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Silicone Oil for Retinal Detachments

Silicone oil is used for recurrent retinal detachments or complicated retinal detachments including PVR (proliferative vitreoretinopathy).  It can be a valuable tool to prevent blindness.

Most retinal detachments are caused by a retinal tear, or hole, in the retina.  In either case, this allows for communication between the vitreous cavity and the potential space underneath the retina.  Fluid may leave the vitreous and accumulate underneath the retina, causing a rhegmatogenous retinal detachment (rhegma = with a hole).

A vitrectomy with gas with or without a scleral buckle are common ways to surgically repair retinal detachments.

Recurrent Retinal Detachments

Occasionally, a retina can redetach and usually shortly after the first surgery.  Common reasons include an additional retinal tear, or, it is conceivable that an extra tear(s) was overlooked and not treated.

Options include repeating the vitrectomy with gas and possibly adding a scleral buckle if one is not present.  This usually does the trick.

Recurrent Detachments and PVR

Repeated retinal detachments due to additional tears usually persuades me to consider using silicone oil to fix the detachment.  In addition, a condition called proliferative vitreoretinopathy (PVR) often requires using silicone oil.

PVR can cause retinal detachments as membranes (scar tissue) form on the surface of the retina and start to pull.  This pulling can cause multiple retinal tears.

How Intraocular Gas Fixes Retinal Detachments

Intraocular gas works by “plugging” the retinal tears or retinal holes.  The gas bubble, when properly positioned against the tear/hole, prevents fluid from getting underneath the retina causing a recurrent detachment. As the gas is absorbed, the bubble will become so small that any untreated or new hole will be uncovered.  Thus, the retina can detach again.

How Silicone Oil Repairs Retinal Detachments

Think of silicone oil as a non-absorbable gas bubble.  Since the silicone oil is not absorbed, it stays large enough to always cover the holes.  This makes it highly unlikely that a redetachment can occur.

Is Intraocular Gas Better than Silicone Oil

Normally, intraocular gas is preferred as it eventually absorbs after reattaching the retina.  A separate procedure is not required to remove the gas.

Silicone oil does require removal and the vision is usually poor with the oil in the eye, however, when warranted, the oil is likely to prevent re-detachment.

What Does This Mean?

Silicone oil is a great tool to repair retinal detachments.  Repeated operations can be mentally straining and can be a hardship on the patient and family.  Also, with each new detachment, the likelihood of permanent vision loss increases, thus, the fewer detachments the better.

Too many retinal physicians, using silicone oil is a last resort to keeping the retina attached.  Often doctors wait until the retina has detached 3-4 times before considering oil (in fairness, I used to be one of them).

My belief is that oil should be used earlier to stop the vicious cycle of re-detachment and re-operation.  By preventing recurrent detachments, the vision can be better preserved in these complicated cases.

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Iluvien Treatment for Diabetic Macular Edema

Iluvien gets closer to FDA approval for treatment of diabetic macular edema.  Earlier this week, I wrote about emerging treatments for diabetic retinopathy.  Of the group, Iluvien is now the most likely to be available.

Alimera Sciences has filed for NDA (New Drug Application) for Iluvien.  In March, the company announced the favorable results in their clinical trials for the FDA.  The NDA is the last step for FDA approval.

Iluvien Releases Steroid

Iluvien is a sustained release drug delivery system.   Similar to Ozurdex, the delivery system will release steroid after injection into the eye.   (Ozurdex is presently FDA approved for retinal vein occlusions, not diabetic retinopathy.  The makers of Ozurdex are hopeful that it may be used for diabetes.)

The steroid released by Iluvien, fluocinolone, will last for 24 months after injection.  The vehicle will remain in the eye after the drug is released.

Alternative to Present Treatments

The present treatment for diabetic macular edema involves laser treatment, anti-VEGF injections and/or steroid injections.  The laser treatment has limited applications, that is, it can’t be used in all patients and also doesn’t work as well as any of the injections.

The injections, on the other hand, don’t last long and need to be repeated.

Iluvien may obviate the need for repeated treatments and offer significant improvement in vision compared to the standard laser therapy.  With fewer injections, there is less chance of infection.

What Does This Mean? Ozurdex was FDA approved about one year ago.  The significance of Iluvien’s NDA is the validation of the advantages of intraocular sustained release drug systems.

All emerging treatments for diabetic macular edema involve injections.  All seem to offer superior treatment compared to the standard of care, laser photocoagulation.  A sustained release system for diabetic retinopathy will change the way we treat this very common eye disease.

The introduction of Iluvien is estimated to be towards the end of the year according to this week’s press release.

I can’t wait.

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New Treatment for Diabetic Eye Disease

A combination of intravitreal injection of Lucentis (ranibizumab) plus laser has just been proven to be a new and more effective treatment for diabetic macular edema.  For the past 25 years, laser photocoagulation (aka laser treatment) has been the mainstay for this most common complication of diabetic retinopathy.

The new treatment involves Lucentis, the anti-VEGF drug also used to treat macular degeneration, in combination with laser photocoagulation.  When used together, a significant improvement is noted.

Traditionally, patients with diabetic macular edema (DME) were treated with laser treatment.  This was pretty successful in keeping patient’s vision stable, yet only a minority of patients did improve.

Over the past two years, there have been many “studies” reporting the use of intravitreal injections of Avastin, Lucentis or steroids as a successful method to treat DME.  This study is noteworthy for the large number of patient that were improved and by the amount of improvement.  Over half the patients experienced vision improvement with the Lucentis plus laser group compared to 28% in the traditional (laser only) treatment.

The significance of the new study was the determination that laser treatment, when given shortly after injection, yielded the best results.

Other combinations were compared; injection with Lucentis and delayed laser as well as triamcinolone (Triesence, a steroid used for injection). Again, the best combination was determined when laser was applied within 3-10 days following the intraocular injection.

During the course of the 24 month study, the  injections were repeated as often as monthly. The visual improvement was sustained over the study period.  3 year results are anticipated.

What Does This Mean? This may quickly become the standard to treat diabetic macular edema. The results, actually of all 3 arms, were improved compared to just laser treatment alone. This may become easily integrated as there really is no new technology introduced to the treatment, but simply combining two regimens already commonly used in the office.

There are small risks with the injections. Intraocular infection is the most feared.

Avastin, an anti-VEGF drug also manufactured by Genetech, will probably be quickly tested, too. It is already used by many of us (retina specialists, that is) for the treatment of wet macular degeneration due to its clinical usefulness and cost (it is much, much cheaper than Lucentis).

Still to be determined is whether this new regimen, Lucentis plus laser, will be endorsed by the insurance companies. Until then, the patient will be responsible for the $2000 cost of the injection. I wouldn’t be surprised if many patients choose Avastin as they have with macular degeneration.

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Sustained Release; Ozurdex Now Treats Diabetic Macular Edema?

Ozurdex, a sustained release drug delivery system,  may soon be used to treat diabetic macular edema. The sustained release intravitreal implant has been tested, with favorable results, for possible use in treating the common retinal swelling caused by diabetes. Results were published recently in the March issue of the Archives of Ophthalmology.

Ozurdex was FDA approved for the treatment of retinal vein occlusions last year. It was the first sustained release drug delivery system for the eye. It releases dexamethasone, a well studied (i.e. old) steroid.

Diabetic macular edema is a common complication of diabetic retinopathy and is the most common cause of lost vision due to diabetes. The most common treatment for DME has been laser photocoagulation.

Over the past years, small anecdotal studies have implicated the favorable use of intraocular injections of either steroid or anti-VEGF medications as an alternative method for treating diabetic macular edema.

It is not uncommon for retinal specialists to turn to intraocular injections as a means to help control the retinal swelling as a first line of therapy or to augment the laser treatment.

The small study involved 171 patients and tested two strengths of Ozurdex along with placebo (i.e. nothing). Both strengths of the Ozurdex group showed improvement, and more importantly, improvement that was sustained for at least 6 months compared to the sham (placebo) group.

What Does This Mean? The results are expected. It is not surprising that a sustained release system shows improvement when the intraocular injections (shorter acting) showed improvement, too.

What is significant is the that the technology continues to move forward and that newer “treatments” continue to emerge based upon this sustained release technology.

Whether or not Ozurdex is going to be used for diabetic macular edema depends upon Medicare. If Medicare is going to reimburse (that is, pay) for Ozurdex in diabetes then docs may start using it routinely.

“Off-label” indications are really not the issue in this case, but the cost of Ozurdex is the issue.  The cost of Ozurdex is about $1300.

If insurance companies do not reimburse Ozurdex, it is too expensive for patients to be willing to cover the expense out of their pocket.

Keep your eye out for news on Iluvien (pSivida/Alimera Sciences). Iluvien is expected to be presented to the FDA for approval for …treatment of diabetic macular edema. Iluvien is a sustained release drug delivery system that releases fluocinolone…a steroid.

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You Look All Bent Out of Shape

Distortion, also known as metamorphopsia, is a symptom of many macular diseases.   Anything that affects the macula can cause distortion; epiretinal membranes, macular holes, macular edema, diabetic retinopathy and macular degeneration.  The macula is a place in the retina, the functional center.  Thus, the term “macular” becomes an adjective when describing retinal disease located in the center of the retina.

OCT scan of a retina at 800nm with an axial re...
Image via Wikipedia

The macula is a small area of the retina measuring about 1.5 x 1.5 mm.  It is very sensitive and allows us our best color vision and the ability to see 20/20.  A normal macula (fovea) is smooth and slightly concave (see OCT).  Light falls on the normal macula giving us vision.  This is very similar to a projector focusing images onto a movie screen.  If there is a physical change to the macula or disease, central vision is usually affected.

Macular Pucker or Epiretinal Membranes

Epiretinal membranes are, as the name implies, membranes that develop on the surface of the retina and cause the underlying retina to wrinkle, or “pucker.”  This physical wrinkling of the macula causes decreased vision and distortion.

Surgically removing the membrane usually improves the distortion and can improve the vision, too.

Macular Holes

If you were to poke a pin through a piece of ballon and then stretch out the rubber, you’d create a nice round hole.  A macular hole is actually a stretch hole in the center of the macula.  Images that fall within this hole are not seen as there literally is no retina in the center of the macula.

Symptoms include decreased vision, distortion and sometimes, scotomas, which are the fancy name for blindspots.

Macular Edema

Swelling of the macula can occur from a variety of causes.  The two most common causes germaine to this web site are diabetic retinopathy (more specificially, diabetic macular edema) and swelling secondary to choroidal neovascularization in cases of wet macular degeneration.

Other causes, however, include central serous retinopathy, central and branch vein occlusions, cystoid macular edema from cataract surgery (uncommon these days) and from cases of intraocular inflammation (aka uveitis).

Macular Degeneration Causes Distortion 3 Different Ways

As above, choroidal neovascularization can physically distort the retina and cause distortion.  These abnormal blood vessels can develop in between the layers of the retina causing physical disruption of the retina.  The analogy here is exactly like the “Princess and the Pea.”

Wet macular degeneration can also cause macular edema as we discussed above.

Dry macular degeneration can also cause symptoms of distortion.  One of the layers of the retina, called the RPE, becomes diseased and degenerates.  This loss of one of the principle layers of the retina can cause distortion.

What Does This Mean? Distortion, or metamorphopsia, can be a symptom of a variety of retinal or macular disorders, not just macular degeneration.  The key for saving your sight is early detection and diagnosis.  Usually this may require consultation with a retina specialist to discuss the various treatments.

A fluorescein angiogram and/or an OCT (Optical Coherence Tomography) may be very helpful to your doctor, but this can vary.

Other causes of metamorphopsia, not related to the retina, could include large amounts of astigmatism or a decentered lens.

While most causes are indeed retina related, it is also important to note that most have a treatment with the exception of dry macular degeneration.  There is some rumbling; however, that there may be some promising treatments for dry macular degeneration in the near future.

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Doctors Improve the Internet!

Doctors can improve the Internet.  Doctors could be creating more web sites that provide good, credible health information, or content, to educate the public.  There is a paucity of reliable “experts” writing on health.  The timing is perfect for docs to become more involved.

Stop Playing Doctor

Too few doctors really use the Internet to engage patients.  There is the mistaken belief that by doing so we may breach patient confidentiality or that we may be liable for advice we give.

So stop playing doctor.  Use the Internet to inform, to educate.  Leave the advice and treatment plans in the office; where it belongs.

Creating a Primary Resource

We all know that good, reliable health information is hard to find on the Internet.  There are lots of web pages out there, but most are written by “perceived” experts.  Perceived experts are those that have taken the time to create content, but it isn’t necessarily good content.  Many times perceived experts are actually trying to sell a product; vitamins and diet plans are good examples.

Doctors, however, are the authority figures.  They are the experts and along with “authority” comes credibility.  Docs use this authority in the office everyday seeing patients.  This same authority could be used on the Internet to create more accurate and relevant health content.

If docs are able to serve as primary resources of information, the health information on the web gets better.

“Just the Facts, Maam” (Sgt. Joe Friday, “Dragnet”)

What am I talking about?  I am not talking about offering medical advice over the Internet.  I am not talking about forming a relationship with a patient online via email or FaceBook.  That would take too much time and would be wrong.

I am; however, interested in getting more docs to publish information about health – for the sole purpose of educating.  For instance, on this web site I educate about two retinal diseases; diabetic retinopathy and macular degeneration.  I have written quite a few articles about the diseases and provide information so others can learn.  I have chosen to share my knowledge.  In contrast, I am NOT offering medical advice nor offering treatments or recommendations per se.

As they used to say on Dragnet, ” Just the facts, maam.”

What Does This Mean? A doctor’s expertise is broken into several parts.  One part of expertise is knowledge and I am advocating that more docs share their knowledge.

Docs like to participate in speaking engagements all the time.  There is not much difference between giving a lecture and preparing content for the web.  In fact, content for the web can be in many formats; including Power Point.

My point is that docs to this same sort of “soft” marketing and lecturing already.  There really is no difference between giving a lecture and preparing content for the web.  It’s stuff we know and are sharing.

Another facet of “expertise” is experience.  Doctors distinguish themselves by their experience, not necessarily their knowledge.  Knowledge without experience is useless.  A doctor can NOT use his experience over the Internet.

A doctor’s experience does not exist on the web, but his knowledge certainly could.

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Drusen Not Associated with Macular Degeneration

Drusen are associated with macular degeneration but are not diagnostic of the disease.  Too many feel that these “spots”  are indicative of ARMD, but they can, and often are, normal.

What Are These White Lesions?

Drusen are white spots, or lesions,  seen within the layers of the retina.  There are two types; hard and soft.  The differences between the two are somewhat subtle.

Hard drusen are small and well defined with sharp borders.  A poppy or sesame seed is an example of an object with sharp margins.  “Hard”  can be associated with macular degeneration, usually dry.

Soft drusen are larger and have fluffier borders.  A cotton ball has fluffy margins.  “Soft” can be normal, but are usually seen more often with exudative, or wet, ARMD.

Familial Drusen

Drusen, by definition, can be found anywhere in the retina.  When they are located outside the macula, they are usually of no consequence and not related to any disease, especially macular degeneration.  I am usually concerned when they are located within the macula.

But most non-retina people (i.e. doctors) are afraid to mention this – drusen away from the macula are of little consequence and can just be a family trait – if anything.

Other “Findings” of Macular Degeneration

“Findings” are the signs or physical characteristics of disease.  These are things we look for as signs of disease.

Symptoms of ARMD are ways you describe changes in your vision.

Other signs of ARMD include, atrophy of pigment, increased pigmentation, fluid and blood.  There may be fibrosis – a sign of old choroidal neovascularization.

Many doctors will term anything abnormal in the macula as “scars.”

Making the Diagnosis of Macular Degeneration

Patients have to have 3 criteria;

  • Patients have to be over 50-55 years old
  • Patients have to “look” like they have the disease (that is, they have  signs)
  • Patients have to have “symptoms” of the disease (that is, they have decreased vision)

Having just drusen, for example, but no change in vision or other signs of the disease, probably do NOT signify macular degeneration.  It may be a sign of early disease and careful monitoring may be prudent.

Many times macular degeneration is diagnosed based solely upon the physical findings, but unless there is any evidence of decreased vision, I’d hold off on making the diagnosis.

Best Test for Diagnosis

If there is any doubt about the diagnosis of macular degeneration, the single best test, in my opinion, is a fluorescein angiogram.  This test can show any damage to the macula that can not be seen by the usual methods.  More subtle damage can be detected in this manner.

Drusen, unassociated ARMD, will not show any macular damage.

What Does This Mean? This means there are far fewer patients that actually have the disease than are diagnosed.  In other words, there are instances where ARMD shouldn’t really be diagnosed.  Many docs feel that it is safer to give the diagnosis for liability reasons.

I don’t understand this.

If there is any question about the presence, or absence, of macular degeneration, have your doctor order a fluorescein angiogram.

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Iluvien: New Drug for Diabetic Macular Edema

Iluvien™,  a new drug for the treatment of diabetic macular edema,  draws one step closer to FDA approval.  Alimera Sciences/pSivida announced that Iluvien showed favorable results in two Phase 3 clinical trials.  The company has announced they will file for a New Drug Application (NDA) based on the favorable results.

Iluvien is a Sustained Release Drug Delivery System

Iluvien releases fluocinolone acetonide, a well studied steroid, after injection into the eye. Intraocular injections have become a popular method for treating a variety of retinal disorders including macular degeneration and diabetic macular edema. The injections are performed in an office setting.

The drug will be released for 24-36 months.  The delivery system is based upon the Medidur™ delivery platform.  Medidur is the proprietary delivery system that, when coupled with fluocinolone acetonide, is dubbed Iluvien.  The platform does not dissolve and remains inside the eye.

Results of the Clinical Trials

Basically, the steroid implant improved vision in almost twice as many patients as those treated with placebo.  In addition, 75% of patients required only one application of the device.

New Drug Application is Last Step for FDA Approval

The last step for Iluvien is now to gain the coveted FDA approval.  The last step following Phase 3 clinical trials is for Alimera Sciences (licensee of Iluvien from manufacturer pSivida) to file a New Drug Application.  It expects to file by the end of the 2nd quarter of this year.

Remember Ozurdex?

Ozurdex™ received FDA approval last summer for the treatment of retinal vein occlusions; branch retinal vein occlusion and central retinal vein occlusion.  Like Iluvien, Ozurdex releases steroid over a period of months.  The major difference between the two technologies is the specific type of steroid (Ozurdex releases dexamethasone), duration of release and the FDA guidelines for use.

Iluvien is most likely going to be the first drug FDA approved for the treatment of diabetic macular edema, whereas, Ozurdex is the first for treatment of retinal vein occlusions.

What Does This Mean? One year ago, sustained release drug delivery did not technically exist in ophthalmology.  By this summer, there may be a second delivery system for treatment of retinal disease.  Clearly the tide is turning in terms of the way we can treat eye disease.

It is quite likely that other drugs will follow…we are anxiously awaiting the first sustained release system for macular degeneration.

I believe that sustained release technology will evolve to treat other eye diseases as well, not just retinal disease.  For instance, what if there were no longer eye drops needed for glaucoma?

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Prevent Vision Loss from Macular Degeneration

Vision loss from macular degeneration increases as we age.  This means that more and more people may lose vision as the population (baby boomers) get older due to ARMD (Age Related Macular Degeneration).  There are lots of recommendations on the Internet that just don’t make sense.  Here are a few practical recommendations and tips about ARMD, prevent vision loss and preserve your retina.

There are Two Types of ARMD

There are two classifications of macular degeneration, so-called “dry” and “wet.”.  They have many similarities, yet differ, principally, in two ways.  First, the “wet” ARMD is defined by the presence of leaky, abnormal blood vessels.  The presence of “neovascularization” (aka choroidal neovascularization) causes a more rapid change, or decrease, in vision.

Most cases of macular degeneration affect both eyes and are of the “dry” type.  The dry form changes vision loss much more slowly than the more aggressive “wet” form and accounts for about 90% of patients.

Both types can cause blurring of the central vision, formation of dark/grey areas in the vision and distortion.  Neither affects the peripheral, or side, vision.

There is No Cure for Macular Degeneration

Unfortunately, despite what you read, there is no cure for either type of ARMD (Age Related Macular Degeneration).  Intraocular injections are a treatment only for the “wet” form of the disease.  It is only a treatment and not a cure.

At present, there is nothing to do for dry ARMD, although you will hear the contrary with regard to vitamins and other supplements.

Only one NIH study has confirmed evidence that vitamins have a role in macular degeneration.  That role, is NOT curative, but may prevent patients with high and intermediate risk factors from experiencing severe vision loss from macular degeneration. The AREDS 1 study was completed over ten years ago.  AREDS 2 is underway.

There is no other indication, or reason, to take vitamins or other supplements.

Most ARMD is NOT Inherited

The term macular degeneration is probably a huge “waste basket” of terms, that is, we will probably learn that ARMD is a collection of different diseases that have similar characteristics and behaviors.   While there are cases of disease that have been found to run in certain areas or families, for the most part, macular degeneration is not passed on.

Regular Examination Prevents Vision Loss

The best way to look for macular degeneration is to have your pupils dilated by your doctor.  This will allow direct examination of the retina.  He or she does not have to be a retina specialist, but you should be referred to one if your exam raises any concerns or suspicions.

A retina specialist, with the aid of a fluorescein angiogram and OCT, may be able to confirm the diagnosis.  Remember, there can be several causes for whatever symptoms that concern you.

Monitor Your Own Vision

Self-monitoring of your vision is probably the best thing you can do for yourself.  Once diagnosed with ARMD, daily use of an Amsler grid or similar device, can help identify any changes that may need to be treated early.

The idea of self-monitoring is to catch any sudden, sustained, change in vision, including distortion, as early as possible.  You should alert your doctor of any changes.

What Does This Mean? There is a lot of “misinformation” regarding macular degeneration.  There are many ways that patients can help themselves including early examination and understanding that there are few, if any, supplements to help with the disease.

Don’t get hung up on seeing a retina specialist off the bat.  If there are concerns regarding your vision, see your eye doctor for a complete examination of your retina for macular degeneration.  There are many reasons you may have changes in your vision.

Just because a family member does have macular degeneration does not mean that you, too, have the disease.  Get examined and have your eye doctor, or retina specialist, confirm the presence, or absence, of the disease.

Lastly, sustained changes in your vision usually don’t go away by themselves.  Get tested!

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It's Not What You Look At, It's What You Look For

Making a diagnosis can be difficult.  Diabetic retinopathy and macular degeneration are easy to diagnose, but you have to know to look for it to see it.  The diagnosis then becomes pretty obvious.  Knowing what to look for is essential to making a correct medical diagnosis.  Retinal disease, such as ARMD and diabetic retinopathy, is easy to diagnose as we can also “see” the eye.

I just read about a 59 year old male who had all the common symptoms of diabetes for several years, yet his doctor treated each symptom separately.  His weight loss was treated with high calorie supplements, his frequent urination was treated as a prostate problem and his multiple nighttime trips to the bathroom were treated with sleeping meds.

He switched doctors and was diagnosed with Type II diabetes.

Just Browsing, But Not looking

Was his first doctor stupid?  Not necessarily, but he failed to “look” for diabetes.  He failed to look for the one diagnosis that could bring all the symptoms together.  He didn’t look for a common denominator.  Had he “looked” for diabetes, he would have checked sugar levels, and then, solved the puzzle.  This doctor was similar to a shopper who is “just browsing.”

Problem Oriented Thinking

The second doctor practiced ‘problem oriented’ medicine.  He was able to find the common denominator of all the “problems” and then knew what tests to order to prove himself correct (namely, serum glucose and hemoglobin A1C).  This doctor was the shopper that went shopping with a finite list of items.

Diabetic Retinopathy and ARMD is Even Easier to Diagnose

Diabetic retinopathy and macular degeneration are even easier to “see.”  Why?  Because I can also “look” at the eye and determine the presence, or absence, of either disease.  Sometimes it takes no testing.

I can rely on my examination for establishing a diagnosis because I, too, know what to “look” for.

In diabetics, I look for blood, microaneurysms, macular edema, exudates, neovascularization and retinal detachments.  Having some of these findings will establish the diagnosis.

So, too, in macular degeneration.  I look for characteristic scarring of the macula, bleeding underneath the retina, drusen and leakage, etc.

Most of the time, if not always, we are able to make a diagnosis by direct examination.  Testing can confirm our suspicions.

What Does This Mean? Because eye docs are able to directly visualize most aspects of your eye, we’re able to tell you with a high degree of certainty, especially with diabetic retinopathy and macular degeneration, if you have the disease or not.  There is usually no beating around the bush.

If there is any doubt, additional testing may be helpful.  To you, the patient, we can offer assurance about the state of your retinal disease.

We know what to “look” for and what to “look” at.

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offices

A detached retina is potentially blinding. The retina is the light sensitive tissue that lines the inside of the eye. A retinal tear or hole usually leads to a retinal detachment. Floaters can sometimes be the earliest, and only, symptom. Many times there is little warning and a retinal detachment usually occurs without trauma.

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Randall V. Wong, M.D.
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