MYELINATED NERVE FIBERS AND VITREORETINAL TUFT

Myelinated nerve nerve fibers have a whitish look as they emerge from the optic nerve in the eye.  Myelination is like insulation around electrical wires.   That myelination exists on the nerves when they exit the eye, but in the eye they are unmyelinated.  Sometimes the myelination will extend in to the eye.  It doesn't cause any problems.  

Vitreoretinal tuft is a traction on the retina from the vitreous bag that fills up the inside of the eye.  As this bag pulls on the retina, it can sometimes be adherent to the retina in a localized place and pull the retina up a little.  A small percentage of these become retinal tears, which can then turn in to detachments which would cause loss of vision.   Therefore they need to be watched with dilated eye exams closely.

CORNEAL ULCER FROM CONTACT LENS OVERWEAR

The photos below are of a corneal ulcer in a patient who frequently sleeps in their "extended wear" contact lenses and doesn't have a good pair of glasses that they like. 

This patient is lucky because the ulcer was just outside the visual axis, meaning that most of her vision should return to normal once the infection is gone and the eye is healed.  This ulcer will take high dosage of very potent topical antibiotics to resolve, followed by anti-inflammatory drops to minimize scarring and maximize vision. 

TREATED RETINAL TEAR

Below is a photo of a treated retina tear. You can see the piece of retina that is broken off. There is a tear underneath it. There are laser scars surrounding it, preventing it from becoming a retinal detachment.

PSEUDOEXFOLIATION GLAUCOMA

Pseudoexfoliation occurs primarily in patients of Scandinavian descent. It is a flaky material that exists on the anterior lens capsule and can also flake off and block the fluid drainage of the eye. This patient ha significant loss of vision in this eye from damage to the optic nerve (as demonstrated by it's lack of good blood perfusion in the bottom picture).

CONJUNCTIVAL CYST

This is a cool picture of a conjunctival cyst. The patient is looking to his left. The cyst grew overnight and stretched the blood vessels, causing a few of them to bleed.

ABMD

This is anterior basement membrane dystrophy, a genetic disease that causes an irregular corneal surface resulting in blurred vision and eye discomfort upon awakening.

"EYELASHITIS"

That is what this 9 year old patient calls this. It's actually blepharitis, a chronic infection of the eyelids.

BEAR TRACKS

Basically bear tracks are pigment on the retina. Kind of like a birth mark.

UNUSUAL RETINOSCHISIS

The photo below is of a retinoschisis. A retinoschisis is a separation of inner layers of the retina from the outer layers of the retina. Usually a retinoschisis is dome shamed. This one, however, is unusual in that it has a steep ridge. This one looks like the head of a wood golf club.

COLOBOMA

The above picture is what the normal optic nerve looks like.

This is a picture of an optic nerve coloboma. It occurs when the eye doesn't develop completely. A coloboma is like a huge crater with the optic nerve on one of the slopes. This patient's vision is only mildly decreased.

CORNEAL ULCER

This is a 29 year old patient who wears her Acuvue Oasys Contact Lenses from the time she gets up until she goes to bed, every day. She complained of pain, redness, and light sensitivity.

Examination shows a single corneal ulcer. This is a bacterial ulcer, similar to what occurs with stomach ulcers. It must be treated very aggressively with a high initial dosage of very potent topical antibiotics and the patient must be followed nearly every day until resolution.

This patient is very fortunate. The ulcer is located peripherally enough that any scar will not effect her vision. She also came in early enough to limit it's progression before it became worse. These ulcers can cause permanent decrease in vision, due to scarring along the visual axis. Aggressive, poorly managed ulcers can cause complete loss of the eye.

People with problems like this are always those who over-wear their contact lenses and they don't dispose of their lenses when they're supposed to. For some reason the patients I see coming in to my office are usually wearing Acuvue Oasys lenses.

The people who do the best in contact lenses are those who rest their eyes from the contacts a few hours a day and a day or two a week.

FOREIGN BODY TRACKS POINT TO THE PROBLEM

A patient of mine showed up one Monday morning complaining of pain in his eye. He said the wind was blowing two days earlier and he thinks that something flew into his eye. No matter how much he flushes the eye out, he can't get rid of it.

When I first looked at him, I couldn't see anything wrong. The cornea looked normal and the eye wasn't red. I flipped the eye lid to look under it and didn't see anything there. So then I put dye in the eye and under red-free light I saw the following on the cornea:

If you magnify the above picture and dim the lights, you'll see several vertical lines in the cornea. These lines represent scratches on the surface of the cornea caused by something trapped under the upper lid. So I knew there had to be something there. Usually a foreign body is metallic and easily identifiable.

On closer look I was able to identify a clear piece of plastic under the lid. I pulled it out and the patient had immediate relief.

CONTACT LENS LOOKING LIKE A PETRI DISH

This is a patient who wears his Purevision Toric contact lenses longer than a month and doesn't remove them. When your contact lenses look like a Petri Dish, you know you're abusing your contact lenses...and your eyes!

SCLEROSING BASAL CELL CARCINOMA

This older gentleman has irritation in the left eye from lashes poking in his eyes. Why are they poking. You can see the irregularity in the lower lid. This can be caused by a deep basal cell carcinoma. If it grows, it will need to be excised and the lower lid would have to be reconstructed.

CONTACT LENS OVERWEAR

This patient overwears their contact lenses and you can see blood vessels growing into the cornea. This is a common problem and people are surprised to see that contact lenses are causing this kind of damage to their eyes.

NUCLEAR CATARACT

The right lens shows barely any cataract at all.

The left lens shows a clouding which changed the patient's eyeglass prescription rapidly and will eventually cloud the vision to the point where he needs cataract surgery.

WASH YOUR HANDS BEFORE PUTTING IN CONTACT LENSES!!!!!

This is the case of a young lady who may not have washed her hands to put her contact lenses in after she had used some facial cream. The cream may be alkaline which is NOT good for the tissues of the eye. Alkaline substances tend to start damaging the cornea and working it's way deeper and deeper into the tissue.

On her way to work she started seeing hazy, but it didn't hurt. She came into the office and she really didn't look that bad, just a little damage to some surface cells of her cornea and a lot of corneal swelling. I had her irrigate her eye and use a lot of artificial tears the rest of the day to wash out everything and lubricate the eye. She called me last night in pain and I prescribed an antiobiotic/steroid combination eyedrop to calm down the inflammation and prevent bacterial infection.

Today she feels a lot better, and although her corneal swelling is a lot better, she has a lot of damage to the epithelial cells and her vision is worse. You can see that damage in the pictures.

Steroids can delay wound healing so, after consulting with my favorite corneal specialist, who concurs with me, I am having her use antibiotic drops only.

She will heal and I will watch her closely to make sure she heals with minimal or no scarring. However, the lesson is learned to WASH YOUR HANDS before putting contact lenses in. Washing hands is not just to prevent infection, but to wash off anything that the hands touched that could be toxic to the cornea.

Below is right eye yesterday.

Below is right eye today, showing the damaged epithelium cells.

This photo below is the left eye yesterday showing mild damage to surface cells.

The picture below is the left eye today, showing two heavily damaged areas of epithelium.

Below is the OS lesion using white light.

MACULAR SCAR

This is a scar from childbirth near the macula. The macula is that portion of the retina that serves the center of our vision. Because this scar is so close to the macula, this patient's best vision is 20/40. He has to eccentrically view, which means that he has to look off to the side a little to see something. Luckily his left eye is perfect 20/20.

SNAIL-TRACK DEGENERATION

This area of white is on the retina in the far periphery. It can only be seen when the eye is dilated. This occurs often as an inherited trait in near-sighted people. People that have this are more susceptible to developing retinal holes and detachments. This picture is of a young patient with the condition. It was discovered without any symptoms on routine dilation. She was educated to watch for flashes of light, floaters, or a curtain coming over her vision. We will follow up with her on a yearly basis.

METAL IN THE EYE

This mechanic's eye started bothering him on Tuesday. He thought it would go away on it's own but everyday it got worse until I saw him in my office on Saturday. He had metal embedded on his cornea. Removal was quick, will leave no scar, and provided instantaneous relief.

AIR HOCKEY INJURY

This patient was watching an air hockey match when the puck flew off the table and hit his eyelid. It lacerated his lid, which will heal rapidly. I dilated the eye to make sure there was no serious injury to the retina and found this area of whitening on the retina corresponding to the location he was hit.

The whitened area of the retina is what we call Commotio Retinae. It is caused by swelling in the retina from trauma. It resolves in about 6 weeks without any consequence to vision or health of the eye.

RETINAL HOLE

The photo below is of a retinal hole, found on routine dilation during a regular eye exam. Fluid can get under these and lift the retina off. Where ever the retina gets lifted off you can't see. So this patient likely will need laser to sort of "weld" around the hole so that if fluid does get under it, it won't spread.

This case illustrates the importance of routine eye examinations, even for people who don't need glasses or contact lenses.

MORE CONTACT LENS OVER WEAR

This is another patient who overwears Acuvue contact lenses. The above arrow points to where the blood vessels should stop. The lower one points to where they extend into this patient's cornea. Ideally contact lens wearers should give their eyes a few hours a day to breath and a couple days a week. We can replace our cars. We can't replace our eyes! These blood vessels will forever be there. But hopefully, with proper lens wear, they can become "ghost" vessels, with no blood in them.

RETINAL TEAR

Below is a retinal tear discovered on routine eye dilation. The arrow points to the tear which, in 3 dimensions, comes out into the vitreous cavity of the eye. The dark area just above it is actually the shadow of the operculum. Retinal tears eventually cause retina detachments. This can lead to complete and irreversible blindness if not caught in time. This patient had no symptoms.

Every week I catch someone with a retinal tear who had no symptoms. We can only catch these when we dilate the eye. Dilation is no extra charge at Sonoran Desert Eye Center.

RETINAL TEAR

You can enlarge this photo to see the retinal tear. Fluid can get under tears and lead to a retinal detachment quickly if not treated. You should call your eye doctor immediately if you notice sudden flashes of light or unusual floaters.

CONTACT LENS OVER WEAR

This is an example of what happens when people over wear their contact lenses. The cornea is the only structure in the body that gets it's oxygen directly from the air. When we wear contact lenses, unless we have enough waking hours of not wearing the lenses, the cornea becomes starved from oxygen. Blood vessels start to grow into the cornea to feed the starved cells. Over time the health of the cornea becomes compromised, leading to inflammations and vision-threatening infections that can cause permanent loss of vision.

These blood vessels should stop at the limbus, the junction between the white part of the eye and the cornea. As you can see, these blood vessels go much further!

CORNEAL SCRATCHES

The two little marks are abrasions from an eyelash separator (not while driving, or it would have been much worse). It healed with no scarring because we did a balance of steroid and antibiotic drops.

GLASS BEAD EMBEDDED ON THE EYE

This gentleman sandblasts the calcium ring on tile using glass beads. He came in complaining of irritation in the eye. This glass bead was stuck on his cornea. It was easy to remove and antibiotic drops will keep it from getting infected.

ARTIFICIAL RETINA SEE'S ABOUT 20/8000

The Best of Ophthalmology.....EyeWorld News Magazine

Nice article about a lady implanted with an artificial retina and how she went from seeing no light to seeing about 20/8000...enough to see a bus go by.

PLUGS FOR DRY EYE

Dry eye causes symptoms of burning, irritation, redness, watering, and foreign body sensation. It is worse in middle-aged females and symptoms are worse toward the end of the day.

There is a canal that goes from your eyes to your nose. Every time you blink, you pump tears away from your eyes and they drain into the nose. If we can plug the opening of those canals, we can keep your natural tears on your eyes longer, significantly decreasing discomfort from dry eye.

Plugs are easy and painless to insert. We try collagen plugs first. These collagen plugs dissolve over a 3-5 day period, during which you can see if your symptoms decreased. If you feel better, we put in permanent plugs (although they can be removed easily). Again, this is a simple and painless procedure that we do here in the clinic.

The picture below shows the cap of a plug that was inserted in the lower opening. The lower lid has been manually pulled away from the eyeball for demonstration purposes.

PIECE OF METAL UNDER THE EYELID

These are photos of a gentleman in his 60's who came to us with an irritated left eye. He had been out in the wind and dust earlier that day. His eye was irritated. He was light sensitive. He felt something was in his eye.

I put fluorescein dye in the eye and discovered the abrasion at the 2 o'clock location on the cornea. There were also foreign body tracks adjacent to the abrasion. Sure enough, when flipping the lid, there was a small piece of metal embedded under the eyelid. I removed the foreign body, gave the patient antibiotic drops, and called him later that evening. He was doing much better!

COLD SORE ON THE EYELID

Below is a photo of a young 12 year old who has a recurring lesion on his eyelid. It always occurs near the same location with yearly frequency. This is the same condition that causes cold sores (which he also gets) on the lips, only it's a different branch of the trigeminal nerve that serves the face.

Herpes Simplex Virus is airborne as well as spread by body fluids. HSV 1 is the non-venereal version that most people harbor. The virus resides in the trigeminal ganglion, which is where the three branches of the trigeminal nerve meet. It only causes lesions in patients when it is triggered, usually during periods of stress, either physical or psychological. It is impossible to completely eradicate it, but lesions can be treated with anti-viral to prevent permanent tissue damage.

RETINAL EMBOLUS

Below is a photograph of a retinal embolus in a right eye retina arteriole of a 68 year old woman. This patient has not been to her doctor in years. She also had corneal arcus, which is cholesterol deposits on the cornea. She is not being treated for high cholesterol.

Retinal emboli are loose pieces of plaque that travel in the blood stream until the artery diameter becomes smaller than the embolus. There the embolus stops and often will plug up the artery, causing death of the tissue that the artery serves. This is what occurs in strokes and heart attacks. Emboli that get deposited

This patient had no symptoms that something was going wrong with her cardiovascular system. It is so important that people over 55 years old have their regular visits with their primary care providers.

MARGINAL KERATITIS

This is a complication of contact lens overwear. This can be very painful. The white dots are collections of white blood cells. Eventually the cornea can ulcerate in those areas and the patient becomes unable to wear contact lenses any longer, without treatment. Treatment is prescription anti-inflammatory and antibiotic drops, a good pair of glasses with the current prescription, and better contact lenses. The bottom picture is what the cornea looked like on the day of presentation. The top picture is 5 days after treatment. This patient had been wearing Acuvue Oasys lenses. We changed her to better quality lenses that have less incidence of marginal keratitis.

PAPILLEDEMA

Normally the optic nerve disc is flush with the retina. In papilledema, intracranial pressure (pressure in the brain cavity) is so high that the optic nerve protrudes into the eye.

Increased intracranial pressure can occur if there are space-occupying lesions in the brain, such as tumors. There is a condition called pseudotumor cerebri where the intracranial pressure is high but there is no space-occupying lesion. The patient often suffers from headaches and ringing in the ears. It often occurs in young, overweight females. This was a patient I saw this week who came in for a routine eye examination.

A space-occupying brain lesion needs to be ruled out with imaging and often a lumbar puncture is performed to confirm the increased intracranial pressure and rule out other possible problems

PERIPAPILLARY ATROPHY

This is a common occurance in people that are very near sighted. The optic nerve is surrounded by a white area. This area is not useful for vision, so this patient has an enlarged blind spot on their visual field. However, it is not progressive.

ANOTHER CHOROIDAL NEVUS

This is another patient with a choroidal nevus. This is a benign pigmented lesion on the retina that has very low potential for growth to become a malignant melanoma. It is photographed and watched on a regular basis.

CHOROIDAL NEVUS

This is a small "freckle" on the back of the eye. We watch it to make sure it doesn't grow into something like a melanoma.