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What if I Have Drusen?

 Drusen and the diagnosis of macular degeneration.  Randall Wong, M.D., Retina Specialist, Fairfax, Virginia 22031


Drusen are not diagnostic of macular degeneration.  These whitish/yellow spots of the retina can be a normal finding and their presence does not mean you will develop macular degeneration (ARMD).  There are other criteria necessary to make the diagnosis of ARMD.

“Druse” may occur in 3 locations within the eye;

  • The Macula
  • The Peripheral Retina (non-macular)
  • and the Optic Nerve

In the Optic Nerve Head (ONHD)

These are not even found in the retina.  These are calcified and found within the optic nerve, but can be diagnosed when looking into the eye during a retinal examination.

These drusen have nothing to do with macular degeneration.  Loss of the peripheral vision is possible.  Patients with ONHD are probably best evaluated by a glaucoma specialist as the mechanism of vision loss is similar to that of glaucoma.

Diagnosis is usually pretty straight forward.  Often these tiny round globules can be seen during a dilated eye exam and can also be detected with ultrasound and CT scan due to the calcification.  They can run in families.

Outside of the Macula

These whitish spots are found in the retina, but not in the macular area.  These are usually whitish/yellow looking flecks found within the layers of the retina and are visible during examination.

When outside of the macula, they are commonly feared to be related to ARMD, but there is no association.  Non-macular lesions are sometimes called “familial drusen” and are a normal finding with no predisposition to the development of ARMD.

Macular Druse: Can Be Associated with ARMD

These are the most confusing and also the most worrisome.  Drusen in the macula can be NORMAL and do NOT necessarily mean you have or will develop macular degeneration.

Those lesions located within the macula are worrisome due to the association with macular degeneration, or ARMD.  There are two types:  hard and soft.  Both may be found in patients with macular degeneration

Hard and soft types differ in appearance and probably have a different association with macular degeneration.  In general, the “hard” variety are more common, especially as we age.  The “soft” lesions are probably found more often in wet ARMD.

Both types of druse may be found in patients with macular degeneration, but the mere presence of  either drusen does not make the diagnosis of macular degeneration nor are they prognostic indicators for the development of the disease.

What If You Have Drusen?

If your doctor diagnosis you with drusen, do the following;

  1. Relax.
  2. Are the within the macula?  If not, probably nothing to worry about.
  3. If they are located in the macula, do you have any symptoms such as decreased vision, distortion or blind spots?  By decreased vision, I mean, with correction, do  you have any of these symptoms?  If not, probably okay to monitor, but make sure you visit your eye specialist if any symptoms develop.

Retina specialists, like me, are the most appropriate to make the diagnosis.  If there is any question, make an appointment to see a specialist.

What Does This Mean?

There are several criteria needed to make the diagnosis of macular degeneration.  You have to look like you have the disease, have the right genetic makeup, be the right age and have evidence of decreased vision.

A retina specialist might consider additional testing, such as a fluorescein angiogram, to determine if there is any evidence of deterioration or degeneration of the retina.

Drusen only are commonly normal.


A1C Now Used to Diagnose Diabetes

The American Diabetes Association now recommends basing the diagnosis of diabetes upon the hemoglobin A1C levels and not on fasting glucose tests.  In addition, an A1C of less than 7.0% should be the target for glucose control.  How with this impact the treatment of diabetic retinopathy?

The change in recommendations stems from the fact that the A1C blood test is an easier, and faster, test to run than measuring a fasting plasma glucose and an oral glucose tolerance test.  Both tests require overnight fasting for accuracy; that is, it relies on patient compliance.  The A1C does NOT require overnight fasting.

A1C measures the average blood glucose levels for the period of up to 3 months and was previously used just to measure sugar control over time, but now, it is recommended to be used for diagnosis;

  • A1C  of 5%  – no disease
  • A1C of 5.7 to 6.4% – likely prediabetes
  • A1C > 6.5% – likely diabetes

The ability to diagnose the test using A1C guidelines now means that the diagnosis of diabetes can be made earlier.  Earlier detection (diagnosis) may mean a greater chance of  “curing” type II diabetes by making lifestyle changes earlier.

What Does This Mean? The ability to diagnose and treat this disease now has some firm, “black and white,” guidelines.  More patients will be detected and at an earlier age.  Therapy and education may be instituted earlier.  For instance, patient education regarding diabetic retinopathy may be instituted sooner.  In this respect, more patients will be “saved” over the long run.  In theory, patients will be directed for eye exams before the retinopathy begins.

It is also likely, that with tighter sugar control (i.e. good A1C levels), diabetic eye disease will progress slower.  We’ll see.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist
Fairfax Virginia

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American Diabetes Month: Diabetic Eye Disease, What Every Doctor Should Know (so, tell them!)

November, 2009, is American Diabetes Month.  In my effort to support American Diabetes Month, there are a few things that every doctor should know about diabetic eye disease.  The list is short and very direct.  Please share this with others; especially your doctors.

I have been in practice since 1993.  As a retina specialist, I take care of patients with diabetic retinopathy.  There was a “movement” to stamp out blindness from diabetes by the year 2000.  While we have dramatically reduced the rate of blindness as of 2007, in fact, with early detection most patients with diabetes are unlikely to suffer severe loss of vision (clic for recent post), there are still far too many people losing vision.

Most people are simply not getting to the eye doctor.  Most doctors are still not aware that patients with diabetes should get regular dilated eye exams (with the pupils dilated)!

What I believe every doctor should know about diabetic eye disease;

1.  Every patient with diabetes needs a dilated eye exam once a year.  Even if the patient has no symptoms. Remember that vision has no correlation with the severity of disease.  I hear from too many patients that they were not referred by their doc because they had no complaints of blurry vision.  Don’t wait for symptoms!

2.  Diabetic retinopathy is not a result of poor sugar control. While sugar control may influence the diabetic retinopathy, the duration of the disease is the clearest predictor of developing eye disease.  Okay, in English, the longer that a patient has been diagnosed with diabetes, the greater the chance of developing eye disease.

3.  Diabetic eye disease may be inevitable. This is a corollary to #2.  While no one knows if this is absolutely true, almost all patients with diabetes do develop the disease.   I have seen only a handful of patients in over 16 years that have no evidence of the disease despite having diabetes for over 25 years.

4.  Having diabetic retinopathy does not mean loss of vision. In fact, the earlier a patient is diagnosed, the less likely there will be severe loss of vision.

Spread the word!  Diabetic eye disease may be inevitable, but the visual prognosis is excellent.  Early detection is the key!


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Diabetes Unlikely to Cause Blindness

Today’s post is about one of my own observations from over 15 years in practice.  While it is a fact that significant vision loss from diabetes is declining, it is not widely known that there is also a very finite time where patients with diabetes can go blind, there is only a finite time while the risk of blindness is highest.  In short, the chance of a diabetic patient going blind these days is much less than 0.5%, especially when under the care of an eye doctor.

Let me explain. Recently, I wrote about the decline in the incidence of diabetic patients going blind.  The statistics say that severe vision loss was reduced to about 0.3% by 2005-2007 (read the article “Vision Problems in Type I Diabetes on the Decline”).  This is truly great news.

I have two observations; 1)  I have never had a patient with diabetes go blind if I had been following them before they developed any complications from proliferative diabetic retinopathy, and 2)  in most cases, when patients develop signs of proliferative diabetic retinopathy, the retinopathy usually becomes controlled within a year and becomes stable.  This means they are highly unlikely to lose vision or to go blind.  The patients that have gone blind usually wait until they have lost vision before seeking medical attention.

What does this mean? There are two major points.  My observations are consistent with published data that correlates early detection of diabetic retinopathy with an excellent long term visual prognosis.  In other words, the earlier we can detect diabetic retinopathy, the better chance that you will never lose vision.  Second,  there is a small window of a year or so (my personal observation) that patients are susceptible to vision loss once proliferative changes are noted.  Once diagnosed with proliferative diabetic retinopathy, a patient is NOT destined to loss of vision or blindness.

So, chances are that most diabetics will not lose vision.  We are stressing early examination to detect diabetic retinopathy early.  Last, diabetics are not a ticking timebomb; waiting for blindness to ensue.

It’s really good news that seems to get lost in this information gap.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Diabetes – A Disease of Blood Vessels, Especially in the Eye

Did you ever hear that diabetes is a disease of blood vessels?  Most people think that the definition of diabetes is simply uncontrolled blood sugar, but, in reality, diabetes may be thought of as a vascular disease.

Diabetes can be a very nasty disease affecting most organs in the body.  Common problems caused by diabetes include peripheral neuropathy, kidney failure and diabetic retinopathy.  The common denominator?  Bad blood vessels.

Patients with diabetes can develop peripheral neuropathy. Symptoms of  peripheral neuropathy include “pain,” but also numbness of the extremities.  Numbness usually begins at the toes and ascends up the legs.  At some point the fingers, hands and arms may become involved.  The upper extremities (hands and arms) become involved when the numbness has reached a high enough point on the leg so it is now about same distance from the heart as the finger tips.  Basically, just remember, when caused by diabetes, peripheral neuropathy begins in the feet.

The problem?  The fine, small caliber blood vessels that feed the nerves at the ends of the toes and fingers that give us sensation, eventually fail.  Loss of blood supply leads to loss of nerve endings that cause numbness.

Diabetes causes diabetic nephropathy in the kidneys. Here, the fine microvasculature (thin, tiny blood vessels) start to become incompetent and the small filters in the kidney, glomeruli, are unable to properly filter blood and “spill” protein into the urine.  Normally, protein, which are rather large molecules, is retained in the blood stream after filtration through the glomeruli in the kidney.  Due to damage caused by diabetes, these vascular filters do not work properly, letting protein accumulate in the urine.  Long-standing diabetic nephropathy can lead to renal (kidney) failure.  Again, small, fine blood vessels are the culprit.

Diabetic retinopathy is a vascular problem as well. As we know, the most common problem in patients with diabetic retinopathy is diabetic macular edema.  Macular edema develops when the small retinal blood vessels also “leak” into the surrounding tissue.  This can cause decreased vision if it occurs within the macula.  The tiny blood vessels become incompetent and start to leak fluid and proteins into the retinal space.  Sound familiar?

Diabetic retinopathy can also cause loss of blood supple to the retina.  When a tissue has reduced blood supply, or, when a tissue does not receive the proper amount of oxygen (via the blood), the condition is called ischemia.  Ischemia arises in the retina when the fine microvasculature of the retina stops to function.  It no longer gets sufficient oxygen to the retinal cells.  This ischemia is not treatable, can cause loss of vision if it affects the macula and may lead to proliferative diabetic retinopathy.

Researchers have focused attention on pericytes, cells that line the blood vessel walls, as the principal culprit in these “vascular” diseases.  Long term exposure to “high sugar” may be related, but indirectly.  Clearly, diabetes is associated with damage to the fine microvascular in the body.  Whether there is a direct cause-effect relationship between sugar and damage, we have yet to know.  Most likely, diabetes causes a cascade of events that can cause, over time, damage to the peripheral nerves, kidney and eyes.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Severe Loss of Vision from Diabetes is DECREASING!

A new study released last week confirms that we are making terrific progress in saving sight!  The incidence of severe vision loss in Type I diabetes has decreased significantly over the past 25 years.  The rate of severe vision loss dropped from 1.19% in 1980-82 to 0.30% in 2005-07.

Incidence: an individual’s chances of developing a medical problem (e.g. severe vision loss) over a time period.

Prevalence: the number of people in a population who already have developed the medical problem

Also noted was that the prevalence of severe vision loss decreased when an earlier diagnosis of diabetic retinopathy was made, that is, the life long risk of developing severe vision loss from diabetic retinopathy is significantly reduced when an early diagnosis is made.

Several observations could account for the reduction;

1)  today’s standard insulin therapies have fewer complication rates than compared to those 25 years ago.  For instance, the chance of developing proliferative diabetic retinopathy is now only 9% compared to 25% (in the early 1980’s).

2)  patient’s now receive better overall health care.  For example,  improved sugar control, better treatments for diabetic retinopathy and blood pressure control.

The authors of the study also noted that, as expected, the longer a patient has been diabetic, the higher the chances of visual impairment.

What Does This Mean? To me this signals that we are making great progress in education and treatment of diabetes, diabetic retinopathy and high blood pressure.  The study underscores the importance of regular medical visits not only for your eyes, but for other diseases as well.  This study suggests that diabetic retinopathy is best treated the earlier it is diagnosed and further stresses why patients with diabetes need routine eye exams!

This is all good news.  The article “Vision Problems in Type I Diabetes on the Decline” may require membership before viewing.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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When Shouldn't Patients with Diabetes Get Glasses?

Patients with diabetes need to be careful when getting new glasses.  Patients with diabetes should NOT get glasses when their blood sugar is abnormally high or low.

Believe it or not, several times a year, I will see a patient that is referred for unexplained decrease in vision, OR, I will have a patient that keeps getting the “wrong” glasses.  The patient goes in for an exam, doctor writes prescription, but 2 weeks later when the glasses come in…………they don’t work.  Similarly, I also see patients that complain of decreased vision after being diagnosed with diabetes.  What’s going on?

Let’s “examine” the patient that has unexplained decreased vision. I will ask some preliminary questions, usually involving health, bathroom habits at night (see post on early signs of diabetes), thirst, weight loss or weight gain, etc.  The undiagnosed diabetic will tell me that there is constant thirst, sleep is interrupted every night for a bathroom (pee) break and there has been weight loss.  This has been going on for months, and now, the vision is horrible.  The eye exam is usually normal; no cataract and no diabetic retinopathy.

Now, let’s talk about the patient who can’t get glasses that work. I will ask the same preliminary questions, suspecting diabetes.  The eye exam is usually also normal.  I will refer the patient back to their primary care physician and ask for a diabetic workup.

Last, the patient who has been recently diagnosed with diabetes and cannot see.  Guess what?  Normal eye exam, too.

In all cases, the blood sugar is abnormal (either high or low).  At this time, I would recommend reading my post on early signs of diabetes.

The case of “unexplained decrease in vision.” This is the typical case of an undiagnosed diabetic.  High blood sugar levels cause the excessive thirst, night time potty breaks and the blurred vision.  As I explain in a previous post, sugar draws water out of our tissues and also into the eye’s lens.  These are common symptoms of undiagnosed diabetes.  Correction of blood sugar should rectify the symptoms in a matter of weeks.  With regard to the glasses, the patient should wait several weeks AFTER treatment has been initiated and the blood sugar has returned to normal before getting new glasses/contacts.

The case of the patient who can’t get glasses that work.  Same rationale as above.  The sugar is probably uncontrolled and too high when initially getting glasses.  Sugar enters the lens, gets changed to sorbitol, water enters the lens and alters the overall eye prescription.  Basically, the sugar level has changed dramatically between eye exam and glasses pickup, thus, the prescription has changed.  Here, as above, wait until sugar has returned to normal for a few weeks, get RE-EXAMINED and obtain new glasses.

The last case of the patient recently diagnosed with diabetes and cannot see. Here, the sugar has been uncontrolled (undiagnosed diabetic) for months or longer.  The patient becomes used to a certain level of vision.  Diabetes is diagnosed and sugar becomes controlled.  The water content of the lens changes with controlled sugar, and…………………… gets blurry.  Probably, all along, the patient needed glasses anyway, was mislead by the sugar/water problem in the lens, and now gets blurry (as he always should have been) with better sugar control.  Again, wait a few weeks with normal sugars and then get glasses.

I recommend read this article for more early signs of diabetes.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Successful Treatment of Diabetic Retinopathy

I have a patient, BG, with diabetes mellitus.  BG has had diabetes for over 45 years.  She is 60 years old.  I saw her yesterday and will not see  her for another 6 months.  She has had a long course with proliferative diabetic retinopathy.  Her vision is 20/25 in both eyes.  BG has had multiple laser treatments and vitrectomy surgery.  I want to share her success.  I want to highlight that most patients with stage of disease actually do very well!

What you may know.  Several years ago, BG developed the proliferative stage of diabetic retinopathy.  You might remember that proliferative diabetic retinopathy (PDR) can lead to blindness.  Signs of PDR include neovascularization (abnormal blood vessels growing on the surface of the retina and iris) as a result of severe retinal ischemia.  The ischemia (lack of oxygen due to poor blood flow) can cause liberation of VEGF (vascular endothelial growth factor) which causes growth of the abnormal blood vessels.  Treatment of choice is laser photocoagulation to the peripheral retina.  If enough laser is performed, the VEGF is no longer produced, the abnormal blood vessels recede and the eye is stable.

Her Case History BG has Type I diabetes.  She developed complications of proliferative diabetic retinopathy over the past several years for which she received panretinal photocoagulation (PRP).  She temporarily lost vision several times over the years from recurrent vitreous hemorrhage (bleeding in the vitreous).  She has always been under the care of a very attentive retina specialist, Dr. JT, who performed the panretinal photocoagulation.

Most recently BG developed a vitreous hemorrhage that did not absorb on its own.  A vitrectomy was performed to clear the vitreous hemorrhage and to perform additional PRP.  Unfortunately, she had significant post-operative bleeding which, again, did not clear.  Re-operation occurred 3 weeks later and then again after the 5th week.

This time the she did not rebleed!  She has had no hemorrhage over the past 2 months.  As I noted above, I won’t see her for 6 months, her vision is excellent and stable!

What does this mean? BG’s story is not abnormal.  There are many patients with proliferative diabetic retinopathy that require vitrectomy for non-clearing vitreous hemorrhage.  There are many patients with proliferative diabetic retinopathy that could go blind, but don’t, thanks to modern vitrectomy and laser (especially the laser!).

Due to the diligence of her retinal specialist, BG was always treated in a timely fashion, thereby avoiding the development of diabetic retinal detachment.  Recurrent vitreous hemorrhage really does not impact her visual prognosis, but severely interrupts her vision by physically blocking light.  The key to treating BG was to remove the blood to allow the retina to be treated with laser.  If blood remained in the eye, it would physically block the laser.

I don’t really know how long it takes for the panretinal photocoagulation to become effective.  When enough laser is performed, VEGF production ceases and the neovascularization regresses.  Laser works by interrupting a chemical pathway.  Laser does not physically or directly destroy blood vessels.  It is not a form of “cauterization,” but acts indirectly.  It usually takes several weeks before PRP exerts its effects.

In the end, despite the severity of the disease, BG, like many others, is enjoying a normal visual outcome.  She loves to garden and continues to paint.  She continues her work as a graphic artist. Her course is atypical given her history, but I want to highlight another success story and to emphasize that treatments for patients with proliferative diabetic retinopathy are usually successful.  Remember, the glass is half full!

Congratulations to BG!


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Diabetic Retinopathy Continues to Rise

Patients with diabetes need to be examined at least annually.  The reason is to be on the look out for the development of diabetic retinopathy.  That’s the disease that diabetes causes in the eye; it affects the retina.  Diabetic retinopathy can cause anything from blurry vision to blindness depending on the severity of the disease.

Researchers compared the prevalence of the disease in different racial/ethnic groups.  The disease was noted to increase from the original study period of 1988-1994 to the more recent time period 2005-2006.  Non-hispanic blacks had the highest prevalence.

In all groups, the prevalence of the disease now approaches about 30% of all diabetics.  The most critical risk factor is the duration of the disease, that is, the number of years a patient is diabetic.  Other risk factors for the development of diabetic retinopathy included male gender, type of sugar control (e.g. insulin vs. diet), blood pressure and hemoglobin A1C.

While measurement of the hemoglobin A1C reflects overall sugar control, I need to stress that the number of years you are diabetic is the highest risk.  Sugar controls helps, but it does not prevent the disease.  Regular examination is the best way to prevent vision loss.  We I docs to a better job at preventing vision loss versus regaining lost sight.


Randall V. Wong, M.D.
Ophthalmologist/Retina Specialist

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Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different's a different arrangement, but it allows more continuous care with many eye specialists. In addition, I am very accessible via the web. To schedule your own appointment, call any of the numbers below.

Virginia Lasik | Office of Anh Nguyen, M.D.
Randall V. Wong, M.D.
Contact: Layla

A: 431 Park Avenue, Suite 103 • Falls Church, Virginia 22046
Ph: 703.534. 4393
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Dressler Ophthalmology Associates, PLC
Randall V. Wong, M.D.
Contact: Ashley (Surgery/Web)
Chrissy Megargee (Web)

A: 3930 Pender Drive, Suite 10 • Fairfax, Virginia 22030
Ph: 703.273.2398
F: 703.273.0239
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