Vitreo Retinal Diseases

2024/05/16

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Age-related Macular Degeneration

Summary of Age-Related Macular Degeneration (ARMD)

Age-Related Macular Degeneration is a chronic and irreversible medical condition that results in the loss of central vision due to damage to the macula, the central part of the retina.

While there is no cure for macular degeneration, starting treatments early can slow the progression of the disease and make symptoms less severe. Treatment options include smoking cessation, vitamin supplements, laser therapy, injection medications, and the use of vision aids.

It may not affect vision in the early stages of disease until the advanced stage.

Risk factors for the disease include adults over age 60, family history, smoking, high blood pressure, hyperlipidaemia, obesity, light skin or eye colour.

What is Age-Related Macular Degeneration (ARMD)?

Age-related macular degeneration (ARMD) is caused by deterioration of the retina and can severely impair vision.

While there is no cure for macular degeneration, starting treatments early can slow the progression of the disease and make symptoms less severe. Treatment options include smoking cessation, vitamin supplements, laser therapy, injection medications, and the use of vision aids

This chronic and irreversible medical condition results in the loss of central vision due to damage to the macula, the central part of the retina. ARMD is a major cause of blindness in individuals over 50 years old. The condition can make it difficult to read or recognise faces, although enough peripheral vision (vision outside the central area of your gaze) remains to allow you to continue with other daily activities. However, driving and reading will be affected.

The Two Main Types of ARMD:

Dry form: Characterised by the presence of yellow deposits called drusen in the macula. Initially, small drusen may not cause changes in vision; however, as they grow in size and increase in number, they can lead to dimming or distortion of vision, particularly noticeable during reading. In advanced stages, there is also a thinning of the light-sensitive layer of cells in the macula leading to atrophy, or tissue death. This atrophic form of dry macular degeneration can cause blind spots in the central vision, eventually leading to the lose central vision.
Wet form: The more serious of the two forms, it is characterised by the growth of abnormal blood vessels from the choroid underneath the macula, a condition known as choroidal neovascularisation. These blood vessels leak blood and fluid into the retina, causing distortion of vision that makes straight lines look wavy, as well as blind spots and loss of central vision. Bleeding from these abnormal blood vessels eventually form a scar, leading to permanent loss of central vision.

Most patients with macular degeneration have the dry form of the disease and can lose some form of central vision. However, the dry form of macular degeneration can lead to the wet form. Although only about 10% of people with macular degeneration develop the wet form, they make up the majority of those who experience serious vision loss from the disease.

It is very important for people with macular degeneration to monitor their eyesight carefully and see their eye doctor on a regular basis.

What Are the Risk Factors for ARMD?

Your risk increases with the following:

Adults over age 60
Positive family history
Smoking
High blood pressure
High cholesterol
Obesity
Light skin
Light eye colour

What Are the Symptoms of ARMD?

In its early stages, macular degeneration may be asymptomatic and go unrecognised until it progresses or affects both eyes. The first sign of macular degeneration is usually blurred vision with a dim, blurry spot in the central vision. This spot may get bigger or darker over time.

Symptoms of macular degeneration include:

Dark, blurry areas in the centre of vision
Diminished or changed colour perception

If you experience any of these symptoms, see an eye specialist as soon as possible.

How Is ARMD Diagnosed?

ARMD can be detected during routine eye examination. One of the most common early signs is the presence of drusen—tiny yellow deposits under the retina, or pigment clumping. Your doctor can see these when examining the eyes. Additionally, your doctor may need you to view an Amsler grid—a checkerboard pattern of straight lines. If some lines appear wavy or are missing, these may be indicative of macular degeneration..

If ARMD is detected, your doctor may recommend a procedure called angiography or Optical Coherence Tomography (OCT). In angiography, dye is injected into a vein in the arm, and photographs are taken as the dye flows through the blood vessels of the retina. This process reveals the precise location and type of any new vessels or vessels leaking fluid or blood in the macula. In contrast, OCT visualises fluid or blood beneath the retina without the need for dye.

Early detection of ARMD is crucial because there are treatments available that can delay or reduce the severity of the disease.

What Treatments Are Available for ARMD?

While there is currently no cure for macular degeneration, there are treatments available that may prevent severe vision loss or slow the progression of the disease. These options include:

Anti-angiogenesis drugs
These medications (Avastin, Eyelea, Lucentis, Macugen) block the development of new blood vessels and leakage from the abnormal vessels within the eye that cause wet macular degeneration. This treatment has marked a major shift in managing ARMD, with many patients regaining lost vision. The treatment may need to be repeated during follow-up visits.
Laser therapy
High-energy laser light can sometimes be used to destroy actively growing abnormal blood vessels in macular degeneration.
Photodynamic laser therapy
This two-step treatment involves the use of a light-sensitive drug (Visudyne) to damage abnormal blood vessels. The drug is injected into the bloodstream, where it is absorbed by the abnormal blood vessels in the eye. Subsequently, a cold laser is directed into the eye to activate the drug, causing damage to the abnormal blood vessels.
Low vision aids
There devices incorporate special lenses or electronic systems that generate enlarged images of nearby objects. They are designed to assist individuals with vision loss from macular degeneration in optimising their remaining vision.

What is the Outlook for Individuals with ARMD?

Complete vision loss is rare in individuals with ARMD. While they may experience poor central vision, most can still carry out many routine daily activities.

The wet form of the disease is a leading cause of irreversible vision loss. When both eyes are affected, it ca n significantly impact the individual's quality of life.

In contrast, the dry form is more common and tends to progress more slowly, allowing individuals to keep most of their vision.

Notably, even with treatment for the wet form, the condition may recur, requiring repeated treatments. Because of this, individuals with ARMD must test their own vision regularly and follow the recommendations of their ophthalmologist. Timely and effective treatment can slow the rate of vision loss and often lead to improvements in vision.

How Do I Know if I Have ARMD?

You may have one of some of these symptoms:

Gradual or rapid onset of blurred vision, especially in the central vision.
Shadows or missing areas of vision.
Distorted vision, e.g., a grid of straight lines appearing wavy, with some parts may appearing blank.
Problems discerning colours, specifically dark colours from other dark colours, and light colours from other light colours.
Slow recovery of visual function after exposure to bright light.
Loss in contrast sensitivity (the ability to tell different levels of luminaries or brightness apart)

What Puts Me at Risk of ARMD?

Your risk increases with:

Age: While current figures on the prevalence of AMD in Singapore are not available, a community study in 1997 revealed that one in four people aged 60 and above in the country experienced the condition.
Positive family history
Gender: Women are more likely to develop AMD
Smoking
Obesity
Cardiovascular diseases

What Can I Do to Prevent ARMD?

While there are no proven preventive medications for AMD, the most effective way to prevent vision loss is through prompt eye examination and diagnosis by an eye doctor. Early detection improves the success of treatment. Using a screening tool called the Amsler grid may help detect subtle changes in the vision. Regularly monitoring your vision with the Amsler grid is advisable. Additionally, adopting healthy habits such as quitting smoking, maintaining a balanced diet rich in leafy green vegetables, and safeguarding your eyes from UV light by wearing protective sunglasses or headgear with brims can contribute to overall eye health.

Diabetic Retinopathy

Summary of Diabetic Eye Diseases

Diabetic eye disease is a set of eye conditions that affect individuals with diabetes.
Diabetic retinopathy is the most common cause of vision loss among individuals with diabetes, and a leading cause of blindness among working-age adults.
It involves changes to retinal blood vessels, leading to bleeding or fluid leakage, and eventually distorting vision.
Diabetic Macular Edema (DME) is a consequence of diabetic retinopathy that causes swelling in the centre of the retina.
Effective management of diabetes through consistent medication adherence, physical activity, and a healthy diet can prevent or delay vision loss.
Because diabetic retinopathy often goes unnoticed until vision loss occurs, individuals with diabetes should undergo a comprehensive dilated eye exam at least once a year.
Early detection, timely treatment and appropriate follow-up care of diabetic eye disease can protect against vision loss.
Diabetic retinopathy can be treated with several therapies, either used alone or in combination.
Common diabetic eye diseases include diabetic retinopathy DME), cataract and glaucoma.

What Causes Diabetic Retinopathy?

Chronically high blood sugar from diabetes is associated with damage in the tiny blood vessels in the retina, leading to diabetic retinopathy. The retina is responsible for detecting light and transmitting signals through the optic nerve to the brain. In diabetic retinopathy, blood vessels in the retina leaks fluid or bleeds, distorting vision. In its most advanced stage, new abnormal blood vessels grow on the surface of the retina, leading to scarring and cell loss in the retina.

Diabetic Retinopathy May Progress Through Four Stages:

Mild non-proliferative retinopathy. This initial stage involves small areas of balloon-like swelling in the retina's tiny blood vessels, known as microaneurysms. These microaneurysms may leak fluid into the retina.
Moderate non-proliferative retinopathy. As the disease progresses, blood vessels that nourish the retina may swell and distort, leading to their impaired ability to transport blood. These changes contribute to the development of DME.
Severe non-proliferative retinopathy. More blood vessels become blocked, depriving blood supply to areas of the retina. These areas secrete growth factors signalling the retina to generate new blood vessels.

What is Diabetic Macular Edema (DME)?

DME is the build-up of fluid (edema) in a region of the retina called the macula, a crucial region of the retina responsible for sharp, straight-ahead vision used in activities like reading, recognising faces and driving. Among individuals with diabetic retinopathy, DME is the most prevalent cause of vision loss, affecting approximately half of all people with diabetic retinopathy. While DME is more likely to develop as diabetic retinopathy advances, it can occur at any stage of the disease.

Who is at Risk for Diabetic Retinopathy?

Individuals with all types of diabetes (type 1, type 2 and gestational) are at risk of diabetic retinopathy, with the likelihood increasing with the duration of diabetes. Women who develop or experience diabetes during pregnancy may face rapid onset or worsening of diabetic retinopathy.

Symptoms and Detection

What are the symptoms of diabetic retinopathy and DME?

The early stages of diabetic retinopathy usually do not present any symptoms. The disease often progresses unnoticed until it affects vision. Bleeding from abnormal retinal blood vessels can cause the appearance of "floating" spots, which may resolve on their own. However, without prompt treatment, bleeding often recurs, increasing the risk of permanent vision loss. If DME occurs, it can cause blurred vision.

How are Diabetic Retinopathy and DME Detected?

Diabetic retinopathy and DME are detected through a comprehensive dilated eye exam, which includes:

Visual acuity testing: This test measures the ability to discern objects at varying distances using an eye chart.
Tonometry: A procedure for measuring intraocular pressure.
Pupil dilation: Eye drops are administered to enlarge the pupil, enabling an examination of the retina and optic nerve.
Optical coherence tomography (OCT): Employing light waves (in contrast to ultrasound's sound waves), this method captures intricate images of internal tissues, including those of the eye.

During this examination, the doctor checks the retina for:

Changes in blood vessels
Signs of leaking blood vessels, such as fatty deposits
Swelling of the macula, indicative of DME
Changes in the lens
Damage to nerve tissue

Should DME or severe diabetic retinopathy be suspected, a fluorescein angiogram may be conducted. This involves the injection of a fluorescent dye is injected into the bloodstream, typically via an arm vein. Images of the retinal blood vessels are captured as the dye circulates to the eye.

Prevention and Treatment

Vision impairment from diabetic retinopathy can often be irreversible. However, early detection and treatment can reduce the risk of blindness by 95%. Diabetic retinopathy frequently presents no early symptoms, hence individuals with diabetes are advised to undergo a comprehensive dilated eye exam at least once a year. Those diagnosed with diabetic retinopathy may require more frequent examinations. Pregnant women with diabetes should have an exam as soon as possible, with additional assessments during pregnancy as necessary.

Managing diabetes effectively can delay the onset and progression of diabetic retinopathy. Studies also indicate that controlling high blood pressure and cholesterol levels can reduce the risk of vision loss among individuals affected by diabetes.

Treatment for diabetic retinopathy typically commences when the condition progresses to proliferative diabetic retinopathy (PDR), or when DME is present. patients with severe non-PDR, at high risk of evolving into PDR, might need eye exams every two to four months.

How is DME Treated?

DME treatment encompasses various therapies, either used independently or in combination:

Anti-Angiogenesis Injection Therapy

Anti-VEGF (vascular endothelial growth factor) medications, such as Avastin (bevacizumab), Lucentis (ranibizumab) and Eylea (aflibercept), are administered via injections into the vitreous gel. These drugs obstruct VEGF, a protein that can prompt the growth and fluid leakage of abnormal blood vessels.

Focal/grid macular laser surgery

This surgery involves creating small laser burns on leaking blood vessels near the centre of the macula. The procedure, typically completed in one session, helps to reduce fluid leakage and retinal swelling. Some patients might require additional treatments. The laser surgery may precede, coincide with, or follow anti-VEGF injections based on the patient's response to the therapy.

Corticosteroids

Corticosteroids, either injected or implanted into the eye, are sometimes utilised alone or in combination with other treatments. The Ozurdex (dexamethasone) implant releases a sustained dose of corticosteroids to suppress DME. However, corticosteroids increase the risk of cataract progression and glaucoma. Patients undergoing this treatment require regular monitoring for increased eye pressure and glaucoma development.

How is Proliferative Diabetic Retinopathy (PDR) Treated?

Historically, PDR has been treated using scatter laser therapy, or panretinal photocoagulation. This involves creating 2000 to 3000 tiny laser burns on peripheral retinal areas to shrink abnormal blood vessels. While often completed in one session, multiple sessions may be necessary. This treatment can preserve central vision but might affect peripheral, colour and night vision. Scatter laser surgery is most effective before the onset of bleeding in new, fragile blood vessels. Recent studies have shown the efficacy of anti-VEGF treatments in managing not only DME but also PDR, making it an increasingly preferred initial treatment option.

What is a Vitrectomy?

Vitrectomy involves surgically removing the vitreous gel from the centre of the eye, typically to address severe bleeding. Performed under local or general anaesthesia, the procedure uses ports for instrument insertion, like a vitrector, for suction and cutting. A saline solution replaces the removed vitreous to maintain eye pressure.

After treatment, the eye may be patched for a period, and it's common to experience redness and soreness. Eye drops have are prescribed to reduce inflammation and infection risk. If both eyes require vitrectomy, the second procedure is usually scheduled after the first eye has recovered.

What if Treatment Doesn’t Improve Vision?

If treatments don't improve vision, the eye doctor can assist in locating low vision and rehabilitation services. They can also recommend devices to optimise the use of remaining vision.

Central Serous Chorioretinopathy CSCR

Summary of Central Serous Chorioretinopathy (CSCR)

Central vision loss or distortion .
Perception of objects as smaller (micropsia) or distorted (metamorphosia) than their actual size.
Reduced colour saturation and contrast sensitivity.
Associated with stress, certain hormonal or endocrine disruptions and the use of steroid medications.
The use of traditional medicine like Ginseng may worsen the condition.
More than five times more likely to affect males than females.

Early detection, timely treatment, and regular follow-up care can prevent vision loss.
CSCR can occasionally resolve on its own within months, particularly if causative factors or medications are identified and discontinued.
CSCR can be treated with several therapies, used alone or in combination.
Common medical treatments include anti-corticosteroid, aspirin, anti-adrenergic agent, anti-VEGF drugs.
Common surgical options include Argon focal laser photocoagulation, photodynamic therapy (PDT) and subthreshold micropulse laser (SML).

What Is Central Serous Chorioretinopathy (CSCR)?

CSCR involves fluid leakage from behind the retina into the macula, causing detachment of the macula from its supporting tissue. The leakage primarily originates from the choroid layer through small breaks in the retinal pigment epithelium (RPE), affecting the retina and distorting vision. This condition can lead to temporary or permanent vision impairment.

What causes CSCR?

Stress or trauma
Stimulants- Steroid drug use, smoking, caffeine and other stimulants
High levels of the hormone cortisol
High blood pressure
Bacteria Helicobacter pylori.
Kidney disease

What are the symptoms of CSCR?

A blurry, dim blind spot in the vision centre
Objects appearing in miniature in the affected eye
Distortion of straight lines

What are the treatments for CSCR?

While CSCR may resolve on its own within a few months, particularly if causative factors or medications causing the issue are identified and addressed, ongoing or recurrent cases necessitate medical and/or laser treatment. Treatments includ, anti-corticosteroid, aspirin, anti-adrenergic agent, anti-VEGF drugs. Laser options include Argon focal laser photocoagulation, photodynamic therapy (PDT) and subthreshold micropulse laser (SML).

Retinal Vascular Disorders

Summary of Retinal Vascular Disorder

Retinal vascular disorders are a set of diseases which include, but not limited to, diabetic retinopathy, hypertensive retinopathy, retinal vein occlusion, retinal artery occlusion and retinopathy of prematurity.
It is often present in older patients with systemic vascular diseases such as hypertension, diabetes, hyperlipidemia and heart disease.
Blockage in one or more retinal blood vessels leads to fluid accumulation and impaired retinal function, causing visual loss. The degree of vision loss depends on the number of affected vessels.
Known risk factors include atherosclerosis (hardening of the arteries), blood clots, blockage or narrowing in the carotid arteries of the neck, heart problems, diabetes, high blood pressure, high cholesterol, obesity, intravenous (IV) drug use, being over the age of 60, glaucoma, smoking, inflammatory disorders and certain rare blood disorders.
Symptoms include sudden changes in vision, such as blurriness or a partial or complete loss of vision. Immediate medical consultation is advised if these symptoms occur.
Along with physical examination, techniques such as fluorescein angiography, optical coherence tomography or ophthalmoscopic examination are employed
There is no currently no specific medication for retinal artery occlusions. Most individuals with this condition will have permanent vision changes.
Common treatments for retinal vein occlusion include anti-VEGF drugs and corticosteroid drugs, as well as laser therapy.
Recovery depends on the disorder's severity. While many regain most of significant vision, complete restoration is not always possible. Co-exiting eye conditions may influence recovery.
Risk reduction strategies include regular exercise, maintaining a healthy weight, a balanced diet, smoking cessation and managing diabetes.

What Are Retinal Vascular Disorders?

Retinal vascular disorders constitute a group of diseases, including but not limited to diabetic retinopathy, hypertensive retinopathy, retinal vein occlusion, retinal artery occlusion and retinopathy of prematurity.

What Causes Retinal Vascular Disorders?

While the exact cause of vascular blockage or blood clots in the retina remains unknown, several risk factors are identified, including:

Atherosclerosis
Diabetes
High blood pressure
High cholesterol
Glaucoma
Blood clots from other body parts
Carotid artery blockages
Cardiac issues
Obesity
Intravenous (IV) drug use
Over the age of 60
Smokin
Rare blood disorders
Inflammatory disorders (giant cell arteritis)

Classification of Retinal Vascular Disorders:

Branch retinal vein occlusion (BRVO)

Blockage of a branch vein in the eye.

Central retinal vein occlusion (CRVO)

Blockage of all veins in the eye.

Branch retinal artery occlusion (BRAO)

Blockage of a small artery in the eye.

Central retinal artery occlusion (CRAO)

Blockage of the main eye artery, leading to sudden, painless vision loss.

Vitreomacular Traction (VMT)

Summary of Vitreomacular Traction (VMT)

The vitreous humor is a clear, gel-like substance filling the eye space between the lens and retina, undergoes age-related degeneration, leading to fluid pockets formation, contraction and volume loss. This can result in the vitreous gel separating from the retina due to liquefaction and continuous tractional forces on the macula.

Weakening of the retina's attachments and structures may cause partial detachment of the posterior hyaloid membrane, leading to posterior vitreous detachment (PVD) and potentially VMT.

Symptoms include decreased visual acuity, photopsia (flashes of light), micropsia (objects appearing smaller) and distorted vision.

More common in older adults, particularly women post-menopause, individuals with high myopia, and those with certain conditions like wet age-related macular degeneration, diabetic macular edema, retinal vein occlusion, and diabetic retinopathy.
Treatment options include observation, pars plana vitrectomy surgery, and pharmacological treatment with Ocriplasmin (Jetrea®), a recombinant form of human plasmin.

What is Vitreomacular Traction (VMT)?

VMT syndrome arises when age-related changes in the vitreous humor lead to partial detachment of the vitreous cortex from the retina. This incomplete PVD can exert tractional forces, causing anatomical damage and potentially leading to VMT syndrome, a condition that threatens vision and hinders daily tasks. VMT can progress to a macular hole, often requiring surgical intervention to prevent permanent vision loss.

What Causes VMT?

Age-related degeneration of the vitreous humor, leading to liquefaction and tractional forces on the macula, can result in VMT. The weakening of the vitreous cortex's attachments to the internal limiting membrane (ILM) of the retina may lead to PVD and potential VMT. This condition is prevalent in older adults, especially post-menopausal women, due to vitreous liquefaction linked with declining oestrogen levels.

Other Risk Factors include:

High myopia
Exudative (wet) age-related macular degeneration
Diabetic macular edema
Retinal vein occlusion
Diabetic retinopathy

What are the Symptoms of VMT?

Decreased visual sharpness
Photopsia (flashes of light)
Micropsia (objects appearing smaller)
Metamorphopsia (distorted vision, with straight lines appearing wavy)
Untreated VMT can lead to continuous visual loss

What are the Treatments for VMT?

VMT treatment varies based on the severity of the condition. Options include:

Regular monitoring and observation with OCT for patients with milld symptoms. Some VMT cases may resolve spontaneously.
Pars plana vitrectomy surgery for severe cases. The invasive procedure releases vitreous attachment and alleviates traction.
Pharmacological treatment involving Ocriplasmin (Jetrea®), a recombinant truncated form of human plasmin. Most patients maintain good visual acuity in the affected eye, even with treatment.

Epiretinal Membrane (Macular Pucker)

Summary of Epiretinal Membrane (Macular Pucker)

A macular pucker is scar tissue formed on macula, the central area of the retina responsible for sharp vision. This condition can lead to blurred and distorted central vision.
Macular pucker is also known as epiretinal membrane, preretinal membrane, cellophane maculopathy, retina wrinkle, surface wrinkling retinopathy, premacular fibrosis and internal limiting membrane disease.
Caused by age-related shrinking and detachment of the vitreous from the retina , leading to scar tissue formation and wrinkling of the retina and macula.
Risk factors include vitreous detachment, torn or detached retina, swelling inside the eye, severe eye damage (from surgery or injury) and issues with retinal blood vessels
Symptoms include vision loss from a macular pucker vary from no loss to severe loss and straight lines can appear wavy, difficulty in seeing fine detail and reading small print, grey area in the centre of your vision, or perhaps even a blind spot.
Diagnoses include: Optical coherence tomography(OCT), OCT scans the back of your eye. This provides very detailed pictures of the retina and macula.
Treatment includes observation for mild symptoms. Surgery (Vitrectomy) is performed when vision deteriorates significantly. No medical treatment, including eye drops or supplements, can resolve vision distortion caused by a macular pucker.
Repairing a macular pucker requires a very delicate surgery, and while vision improves in most cases, it does not usually return to normal.
Risk of surgery (vitrectomy) includes eye infection, bleeding , retinal detachment, recurrence of the membrane and cataract development.

What Is Epiretinal Membrane (Macular Pucker)?

An epiretinal membrane, or marcular pucker, is scar tissue on the macula in the retina’s center. This condition, leading to blurred and distorted vision, results from vitreous shrinkage and detachment as part of normal ageing. In some cases, this detachment causes microscopic damage to the retina, leading to scar tissue formation and wrinkling, particularly affecting central vision if over the macula.

What Causes Epiretinal Membrane?

The eye’s interior is filled with vitreous, a gel-like substance that fills about 80 percent of the eye and helps it maintain a round shape. The vitreous contains millions of fine fibres that are attached to the surface of the retina. As we age, the vitreous slowly shrinks and pulls away from the retinal surface. This is called a vitreous detachment, and is normal. In most cases, there are no adverse effects. However, sometimes when the vitreous pulls away from the retina, there is microscopic damage to the retina’s surface. When this happens, the retina begins a healing process to the damaged area and forms scar tissue, or an epiretinal membrane, on the surface of the retina. This scar tissue is firmly attached to the retina surface. When the scar tissue contracts, it causes the retina to wrinkle, usually without any effect on central vision. However, if the scar tissue has formed over the macula, our sharp, central vision becomes blurred and distorted.

What Are the Symptoms of Epiretinal Membrane?

Symptoms can range from no vision loss to severe impairment, with common issues including blurry or distorted vision, difficulty in discerning fine details or reading small print and possible presence of a grey area or blind spot in central vision.

What Are the Treatments for Epiretinal Membrane?

Treatment may not be necessary in mild cases, as patients often adjust to the visual distortion. Eye drops, medications, or supplements are ineffective in improving vision affected by macular pucker. In severe cases affecting daily activities, vitrectomy surgery may be recommended. This surgery involves removing the vitreous gel and scar tissue and is typically performed under local anaesthesia. Recovery includes wearing an eye patch and using medicated eye drops to prevent infection.

What Are the Risks of Surgery?

While vision often improves post-surgery, it may not return to normal. On average, about half of the vision is restored, with significant variation among individuals. Vision distortion generally reduces, with recovery taking up to three months. Common complications include accelerated cataract development, retinal detachment, infection and rare instances of membrane growth.

Macular Hole

Summary of Macular Hole

A macular hole is a small break in the macula, the central part of the retina responsible for sharp, central vision needed for activities like reading and driving.
A macular hole can cause blurred and distorted central vision. It typically occurs in individual over 60 and is associated with ageing.
There are three stages of Macular hole: Stage I (Foveal detachments), Stage II (Partial-thickness holes) and Stage III (Full-thickness holes). Progression likelihood increases with each stage.
The size and location of the hole determine the extent of vision loss. Stage III macular holes can lead to significant loss of central and detailed vision and may progress to retinal detachment if untreated.
Causes of macular hole include vitreous shrinkage and/or separation, diabetic eye disease, high myopia, macular pucker, detached retina, Best's disease and eye injury.
Symptoms of macular holes include gradual vision distortion or blurriness, with straight lines appearing bent or wavy. There will be difficulty in reading and performing routine tasks using the affected eye.
Surgery (Vitrectomy) is the only treatment. Neither eye drops nor medications can resolve the issue. Surgical risks include eye infection, bleeding, retinal detachment and cataract formation.
Strict adherence to a face-down position for a week or longer is crucial for healing. Air travel is prohibited until the gas bubble dissipates.

What is Macular Hole?

A macular hole in the retina's tiny central area, the macula, can cause blurred vision, blank spots, and distortion in central vision.

What Causes Macular Hole?

The vitreous gel inside the eye naturally shrinks and pulls away from the retina with age. This can sometimes lead to a macular hole.

Other Conditions that Increase Risk:

Presence of another eye condition.
Severe short-sightedness
Progression to epiretinal membranes (macular pucker)
Retinal detachment
Diabetic retinopathy
Eye injury or trauma

What Are the Symptoms of Macular Hole?

The condition often begins with slight distortion or blurriness in central vision, where straight lines or objects may appear bent or wavy. This can make reading and routine tasks challenging.

What are the Treatments for Macular Hole?

While some macular holes may heal without intervention, surgery (vitrectomy) is often necessary to improve vision. This involves removing the vitreous gel add replacing it with a bubble containing a mixture of air and gas to facilitate healing. The surgery is typically performed on an outpatient basis, under local anaesthesia. Post-operative care includes maintaining a face-down position for a specific period to ensure proper healing.

What are the Risks of Surgery?

Common risks include accelerated cataract development, infection and retinal detachment. Air travel is restricted for a few months after surgery due to pressure changes affecting the gas bubble. Vision recovery varies, with better outcomes generally seen in individuals with a shorter duration of the macular hole.

Myopic Maculopathy

Summary of Myopic Maculopathy

Myopic maculopathy occurs when the central retina displays degenerative changes due to an excessively elongated eyeball, leading to a stretched and fragile retina.
Severe and rapid decline in visual acuity can occur with the development of abnormal blood vessels in the central retina.
The condition is primarily due to the stretching of the retina associated with a longer than normal eyeball.
Individuals with severe short-sightedness, typically over eight diopters, are most at risk.
Diagnoses include fluorescein angiography, infrared angiography with indocyanine green and dilated eye examination.
Treatment involves the injection of anti-vascular endothelial growth factors for lesions involving the central fovea. Laser photocoagulation is effective for choroidal neovascularisation not impacting the central retina, while dynamic phototherapy can be utilised for central retinal conditions.

What is Myopic Maculopathy?

Characterised by an elongated eyeball, myopic maculopathy manifests when the central retina exhibits degenerative abnormalities due to excessive length and atrophy of the retina. The condition can lead to a significant and rapid decrease in visual acuity if abnormal blood vessels develop in the central retina.

What Causes and Symptoms of Myopic Maculopathy?

Early symptoms typically include a decline in close-up vision and distortion of straight lines. Patients may also notice black marks or spots in their visual field and blurred colors. While maculopathy is painless, the healthy eye may compensate, delaying symptom recognition. Symptoms can include image distortion (metamorphopsis) and the appearance of a central blind spot, progressing either rapidly or over several months.

What are the Treatments for Myopic Maculopathy?

Treatment includes the injection of anti-vascular endothelial growth factors for lesions involving the central fovea. Laser photocoagulation suitable for choroidal neovascularisation outside the central retina. Dynamic phototherapy may also be utilised for central retinal disease.

What are the Risk Factors of Surgery?

Macular surgery, including laser surgery for maculopathy, is delicate usually considered only when significant advantages are anticipated. The most serious complication following intravitreal injections for maculopathy therapy is infection, which, although rare, can be severe.

Floaters & Flashes

Summary of Floaters and Flashes:

Floaters appear as small specks, dots, circles, lines or cobwebs in the field of vision, caused by clumps in the vitreous casting shadows on the retina. Common symptoms include the perception of black spots or cobweb-like structures.
Flashes resemble flashing lights or lightning streaks in the field of vision. They occur when the vitreous rubs or pulls on the retina and are common with ageing. Symptoms include seeing sporadic flashes of light, resembling sparkles, lightning or fireworks.
Caused by the natural ageing process where the vitreous jelly shrinks, or could be due to blood cells or pigmented cells releasing into the vitreous, retinal tears or trauma.
Risk factors include ageing, high myopia, eye trauma, inflammation inside the eye (uveitis) or recent intraocular surgery.

Diagnosis is conducted through clinical examination and eye ultrasound.
Treatments include observation. In cases of underlying issues like retinal tears, laser or freezing therapy or surgery may be necessary. No effective medical treatments exists for this condition.
Sudden increase in black spots , continuous flashes or a curtain-like loss of vision requires immediate consultation with an eye specialist.

What Are Floaters and Flashes?

Floaters are tiny, dark shapes resembling spots, strands, or squiggly lines in the field of vision, often more noticeable when they become numerous or prominent. They tend to settle below the line of sight over time but rarely disappear completely.

Flashes are random flashes of light in the line of vision, sometimes experienced following eye impact, leading to the sensation of seeing stars.

What Causes Floaters and Flashes?

Both conditions are commonly part of the natural ageing process, occurring as the vitreous gel inside the eye shrinks and becomes stringy, casting shadows on the retina.

While often simply an annoyance, more serious causes of include infection, inflammation, haemorrhaging, retinal tears and eye injuries.

What Are the Symptoms of Floaters and Flashes?

Floaters appear as small, dark, moving shapes in the vision, not following eye movements precisely and often drifting when the eyes stop moving.

Flashes manifest as sudden, random brief flashes of light in the line of vision, often without a clear cause

What Are the Treatments for Floaters and Flashes?

Treatment is typically not recommended for floaters unless they significantly affect vision. In such cases, a vitrectomy may be performed, removing the vitreous and its debris and replacing it with a salt solution. However, this surgery carries significant risks like retinal detachment, retinal tears and cataract formation. This procedure is only considered when floaters severely impair vision.

Retinal Tears and Detachment

Summary of Retinal Tears and Detachment

The retina, the light-sensitive tissue lining the back of the eye, can detach from its normal position, potentially leading to permanent vision loss. Retinal tears or breaks can precede retinal detachment.
A retinal tear occurs when the vitreous gel tugs on the retina, potentially causing bleeding if retinal blood vessels are involved.
Retinal tears are common in the elderly, particularly those with high myopia, a history of eye injury, strong vitreoretinal attachments or family history of retinal tears or detachments.
Symptoms include a sudden or gradual increase in of floater, light flashes or a curtain-like shadow in the field of vision. Immediate medical attention is essential.
Retinal tears and detachment are more prevalent in men, individuals over 40, those with extreme near-sightedness, a history of retinal detachment, family history of retinal detachment, cataract surgery, certain eye diseases or disorders, such as retinoschisis, uveitis, degenerative myopia, lattice degeneration or eye injuries.
Diagnosis involves dilated eye examination with indirect ophthalmoscopy, scleral depression and 3-mirror contact fundus lens.
Treatments include laser surgery for minor tears and cryopexy for areas where laser treatment is unsuitable. A period of decreased activity is recommended post-treatment, with flashing lights and floaters possibly persisting.
Risk of surgery includes recurrence. Laser treatment does not treat floaters or flashing lights. These typically resolve gradually on their own over a period of weeks to months.

What Are Retinal Tears and Detachment?

When the retina detaches, it is pulled from its normal position, risking permanent vision loss. Retinal tears are small breaks that can lead to retinal detachment.

What Causes Retinal Tears and Detachment and Who Are at Risk?

Retinal detachment is often a result of ageing vitreous fluid shrinkage but can also be caused by inflammation or myopia.

Increased risk includes:

History of eye surgery
History of eye injury
Family history of retinal problems
Diabetes
Extreme near-sightedness (myopia)
History of other eye diseases or disorders

What Are the Symptoms of Retinal Tears and Detachment?

Retinal detachment is painless. Warning signs include:

Blind spots
Blurred or shadowy vision
A curtain-like effect over vision
Sudden appearance of many floaters or flashes of light

Immediate consultation with an eye specialist is advised.

How is Retinal Tears and Detachment Diagnosed?

A detached retina cannot be observed externally. The diagnosis is made through a comprehensive eye examination, utilising instruments like a slit lamp or ultrasound.

What Are the Treatments for Retinal Tears and Detachment?

For retinal tears: Prompt treatment can prevent detachment. The recommended procedure depends on the tear's severity. Available options include:
Laser photocoagulation: Effective for repairing small retinal tears. The technique involves using a laser to create small burns around the edges of the tear, forming scars that seal the tear and prevent fluid from leaking toward the retina.
Cryopexy: Involves using extreme cold to create scars and seal the edges of a retinal tear.
Liquid silicone: Used to replace vitreous fluid, maintaining the eye's normal shape and aligning the retina and eye wall. In cases of actual retinal detachment, fluid is drained from under the retina to minimise the gap between it and the eye wall. A silicone band may be applied externally to press the eye wall against the retina.
For retinal detachment: Surgery is necessary to repair the detachment. The type of surgery is determined based on the detachment's severity and includes:
Pneumatic retinopexy: Involves injecting air or gas into the eye’s central part. The resulting bubble presses the affected retina area against the eye wall, stopping fluid flow behind the retina. Patients may need to maintain a specific head position for several days to keep the bubble correctly positioned.
Scleral buckling: This procedure involves suturing a piece of silicone material onto the sclera (white of the eye) over the affected area, indenting the eye wall to alleviate the force exerted by the vitreous on the retina.
Vitrectomy: The vitreous and any tugging tissue are removed. Air, gas or silicone oil is injected into the vitreous space to flatten the retina. Over time, these substances are absorbed, and the vitreous space refills with body fluid.
Liquid silicone injection: Also used in retinal detachment repair, this involves replacing the vitreous fluid to maintain the eye’s shape and keep the retina and eye wall aligned.

Proliferative Vitreoretinopathy

Proliferative Vitreoretnopathy

Proliferative vitreoretinopathy (PVR) involves the formation of scar tissue within the vitreous cavity, impeding normal healing. This scar tissue can stiffen the retina, leading to recurrent detachment.
Recurrent retinal detachment due to PVR typically requires a vitrectomy operation using specialised techniques. Complete removal of all scar tissue on or beneath the retina is essential. The retina is then reattached using a gas bubble or silicone oil. The physician will tailor the surgical approach to the patient's specific needs.
The complexity of PVR with retinal stiffening reduces the likelihood of a completely successful surgery. However, with modern techniques, partial restoration of vision is often achievable.
Post-operative care may involve maintain the head in an elevated or specific position to aid in retinal reattachment. Prescription of eye drops and other medications will be individualised. Should the retina be successfully reattached surgically, vision improvement can be expected over several months. Any degree of vision restoration following PVR is considered a success.

Doctors

Clinical Associate Professor Caroline Chee
Associate Professor Lingam Gopal
Dr Chan Hwei Wuen
Dr Su Xinyi
Dr Yuen Yew Sen
Dr George Thomas
Professor Wong Tien Yin (Visiting Senior Consultant)
Dr Paul Zhao (Visiting Senior Consultant)
Associate Professor Adrian Koh (Visiting Consultant)
Dr Marcus Tan Chiang Lee (Visiting Consultant)
Dr Errol Chan (Visiting Consultant)