Cataracts

Cataracts cause half of all cases of blindness and 33% of visual impairment worldwide.

A cataract is a clouding of the lens in the eye which leads to a decrease in vision. Cataracts often develop slowly and can affect one or both eyes. The underlying mechanism involves accumulation of clumps of protein or yellow-brown pigment in the lens that reduces transmission of light to the retina at the back of the eye.

Symptoms

May include faded colours, blurry or double vision, halos around light, trouble with bright lights, and trouble seeing at night. This may result in trouble driving, reading, or recognizing faces.

Causes

Cataracts are most commonly due to aging but may also occur due to trauma or radiation exposure, be present from birth, infections, certain medications or occur following eye surgery for other problems.

Risk Factors

Include age, diabetes, smoking tobacco, prolonged exposure to sunlight, and alcohol.

Related issues:

Poor vision caused by cataracts may also result in an increased risk of falling and depression.

Treatment

  • Prevention includes wearing sunglasses and avoiding smoking
  • Early on symptoms may be improved with wearing glasses
  • If glasses do not improve the situation then surgery to remove the cloudy lens and replace it with an artificial lens is an effective treatment

Glaucoma

Glaucoma is a group of eye diseases which result in damage to the optic nerve and cause vision loss. The most common type is open-angle glaucoma with less common types including closed-angle glaucoma and normal-tension glaucoma. Vision loss from glaucoma, once it has occurred, is permanent.

Symptoms

Open-angle glaucoma develops slowly over time and there is no pain. Peripheral vision may begin to decrease followed by central vision resulting in blindness if not treated.

Closed-angle glaucoma can present gradually or suddenly. The sudden presentation may involve severe eye pain, blurred vision, mid-dilated pupil, redness of the eye, and nausea.

Causes

Of the several causes for glaucoma, ocular hypertension (the presence of elevated pressure inside the eye) is the most important risk factor in most glaucomas. Many people of East Asian descent are prone to developing angle closure glaucoma due to shallower anterior chamber depths, with the majority of cases of glaucoma in this population consisting of some form of angle closure.

Risk Factors

Risk factors for glaucoma include increased pressure in the eye, a family history of the condition,trauma and high blood pressure.

Treatment

The modern goals of glaucoma management are to avoid glaucomatous damage and nerve damage, and preserve visual field and total quality of life for patients, with minimal side-effects. This requires appropriate diagnostic techniques and follow-up examinations, and judicious selection of treatments for the individual patient.

Although is only one of the major risk factors for glaucoma, lowering intraocular pressure (IOP) via various pharmaceuticals and/or surgical techniques is currently the mainstay of glaucoma treatment.

Macular Degeneration

Also known as Age-related macular degeneration (AMD or ARMD)

A medical condition which may result in blurred or no vision in the centre of the visual field.

Symptoms

Distorted vision in the form of metamorphopsia, in which a grid of straight lines appear wavy and parts of the grid may appear blank: Patients often first notice this when looking at things like blinds in their home or telephone poles while driving.

Early on there are often no symptoms. Over time, however, some people experience a gradual worsening of vision that may affect one or both eyes. While it does not result in complete blindness, loss of central vision can make it hard to recognize faces, drive, read, or perform other activities of daily life.Slow recovery of visual function after exposure to bright light (photostress test)

  • Visual acuity drastically decreasing (two levels or more), e.g.: 20/20 to 20/80
  • Blurred vision:
  • Trouble discerning colours, specifically dark ones from dark ones and light ones from light ones
  • A loss in contrast sensitivity
  • Formed visual hallucinations and flashing lights have also been associated with severe visual loss secondary to wet AMD
  • Visual hallucinations may also occur

Causes

Macular degeneration typically occurs in older people. Genetic factors and smoking also play a role.

Risk Factors

Aging, genetics, smoking, hypertension, atherosclerosis, obesity, fat intake, overexposure to UV lights.

Treatment

Treatment of AMD varies depending on the category of the disease at the time of diagnosis. In general, treatment is aimed at slowing down the progression of AMD.

As of 2018, there are no treatments to reverse the effects of AMD.

Anti-angiogenic drugs.

  • Are injected into your eye. They stop new blood vessels from forming and block the leaking from the abnormal vessels that cause wet macular degeneration.
  • Some people who take these drugs have been able to regain vision that they lost from AMD. You will likely need to get the treatment repeated on follow-up visits.

Laser therapy.

  • Your doctor may suggest a treatment with high-energy laser light that can sometimes destroy actively growing abnormal blood vessels from AMD.

Photodynamic laser therapy.

  • It’s a two-step treatment that uses a light-sensitive drug to damage your abnormal blood vessels.
  • Your doctor injects a medication into your bloodstream, which gets absorbed by the abnormal blood vessels in your eye. Next, he shines a laser into the eye to activate the drug, which damages the abnormal blood vessels.

Diabetic retinopathy

Diabetic retinopathy is also known as diabetic eye disease. At least 90% of new cases could be reduced with proper treatment and monitoring of the eyes. It is a leading cause of blindness.

A medical condition in which damage occurs to the retina due to diabetes mellitus. Diabetic retinopathy affects up to 80 percent of those who have had diabetes for 20 years or more. The longer a person has diabetes, the higher his or her chances of developing diabetic retinopathy

Symptoms

The first stage, called non-proliferative diabetic retinopathy (NPDR), has no symptoms. Patients may not notice the signs and have 20/20 vision. The only way to detect NPDR is by fundus photography, in which microaneurysms (microscopic blood-filled bulges in the artery walls) can be seen. If there is reduced vision, fluorescein angiography can show narrowing or blocked retinal blood vessels clearly (lack of blood flow or retinal ischemia).

Causes

All people with diabetes mellitus are at risk – those with Type I diabetes and those with Type II diabetes. The longer a person has had diabetes, the higher their risk of developing some ocular problem.

Treatment

There are three major treatments for diabetic retinopathy, which are very effective in reducing vision loss from this disease. In fact, even people with advanced retinopathy have a 95 percent chance of keeping their vision when they get treatment before the retina is severely damaged.

These three treatments are:

  • Laser surgery
  • Injection of corticosteroids anti-VEGF agents into the eye
  • Vitrectomy

Dry Eye

This is a very common eye problem and occurs either when there are insufficient tears produced or due to increased evaporation of the tears.

Symptoms

Dry eye can cause a significant decrease in quality of life due to its impact in all daily activities. It may cause irritation, tearing, redness, decrease in vision, light sensitivity and may even lead to corneal staining with secondary infections and scarring.

Causes and risk factors

There are numerous factors that may precipitate or worsen dry eye disease. These include age, sex, work environments, travel and air conditioning, certain chronic illnesses such as autoimmune diseases, medications, previous or current ocular problems, ocular surgery and Lasik , contact lens wear and lid abnormalities.

Treatment

The treatment depends on the cause as well as and predisposing factors. There are numerous types of drops and supplements as well as lifestyle changes that may be applicable. This will depend on what your Ophthalmologist finds. Treatment is usually chronic and requires dedication from the patient.

Corneal Infections

The cornea is the front clear part of the eye which covers the iris and the round pupil.  When this layer is compromised or damaged, infection can gain access and cause a corneal infection or even an ulcer.  This is called keratitis.

Symptoms

Corneal infections/ulcers usually presents with redness of eye, eye pain, eyelid swelling, the sensation of having something in the eye, excessive tearing, pus or discharge, sensitivity to light or blurry or worsening vision.  A white area or spot may be noted on the front of the eye.

Causes

If the first layer of the cornea (epithelium) is damaged the cornea becomes vulnerable to infection by bacteria, viruses, parasites or fungi.  Recognising the infection early is critical to initiating treatment before permanent eye damage occurs.

Risk factors

Some factors that place you at risk for corneal infections/ulcers include:

  • Injury, abrasion or burns to the cornea: Scratches, scrapes and cuts from fingernails, makeup brushes or tree branches as well as chemicals can all cause trauma and damage to the cornea. Using appropriate protective eyewear when doing any work or play that may lead to an eye injury is important.
  • Contact lens wearers: appropriate lens handling, storage and cleaning is important to reduce the risk of infection.
  • The use of steroid eye drops
  • Dry eyes
  • Eyelid disorders that prevent proper functioning of the eyelid
  • A history of shingles or cold sores

Diagnosis

Your ophthalmologist will use a special microscope called a slit-lamp and a special stain called fluorescein to determine the extent of the damage.  If more information is needed a sample of the infection (called a corneal scrape) can be taken which is sent to the lab to determine the cause of the infection.

Treatment

Depending on the cause, antibiotic, antiviral or antifungal treatment will be prescribed.  This treatment can be in eyedrop, tablet form or both. Your ophthalmologist will then follow you up closely and monitor your response to treatment. Early evaluation and treatment is crucial and recommended to prevent any permanent damage to your eye and vision.

Keratoconus

This is a condition where the cornea (the clear front part of the eye) has an abnormal, weaker shape, and as a consequence the vision deteriorates over time.

Symptoms

Keratoconus often affects both eyes and can cause a slow painless deterioration in vision.  Typically, it begins in the late teens to early 20’s and slowly gets worse over 10-20 years.  Symptoms can be different in each eye.  Initially one may experience mild blurring or distortion of vision.  There may be increased sensitivity to light and glare.  This can progress with symptoms of worsening vision and increased near sightedness or astigmatism.  If your optometrist keeps changing your glasses and your eyes are getting “weaker” quickly, it is a good idea to have an ophthalmologist review your eyes.

Causes

The underlying cause of keratoconus is not completely clear.  In some cases it appears to be genetic and is passed down in families.  Keratoconus has a strong association with eye allergies and eye rubbing so excessive eye rubbing should be avoided.

Risk factors

As noted, keratoconus has a strong association with ocular allergies.  If your eyes are very itchy, red and tearing and you rub your eyes a lot, one should see an ophthalmologist.  By adequate management of your allergies, one can prevent the eye rubbing that can change or worsen the shape of the front of the eye which can result in keratoconus.

Treatment

Keratoconus treatment depends on your symptoms and the extent of curvature change and thinning.  Early diagnosis and follow up by an ophthalmologist is important.  Both the stage of disease and rate of progression will be assessed and then managed appropriately based on this.  Your ophthalmologist will also manage any other associated conditions and symptoms, all which can help slow down the progression of keratoconus.

Early on, glasses are usually sufficient to compensate for this curvature change.  Later, hard contact lenses may be needed to maintain vision and focus.

Corneal collagen cross-linking can also be used.  Here, special ultraviolet light and eye drops are used together to strengthen and stiffen the cornea and slow down the progression of keratoconus.  Another treatment option are Intacs which are small curved devices that can be placed into your cornea.  These can help flatten the curvature of your cornea to improve vision.  In advanced cases one may need a corneal transplant to correct the condition.  Here, your ophthalmologist will replace all or part of your diseased cornea with healthy donor cornea tissue.

Chloroquine and Hydroxychloroquine

What are chloroquine and hydroxychloroquine used for?

Chloroquine and hydroxychloroquine can used to treat arthritis and other autoimmune conditions.  Although it is a very good drug, long-term use can have significant adverse effects.  One such side effect is damage to the retina-specifically the macula (the central area of the retina that is responsible for our best vision) and it can potentially cause irreversible damage to this area known as a maculopathy.

 Symptoms of toxicity

Initially there will be no eye complaints.  With more extensive damage one might notice a subtle decrease in vision or visual disturbances for instance where straight lines appear wavy (metamorphopsia).  As symptoms can be absent and as the damage is permanent, it is very important that all patients on chloroquine and hydroxychloroquine be under the care of an ophthalmologist.

Risk factors for toxicity

High dose and long duration are the most significant risk factors.  Patients with kidney diseases are also at higher risk.  The damage caused by chloroquine and hydroxychloroquine is irreversible so it is important for patients to know about this potential damage and to undergo screening by their ophthalmologist.

Screening and Treatment

A baseline eye examination should be performed to rule out any pre-existing conditions affecting the macula.  Yearly screening should then be performed after 5 years for patients on acceptable doses and without any major risk factors.

Your ophthalmologist will make use of various screening tests to pick up any subtle damage.  These include visual field testing and other retinal scanning devices such as optical coherence tomography.  These modern screening tests should detect early damage before it is seen clinically.

If early damage is detected, your ophthalmologist will advise your rheumatologist to stop the chloroquine/hydroxychloroquine in favor of an alternative treatment option.  With appropriate screening one can avoid the irreversible damage to vision that can happen with these drugs

Pterygium

This is a non-cancerous growth that occurs on your conjunctiva ( the mucus membrane covering the eye ) and can grow onto your cornea. It is often wedge shaped and occurs more commonly in the nasal aspect of the eye, however can occur temporally.

Symptoms

If the ptergium is small it is called a penguecula and may have no symptoms. As is grows larger it can be a cosmetic complaint or it can lead to dryness and irritation. If it becomes inflamed it can be extremely irritating and look very large and red. It can grow over your cornea and cause astigmatism and affect vision

Causes and risk factors

Uv exposure, warm climates, pollen, dust and genetics have all been implicated in pterygium formation

Treatment

Depending on the size and whether it is causing symptoms or inflamed, treatment can vary from protective measures, lubrication, short term steroid drop use or surgery. Your Ophthalmologist will guide you as to what is the best option for you.

Ocular Allergies

This is a very common condition that can range from mild to severe. It can also occur in children in a separate condition known as vernal keratoconjuncitivis and these children need regular follow up and treatment by an Ophthalmologist as the complications can be sight threatening.

Symptoms

Patients typically present with red, itchy eyes. There might be associated eyelid or conjunctival swelling as well as other allergic symptoms such as a runny nose or sneezing. With VKC (vernal keratoconjunctivitis ) the patients may have brown looking sclera, jelly like bumps around the cornea or even corneal ulcers.

Causes and Risk factors

Determining the cause is often very difficult and common allergens include dust, pollen, animal dander, pollution and grass. Patients are often prone to other allergic diseases. There is often a seasonal exacerbation when the allergic conjunctivitis may be worse. With VKC the patient may suffer from dermatitis/eczema or general atopy and there may be a genetic component.

Treatment

Depending on the age of the patient and the severity of the disease the treatment will vary. Typical allergic eye drops will often be used and possibly the addition of steroid eye drops and lubrication. In children with VKC the treatment is usually more intense with repeated follow-ups and tests to prevent or treat sight threatening complications.

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