The retina is the light-sensitive tissue lining the back of our eye. Light rays are focused onto the retina through our cornea, pupil and lens. The retina then converts the light rays into impulses that travel through the optic nerve to our brain, where they are interpreted as the images we see. Distortions of vision, such as blurred words on a page, dark spots that appear in the center of vision, or straight lines that appear wavy, can all be signs of a retinal condition.
Sushma K. Vance, MD
At Atlantic Retina, Dr. Sushma Vance provides advanced diagnostic testing and minimally invasive treatments to manage retinal diseases and conditions.
Dr. Vance is a board certified, fellowship trained retina specialist. She graduated with distinction from the University of Michigan in biology and anthropology and received her medical degree and ophthalmology residency training at Northeast Ohio Medical University. While in residency, Dr. Vance authored and secured several research and community service grants and was also awarded the William H. Falor award for best resident research. After completing her ophthalmology residency, Dr. Vance completed a medical retina fellowship at the Vitreous Retina Macula Consultants of New York and the Manhattan Eye, Ear, and Throat Hospital followed by a surgical retina fellowship with Texas Retina Associates in Dallas. After fellowship, Dr. Vance was in private practice for six years before joining the Atlantic Eye Institute in January 2017. Dr. Vance specializes in the treatment of age-related macular degeneration, diabetic retinopathy, retinal vascular disease, retinal tears and detachments, uveitis, and inherited retinal diseases.
During your visit, Dr. Vance may order testing to understand your unique condition better. This will allow her to determine the best course of treatment for you. Some tests may be repeated to monitor any changes in your condition throughout your treatment. These tests are performed in the comfort of our office by one of our compassionate and friendly retina technicians.
Fluorescein and Indocyanine Green (ICG)
Angiographies are very useful for finding leakage or damage to the blood vessels which nourish the retina. In both tests, a colored dye is injected into your arm. The dye travels through the veins and into the arteries that circulate throughout the body. As the dye passes through the blood vessels of the retina, a technician uses a special camera to take a series of photographs. These photographs will reveal the condition of the blood vessels within the retina. This information is used to determine whether additional monitoring, laser procedures or injections are warranted.
Optical Coherence Tomography (OCT)
OCTs allow for the imaging and measurement of retinal thickness. It is very useful in detecting retinal swelling or fluid accumulation due to a variety of retinal conditions. It is also helpful for following the response of a retinal treatment.
Fundus Autofluorescence (FAF)
FAF is an imaging technique which assesses the retina at a metabolic level and can be used to detect certain eye diseases, which may not yet be visible when viewing the retina with more traditional methods. It works by identifying chemical structures called fluorophores. When exposed to a particular wavelength of light, fluorophores become illuminated.
FAF is an effective method of detecting early signs of retinal disease and can be used as a diagnostic or monitoring tool for hereditary conditions such as Best’s and Stargardt’s disease. It has also been shown to detect early stages of Macular Degeneration.
B-scans use sound waves to view the internal structures of the eye. It is used when the physician cannot obtain a clear view of your retina or other internal structures due to bleeding, a dense cataract, corneal cloudiness or lesions. It can also be used to locate, measure, and follow tumors and other abnormalities.
Common Retinal Diseases & Conditions:
Age-Related Macular Degeneration (AMD)
AMD is the deterioration of the macula, the center of the retina that accounts for sharp, central vision. This vision is important for reading, driving, and seeing fine detail. AMD comes in two forms, dry and wet. Dry AMD is the most common type for people over the age of 50, and it usually progresses slowly appearing as distorted, wavy vision. There is typically no treatment for dry AMD, but if your condition is diagnosed early, you can take steps to slow its progression, such as taking vitamins, supplements, eating healthy and not smoking. It should also be closely monitored with yearly dilated exams to assure that it does not progress into the wet form. In between visits, you can do a self-assessment of your vision using an Amsler grid[link to grid].
Wet AMD is caused when new blood vessels grow under the retina and leak into the macula causing loss of vision. It is usually sudden in onset and can appear as dark spots in the center of your vision. Wet AMD may be treated with injections, photodynamic therapy or laser surgery. None of these treatments cure AMD but may slow the rate of vision decline or stop further vision loss.
Diabetic Retinopathy is a complication of diabetes which causes abnormalities in the tiny blood vessels nourishing the retina. These vessels weaken, leak fluid and blood, and fail to provide nutrients necessary for good retinal health. Left untreated, diabetic retinopathy can result in a severe visual loss, including blindness. Diabetic retinopathy can take two forms, non-proliferative retinopathy and proliferative retinopathy.
Non-proliferative diabetic retinopathy (NPDR) is considered the early stage of the disease in which small blood vessels in the retina leak a clear fluid into the surrounding tissue which causes swelling. Abnormal blood vessels may also hemorrhage or leak fats and proteins which form deposits. If fluid collects in the macula, the center of the retina, diminished or blurred vision will result. However, if leakage or deposits occur in the outer edges of the retina, no symptoms may be noticed.
Proliferative diabetic retinopathy (PDR) is the more advanced stage of the disease. New abnormal blood vessels grow over the retina. These new blood vessels bleed into the vitreous, blocking light from reaching the retina and causing vision to become cloudy. Connective tissue growing along the abnormal blood vessels may contract, pulling the retina off its underlying structures and towards the vitreous (retinal detachment).
Treatment of diabetic retinopathy depends on the location of the disease and the degree of damage to the retina. If retinopathy occurs in the peripheral retina, careful monitoring may be all that is necessary. When retinopathy affects the macula and central vision, laser treatment, intravitreal injections, or surgery may be necessary. Early detection and management are important to arrest or slow the development of the more sight damaging stages of the disease. Even when no symptoms are noticed, those with diabetes should have frequent eye examinations, as recommended by their doctor. With careful monitoring, treatment of diabetic retinopathy can usually be started before sight is affected.
Hypertensive Retinopathy is damage to the retina caused by high blood pressure. Symptoms usually do not develop until late in the disease and include blurred vision or visual field defects. Hypertensive retinopathy is managed primarily by controlling blood pressure, but if vision loss occurs, treatment with laser or with intravitreal injections of corticosteroids or anti-vascular endothelial growth factor (anti-VEGF) drugs may be useful.
Retinal Artery Occlusion
Retinal Artery Occlusion occurs when there is a blockage in one of the blood vessels that supply blood to the eye. This blockage prevents oxygen and important nutrients from getting to the retina. A retinal artery occlusion causes a painless, yet the sudden loss of vision in one eye. This can affect all or just part of your visual field – depending on whether it affects the central artery or a branched artery. It is incredibly important that you receive treatment immediately or else vision loss in that area can be permanent.
There is no treatment for artery occlusions. However, the formation of new retinal blood vessels that are prone to bleed is a rare complication. The growth of these vessels can further decrease vision. If this happens, laser photocoagulation therapy is used to create burns in the area of the blocked artery to try to lower the oxygen demand of the retina and thus stop the abnormal blood vessels from growing. Anti-VEGF intravitreal injections such as Avastin®, Lucentis® or Eylea® may also be used in such cases.
Retinal Vein Occlusion
Retinal vein occlusion refers to a blockage of retinal veins that are responsible for carrying deoxygenated blood away from the nerve cells in the retina. This leads to bleeding and leakage of fluid from the blocked blood vessels. A blockage in the retina’s main vein is called central retinal vein occlusion (CRVO), and a blockage in a smaller vein is called branch retinal vein occlusion (BRVO). The symptoms of retinal vein occlusion range from subtle to very obvious and can present as a painless, blurring or loss of vision in one eye. This can be progressive over time or present as a complete loss of vision immediately. Treatment options include intravitreal injections of corticosteroids or anti-VEGF drugs, focal laser therapy, and pan-retinal photocoagulation therapy.
The macula is the center of the retina that provides central vision. A macular pucker is the wrinkling or scarring of the macula causing distorted, wavy vision. Most of the time this condition can be simply monitored through a dilated exam, special testing and home monitoring with an Amsler grid [link to grid]. If a macular pucker is torn, it can cause a macular hole – a small break in the macula, that can lead to blurred, distorted or missing vision. This condition often requires surgery to repair the retina to restore vision.
Retinal Tears & Detachments
Retinal Tears and Detachments most often occur after the age of 40 as a result of the natural aging process where the clear fluid which fills the inner cavity of the eye (vitreous) begins to shrink and pull away from the retina. Most of the time this process causes no damage to the eye. However, sometimes the vitreous remains attached to the retina during shrinkage and causes the retina to tear. Left untreated, retinal tears can lead to retinal detachments. The part of the retina which becomes detached will not function properly, resulting in vision loss.
Persons who are severely nearsighted, have a family history of retinal problems, or have undergone eye surgery are more likely to develop the disease. Retinal detachments can also be caused by significant eye injuries, tumors, inflammation, and complications of diabetes.
Symptoms of a retinal tear or detachment may include decreased vision, flashes of light, black spots or lines in the field of vision, and/or a curtain or veil coming across the field of vision. Treatment options depend on the severity of the tear or detachments as well as the location.
Uveitis is inflammation of the uvea, which is the middle layer of the eye’s surface, comprised of the iris, choroid, and ciliary body. Uveitis can be caused by a variety of factors: from a bacterial or viral infection, an eye injury, or an autoimmune disorder. Common symptoms of uveitis include light sensitivity, redness of the eye, and floaters, which are moving dark spots in your vision. If left untreated, it can cause vision loss. Treatment for uveitis includes the use of dark glasses or medication to dilate your pupil, allowing your iris to rest and heal; corticosteroid injections to decrease inflammation; or in the case of an infection, antibiotics or antiviral medication.
Retinitis Pigmentosa (RP)
Retinitis Pigmentosa (RP) is a rare, inherited retinal disease that can lead to vision loss. Over time, RP causes the breakdown of photoreceptor cells, which are responsible for capturing light. Because these cells help us to see, losing these cells leads to decreased vision. Symptoms commonly begin in childhood. Children with RP will often have difficulty getting around in the dark or take a noticeably long time to adjust to changes in lighting. As the condition progresses, people with RP lose more and more of their peripheral vision, causing tunnel vision. This restricted visual field can make bright lights uncomfortable and can cause patients to trip over objects easily or struggle with reading, driving, walking without assistance, or recognizing faces. While there is no cure for RP, Dr. Vance can recommend treatments to slow its progression.
Minimally Invasive Procedures:
MicroPulse Laser Therapy
MicroPulse Laser Therapy is effective with conditions such as retinal tears and complications from diabetic macular edema. This treatment uses a laser to seal the area around a retinal tear to prevent a retinal detachment. When treating diabetic macular edema, this treatment helps prevent recurrent swelling, helping to preserve vision.
Argon Laser Photocoagulation
Argon Laser Photocoagulation can be used in people who have abnormal blood vessels commonly caused by retinal occlusions and diabetic retinopathy. This laser is applied to the peripheral retinal, shrinking the abnormal blood vessels and often prevents them from regrowing. This decreases the risk of blood vessels bleeding into the back of the eye causing further vision loss.
Pneumatic Retinopexy is a treatment option for certain types of retinal detachments. During the procedure a gas bubble is injected into the vitreous. As the gas bubble rises, it presses the retina back into place. The bubble is usually absorbed into the eye within 1 to 3 weeks.
Subtenon & Intravitreal Injections
Subtenon & Intravitreal Injections are common procedures used to slow or prevent progression of sight-threatening retinal conditions. It involves administering a medication into the vitreous, the jelly like structure that fills the middle of the eye. This allows the medication to be placed much closer to where the condition is occurring, while decreasing the risk of side effects. Two types of medications commonly used are Corticosteroids and Anti-VEGF drugs such as Avastin, Lucentis or Eyelea.
Once the eyes are dilated and examined, the actual procedure takes very little time. You will lie face up in a comfortable position and your eyes will be numbed with drops. Dr. Vance will then use a device to separate your eyelids and keep your eyes open. During the injection, you may feel some slight pressure on the eye, but you should not experience any pain. After the procedure, some patients may notice the appearance of floaters, but these usually disappear after several days. Depending on your condition, injections may be administered as frequently as every month to attain the best results.