Cystoid Macular Edema is a swelling in the central most part of the retina creating small cyst like lesions. It may occur for a number of reasons, but I will concentrate on the incidence occurring following cataract surgery.

The standard of care has changed greatly over the years with cataract surgery; attempting to reduce or eliminate post surgical complications. In years past, antibiotics were employed both pre and post operative to prevent infections. That has not changed, although the antibiotics have. Likewise steroid use has been used to reduce inflammation on, and in the eye. In doing so healing improves, the patient has reduced pain, and there is less likelihood of post surgical scarring.

Years ago, if there was an increased pressure in the eye following the procedure, Propine was used to reduce it. Frequently, these patients developed Cystoid Macular Edema(CME). CME can reduce the vision dramatically, and requires aggressive treatment to prevent damage. When it was determined that it was the Propine that caused the CME, it was stopped immediately. Over time, surgeons have tried to prevent CME pharmaceutically and thus reduce a serious complication.

The answer turned out to be Non Steroidal Anti-inflammatory Drugs(NSAIDs). The standard of care in cataract surgery now includes the use of these NSAIDs. At first, just those individuals with Uveitis, diabetes or retinal vascular conditions were prescribed these great drugs. Now, ALL cataract patients are told to use them. Since CME is the most common cause of visual decline in uncomplicated cataract surgery, it is important to prevent it. NSAIDs inhibit prostaglandin synthesis which is responsible for most of the post surgical inflammation. Therefore, preventing the prostaglandins will increase comfort, prevent miosis(small pupils) and avoid CME. The usual use for NSAIDs is 2-3 days prior to surgery and then at least a month post surgically.

The most commonly used NSAIDs are Acular, Xibrom, which is frequently used for pain management, and Nevanac. These new drugs dramatically improve surgical results while reducing patient discomfort.

Tech Tags: Cystoid Macular Edema NSAID Cataracts antibiotic inflammation Propine Uveitis diabetes Acular Xibrom

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Patients with systemic diseases and conditions frequently will also have ocular manifestations of those disorders. Recognizing these findings is vital to proper treatment.

Patients who come to our office with complaints of dry eyes, or inflammatory conditions like Iritis, Uveitis, Scleritis or Episcleritis frequently are also suffering form immunological conditions as well. While we can usually treat the ocular conditions effectively, the individual must seek medical treatment from his/her general practitioner for the underlying disorder.

Rheumatoid Arthritis is an autoimmune condition resulting in inflammation. The Rheumatoid factor attacks the immunoglobulin G (IgG), resulting in the release of inflammatory cytokines from white blood cells causing edema and cell death. The joints are particularly at risk for damage. In the eye, the basement membranes break down; thereby permitting the destruction of the underlying ocular tissue. At first, this occurs at the tear producing gland (lacrimal gland) causing a decrease in tear production, and then dry eye. Episcleritis, the inflammation of the outer most layer of the eye wall, is a common result as well. These conditions are frequently treated with either topical steroids, and/or NSAIDs very effectively. A more serious condition is Uveitis which is an internal inflammation. This may result in permanent damage to the eye. In severe cases Anti-rheumatoid medicines such as Plaquenil must be employed.

HLA-B27 disorders are a group of diseases that present with similar ocular findings. The conditions include Ankylosing Spondylitis, Psoriatic Arthritis, Arthritis, and Behcet’s Disease; there are other connective tissue disorders as well. The most common ocular finding with these disorders is nongranulomatous Uveitis, and Iritis. Treatment includes pupillary dilation, and topical steroids like Pred Forte. Recurrence frequently occurs, and rapid aggressive treatment is needed to prevent chronic inflammation and ocular damage.

Acne Rosacea presents with pustules, papules, and telangiectasia (small blood vessels in the skin). Ocular findings include chronic blepharitis (lid inflammations), conjunctivitis, meibomian gland break down, corneal thinning and then perforation. Treatment begins with artificial tears and warm compresses, and increases to antibiotic eye drops and steroids drops if needed. Doxycycline, an oral antibiotic has been found to be very affective in curing the blepharitis component of the disorder.

Giant Cell Arteritis is an inflammation of the giant cell arteries in the cranial cavity, and requires emergency treatment. Rapid treatment is required, or the condition can be fatal. The eye doctor may notice changes in the Optic nerve. This patient needs to be hospitalized as soon as possible.

Inflammatory Bowel Disease (IBD) such as Crohn’s, Ulcerative Colitis and Proctitis, are inflammations in the intestinal walls. Ocular manifestations may include Episcleritis and Uveitis. Unlike with the other conditions discussed, IBD may results in Posterior Uveitis which is more serious, and may result in greater ocular damage. Treatment then may require systemic immunosuppressant and injections directly in the eye. This treatment may lead to Cataracts, Glaucoma and Cystoid Macular Edema. Treatment must therefore be carefully monitored.

With immunological disorders the key to proper treatment is rapid, accurate diagnosis. If left untreated, many of these ocular findings can severely damage the eye and reduce vision.

Tech Tags: Immunological Disorders inflammatory conditions Uveitis Scleritis Episcleritis Rheumatoid Arthritis lacrimal gland NSAID Plaquenil HLA-B27 Ankylosing Spondylitis Disease Acne Rosacea blepharitis Doxycycline Giant Cell Arteritis Inflammatory Bowel Cataracts Glaucoma Cystoid Macular Edema

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Multiple Sclerosis is the gradual damage to the nervous system, leading to demyelination, and system failures. Previously, diagnosis was made when there were “several episodes separated by time and space”. As the symptoms piled up, and there were clear signs of the disorder a diagnosis was made. The problem, of course, was that by that time there was substantial damage to the body and the nervous system. Therefore, early accurate diagnosis is required to help deter the long term damage and preserve nerve function.

MRIs and spinal taps have been used for this purpose, but have not been as accurate as was required to begin early treatment. According to a study reported in the October issue of Neurology researchers at The John’s Hopkins Multiple Sclerosis Center have found that the Optical Coherence Tomography ( OCT) can identify MS earlier on in the disease process then all other testing methods. The OCT scans the nerve fiber layer in the eye, and there is a very strong association between RNFL loss and brain atrophy.

Optic Neuritis, inflammation of the optic nerve, is the initial sign in 20% of MS cases presenting in the eye doctor’s office. In addition these patients may also show signs of Retrobulbar Neuritis, which is swelling of the optic nerve behind the eye. Both of these conditions can, and often do lead to death of the nerve tissue; especially if left untreated. MS affects the optic nerve in about 60% of the patients over the course of the disorder. Therefore, by using the OCT as a window into the nervous system via the optic nerve, early treatment can begin preventing or at least pushing off damage to the body.

In summary, the OCT a frequently used optical tool in examinations of the eye can diagnosis MS earlier on then all other testing methods and treatment can begin helping the patient maintain the nervous system integrity.

Tech Tags: Multiple Sclerosis MRI spinal taps Neurology Optical Coherence Tomography Optic Neuritis inflammation optic nerve Retrobulbar

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