachment requires surgery and there is a chance of lost 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

Board Certified Eye Doctor

What does board certified really mean…and what’s a retina specialist?

I am both a board certified ophthalmologist (eye doctor) and a retina specialist. Board certification requires periodic testing of knowledge.

To become a retina specialist required additional training following my completion of ophthalmology residency.

The test to become a board certified certified ophthalmologist had nothing to do with my decision to become a retina specialist. Board certification is required to obtain hospital privileges, state licensure and, perhaps, participate in many health insurance plans.

Ophthalmology Residency

After completion of medical school, all graduates are technically an “M.D.”

Internship: In most cases, the first year after graduating from medical school is spent as an intern where we gain practical experience in various core fields of medicine such as internal medicine, general surgery or some combination of the other specialties. We do not focus on ophthalmology.

Residency: Ophthalmology residency begins after the internship. Most residency programs are 3 years long and for this period, we learn nothing but ophthalmology. Residents are essentially apprentices to the craft of ophthalmology learning from practicing ophthalmology attending physicians.

At the end of residency, many of my colleagues chose to start private practice in general ophthalmology. A general ophthalmologist usually performs cataract surgery, treats various diseases such as glaucoma, diabetic retinopathy, etc.

Fellowship Trained Retina Specialist

The period of training following residency is dedicated to sub-specialty training and is called a fellowship. To become a retina specialist, I completed an additional 2 years of training after completion of residency.

In other words, after I was qualified to become a general ophthalmologist, I took on optional training to allow me to become a retina specialist.

There are about eight or recognized sub-specialties within ophthalmology. Diseases of the retina is one of the these sub-specialty areas.

The sub-specialties in ophthalmology are:

  • Cornea/Refractive
  • Glaucoma
  • Neuro-ophthalmology
  • Ocular pathology
  • Oculoplastics
  • Pediatrics
  • Oncology
  • Uveitis
  • Retina Specialist

Most fellowship trained doctors eventually practice only their sub-specialty, that is, as a retina specialist, I only take care of patients with problems with the retina.

While I am qualified to perform cataract surgery and diagnose glaucoma, I choose not to.

Board Certified

What does this mean?

Board certification, at least in ophthalmology, is a test or certification of competency in general ophthalmology. It has nothing to do with my being a retina specialist. At this time, there is no sub-specialty board certification.

Though I am a retina specialist, my board certification reflects that I am fluent and knowledgeable in all the various areas of ophthalmology. This is true of all ophthalmologists who practice a sub-specialty.

“Board certified” simply means I know a lot about general ophthalmology.

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 Legal Blindness?

Legal blindness can be caused by a variety of diseases. Here’s how it is defined and links to resources.

Legal blindness is a legal definition that is used to refer to patients with vision loss who qualify for government assistance. This is not total blindness.

Legal blindness is defined as a patient’s best visual acuity (aka best corrected) in either eye is 20/200 or less or the size of the visual field (peripheral vision) is less than 20 degrees. In other words, if both eyes do not see well, the vision is no better than 20/200 in better seeing eye.

“Best corrected” refers to the use of the best corrective lens/contact lens for the patient.

A central visual acuity of 20/200 or worse means that a legally blind person must be 20 feet away from an object to see what a “normal” person can see from 200 feet away.

Loss of peripheral vision can also qualify as legal blindness. Most patients normal peripheral vision can see at least 140 degrees without turning the head. Legally blind peripheral vision is less than 20 degrees.

Causes of Legal Blindness

  • Age-related macular degeneration (ARMD) is one of the leading causes of legal blindness in Americans aged 60 and older. ARMD affects the macula (functional center of the retina) and therefore decreases central vision.
  • Cataracts will affect almost everyone by the age of 80. Cataracts blur both central and peripheral vision (though reversible with cataract surgery).
  • Diabetic retinopathy is another leading cause of blindness and affects the blood vessels in the back of the retina. Diabetic retinopathy causes either blurring of the central vision (most common), but can affect peripheral vision, too.
  • Glaucoma is a progressive disease that damages the optic nerve. Glaucoma primarily causes visual field loss and, only in the late stages, affects central vision.

NOTE: All of the disease described above have available treatments which, in most cases, can preserve vision or slow down progression if diagnosed timely.

Low Vision Aids

May low-vision aids and devices are available to assist individuals who are legally blind. Both near and distance vision can be improved with low-vision aids.

For example, desktop, stand-alone and hand-held magnifiers are available. These may be helpful for close range work such as reading or computer use. Prices vary up to several hundred dollars.

Wearable devices that magnify are also available. Mounted binoculars, wearable HD autofocus cameras with TV viewing and electronic headsets with built-in cameras can help patients with central and peripheral vision loss. Prices vary up to several thousand dollars.

Resources

There are many governmental and non-governmental resources for those who are legally blind.

For example, the American Foundation for the Blind (AFB) can assist those with low-vision. Founded in 1921, the AFB ensures that patients who are blind, legally blind or otherwise visually impaired have access to educational materails, technology and legal information.

Here are additional resources that help blind, legal blindness and visually impaired.

Low Vision Evaluation

If you feel you suffer from legal blindness or need more information, a low-vision examination is the first place to start. Eye doctors specializing in low vision can advise and educate you about the best low-vision aids for your specific visual needs.

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

Telemedicine for Retina Specialists

Ready for telemedicine? Here’s what you need to know to get prepared…if it’s available at all from your doctor.

It’s May 2020 and we are in the midst of the pandemic.  In most states, stay at home orders have been in effect for about 6 weeks and healthcare has been moving along with guidelines designed to not stress our healthcare system.

In March, the American Academy of Ophthalmology and Centers for Disease Control and Prevention made strong recommendations to ophthalmologists to reduce patient care to those with urgent and emergent conditions.

About the same time, the American Academy of Ophthalmology and CMS introduced several changes to promote the use of telemedicine as an alternative to face-to-face examinations.  The idea is to reduce COVID-19 exposure to ourselves, our staff and patients. 

What is Telemedicine?

Until the pandemic, telemedicine was probably used loosely to refer to the remote screening and management of patients.  Telemedicine has the potential to help patients in remote areas (rural communities, war zones) where healthcare is sparse.  Telemedcine has the potential to screen and triage patients, but since the pandemic, telemedicine might substitute as an office visit if you are unable or unwilling to expose yourself to others who might be infected. 

Most commonly, telemedicine uses our phones and computers to create audio-visual connections between patients and providers.

While the exact platforms (digital programs) vary from office to office, a connection providing audio and visual information is at the core of effective telemedicine.

Common platforms for telemedicine include:

  • Face Time
  • Facebook Messenger Video
  • Google Hangouts
  • Zoom
  • Go-to-Meeting 
  • Skype
  • Others

Many of us are already using these platforms for connecting with friends, family and business colleagues.  Ask your own doctor/healthprovider to see what platforms they are using.

What You Need for Your “Appointment”

In most cases, you’ll need your smart phone.  While an Internet connection and a computer may suffice, it may add technical complexity to speaking with your provider.  

In addition to having the proper digital tools, be prepared to have or do the following:

  • Give consent to the telehealth visit (minors need parental permission)
  • Current health problems and details
  • Medical history
  • List of medications
  • Knowledge of operating your device (e.g. can you take a selfie?)

Your eye doctor may be able to check your vision remotely and examine different parts of your eyes and face.  You will likely need to assist by changing positions and changing camera angles.  For ophthalmology, taking a “selfie” may be necessary.

Your provider should have a discussion with you – be prepared by having a list of questions ready before starting the visit. 

Your provider may ask you to follow up with pictures, emails or texts.  

Telemedicine for Retina Specialists


Telemedicine works better for some specialists and not as well for others.   For instance, telemedicine probably works great for psychiatry, but perhaps not as well for dentistry.

Similarly, a retina specialist may have more difficulty fully utilizing the advantages of telehealth because patients must have a dilated exam.  While there are screening devices available to avoid a dilated eye exam, these devices are available on a commercial basis and not available for home use.

In general, for a retina specialist to best examine and diagnose your retinal problem, dilating the pupils, optical coherence tomography and fluorescein angiography may need to be completed which requires a trip to the office.

Still, if you are having symptoms, such as acute loss of vision or pain, you may start your journey by calling your eye doctor to see if a telemedicine visit is right for 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

Possible COVID-19 Treatment can Cause Eye Damage

Hydroxychloroquine is FDA approved for certain autoimmune diseases and malaria, but has the potential for toxicity…

Hydroxychloroquine has long been used to safely treat patients with malaria and certain autoimmune diseases such as lupus erythematosus and rheumatoid arthritis, but NOT COVID019.

In the news, there have been small, inconclusive studies using two malaria and autoimmune medications to treat COVID-19 (coronavirus 2019). Some studies suggest the medications might be helpful, while other studies saw no difference.

Currently, there is not enough medical data to prove that hydroxychloroquine and chloroquine work for COVID-19.

Hydroxychloroquine Approved for Malaria

Chloroquine was approved by the FDA in 1949 as a treatment for malaria, an infection caused by a parasite. Hydroxychloroquine was approved by the FDA in 1955 for the treatment of malaria. Hydroxychloroquine is preferred over chloroquine because it has fewer side effects.

Both drugs are available in pill form. Plaquenil is also approved for long-term use in rheumatoid arthritis and lupus.

The side effects of both medications include:

  • Retinal damage and irreversible vision loss (Plaquenil Toxicity)
  • Headache
  • Abnormal heart rhythm
  • Muscle weakness or nerve pain
  • Gastrointestinal issues (nausea, cramping, vomiting, and diarrhea)
  • Hypoglycemia (low blood glucose)
  • Worsening of psoriasis

Retinal Damage | Plaquenil Toxicity

The overall prevalence of chloroquine/hydroxychloroquine retinopathy is 7.5%. Retinal damage is one of the most serious adverse effects of hydroxychloroquine (HCQ) since the retinal damage caused by the drug is irreversible. Chloroquine/hydroxychloroquine retinopathy is more common with higher daily doses and long-term use.

A baseline retinal examination is recommended for all patients taking HCQ, along with regular monitoring examinations. The baseline and monitoring examinations should include the following:

  • Uncorrected visual acuity test
  • Best-corrected visual acuity test
  • Examination with ophthalmoscope
  • Examination using slit-lamp
  • Optical Coherence Tomography

The FDA previously issued an Emergency Use Authorization (EUA) that allows physicians to request a supply of hydroxychloroquine or chloroquine for hospitalized patients with COVID-19 who are unable to join a clinical trial. 

As of this writing 4/24/20, the FDA now warns against the use of hydroxychloroquine for the treatment of COVID-19 after reports of irregular heart rhythms and deaths.

If you are presently taking Plaquenil, talk to your prescribing doctor to insure that you are getting regular eye exams.

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

Symptoms of Eye Emergencies

During the pandemic, the American Academy of Ophthalmology and the Centers for Disease Control and Prevention, have mandated that your eye doctor limit practice to those patients with eye emergencies or urgencies. Elective surgery has been postponed.

There are several warning signs or symptoms which should alert you to call your eye doctor.

Pain

Eye pain can be caused by a corneal abrasion, inflammation or advanced glaucoma.

Corneal abrasions may also be associated with tearing, redness and blurry vision. The corneal is ultra sensitive and even a slight abrasion can be painful. The corneal surface allows for about 2/3 of the total focusing power of the eye. If the surface becomes abraded, blurred vision is common.

Inflammation, such as iritis, causes pain, redness, sensitivity to light and blurry vision. Advanced glaucoma can lead to uncontrolled eye pressure causing pain, redness, tearing, nausea and decreased vision.

Eye pain associated with redness should prompt a call to your doctor. Almost any and every “eye related” cause of eye pain involves redness.

Sudden Decreased Vision

Sudden decreased or vision loss can be an emergency.

Most retinal diseases can cause sudden and painless vision loss, such as:

While there are other causes, I’m listing the common causes of acute vision loss from retinal diseases.

Sudden Distortion

Distortion is usually caused by a macular problem.

While distortion is a common complaint in patients with macular holes or epiretinal membranes, the onset is usually gradual and not acute.

Acute distortion can be from macular edema (swelling) from an retinal vascular occlusion or leakage/bleeding from wet macular degeneration. Sometimes a retinal detachment can cause distortion, but this is usually associated with complaints of loss of peripheral vision.

Exacerbation of wet macular degeneration is certainly an emergency and may require prompt treatment with anti-VEGF medications.

If you are experiencing pain, loss of vision or new distortion, make sure to call your eye doctor or retina specialist.

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

Elective Surgery May Stop

Here’s why your follow up visit or even your surgery may be canceled.

As the COVID-19 pandemic continues to spread, the American Academy of Ophthalmology (AAO), the Centers for Disease Control and Prevention (CDC) and the American Hospital Association have issued recommendations aimed at reducing exposure and preserving healthcare resources, aka, “flattening the curve.”

Will this affect all eye doctors?  Will this affect you?

Stop Routine Care

The American Academy of Ophthalmology is recommending that eye doctors stop routine eye care at this time and focus only on those patients with urgent and emergent conditions.  Examples of “routine” care might include glasses prescriptions, routine follow-up or cataract evaluations. 

Please check with your own doctor if you need to be seen.

As a retina specialist, I may not necessarily “need” to see a patient I see every 6 months with diabetes who is not noticing any changes since the last visit, but I may need to evaluate someone who recently lost vision or developed pain.  

By limiting the number of patients who come through our offices, we are protecting our patients, our staff and ourselves from exposure to the virus.  It is our way of increasing the likelihood that a patient may remain in place and limit the spread of this disease. 

Stop Elective Surgery

Both the American Hospital Association and the Centers for Disease Control and Prevention are recommending that hospitals stop performing elective surgery and non-urgent surgical procedures.  Examples of each might include joint replacements and cataract surgery. Non-urgent surgical procedures might include a colonoscopy.

What’s the rationale?  It saves resources.  

Elective surgeries and procedures take up hospital resources.   By canceling or postponing these procedures, for example, hospital beds and staff can be freed to help with more critical patients elsewhere in the hospital system.

Nurses and aides who normally work in an elective surgical center may be needed elsewhere such as the emergency room.

This practice will also limit exposure to healthy patients.  

Don’t forget that while this pandemic is progressing, patients will still need emergency surgery, chemotherapy, and require care for heart attacks and strokes. 

This is an effort to avoid overburdening our hospital resources and “flatten the curve.”

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

Retinal Disease Urgencies & Emergencies

As the pandemic looms, do you know what urgent and emergent eye conditions might mean?

Eye doctors will likely be asked to see only patients with urgent and emergent conditions. Retinal diseases often require emergent or urgent treatment.

Suggestions have been made to limit office visits to those patients with only urgent and emergency conditions.  In addition, hospitals have been canceling elective surgery and procedures to a later date. Both measures are intended to protect healthy individuals from unnecessary exposure to the virus and to preserve healthcare resources.

Retinal specialists treat “urgent” and “emergent” on a daily basis.  Here’s a short list of what a retina specialist treats on a daily basis.  

Disclaimer:  This article reflects my opinion only.  Your own doctor may have a different opinion.  Please check with your doctor if you have questions or if you are having problems with your vision.  In my opinion, any condition which causes a change in vision or pain should warrant an urgent visit to your doctor….call your doctor.  

N. Moinfar, M.D.

Diabetic Retinopathy

Diabetic retinopathy is the disease diabetes causes in the eye.  Most patients will develop some degree of diabetic retinopathy in their lifetime, and because of this, patients need to be seen regularly whether there are changes in their vision or not.

If there are no acute changes in vision since last visit, then there is probably no urgency to get an examination, though this may not be true in patients with proliferative diabetic retinopathy.  You may call your doctor and discuss how long you can wait after the pandemic is over. 

Diabetes can cause sudden loss of vision due to a vitreous hemorrhage.  Your doctor may want to see you quickly.

New Onset Floaters

Usually new onset floaters are due to a posterior vitreous detachment (PVD).  A PVD can cause a retinal tear which can be diagnosed only by prompt examination and, therefore, new onset floaters should be deemed urgent.  Retinal tears can cause a retinal detachment, hence, the concern.

Macular Degeneration

Patients with macular degeneration can develop loss of central vision and/or distortion.  Many patients self monitor at home with the aid of an Amsler grid, a simple way to look for new distortion in their vision.  If you notice new loss of vision and/or worsening distortion, especially if you are receiving anit-VEGF injections, I would recommend you call your doctor for an urgent evaluation.

Complications from Cataract Surgery

Complications from cataract surgery are usually seen by a retina specialist within a few days of occurrence.  Since cataract surgery is deemed elective, there should not be any complications during the pandemic as cataract surgery is being rescheduled to preserve hospital resources and decrease exposure of healthy people to the virus. 

Retinal Detachment

Retinal detachments can be an emergency, especially if there is progressive loss of vision, but the central vision is spared.  The goal of retinal detachment surgery is to diagnose and perform surgery before the central vision is affected.  

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