NORMA: My "rotten" eye flashes quite a bit, depending on lighting conditions or stress. I know flashing might be an indication of trouble, but how can we tell which eye is flashing? How can we determine that it is not the good eye signaling trouble ahead? Also, I wonder if you might explain to me the difference between classic and occult md - sometimes the terms are confusing.

DR. SONKIN: "Flashes" can be a normal symptom of "normal" changes in the vitreous jelly, but is also concerning for retinal tears, retinal traction, and retinal detachment. Fluid under the macula can also cause flashes. It is true that it can be very difficult at times to determine which eye is causing the symptoms. If you are having new symptoms, the best advice is to see your retina doctor, and have it checked.

With regards to your question about classic versus occult wet AMD: try not to worry about this distinction. It is two different forms of wet AMD that are distinguished by the clinical appearance and angiogram findings. It is pertinent for the retina doctor and patient, in that this distinction helps to predict the natural history and is critical in deciding which, if any, treatment would be of benefit.

SHARON: My question today is with regards to drugs we should avoid or limit. It came to me that our personal physician may not fully understand our needs, particularly if they have not been clearly articulated to the doctor. Blood thinners would be a concern, Also, Vitamin E over 400 mg, and apparently steroids. What else should we be questioning?

DR. SONKIN: Systemic medications can affect the eyes. In theory, blood thinners may make active bleeds worse, but this has never been proven. Also, blood thinners have never been shown to increase the risk of macular bleeding from AMD. I tell my patients that if they need to be on aspirin or other "antiplatelet" medications to reduce the risk of stroke, heart attack, etc., that this should take precedence over the small risk to the eye. For patients on coumadin, it is important to make sure the dose is correct and that the PT is at the appropriate level (this is a measure of how effectively the blood is thinned).

SHARON: I also require a definition, if you would be so kind. What does it mean when they say to the right of the disc? Is this the macula? Can you explain disciform scar please. Is there a relationship between the two?

DR. SONKIN: To the "right" of the macula means nothing unless you know which eye. We also do not use the terms right or left. Instead, we describe retinal location in reference to landmarks (e.g. the disk or macula) as being either temporal or nasal. Nasal means towards the nasal side, and temporal away from the nasal side. "Temporal" to the disk refers to the macula. Disciform scarring is the fibrosis and scarring that develops in the later stages of wet AMD.

STEPHANIE: Do you have any thoughts or hopes for stem cell research/progress in the near future? Do you have any ideas about new things on the horizon in that area of research?

DR. SONKIN: This sort of research holds hopes for the future, but is not clinically applicable at this time. It is directed at trying to restore normal RPE cells in the macula. There is great research work ongoing, and hopefully it will add to our treatment options in the future.

SUE: Of what practical use is an angiogram or series of angiograms when a patient only has drusen, for which nothing can be done?

DR. SONKIN: Fluorescein angiograms are done to help with treatment, treatment decisions, and sometimes to help with diagnosis. We often get angiograms to check for "wet" CNV growth even if not detected on clinical exam, particularly if the patient is having new symptoms or if the patient has high-risk changes, such as multiple soft drusen, extensive atrophy, irregular RPE, etc. We also sometimes get fluorescein angiograms to evaluate the degree of atrophy (dry changes) and to evaluate the retinal circulation. There is a small risk of allergic reaction, GI symptoms including nausea, etc. There is no risk of permanent damage to the retina.

JACK: My report said: "A fluorescein angiogram confirmed the presence of blocked choroidal fluorescene due to the buildup of lipofusin within the pigment epithelial cells..." Is that typical for Stargardt's? Or is it some additional complication?

DR. SONKIN: Your FA description sounds consistent with Stargardt's. The FA in Stargardt's has a very typical appearance known as a "silent choroid," where the normally visible choroidal circulation is "blocked" as you described. You also get blocked fluorescence from the "flecks" associated with the disease and the RPE pigmentary changes that can develop in the macula. Ask your retina doctor to clarify at your next appointment.

SHERRY: I have glaucoma and had trabeculectomies in both eyes. The most recent one in April developed hypotony right after surgery due to a couple of small bleb leaks. The hypotony resolved in a couple of weeks and my pressures are now excellent, hovering around 8. I was left with some sort of maculopathy. What questions should I be asking the RS when I see him again?

DR. SONKIN: Low pressure (hypotony) after glaucoma surgery is not uncommon. In some cases, it can result in a "hypotony maculopathy", choroidal folds, choroidal hemorrhages, etc. Hypotony-related changes are treated by bringing the pressure up if it is close to zero. It sounds like your pressure is good now. I would wait and see what the retina surgeon finds on exam, and then make sure you have a good understanding of what the problem is, why the vision is reduced, and whether or not there is any treatment that might help.

TESS: I had a bad experience with a retinal surgeon and that has left me wary of them ever since. I know all retinal surgeons are individuals, that they are only human, and should be judged on their own merits. However, when once has been "burned" it is very hard to give that trust back. Probably, in my case, it helps that my optometrist is a low vision specialist who is very familiar with my condition. We have a very good rapor, as he is honest, down to earth, very understanding and, every so often, is quite direct. I know he has my best intersests at heart. I do think it is important to have professionals you feel you can trust. After all, it is your vision they are dealing with!

DR. SONKIN: Retina surgeons are no different than dermatologist, optometrists, hair dressers, salesmen, lawyers, etc., in that there are good ones and bad ones. Although it is hard not to prejudge based on bad experiences, I can assure you there are more good ones than bad ones. If your optometrist finds a new active problem, don't be afraid to see a new retina specialist. After all, you are always in control of what is done, and if you do not agree or understand what is told to you, you can always get a second opinion. This holds true for all that we do, whether it is a recommendation from a retina doctor regarding treatment, or a recommendation from a hardware store salesperson regarding what type of paint to use. Good luck, and remember that the final decision is always the patient's decision.

DOTTIE: I just received an e-mail from my friend who had a torn retina. I know she had it operated on and now I received this. Could you explain just what is going on? She wrote: "I saw the retina man on October 30th. Would you believe I must have further surgery. When the retina tore, little pieces of it flaked off and that is floating around behind the eye. Also, scar tissue has formed and he said he must go inside the eye to extract the jell and that will remove all that crud that is floating around in there."

DR. SONKIN: Your friend's description can mean several things. When we develop a PVD (vitreous separation), it can pull on the retina and cause a tear. If this is caught when it is just a tear, we "seal" the tear down with either laser or cryotherapy. If fluid gets through the tear and under the retina, this is a retinal detachment, and it requires surgery. After a simple PVD, we can frequently develop a "scar tissue" on the macula that causes a wrinkling or puckering. This is known as a macular pucker or epiretinal membrane (erm). What your friend describes sounds most like an erm that has probably caused a reduction or distortion in central vision. The other possibility is that she has developed proliferative vitreoretinopathy (PVR), which is another form of scar tissue that grows diffusely over the retina, including the periphery. This is much more damaging and can sometimes result in a recurrent RD that is difficult to fix.

DR. SONKIN: I have a macular pucker. Could this have been caused by my cataract surgery? Do I need to ask if I should have surgery to have it repaired?

DR. SONKIN: Macular pucker usually occurs after posterior vitreous separation (PVD), but it can be idiopathic or related to such things as retinal vein occlusion, uveitis, etc. Puckers should be removed surgically only if they are visually significant, and this varies from patient to patient. Many surgeons use 20/70 as an approximate cutoff, but in some patients, 20/40 can be bothersome enough to warrant surgery. It is also important to make sure there is not another problem that is causing the majority of the visual disturbance, e.g. cataract, AMD, etc.

JACK: Does the MD get worse faster if you use your eyes for a lot of detail work like reading, computer use, etc?

DR. SONKIN: Although reading and focusing may cause some "straining," this does not have an effect on the health of the macula. I would recommend continuing with activities that you enjoy, and rest when needed.

JACK: I just read recently, (on the MDForum I believe), that Stargardt's (recessive type) skips a generation. Is that true even if both parents have the gene and pass it on?

DR. SONKIN: Stargardt's is a hereditary disease usually with a recessive inheritance pattern (some dominant forms reported). Recessive diseases skip generations, and do require both parents to either be affected or carriers of the abnormal gene to pass the disease to an offspring.

JACK: What are your thoughts on what is happening with retina implants?

DR. SONKIN: A friend of mine is at the forefront of research into retinal implants. His name is Dr. Mark Humayan, who was formerly at Wilmer Eye Institute (Johns Hopkins), but recently moved to Doheny at USC. Retinal implants are mostly applicable for patients with total or near total blindness, and potentially provides the ability to see light. It is not clinically available and is still being researched. Fortunately, patients with AMD have much better vision already.

KAY After reading about central serous retinopathy, I decided it could be as bad as MD or worse. Couldn't this be found with the extensive exam the RS gave me? I have signed a form ready to mail asking for my records, which I believe another expert should look at. What is your opinion?

DR. SONKIN: CSR overall has a much much better prognosis than AMD, although there is variability with each condition. If you feel unsure of your diagnosis, there is no harm in seeking another opinion.

DR. STROUSE: Recently, there was a discussion on the MDList about the proper amount of lutein a person with macular degeneration should take per day, and there is a lot of variation in the amounts recommended. Robert Abel, Jr., MD recommends 6mg for several months and then 2mg daily after that. Edward Paul, OD, PhD recommends a minimum of 12mg per day. What amount do you recommend? Have you read other articles with varying amounts recommended?

Also, Dr. Abel recommends taking DHA (the omega-3 fatty acid) which is found mainly in oily fish, such as tuna, mackerel, and salmon. He recommends that his macular degeneration patients take an antioxidant, a separate lutein supplement, and 500mg DHA. What have you read about DHA and what would you recommend to the MDListers?

DR. SONKIN: The only good prospective placebo-controlled study that I know of examining the role of vitamins in AMD is the recently released AREDS study. The benefits were limited to a few subgroups and were not overwhelming. The data is for 5 years of follow-up. Some potential side effects were discussed.

I still recommend a good multivitamin and well-balanced diet. I do not believe there is enough in the literature to warrant a recommendation other than this to my patients. If a patient wants to take higher doses of vitamins, I try to discuss the potential side effects and the potential risks/benefits, and I leave it up to them. Hopefully we will have more information in the future.

DAN: Many of you have written to thank Dr. Sonkin for his time during this past week, and I want to add my words of appreciation. This has been one of our most active sessions, and I'm sure it is due to his obvious expertise and the concern which he shows. This discussion will remain permanently in our Clinic section for the benefit of future visitors to our site and for continued reference by us. Dr. Sonkin, we greatly appreciate the time you have spent with us.

DR. SONKIN: I have really enjoyed the last two weeks of discussion, and I hope my participation has helped to answer your questions and concerns. I have also learned a lot from our conversations, and I am sure this experience will only help me in communicating with my own patients. I look forward to another session in the future, and I wish you all the best.