Ear, Nose, and Throat Disorders

Allergic Rhinitis What is allergic rhinitis? Rhinitis is a reaction that occurs in the nose when airborne irritants (allergens) trigger the release of histamine. Histamine causes inflammation and fluid production in the fragile linings of nasal passages, sinuses, and eyelids. There is usually a family history of allergic rhinitis. What are the types of allergic rhinitis? The two categories of allergic rhinitis include: y seasonal - occurs particularly during pollen seasons. Seasonal allergic rhinitis does not usually develop until after six years of age. y perennial - occurs throughout the year. This type of allergic rhinitis is commonly seen in younger children. What are the causes of allergic rhinitis? The most common causes of allergic rhinitis include the following: y pollen y dust mites y mold y animal dander What are the symptoms of allergic rhinitis? The following are the most common symptoms of allergic rhinitis. However, each child may experience symptoms differently. Symptoms may include: y sneezing y congestion y runny nose y itchy nose, throat, eyes, and ears y nosebleeds y clear drainage from the nose Children with perennial allergic rhinitis may also have the following: y recurrent ear infections y snoring y mouth breathing y fatigue y poor performance in school y "allergic salute" - when a child rubs his/her hand upward across the bridge of the nose while sniffing. This may cause a line or crease to form across the bridge of the nose. The symptoms of allergic rhinitis may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis. How is allergic rhinitis diagnosed? Typically, the diagnosis is made by your child's physician based on a thorough medical history and physical examination. In addition to the above symptoms, your child's physician may find, upon physical examination, dark circles under the eyes, creases under the eyes, and swollen tissue inside the nose. Treatment for allergic rhinitis: Specific treatment for allergic rhinitis will be determined by your child's physician based on: y your child's age, overall health, and medical history y extent of the reaction y your child's tolerance for specific medications, procedures, or therapies y expectations for the course of the reaction y your opinion or preference Treatment options may include: y avoidance of the allergens Avoidance of the allergens that are causing the problem is the best treatment. y over-the-counter antihistamines Antihistamines help to decrease the release of histamine, possibly decreasing the symptoms of itching, sneezing, or runny nose. Some examples of antihistamines are diphenhydramine (Benadryl) or hydroxyzine (Atarax). These medications may cause drowsiness. Consult your child's physician to determine the proper dosage for your child. y nonsedating prescription antihistamines Nonsedating antihistamines work like antihistamines but without the side effect of drowsiness. Nonsedating antihistamines may include cetirizine (Zyrtec), loratadine (Claritin), or fexofenadine (Allegra). Consult your child's physician to determine the proper dosage for your child. y anti-inflammatory nasal sprays Anti-inflammatory nasal sprays help to decrease the swelling in the nose. Consult your child's physician to determine the proper dosage for your child.

corticosteroid nasal sprays Corticosteroid nasal sprays also help to decrease the swelling in the nose. Corticosteroid nasal sprays work best when used before the symptoms start, but can also be used during a flare-up. Consult your child's physician to determine the proper dosage for your child. y decongestants Decongestants help by making the blood vessels in the nose smaller, thus, decreasing congestion. Decongestants can be purchased either over-the-counter or by prescription. Consult your child's physician to determine the proper dosage for your child. y anti-leukotrienes These are a relatively new type of medication being used to control the symptoms of asthma. These medications help to decrease the narrowing of the lung and to decrease the chance of fluid in the lungs. These are usually given by mouth. If your child does not respond to avoidance or to the above medications, your child's allergist then may recommend allergy shots or immunotherapy based on the findings. Immunotherapy usually involves a three- to five-year course of repeated injections of specific allergens to decrease the reaction to these allergens when your child comes into contact with them. Consult your child's physician for more information. How is allergic rhinitis prevented? Preventive measures for avoiding allergic rhinitis include: y environmental controls, such as air conditioning, during pollen season y avoiding areas where there is heavy dust, mites, molds y avoiding pets The link between allergic rhinitis and asthma: Controlling asthma may mean controlling allergic rhinitis in some patients, according to allergy and asthma experts. The majority of asthma patients have rhinitis, and patients with rhinitis have a much higher prevalence of asthma than those who do not have rhinitis. Guidelines from the World Health Organization (WHO) recognize the link between allergic rhinitis and asthma. Although the link is not fully understood, one theory asserts that rhinitis makes it difficult to breathe through the nose, which hampers the normal function of the nose. Breathing through the mouth does not warm the air, or filter or humidify it before it enters the lungs, which can make asthma worse. Deviated Septum What is a deviated septum? A septum is a wall that divides two cavities. In the nose, the septum is made of cartilage, and divides the nose into two separate chambers (right and left). A deviated septum is an abnormal shape of the cartilage, which may cause problems with proper breathing or nasal discharge. What is septoplasty? Septoplasty is a reconstructive plastic surgery performed to correct an improperly formed nasal septum that may be caused by: y birth defect y injury y damage from previous medical treatments In addition to correcting a deviated nasal septum, septoplasty may also be performed to correct other problems, such as cleft abnormalities that affect the nose and nasal cavity. About the procedure: Septoplasty may be performed with the traditional open surgical technique from inside the nose. When open surgery is performed, small scars will be located on the base of the nose, but they usually are not noticeable. Scarring is not visible when internal surgery is performed. Depending on the severity of the deviation, septoplasty may be performed in the following settings: y a surgeon's office y an outpatient surgery center y a hospital as an outpatient y a hospital as an inpatient The surgeon will provide guidelines for resuming normal activities. Many children are up and around within a few days and able to return to school in a week or so. What are the complications associated with nasal surgery? Children vary greatly in their anatomy and healing ability, and the outcome is never completely predictable. Complications may occur, including, but not limited to, the following: y infection y nosebleed y reaction to the anesthesia Short-term side effects of surgery may include: The following short-term side effects may occur. If symptoms do not subside, consult your child's physician. y splint applied to nose to help maintain new shape y nasal packs or soft plastic splints placed in nostrils to stabilize septum y face will feel puffy y

y nose may ache y dull headache y swelling around the eyes y bruising around the eyes y small amount of bleeding in first few days y small burst blood vessels may appear as tiny red spots on the skin's surface Nosebleeds Nosebleeds can be a scary occurrence, but are usually not dangerous. The medical term for nosebleed is epistaxis. They are fairly common in children, especially in dry climates or during the winter months when dry heat inside homes and buildings can cause drying, cracking, or crusting inside the nose. Many times, children outgrow the tendency for nosebleeds during their teenage years. The front part of the nose contains many fragile blood vessels that can be damaged easily. Most nosebleeds in children occur in the front part of the nose close to the nostrils. What causes a nosebleed? Nosebleeds are caused by many factors, but some of the most common causes include the following: y picking the nose y blowing the nose too hard y injury to the nose y over-dry air y colds and allergies y foreign body in the nose Many times no apparent cause for a nosebleed can be found. First-aid for nosebleeds: y Calm your child and let him/her know you can help. y Pinch the nostrils together for five to 10 minutes without checking to see if bleeding has stopped. y Have your child sit up and lean forward to avoid swallowing blood. y Apply ice or a cold water compress to the bridge of the nose. y If bleeding does not stop, try the above steps one more time. y Do not pack your child's nose with tissues or gauze. When should I call my child's physician? Specific treatment for nosebleeds, that require more than minor treatment at home, will be determined by your child's physician. In general, call your child's physician for nosebleeds if: y you are unable to stop the nosebleed or if it recurs. y your child also has a nose injury that may indicate a more serious problem (such as a fractured nose or other trauma to the head). y there is a large amount or rapid loss of blood. y your child feels faint, weak, ill, or has trouble breathing. y your child has bleeding from other parts of the body (such as in the stool, urine, or gums) or bruises easily. y there is a foreign body stuck in your child's nose. Prevention of nosebleeds: If your child has frequent nosebleeds, some general guidelines to help prevent nosebleeds from occurring include the following: y Use a cool mist humidifier in your child's room at night if the air in your home is dry. Be sure to follow the manufacturer's advice for cleaning the humidifier so that germs and mold do not grow in it. y Teach your child not to pick his/her nose or blow it too forcefully. y Apply petroleum jelly inside the nostrils several times a day, especially at bedtime, to help keep the area moist. y Use saline (salt water) drops or a saline nose spray, as directed by your child's physician. y See your child's physician for treatment of allergies that may contribute to frequent nosebleeds. Obstructive Sleep Apnea What is obstructive sleep apnea? Obstructive sleep apnea occurs when a child stops breathing during periods of sleep. The cessation of breathing usually occurs because of a blockage (obstruction) in the airway. Tonsils and adenoids may grow to be large relative to the size of a child's airway (passages through the nose and mouth to the windpipe and lungs). Inflamed and infected glands may grow to be larger than normal, thus causing more blockage. The enlarged tonsils and adenoids block the airway during sleep, for a period of time. The tonsils and adenoids are made of lymph tissue and are located at the back and to the sides of the throat. During episodes of blockage, the child may look as if he/she is trying to breath (the chest is moving up and down), but no air is being exchanged within the lungs. Often these episodes conclude with a period of awakening and compensation for lack of breathing. Periods of blockage occur regularly throughout the night and result in a poor, interrupted sleep pattern. Sometimes, the inability to circulate air and oxygen in and out of the lungs results in lowered blood oxygen levels. If this pattern continues, the lungs and heart may suffer permanent damage.

Obstructive sleep apnea is most commonly found in children between three to six years of age. It occurs more commonly in children with Down syndrome and other congenital conditions affecting the upper airway (i.e., conditions causing large tongue, small jaw, etc.). What causes obstructive sleep apnea? In children, the most common cause of obstructive sleep apnea is enlarged tonsils and adenoids in the upper airway. Infections may cause these glands to enlarge. Large adenoids may completely block the nasal passages and make breathing through the nose difficult or impossible. There are many muscles in the head and neck that help to keep the airway open. When a person (child or adult) falls asleep, muscle tone tends to decrease, thus, allowing tissues to fold closer together. If the airway is partially closed (by enlarged glands) while awake, falling asleep may result in a completely closed passage. Obesity may cause obstructive sleep apnea. While a common cause in adults, obesity is a far less common reason for obstructive sleep apnea in children. A rare cause of obstructive sleep apnea in children is a tumor or growth in the airway. Certain syndromes or birth defects, such as Down syndrome and Pierre-Robin syndrome, can also cause obstructive sleep apnea. What are the symptoms of obstructive sleep apnea? The following are the most common symptoms of obstructive sleep apnea. However, each child may experience symptoms differently. Symptoms may include: y loud snoring or noisy breathing during sleep y periods of not breathing - although the chest wall is moving, no air or oxygen is moving through the nose and mouth into the lungs. The duration of these periods is variable and measured in seconds. y mouth breathing - the passage to the nose may be completely blocked by enlarged tonsils and adenoids. y restlessness during sleep (with or without periods of being awake) y excessive daytime sleepiness or irritability (because the quality of sleep is poor, the child may be sleepy or irritable in the daytime) y hyperactivity during the day The symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis. How is obstructive sleep apnea diagnosed? Your child's physician should be consulted if noisy breathing during sleep or snoring becomes noticeable. Your child may be referred to an ear, nose, and throat (ENT) physician (otolaryngologist) for further evaluation. In addition to a complete medical history and physical examination, diagnostic procedures for obstructive sleep apnea may include: y sleep history - report from parents or caretaker y evaluation of the upper airway y sleep study (Also called polysomnography.) - the best test available for diagnosing obstructive sleep apnea. The test requires a high level of collaboration on the part of the child and may not be possible in younger and/or uncooperative children. Two types of tests are available. In the first type, the child will sleep in a specialized sleep laboratory. In the second type, the child has on similar monitors but sleeps in his/her own bed. During the sleep study a variety of testing occurs to evaluate the following: y brain activity y electrical activity of the heart y oxygen content in the blood y chest and abdominal wall movement y muscle activity y amount of air flowing through the nose and mouth During the sleep study, episodes of apnea and hypopnea will be recorded: y apnea - complete airway obstruction. y hypopnea - the partial airway obstruction combined with a significant decrease in the oxygen content of the blood. Based on the laboratory test, sleep apnea is generally considered significant in children if more than 10 apnea episodes occur per night, or one or more occur per hour. Some experts define the problem as significant if a combination of one or more episodes of apnea and/or hypopnea occur per hour of sleep. Symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Consult your child's physician for more information. Treatment for obstructive sleep apnea: Specific treatment for obstructive sleep apnea will be determined by your child's physician based on: y your child's age, overall health, and medical history y cause of the condition y your child's tolerance for specific medications, procedures, or therapies y expectations for the course of the condition y your opinion or preference The treatment for obstructive sleep apnea is based on the cause. Since enlarged tonsils and adenoids are the most common cause of airway blockage in children, the treatment is surgery and removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy). Your child's otolaryngologist will discuss the treatment options, risks, and benefits

with you. This surgery requires general anesthesia. Depending on the health of the child, surgery may be performed on an outpatient basis. If the cause of the disorder is obesity, less invasive treatments may be appropriate, including weight loss and wearing a special mask while sleeping to keep the airway open. This mask delivers continuous positive airway pressure (CPAP). The device itself is often clumsy, and it may be difficult to convince a child to wear such a mask. Surgery may be necessary. What happens during tonsillectomy and adenoidectomy? Tonsillectomy and adenoidectomy (T&A) surgery is a common major surgery performed on children in the US. About 400,000 surgeries are performed each year. The need for a T&A will be determined by your child's ear, nose, and throat surgeon and discussed with you. Most T & A surgeries are done on an outpatient basis. This means that your child will have surgery and then go home the same day. Some children may be required to stay overnight, such as, but not limited to, children who: y are not drinking well after surgery. y have other chronic diseases or problems with seizures. y have complications after surgery, such as bleeding. y are younger than 3 years of age. Before the surgery, you will meet with different members of the healthcare team who are going to be involved with your child's care. These may include: y day surgery nurses - nurses who prepares your child for surgery. Operating room nurses assist the physicians during surgery. Recovery room (also called the Post Anesthesia Care Unit) nurses care for your child as he/she emerges from general anesthesia. y surgeon - a physician who specializes in surgery of the ear, nose, and throat. y anesthesiologist - a physician with specialized training in anesthesia. He/she will complete a medical history and physical examination and formulate a plan of anesthesia for your child. The plan will be discussed with you and your questions will be answered. This surgery requires a general anesthesia. During the surgery, your child will be anesthetized in the operating room. The surgeon will remove your child's tonsils and adenoids through the mouth. There will be no cut on the skin. In most cases, after the surgery, your child will go to a recovery room where he/she can be monitored closely. After the child is fully awake and doing well, the recovery room nurse will bring the child back to the day surgery area. At this point, if everything is going well, you and your child will be able to go home. If your child is going to stay the night in the hospital, the child will be brought from the recovery room to his/her room. Usually, the parents are in the room to meet the child. Bleeding is a complication of this surgery and should be addressed immediately by the surgeon. If the bleeding is severe, the child may return to the operating room. At home after a T&A: The following are some of the instructions that may be given to you to help care for your child: y increased fluid intake y pain medication, as prescribed y no heavy or rough play for a duration of time recommended by the surgeon What are the risks of having a T&A? Any type of surgery poses a risk to a child. About 4 percent of the children begin bleeding from the surgery within the first two weeks after the surgery, and may require additional blood and/or surgery. Some children may have a change in the sound of their speech due to the surgery. The following are some of the other complications that may occur: y bleeding (may happen during surgery, immediately after surgery, or at home) y dehydration (due to decreased fluid intake; if severe, fluids through an intravenous, or IV, catheter in the hospital may be necessary) y fever y difficulty breathing (swelling of the area around the surgery; may be life threatening if not treated immediately) Pharyngitis and Tonsillitis What is pharyngitis and tonsillitis? Pharyngitis and tonsillitis are infections in the throat that cause inflammation. If the tonsils are primarily affected, it is called tonsillitis. If the throat is primarily affected, it is called pharyngitis. A child might even have inflammation and infection of both the tonsils and the throat. This would be called pharyngotonsillitis. These infections are spread by close contact with other individuals. Bacterial infections are more common during the winter. Viral infections are more common in summer and fall. Facts about pharyngitis and tonsillitis: y Pharyngitis and tonsillitis are most commonly seen in children between the ages of 6 and 8. y Children under age 2 rarely develop group A - hemolytic streptococcus (GABHS), or strep throat. What causes pharyngitis and tonsillitis? There are many causes of infections in the throat. The following are the most common infectious agents: y viruses: o adenovirus o influenza virus o Epstein-Barr virus

o herpes simplex virus bacteria: o group A - hemolytic streptococci (GABHS) o Neisseria gonorrhea o Haemophilus influenzae Type B o mycoplasma y fungal infections y parasitic infections y cigarette smoke What are the symptoms of pharyngitis and tonsillitis? The symptoms of pharyngitis and tonsillitis depend greatly on the cause of the infection and the person affected. For some children, the onset of symptoms may be quick; for others, symptom onset is slow. The following are the most common symptoms of pharyngitis and tonsillitis. However, each child may experience symptoms differently. Symptoms may include: y sore throat y fever (either low-grade or high) y headache y decrease in appetite y not feeling well y nausea y vomiting y stomach aches y painful swallowing y visual redness or drainage in the throat How are pharyngitis and tonsillitis diagnosed? In most cases, it is hard to distinguish between a viral sore throat and a strep throat based on physical examination. It is important, though, to know if the sore throat is caused by GABHS, as this requires antibiotic treatment to help prevent the complications associated with these bacteria. As a result, most children, when they have the above symptoms, will receive a strep test and throat culture to determine if it is an infection caused by GABHS. This usually involves a throat swab (called quick tests or rapid strep tests) in the physician's office. This may immediately become positive for GABHS and antibiotics will be started. If it is negative, part of the throat swab will be kept for a throat culture. This will further identify, in two to three days, if there is any GABHS present. Your child's physician will decide the treatment plan based on the findings. Treatment for pharyngitis and tonsillitis: Specific treatment for pharyngitis and tonsillitis will be determined by your child's physician based on: y your child's age, overall health, and medical history y extent of the condition y cause of the condition y your child's tolerance for specific medications, procedures, or therapies y expectations for the course of the condition y your opinion or preference If bacteria do not cause the infection, then the treatment is focused on comfort of your child. Antibiotics will not help treat viral sore throats. Treatment may include: y acetaminophen (for pain) y increased fluid intake y throat lozenges y antibiotics (if the cause of the infection is bacterial, not viral) Sinusitis What are sinuses? The sinuses are cavities, or air-filled pockets, near the nasal passage. Like the nasal passage, the sinuses are lined with mucous membranes. There are four different types of sinuses: y ethmoid sinus - located inside the face, around the area of the bridge of the nose. This sinus is present at birth, and continues to grow. y maxillary sinus - located inside the face, around the area of the cheeks. This sinus is also present at birth, and continues to grow. y frontal sinus - located inside the face, in the area of the forehead. This sinus does not develop until around 7 years of age. y sphenoid sinus - located deep in the face, behind the nose. This sinus does not develop until adolescence. What is sinusitis? Sinusitis is an infection of the sinuses near the nose. These infections usually occur after a cold or after an allergic inflammation. There are four types of sinusitis: y acute - symptoms of this type of infection last less than four weeks and get better with the appropriate treatment. y

subacute - this type of infection does not get better with treatment initially, and symptoms last four to eight weeks. y chronic - this type of infection happens with repeated acute infections or with previous infections that were inadequately treated. These symptoms last eight weeks or longer. y recurrent - three or more episodes of acute sinusitis a year. What causes sinusitis? Sometimes, a sinus infection happens after an upper respiratory infection (URI) or common cold. The URI causes inflammation of the nasal passages that can block the opening of the paranasal sinuses, and result in a sinus infection. Allergies can also lead to sinusitis because of the swelling of the nasal tissue and increased production of mucus. There are other possible conditions that can block the normal flow of secretions out of the sinuses and can lead to sinusitis including the following: y abnormalities in the structure of the nose y enlarged adenoids y diving and swimming y infections from a tooth y trauma to the nose y foreign objects stuck in the nose y cleft palate y gastroesophageal reflux disease (GERD) y secondhand smoke When the flow of secretions from the sinuses is blocked, bacteria may begin to grow. This leads to a sinus infection, or sinusitis. The most common bacteria that cause sinusitis include the following: y Streptococcus pneumonia y Haemophilus influenzae y Moraxella catarrhalis What are the symptoms of sinusitis? The symptoms of sinusitis depend greatly on the age of the child. The following are the most common symptoms of sinusitis. However, each child may experience symptoms differently. Symptoms may include: younger children: y runny nose o lasts longer than seven to 10 days o discharge is usually thick green or yellow, but can be clear y nighttime cough y occasional daytime cough y swelling around the eyes y usually no headaches younger than 5 years of age older children and adults: y runny nose or cold symptoms lasting longer than seven to 10 days y drip in the throat from the nose y headaches* y facial discomfort y bad breath y cough y fever y sore throat y swelling around the eye, often worse in the morning The symptoms of sinusitis may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis. *One 2002 study has found that nine out of 10 physician-diagnosed or self-described sinus headaches are actually migraine-related. The researchers found that the participants described the classic symptoms of pain in the front of the face and pressure under the eyes. However, the participants lacked other symptoms of a true sinus infection, including yellow or green discharge and fever. In addition, not every migraine has telltale symptoms of nausea, vomiting, and sensitivity to light. Always consult your child's physician for a diagnosis. How is sinusitis diagnosed? Generally, your child's physician can diagnose sinusitis based on your child's symptoms and physical examination. In some cases additional tests may be performed to confirm the diagnosis. These may include: y sinus x-rays - diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. (X-rays are not typically used, but may help assist in the diagnosis.) y computed tomography (Also called CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays. y

cultures from the sinuses - laboratory tests that involve the growing of bacteria or other microorganisms to aid in diagnosis. Treatment for sinusitis: Specific treatment for sinusitis will be determined by your child's physician based on: y your child's age, overall health, and medical history y extent of the infection y your child's tolerance for specific medications, procedures, or therapies y expectations for the course of the infection y your opinion or preference Treatment of sinusitis may include the following: y antibiotics, as determined by your child's physician (antibiotics are usually given for at least 14 days) y acetaminophen (for pain or discomfort) y a decongestant (i.e., pseudoephedrine [Sudafed]) and/or mucus thinner (i.e., guaifenesin [Robitussin]) y cool humidifier in your child's room y nasal spray to reduce inflammation y medications to treat GERD y surgery to remove the adenoids y endoscopic sinus surgery Antibiotics may be withheld for 10 to 14 days, unless severe symptoms develop, such as: fever, facial pain or tenderness, or swelling around the eye. Surgery should be considered only if other treatments have failed. Referral to an allergist/immunologist is often needed, particularly for people with chronic or recurrent sinusitis and for patients who have had sinus surgery, but still experience sinusitis. Antihistamines do not help the symptoms of sinusitis unless an allergy is involved. Stridor What is stridor? Stridor is a high-pitched sound that is usually heard best when a child breaths in (inspiration). It is usually caused by an obstruction or narrowing in your child's upper airway. The upper airway consists of the following structures in the upper respiratory system: y nose nasal cavity sinuses - cavities, or air-filled pockets, that are near the nasal passage. o ethmoid sinus - located inside the face, around the area of the bridge of the nose. This sinus is present at birth, and continues to grow. o maxillary sinus - located inside the face, around the area of the cheeks. This sinus is also present at birth, and continues to grow. o frontal sinus - located inside the face, in the area of the forehead. This sinus does not develop until around seven years of age. o sphenoid sinus - located deep in the face, behind the nose. This sinus does not develop until adolescence. y larynx - also known as the voice box, the larynx is a cylindrical grouping of cartilage, muscles, and soft tissue which contains the vocal cords. The vocal cords are the upper opening into the windpipe (trachea), the passageway to the lungs. y trachea (windpipe) - a tube that reaches from the voice box to the bronchi in the lungs. The sound of stridor depends on location of the obstruction in the upper respiratory tract. Usually, the stridor is heard when the child breathes in (inspiration), but can also be heard when the child breathes out (expiration). What are the causes of stridor? There are many different causes of stridor. Some of the causes are diseases, while others are problems with the anatomical structure of the child's airway. The upper airway in children is shorter and narrower than that of an adult, and, therefore, more likely to lead to problems with obstruction. The following are some of the more common causes of stridor in children: y Congenital causes (problems present at birth): o laryngomalacia Parts of the larynx are floppy and collapse causing partial airway obstruction. The child will usually outgrow this condition by the time he/she is 18 months old. This is the most common congenital cause of stridor. Very rarely children may need surgery. o subglottic stenosis The larynx (voice box) may become too narrow below the vocal cords. Children with subglottic stenosis are usually not diagnosed at birth, but, more often, a few months after, particularly if the child's airway becomes stressed by a cold or other virus. The child may eventually outgrow this problem without intervention. Most children will need a surgical procedure if the obstruction is severe. o subglottic hemangioma A type of mass that consists mostly of blood vessels. Subglottic hemangioma grows quickly in the y y y

child's first few months of life. The child will usually shows signs around the age of three to six months. Some children may outgrow this problem, as the hemangioma will begin to get smaller after the first year of life. Most children will need surgery if the obstruction is severe. This condition is very rare. o vascular rings The trachea, or windpipe, may be compressed by another structure (an artery or vein) around the outside. Surgery may be required to alleviate this condition. y Infectious causes: o croup Croup is an infection caused by a virus that leads to swelling in the airways and causes breathing problems. Croup is caused by a variety of different viruses, most commonly the parainfluenza virus. o epiglottitis Epiglottitis is an acute life-threatening bacterial infection that results in swelling and inflammation of the epiglottis. (The epiglottis is an elastic cartilage structure at the root of the tongue that prevents food from entering the windpipe when swallowing.) This causes breathing problems that can progressively worsen which may, ultimately, lead to airway obstruction. There is so much swelling that air cannot get in or out of the lungs, resulting in a medical emergency. Epiglottitis is usually caused by the bacteria Haemophilus influenzae, and now is rare because infants are routinely vaccinated against this bacteria. The vaccine is recommended for all infants. o bronchitis Bronchitis is an inflammation of the breathing tubes (airways), called bronchi, which causes increased production of mucus and other changes. Acute bronchitis is usually caused by infectious agents such as bacteria or viruses. It may also be caused by physical or chemical agents - dusts, allergens, strong fumes - and those from chemical cleaning compounds, or tobacco smoke. o severe tonsillitis The tonsils are small, round pieces of tissue that are located in the back of the mouth on the side of the throat. Tonsils are thought to help fight infections by producing antibodies. The tonsils can usually be seen in the throat of your child by using a light. Tonsillitis is defined as inflammation of the tonsils from infection. o abscess in the back of the throat (retropharyngeal abscess) An abscess in the throat is a collection of pus surrounded by inflamed tissue. If the abscess is large enough, it may narrow the airway to a critically small opening. y Traumatic causes: o Foreign bodies in the ear, nose, and breathing tract may cause symptoms to occur. Foreign bodies are any objects placed in the ear, nose, or mouth that do not belong there. For example, a coin in the trachea (windpipe) may close off breathing passages and result in suffocation and death. o fractures in the neck o swallowing a harmful substance which may cause damage to the airways How is stridor diagnosed? Stridor is usually diagnosed solely on the medical history and physical examination of your child. It is important to remember that stridor is a symptom of some underlying problem or condition. If your child has stridor, your child's physician may order some of the following tests to help determine the cause of the stridor: y chest and neck x-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. y bronchoscopy - congenital, chronic, or severe stridor may require direct visualization of the airways with a flexible fiberoptic bronchoscope. This procedure is under sedation and local anesthesia, and may be performed on an outpatient, as well as an inpatient basis. y pulse oximetry - an oximeter is a small machine that measures the amount of oxygen in the blood. To obtain this measurement, a small sensor (like a Band-Aid) is taped onto a finger or toe. When the machine is on, a small red light can be seen in the sensor. The sensor is painless and the red light does not get hot. y sputum culture - a diagnostic test performed on the material that is coughed up from the lungs and into the mouth. A sputum culture is often performed to determine if an infection is present. Treatment of stridor: Specific treatment of stridor will be determined by your child's physician based on: y your child's age, overall health, and medical history y cause of the condition y extent of the condition y your child's tolerance for specific medications, procedures, or therapies y expectations for the course of the condition y your opinion or preference Treatment may include: y referral to an ear, nose, and throat specialist (otolaryngologist) for further evaluation (if your child has a history of stridor) y surgery

y medications by mouth or injection (to help decrease the swelling in the airways) Hospitalization and emergency surgery may be necessary depending on the severity of the stridor. Congenital Laryngeal Stridor / Laryngomalacia What is congenital laryngeal stridor? Congenital laryngeal stridor (also called laryngomalacia) results from a congenital (present at birth) anomaly of the larynx (voice box). A weakness in the structures in the larynx, can cause stridor. Stridor is a high-pitched sound that is heard best when the child breaths in (inspiration). What causes congenital laryngeal stridor? Congenital laryngeal stridor is a defect that is present at birth. During fetal development, the structures in the larynx may not fully develop. As a result, there is a weakness in these structures at birth, causing them to collapse during breathing. In children, congenital laryngeal stridor is the most common cause of chronic stridor. Sixty percent of infants born with congenital laryngeal stridor will have symptoms in the first week of life. Most other infants will show symptoms by 5 weeks old. What are the symptoms of congenital laryngeal stridor? The major symptom of this disorder is the stridor that is heard as the infant breathes. The stridor is usually heard when the infant breathes in (inspiration), but can also be heard when the infant breaths out (expiration). Other characteristics of the stridor may include: y The stridor changes with activity. y The stridor is usually less noisy when the child is laying on his/her stomach. y The stridor gets worse if the infant has an upper respiratory infection. The symptoms of congenital laryngeal stridor may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis. How is congenital laryngeal stridor diagnosed? In addition to a complete medical history and physical examination, diagnostic procedures for congenital laryngeal stridor may include bronchoscopy of the airways - a procedure which involves a tube being passed into the airways to allow your child's physician to observe the airways during breathing. Treatment for congenital laryngeal stridor: In most cases, congenital laryngeal stridor is a harmless condition that resolves on its own, without medical intervention. The condition usually improves by the time the infant is 18 months old and has no long-term complications. In some cases, the stridor is apparent until about the age of 5. Each child's case is unique. A small percentage develop severe respiratory problems which require medical and surgical interventions.

Meniere's Disease
Meniere's disease is a disorder characterized by recurring attacks of disabling vertigo (a whirling sensation), hearing loss, and noise in the ear (tinnitus). y Symptoms include sudden, unprovoked attacks of severe, disabling vertigo, nausea, and vomiting. y Doctors usually perform hearing tests and sometimes magnetic resonance imaging. y A low-salt diet and a diuretic may lower the frequency of attacks. y Drugs such as meclizine , lorazepam , orscopolamine may help relieve vertigo. Meniere's disease (also called endolymphatic hydrops) is thought to be caused by an imbalance in the fluid that is normally present in the inner ear. This fluid is continually being secreted and reabsorbed, maintaining a constant amount. Either an increase in production of inner ear fluid or a decrease in its reabsorption results in an imbalance of fluid. Why either happens is not known. Symptoms include sudden, unprovoked attacks of severe, disabling vertigo, nausea, and vomiting. These symptoms usually last for 2 to 3 hours but can (rarely) last up to 24 hours. Periodically, a person may feel a fullness or pressure in the affected ear. Hearing tends to fluctuate but progressively worsens over the years. Tinnitus, which may be constant or intermittent, may be worse before, during, or after an attack of vertigo. Both hearing loss and tinnitus usually affect only one ear. In one form of Meniere's disease, hearing loss and tinnitus precede the first attack of vertigo by months or years. After the attacks of vertigo begin, hearing may improve. Diagnosis and Treatment A doctor suspects Meniere's disease because of the typical symptoms of vertigo with tinnitus and hearing loss in one ear. Doctors usually perform hearing tests and sometimes magnetic resonance imaging (MRI) to look for other causes. A low-salt diet and a diuretic (a drug that increases the excretion of urine) may lower the frequency of attacks in some people. When attacks do occur, vertigo may be relieved temporarily with drugs given by mouth, such as meclizine, lorazepam, or scopolamine

. Scopolamine is also available in skin patches. Nausea and vomiting may be relieved by suppositories containing the drug prochlorperazine. Several procedures are available for people who are disabled by frequent attacks of vertigo despite drug treatment. The procedures aim to either reduce fluid pressure in the inner ear or destroy inner ear balance function. The endolymphatic shunt procedure, in which a thin sheet of flexible plastic material is placed in the inner ear, is the least destructive of these procedures. To destroy inner ear balance function, a solution of gentamicin can be injected through the eardrum into the middle ear. Gentamicin selectively destroys balance function before affecting hearing, but hearing loss is still a risk. The risk of hearing loss is lower if doctors inject the gentamicin only once and wait several weeks before repeating if necessary. Cutting the vestibular nerve permanently destroys inner ear balance, while preserving hearing, and is successful 95% of the time in controlling vertigo. This procedure is usually performed on people whose symptoms do not lessen after an endolymphatic shunt or on people who never want to experience another spell of vertigo. Finally, when vertigo is disabling and hearing has deteriorated in the involved ear, the entire semicircular canals can be drilled away in a procedure called a labyrinthectomy. None of the surgical procedures that treat vertigo are useful in treating the hearing loss that often accompanies Meniere's disease. SURGICAL MANAGEMENT Tonsillectomy and Adenoidectomy What are the tonsils? The tonsils are small, round pieces of tissue that are located in the back of the mouth on the side of the throat. Tonsils are thought to help fight infections by producing antibodies. The tonsils can usually be seen in the throat of your child by using a light. Tonsillitis occurs when the tonsils become inflamed from infection. What are adenoids? Adenoids are similar to the tonsils. The adenoids are made up of lymph tissue and are located in the space above the soft roof of the mouth (nasopharynx) and cannot be seen by looking in your child's nose or throat. Adenoids also help to fight infections. Adenoids may cause problems if they become enlarged or infected. Adenoiditis is when the adenoids become inflamed from infection. What are the symptoms of tonsillitis? The symptoms of tonsillitis vary greatly depending on the cause of the infection, and can occur either suddenly or gradually. The following are the most common symptoms of tonsillitis. However, each child may experience symptoms differently. Symptoms may include: y sore throat y fever (either low-grade or high-grade) y headache y decrease in appetite y not feeling well y nausea and vomiting y stomach aches y painful swallowing y visual redness or drainage in the throat The symptoms of tonsillitis may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis. What are the symptoms of adenoiditis, or enlarged adenoids? The symptoms of adenoiditis vary greatly depending on the cause of the infection, and can occur either suddenly or gradually. The following are the most common symptoms of adenoiditis. However, each child may experience symptoms differently. Symptoms may include: y breathing through the mouth y noisy breathing y snoring y nasal speech y periods at night when breathing stops for a few seconds The symptoms of adenoiditis may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis. Treatment for tonsillitis and adenoiditis: Specific treatment for tonsillitis and adenoiditis will be determined by your child's physician based on: y your child's age, overall health, and medical history y extent of the infection y type of infection y your child's tolerance for specific medications, procedures, or therapies y expectations for the course of the infection y your opinion or preference

Your child's physician will decide the best treatment for your child. Treatment depends on the cause of the infection, the severity of the infection, and the number of times the child has developed infections. Your child's physician may order antibiotics to help with the infection. Some children may be referred to an ear, nose, and throat surgeon to have the tonsils and adenoids removed. This surgery is called a tonsillectomy and adenoidectomy (T&A). Often, the tonsils and adenoids are removed at the same time, but, sometimes, only one is removed. Your child's physician will discuss this with you. What are the reasons to have a tonsillectomy and adenoidectomy (T&A)? The reasons for this surgery are not well defined, and many surgeons differ in their views. The following are some of the more widely accepted reasons for having a T&A: y sleep apnea, or periods at night when your child stops breathing y trouble swallowing y tumor in the throat or nasal passage y bleeding from the tonsils that cannot be stopped y significant blockage of the nasal passage and uncomfortable breathing The following are T&A Guidelines from the American Academy of Otolaryngology: y seven sore throats in one year y five sore throats in each of two years y three sore throats in each of three years The sore throats may be associated with the following: y fever above 101 F y discharge on the tonsils y positive strep throat culture The following are additional reasons that are more controversial regarding the removal of the adenoids and tonsils: y bad snoring y recurrent infections or abscesses in the throat y recurrent ear infections y hearing loss y chronic sinusitis, or infection in the sinuses y constant mouth breathing y frequent colds y cough y bad breath The following are some situations that DO NOT require removal of the tonsils, although each child will be evaluated on an individual basis: y large tonsils Some children have large tonsils. The tonsils will decrease in size after the ages of 8 to 12 years. This, in itself, is not a reason to remove the tonsils, in most cases. y school absence If your child seems to miss a lot of school due to different symptoms, such as a sore throat, removing the tonsils will not increase school attendance. y poor appetite, allergies, or seizures A T&A will not help any of these problems. What happens during tonsillectomy and adenoidectomy? The need for tonsillectomy and adenoidectomy (T&A) surgery will be determined by your child's ear, nose, and throat surgeon and discussed with you. Most T & A surgeries are done on an outpatient basis. This means that your child will have surgery and then go home the same day. Some children may be required to stay overnight, such as, but not limited to, children who: y are not drinking well after surgery. y have other chronic diseases or problems with seizures. y have complications after surgery, such as bleeding. y are younger than 3 years of age. Before the surgery, you will meet with different members of the healthcare team who are going to be involved with your child's care. These may include: y day surgery nurses - nurses who prepares your child for surgery. Operating room nurses assist the physicians during surgery. Recovery room (also called the Post Anesthesia Care Unit) nurses care for your child as he/she emerges from general anesthesia. y surgeon - a physician who specializes in surgery of the ear, nose, and throat. y anesthesiologist - a physician with specialized training in anesthesia. He/she will complete a medical history and physical examination and formulate a plan of anesthesia for your child. The plan will be discussed with you and your questions will be answered. This surgery requires a general anesthesia. During the surgery, your child will be anesthetized in the operating room. The surgeon will remove your child's tonsils and adenoids through the mouth. There will be no cut on the skin. In most cases, after the surgery your child will go to a recovery room where he/she can be monitored closely. After the child is fully awake and doing well, the recovery room nurse will bring the child back to the day surgery area.

At this point, if everything is going well, you and your child will be able to go home. If your child is going to stay the night in the hospital, the child will be brought from the recovery room to his/her room. Usually, the parents are in the room to meet the child. Bleeding is a complication of this surgery and should be addressed immediately by the surgeon. If the bleeding is severe, the child may return to the operating room. At home after a T&A: The following are some of the instructions that may be given to you to help care for your child: y increased fluid intake y pain medication, as prescribed y no heavy or rough play for a duration of time recommended by the surgeon What are the risks of having a T&A? Any type of surgery poses a risk to a child. About 5 percent of the children begin bleeding from the surgery site about five to eight days after the surgery, and may require additional blood and/or surgery. Some children may have a change in the sound of their speech due to the surgery. The following are some of the other complications that may occur: y bleeding (may happen during surgery, immediately after surgery, or at home) y dehydration (due to decreased fluid intake; if severe, fluids through an intravenous, or IV, catheter in the hospital may be necessary) y fever y difficulty breathing (swelling of the area around the surgery; may be life threatening if not treated immediately) Endoscopic Sinus Surgery The purpose of endoscopic sinus surgery is to open the passages of the sinuses allowing for proper drainage to the nose. It is called an endoscopic procedure because the physician uses an endoscope (a small, flexible tube with a light and a camera lens at the end) to view the inside of the nose. Small incisions or cuts are made to allow the scope to pass. The cuts are usually made inside of the nose. The physician may create new passages or open existing ones by removing polyps, cysts, or thickened mucous membranes. Endoscopic sinus surgery: y Endoscopic sinus surgery usually takes between one and three hours and is done in the operating room with the child under general anesthesia. y Most young children spend the night in the hospital, but some older children may stay for only a couple of hours after surgery. y Depending on the surgeon's preference and the needs of the child, endoscopic sinus surgery may be performed at the same time as another operation such as septoplasty, tonsillectomy, adenoidectomy, or insertion of ear tubes. What to expect after surgery: y Your child will have intravenous (IV) fluids until time of discharge. Clear liquids for your child to drink are available in the Post Anesthesia Care Unit (PACU), also called the recovery room. y Your child may complain of a sore nose, not being able to breathe through the nose, and difficulty swallowing. y A pain reliever may be given for pain. An antibiotic is occasionally prescribed to prevent infection. y The head of the bed will be raised in the PACU to help with swelling, breathing, and drainage. At home you should have pillows or a recliner chair available to help your child stay comfortable with his/her head elevated above the level of the chest. y There may be packing in the nose to prevent bleeding. Sometimes, this packing is dissolvable. The physician may remove this packing in one or two weeks or it may dissolve on its own. If the packing needs to be removed, it may be done in the physician's office for older, cooperative children, or may be done in the operation room under anesthesia. y If a septoplasty (straightening of the bone and cartilage in the center of the nose) is performed, then splints will be placed inside the nose at the end of the operation. These will be removed at the physician's office in one to two weeks and may cause some discomfort while they are in place. y If packing is used, your child may be able to feel it in his/her nose. Your child should be told before surgery that they may feel like they have something in their nose when they wake up. If packing is not used, swelling may cause this feeling. Your child should know that he/she will not be allowed to forcefully blow his/her nose for a week or two. y At first, there may be some drainage from the nose. You may see a small piece of gauze taped under your child's nose. This is called a "drip pad." This is usually only needed for the first day, if at all. The drainage from the nose will probably be tinged with blood. Your child may cough or spit up some pink or brown mucus. y Most children are fussy the first few hours after this procedure. y Your child may begin normal play after several days, but may need to stay home from school until the discomfort improves. Consult your child's physician for more specific recommendations. y Your child's physician may recommend the use of nasal ointment, salt water spray, or nasal steroid spray after surgery. Follow instructions carefully. When to call your child's physician: Signs of Dehydration

The following are some of the symptoms that may indicate a need for you to y dry mouth promptly contact your child's physician: y sunken look around eyes y bright red bleeding from the nose or mouth y decreased amount of y double or impaired vision urine (i.e., fewer wet y a persistent leak of clear fluid from the nose diapers than usual in an y if your child vomits bright red blood or a coffee ground-like material infant) y if your child develops a croupy (barky) cough/cry or wheezing y no tears when crying y if your child's temperature rises greater than 101.5 F rectally or greater y skin that, when pinched, than 100.5F orally forms and holds the y vomiting (or if the vomiting becomes severe) shape of a tent y signs of dehydration (a child can become dehydrated when he/she has prolonged or severe vomiting and is not able to drink enough fluid) Follow-up: A visit with your child's physician will be scheduled for one to two weeks after surgery and then again several more times in the months after surgery to make sure that the nose is healing properly. Consult your child's physician if you have any questions.

Eye Disorders
Definition Eyeglasses and contact lenses are devices that correct refractive errors in vision. Eyeglass lenses are mounted in frames worn on the face, sitting mostly on the ears and nose, so that the lenses are positioned in front of the eyes. Contact lenses appear to be worn in direct contact with the cornea, but they actually float on a layer of tears that separates them from the cornea. Purpose The purpose of eyeglasses and contact lenses is to correct or improve the vision of people with nearsightedness (myopia), farsightedness (hyperopia), presbyopia, and astigmatism. Precautions People allergic to certain plastics should not wear contact lenses or eyeglass frames or lenses manufactured from that type of plastic. People allergic to nickel should not wear Flexon frames. People at risk of being in accidents that might shatter glass lenses should wear plastic lenses, preferably polycarbonate. (Lenses made from polycarbonate, the same type of plastic used for the space shuttle windshield, are about 50 times stronger than other lens materials.) Also, people at risk of receiving electric shock should avoid metal frames. People employed in certain occupations may be prohibited from wearing contact lenses, or may be required to wear safety eyewear over the contact lenses. Some occupations, such as construction or auto repair, may require safety lenses and safety frames. Physicians and employers should be consulted for recommendations. Description Eyes are examined by optometrists (O.D.) or by ophthalmologists (M.D. or D.O.--doctor of osteopathy). Prescriptions, if necessary, are then given to patients for glasses. The glasses are generally made by an optician. A separate contact lens-fitting exam is necessary if the patient wants contact lenses, because an eyeglass prescription is not the same as a contact lens prescription. Eyeglasses Over 140 million people in the United States wear eyeglasses. People whose eyes have refractive errors do not see clearly without glasses, because the light emitted from the objects they are observing does not come into focus on their retinas. For people who are farsighted, images come into focus behind the retina; for people who are nearsighted, images come into focus in front of the retina. LENSES Lenses work by changing the direction of light so that images come into focus on the retina. The greater the index of refraction of the lens material and the greater the difference in the curvature between the two surfaces of the lens, the greater the change in direction of light that passes through it, and the greater the correction. Lenses can be unifocal, with one correction for all distances, or they can be correct for more than one distance (multifocal). One type of multifocal, the bifocal, has an area of the lens (usually at the bottom) that corrects for nearby objects (about 14 in from the eyes); the remainder of the lens corrects for distant objects (about 20 ft from the eyes). Another type of multifocal, a trifocal, has an area in-between that corrects for intermediate distances (usually about 28 in). Conventional bifocals and trifocals have visible lines between the areas of different correction; however, lenses where the correction gradually changes from one area to the other, without visible lines, have been available since the 1970s. Such lenses are sometimes called progressives or no-line bifocals. To be suitable for eyeglass lenses, a material must be transparent, without bubbles, and have a high index of refraction. The greater the index of refraction, the thinner the lens can be. Lenses are made from either glass or plastic (hard resin). The advantage of plastic is that it is lightweight and more impact resistant than glass. The advantage of glass is that it is scratch resistant and provides the clearest possible vision. Glass was the first material to be used for eyeglass lenses, and was used for several hundred years before plastic was introduced. The crown glass used for eyeglass lenses has an index of refraction of 1.52. Optical-quality acrylic was introduced for eyeglass use in the early 1940s, but because it was easily scratched, brittle, and discolored rapidly, it did not supplant glass as the material of choice. Furthermore, it had a relatively low index of

refraction, so it wasn't suitable for people with large refractive errors. A plastic called CR-39, introduced in the 1960s, was more suitable. Today, eyeglass wearers can also choose between polycarbonate, which is the most impactresistant material available for eyewear, and polyurethane, which has exceptional optical qualities and an index of refraction of up to 1.66, much higher than the conventional plastics used for lenses, and even higher than glass. Patients with high prescriptions should ask about high index material options for their lenses. Aspheric lenses are also useful for high prescriptions. They are flatter and lighter than conventional lenses. There are many lenses and lens-coating options for individual needs, including coatings that block the ultraviolet (UV) light or UV and blue light which have been found to be harmful to the eyes. Such coatings are not needed on polycarbonate lenses, which already have UV protection. UV coatings are particularly important on sunglasses and ski goggles. Sunglasses, when nonprescription, should be labeled with an indication that they block out 99-100% of both UV-A and UV-B rays. There are anti-scratch coatings that increase the surface hardness of lenses (an important feature when using plastic lenses) and anti-reflective (AR) coatings that eliminate almost all glare and allow other people to see the eyes of the wearer. AR coatings may be particularly helpful to people who use computers or who drive at night. Mirror coatings that prevent other people from seeing the wearer's eyes are also available. There is a whole spectrum of tints, from light tints to darker tints, used in sunglasses. Tint, however, does not block-out UV rays, so a UV coating is needed. Polaroid lenses that block out much of the reflected light also allow better vision in sunny weather and are helpful for people who enjoy boating. Photosensitive (photochromatic) lenses that darken in the presence of bright light are handy for people who don't want to carry an extra set of glasses. Photochromatic lenses are available in glass and plastic. FRAMES Frames can be made from metal or plastic, and they can be rimless. There is an almost unlimited variety of shapes, colors, and sizes. The type and degree of refractive correction in the lens determine to some extent the type of frame most suitable. Some lenses are too thick to fit in metal rims, and some large-correction prescriptions are best suited to frames with small-area lenses. Rimless frames are the least noticeable type, and they are lightweight because the nosepiece and temples are attached directly to the lenses, eliminating the weight of the rims. They tend to not be as sturdy as frames with rims, so they are not a good choice for people who frequently remove their glasses and put them on again. They are also not very suitable for lenses that correct a high degree of farsightedness, because such lenses are thin at the edges. Metal frames are less noticeable than plastic, and they are lightweight. They are available in solid gold, gold-filled, anodized aluminum, nickel, silver, stainless steel, and now titanium and titanium alloy. Until the late 1980s, when titanium-nickel alloy and titanium frames were introduced, metal frames were, in general, more fragile than plastic frames. The titanium frames, however, are very strong and lightweight. An alloy of titanium and nickel, called Flexon, is not only strong and lightweight, but returns to its original shape after being twisted or dented. It is not perfect for everyone, though, because some people are sensitive to its nickel. Flexon frames are also relatively expensive. Plastic frames are durable, can accommodate just about any lens prescription, and are available in a wide range of prices. They are also offered in a variety of plastics (including acrylic, epoxy, cellulose acetate, cellulose propionate, polyamide, and nylon) and in different colors, shapes, and levels of resistance to breakage. Epoxy frames are resilient and return to their original shape after being deformed, so they do not need to be adjusted as frequently as other types. Nylon frames are almost unbreakable. They revert to their original shape after extreme trauma and distortion; because of this property, though, they cannot be readjusted after they are manufactured. FIT The patient should have the distance between the eyes (PD) measured, so that the optical centers of the lenses will be in front of the patient's pupils. Bifocal heights also have to be measured with the chosen frame in place and adjusted on the patient. Again, this is so the lenses will be positioned correctly. If not positioned correctly, the patient may experience eyestrain or other problems. This can occur with over-the-counter reading glasses. The distance between the lenses is for a "standard" person. Generally, this will not be a problem, but if a patient is sensitive or has more closely set eyes, for example, it may pose a problem. Persons buying ready-made sunglasses or reading glasses should hold them up to see if they appear clear. They should also hold the lenses to see an object with straight lines reflected off of the lenses. If the lines don't appear straight, the lenses may be warped or inferior. Patients may sometimes need a few days to adjust to a new prescription; however, problems should be reported, because the glasses may need to be rechecked. Contact lenses Over 32 million people in the United States wear these small lenses that fit on top of the cornea. They provide a field of view unobstructed by eyeglass frames; they do not fog-up or get splattered, so it is possible to see well while walking in the rain; and they are less noticeable than any eyeglass style. On the other hand, they take time to get accustomed to; require more measurements for fitting; require many follow-up visits to the eye doctor; can lead to complications such as infections and corneal damage; and may not correct astigmatism as well as eyeglasses, especially if the astigmatism is severe. Originally, hard contact lenses were made of a material called PMMA. Although still available, the more common types of contact lenses are listed below: Rigid gas-permeable (RGP) daily-wear lenses are made of plastic that does not absorb water but allows oxygen to get from the atmosphere to the cornea. (This is important because the cornea has no blood supply and needs to get its oxygen from the atmosphere through the film of tears that moves beneath the lens.) They must be removed and cleaned each night.

 Rigid gas-permeable (RGP) extended-wear lenses are made from plastic that also does not absorb water but is more permeable to oxygen than the plastic used for daily-wear lenses. They can be worn up to a week. Daily wear soft lenses are made of plastic that is permeable to oxygen and absorbs water; therefore, they are soft and flexible. These lenses must be removed and cleaned each night, and they do not correct all vision problems. Soft lenses are easier to get used to than rigid lenses, but are more prone to tears and do not last as long. Extended-wear soft lenses are highly permeable to oxygen, are flexible by virtue of their ability to absorb water, and can usually be worn for up to one week. They do not correct all vision problems. There is more of a risk of infection with extended-wear lenses than with daily-wear lenses. Extended-wear disposable lenses are soft lenses worn continually for up to six days and then discarded, with no need for cleaning. Planned-replacement soft lenses are daily wear lenses that are replaced on a regular schedule, which is usually every two weeks, monthly, or quarterly. They must also be cleaned. Soft contact lenses come in a variety of materials. There are also different kinds of RGP and soft multifocal contact lenses available. Monovision, where one contact lens corrects for distance vision while the other corrects for near vision, may be an option for presbyopic patients. Monovision, however, may affect depth perception and may not be appropriate for everyone. Contact lenses also come in a variety of tints. Soft contacts are available that can change dark-colored eyes a different color. Even though such lenses have no prescription, they must still be fitted and checked to make sure that an eye infection does not occur. People should NEVER wear someone else's contact lenses. This can lead to infection or damage to the eye. Aftercare Contact lens wearers must be examined periodically by their eye doctors to make sure that the lenses fit properly and that there is no infection. Both infection and lenses that do not fit properly can damage the cornea. Patients can be allergic to certain solutions that are used to clean or lubricate the lenses. For that reason, patients should not randomly switch products unless they speak with their doctor. Contact lens wearers should seek immediate attention if they experience eye pain, a burning sensation, red eyes, intolerable sensitivity to light, cloudy vision, or an inability to keep the eyes open. To avoid infection, it is important for contact lens wearers to exactly follow their instructions for lens insertion and removal, as well as cleaning. Soft contact lens wearers should never use tap water to rinse their lenses or to make-up solutions. All contact lens wearers should also always have a pair of glasses and a carrying case for their contacts with them, in case the contacts have to be removed due to eye irritation. Risks Wearing contact lenses increases the risk of corneal damage and eye infections. Normal results The normal expectation is that people will achieve 20/20 vision while wearing corrective lenses. Definition of Terms: Astigmatism Assymetric vision defects due to irregularities in the cornea. Cornea The clear outer covering of the front of the eye. Index of refraction A constant number for any material for any given color of light that is an indicator of the degree of the bending of the light caused by that material. Lens A device that bends light waves. Permeable Capable of allowing substances to pass through. Polycarbonate A very strong type of plastic often used in safety glasses, sport glasses, and children's eyeglasses. Polycarbonate lenses have approximately 50 times the impact resistance of glass lenses. Polymer A substance formed by joining smaller molecules. For example, plastic, acrylic, cellulose acetate, cellulose propionate, nylon, etc. Presbyopia A condition affecting people over the age of 40 where the system of accommodation that allows focusing of near objects fails to work because of age-related hardening of the lens of the eye. Retina The inner, light-sensitive layer of the eye containing rods and cones; transforms the image it receives into electrical messages sent to the brain via the optic nerve. Ultraviolet (UV) light Part of the electromagnetic spectrum with a wavelength just below that of visible light. It is damaging to living material, especially eyes and DNA. Age-Related Macular Degeneration What is age-related macular degeneration?

Age-related macular degeneration (AMD) is a disease that blurs the sharp, central vision you need for "straight-ahead" activities such as reading, sewing, and driving. AMD affects the macula, the part of the eye that allows you to see fine detail. AMD causes no pain. In some cases, AMD advances so slowly that people notice little change in their vision. In others, the disease progresses faster and may lead to a loss of vision in both eyes. AMD is a leading cause of vision loss in Americans 60 years of age and older. Where is the macula? The macula is located in the center of the retina, the light-sensitive tissue at the back of the eye. The retina instantly converts light, or an image, into electrical impulses. The retina then sends these impulses, or nerve signals, to the brain. Are there different forms of AMD? AMD occurs in two forms: wet and dry. What is wet AMD? Wet AMD occurs when abnormal blood vessels behind the retina start to grow under the macula. These new blood vessels tend to be very fragile and often leak blood and fluid. The blood and fluid raise the macula from its normal place at the back of the eye. Damage to the macula occurs rapidly. With wet AMD, loss of central vision can occur quickly. Wet AMD is considered to beadvanced AMD and is more severe than the dry form. An early symptom of wet AMD is that straight lines appear wavy. If you notice this condition or other changes to your vision, contact your eye care professional at once. You need a comprehensive dilated eye exam. What is dry AMD? Dry AMD occurs when the light-sensitive cells in the macula slowly break down, gradually blurring central vision in the affected eye. As dry AMD gets worse, you may see a blurred spot in the center of your vision. Over time, as less of the macula functions, central vision in the affected eye can be lost gradually. The most common symptom of dry AMD is slightly blurred vision. You may have difficulty recognising faces. You may need more light for reading and other tasks. Dry AMD generally affects both eyes, but vision can be lost in one eye while the other eye seems unaffected. One of the most common early signs of dry AMD is drusen. Drusen are yellow deposits under the retina. They often are found in people over age 60. Your eye care professional can detect drusen during a comprehensive dilated eye exam. Dry AMD has three stages, all of which may occur in one or both eyes: 1. Early AMD. People with early AMD have either several small drusen or a few medium-sized drusen. At this stage, there are no symptoms and no vision loss. 2. Intermediate AMD. People with intermediate AMD have either many medium-sized drusen or one or more large drusen. Some people see a blurred spot in the center of their vision. More light may be needed for reading and other tasks. 3. Advanced Dry AMD. In addition to drusen, people with advanced dry AMD have a breakdown of light-sensitive cells and supporting tissue in the central retinal area. This breakdown can cause a blurred spot in the center of your vision. Over time, the blurred spot may get bigger and darker, taking more of your central vision. You may have difficulty reading or recognising faces until they are very close to you. If you have vision loss from dry AMD in one eye only, you may not notice any changes in your overall vision. With the other eye seeing clearly, you still can drive, read, and see fine details. You may notice changes in your vision only if AMD affects both eyes. If blurriness occurs in your vision, see an eye care professional for a comprehensive dilated eye exam Do drusen cause vision loss in advanced dry AMD? Drusen alone do not usually cause vision loss. In fact, scientists are unclear about the connection between drusen and AMD. They do know that an increase in the size or number of drusen raises a person's risk of developing either advanced dry AMDor wet AMD. These changes can cause serious vision loss. The dry form has early and intermediate stages. Does the wet form have similar stages? No. The wet form is considered advanced AMD. Can advanced AMD be either the dry form or the wet form? Yes. Both the wet form and the advanced dry form are considered advanced AMD. Vision loss occurs with either form. In most cases, only advanced AMD can cause vision loss. People who have advanced AMD in one eye are at especially high risk of developingadvanced AMD in the other eye. Which is more common--the dry form or the wet form? The dry form is much more common. More than 85 percent of all people withintermediate and advanced AMD combined have the dry form. However, if only advanced AMD is considered, about two-thirds of patients have thewet form. Because almost all vision loss comes from advanced AMD, the wet formleads to significantly more vision loss than the dry form. Can the dry form turn into the wet form? Yes. All people who have the wet form had the dry form first. The dry form can advance and cause vision loss without turning into the wet form. The dry form also can suddenly turn into the wet form, even during early stage AMD. There is no way to tell if or when the dry form will turn into the wet form. Who is at risk for AMD? AMD can occur during middle age. The risk increases with aging. Other risk factors include:

Smoking. Obesity. Research studies suggest a link between obesity and the progression of early and intermediate stage AMD to advanced AMD. y Race. Whites are much more likely to lose vision from AMD than African Americans. y Family history. People with a family history of AMD are at higher risk of getting the disease. y Gender. Women appear to be at greater risk than men. How is AMD detected? AMD is detected during a comprehensive eye exam that includes: y Visual acuity test. This eye chart test measures how well you see at various distances. y Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of AMD and other eye problems. After the exam, your close-up vision may remain blurred for several hours. y Tonometry. An instrument measures the pressure inside the eye. Numbing drops may be applied to your eye for this test. Your eye care professional also may do other tests to learn more about the structure and health of your eye. During an eye exam, you may be asked to look at an Amsler grid. The pattern of the grid resembles a checkerboard. You will cover one eye and stare at a black dot in the center of the grid. While staring at the dot, you may notice that the straight lines in the pattern appear wavy. You may notice that some of the lines are missing. These may be signs of AMD. If your eye care professional believes you need treatment for wet AMD, he or she may suggest a fluorescein angiogram. In this test, a special dye is injected into your arm. Pictures are taken as the dye passes through the blood vessels in your retina. The test allows your eye care professional to identify any leaking blood vessels and recommend treatment. How is dry AMD treated? Once dry AMD reaches the advanced stage, no form of treatment can prevent vision loss. However, treatment can delay and possibly prevent intermediate AMD from progressing to the advanced stage, in which vision loss occurs. The National Eye Institute's Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants and zinc significantly reduces the risk of advanced AMD and its associated vision loss. Slowing AMD's progression from the intermediate stage to the advanced stage will save the vision of many people. What is the dosage of the AREDS formulation? The specific daily amounts of antioxidants and zinc used by the study researchers were 500 milligrams of vitamin C, 400 International Units of vitamin E, 15 milligrams of beta-carotene (often labeled as equivalent to 25,000 International Units of vitamin A), 80 milligrams of zinc as zinc oxide, and two milligrams of copper as cupric oxide. Copper was added to the AREDS formulation containing zinc to prevent copper deficiency anemia, a condition associated with high levels of zinc intake. Who should take the AREDS formulation? People who are at high risk for developing advanced AMD should consider taking the formulation. You are at high risk for developing advanced AMD if you have either: 1. Intermediate AMD in one or both eyes. OR 2. Advanced AMD (dry or wet) in one eye but not the other eye. Your eye care professional can tell you if you have AMD, its stage, and your risk for developing the advanced form. The AREDS formulation is not a cure for AMD. It will not restore vision already lost from the disease. However, it may delay the onset of advanced AMD. It may help people who are at high risk for developing advanced AMD keep their vision. Can people with early stage AMD take the AREDS formulation to help prevent the disease from progressing to the intermediate stage? There is no apparent need for those diagnosed with early stage AMD to take the AREDS formulation. The study did not find that the formulation provided a benefit to those with early stage AMD. If you have early stage AMD, a comprehensive dilated eye exam every year can help determine if the disease is progressing. If early stage AMD progresses to the intermediate stage, discuss taking the formulation with your doctor. Can diet alone provide the same high levels of antioxidants and zinc as the AREDS formulation? No. The high levels of vitamins and minerals are difficult to achieve from diet alone. However, previous studies have suggested that people who have diets rich in green leafy vegetables have a lower risk of developing AMD. Can a daily multivitamin alone provide the same high levels of antioxidants and zinc as the AREDS formulation? No. The formulation's levels of antioxidants and zinc are considerably higher than the amounts in any daily multivitamin. If you are already taking daily multivitamins and your doctor suggests you take the high-dose AREDS formulation, be sure to review all your vitamin supplements with your doctor before you begin. Because multivitamins contain many important vitamins not found in the AREDS formulation, you may want to take a multivitamin along with the AREDS formulation. For example, people with osteoporosis need to be particularly concerned about taking vitamin D, which is not in the AREDS formulation. How is wet AMD treated? y y

Wet AMD can be treated with laser surgery, photodynamic therapy, and injections into the eye. None of these treatments is a cure for wet AMD. Each treatment may slow the rate of vision decline or stop further vision loss, but the disease and loss of vision may progress despite treatment. y Laser surgery. This procedure uses a laser to destroy the fragile, leaky blood vessels. A high energy beam of light is aimed directly onto the new blood vessels and destroys them, preventing further loss of vision. However, laser treatment also may destroy some surrounding healthy tissue and some vision. Only a small percentage of people with wet AMD can be treated with laser surgery. Laser surgery is more effective if the leaky blood vessels have developed away from the fovea, the central part of the macula. Laser surgery is performed in a doctor's office or eye clinic. The risk of new blood vessels developing after laser treatment is high. Repeated treatments may be necessary. In some cases, vision loss may progress despite repeated treatments. y Photodynamic therapy.A drug called verteporfin is injected into your arm. It travels throughout the body, including the new blood vessels in your eye. The drug tends to "stick" to the surface of new blood vessels. Next, a light is shined into your eye for about 90 seconds. The light activates the drug. The activated drug destroys the new blood vessels and leads to a slower rate of vision decline. Unlike laser surgery, this drug does not destroy surrounding healthy tissue. Because the drug is activated by light, you must avoid exposing your skin or eyes to direct sunlight or bright indoor light for five days after treatment. Photodynamic therapy is relatively painless. It takes about 20 minutes and can be performed in a doctor's office. Photodynamic therapy slows the rate of vision loss. It does not stop vision loss or restore vision in eyes already damaged by advanced AMD. Treatment results often are temporary. You may need to be treated again. y Injections. Wet AMD can now be treated with a new drug that is injected into the eye (anti-VEGF therapy). Abnormally high levels of a specific growth factor occur in eyes with Wet AMD and promote the growth of abnormal new blood vessels. This drug treatment blocks the effects of the growth factor. You will need multiple injections, usually given about six weeks apart. The eye is numbed before each injection. After the injection, you will remain in the doctor's office for a while and your eye will be monitored. As with photodynamic therapy, the main benefit for patients treated with the drug is to slow vision loss from AMD. What can I do if I already have lost some vision from AMD? If you have lost some sight from AMD, don't be afraid to use your eyes for reading, watching TV, and other routine activities. Normal use of your eyes will not cause further damage to your vision. If you have lost some sight from AMD, ask your eye care professional about low vision services and devices that may help you make the most of your remaining vision. Ask for a referral to a specialist in low vision. Many community organisations and agencies offer information about low vision counselling, training, and other special services for people with visual impairments. A nearby school of medicine or optometry may provide low vision services. What can I do to protect my vision? Dry AMD - If you have dry AMD, you should have a comprehensive dilated eye exam at least once a year. Your eye care professional can monitor your condition and check for other eye diseases. Also, if you have intermediate AMD in one or both eyes, or advanced AMD in one eye only, your doctor may suggest that you take the AREDS formulation containing the high levels of antioxidants and zinc. Because dry AMD can turn into wet AMD at any time, you should get an Amsler grid from your eye care professional. Use the grid every day to evaluate your vision for signs of wet AMD. This quick test works best for people who still have good central vision. Check each eye separately. Cover one eye and look at the grid. Then cover your other eye and look at the grid. If you detect any changes in the appearance of this grid or in your everyday vision while reading the newspaper or watching television, get a comprehensive dilated eye exam. Wet AMD - If you have wet AMD and your doctor advises treatment, do not wait. After laser surgery or photodynamic therapy, you will need frequent eye exams to detect any recurrence of leaking blood vessels. Studies show that people who smoke have a greater risk of recurrence than those who don't. In addition, check your vision at home with the Amsler grid. If you detect any changes, schedule an eye exam immediately. Can my lifestyle make a difference? Your lifestyle can play a role in reducing your risk of developing AMD. y Eat a healthy diet high in green leafy vegetables and fish. y Don't smoke. y Maintain normal blood pressure. y Watch your weight. y Exercise. Amblyopia (Lazy Eye) What is amblyopia? The brain and the eye work together to produce vision. Light enters the eye and is changed into nerve signals that travel along the optic nerve to the brain. Amblyopia is the medical term used when the vision in one of the eyes is reduced because the eye and the brain are not working together properly. The eye itself looks normal, but it is not being used normally because the brain is favoring the other eye. This condition is also sometimes called lazy eye. How common is amblyopia? Amblyopia is the most common cause of visual impairment in childhood. The condition affects approximately 2 to 3 out of every 100 children. Unless it is successfully treated in early childhood, amblyopia usually persists into adulthood,

and is the most common cause of monocular (one eye) visual impairment among children and young and middle-aged adults. What causes amblyopia? Amblyopia may be caused by any condition that affects normal visual development or use of the eyes. Amblyopia can be caused by strabismus, an imbalance in the positioning of the two eyes. Strabismus can cause the eyes to cross in (esotropia) or turn out (exotropia). Sometimes amblyopia is caused when one eye is more nearsighted, farsighted, or astigmatic than the other eye. Occasionally, amblyopia is caused by other eye conditions such as cataract. How is amblyopia treated in children? Treating amblyopia involves making the child use the eye with the reduced vision (weaker eye). Currently, there are two ways used to do this: Atropine A drop of a drug called atropine is placed in the stronger eye once a day to temporarily blur the vision so that the child will prefer to use the eye with amblyopia. Treatment with atropine also stimulates vision in the weaker eye and helps the part of the brain that manages vision develop more completely. Patching An opaque, adhesive patch is worn over the stronger eye for weeks to months. This therapy forces the child to use the eye with amblyopia. Patching stimulates vision in the weaker eye and helps the part of the brain that manages vision develop more completely. Previously, eye care professionals often thought that treating amblyopia in older children would be of little benefit. However, surprising results from a nationwide clinical trial show that many children age seven through 17 with amblyopia may benefit from treatments that are more commonly used on younger children. This study shows that age alone should not be used as a factor to decide whether or not to treat a child for amblyopia. Can amblyopia be treated in adults? Studies are very limited at this time and scientists dont know what the success rate might be for treating amblyopia in adults. During the first six to nine years of life, the visual system develops very rapidly. Complicated connections between the eye and the brain are created during that period of growth and development. Scientists are exploring whether treatment for amblyopia in adults can improve vision. Anophthalmia and Microphthalmia (Small Eye Syndrome) Anophthalmia and Microphthalmia, are also referred to as anophthalmos and microphthalmos, and small eye syndrome. What are anophthalmia and microphthalmia? Anophthalmia and microphthalmia are often used interchangeably. Microphthalmia is a disorder in which one or both eyes are abnormally small, while anophthalmia is the absence of one or both eyes. These rare disorders develop during pregnancy and can be associated with other birth defects. What causes anophthalmia and microphthalmia? Causes of these conditions may include genetic mutations and abnormal chromosomes. Researchers also believe that environmental factors, such as exposure to X-rays, chemicals, drugs, pesticides, toxins, radiation, or viruses, increase the risk of anophthalmia and microphthalmia, but research is not conclusive. Sometimes the cause in an individual patient cannot be determined. Can anophthalmia and microphthalmia be treated? There is no treatment for severe anophthalmia or microphthalmia that will create a new eye or restore vision. However, some less severe forms of microphthalmia may benefit from medical or surgical treatments. In almost all cases improvements to a child's appearance are possible. Children can be fitted for a prosthetic (artificial) eye for cosmetic purposes and to promote socket growth. A newborn with anophthalmia or microphthalmia will need to visit several eye care professionals, including those who specialize in paediatrics, vitreoretinal disease, orbital and oculoplastic surgery, ophthalmic genetics, and prosthetic devices for the eye. Each specialist can provide information and possible treatments resulting in the best care for the child and family. The specialist in prosthetic diseases for the eye will make conformers, plastic structures that help support the face and encourage the eye socket to grow. As the face develops, new conformers will need to be made. A child with anophthalmia may also need to use expanders in addition to conformers to further enlarge the eye socket. Once the face is fully developed, prosthetic eyes can be made and placed. Prosthetic eyes will not restore vision. How do conformers and prosthetic eyes look? A painted prosthesis that looks like a normal eye is usually fitted between ages one and two. Until then, clear conformers are used. When the conformers are in place the eye socket will look black. These conformers are not painted to look like a normal eye because they are changed too frequently. Every few weeks a child will progress to a larger size conformer until about two years of age. If a child needs to wear conformers after age two, the conformers will be painted like a regular prosthesis, giving the appearance of a normal but smaller eye. The average child will need three to four new painted prostheses before the age of 10. How is microphthalmia managed if there is residual vision in the eye? Children with microphthalmia may have some residual vision (limited sight). In these cases, the good eye can be patched to strengthen vision in the microphthalmic eye. A prosthesis can be made to cap the microphthalmic eye to help with cosmetic appearance, while preserving the remaining sight. Behet's disease of the Eye What is Behet's disease?

Behet's disease is an autoimmune disease that results from damage to blood vessels throughout the body, particularly veins. In an autoimmune disease, the immune system attacks and harms the body's own tissues. What causes Behet's disease? The exact cause is unknown. It is believed that an autoimmune reaction may cause blood vessels to become inflamed, but it is not clear what triggers this reaction. What are the symptoms of Behet's disease? Behet's disease affects each person differently. The four most common symptoms are mouth sores, genital sores, inflammation inside of the eye, and skin problems. Inflammation inside of the eye (uveitis, retinitis, and iritis) occurs in more that half of those with Behet's disease and can cause blurred vision, pain, and redness. Other symptoms may include arthritis, blood clots, and inflammation in the central nervous system and digestive organs. How is Behet's disease treated? There is no cure for Behet's disease. Treatment typically focuses on reducing discomfort and preventing serious complications. Corticosteroids and other medications that suppress the immune system may be prescribed to treat inflammation. What is the prognosis for someone with Behet's disease? Behet's is a chronic disease that recurs. However, patients may have periods of time when symptoms go away temporarily (remission). How severe the disease is varies from patient to patient. Some patients may live normal lives, but others may become blind or severely disabled. Bietti's Crystalline Dystrophy What is Bietti's Crystalline Dystrophy? Bietti's crystalline dystrophy (BCD, Bietti's crystalline corneoretinal dystrophy) is an inherited eye disease named for Dr. G. B. Bietti, an Italian ophthalmologist, who described three patients with similar symptoms in 1937. The symptoms of BCD include: crystals in the cornea (the clear covering of the eye); yellow, shiny deposits on the retina; and progressive atrophy of the retina, choriocapillaries and choroid (the back layers of the eye). This tends to lead to progressive night blindness and visual field constriction. BCD is a rare disease and appears to be more common in people with Asian ancestry. People with BCD have crystals in some of their white blood cells (lymphocytes) that can be seen by using an electron microscope. Researchers have been unable to determine exactly what substance makes up these crystalline deposits. Their presence does not appear to harm the patient in any other way except to affect vision. What causes Bietti's Crystalline Dystrophy? From family studies, we know that BCD is inherited primarily in an autosomal recessive fashion. This means that an affected person receives one nonworking gene from each of his or her parents. A person who inherits a nonworking gene from only one parent will be a carrier, but will not develop the disease. A person with BCD syndrome will pass on one gene to each of his or her children. However, unless the person has children with another carrier of BCD genes, the individual's children are not at risk for developing the disease. In September 2000, NEI researchers reported that the BCD gene had been localized to chromosome #4. In this region of chromosome #4 there are hundreds of genes. Researchers are now looking for which of the genes in this region of chromosome #4 causes BCD. Finding the gene may shed light on the composition of the crystals found in the corneas of patients with BCD and on what causes the condition. Can Bietti's Crystalline Dystrophy Be Treated? At this time, there is no treatment for BCD. Scientists hope that findings from gene research will be helpful in finding treatments for patients with BCD. Blepharitis (Granulated Eyelids) What is blepharitis? Blepharitis (granulated eyelids) is a common condition that causes inflammation of the eyelids. The condition can be difficult to manage because it tends to recur. What causes blepharitis? Blepharitis occurs in two forms: Anterior blepharitis affects the outside front of the eyelid, where the eyelashes are attached. The two most common causes of anterior blepharitis are bacteria (Staphylococcus) and scalp dandruff. Posterior blepharitis affects the inner eyelid (the moist part that makes contact with the eye) and is caused by problems with the oil (meibomian) glands in this part of the eyelid. Two skin disorders can cause this form of blepharitis: acne rosacea, which leads to red and inflamed skin, and scalp dandruff (seborrheic dermatitis). What are the symptoms of blepharitis? Symptoms of either form of blepharitis include a foreign body or burning sensation, excessive tearing, itching, sensitivity to light (photophobia), red and swollen eyelids, redness of the eye, blurred vision, frothy tears, dry eye, or crusting of the eyelashes on awakening. What other conditions are associated with blepharitis? Complications from blepharitis include: Stye: A red tender bump on the eyelid that is caused by an acute infection of the oil glands of the eyelid. Chalazion: This condition can follow the development of a stye. It is a usually painless firm lump caused by inflammation of the oil glands of the eyelid. Chalazion can be painful and red if there is also an infection.

Problems with the tear film: Abnormal or decreased oil secretions that are part of the tear film can result in excess tearing or dry eye. Because tears are necessary to keep the cornea healthy, tear film problems can make people more at risk for corneal infections. How is blepharitis treated? Treatment for both forms of blepharitis involves keeping the lids clean and free of crusts. Warm compresses should be applied to the lid to loosen the crusts, followed by a light scrubbing of the eyelid with a cotton swab and a mixture of water and baby shampoo. Because blepharitis rarely goes away completely, most patients must maintain an eyelid hygiene routine for life. If the blepharitis is severe, an eye care professional may also prescribe antibiotics or steroid eyedrops. When scalp dandruff is present, a dandruff shampoo for the hair is recommended as well. In addition to the warm compresses, patients with posterior blepharitis will need to massage their eyelids to clean the oil accumulated in the glands. Patients who also have acne rosacea should have that condition treated at the same time. Blepharospasm (Benign essential blepharospasm, hemifacial spasm) What is Blepharospasm? Blepharospasm (Benign essential blepharospasm, hemifacial spasm) is an abnormal, involuntary blinking or spasm of the eyelids. What causes Blepharospasm? Blepharospasm is associated with an abnormal function of the basal ganglion from an unknown cause. The basal ganglion is the part of the brain responsible for controlling the muscles. In rare cases, heredity may play a role in the development of blepharospasm. What are the symptoms of Blepharospasm? Most people develop blepharospasm without any warning symptoms. It may begin with a gradual increase in blinking or eye irritation. Some people may also experience fatigue, emotional tension, or sensitivity to bright light. As the condition progresses, the symptoms become more frequent, and facial spasms may develop. Blepharospasm may decrease or cease while a person is sleeping or concentrating on a specific task. How is Blepharospasm treated? To date, there is no successful cure for blepharospasm, although several treatment options can reduce its severity. In the United States and Canada, the injection of Oculinum (botulinum toxin, or Botox) into the muscles of the eyelids is an approved treatment for blepharospasm. Botulinum toxin, produced by the bacterium Clostridium botulinum, paralyzes the muscles of the eyelids. Medications taken by mouth for blepharospasm are available but usually produce unpredictable results. Any symptom relief is usually short term and tends to be helpful in only 15 percent of the cases. Myectomy, a surgical procedure to remove some of the muscles and nerves of the eyelids, is also a possible treatment option. This surgery has improved symptoms in 75 to 85 percent of people with blepharospasm. Alternative treatments may include biofeedback, acupuncture, hypnosis, chiropractic, and nutritional therapy. The benefits of these alternative therapies have not been proven. Cataracts & Cataract Surgery What is a cataract? A cataract is a clouding of the lens in the eye that affects vision. Most cataracts are related to aging. Cataracts are very common in older people. By age 80, more than half of all Americans either have a cataract or have had cataract surgery. A cataract can occur in either or both eyes. It cannot spread from one eye to the other. How do cataracts develop? Age-related cataracts develop in two ways: 1. Clumps of protein reduce the sharpness of the image reaching the retina. The lens consists mostly of water and protein. When the protein clumps up, it clouds the lens and reduces the light that reaches the retina. The clouding may become severe enough to cause blurred vision. Most age-related cataracts develop from protein clumpings. When a cataract is small, the cloudiness affects only a small part of the lens. You may not notice any changes in your vision. Cataracts tend to "grow" slowly, so vision gets worse gradually. Over time, the cloudy area in the lens may get larger, and the cataract may increase in size. Seeing may become more difficult. Your vision may get duller or blurrier. 2. The clear lens slowly changes to a yellowish/brownish colour, adding a brownish tint to vision. As the clear lens slowly colors with age, your vision gradually may acquire a brownish shade. At first, the amount of tinting may be small and may not cause a vision problem. Over time, increased tinting may make it more difficult to read and perform other routine activities. This gradual change in the amount of tinting does not affect the sharpness of the image transmitted to the retina. If you have advanced lens discoloration, you may not be able to identify blues and purples. You may be wearing what you believe to be a pair of black socks, only to find out from friends that you are wearing purple socks. Who is at risk for cataract? The risk of cataract increases as you get older. Other risk factors for cataract include: y Certain diseases (for example, diabetes). y Personal behaviour (smoking, alcohol use). y The environment (prolonged exposure to ultraviolet sunlight). What are the symptoms of a cataract? The most common symptoms of a cataract are:

y Cloudy or blurry vision. y Colors seem faded. y Glare. Headlights, lamps, or sunlight may appear too bright. A halo may appear around lights. y Poor night vision. y Double vision or multiple images in one eye. (This symptom may clear as the cataract gets larger.) y Frequent prescription changes in your eyeglasses or contact lenses. These symptoms also can be a sign of other eye problems. If you have any of these symptoms, check with your eye care professional. Are there other types of cataract? Yes. Although most cataracts are related to aging, there are other types of cataract: y Secondary cataract. Cataracts can form after surgery for other eye problems, such as glaucoma. Cataracts also can develop in people who have other health problems, such as diabetes. Cataracts are sometimes linked to steroid use. y Traumatic cataract. Cataracts can develop after an eye injury, sometimes years later. y Congenital cataract. Some babies are born with cataracts or develop them in childhood, often in both eyes. These cataracts may be so small that they do not affect vision. If they do, the lenses may need to be removed. y Radiation cataract. Cataracts can develop after exposure to some types of radiation. How is a cataract detected? Cataract is detected through a comprehensive eye exam that includes: y Visual acuity test. This eye chart test measures how well you see at various distances. y Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye problems. After the exam, your close-up vision may remain blurred for several hours. y Tonometry. An instrument measures the pressure inside the eye. Numbing drops may be applied to your eye for this test. Your eye care professional also may do other tests to learn more about the structure and health of your eye. How is a cataract treated? The symptoms of early cataract may be improved with new eyeglasses, brighter lighting, anti-glare sunglasses, or magnifying lenses. If these measures do not help, surgery is the only effective treatment. Surgery involves removing the cloudy lens and replacing it with an artificial lens. A cataract needs to be removed only when vision loss interferes with your everyday activities, such as driving, reading, or watching TV. You and your eye care professional can make this decision together. Once you understand the benefits and risks of surgery, you can make an informed decision about whether cataract surgery is right for you. In most cases, delaying cataract surgery will not cause long-term damage to your eye or make the surgery more difficult. You do not have to rush into surgery. Sometimes a cataract should be removed even if it does not cause problems with your vision. For example, a cataract should be removed if it prevents examination or treatment of another eye problem, such as age-related macular degeneration or diabetic retinopathy. If you choose surgery, your eye care professional may refer you to a specialist to remove the cataract. If you have cataracts in both eyes that require surgery, the surgery will be performed on each eye at separate times, usually four to eight weeks apart. Is cataract surgery effective? Cataract removal is one of the most common operations performed in the United States. It also is one of the safest and most effective types of surgery. In about 90 percent of cases, people who have cataract surgery have better vision afterward. Are there different types of cataract surgery? There are two types of cataract surgery. Your doctor can explain the differences and help determine which is better for you: y Phacoemulsification, or phaco. A small incision is made on the side of the cornea, the clear, dome-shaped surface that covers the front of the eye. Your doctor inserts a tiny probe into the eye. This device emits ultrasound waves that soften and break up the lens so that it can be removed by suction. Most cataract surgery today is done by phacoemulsification, also called "small incision cataract surgery." y Extracapsular surgery. Your doctor makes a longer incision on the side of the cornea and removes the cloudy core of the lens in one piece. The rest of the lens is removed by suction. After the natural lens has been removed, it often is replaced by an artificial lens, called an intraocular lens (IOL). An IOL is a clear, plastic lens that requires no care and becomes a permanent part of your eye. Light is focused clearly by the IOL onto the retina, improving your vision. You will not feel or see the new lens. Some people cannot have an IOL. They may have another eye disease or have problems during surgery. For these patients, a soft contact lens, or glasses that provide high magnification, may be suggested. What are the risks of cataract surgery? As with any surgery, cataract surgery poses risks, such as infection and bleeding. Before cataract surgery, your doctor may ask you to temporarily stop taking certain medications that increase the risk of bleeding during surgery. After

surgery, you must keep your eye clean, wash your hands before touching your eye, and use the prescribed medications to help minimize the risk of infection. Serious infection can result in loss of vision. Cataract surgery slightly increases your risk of retinal detachment. Other eye disorders, such as high myopia (nearsightedness), can further increase your risk of retinal detachment after cataract surgery. One sign of a retinal detachment is a sudden increase in flashes or floaters. Floaters are little "cobwebs" or specks that seem to float about in your field of vision. If you notice a sudden increase in floaters or flashes, see an eye care professional immediately. A retinal detachment is a medical emergency. If necessary, go to an emergency service or hospital. Your eye must be examined by an eye surgeon as soon as possible. A retinal detachment causes no pain. Early treatment for retinal detachment often can prevent permanent loss of vision. The longer the retina stays detached, the less likely you will regain good vision once you are treated. Even if you are treated promptly, some vision may be lost. Talk to your eye care professional about these risks. Make sure cataract surgery is right for you. What if I have other eye conditions and need cataract surgery? Many people who need cataract surgery also have other eye conditions, such as age-related macular degeneration or glaucoma. If you have other eye conditions in addition to cataract, talk with your doctor. Learn about the risks, benefits, alternatives, and expected results of cataract surgery. What happens before surgery? A week or two before surgery, your doctor will do some tests. These tests may include measuring the curve of the cornea and the size and shape of your eye. This information helps your doctor choose the right type of IOL. You may be asked not to eat or drink anything 12 hours before your surgery. What happens during surgery? At the hospital or eye clinic, drops will be put into your eye to dilate the pupil. The area around your eye will be washed and cleansed. The operation usually lasts less than one hour and is almost painless. Many people choose to stay awake during surgery. Others may need to be put to sleep for a short time. If you are awake, you will have an anaesthetic to numb the nerves in and around your eye. After the operation, a patch may be placed over your eye. You will rest for a while. Your medical team will watch for any problems, such as bleeding. Most people who have cataract surgery can go home the same day. You will need someone to drive you home. What happens after surgery? Itching and mild discomfort are normal after cataract surgery. Some fluid discharge is also common. Your eye may be sensitive to light and touch. If you have discomfort, your doctor can suggest treatment. After one or two days, moderate discomfort should disappear. For a few days after surgery, your doctor may ask you to use eyedrops to help healing and decrease the risk of infection. Ask your doctor about how to use your eyedrops, how often to use them, and what effects they can have. You will need to wear an eye shield or eyeglasses to help protect your eye. Avoid rubbing or pressing on your eye. When you are home, try not to bend from the waist to pick up objects on the floor. Do not lift any heavy objects. You can walk, climb stairs, and do light household chores. In most cases, healing will be complete within eight weeks. Your doctor will schedule exams to check on your progress. Can problems develop after surgery? Problems after surgery are rare, but they can occur. These problems can include infection, bleeding, inflammation (pain, redness, swelling), loss of vision, double vision, and high or low eye pressure. With prompt medical attention, these problems usually can be treated successfully. Sometimes the eye tissue that encloses the IOL becomes cloudy and may blur your vision. This condition is called an after-cataract. An after-cataract can develop months or years after cataract surgery. An after-cataract is treated with a laser. Your doctor uses a laser to make a tiny hole in the eye tissue behind the lens to let light pass through. This outpatient procedure is called a YAG laser capsulotomy. It is painless and rarely results in increased eye pressure or other eye problems. As a precaution, your doctor may give you eyedrops to lower your eye pressure before or after the procedure. When will my vision be normal again? You can return quickly to many everyday activities, but your vision may be blurry. The healing eye needs time to adjust so that it can focus properly with the other eye, especially if the other eye has a cataract. Ask your doctor when you can resume driving. If you received an IOL, you may notice that colors are very bright. The IOL is clear, unlike your natural lens that may have had a yellowish/brownish tint. Within a few months after receiving an IOL, you will become used to improved colour vision. Also, when your eye heals, you may need new glasses or contact lenses. What can I do if I already have lost some vision from cataract? If you have lost some sight from cataract or cataract surgery, ask your eye care professional about low vision services and devices that may help you make the most of your remaining vision. Ask for a referral to a specialist in low vision. Many community organisations and agencies offer information about low vision counselling, training, and other special services for people with visual impairments. A nearby school of medicine or optometry may provide low vision services. What can I do to protect my vision? Wearing sunglasses and a hat with a brim to block ultraviolet sunlight may help to delay cataract. If you smoke, stop. Researchers also believe good nutrition can help reduce the risk of age-related cataract. They recommend eating green leafy vegetables, fruit, and other foods with antioxidants.

If you are age 60 or older, you should have a comprehensive dilated eye exam at least once every two years. In addition to cataract, your eye care professional can check for signs of age-related macular degeneration, glaucoma, and other vision disorders. Early treatment for many eye diseases may save your sight. Cornea and Corneal Disease What is the cornea? The cornea is the eye's outermost layer. It is the clear, dome-shaped surface that covers the front of the eye. What is the function of the cornea? Because the cornea is as smooth and clear as glass but is strong and durable, it helps the eye in two ways: 1. It helps to shield the rest of the eye from germs, dust, and other harmful matter. The cornea shares this protective task with the eyelids, the eye socket, tears, and the sclera, or white part of the eye. 2. The cornea acts as the eye's outermost lens. It functions like a window that controls and focuses the entry of light into the eye. The cornea contributes between 65-75 percent of the eye's total focusing power. When light strikes the cornea, it bends--or refracts--the incoming light onto the lens. The lens further refocuses that light onto the retina, a layer of light sensing cells lining the back of the eye that starts the translation of light into vision. For you to see clearly, light rays must be focused by the cornea and lens to fall precisely on the retina. The retina converts the light rays into impulses that are sent through the optic nerve to the brain, which interprets them as images. The refractive process is similar to the way a camera takes a picture. The cornea and lens in the eye act as the camera lens. The retina is similar to the film. If the image is not focused properly, the film (or retina) receives a blurry image. The cornea also serves as a filter, screening out some of the most damaging ultraviolet (UV) wavelengths in sunlight. Without this protection, the lens and the retina would be highly susceptible to injury from UV radiation. How does the cornea respond to injury? The cornea copes very well with minor injuries or abrasions. If the highly sensitive cornea is scratched, healthy cells slide over quickly and patch the injury before infection occurs and vision is affected. If the scratch penetrates the cornea more deeply, however, the healing process will take longer, at times resulting in greater pain, blurred vision, tearing, redness, and extreme sensitivity to light. These symptoms require professional treatment. Deeper scratches can also cause corneal scarring, resulting in a haze on the cornea that can greatly impair vision. In this case, a corneal transplant may be needed. What are some diseases and disorders affecting the cornea? Some diseases and disorders of the cornea are: y Allergies. Allergies affecting the eye are fairly common. The most common allergies are those related to pollen, particularly when the weather is warm and dry. Symptoms can include redness, itching, tearing, burning, stinging, and watery discharge, although they are not usually severe enough to require medical attention. Antihistamine decongestant eyedrops can effectively reduce these symptoms, as does rain and cooler weather, which decreases the amount of pollen in the air. An increasing number of eye allergy cases are related to medications and contact lens wear. Also, animal hair and certain cosmetics, such as mascara, face creams, and eyebrow pencil, can cause allergies that affect the eye. Touching or rubbing eyes after handling nail polish, soaps, or chemicals may cause an allergic reaction. Some people have sensitivity to lip gloss and eye makeup. Allergy symptoms are temporary and can eliminated by not having contact with the offending cosmetic or detergent. Conjunctivitis (Pink Eye). This term describes a group of diseases that cause swelling, itching, burning, and redness of the conjunctiva, the protective membrane that lines the eyelids and covers exposed areas of the sclera, or white of the eye. Conjunctivitis can spread from one person to another and affects millions of Americans at any given time. Conjunctivitis can be caused by a bacterial or viral infection, allergy, environmental irritants, a contact lens product, eyedrops, or eye ointments. At its onset, conjunctivitis is usually painless and does not adversely affect vision. The infection will clear in most cases without requiring medical care. But for some forms of conjunctivitis, treatment will be needed. If treatment is delayed, the infection may worsen and cause corneal inflammation and a loss of vision. Corneal Infections. Sometimes the cornea is damaged after a foreign object has penetrated the tissue, such as from a poke in the eye. At other times, bacteria or fungi from a contaminated contact lens can pass into the cornea. Situations like these can cause painful inflammation and corneal infections called keratitis. These infections can reduce visual clarity, produce corneal discharges, and perhaps erode the cornea. Corneal infections can also lead to corneal scarring, which can impair vision and may require a corneal transplant. As a general rule, the deeper the corneal infection, the more severe the symptoms and complications. It should be noted that corneal infections, although relatively infrequent, are the most serious complication of contact lens wear. Minor corneal infections are commonly treated with anti-bacterial eye drops. If the problem is severe, it may require more intensive antibiotic or anti-fungal treatment to eliminate the infection, as well as steroid eye drops to reduce inflammation. Frequent visits to an eye care professional may be necessary for several months to eliminate the problem.

Dry Eye. The continuous production and drainage of tears is important to the eye's health. Tears keep the eye moist, help wounds heal, and protect against eye infection. In people with dry eye, the eye produces fewer or less quality tears and is unable to keep its surface lubricated and comfortable. The tear film consists of three layers--an outer, oily (lipid) layer that keeps tears from evaporating too quickly and helps tears remain on the eye; a middle (aqueous) layer that nourishes the cornea and conjunctiva; and a bottom (mucin) layer that helps to spread the aqueous layer across the eye to ensure that the eye remains wet. As we age, the eyes usually produce fewer tears. Also, in some cases, the lipid and mucin layers produced by the eye are of such poor quality that tears cannot remain in the eye long enough to keep the eye sufficiently lubricated. The main symptom of dry eye is usually a scratchy or sandy feeling as if something is in the eye. Other symptoms may include stinging or burning of the eye; episodes of excess tearing that follow periods of very dry sensation; a stringy discharge from the eye; and pain and redness of the eye. Sometimes people with dry eye experience heaviness of the eyelids or blurred, changing, or decreased vision, although loss of vision is uncommon. Dry eye is more common in women, especially after menopause. Surprisingly, some people with dry eye may have tears that run down their cheeks. This is because the eye may be producing less of the lipid and mucin layers of the tear film, which help keep tears in the eye. When this happens, tears do not stay in the eye long enough to thoroughly moisten it. Dry eye can occur in climates with dry air, as well as with the use of some drugs, including antihistamines, nasal decongestants, tranquilizers, and anti-depressant drugs. People with dry eye should let their health care providers know all the medications they are taking, since some of them may intensify dry eye symptoms. People with connective tissue diseases, such as rheumatoid arthritis, can also develop dry eye. It is important to note that dry eye is sometimes a symptom of Sjgren's syndrome, a disease that attacks the body's lubricating glands, such as the tear and salivary glands. A complete physical examination may diagnose any underlying diseases. Artificial tears, which lubricate the eye, are the principal treatment for dry eye. They are available over-thecounter as eye drops. Sterile ointments are sometimes used at night to help prevent the eye from drying. Using humidifiers, wearing wrap-around glasses when outside, and avoiding outside windy and dry conditions may bring relief. For people with severe cases of dry eye, temporary or permanent closure of the tear drain (small openings at the inner corner of the eyelids where tears drain from the eye) may be helpful. Fuchs' Dystrophy. Fuchs' dystrophy is a slowly progressing disease that usually affects both eyes and is slightly more common in women than in men. Although doctors can often see early signs of Fuchs' dystrophy in people in their 30s and 40s, the disease rarely affects vision until people reach their 50s and 60s. Fuchs' dystrophy occurs when endothelial cells gradually deteriorate without any apparent reason. As more endothelial cells are lost over the years, the endothelium becomes less efficient at pumping water out of the stroma. This causes the cornea to swell and distort vision. Eventually, the epithelium also takes on water, resulting in pain and severe visual impairment. Epithelial swelling damages vision by changing the cornea's normal curvature, and causing a sight-impairing haze to appear in the tissue. Epithelial swelling will also produce tiny blisters on the corneal surface. When these blisters burst, they are extremely painful. At first, a person with Fuchs' dystrophy will awaken with blurred vision that will gradually clear during the day. This occurs because the cornea is normally thicker in the morning; it retains fluids during sleep that evaporate in the tear film while we are awake. As the disease worsens, this swelling will remain constant and reduce vision throughout the day. When treating the disease, doctors will try first to reduce the swelling with drops, ointments, or soft contact lenses. They also may instruct a person to use a hair dryer, held at arm's length or directed across the face, to dry out the epithelial blisters. This can be done two or three times a day. When the disease interferes with daily activities, a person may need to consider having a corneal transplant to restore sight. The short-term success rate of corneal transplantation is quite good for people with Fuchs' dystrophy. However, some studies suggest that the long-term survival of the new cornea can be a problem. Corneal Dystrophies A corneal dystrophy is a condition in which one or more parts of the cornea lose their normal clarity due to a buildup of cloudy material. There are over 20 corneal dystrophies that affect all parts of the cornea.

These diseases share many traits: 1. They are usually inherited. 2. They affect the right and left eyes equally. 3. They are not caused by outside factors, such as injury or diet. 4. Most progress gradually. 5. Most usually begin in one of the five corneal layers and may later spread to nearby layers. 6. Most do not affect other parts of the body, nor are they related to diseases affecting other parts of the eye or body. 7. Most can occur in otherwise totally healthy people, male or female. Corneal dystrophies affect vision in widely differing ways. Some cause severe visual impairment, while a few cause no vision problems and are discovered during a routine eye examination. Other dystrophies may cause repeated episodes of pain without leading to permanent loss of vision. Some of the most common corneal dystrophies include Fuchs' dystrophy, keratoconus, lattice dystrophy, and map-dot-fingerprint dystrophy. y y Herpes Zoster (Shingles). This infection is produced by the varicella-zoster virus, the same virus that causes chickenpox. After an initial outbreak of chickenpox (often during childhood), the virus remains inactive within the nerve cells of the central nervous system. But in some people, the varicella-zoster virus will reactivate at another time in their lives. When this occurs, the virus travels down long nerve fibers and infects some part of the body, producing a blistering rash (shingles), fever, painful inflammations of the affected nerve fibers, and a general feeling of sluggishness. Varicella-zoster virus may travel to the head and neck, perhaps involving an eye, part of the nose, cheek, and forehead. In about 40 percent of those with shingles in these areas, the virus infects the cornea. Doctors will often prescribe oral anti-viral treatment to reduce the risk of the virus infecting cells deep within the tissue, which could inflame and scar the cornea. The disease may also cause decreased corneal sensitivity, meaning that foreign matter, such as eyelashes, in the eye are not felt as keenly. For many, this decreased sensitivity will be permanent. Although shingles can occur in anyone exposed to the varicella-zoster virus, research has established two general risk factors for the disease: (1) Advanced age; and (2) A weakened immune system. Studies show that people over age 80 have a five times greater chance of having shingles than adults between the ages of 20 and 40. Unlike herpes simplex I, the varicella-zoster virus does not usually flare up more than once in adults with normally functioning immune systems. Be aware that corneal problems may arise months after the shingles are gone. For this reason, it is important that people who have had facial shingles schedule follow-up eye examinations. Iridocorneal Endothelial Syndrome. More common in women and usually diagnosed between ages 30-50, iridocorneal endothelial (ICE) syndrome has three main features: (1) Visible changes in the iris, the colored part of the eye that regulates the amount of light entering the eye; (2) Swelling of the cornea; and (3) The development of glaucoma, a disease that can cause severe vision loss when normal fluid inside the eye cannot drain properly. ICE is usually present in only one eye. ICE syndrome is actually a grouping of three closely linked conditions: iris nevus (or Cogan-Reese) syndrome; Chandler's syndrome; and essential (progressive) iris atrophy (hence the acronym ICE). The most common feature of this group of diseases is the movement of endothelial cells off the cornea onto the iris. This loss of cells from the cornea often leads to corneal swelling, distortion of the iris, and variable degrees of distortion of the pupil, the adjustable opening at the center of the iris that allows varying amounts of light to enter the eye. This cell movement also plugs the fluid outflow channels of the eye, causing glaucoma. The cause of this disease is unknown. While we do not yet know how to keep ICE syndrome from progressing, the glaucoma associated with the disease can be treated with medication, and a corneal transplant can treat the corneal swelling. Keratoconus. This disorder--a progressive thinning of the cornea--is the most common corneal dystrophy in the U.S., affecting one in every 2000 Americans. It is more prevalent in teenagers and adults in their 20s. Keratoconus arises when the middle of the cornea thins and gradually bulges outward, forming a rounded cone shape. This abnormal curvature changes the cornea's refractive power, producing moderate to severe distortion (astigmatism) and blurriness (nearsightedness) of vision. Keratoconus may also cause swelling and a sight-impairing scarring of the tissue. Studies indicate that keratoconus stems from one of several possible causes: 1. An inherited corneal abnormality. About seven percent of those with the condition have a family history of keratoconus.

2. 3. 4.

An eye injury, i.e., excessive eye rubbing or wearing hard contact lenses for many years. Certain eye diseases, such as retinitis pigmentosa, retinopathy of prematurity, and vernal keratoconjunctivitis. Systemic diseases, such as Leber's congenital amaurosis, Ehlers-Danlos syndrome, Down syndrome, and osteogenesis imperfecta.

Keratoconus usually affects both eyes. At first, people can correct their vision with eyeglasses. But as the astigmatism worsens, they must rely on specially fitted contact lenses to reduce the distortion and provide better vision. Although finding a comfortable contact lens can be an extremely frustrating and difficult process, it is crucial because a poorly fitting lens could further damage the cornea and make wearing a contact lens intolerable. In most cases, the cornea will stabilize after a few years without ever causing severe vision problems. But in about 10 to 20 percent of people with keratoconus, the cornea will eventually become too scarred or will not tolerate a contact lens. If either of these problems occur, a corneal transplant may be needed. This operation is successful in more than 90 percent of those with advanced keratoconus. Several studies have also reported that 80 percent or more of these patients have 20/40 vision or better after the operation. y Lattice Dystrophy. Lattice dystrophy gets its name from an accumulation of amyloid deposits, or abnormal protein fibers, throughout the middle and anterior stroma. During an eye examination, the doctor sees these deposits in the stroma as clear, comma-shaped overlapping dots and branching filaments, creating a lattice effect. Over time, the lattice lines will grow opaque and involve more of the stroma. They will also gradually converge, giving the cornea a cloudiness that may also reduce vision. In some people, these abnormal protein fibers can accumulate under the cornea's outer layer--the epithelium. This can cause erosion of the epithelium. This condition is known as recurrent epithelial erosion. These erosions: (1) Alter the cornea's normal curvature, resulting in temporary vision problems; and (2) Expose the nerves that line the cornea, causing severe pain. Even the involuntary act of blinking can be painful. To ease this pain, a doctor may prescribe eye drops and ointments to reduce the friction on the eroded cornea. In some cases, an eye patch may be used to immobilise the eyelids. With effective care, these erosions usually heal within three days, although occasional sensations of pain may occur for the next six-toeight weeks. By about age 40, some people with lattice dystrophy will have scarring under the epithelium, resulting in a haze on the cornea that can greatly obscure vision. In this case, a corneal transplant may be needed. Although people with lattice dystrophy have an excellent chance for a successful transplant, the disease may also arise in the donor cornea in as little as three years. In one study, about half of the transplant patients with lattice dystrophy had a recurrence of the disease from between two to 26 years after the operation. Of these, 15 percent required a second corneal transplant. Early lattice and recurrent lattice arising in the donor cornea responds well to treatment with the excimer laser. Although lattice dystrophy can occur at any time in life, the condition usually arises in children between the ages of two and seven. Map-Dot-Fingerprint Dystrophy. This dystrophy occurs when the epithelium's basement membrane develops abnormally (the basement membrane serves as the foundation on which the epithelial cells, which absorb nutrients from tears, anchor and organize themselves). When the basement membrane develops abnormally, the epithelial cells cannot properly adhere to it. This, in turn, causes recurrent epithelial erosions, in which the epithelium's outermost layer rises slightly, exposing a small gap between the outermost layer and the rest of the cornea. Epithelial erosions can be a chronic problem. They may alter the cornea's normal curvature, causing periodic blurred vision. They may also expose the nerve endings that line the tissue, resulting in moderate to severe pain lasting as long as several days. Generally, the pain will be worse on awakening in the morning. Other symptoms include sensitivity to light, excessive tearing, and foreign body sensation in the eye. Map-dot-fingerprint dystrophy, which tends to occur in both eyes, usually affects adults between the ages of 40 and 70, although it can develop earlier in life. Also known as epithelial basement membrane dystrophy, map-dot-fingerprint dystrophy gets its name from the unusual appearance of the cornea during an eye examination. Most often, the affected epithelium will have a map-like appearance, i.e., large, slightly gray outlines that look like a continent on a map. There may also be clusters of opaque dots underneath or close to the map-like patches. Less frequently, the irregular basement membrane will form concentric lines in the central cornea that resemble small fingerprints. Typically, map-dot-fingerprint dystrophy will flare up occasionally for a few years and then go away on its own, with no lasting loss of vision. Most people never know that they have map-dot-fingerprint dystrophy, since they do not have any pain or vision loss. However, if treatment is needed, doctors will try to control the

pain associated with the epithelial erosions. They may patch the eye to immobilise it, or prescribe lubricating eye drops and ointments. With treatment, these erosions usually heal within three days, although periodic flashes of pain may occur for several weeks thereafter. Other treatments include anterior corneal punctures to allow better adherence of cells; corneal scraping to remove eroded areas of the cornea and allow regeneration of healthy epithelial tissue; and use of the excimer laser to remove surface irregularities. Ocular Herpes. Herpes of the eye, or ocular herpes, is a recurrent viral infection that is caused by the herpes simplex virus and is the most common infectious cause of corneal blindness in the U.S. Previous studies show that once people develop ocular herpes, they have up to a 50 percent chance of having a recurrence. This second flare-up could come weeks or even years after the initial occurrence. Ocular herpes can produce a painful sore on the eyelid or surface of the eye and cause inflammation of the cornea. Prompt treatment with anti-viral drugs helps to stop the herpes virus from multiplying and destroying epithelial cells. However, the infection may spread deeper into the cornea and develop into a more severe infection called stromal keratitis, which causes the body's immune system to attack and destroy stromal cells. Stromal keratitis is more difficult to treat than less severe ocular herpes infections. Recurrent episodes of stromal keratitis can cause scarring of the cornea, which can lead to loss of vision and possibly blindness. Like other herpetic infections, herpes of the eye can be controlled. An estimated 400,000 Americans have had some form of ocular herpes. Each year, nearly 50,000 new and recurring cases are diagnosed in the United States, with the more serious stromal keratitis accounting for about 25 percent. In one large study, researchers found that recurrence rate of ocular herpes was 10 percent within one year, 23 percent within two years, and 63 percent within 20 years. Some factors believed to be associated with recurrence include fever, stress, sunlight, and eye injury. Pterygium. A pterygium is a pinkish, triangular-shaped tissue growth on the cornea. Some pterygia grow slowly throughout a person's life, while others stop growing after a certain point. A pterygium rarely grows so large that it begins to cover the pupil of the eye. Pterygia are more common in sunny climates and in the 20-40 age group. Scientists do not know what causes pterygia to develop. However, since people who have pterygia usually have spent a significant time outdoors, many doctors believe ultraviolet (UV) light from the sun may be a factor. In areas where sunlight is strong, wearing protective eyeglasses, sunglasses, and/or hats with brims are suggested. While some studies report a higher prevalence of pterygia in men than in women, this may reflect different rates of exposure to UV light. Because a pterygium is visible, many people want to have it removed for cosmetic reasons. It is usually not too noticeable unless it becomes red and swollen from dust or air pollutants. Surgery to remove a pterygium is not recommended unless it affects vision. If a pterygium is surgically removed, it may grow back, particularly if the patient is less than 40 years of age. Lubricants can reduce the redness and provide relief from the chronic irritation. Stevens-Johnson Syndrome. Stevens-Johnson Syndrome (SJS), also called erythema multiforme major, is a disorder of the skin that can also affect the eyes. SJS is characterised by painful, blistery lesions on the skin and the mucous membranes (the thin, moist tissues that line body cavities) of the mouth, throat, genital region, and eyelids. SJS can cause serious eye problems, such as severe conjunctivitis; iritis, an inflammation inside the eye; corneal blisters and erosions; and corneal holes. In some cases, the ocular complications from SJS can be disabling and lead to severe vision loss. Scientists are not certain why SJS develops. The most commonly cited cause of SJS is an adverse allergic drug reaction. Almost any drug--but most particularly sulfa drugs--can cause SJS. The allergic reaction to the drug may not occur until 7-14 days after first using it. SJS can also be preceded by a viral infection, such as herpes or the mumps, and its accompanying fever, sore throat, and sluggishness. Treatment for the eye may include artificial tears, antibiotics, or corticosteroids. About one-third of all patients diagnosed with SJS have recurrences of the disease.

SJS occurs twice as often in men as women, and most cases appear in children and young adults under 30, although it can develop in people at any age. What is a corneal transplant? Is it safe? A corneal transplant involves replacing a diseased or scarred cornea with a new one. When the cornea becomes cloudy, light cannot penetrate the eye to reach the light-sensitive retina. Poor vision or blindness may result. In corneal transplant surgery, the surgeon removes the central portion of the cloudy cornea and replaces it with a clear cornea, usually donated through an eye bank. A trephine, an instrument like a cookie cutter, is used to remove the cloudy cornea. The surgeon places the new cornea in the opening and sews it with a very fine thread. The thread stays in for months or even years until the eye heals properly (removing the thread is quite simple and can easily be done in an ophthalmologist's office). Following surgery, eye drops to help promote healing will be needed for several months. Corneal transplants are very common in the United States; about 40,000 are performed each year. The chances of success of this operation have risen dramatically because of technological advances, such as less irritating sutures, or threads, which are often finer than a human hair; and the surgical microscope. Corneal transplantation has restored

sight to many, who a generation ago would have been blinded permanently by corneal injury, infection, or inherited corneal disease or degeneration. What problems can develop from a corneal transplant? Even with a fairly high success rate, some problems can develop, such as rejection of the new cornea. Warning signs for rejection are decreased vision, increased redness of the eye, increased pain, and increased sensitivity to light. If any of these last for more than six hours, you should immediately call your ophthalmologist. Rejection can be successfully treated if medication is administered at the first sign of symptoms. Are there alternatives to a corneal transplant? Phototherapeutic keratectomy (PTK) is one of the latest advances in eye care for the treatment of corneal dystrophies, corneal scars, and certain corneal infections. Only a short time ago, people with these disorders would most likely have needed a corneal transplant. By combining the precision of the excimer laser with the control of a computer, doctors can vaporize microscopically thin layers of diseased corneal tissue and etch away the surface irregularities associated with many corneal dystrophies and scars. Surrounding areas suffer relatively little trauma. New tissue can then grow over the now-smooth surface. Recovery from the procedure takes a matter of days, rather than months as with a transplant. The return of vision can occur rapidly, especially if the cause of the problem is confined to the top layer of the cornea. Studies have shown close to an 85 percent success rate in corneal repair using PTK for well-selected patients. One of the technologies developed to treat corneal disease is the excimer laser. This device emits pulses of ultraviolet light--a laser beam--to etch away surface irregularities of corneal tissue. Because of the laser's precision, damage to healthy, adjoining tissue is reduced or eliminated. The PTK procedure is especially useful for people with inherited disorders, whose scars or other corneal opacities limit vision by blocking the way images form on the retina. Diabetic Retinopathy What is diabetic retinopathy? Diabetic retinopathy is a complication of diabetes and a leading cause of blindness. It occurs when diabetes damages the tiny blood vessels inside the retina, the light-sensitive tissue at the back of the eye. A healthy retina is necessary for good vision. If you have diabetic retinopathy, at first you may notice no changes to your vision. But over time, diabetic retinopathy can get worse and cause vision loss. Diabetic retinopathy usually affects both eyes. What are the stages of diabetic retinopathy? Diabetic retinopathy has four stages: 1. Mild Nonproliferative Retinopathy. At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina's tiny blood vessels. 2. Moderate Nonproliferative Retinopathy. As the disease progresses, some blood vessels that nourish the retina are blocked. 3. Severe Nonproliferative Retinopathy. Many more blood vessels are blocked, depriving several areas of the retina with their blood supply. These areas of the retina send signals to the body to grow new blood vessels for nourishment. 4. Proliferative Retinopathy. At this advanced stage, the signals sent by the retina for nourishment trigger the growth of new blood vessels. This condition is called proliferative retinopathy. These new blood vessels are abnormal and fragile. They grow along the retina and along the surface of the clear, vitreous gel that fills the inside of the eye. By themselves, these blood vessels do not cause symptoms or vision loss. However, they have thin, fragile walls. If they leak blood, severe vision loss and even blindness can result. Who is at risk for diabetic retinopathy? All people with diabetes--both type 1 and type 2--are at risk. That's why everyone with diabetes should get a comprehensive dilated eye exam at least once a year. Between 40 to 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy. If you have diabetic retinopathy, your doctor can recommend treatment to help prevent its progression. During pregnancy, diabetic retinopathy may be a problem for women with diabetes. To protect vision, every pregnant woman with diabetes should have a comprehensive dilated eye exam as soon as possible. Your doctor may recommend additional exams during your pregnancy. How does diabetic retinopathy cause vision loss? Blood vessels damaged from diabetic retinopathy can cause vision loss in two ways: 1. Fragile, abnormal blood vessels can develop and leak blood into the center of the eye, blurring vision. This is proliferative retinopathy and is the fourth and most advanced stage of the disease. 2. Fluid can leak into the center of the macula, the part of the eye where sharp, straight-ahead vision occurs. The fluid makes the macula swell, blurring vision. This condition is called macular oedema. It can occur at any stage of diabetic retinopathy, although it is more likely to occur as the disease progresses. About half of the people with proliferative retinopathy also have macular oedema Does diabetic retinopathy have any symptoms? Diabetic retinopathy often has no early warning signs. Don't wait for symptoms. Be sure to have a comprehensive dilated eye exam at least once a year. What are the symptoms of proliferative retinopathy if bleeding occurs?

At first, you will see a few specks of blood, or spots, "floating" in your vision. If spots occur, see your eye care professional as soon as possible. You may need treatment before more serious bleeding occurs. Hemorrhages tend to happen more than once, often during sleep. Sometimes, without treatment, the spots clear, and you will see better. However, bleeding can reoccur and cause severely blurred vision. You need to be examined by your eye care professional at the first sign of blurred vision, before more bleeding occurs. If left untreated, proliferative retinopathy can cause severe vision loss and even blindness. Also, the earlier you receive treatment, the more likely treatment will be effective. How are macular oedema and diabetic retinopathy detected? Macular oedema and diabetic retinopathy are detected during a comprehensive eye exam that includes: y Visual acuity test. This eye chart test measures how well you see at various distances. y Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye problems. After the exam, your close-up vision may remain blurred for several hours. y Tonometry. An instrument measures the pressure inside the eye. Numbing drops may be applied to your eye for this test. Your eye care professional checks your retina for early signs of the disease, including: y Leaking blood vessels. y Retinal swelling (macular oedema). y Pale, fatty deposits on the retina--signs of leaking blood vessels. y Damaged nerve tissue. y Any changes to the blood vessels. If your eye care professional believes you need treatment for macular oedema, he or she may suggest a fluorescein angiogram. In this test, a special dye is injected into your arm. Pictures are taken as the dye passes through the blood vessels in your retina. The test allows your eye care professional to identify any leaking blood vessels and recommend treatment. How is a macular oedema treated? Macular oedema is treated with laser surgery. This procedure is called focal laser treatment. Your doctor places up to several hundred small laser burns in the areas of retinal leakage surrounding the macula. These burns slow the leakage of fluid and reduce the amount of fluid in the retina. The surgery is usually completed in one session. Further treatment may be needed. A patient may need focal laser surgery more than once to control the leaking fluid. If you have macular oedema in both eyes and require laser surgery, generally only one eye will be treated at a time, usually several weeks apart. Focal laser treatment stabilizes vision. In fact, focal laser treatment reduces the risk of vision loss by 50 percent. In a small number of cases, if vision is lost, it can be improved. Contact your eye care professional if you have vision loss. How is diabetic retinopathy treated? During the first three stages of diabetic retinopathy, no treatment is needed, unless you have macular oedema. To prevent progression of diabetic retinopathy, people with diabetes should control their levels of blood sugar, blood pressure, and blood cholesterol. Proliferative retinopathy is treated with laser surgery. This procedure is called scatter laser treatment. Scatter laser treatment helps to shrink the abnormal blood vessels. Your doctor places 1,000 to 2,000 laser burns in the areas of the retina away from the macula, causing the abnormal blood vessels to shrink. Because a high number of laser burns are necessary, two or more sessions usually are required to complete treatment. Although you may notice some loss of your side vision, scatter laser treatment can save the rest of your sight. Scatter laser treatment may slightly reduce your colour vision and night vision. Scatter laser treatment works better before the fragile, new blood vessels have started to bleed. That is why it is important to have regular, comprehensive dilated eye exams. Even if bleeding has started, scatter laser treatment may still be possible, depending on the amount of bleeding. If the bleeding is severe, you may need a surgical procedure called a vitrectomy. During a vitrectomy, blood is removed from the center of your eye. What happens during laser treatment? Both focal and scatter laser treatment are performed in your doctor's office or eye clinic. Before the surgery, your doctor will dilate your pupil and apply drops to numb the eye. The area behind your eye also may be numbed to prevent discomfort. The lights in the office will be dim. As you sit facing the laser machine, your doctor will hold a special lens to your eye. During the procedure, you may see flashes of light. These flashes eventually may create a stinging sensation that can be uncomfortable. You will need someone to drive you home after surgery. Because your pupil will remain dilated for a few hours, you should bring a pair of sunglasses. For the rest of the day, your vision will probably be a little blurry. If your eye hurts, your doctor can suggest treatment. What is a vitrectomy? If you have a lot of blood in the center of the eye (vitreous gel), you may need a vitrectomy to restore your sight. If you need vitrectomies in both eyes, they are usually done several weeks apart. A vitrectomy is performed under either local or general anaesthesia. Your doctor makes a tiny incision in your eye. Next, a small instrument is used to remove the vitreous gel that is clouded with blood. The vitreous gel is replaced with

a salt solution. Because the vitreous gel is mostly water, you will notice no change between the salt solution and the original vitreous gel. You will probably be able to return home after the vitrectomy. Some people stay in the hospital overnight. Your eye will be red and sensitive. You will need to wear an eye patch for a few days or weeks to protect your eye. You also will need to use medicated eyedrops to protect against infection. Are scatter laser treatment and vitrectomy effective in treating proliferative retinopathy? Yes. Both treatments are very effective in reducing vision loss. People with proliferative retinopathy have less than a five percent chance of becoming blind within five years when they get timely and appropriate treatment. Although both treatments have high success rates, they do not cure diabetic retinopathy. Once you have proliferative retinopathy, you always will be at risk for new bleeding. You may need treatment more than once to protect your sight. What can I do if I already have lost some vision from diabetic retinopathy? If you have lost some sight from diabetic retinopathy, ask your eye care professional about low vision services and devices that may help you make the most of your remaining vision. Ask for a referral to a specialist in low vision. Many community organisations and agencies offer information about low vision counselling, training, and other special services for people with visual impairments. A nearby school of medicine or optometry may provide low vision services. Floaters Floaters are little "cobwebs" or specks that float about in your field of vision. They are small, dark, shadowy shapes that can look like spots, thread-like strands, or squiggly lines. They move as your eyes move and seem to dart away when you try to look at them directly. They do not follow your eye movements precisely, and usually drift when your eyes stop moving. In most cases, floaters are part of the natural aging process and simply an annoyance. They can be distracting at first, but eventually tend to "settle" at the bottom of the eye, becoming less bothersome. They usually settle below the line of sight and do not go away completely. Most people have floaters and learn to ignore them; they are usually not noticed until they become numerous or more prominent. Floaters can become apparent when looking at something bright, such as white paper or a blue sky. Floaters occur when the vitreous, a gel-like substance that fills about 80 percent of the eye and helps it maintain a round shape, slowly shrinks. As the vitreous shrinks, it becomes somewhat stringy, and the strands can cast tiny shadows on the retina. These are floaters. Floaters are more likely to develop as we age and are more common in people who are very nearsighted, have diabetes, or who have had a cataract operation. There are other, more serious causes of floaters, including infection, inflammation (uveitis), haemorrhaging, retinal tears, and injury to the eye. Sometimes a section of the vitreous pulls the fine fibers away from the retina all at once, rather than gradually, causing many new floaters to appear suddenly. This is called a vitreous detachment, which in most cases is not sightthreatening and requires no treatment. However, a sudden increase in floaters, possibly accompanied by light flashes or peripheral (side) vision loss, could indicate a retinal detachment. A retinal detachment occurs when any part of the retina, the eye's light-sensitive tissue, is lifted or pulled from its normal position at the back wall of the eye. A retinal detachment is a serious condition and should always be considered an emergency. If left untreated, it can lead to permanent visual impairment within two or three days or even blindness in the eye. Those who experience a sudden increase in floaters, flashes of light in peripheral vision, or a loss of peripheral vision should have an eye care professional examine their eyes as soon as possible. For people who have floaters that are simply annoying, no treatment is recommended. On rare occasions, floaters can be so dense and numerous that they significantly affect vision. In these cases, a vitrectomy, a surgical procedure that removes floaters from the vitreous, may be needed. A vitrectomy removes the vitreous gel, along with its floating debris, from the eye. The vitreous is replaced with a salt solution. Because the vitreous is mostly water, you will not notice any change between the salt solution and the original vitreous. This operation carries significant risks to sight because of possible complications, which include retinal detachment, retinal tears, and cataract. Most eye surgeons are reluctant to recommend this surgery unless the floaters seriously interfere with vision. Glaucoma What is glaucoma? Glaucoma is a group of diseases that can damage the eye's optic nerve and result in vision loss and blindness. However, with early treatment, you can often protect your eyes against serious vision loss. What is the optic nerve? The optic nerve is a bundle of more than 1 million nerve fibers. It connects the retina to the brain. The retina is the light-sensitive tissue at the back of the eye. A healthy optic nerve is necessary for good vision. How does open-angle glaucoma damage the optic nerve? In the front of the eye is a space called the anterior chamber. A clear fluid flows continuously in and out of the chamber and nourishes nearby tissues. The fluid leaves the chamber at the open angle where the cornea and iris meet. When the fluid reaches the angle, it flows through a spongy meshwork, like a drain, and leaves the eye. Sometimes, when the fluid reaches the angle, it passes too slowly through the meshwork drain. As the fluid builds up, the pressure inside the eye rises to a level that may damage the optic nerve. When the optic nerve is damaged from increased pressure, open-angle glaucoma--and vision loss--may result. That's why controlling pressure inside the eye is important. Does increased eye pressure mean that I have glaucoma?

Not necessarily. Increased eye pressure means you are at risk for glaucoma, but does not mean you have the disease. A person has glaucoma only if the optic nerve is damaged. If you have increased eye pressure but no damage to the optic nerve, you do not have glaucoma. However, you are at risk. Follow the advice of your eye care professional. Can I develop glaucoma if I have increased eye pressure? Not necessarily. Not every person with increased eye pressure will develop glaucoma. Some people can tolerate higher eye pressure better than others. Also, a certain level of eye pressure may be high for one person but normal for another. Whether you develop glaucoma depends on the level of pressure your optic nerve can tolerate without being damaged. This level is different for each person. That's why a comprehensive dilated eye exam is very important. It can help your eye care professional determine what level of eye pressure is normal for you. Can I develop glaucoma without an increase in my eye pressure? Yes. Glaucoma can develop without increased eye pressure. This form of glaucoma is called low-tension or normaltension glaucoma. It is not as common as open-angle glaucoma. Who is at risk for open-angle glaucoma? Anyone can develop glaucoma. Some people are at higher risk than others. They include: y African Americans over age 40. y Everyone over age 60, especially Mexican Americans. y People with a family history of glaucoma. A comprehensive dilated eye exam can reveal more risk factors, such as high eye pressure, thinness of the cornea, and abnormal optic nerve anatomy. In some people with certain combinations of these high-risk factors, medicines in the form of eyedrops reduce the risk of developing glaucoma by about half. What are the symptoms of glaucoma? At first, open-angle glaucoma has no symptoms. It causes no pain. Vision stays normal. As glaucoma remains untreated, people may miss objects to the side and out of the corner of their eye. Without treatment, people with glaucoma will slowly lose their peripheral (side) vision. They seem to be looking through a tunnel. Over time, straight-ahead vision may decrease until no vision remains. Glaucoma can develop in one or both eyes. How is glaucoma detected? Glaucoma is detected through a comprehensive eye exam that includes: Visual acuity test. This eye chart test measures how well you see at various distances. Visual field test. This test measures your side (peripheral) vision. It helps your eye care professional tell if you have lost side vision, a sign of glaucoma. Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye problems. After the exam, your close-up vision may remain blurred for several hours. Tonometry. An instrument (right) measures the pressure inside the eye. Numbing drops may be applied to your eye for this test. Pachymetry. A numbing drop is applied to your eye. Your eye care professional uses an ultrasonic wave instrument to measure the thickness of your cornea. Can glaucoma be cured? No. There is no cure for glaucoma. Vision lost from the disease cannot be restored. Can glaucoma be treated? Yes. Immediate treatment for early stage, open-angle glaucoma can delay progression of the disease. That's why early diagnosis is very important. Glaucoma treatments include medicines, laser trabeculoplasty, conventional surgery, or a combination of any of these. While these treatments may save remaining vision, they do not improve sight already lost from glaucoma. Medicines. Medicines, in the form of eyedrops or pills, are the most common early treatment for glaucoma. Some medicines cause the eye to make less fluid. Others lower pressure by helping fluid drain from the eye. Before you begin glaucoma treatment, tell your eye care professional about other medicines you may be taking. Sometimes the drops can interfere with the way other medicines work. Glaucoma medicines may be taken several times a day. Most people have no problems. However, some medicines can cause headaches or other side effects. For example, drops may cause stinging, burning, and redness in the eyes. Many drugs are available to treat glaucoma. If you have problems with one medicine, tell your eye care professional. Treatment with a different dose or a new drug may be possible. Because glaucoma often has no symptoms, people may be tempted to stop taking, or may forget to take, their medicine. You need to use the drops or pills as long as they help control your eye pressure. Regular use is very important. Make sure your eye care professional shows you how to put the drops into your eye. Laser trabeculoplasty. Laser trabeculoplasty helps fluid drain out of the eye. Your doctor may suggest this step at any time. In many cases, you need to keep taking glaucoma drugs after this procedure. Laser trabeculoplasty is performed in your doctor's office or eye clinic. Before the surgery, numbing drops will be applied to your eye. As you sit facing the laser machine, your doctor will hold a special lens to your eye. A highintensity beam of light is aimed at the lens and reflected onto the meshwork inside your eye. You may see flashes of bright green or red light. The laser makes several evenly spaced burns that stretch the drainage holes in the meshwork. This allows the fluid to drain better.

Like any surgery, laser surgery can cause side effects, such as inflammation. Your doctor may give you some drops to take home for any soreness or inflammation inside the eye. You need to make several followup visits to have your eye pressure monitored. If you have glaucoma in both eyes, only one eye will be treated at a time. Laser treatments for each eye will be scheduled several days to several weeks apart. Studies show that laser surgery is very good at reducing the pressure in some patients. However, its effects can wear off over time. Your doctor may suggest further treatment. Conventional surgery. Conventional surgery makes a new opening for the fluid to leave the eye. Your doctor may suggest this treatment at any time. Conventional surgery often is done after medicines and laser surgery have failed to control pressure. Conventional surgery is performed in an eye clinic or hospital. Before the surgery, you will be given medicine to help you relax. Your doctor will make small injections around the eye to numb it. A small piece of tissue is removed to create a new channel for the fluid to drain from the eye. For several weeks after the surgery, you must put drops in the eye to fight infection and inflammation. These drops will be different from those you may have been using before surgery. As with laser surgery, conventional surgery is performed on one eye at a time. Usually the operations are four to six weeks apart. Conventional surgery is about 60 to 80 percent effective at lowering eye pressure. If the new drainage opening narrows, a second operation may be needed. Conventional surgery works best if you have not had previous eye surgery, such as a cataract operation. In some instances, your vision may not be as good as it was before conventional surgery. Conventional surgery can cause side effects, including cataract, problems with the cornea, and inflammation or infection inside the eye. The buildup of fluid in the back of the eye may cause some patients to see shadows in their vision. If you have any of these problems, tell your doctor so a treatment plan can be developed. What are some other forms of glaucoma? Open-angle glaucoma is the most common form. Some people have other types of the disease. In low-tension or normal-tension glaucoma, optic nerve damage and narrowed side vision occur in people with normal eye pressure. Lowering eye pressure at least 30 percent through medicines slows the disease in some people. Glaucoma may worsen in others despite low pressures. A comprehensive medical history is important in identifying other potential risk factors, such as low blood pressure, that contribute to low-tension glaucoma. If no risk factors are identified, the treatment options for low-tension glaucoma are the same as for open-angle glaucoma. In angle-closure glaucoma, the fluid at the front of the eye cannot reach the angle and leave the eye. The angle gets blocked by part of the iris. People with this type of glaucoma have a sudden increase in eye pressure. Symptoms include severe pain and nausea, as well as redness of the eye and blurred vision. If you have these symptoms, you need to seek treatment immediately. This is a medical emergency. If your doctor is unavailable, go to the nearest hospital or clinic. Without treatment to improve the flow of fluid, the eye can become blind in as few as one or two days. Usually, prompt laser surgery and medicines can clear the blockage and protect sight. In congenital glaucoma, children are born with a defect in the angle of the eye that slows the normal drainage of fluid. These children usually have obvious symptoms, such as cloudy eyes, sensitivity to light, and excessive tearing. Conventional surgery typically is the suggested treatment, because medicines may have unknown effects in infants and be difficult to administer. Surgery is safe and effective. If surgery is done promptly, these children usually have an excellent chance of having good vision. Secondary glaucomas can develop as complications of other medical conditions. These types of glaucomas are sometimes associated with eye surgery or advanced cataracts, eye injuries, certain eye tumours, or uveitis (eye inflammation).Pigmentary glaucoma occurs when pigment from the iris flakes off and blocks the meshwork, slowing fluid drainage. A severe form, called neovascular glaucoma, is linked to diabetes. Corticosteroid drugs used to treat eye inflammations and other diseases can trigger glaucoma in some people. Treatment includes medicines, laser surgery, or conventional surgery. What can I do if I already have lost some vision from glaucoma? If you have lost some sight from glaucoma, ask your eye care professional about low vision services and devices that may help you make the most of your remaining vision. Ask for a referral to a specialist in low vision. Many community organisations and agencies offer information about low vision counselling, training, and other special services for people with visual impairments. A nearby school of medicine or optometry may provide low vision services. Ocular Histoplasmosis Syndrome (OHS) What is histoplasmosis? Histoplasmosis is a disease caused when airborne spores of the fungusHistoplasma capsulatum are inhaled into the lungs, the primary infection site. This microscopic fungus, which is found throughout the world in river valleys and soil where bird or bat droppings accumulate, is released into the air when soil is disturbed by plowing fields, sweeping chicken coops, or digging holes. Histoplasmosis is often so mild that it produces no apparent symptoms. Any symptoms that might occur are often similar to those from a common cold. In fact, if you had histoplasmosis symptoms, you might dismiss them as those from a cold or flu, since the body's immune system normally overcomes the infection in a few days without treatment. However, histoplasmosis, even mild cases, can later cause a serious eye disease called ocular histoplasmosis syndrome (OHS), a leading cause of vision loss in Americans ages 20 to 40.

How does histoplasmosis cause ocular histoplasmosis syndrome? Scientists believe that Histoplasma capsulatum (histo) spores spread from the lungs to the eye, lodging in the choroid, a layer of blood vessels that provides blood and nutrients to the retina. The retina is the light-sensitive layer of tissue that lines the back of the eye. Scientists have not yet been able to detect any trace of the histo fungus in the eyes of patients with ocular histoplasmosis syndrome. Nevertheless, there is good reason to suspect the histo organism as the cause of OHS. How does OHS develop? OHS develops when fragile, abnormal blood vessels grow underneath the retina. These abnormal blood vessels form a lesion known as choroidal neovascularization (CNV). If left untreated, the CNV lesion can turn into scar tissue and replace the normal retinal tissue in the macula. The macula is the central part of the retina that provides the sharp, central vision that allows us to read a newspaper or drive a car. When this scar tissue forms, visual messages from the retina to the brain are affected, and vision loss results. Vision is also impaired when these abnormal blood vessels leak fluid and blood into the macula. If these abnormal blood vessels grow toward the center of the macula, they may affect a tiny depression called the fovea. The fovea is the region of the retina with the highest concentration of special retinal nerve cells, called cones,that produce sharp, daytime vision. Damage to the fovea and the cones can severely impair, and even destroy, this straight-ahead vision. Early treatment of OHS is essential; if the abnormal blood vessels have affected the fovea, controlling the disease will be more difficult. Since OHS rarely affects side, or peripheral vision, the disease does not cause total blindness. What are the symptoms of OHS? OHS usually has no symptoms in its early stages; the initial OHS infection usually subsides without the need for treatment. This is true for other histo infections; in fact, often the only evidence that the inflammation ever occurred are tiny scars called "histo spots," which remain at the infection sites. Histo spots do not generally affect vision, but for reasons that are still not well understood, they can result in complications years--sometimes even decades--after the original eye infection. Histo spots have been associated with the growth of the abnormal blood vessels underneath the retina. In later stages, OHS symptoms may appear if the abnormal blood vessels cause changes in vision. For example, straight lines may appear crooked or wavy, or a blind spot may appear in the field of vision. Because these symptoms indicate that OHS has already progressed enough to affect vision, anyone who has been exposed to histoplasmosis and perceives even slight changes in vision should consult an eye care professional. Who is at risk for OHS? Although only a tiny fraction of the people infected with the histo fungus ever develops OHS, any person who has had histoplasmosis should be alert for any changes in vision similar to those described above. Studies have shown the OHS patients usually test positive for previous exposure to histoplasmosis. In the United States, the highest incidence of histoplasmosis occurs in a region often referred to as the "Histo Belt," where up to 90 percent of the adult population has been infected by histoplasmosis. This region includes all of Arkansas, Kentucky, Missouri, Tennessee, and West Virginia as well as large portions of Alabama, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Mississippi, Nebraska, Ohio, Oklahoma, Texas, and Virginia. Since most cases of histoplasmosis are undiagnosed, anyone who has ever lived in an area known to have a high rate of histoplasmosis should consider having their eyes examined for histo spots. How is OHS diagnosed? An eye care professional will usually diagnose OHS if a careful eye examination reveals two conditions: (1) The presence of histo spots, which indicate previous exposure to the histo fungus spores; and (2) Swelling of the retina, which signals the growth of new, abnormal blood vessels. To confirm the diagnosis, a dilated eye examination must be performed. This means that the pupils are enlarged temporarily with special drops, allowing the eye care professional to better examine the retina. If fluid, blood, or abnormal blood vessels are present, an eye care professional may want to perform a diagnostic procedure called fluorescein angiography. In this procedure, a dye, injected into the patient's arm, travels to the blood vessels of the retina. The dye allows a better view of the CNV lesion, and photographs can document the location and extent to which it has spread. Particular attention is paid to how close the abnormal blood vessels are to the fovea. How is OHS treated? The only proven treatment for OHS is a form of laser surgery calledphotocoagulation. A small, powerful beam of light destroys the fragile, abnormal blood vessels, as well as a small amount of the overlying retinal tissue. Although the destruction of retinal tissue during the procedure can itself cause some loss of vision, this is done in the hope of protecting the fovea and preserving the finely-tuned vision it provides. How effective is laser surgery? Controlled clinical trials, sponsored by the National Eye Institute, have shown that photocoagulation can reduce future vision loss from OHS by more than half. The treatment is most effective when: y The CNV has not grown into the center of the fovea, where it can affect vision. y The eye care professional is able to identify and destroy the entire area of CNV. Does laser surgery restore lost vision? Laser photocoagulation usually does not restore lost vision. However, it does reduce the chance of further CNV growth and any resulting vision loss. Does laser surgery cure OHS? No. OHS cannot be cured. Once contracted, OHS remains a threat to a person's sight for their lifetime.

People with OHS who experience one bout of abnormal blood vessel growth may have recurrent CNV. Each recurrence can damage vision and may require additional laser therapy. It is crucial to detect and treat OHS as early as possible before it causes significant visual impairment. Is there a simple way to check for signs of OHS damage to the macula? Yes. A person can check for signs of damage to the macula by looking at a printed pattern called an Amsler grid. If the macula has been damaged, the vertical and horizontal lines of the grid may appear curved, or a blank spot may seem to appear. Many eye care professionals advise patients who have received treatment for OHS, as well as those with histo spots, to check their vision daily with the Amsler grid one eye at a time. Patients with OHS in one eye are likely to develop it in the other. What help is available for people who have already lost significant vision from OHS? Scientists and engineers have developed many useful devices to help people with severe visual impairment in both eyes. These devices, called low vision aids, use special lenses or electronics to create enlarged visual images. An eye care professional can suggest sources that provide information on counselling, training, and special services for people with low vision. Many organisations for people who are blind also serve those with low vision. Low Vision What is low vision? Low vision means that even with regular glasses, contact lenses, medicine, or surgery, people find everyday tasks difficult to do. Reading the mail, shopping, cooking, seeing the TV, and writing can seem challenging. Millions of people lose some of their vision every year. Irreversible vision loss is most common among people over age 65. Is losing vision just part of getting older? No. Some normal changes in our eyes and vision occur as we get older. However, these changes usually don't lead to low vision. Most people develop low vision because of eye diseases and health conditions like macular degeneration, cataract, glaucoma, and diabetes. A few people develop vision loss after eye injuries or from birth defects. While vision that's lost usually cannot be restored, many people can make the most of the vision they have. Your eye care professional can tell the difference between normal changes in the aging eye and those caused by eye diseases. How do I know if I have low vision? There are many signs that can signal vision loss. For example, even with your regular glasses, do you have difficulty: y Recognising faces of friends and relatives? y Doing things that require you to see well up close, like reading, cooking, sewing, or fixing things around the house? y Picking out and matching the colour of your clothes? y Doing things at work or home because lights seem dimmer than they used to? y Reading street and bus signs or the names of stores? Vision changes like these could be early warning signs of eye disease. Usually, the earlier your problem is diagnosed, the better the chance of successful treatment and keeping your remaining vision. How do I know when to get an eye exam? Regular dilated eye exams should be part of your routine health care. However, if you believe your vision has recently changed, you should see your eye care professional as soon as possible. What can I do if I have low vision? Many people with low vision are taking charge. They want more information about devices and services that can help them keep their independence. It's important to talk with your eye care professional about your vision problems. Even though it may be difficult, ask for help. Find out where you can get more information about services and devices that can help you. Macular Hole (Macular Cyst, Retinal Hole/Tear/Perforation) What is a macular hole? A macular hole is a small break in the macula, located in the center of the eye's light-sensitive tissue called the retina. The macula provides the sharp, central vision we need for reading, driving, and seeing fine detail. A macular hole can cause blurred and distorted central vision. Macular holes are related to aging and usually occur in people over age 60. Is a macular hole the same as age-related macular degeneration? No. Macular holes and age-related macular degeneration are two separate and distinct conditions, although the symptoms for each are similar. Both conditions are common in people 60 and over. An eye care professional will know the difference. What causes a macular hole? Most of the eye's interior is filled with vitreous, a gel-like substance that fills about 80 percent of the eye and helps it maintain a round shape. The vitreous contains millions of fine fibers that are attached to the surface of the retina. As we age, the vitreous slowly shrinks and pulls away from the retinal surface. Natural fluids fill the area where the vitreous has contracted. This is normal. In most cases, there are no adverse effects. Some patients may experience a small increase in floaters, which are little "cobwebs" or specks that seem to float about in your field of vision. However, if the vitreous is firmly attached to the retina when it pulls away, it can tear the retina and create a macular hole. Also, once the vitreous has pulled away from the surface of the retina, some of the fibers can remain on the

retinal surface and can contract. This increases tension on the retina and can lead to a macular hole. In either case, the fluid that has replaced the shrunken vitreous can then seep through the hole onto the macula, blurring and distorting central vision. Macular holes can also occur from eye disorders, such as high myopia (nearsightedness), macular pucker, and retinal detachment; eye disease, such diabetic retinopathy and Best's disease; and injury to the eye. What are the symptoms of a macular hole? Macular holes often begin gradually. In the early stage of a macular hole, people may notice a slight distortion or blurriness in their straight-ahead vision. Straight lines or objects can begin to look bent or wavy. Reading and performing other routine tasks with the affected eye become difficult. Are there different types of a macular hole? Yes. There are three stages to a macular hole: y Foveal detachments (Stage I). Without treatment, about half of Stage I macular holes will progress. y Partial-thickness holes (Stage II). Without treatment, about 70 percent of Stage II macular holes will progress. y Full-thickness holes (Stage III). The size of the hole and its location on the retina determine how much it will affect a person's vision. When a Stage III macular hole develops, most central and detailed vision can be lost. If left untreated, a macular hole can lead to a detached retina, a sight-threatening condition that should receive immediate medical attention. How is a macular hole treated? Although some macular holes can seal themselves and require no treatment, surgery is necessary in many cases to help improve vision. In this surgical procedure--called a vitrectomy--the vitreous gel is removed to prevent it from pulling on the retina and replaced with a bubble containing a mixture of air and gas. The bubble acts as an internal, temporary bandage that holds the edge of the macular hole in place as it heals. Surgery is performed under local anaesthesia and often on an out-patient basis. Following surgery, patients must remain in a face-down position, normally for a day or two but sometimes for as long as two-to-three weeks. This position allows the bubble to press against the macula and be gradually reabsorbed by the eye, sealing the hole. As the bubble is reabsorbed, the vitreous cavity refills with natural eye fluids. Maintaining a face-down position is crucial to the success of the surgery. Because this position can be difficult for many people, it is important to discuss this with your doctor before surgery. What are the risks of surgery? The most common risk following macular hole surgery is an increase in the rate of cataract development. In most patients, a cataract can progress rapidly, and often becomes severe enough to require removal. Other less common complications include infection and retinal detachment either during surgery or afterward, both of which can be immediately treated. For a few months after surgery, patients are not permitted to travel by air. Changes in air pressure may cause the bubble in the eye to expand, increasing pressure inside the eye. How successful is this surgery? Vision improvement varies from patient to patient. People that have had a macular hole for less than six months have a better chance of recovering vision than those who have had one for a longer period. Discuss vision recovery with your doctor before your surgery. Vision recovery can continue for as long as three months after surgery. What if I cannot remain in a face-down position after the surgery? If you cannot remain in a face-down position for the required period after surgery, vision recovery may not be successful. People who are unable to remain in a face-down position for this length of time may not be good candidates for a vitrectomy. However, there are a number of devices that can make the "face-down" recovery period easier on you. There are also some approaches that can decrease the amount of "face-down" time. Discuss these with your doctor. Is my other eye at risk? If a macular hole exists in one eye, there is a 10-15 percent chance that a macular hole will develop in your other eye over your lifetime. Your doctor can discuss this with you. Macular Pucker Other Names for Macular Pucker Epiretinal membrane, preretinal membrane, cellophane maculopathy, retina wrinkle, surface wrinkling retinopathy, premacular fibrosis, and internal limiting membrane disease. What is a macular pucker? A macular pucker is scar tissue that has formed on the eye's macula, located in the center of the eye's light-sensitive tissue called the retina. The macula provides the sharp, central vision we need for reading, driving, and seeing fine detail. A macular pucker can cause blurred and distorted central vision. Most of the eye's interior is filled with vitreous, a gel-like substance that fills about 80 percent of the eye and helps it maintain a round shape. The vitreous contains millions of fine fibers that are attached to the surface of the retina. As we age, the vitreous slowly shrinks and pulls away from the retinal surface. This is called a vitreous detachment, and is normal. In most cases, there are no adverse effects, except for a small increase in floaters, which are little "cobwebs" or specks that seem to float about in your field of vision. However, sometimes when the vitreous pulls away from the retina, there is microscopic damage to the retina's surface (Note: This is not a macular hole). When this happens, the retina begins a healing process to the damaged area and forms scar tissue, or an epiretinal membrane, on the surface of the retina. This scar tissue is firmly attached to the retina surface. When the scar tissue contracts, it causes the retina to wrinkle, or pucker, usually without any effect on

central vision. However, if the scar tissue has formed over the macula, our sharp, central vision becomes blurred and distorted. What causes a macular pucker? Most macular puckers are related to vitreous detachment, which usually occurs in people over age 50. As you age, you are at increased risk for macular pucker. A macular pucker can also be triggered by certain eye diseases and disorders, such as a detached retina and inflammation of the eye (uveitis). Also, people with diabetes sometimes develop an eye disease called diabetic retinopathy, which can cause a macular pucker. A macular pucker can also be caused by trauma from either surgery or an eye injury. What are the symptoms of a macular pucker? Vision loss from a macular pucker can vary from no loss to severe loss, although severe vision loss is uncommon. People with a macular pucker may notice that their vision is blurry or mildly distorted, and straight lines can appear wavy. They may have difficulty in seeing fine detail and reading small print. There may be a gray area in the center of your vision, or perhaps even a blind spot. Is a macular pucker the same as age-relaed macular degeneration? No. A macular pucker and age-related macular degeneration are two separate and distinct conditions, although the symptoms for each are similar. An eye care professional will know the difference. Can macular pucker get worse? For most people, vision remains stable and does not get progressively worse. Usually macular pucker affects one eye, although it may affect the other eye later. Is a macular pucker similar to a macular hole? A macular pucker and a macular hole are different conditions, although they both result from the same reason: The pulling on the retina from a shrinking vitreous. When the "pulling" causes microscopic damage, the retina can heal itself; scar tissue, or a macular pucker, can be the result. If the shrinking vitreous pulls too hard, it can tear the retina, creating a macular hole, which is more serious. Both conditions have similar symptoms - distorted and blurred vision. Also, a macular pucker will not "develop" into a macular hole. An eye care professional will know the difference. How is a macular pucker treated? A macular pucker usually requires no treatment. In many cases, the symptoms of vision distortion and blurriness are mild, and no treatment is necessary. People usually adjust to the mild visual distortion, since it does not affect activities of daily life, such as reading and driving. Neither eye drops, medications, nor nutritional supplements will improve vision distorted from macular pucker. Sometimes the scar tissue--which causes a macular pucker--separates from the retina, and the macular pucker clears up. Rarely, vision deteriorates to the point where it affects daily routine activities. However, when this happens, surgery may be recommended. This procedure is called a vitrectomy, in which the vitreous gel is removed to prevent it from pulling on the retina and replaced with a salt solution (Because the vitreous is mostly water, you will notice no change between the salt solution and the normal vitreous). Also, the scar tissue which causes the wrinkling is removed. A vitrectomy is usually performed under local anaesthesia. After the operation, you will need to wear an eye patch for a few days or weeks to protect the eye. You will also need to use medicated eye drops to protect against infection. How successful is this surgery? Surgery to repair a macular pucker is very delicate, and while vision improves in most cases, it does not usually return to normal. On average, about half of the vision lost from a macular pucker is restored; some people have significantly more vision restored, some less. In most cases, vision distortion is significantly reduced. Recovery of vision can take up to three months. Patients should talk with their eye care professional about whether treatment is appropriate. What are the risks of surgery? The most common complication of a vitrectomy is an increase in the rate of cataract development. Cataract surgery may be needed within a few years after the vitrectomy. Other, less common complications are retinal detachment either during or after surgery, and infection after surgery. Also, the macular pucker may grow back, but this is rare. Retinal Detachment (Detached Retina, Retinal Tear) What is retinal detachment? The retina is the light-sensitive layer of tissue that lines the inside of the eye and sends visual messages through the optic nerve to the brain. When the retina detaches, it is lifted or pulled from its normal position. If not promptly treated, retinal detachment can cause permanent vision loss. In some cases there may be small areas of the retina that are torn. These areas, called retinal tears or retinal breaks, can lead to retinal detachment. What are the symptoms of retinal detachment? Symptoms include a sudden or gradual increase in either the number of floaters, which are little "cobwebs" or specks that float about in your field of vision, and/or light flashes in the eye. Another symptom is the appearance of a curtain over the field of vision. A retinal detachment is a medical emergency. Anyone experiencing the symptoms of a retinal detachment should see an eye care professional immediately. What are the different types of retinal detachment? There are three different types of retinal detachment: Rhegmatogenous [reg-ma-TAH-jenous] -- A tear or break in the retina allows fluid to get under the retina and separate it from the retinal pigment epithelium (RPE), the pigmented cell layer that nourishes the retina. These types of retinal detachments are the most common.

Tractional -- In this type of detachment, scar tissue on the retina's surface contracts and causes the retina to separate from the RPE. This type of detachment is less common. Exudative -- Frequently caused by retinal diseases, including inflammatory disorders and injury/trauma to the eye. In this type, fluid leaks into the area underneath the retina, but there are no tears or breaks in the retina. Who is at risk for retinal detachment? A retinal detachment can occur at any age, but it is more common in people over age 40. It affects men more than women, and Whites more than African Americans. A retinal detachment is also more likely to occur in people who: y Are extremely nearsighted y Have had a retinal detachment in the other eye y Have a family history of retinal detachment y Have had cataract surgery y Have other eye diseases or disorders, such as retinoschisis, uveitis, degenerative myopia, or lattice degeneration y Have had an eye injury How is retinal detachment treated? Small holes and tears are treated with laser surgery or a freeze treatment called cryopexy. These procedures are usually performed in the doctor's office. During laser surgery tiny burns are made around the hole to "weld" the retina back into place. Cryopexy freezes the area around the hole and helps reattach the retina. Retinal detachments are treated with surgery that may require the patient to stay in the hospital. In some cases a scleral buckle, a tiny synthetic band, is attached to the outside of the eyeball to gently push the wall of the eye against the detached retina. If necessary, a vitrectomy may also be performed. During a vitrectomy, the doctor makes a tiny incision in the sclera (white of the eye). Next, a small instrument is placed into the eye to remove the vitreous, a gellike substance that fills the center of the eye and helps the eye maintain a round shape. Gas is often injected to into the eye to replace the vitreous and reattach the retina; the gas pushes the retina back against the wall of the eye. During the healing process, the eye makes fluid that gradually replaces the gas and fills the eye. With all of these procedures, either laser or cryopexy is used to "weld" the retina back in place. With modern therapy, over 90 percent of those with a retinal detachment can be successfully treated, although sometimes a second treatment is needed. However, the visual outcome is not always predictable. The final visual result may not be known for up to several months following surgery. Even under the best of circumstances, and even after multiple attempts at repair, treatment sometimes fails and vision may eventually be lost. Visual results are best if the retinal detachment is repaired before the macula (the center region of the retina responsible for fine, detailed vision) detaches. That is why it is important to contact an eye care professional immediately if you see a sudden or gradual increase in the number of floaters and/or light flashes, or a dark curtain over the field of vision. Retinopathy of Prematurity (ROP, Retrolental Fibroplasia) What is retinopathy of prematurity? Retinopathy of prematurity (ROP) is a potentially blinding eye disorder that primarily affects premature infants weighing about 2 pounds (1250 grams) or less that are born before 31 weeks of gestation (A full-term pregnancy has a gestation of 3842 weeks). The smaller a baby is at birth, the more likely that baby is to develop ROP. This disorder which usually develops in both eyesis one of the most common causes of visual loss in childhood and can lead to lifelong vision impairment and blindness. ROP was first diagnosed in 1942. How many infants have ROP? Today, with advances in neonatal care, smaller and more premature infants are being saved. These infants are at a much higher risk for ROP. Not all babies who are premature develop ROP. There are approximately 3.9 million infants born in the U.S. each year; of those, about 28,000 weigh 2 pounds or less. About 14,00016,000 of these infants are affected by some degree of ROP. The disease improves and leaves no permanent damage in milder cases of ROP. About 90 percent of all infants with ROP are in the milder category and do not need treatment. However, infants with more severe disease can develop impaired vision or even blindness. About 1,1001,500 infants annually develop ROP that is severe enough to require medical treatment. About 400600 infants each year in the US become legally blind from ROP. What causes ROP? ROP occurs when abnormal blood vessels grow and spread throughout the retina, the tissue that lines the back of the eye. These abnormal blood vessels are fragile and can leak, scarring the retina and pulling it out of position. This causes a retinal detachment. Retinal detachment is the main cause of visual impairment and blindness in ROP. Several complex factors may be responsible for the development of ROP. The eye starts to develop at about 16 weeks of pregnancy, when the blood vessels of the retina begin to form at the optic nerve in the back of the eye. The blood vessels grow gradually toward the edges of the developing retina, supplying oxygen and nutrients. During the last 12 weeks of a pregnancy, the eye develops rapidly. When a baby is born full-term, the retinal blood vessel growth is mostly complete (The retina usually finishes growing a few weeks to a month after birth). But if a baby is born prematurely, before these blood vessels have reached the edges of the retina, normal vessel growth may stop. The edges of the retinathe peripherymay not get enough oxygen and nutrients. Scientists believe that the periphery of the retina then sends out signals to other areas of the retina for nourishment. As a result, new abnormal vessels begin to grow. These new blood vessels are fragile and weak and can bleed, leading to retinal scarring. When these scars shrink, they pull on the retina, causing it to detach from the back of the eye. Are there different stages of ROP?

Yes. ROP is classified in five stages, ranging from mild (stage I) to severe (stage V): Stage I Mildly abnormal blood vessel growth. Many children who develop stage I improve with no treatment and eventually develop normal vision. The disease resolves on its own without further progression. Stage II Moderately abnormal blood vessel growth. Many children who develop stage II improve with no treatment and eventually develop normal vision. The disease resolves on its own without further progression. Stage III Severely abnormal blood vessel growth. The abnormal blood vessels grow toward the center of the eye instead of following their normal growth pattern along the surface of the retina. Some infants who develop stage III improve with no treatment and eventually develop normal vision. However, when infants have a certain degree of Stage III and "plus disease" develops, treatment is considered. "Plus disease" means that the blood vessels of the retina have become enlarged and twisted, indicating a worsening of the disease. Treatment at this point has a good chance of preventing retinal detachment. Stage IV Partially detached retina. Traction from the scar produced by bleeding, abnormal vessels pulls the retina away from the wall of the eye. Stage V Completely detached retina and the end stage of the disease. If the eye is left alone at this stage, the baby can have severe visual impairment and even blindness. Most babies who develop ROP have stages I or II. However, in a small number of babies, ROP worsens, sometimes very rapidly. Untreated ROP threatens to destroy vision. How is ROP treated? The most effective proven treatments for ROP are laser therapy or cryotherapy. Laser therapy "burns away" the periphery of the retina, which has no normal blood vessels. With cryotherapy, physicians use an instrument that generates freezing temperatures to briefly touch spots on the surface of the eye that overlie the periphery of the retina. Both laser treatment and cryotherapy destroy the peripheral areas of the retina, slowing or reversing the abnormal growth of blood vessels. Unfortunately, the treatments also destroy some side vision. This is done to save the most important part of our sightthe sharp, central vision we need for "straight ahead" activities such as reading, sewing, and driving. Both laser treatments and cryotherapy are performed only on infants with advanced ROP, particularly stage III with "plus disease." Both treatments are considered invasive surgeries on the eye, and doctors don't know the long-term side effects of each. In the later stages of ROP, other treatment options include: y Scleral buckle. This involves placing a silicone band around the eye and tightening it. This keeps the vitreous gel from pulling on the scar tissue and allows the retina to flatten back down onto the wall of the eye. Infants who have had a sclera buckle need to have the band removed months or years later, since the eye continues to grow; otherwise they will become nearsighted. Sclera buckles are usually performed on infants with stage IV or V. y Vitrectomy. Vitrectomy involves removing the vitreous and replacing it with a saline solution. After the vitreous has been removed, the scar tissue on the retina can be peeled back or cut away, allowing the retina to relax and lay back down against the eye wall. Vitrectomy is performed only at stage V. What happens if treatment does not work? While ROP treatment decreases the chances for vision loss, it does not always prevent it. Not all babies respond to ROP treatment, and the disease may get worse. If treatment for ROP does not work, a retinal detachment may develop. Often, only part of the retina detaches (stage IV). When this happens, no further treatments may be needed, since a partial detachment may remain the same or go away without treatment. However, in some instances, physicians may recommend treatment to try to prevent further advancement of the retinal detachment (stage V). If the center of the retina or the entire retina detaches, central vision is threatened, and surgery may be recommended to reattach the retina. Are there other risk factors for ROP? In addition to birth weight and how early a baby is born, other factors contributing to the risk of ROP include anemia, blood transfusions, respiratory distress, breathing difficulties, and the overall health of the infant. An ROP epidemic occurred in the 1940s and early 1950s when hospital nurseries began using excessively high levels of oxygen in incubators to save the lives of premature infants. During this time, ROP was the leading cause of blindness in children in the US. In 1954, scientists funded by the National Institutes of Health determined that the relatively high levels of oxygen routinely given to premature infants at that time were an important risk factor, and that reducing the level of oxygen given to premature babies reduced the incidence of ROP. With newer technology and methods to monitor the oxygen levels of infants, oxygen use as a risk factor has diminished in importance. Although it had been suggested as a factor in the development of ROP, researchers supported by the National Eye Institute determined that lighting levels in hospital nurseries has no effect on the development of ROP. Can ROP cause other complications? Yes. Infants with ROP are considered to be at higher risk for developing certain eye problems later in life, such as retinal detachment, myopia (nearsightedness), strabismus (crossed eyes), amblyopia (lazy eye), and glaucoma. In many cases, these eye problems can be treated or controlled. Usher Syndrome What Is Usher Syndrome? Usher syndrome is an inherited condition that causes 1) a serious hearing loss that is usually present at birth or shortly thereafter and 2) progressive vision loss caused by retinitis pigmentosa (RP). RP is a group of inherited diseases that

cause night-blindness and peripheral (side) vision loss through the progressive degeneration of the retina, the lightsensitive tissue at the back of the eye that is crucial for vision. Researchers have described three types of Usher syndrome-type I, type II and type III. y Individuals with Usher syndrome type I are nearly or completely deaf and experience problems with balance from a young age. They usually begin to exhibit signs of RP in early adolescence. y Individuals with Usher syndrome type II experience moderate to severe hearing impairment, have normal balance, and experience symptoms of RP later in adolescence. y Individuals with Usher syndrome type III are born with normal hearing but develop RP and then progressive hearing loss. How is Usher syndrome inherited? The Usher syndrome types are inherited as an autosomal recessive trait. This means that an affected person receives one abnormal gene from each of his or her parents. A person who inherits a gene from only one parent will be a carrier, but will not develop the disease. A person with Usher syndrome must pass on one disease gene to each of his or her children. However, unless the person has children with another carrier of Usher genes, the individual's children are not at risk for developing the disease. Currently we cannot reasonably test everyone for carrier status, but this may change in the years ahead. How is Usher syndrome diagnosed? Since individuals with Usher syndrome have both hearing and visual symptoms, we perform testing of both systems. This testing includes: 1. visual function tests: visual fields and electroretinogram (ERG) 2. a retinal examination 3. hearing tests 4. balance tests for all patients age ten years and older Although some of the genes that cause Usher syndrome have been identified, the diagnosis is still based on ocular and clinical testing. Is genetic testing for Usher syndrome available? At this time, genetic testing for Usher syndrome is done only as part of research projects. This is due to many factors. Usher syndrome is not caused by only one gene. So far, 10 Usher genes have been mapped: 7 for type I, 3 for type II, and 1 for type 3. There are still more genes to find. A few of these genes have been sequenced and described. These are MYO7A, harmonin, CDH23, PCDH15, all causing type I. The usherin gene causes type II disease. Finding the genes is a very important advance in the fight against Usher syndrome. Further study is required to characterise these genes, and determine how the mutated genes cause Usher syndrome. Additional genes that cause Usher syndrome also need to be identified. Several researchers throughout the world are working on Usher syndrome. Findings from this research may one day allow treatments for Usher syndrome to be developed. Vitreous Detachment Most of the eye's interior is filled with vitreous, a gel-like substance that helps the eye maintain a round shape. There are millions of fine fibers intertwined within the vitreous that are attached to the surface of the retina, the eye's lightsensitive tissue. As we age, the vitreous slowly shrinks, and these fine fibers pull on the retinal surface. Usually the fibers break, allowing the vitreous to separate and shrink from the retina. This is a vitreous detachment. In most cases, a vitreous detachment is not sight-threatening and requires no treatment. As the vitreous shrinks, it becomes somewhat stringy, and the strands can cast tiny shadows on the retina that you may notice as floaters, which appear as little "cobwebs" or specks that seem to float about in your field of vision. If you try to look at these shadows they appear to quickly dart out of the way. One symptom of a vitreous detachment is a small but sudden increase in the number of new floaters. This increase in floaters may be accompanied by flashes of light (lightning streaks) in your peripheral, or side, vision. In most cases, either you will not notice a vitreous detachment, or you will find it merely annoying because of the increase in floaters. A vitreous detachment is a common condition that usually affects people over age 50, and is very common after age 80. People who are nearsighted are also at increased risk. Those who have a vitreous detachment in one eye are likely to have one in the other, although it may not happen until years later. Although a vitreous detachment does not threaten sight, once in a while some of the vitreous fibers pull so hard on the retina that they create a macular hole or lead to a retinal detachment. Both of these conditions are sight-threatening and should be treated immediately. If left untreated, a macular hole or detached retina can lead to permanent vision loss in the affected eye. Those who experience a sudden increase in floaters or an increase in flashes of light in peripheral vision should have an eye care professional examine their eyes as soon as possible. The only way to diagnose the cause of the problem is by a comprehensive dilated eye examination. If the vitreous detachment has led to a macular hole or detached retina, early treatment can help prevent loss of vision.