Fluorescein Angiography


Fluorescein angiography, a clinical test to look at blood circulation inside the back of the eye, aids in the diagnosis of retinal conditions associated with diabetes, age-related macular degeneration, and other eye abnormalities. The test can also help follow the course of a disease and monitor its treatment. It may be repeated on multiple occasions.

Fluorescein, a virtually harmless orange-red dye, is injected into a vein in the arm. The dye travels through the body to the blood vessels in the retina, the light-sensitive nerve layer at the back of the eye. A special camera with a green filter flashes a blue light into the eye and takes multiple photographs of the retina. We use the most advanced digital angiography system (the Heidelberg Retinal Angiographic suite) available today. No X-rays are involved.

If there are abnormal blood vessels, the dye leaks into the retina or stains the blood vessels. Damage to the lining of the retina or atypical new blood vessels may be revealed as well. These abnormalities are determined through a careful interpretation of the images.

The dye can discolor skin and urine for about 24 hours until it is removed from the body by the kidneys. There is little risk in having fluorescein angiography, though some people may have mild allergic reactions to the dye. Severe allergic reactions have been reported but very rarely. Being allergic to X-ray dyes with iodine does not mean you'll be allergic to fluorescein. Occasionally, some of the dye leaks out of the vein at the injection site, causing a slight burning sensation that usually goes away quickly.


 

Indocyanine Green Angiography (ICG)


ICG angiography is a clinical test used to detect abnormal blood vessels in the choroid, the layer of blood vessels under the retina. These abnormal blood vessels, typically associated with macular degeneration, may cause bleeding, scarring, and vision loss. If the blood vessels can be restricted by laser surgery, vision loss may be stabilized or improved.

lndocyanine, a virtually harmless green dye, gives off infrared light. When injected into the bloodstream, the dye travels through the veins to the blood vessels in the eye. A highly sophisticated camera connected to a computer picks up the infrared light and makes a picture of the blood's circulation. No film or x-rays are involved.

Following the test, the liver removes the dye. There is little risk in having an ICG angiogram. Some people may have mild allergic reactions and, although rare, a few severe allergic reactions have been reported in people allergic to iodine, X-ray dyes and shellfish.


 

B-scan ultrasound


We use B-scan ultrasound to image the retina in cases where blood or other obstacles prevent adequate visualization of the retina. Most people are familiar with ultrasound in the context of imaging a fetus with the mother's womb. Sometimes it's the only way we have to image the retina.


 

Laser photocoagulation


At MaculaCare we have the latest state-of-the-art ophthalmic lasers. We use both a conventional 532nm Nidek laser system to treat a variety of retinal disorders and a Zeiss Visulas 690 nm system to perform Photodynamic therapy with Visudyne.


 

Cryotherapy


A Frigitronics cryopexy unit with specialized retinal probes is used to treat certain retinal tears and other lesions in the retina in the office.


 

Visual Fields


A Zeiss Humphrey automated perimeter is used to formally assess peripheral vision in selected patients.


 

OCT, Optical Coherence Tomography


The OCT is a new non-invasive diagnostic tool used to image retinal tissue. This advanced technology provides an unmatched level of detail and accuracy in examining the cross section of the retina. This capability helps to detect subtle findings in macular diseases and is an excellent tool for early diagnosis and monitoring treatment effects. This new diagnostic test is important in conditions such as age-related macular degeneration, macular edema in vascular occlusion, diabetic macular edema, macular hole, macular pucker, cystoid macular edema, and vitreo-macular traction.


 

Lucentis


Lucentis is a new FDA approved treatment for Wet Age-Related Macular Degeneration. This medication is delivered into the vitreous cavity in order to achieve a high level of concentration. It works by interrupting a signaling pathway that is necessary for the growth of abnormal blood vessels (Choroidal Neovascularization). These blood vessels bleed and leak fluid under the retina causing distortion and loss of vision in the "Wet" Macular Degeneration. Compared to previous methods of treatment, it is a more sophisticated and elegant approach because it targets the abnormal growth of blood vessels and suppresses the formation of new vessels. This may lead to less destruction of surrounding retinal and choroidal tissue. Because the signaling pathway needs to be continually suppressed, the treatment needs to be repeated about every six weeks.


 

 

Treatments for Age Related Macular Degeneration (AMD)


Several treatments have been demonstrated to be of benefit and are all performed by Dr. Rosberger at MaculaCare:

1. Conventional Laser Photocoagulation uses a thermal laser (Nidek 532nm) to cauterize the abnormal new blood vessel growth under the retina. This was the standard of care until recently. Unfortunately, while this technique is very effective at destroying the new vessel growth and stopping the bleeding and leakage associated with wet AMD, it also causes significant "bystander" damage to the retina itself. Because of this, we generally reserve this treatment for patients whose lesions are outside of the center of the macula (the fovea).

2. Photodynamic therapy (PDT) with Visudyne is the most important improvement in the treatment of wet macular degeneration in over a decade. In this exciting treatment, patients receive an intravenous infusion of a photoreactive drug, Visudyne that is then activated by a special Zeiss 690 nm wavelength laser. This treatment usually stops the leakage and bleeding from the abnormal new vessels, but causes much less damage to surrounding tissue. We have had excellent results with this procedure and it has become the treatment of choice. Patients are cautioned however, that they need to stay out of bright lights and sunlight for several days after treatment. In addition, POT is a treatment and not a cure. On average patients require retreatment every three to four months.

3. Feeder Vessel Treatment is an exciting minimally invasive treatment for wet AMD. By using a very sophisticated imaging technique, Heidelberg Retinal Angiography, we are able to obtain exceedingly high-speed fluorescein and indocyanine green angiographic pictures of the new blood vessel complex. When we are able to identify specific early blood vessels feeding the much larger neovascular complex, we can selectively target this "feeder vessel" with laser. We are able to place a small laser burn outside the fovea that will destroy the new blood vessels underneath the fovea.

4. Transpupillary Thermal Therapy is a technique that treats wet AMD with a large spot of light heating. Although there are some indications for this treatment, we have largely abandoned it in favor of Photodynamic Therapy with Visudyne.

5. Submacular surgery is a surgical technique that is performed in the operating room. There, we can surgically evacuate subretinal hemorrhage and sometimes even the abnormal new blood vessels and scar tissue of wet AMD.

6. Macular Translocation Surgery is another surgical procedure performed in the operating room.  In this technique, the macula is actually rotated to another part of the eye that is unaffected by wet AMD. While there have been some remarkable successes with this procedure, we reserve it for very selected cases.

Procedures & Treatments

Age Related Macular Degeneration (AMD)


Age related macular degeneration (AMD) is one of the leading causes of vision loss in older Americans. Although the underlying cause is unknown, age is the most significant risk factor for developing AMD. Heredity, light colored iris, high blood pressure, cardiovascular disease, and smoking have also been identified as risk factors.


The visual symptoms of AMD involve loss of central vision. While peripheral vision is unaffected, one loses the sharp, straight ahead vision necessary for driving, reading, recognizing faces, and generally looking at detail. Imagine being able to see a clock on the wall but unable to make out the time or unable to read because you could not see parts of words on the page.

Several treatments have been demonstrated to be of benefit and are all performed by Dr. Rosberger at MaculaCare.  Click here for more information.


 

Diabetic Retinopathy


Diabetic retinopathy is a frequent complication of diabetes that causes damage to the blood vessels in the retina. In the early stages, non-proliferative diabetic retinopathy (NPDR), this damage causes the vessels to leak and bleed. This in turn, can cause swelling of the macula and decreased vision. This swelling, or edema, can be reduced with appropriate laser treatment.


As the damage progresses, there is closure of the normal blood vessels and the creation of new, abnormal blood vessels. This more advanced form, proliferative diabetic retinopathy (PDR) is very serious and can cause total blindness. Unfortunately, these new blood vessels are abnormal and grow on the surface of the retina, so they do not resupply the retina with blood.

Diabetic retinopathy often has no symptoms, if you have any form of diabetes you should have your eyes examined regularly.


 

Retinal Artery Occlusion


High blood pressure can affect vision by damaging arteries in the eye.

Retinal artery occlusions are blockages in the central (main) retinal artery or one of its four branches that supply the retina, the light- sensing nerve layer lining the back of the eye. The most common cause of artery occlusion is a thrombosis, the formation of a blood clot. Sometimes the blockage is caused by an embolus, a clot carried by the blood from another part of the body.


 

Retinal Vein Occlusion


Vein occlusions are blockages of the central (main) vein or one of its four branches draining the retina. Although there are many causes of vein occlusions, the most common identified risk factors include advanced age, high blood pressure, diabetes and glaucoma.

Branch retinal vein occlusion blocks small veins in the retina, the layer of light sensing cells at the back of the eye. If the blocked retinal veins are ones that nourish the macula, the part of the retina responsible for straight-ahead vision, some central vision is lost. During the course of vein occlusion, sixty percent or greater will have swelling of the central macular vision area. In about one third of people, this macular edema will remain for over one year.


 

Cytomegalovirus Retinitis (CMV Retinitis)


CMV retinitis is a serious eye infection of the retina, the light-sensing nerve layer that lines the back of the eye. It is a significant threat to people with weak immune systems, such as people with HIV and AIDS, newborns, the elderly, people taking chemotherapy, and recipients of organ transplants.

Warning signs that should be examined by an ophthalmologist immediately are floating spots or spiderwebs, flashing lights, blind spots or blurred vision. Recurrence of CMV retinitis is common so frequent retinal examinations are important.


 

Floaters and Flashes


Small specks or clouds moving in your field of vision as you look at a blank wall or a clear blue sky are known as floaters. Most people have some floaters normally but do not notice them until they become numerous or more prominent.  In most cases, floaters are part of the natural aging process.

The appearance of flashing lights comes from the traction of the vitreous gel on the retina at the time of vitreous separation. Flashes look like twinkles or lightning streaks. You may have experienced the same sensation if you have ever been hit in the eye and seen stars.

Floaters and flashes are sometimes associated with retinal tears. 


 

Detached and Torn Retina


A retinal detachment is a very serious problem that almost always causes permanent blindness unless treated. The appearance of flashing lights, floating objects, or a gray curtain moving across the field of vision are all indications of a retinal detachment. If any of these occur, you should be seen immediately.

As one gets older, the vitreous, the clear gel-like substance that fills the inside of the eye, tends to shrink slightly and take on a more watery consistency. Sometimes as the vitreous shrinks it exerts enough force on the retina to make it tear.


Retinal tears increase the chance of developing a retinal detachment Fluid vitreous, passing through the tear, lifts the retina off the back of the eye like wallpaper peeling off a wall. Laser surgery or cryotherapy (freezing) is often used to seal retinal tears and prevent detachment.

If the retina is detached, it must be reattached before sealing the retinal tear. 


 

Macular Hole


The macula is the part of the retina responsible for acute central vision, the vision one uses for reading, watching television, and recognizing faces.  A macular hole is a small round opening in the macula. The hole causes a blind spot or blurred area directly in the center of your vision.

Vitrectomy surgery, the only treatment for a macular hole.  With treatment, most macular holes close and some of the lost central vision returns. The amount of visual improvement typically depends on the length of time the hole was present.


 

Epiretinal Membranes


Epiretinal membranes, also known as cellophane maculopathy, retinal wrinkling, and macular pucker, is a condition where a fine growth of fibrous tissue occurs on the surface of the macula causing surface wrinkling and distortion of the macula. Patients with epiretinal membranes usually complain that they see wavy lines and images where they should be straight.

Treatment involves removing the vitreous gel and gently peeling the membrane from the surface of the retina. This usually results in a significant improvement in the distortion seen by the patient as well as some improvement in visual acuity.


 

Retinal Manifestations of Rheumatologic Diseases


Many rheumatologic diseases (systemic lupus erythmatosis, sarcoiciosis, Behcet's disease, rheumatoid arthritis, and others) can cause problems with the retina.  In addition, several of the medications used to treat these conditions (Plaquenil) can cause retinal toxicity.  Dr. Rosberger has a Ph.D. in Clinical Immunology in addition to his extensive training in ophthalmology and retinal diseases.  He has a particular interest in the retinal manifestations of rheumatologic diseases.

  

Conditions

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