The Aging Eye
The eyes, just like other parts of the body, undergo normal aging changes. In many people, the first sign of visual changes are noticed in the 4th decade, when the ability to read and see things up close diminishes. This is due to a gradual loss of flexibility in the focusing system. Many people begin to use reading glasses for close tasks. The eyes continue to gradually lose flexibility in focusing for years, requiring stronger glasses over time. Contrary to popular myth, this process is not accelerated by the use of glasses.
Later in life, other visual changes are often noticed. Aging causes a slowing in dark adaptation that can be attributed to delayed rhodopsin regeneration in the retinal photoreceptors. This age related delay in dark adaptation may also contribute to night vision problems commonly experienced by the elderly. Color vision and contrast sensitivity are also affected by aging. The yellowing of the lens in the eye is believed to be responsible for this effect. As the yellowing of the lens of the eye progresses, it is called a cataract.
Aging also causes laxity and downward shift of eyelid tissues and atrophy of the fatty tissue surrounding the eyes. These changes contribute to eyelid disorders such as ectropion (eyelid turning out), entropion (eyelid turning in), dermatochalasis (excess skin overhanging eyes), and ptosis (drooping of eyelids).
Over time, many people begin to notice small floaters in their vision. Early in life, the gel that fills the eye is clear and is attached to the retina. Later in life as the gel ages, it gradually liquifies and condenses. The gel peals off of the retina (called a posterior vitreous detachment). This is a natural process. Small opacities can form in the vitreous gel which can become visible as floaters if centrally located.
Just like hay fever and skin rashes, eye allergies develop when the body’s immune system becomes sensitized and overreacts to something that is ordinarily harmless. An allergic reaction can occur whenever that “something” – called an allergen – comes into contact with your eyes. The allergen causes certain cells in the eye (called mast cells) to release histamine and other substances or chemicals that cause blood vessels in the eyes to swell, and the eyes to become itchy, red and watery.
Treatment begins with identifying the allergen, and decreasing exposure to it. Cool compresses applied to the eyes can be helpful. In addition, over-the-counter lubricating eye drops can provide some relief as this dilutes the allergen in the eyes. Some find it helpful to keep the lubricating eye drops refrigerated and instill chilled drops several times a day. Prescription eye drops may be necessary and these include antihistamine type drops, mast-cell stabilizing drops, and steroid drops. Steroid eye drops should always be used only as prescribed as they can have long-term side effects if used on a chronic basis.
Astigmatism is a vision condition that causes blurred vision due to the irregular shape of the cornea, the clear front cover of the eye. A cornea that is perfectly round has no astigmatism. A cornea that is oval, shaped like the back of a teaspoon, results in astigmatism. An oval cornea prevents light from focusing properly on the retina, the light sensitive surface at the back of the eye. As a result, vision becomes blurred at any distance.
Astigmatism is a very common vision condition. Most people have some degree of astigmatism. Slight amounts of astigmatism usually don’t affect vision and don’t require treatment. However, larger amounts cause blurred vision.
When vision is blurred from astigmatism, glasses or contact lenses can usually be prescribed to sharpen the vision.
Blepharitis is a chronic inflammation of the eyelids and it is one of the most common problems we see in the office.
Patients with blepharitis often complain of itching, burning, a chronic mild foreign body sensation, and mattering on lashes (particularly in the morning). Patients who also have dry eyes seem to be bothered the most by blepharitis.
There are several causes for blepharitis but by far the most common are Staphylococcal bacterial infection, meibomian gland dysfunction (these glands of the eyelid produce components of the eye’s tear film) and seborrhea. Staph infection of the eyelid commonly begins in childhood and continues for life. Bacteria such as staph, like it or not, colonize on our bodies; such colonization on the eyelids can lead to crusty deposits along the lashes, irregularity and redness of the lid margin and a red irritated eye. It is likely that decreased tear production (dry eye) may predispose individuals to such Staph blepharitis by altering local resistance to such bacteria. If the lash or lid glands become involved, a stye or chalazion (a blocked and enlarged lid gland) may result. The goal to treatment is to reduce the amount of bacteria on the eyelid margins.
Meibomian gland dysfunction can cause eyelid redness and irritation. Their secretions often fill the glands and thicken the eyelid margin. This is best initially treated with daily warm compresses and gentle lid message to express the material from the glands. Oral antibiotics can be helpful in severe cases.
Seborrhea/Rosacea is a skin disorder that can affect the eyelids and cause a greasy, waxy, scaling accumulation of skin along the lid margin. The oil producing glands in the lid are overactive. Seborrhea can also affect other areas of skin such as the scalp, back, chest and behind the ears. If the scalp is affected, daily treatment of scalp seborrhea with medicated shampoo may help the eyelids as well.
The initial step in treating all forms of blepharitis is to undertake eyelid hygiene. Most patients simply apply a warm compress for a few minutes to soften adherent material and/or warm the meibomian secretions, then clean the eyelid margins. To clean the lid margins, we recommend placing a few drops of baby shampoo into a cup of warm water then use this solution to gently scrub the lashes and eyelid margins with a wash cloth or cotton applicator. Simply use warm water alone if the shampoo is irritating. We recommend doing this daily, for life, in all blepharitis patients. When the irritation and redness really flare up it is wise to scrub the lids more than once a day. Artificial tears can also provide some comfort, particularly if the eyes are also dry. Only in recalcitrant cases or severe flare ups are antibiotics needed. Antibiotic ointments work best as they can be applied to the lashes but occasionally oral antibiotics are needed to treat the eyelid glands. Rarely a steroid/antibiotic combination ointment can be used to kill the bacteria and provide relief of bothersome symptoms.
Separating these three common forms of blepharitis is sometimes very difficult as they frequently appear together. The important thing to remember is that all forms of blepharitis can be treated with a brief warm compress and lid scrubs (scrubbing the eyelashes and eyelid margins) every night with warm water or dilute baby shampoo. The problem is chronic and many patients unfortunately stop their lid scrubs when they feel better only to find they will flare up in a few days. If you have blepharitis, remember, lid scrubs every night will lead to greater comfort on a daily basis.
A cataract is a clouding of the normally clear lens of your eye. Most cataracts represent a normal aging change of the lens, although cataracts can form for other reasons such as trauma and as a side effect of some medications. For people who have cataracts, seeing through cloudy lenses is a bit like looking through a frosty or fogged-up window. Clouded vision caused by cataracts can make it more difficult to read or drive a car — especially at night.
Most cataracts develop slowly and don’t disturb your eyesight early on. But with time, cataracts will eventually interfere with your vision.
At first, stronger lighting and eyeglasses can help you deal with cataracts. But if impaired vision interferes with your usual activities, you might need cataract surgery. Fortunately, cataract surgery is generally a safe, effective out-patient procedure.
A chalazion is a lump found on your eyelid. On the edge of your upper and lower eyelids are oil glands that keep your eyes moist. Occasionally, the oil glands may become blocked by thickened secretions. When the opening of an oil gland is blocked, oil collects in your eyelid and can harden and form a lump called a chalazion.
Applying warm compresses several times a day has been shown to be one of the most effective treatments. In fact, approximately 90% of cases will improve over time by applying compresses. Occasionally, an antibiotic/steroid eyedrop or ointment may prove helpful. If a chalazion persists, it may require an in-office minor procedure to open and drain the contents.
A corneal abrasion is a painful scrape or scratch of the surface of the clear part of the eye. This clear tissue of the eye is known as the cornea, which has many nerve endings just under the surface, so that any disruption of the surface may be extremely painful. The cornea tends to heal very rapidly, and usually without any long term problems.
Dry eyes are one of the most common eye problems that afflict the general population today. It can affect people of any age. However, its effect and magnitude are usually advanced with age. The reduction in the moisture of the eyes causes an uncomfortable feeling often described as a “foreign body sensation”. It can also cause a reduction in vision if it is sever
The most common treatment is the use of artificial tears. Artificial tears provide a temporary relief, and in order to be truly effective the drops need to be used very often. The reason for this has to do with the functioning of the eyes and with the continuous emptying of the tears into the nose via a small canal connecting the eyes and the nasal passages. When the artificial tears are put into the eyes they moisturize the eyes, but soon the fluid is drained and the eye becomes dry again.
Another form of treatment for dry eyes are punctal plugs. These are tiny microscopic plugs that are put into the small openings of the drainage canal (punctal openings) to slow down the drainage and increase the moisture in the eyes. Since this leads to an increased level of the natural tears of the eyes and the effect is lasting, Punctal Plugs may be favored by patients over the continuous use of artificial tears. Another benefit is that the increased moisture is now due to the natural tears of the eyes rather than artificial tears. The insertion is done at the office, is painless and takes just a few minutes. Side effects are rare and include minor irritation and increased tearing. However removal of the plugs is as easy as the insertion.
Some patients may be a candidate for a prescription eyedrop that, when used over time, can actually increase tear production.
Floaters and Flashers
Eye Floaters, Flashes and Spots
(from article By Marilyn Haddrill, with contributions and review by Charles Slonim)
Eye floaters are those tiny spots, specks, flecks and “cobwebs” that drift aimlessly around in your field of vision. While annoying, ordinary eye floaters and spots are very common and usually aren’t cause for alarm.
Floaters and spots typically appear when tiny pieces of the eye’s gel-like vitreous break loose within the inner back portion of the eye.
When we are born and throughout our youth, the vitreous has a gel-like consistency. But as we age, the vitreous begins to dissolve and liquefy to create a watery center.
Some undissolved gel particles occasionally will float around in the more liquid center of the vitreous. These particles can take on many shapes and sizes to become what we refer to as “floaters.”
You’ll notice that these types of spots and floaters are particularly pronounced when you peer at a bright, clear sky or a white computer screen. But you can’t actually see tiny bits of debris floating loose within your eye. Instead, shadows from these floaters are cast on the retina as light passes through the eye, and those shadows are what you see.
You’ll also notice that these specks never seem to stay still when you try to focus on them. Floaters and spots move when your eye moves, creating the impression that they are “drifting.”
When Are Eye Floaters and Flashes a Medical Emergency?
If you see a shower of floaters and spots, sometimes accompanied by light flashes, you should seek medical attention immediately.
The sudden appearance of these symptoms could mean that the vitreous is pulling away from your retina or that the retina itself is becoming dislodged from the inner back of the eye that contains blood, nutrients and oxygen vital to healthy function. When the retina is torn, vitreous can invade the opening and push out the retina — leading to a retinal detachment. An eye exam with dilated pupils will help differentiate between a vitreous detachment and a retinal detachment.
A study reported in the Journal of the American Medical Association in late 2009 found that sudden presence of eye floaters and flashes means that one in seven people with these symptoms will have a retinal tear or detachment. And up to 50 percent of people with a retinal tear will have a subsequent detachment.
In cases of retinal tear or detachment, action must be taken as soon as possible so that an eye surgeon can reattach the retina and restore function before vision is lost permanently.
Posterior vitreous detachments (PVDs) are far more common than retinal detachments and often are not an emergency even when floaters appear suddenly. But some vitreous detachments also can damage the retina by tugging on it, leading to a tear or detachment.
Light flashes known as photopsia can occur when your retina receives non-visual (mechanical) stimulation, which can happen when it is being tugged, torn or detached.
Fuchs Corneal Dystrophy
Fuchs’ dystrophy is an inherited condition that affects the innermost layer of the cornea. The cornea has 5 layers, the innermost is called the endothelium. The endothelium functions as a pump mechanism, constantly removing fluid from the cornea to maintain its clarity. Patients gradually lose these endothelial cells as the dystrophy progresses. Once lost, the endothelial cells do not grow back, but instead spread out to the fill empty spaces. The pump system becomes less efficient, causing corneal clouding, swelling and eventually, reduced vision.
In the early stages, Fuchs’ patients may not notice any symptoms. In time, vision may not seem as clear, even when corrected with glasses. Glare and light sensitivity may develop. As the dystrophy progresses, the vision may seem blurred in the morning and sharper later in the day. This happens because the internal layers of the cornea tend to retain more moisture during sleep that evaporates when the eyes are open. As the dystrophy worsens, the vision becomes continuously blurred.
Fuchs’ affects both eyes although it may be asymmetric. It generally begins at 30-40 years of age and gradually progresses. If the vision becomes significantly impaired, a surgical procedure may be indicated to replace the endothelial cells of the cornea.
Glaucoma: Open and Closed Angle
There are two categories of glaucoma and they have very different mechanisms. Open-angle glaucoma is the most common type in our country. Glaucoma is one of the leading causes of blindness. There are many risk factors for developing glaucoma, such as aging, family history of glaucoma, a history of eye trauma, elevated eye pressure, and race (more common in African-Americans). Many of the risk factors we cannot change. We can, however, lower the eye pressure with eye drops and/or laser, and reduce the risk of visual loss.
In order to understand the difference between open angle glaucoma and closed angle (narrow angle) glaucoma, it is important to understand the anatomy of the eye. The optic nerve connects the eye to the brain and transmits all of the impulses for vision to the brain. If glaucoma goes untreated, it is the optic nerve that sustains damage and cell death, and visual loss.
The inside of the eyes are filled with fluid called aqueous humor. The fluid is continuously produced by cells behind the iris (the colored part of the eye). The fluid continuously flows to a drainage canal/meshwork located in front of the iris where the fluid percolates through a meshwork of cells and gets reabsorbed into the blood vessels. The meshwork is located in an angle between the cornea and iris.
One of the tests to determine whether someone has glaucoma, or is at an increased risk of developing glaucoma, is a test to measure the eye pressure. If the eye pressure is elevated, it means that there is a problem with drainage of aqueous humor. Sometimes, the angle between the cornea and iris is narrow or closed, and the fluid cannot get to the meshwork for drainage. This is termed closed angle or narrow angle glaucoma. In other cases, the angle between the cornea and iris is wide open and the fluid can easily get to the meshwork for drainage, but the flow through the meshwork is too slow. This is termed open angle glaucoma. Some people can have a component of both, termed mixed-mechanism glaucoma.
Please see the following YouTube link:
Iritis is the inflammation of the iris, the colored portion of the eye. Iritis, which is often the result of a disease in another part of the body, can be a recurring condition. A fairly common eye problem, iritis usually responds well to treatment. However, the condition may become sight threatening when left untreated.
In many cases, iritis is related to a disease or infection in another part of the body. Diseases and infections such as arthritis, lupus, sarcoidosis, ankylosing spondylitis, crohn’s disease, tuberculosis, Lyme Disease, and syphilis can contribute to the development of iritis. In other cases, iritis may follow injury to the eye or an infection of the cornea.
In approximately half the cases, the exact cause of the disorder remains unknown.
Keratoconus occurs when your cornea — the clear, dome-shaped front surface of your eye — thins and gradually bulges outward into a cone shape. A cone-shaped cornea causes blurred vision and may cause sensitivity to light and glare. Keratoconus usually affects both eyes and typically begins during puberty or in your late teens. The condition may progress slowly for 10 years or longer.
In the early stages of keratoconus, vision problems can be corrected with glasses or soft contact lenses. As keratoconus progresses, you may have to be fitted with special rigid gas permeable contact lenses. Advanced keratoconus may require surgery.
Most people with keratoconus can see reasonably well with contacts or glasses for years. In fact, most cases do not require surgical intervention. If, however, vision deteriorates due to progressive disease, corneal scar tissue, or inability to wear contact lenses, a corneal transplant (outpatient surgery) may be a good option to restore vision.
Macular degeneration, or age-related macular degeneration (AMD) is a leading cause of vision loss in Americans 60 and older. It is a disease that destroys your sharp, central vision. You need central vision to see objects clearly and to do tasks such as reading and driving.
AMD affects the macula, the part of the eye that allows you to see fine detail. It does not hurt, but it causes cells in the macula to die. In some cases, AMD advances so slowly that people notice little change in their vision. In others, the disease progresses faster and may lead to a loss of vision in both eyes.
AMD is typically divided into two types: Dry AMD and Wet AMD. 90% of patients have the dry form, which is slowly progressive. 10% have the wet form, which can lead to a rapid deterioration in vision.
The “dry” form of AMD, causes decreased vision through loss of photoreceptors (rods and cones) in the central part of the retina. No medical or surgical treatment is available for this condition, however vitamin supplements with high doses of antioxidants, lutein and zeaxanthin, have been suggested by the National Eye Institute to possibly slow the progression of dry macular degeneration.
The “wet” form of AMD, causes vision loss due to abnormal blood vessel growth beneath the retina. Bleeding, leaking, and scarring from these blood vessels eventually cause irreversible damage to the photoreceptors and rapid vision loss if left untreated.
Until recently, no effective treatments were known for wet macular degeneration. However, new drugs, VEGF (Vascular Endothelial Growth Factor) inhibiting agents, can cause regression of the abnormal blood vessels and improvement of vision when injected directly into the eye. The injections have to be repeated on a monthly or bi-monthly basis. Only about 10% of patients suffering from macular degeneration have the wet type.
Map-dot-fingerprint dystrophy is an abnormality of the cornea, the clear covering of the eye. It specifically affects the membrane separating the top two layers of the cornea. As this membrane that separates the 1st and 2nd layers of the cornea grows irregularly (thicker in some places, thinner in others), findings that resemble maps, dots, and small fingerprints appear in the cornea.
Map-dot-fingerprint dystrophy usually affects adults between the ages of 40 and 70, or children as a result of heredity. It is usually painless and causes no vision loss, and sometimes clears up without treatment. In some cases, however, erosions of the cells that cover the cornea may occur. Erosions can expose the nerves lining the cornea, causing severe pain.
Some people affected by this condition notice mild fluctuations in vision over time, due to regeneration of corneal cells in an uneven manner.
Ocular migraines can produce a variety of visual symptoms. Typically you will see a small, enlarging blind spot in your central vision with bright, flickering lights or a shimmering zig-zag line inside the blind spot. The blind spot usually enlarges and may move across your field of vision. This entire migraine phenomenon may end in only a few minutes, but usually lasts as long as about 20-30 minutes.
During migraine processes, changes may take place in blood flow to the area of the brain responsible for vision (visual cortex or occipital lobe). Resulting ophthalmic or ocular migraines commonly can produce visual symptoms even without a headache.
Pink Eye: Conjunctivitis
Conjunctivitis, also called “pink eye,” is defined as an inflammation of the conjunctiva. The conjunctiva is the thin membrane that lines the inner surface of the eyelids and the whites of the eyes (called the sclera). Conjunctivitis can affect children and adults. The most common symptoms of conjunctivitis include a red eye and discharge.
There are many potential causes of conjunctivitis, including bacteria, viruses, fungi, and allergies. All types of conjunctivitis cause a red eye. Treatment depends on the cause, and may include antibiotic eye drops, steroid eye drops, or antihistamine eye drops. Some conditions are self-limiting and do not require medication.
Recurrent Corneal Erosions
The cornea is the clear dome-shaped covering of the eye. The cornea has 5 layers. The surface layer consists of a thin sheet of cells which are connected to each other (horizontally) and also to the second layer of the cornea (vertically). When there is a disruption of the surface layer of cells, it is called a corneal abrasion. Usually, the cells on the surface of the cornea regenerate very rapidly and the abrasion heals. When a corneal abrasion heals, the cells form horizontal connections rapidly, and vertical connections to the underlying layer over a longer period of time.
In some people, as the eye dries out, the surface cells can stick to the inside of the eyelid (especially when sleeping as the eye tends to produce less fluid during sleep). When this occurs, the surface cells can stick to the inside of the eyelid and rip away from the surface of the cornea, resulting in another abrasion. This most often occurs upon awakening in the morning or when the eyes dry out. This phenomenon is called a recurrent corneal erosion.
Retinal drusen are small yellow deposits in the retina that, if mild, usually do not interfere with vision. Drusen tend to occur most frequently in people older than 60 years of age and are commonly associated with age-related macular degeneration. It is important to protect the eyes from UV light and to take anti-oxidant vitamins.
Posterior vitreous detachments or PVDs are common causes of vitreous floaters. Far less commonly, these symptoms can be associated with retinal tears or detachments that may be linked to PVDs.
What leads to vitreous detachments in the first place?
The eye is filled with a gel-like substance called vitreous gel. The vitreous gel is attached to the back wall of the eye (the retina). Over time, the vitreous becomes more liquefied in the center. This sometimes means that the central, more watery vitreous cannot support the weight of the heavier, more peripheral vitreous gel.
Vitreous gel then collapses into the central, liquefied vitreous. While this occurs, the peripheral vitreous detaches from the inner back of the eye where the retina is located. The vitreous shrinks and pulls away from the retina. This is a natural process that occurs with aging and is distinct from a detached retina, which is much more serious.
Floaters resulting from a vitreous detachment are then concentrated in the more liquid vitreous found in the interior center of the eye.
Most people by the time they are 80 will have had a vitreous detachment. A vitreous detachment can even occur at a young age. If you also experience light flashes, then you have about a chance of also developing a retinal tear.
Light flashes during this process mean that traction is being applied to your retina while the PVD takes place. Once the vitreous finally detaches and pressure on the retina is eased, the light flashes should gradually subside.