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Vitreous Hemorrhage | A Dilemma

Vitreous Hemorrhage presents dilemma in treatment | Randall Wong, M.D., Retina Specialist, Fairfax, VirginiaOn Thursday morning, I met a 75 YOM (year old male) who had lost vision just the day before.  He was referred to me for evaluation of a dense vitreous hemorrhage in his left eye.  He is healthy and never had any eye problems before.

This is one of the more difficult patient situations for me to manage.  This is a case of a dense vitreous hemorrhage in a patient without diabetes.

The situation is challenging for several reasons.  The hemorrhage happens suddenly and without warning.  A vitreous hemorrhage is painless, yet can produce profound vision loss depending upon the amount of bleeding.   Up to this moment, most patients have enjoyed excellent vision.   I don’t blame patients for being anxious.

The situation is more complex because I can’t make a definitive diagnosis as to the actual cause of the vitreous bleeding.  Blood in the vitreous causes immediate loss of vision because it blocks the light from hitting the retina.

Patients can’t see “out” and I can’t see “in.”

Causes of Vitreous Hemorrhage

There are only 2 likely causes of the vitreous hemorrhage in this scenario.   Bleeding with a retinal tear or bleeding without a retinal tear.

Remember that retinal tears can cause retinal detachments.  Retinal detachments are potentially blinding and will require surgery to repair.

Therefore, an undiagnosed retinal tear has the potential for developing a retinal detachment at any time.

Appropriate treatment for a retinal tear with vitreous hemorrhage might be to operate (vitrectomy) and remove the blood.  Removal of the blood allows excellent visualization of the retina and the tear.

Appropriate treatment for a vitreous hemorrhage without a tear is to wait – do nothing.

After performing an ultrasound (B-Scan ultrasound), I was able to determine that the retina was not detached.  Therefore,  there was no immediate cause for concern.

Vitrectomy for Vitreous Hemorrhage, or NOT?

Again, the dilemma is that I don’t know for sure if there is a retinal tear.  I only know that there is no retinal detachment and there may or may not be a retinal tear.

The might absorb over the next few weeks allowing better and more definitive examination, or it might not.  There’s about a 50/50 chance the blood will absorb.  It may take weeks to go away if at all.

Meanwhile, a retinal detachment could ensue.

Advantages of waiting are avoidance of an operation and its possible complications.

Disadvantages of waiting:

  • retinal detachment develops (potential for permanent loss of vision)
  • possibility of emergency surgery (never ideal)
  • surgery may be needed anyway (blood doesn’t absorb)
  • frequent return office visits

Advantage to Vitrectomy

  • definitive treatment
  • faster restoration of vision
  •  likely avoid retinal detachment

Risks of Vitrectomy

  • blinding infection (endophthalmitis – chance is less than cataract surgery)
  • creating a retinal detachment (about 2% chance)

After balancing all his options, my patient chose to operate.

Vitrectomy for Diabetic Retinopathy

Proliferative Diabetic Retinopathy Causes Vitreous Hemorrhage and Diabetic Retinal Detachment

There are two times when a patient needs vitrectomy eye surgery for diabetic retinopathy.  Patients with either a vitreous hemorrhage and/or a diabetic retinal detachment will require a vitrectomy.

Both occur when the diabetic retinopathy has advanced to “proliferative diabetic retinopathy.”  By definition, abnormal blood vessels, called neovascularization have developed somewhere on the retina.

Neither case requires emergency surgery.

What is Proliferative Diabetic Retinopathy

Neovascularization, the abnormal blood vessels, is very fragile.  These delicate blood vessels have grown somewhere inside the eye; usually on the surface of the retina.

There are 3 types of neovascular tissue named based on the location;  neovascularization elsewhere (NVE), neovascularization of the disc (NVD) or neovascularization on the iris (NVI).

Regardless, just remember proliferative diabetic retinopathy, by definition, means abnormal blood vessels are somewhere in the eye!

Vitreous Hemorrhage

At times, these delicate blood vessels may bleed and cause a vitreous hemorrhage.  Blood accumulates inside the eye and blocks the vision.  Patients can’t see “out” and doctors can’t see “in.”

Though the vision loss can be dramatic, and as long as nothing else could have caused the bleeding (i.e. a retinal tear can also cause a vitreous hemorrhage), we usually wait for the blood to clear.  This may take several weeks or longer.

If the blood doesn’t clear, a vitrectomy is needed to remove the blood not absorbed by mother nature.

Diabetic Retinal Detachment

Untreated neovascular tissue may “proliferate” or grow inside the eye.  The tissue may creep along the surface of the retina much the same way ivy grows along the ground…moving slowly from one point to another.

With time, the NV may contract and start to detach the retina.  This type of “traction” retinal detachment is different than retinal detachments sustained by non-diabetic patients.

A retinal detachment caused by diabetes requires vitrectomy surgery to physically cut away or remove the offending tissue pulling up on the retina.

What Does This Mean?

In both cases, laser treatment (panretinal photocoagulation or PRP) is needed to stop the neovascularization.

In the case of a vitreous hemorrhage, if the blood is not absorbed, laser can be performed at the same time as the operation.  If the blood does absorb, laser treatment can be performed in the office.

For patients with a diabetic retinal detachment; however, an operation is often the best and only choice.

With routine eye examination, the neovascular tissue is often detected before bleeding or retinal detachment has occurred.  Treatment can be initiated, operations avoided, and vision preserved!

Vitreous Hemorrhage and Diabetes

A vitreous hemorrhage can result in sudden, painless loss of vision.  In patients with diabetes, the cause may be due to either a posterior vitreous detachment (PVD) or proliferative diabetic retinopathy (PDR).  Remember, the proliferative phase of the diabetic retinopathy means that there are areas of neovascularization (abnormal blood vessel proliferation) on the surface of the retina.

In cases where a diabetic patient is diagnosed with a vitreous hemorrhage, my job is to ensure that the cause  is not due to a retinal tear or a retinal detachment.  This can be done by dilating the eye and examining.

You Can’t See Out and I Can’t See In

Sometimes there is so much blood I can not see much or any of the retina.  In these cases, we perform an ultrasound of the eye to make sure the retina is attached.

Sometimes, an ultrasound can locate a retinal tear.  If there is no retinal tear, or retinal detachment, then I am pretty sure that the vitreous hemorrhage is due to the proliferative diabetic retinopathy.

Fragile Vessels

Neovascular vessels are very fragile and may easily break open and bleed.  This may occur with or without straining.  The blood can fill the vitreous cavity causing sudden “loss” of sight.  Vision is “lost”  (not permanently) due to physical blockage of light.

Vitreous Hemorrhage, Proliferative Diabetic Retinopathy, Randall V. Wong, M.D., Fairfax, Virginia.
Vitreous Hemorrhage

Bleeding in the vitreous is benign.  It causes no damage to the vision or to any part of the eye.  On the other hand, as it physically blocks light, patients don’t see well.

Sometimes it is Best to do Nothing

Usually, when I am sure the bleeding is due to diabetic retinopathy, I recommend a period of doing nothing.  We watch and wait.  In doctor lingo, we are observing.

Patients Tire of Not Seeing

After a few weeks, or sometimes longer, we may decide to operate to remove the blood.  Sometimes the blood absorbs on its own and sometimes it doesn’t.  At some point, patients with non-absorbing blood in the eye become tired of the prolonged decreased vision.  A vitrectomy is then scheduled to remove the blood.

What Does This Mean? The sudden loss of vision can be devastating for anyone.  In cases when the loss of vision is due to a vitreous hemorrhage, we need to assess the threat of permanent vision loss due to other causes such as a retinal tear or retinal detachment.

If the eye is stable, that is, we can safely observe, it is sometimes tough to reassure patients that while they just “lost” their vision, the best idea is to do nothing!  Their “lost” vision is temporary.

I often will have a patient return in a short week or two to reassess and help relieve anxiety.

Patients with proliferative diabetic retinopathy, if you remember, will require laser treatment (pan-retinal photocoagulation, aka PRP) to reverse the neovascularization.

While we are waiting for the hemorrhage to clear, at the same time we are mindful that laser treatment is ultimately needed.  If the vitreous hemorrhage clears by itself, laser can be applied in the office.  If we end up operating, the laser can be applied at the same time as the vitrectomy.

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Blood Thinners Don't Cause Bleeding

Patients with macular degeneration or diabetic retinopathy commonly have “bleeding” inside the eye.  These same patients may be taking “blood thinners” for other medical problems.  If bleeding occurs in the eye, should we stop the blood thinners?  What if you need surgery?

Patients with diabetic retinopathy can have blood spots within the retina.  These small spots are common and, in fact, typical of almost any patient with diabetic retinopathy.  They do no harm and are a result of a tiny bit of blood leaking out of a blood vessel into the surrounding retinal tissue.

In cases of proliferative diabetic retinopathy, VEGF has causes some abnormal blood vessels to start growing on the surface of the retina.  These blood vessels are extremely fragile and can break open and bleed causing a vitreous hemorrhage.  Again, the blood, per se, is not causing any harm.  Significant loss of vision may have occurred as the blood may be blocking light from reaching the retina, but this is reversible.

There are two forms of macular degeneration; wet and dry.  The wet form is distinguished by the presence of abnormal blood vessels, or neovascularization, underneath or within, the layers of the retina.  This subretinal neovascularization is also very fragile and bleeding commonly occurs.  Again, the blood, itself, is not harming any tissues.

Aspirin, Coumadin and Plavix are common “blood thinners.”  While not truly thinning the blood, they increase the chances of bleeding as they reduce the blood’s ability to naturally clot.  Patients may be taking these medicines to prevent stroke, heart attack or to improve circulation.

In my opinion, there is no need to stop any blood thinners if bleeding occurs with diabetic retinopathy or macular degeneration.

(This information is not to be taken as a substitute for medical advice.  Bleeding in other parts of the body can be dangerous or life-threatening.  Please consult your doctor if you experience bleeding and are on blood thinners.)

What Does This Mean? In all situations where “bleeding” may occur in diabetic retinopathy and macular degeneration, the blood itself, is benign.  While it may be a “sign” of serious eye disease, the blood causes no permanent harm.

In cases of diabetic retinopathy, aspirin has not been shown to increase the chance of bleeding.  Even in cases of impending retinal surgery, I prefer NOT to stop the “blood thinners” as I am able to control bleeding while I operate, that is, any potential bleeding would not interfere with the ability to complete surgery.  In other types of eye surgery, this is not so.

From a practical standpoint, I would prefer to continue any medication decreasing the chance of stroke and heart attack.  Even if bleeding in macular degeneration and diabetic retinopathy were harmful, I’d risk vision over stroke and heart attack.

My point today was to allay any fears of blood thinners and bleeding in the eye.  In my view, there is no harm to continuing the medications for the reasons listed above.  Obviously, please consult your physician if you have questions.

“Randy”

Randall V. Wong, M.D.

Ophthalmologist, Retina Specialist
Fairfax, Virginia

"Top Ten" Eye Emergencies: Part 1

Any vision loss can be scary.  Sudden vision loss is even more frightening.  There are really only a couple of “true” retinal eye emergencies.  I’ve listed the “top ten,”  remember that there are many ways to define an emergency.  All involve loss of vision, or at least a change in vision, and that alone probably qualifies as an “emergency.”  By the way, if you have sustained any of these symptoms, please call your doctor.  This article, and web site, is not intended to replace medical advice.

So here goes;  my “Top Ten” Retinal Emergencies;

10.  Vitreous hemorrhage – the symptoms of a vitreous hemorrhage can range from the onset of sudden floaters to rather impressive loss of vision, depending upon the amount of bleeding into the vitreous.

9.  Vascular Occlusions – either vein occlusions or artery occlusions.  Patients experience sudden loss of vision.

  • Causes
  • Vein Occlusions – may be associated with hypertension or diabetes, often healthy individual
  • Artery Occlusions – look for cardiovascular disease/stroke
  • Concerns – may develop “neovascular” glaucoma
  • Comments – treatments include laser treatment, Ozurdex (vein).

8.  Submacular Hemorrhage – sudden bleeding underneath the macula/retina.  Causes a dark area in the vision.  Usually the peripheral vision is normal.

  • Causes – valsalva, trauma, macular degeneration
  • Concerns – source of the bleeding
  • Comments – valsalva (aka straining) has the best prognosis, remember blood underneath the retina is not toxic

7.  “Wet” Macular Degeneration – rapidly (days to weeks) decreasing vision, distortion.

  • Causes – fluid/blood accumulating in the macula
  • Concerns – look for abnormal blood vessels (neovascularization)
  • Comment – fluorescein angiography is helpful

6.  Uveitis/Iritis – this is inflammation inside the eye, not unlike arthritis.  Patients may experience pain, sensitivity to light, decreased vision.  Eye may turn red.

  • Causes – endogenous, some rheumatologic diseases, trauma
  • Concerns – relief of pain, may look for associated systemic disease
  • Comment – usually steroids play a big role in controlling this

To Be Continued…

Blood in the Eye: You Make the Call

Last week another long time patient of mine (as most are with diabetic retinopathy and macular degeneration) returned with complaints of the sudden onset of floaters in the left eye.   The floaters had been present for about one month, they hadn’t cleared and he made an appointment.

I’ve added this illustration that resembles what I saw after dilating his pupils.  What do you see?

Vitreous Hemorrhage

My patient has had diabetes mellitus for about 18 years.  He is 64 years old.  Several years ago, he had a similar problem in the other eye.  He developed a vitreous hemorrhage from proliferative diabetic retinopathy.  In the illustration above, note the abnormal blood vessels, so-called “neovascularization,” that has formed on the surface of the retina.

Neovascularization develops when the oxygen supply to the retina is poor, causing retinal ischemia.  The ischemic retina then produces VEGF (vascular endothelial growth factor) in response to this lack of oxygen – sounding familiar?  The VEGF causes neovascularization to proliferate.

Neovascular blood vessels are also very fragile.  They can break open and bleed at any time and without apparent cause.  The blood physically blocks light.  A little bit of blood may cause “floaters,” while substantial bleeding seems to fill the eye, severely affecting vision.

What is next?  My first job is to make sure that nothing else is causing the vitreous hemorrhage.  A tear in the retina can cause a similar picture.  If there is no hemorrhage, then I am more confident that the hemorrhage might be due to diabetic retinopathy.  Our choices at this point are; observation (aka do nothing) or perform a vitrectomy eye surgery.  Ultimately, any patient with proliferative diabetic retinopathy needs pan-retinal photocoagulation (laser treatment).  At the present state, blood physically blocks light, therefore, laser treatment is not possible.  We can either wait for the blood to absorb, and then perform laser surgery, or go ahead an perform a vitrectomy, remove the blood and perform laser all at once.  We operated.

What Does This Mean? In cases of vitreous hemorrhage due to diabetic retinopathy, the single most important therapeutic option is to perform PRP (pan-retinal photocoagulation).  This will indirectly stop the VEGF from being produced and the neovascular tissue will regress; that is, shrink up and go away.  Vision is stable, chance of blindness is halted.

VEGF is also implicated macular degeneration.  It is the same VEGF.  Avastin and other anti-VEGF drugs (Lucentis/Macugen) are also used to control proliferative diabetic retinopathy…at times.  I use it when the laser doesn’t seem to be working, but I expect more and more docs will use it the future.

“Randy”

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

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Sometimes You Just Need a Vitrectomy

A vitrectomy is an eye operation. It is performed by retina specialists for a variety of reasons. In patients with diabetic retinopathy, a vitrectomy may be useful to remove blood in the vitreous, aka a vitreous hemorrhage. There is no reason, to perform a vitrectomy in cases of macular degeneration.

Vitrectomy Surgery to Clear Hemorrhage
Vitrectomy Surgery to Clear Hemorrhage

In cases of vitreous hemorrhage, bleeding has and blood remains suspended in the vitreous. The vitreous is the gel-like substance that fills most of the eye. It is very similar to jellyfish, it has substance, but is mostly water.  It is optically clear.

A vitreous hemorrhage is benign, that is, the blood does not cause any damage to any portion of the eye, especially the retina. The vitreous hemorrhage physically blocks light and causes loss of vision. Sometimes the vitreous hemorrhage can absorb on its own, but if not, a vitrectomy is necessary to remove the non-clearing vitreous hemorrhage. At this point vision should be restored. It can take weeks or months to absorb. Many times we can’t wait that long.

Advanced diabetic retinopathy, or proliferative diabetic retinopathy, can have a retinal detachment associated with it. This type of retinal detachment is different. Most retinal detachments are caused by a retinal tear or retinal hole, called a “rhegmatogenous” retinal detachment.

Retinal detachments associated with diabetic retinopathy are called “traction” retinal detachments. The mechanism is different than rhegmatogenous retinal detachments in that the retina is pulled, like a tent, apart from the underlying layers. “Scar” tissue has formed on the surface of the retina, contracted and exerts this pulling.

A vitrectomy is necessary to correct/repair this type of retinal detachment. The vitreous is removed to allow access to the retinal surface. The abnormal scar tissue is cut away to relieve the “pulling.”

Vitrectomy surgery is also used for other retinal problems; rhegmatogenous retinal detachments, epiretinal membranes, macular holes, floaters, certain trauma, etc. Major risks of the surgery include blindness from infection and retinal detachment. The risks, however, are very, very uncommon.

Vitrectomy surgery has been around  for about 30 years.  It has allowed us to prevent potentially blinding retinal detachments in our diabetic retinopathy patients.  On the other hand, the whole focus of this site is to educate.  If you are seen early enough, you’ll never even need a vitrectomy.

“Randy”

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

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Here's Blood in Your Eye!

Blood in your eye can mean many things to different people.  The most common “blood” is the sudden appearance of fire engine red blood on the outside of the.  It is called a subconjunctival hemorrhage.  It is usually scary, painless, ugly and benign.  As a black and blue bruise, it will clear in about 1-2 weeks.

I am talking about blood inside your eye.

Vitreous Hemorrhage – In patients with diabetic retinopathy, the sudden appearance of “floaters” can be signs of a vitreous hemorrhage.  Patients with proliferative diabetic retinopathy, by definition, have developed neovascularization, or abnormal blood vessels, somewhere inside the eye.  Most commonly, the neovascularization, is found on the surface of the retina, but can also be present on the optic nerve and iris. These blood vessels are very fragile and may break open and bleed causing blood to accumulate in the vitreous.

A vitreous hemorrhage can cause dramatic loss of vision as it physically may block light from hitting the retina.  It is not an emergency despite the significant loss of vision.  As long as the retina is attached, the hemorrhage may be observed for weeks or even months.  It causes no damage, just anxiety.

A vitreous hemorrhage may also be caused by a tear in the retina.  Retinal tears may occur in anyone.  So, in diabetic patients with a vitreous hemorrhage……….As long as the retina is attached and without a tear, we can wait.

Laser treatment to the retina is the antidote for proliferative diabetic retinopathy.  If there is too much blood in the vitreous, it may not be possible to laser the retina.  Sometimes we can wait for the hemorrhage to absorb and then treat with laser in the office.  Other times, the hemorrhage does not clear and we may choose to operate, that is, perform a “vitrectomy.”  In this case, the blood is mechanically removed and then the retina is treated with laser during the operation.

Sub-Retinal Hemorrhage – Blood underneath the retina is called a sub-retinal hemorrhage.

A sub-retinal hemorrhage may occur in patients with wet macular degeneration.  Abnormal blood vessels,  called choroidal neovascularization, may develop within the layers of the retina in “wet” macular degeneration.  Patients with “wet” macular degeneration, by definition, have developed neovascularization underneath the retina.

The blood underneath the retina, too, is benign.  It does no harm to the retina. The neovascular tissue; however, may be causing some damage and efforts are made to quickly arrest further progression of the abnormal blood vessels.

Once the presence of neovascularization is confirmed underneath the retina by a fluorescein angiogram, the treatment of choice may be anti-VEGF medications such as Avastin®, Lucentis® or Macugen®.

“Randy”

Randall V. Wong, M.D.
www.TotalRetina.com
Ophthalmologist, Retina Specialist

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Floaters, Are They Normal or due to Diabetic Retinopathy?

Floaters are generically defined as black spots in your vision.  They move to and fro with eye movement.  Most of the time they are small, tiny and black, but really can be large and translucent, too.  From a doctor’s standpoint, size does not matter.  New floaters can mean a retinal tear and the development of a retinal detachment.

Floaters can develop from a variety of causes such as a posterior vitreous detachment (PVD) or a retinal tear.  A posterior vitreous detachment (PVD) is a normal occurrence and happens more frequently as we age, with increased near-sightedness (eye slightly larger) and with trauma.  The vitreous is the “gel” that fills most of the eye.  With time it will separate from the surface of the retina and usually produces the sudden onset of new floaters  (For additional article on floaters/flashes, click here).

A PVD can cause a retinal tear.  It usually does not, but it can.  New floaters require a dilated eye exam to exclude a tear in the retina.  Patients are usually at highest risk for developing a tear following a posterior vitreous detachment for the first 6 weeks following symptoms.  Retinal tears can develop into a retinal detachment if not treated.

Occasionally, a vitreous hemorrhage can result from a retinal tear.  So, add this to the list of causes, too.

Floaters and Diabetic Retinopathy In a patient with diabetic retinopathy, new floaters can be related to a PVD or retinal tear just as any other person without diabetes.  New floaters; however, can also be related to the diabetic retinopathy and are caused by a vitreous hemorrhage.  Bleeding into the vitreous is caused by the presence of abnormal (aka neovascularization) blood vessels on the surface of the retina.  This signals the development of proliferative diabetic retinopathy.

What to you need to do? In any case, alert your doctor to your new symptoms.  It is recommended that you get a dilated eye exam to look for a posterior vitreous detachment (PVD), vitreous hemorrhage or retinal tear.

“Randy”

Randall V. Wong, M.D.
www.TotalRetina.com
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!

“Randy”

Randall V. Wong, M.D.
www.TotalRetina.com
Ophthalmologist, Retina Specialist

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offices

Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different practices.....it'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.

Capital Eye Consultants
Randall V. Wong, M.D.
Contact: Brigitte O’Brien

A: 3025 Hamaker Court, Suite 101 • Fairfax, Virginia 22031
Ph: 703.876.9630
F: 703.876.0163
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Dressler Ophthalmology Associates, PLC
Randall V. Wong, M.D.
Contact: Andrea Armstrong (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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