Surgical and Medical Retina

General Information when You are Referred to our Retinal Specialists
Age Related Macular Degeneration (AMD)
Macular Pucker
Macular Hole Surgery
Branch Retinal Vein Occlusion (BRVO)
Central Retinal Vein Occlusion (CRVO)

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General Information when You are Referred to our Retinal Specialists

You will have been referred to one of our Retinal Surgeons because of their recognised expertise in retinal diseases. Our Retinal specialists concentrate on the internal structures of the eye, for example macular degeneration, diabetic damage and retinal detachments. They do not normally prescribe glasses or treat ‘weeping or dry eye’. Therefore it is necessary that you continue to see your Optometrist/General Ophthalmologist for non-retinal conditions or general eye checks.

Your consultation will include an initial assessment by an Orthoptist (a university trained allied health professional) including a full ocular history, vision testing and intraocular pressure measurement. Drops will then be instilled to enlarge your pupils to facilitate detailed examination of the internal eye. These drops take up to ½ hour to work and you will be asked to return to the waiting room whilst the drops take effect.

Depending upon what is found in the initial examination, you may be required to undergo further testing to assist in a more definitive diagnosis. This may include:

Fluorescein Angiogram - During this test a special yellow dye is injected into a vein in your arm or hand. This dye passes through blood vessels in the retina and photos are taken to detect whether abnormal blood vessels have grown or if dye has leaked from damage retinal blood vessels.

Ocular Coherence Tomography (OCT) - OCT is the most important advance in the diagnosis and treatment of diseases of the retina and vitreous in the last 30 years. The test requires you to be seated at a machine whilst an operator uses a very low power laser beam to scan the retinal surface to detect irregularities of the retinal surface, thickening or other abnormality of the retina.

Other tests - Specific colour vision testing, visual field testing or other glaucoma measurements or ultrasound examination may be necessary.

Therefore it is necessary for you to allow 1½ - 2 hours for your appointment. We also recommend that you bring a relative or friend along as you will be unable to drive home because the dilation of your eyes will last for several hours. As the diagnosis and suggested treatment can be complicated, someone with you can help remember all that is said, providing you with an opportunity to discuss the outcomes at a time when you are under a little less stress.

You may be asked to read and complete forms relevant to your consultation with the Doctor. When your appointment is confirmed we will provide these forms or links to those that appear on our website if this suits you better. In preparing for you visit please note any questions you may have regarding the possible tests so that these can be answered prior to the test being undertaken.

Our costs are listed on the Eye Surgery Associates registration form, which you are welcome to print and fill in as completely as you can before your first visit - we will help you finalise the form when you first visit us.

In the meantime our staff are happy to discuss the likely costs with you. Most of our costs are claimable through Medicare and adjustments may be made to the cost of multiple procedures by the Doctor to ensure that your out of pocket costs are kept to a reasonable level. If you have any questions, please do not hesitate to contact our rooms on 9509 4233.

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Age Related Macular Degeneration (AMD)

Preventive strategies

In Summary:

  • Try hard to include antioxidants, and healthy lifestyle and dietary choices in your daily way of life.
  • Report any changes promptly. Any sudden changes to your vision will not be related to cataracts or glasses prescriptions - these sorts of changes occur gradually.
  • Use the Amsler Grid to regularly monitor your vision. Early intervention is critical to prevent irreversible damage. The grid will detect early changes and allow us to preserve as much vision is possible. Should any distortion or blurring occur you should contact the office for an assessment within a few days.

Antioxidants

  • AREDS formulation tablets - The Age Related Eye Disease Study (AREDS) found that particular antioxidants are beneficial in reducing the risk of end stage Macular Degeneration. Either of the tablets below taken twice a day will provide these nutrients.
    • Ocuvite Preservision
    • Macu-vision
  • Lutein and Zeaxanthin - The eye contains two agents to protect it from light induced damage - Lutein & Zeaxanthin. These compounds have 2 critical functions: they filter high energy blue light to protect the deeper retinal layers and both are very effective protective antioxidants.
    • Lutein - Green leafy vegetables – spinach, broccoli and cabbage are the best. Kale (wrinkly cabbage) 39mg/100gm., collards 8mg/100gm., spinach 5mg/100gm., lettuce 2.5mg/100gm. and broccoli 2mg/100gm.
      Blackmores ‘Lutein-vision’ contains extracts from the green leafy vegetables and selenium which may have an additional protective agent which many Australians over 65 are deficient in - one tablet twice a day is best.
    • Zeaxanthin - Yellow vegetables – Per ½ cup:
      • kale: 10mg;
      • spinach: 6mg;
      • broccoli: 1.5mg;
      • corn: 1.5mg;
      • Brussels sprouts: 1mg;
      • Romaine lettuce 0.75mg;
      • cooked peas: 1mg.
      Corn, mango, orange juice, yellow capsicum are good sources but the most concentrated source is Chinese wolfberry.

Note: Egg yolks contain both Lutein & Zeaxanthin and are an excellent form for maximal absorption. Eggs have been shown to have negligible impact on cholesterol. Six eggs per week achieve a useful boost in macular protection within three months.

Further information about Lutein and Zeaxanthin is available from the The Lutein - Macular Degeneration Risk Reduction website.

Other Important Dietary & Lifestyle Choices

  • Fish - Deep Sea fish twice per week or fish oil tablets are protective to the eye as they contain omega-3 fatty acids.
  • A low saturated fat diet.
  • No smoking! Smoking greatly increases the risk of blindness from wet AMD and many other eye diseases up to 400%.

There is less evidence for the following but they may be helpful:

  • Nuts - Twice per week can be beneficial (almonds, walnuts and Brazil nuts).
  • Minimisation of light exposure with sunglasses and a hat. Remember that our eyes evolved to have colour vision in daylight and “black and white” vision at night. We now use our “B&W” system for long hours at daylight lighting levels with artificial lighting. It wears out.

Monitor your vision

Use the Amsler Grid below, and notify us if any distortion or blurring occurs.

Using the Amsler Chart to test your vision

  1. Sit in an area with good lighting, wear your reading glasses and look at the grid at a comfortable distance (30-40cm).
  2. Cover one eye.
  3. Look directly at the centre dot. While looking directly at the dot note whether all lines of the grid are straight or if any areas are distorted, blurred or dark.
  4. Repeat the test with the other eye.
Image of Amsler Grid used for testing eyesight quality

Current Treatment Options for AMD

The management of Age-related Macular Degeneration (ARMD) is undergoing a radical transformation.

There is a new generation of drugs that offer the promise of visual improvement whereas previously there was no prospect of improvement-the best available was to slowdown the decline of vision.

The main type of treatment currently is Anti-VEGF agents. The current agent is Lucentis and this is funded in the PBS as of 1st August 2007. It is the treatment of choice because it has been tested and proven in long term studies to be beneficial to patients with wet ARMD and without significant side effects showing in the 2 year period of testing.

Other treatment options are Photodynamic therapy with the drug Visudyne, Intravitreal injection of a Steroid (Triamcinolone) and Anacortave acetate (Retaane).

Anti-VEGF drugs (Lucentis)

Wet ARMD progresses due to a "fertilizer" promoting new blood vessels to grow. This fertilizer is called Vascular Endothelial Growth Factor (VEGF). If the fertiliser 'VEGF' can be totally inactivated vision is stabilised and can improve. The major breakthrough is a group of drugs that inactivate this fertiliser 'VEGF' and they are called 'Anti-VEGF' drugs.

The initial results for Lucentis have been very exciting because not only does it slow down visual decline but vision has improved in at least 25% of patients. Lucentis is funded by the PBS from 1st August 2007.

Lucentis is injected directly into the central eye. This is done in our private rooms under sterile conditions. As with all intravitreal injections, there is the risk of infection developing in the eye and this could cause blindness. This risk is less than 2 cases per 1000 INJECTIONS. We give you antibiotic drops to use after the procedure to reduce this risk.

The patient is then reviewed in 4 weeks to see if the AMD is stabilised. If it hasn’t then a repeat injection is indicated. It is impossible to know prior to beginning treatment how many injections, over how long a period an individual may need to stabilise their condition.

Photodynamic therapy (Visudyne)

Photodynamic therapy has been available for several years and was a breakthrough in reducing the risk of loss, and preserving vision, for many patients. The procedure is done at our Freemasons rooms.

The drug Visudyne is injected into an arm vein and internally coats abnormal blood vessels.

Then Visudyne is activated by a low intensity laser to create a locally active by product that shuts down the abnormal blood vessels without damaging normal vessels. The laser is not painful and you simply sit up to the machine as when Dr Heriot checks you eyes. This treatment is remarkably risk-free, but the frustration is that vision does not improve for most patients - it simply slows down the deterioration.

Intravitreal injection of a Steroid (Triamcinolone)

In conjunction with photodynamic therapy, intravitreal Triamcinolone injection has made a significant change in management of a variety of eye problems, particularly ARMD.

It remains a useful addition to our management but has been largely overshadowed by Lucentis. Triamcinolone and has a clearly defined complication profile: 20% of people get an elevation of pressure in the eye (a type of temporary drug induced glaucoma) and require drops to stabilize the pressure for a few months. Cataracts can also occur within 1-2 years in some patients and less than 2per 1000 get an infection within the eye that can cause blindness.

Anacortave acetate (Retaane)

Anacortave acetate (Retaane) is a drug used to stop new blood vessels growing. It is effectively ‘risk-free’ but its efficiency is modest. As it has not been proven to be as efficient as these other drug options it is rarely used as a primary therapy. It may be useful in reducing the number of Lucentis doses required in the long term as Retaane has a 6 month activity. It is simply injected under the upper lid to form a slow release depot behind the eye.

Treatment Strategies

We now have some exciting options that not only reduce the risk of deteriorated vision from wet ARMD, but also can recover vision that has recently been lost. Note: No treatment can bring back lost vision from long standing ARMD.

There are many factors to take into consideration when deciding which is the best option, or the best combination for each individual.

For some patients it will be fairly clear; but the choices for many are difficult and will be a ‘balance of risks of the disease progression’ versus the slight risk of complications and of course the cost.

In most instances it will be the failure to partake in treatment quick enough, rather than a complication of treatment that will cause further deterioration in vision.

There are many factors to take into consideration when deciding which is the best option, or the best combination for each individual.

For some patients it will be fairly clear; but the choices for many are difficult and will be a ‘balance of risks of the disease progression’ versus the slight risk of complications and of course the cost.

In most instances it will be the failure to partake in treatment quick enough, rather than a complication of treatment that will cause further deterioration in vision.

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Macular Pucker

Macular pucker is a condition where a fine layer of scar tissue forms on the surface of the retina causing wrinkles. The wrinkles distort and blur vision sometimes causing 'image rivalry' so that the two eyes see a different picture and it confuses the brain. This scar tissue can also be called an ‘Epiretinal Membrane’.

The formation of a fine layer of scar tissue is very common in eyes of people over the age of 70 but in the vast majority of people it does not cause any significant visual disturbance.

Surgery to improve sight affected by macular pucker has been performed for over 25 years and is a very well established procedure.

A Vitrectomy is performed using microsurgical instruments within the eye to remove some of the abnormal jelly structure and this gives access to the surface of the retina so that the scar tissue can be peeled off. It is a similar process (but at the microsurgical level) to slowly peeling sticky tape off something that it is adhered to.

Surgery is performed with the eye locally anaesthetised and the patient sedated. General anesthetic is rarely necessary. The surgery is performed in hospital, usually as a day case so you will go home once stable after surgery. Dr Heriot will review you the day following surgery and the weeks following.

The major problem following vitrectomy and membrane peeling for macular pucker is the formation of cataracts. If a cataract is already present it may be removed during the surgery as well as a ‘combined procedure’.

Other rare risk factors include infection, retinal tears, retinal detachments, haemorrhage or inflammation.

After the Surgery

  • The eye will be bloodshot and may feel a bit scratchy as if there was something in it.
  • Usually only Panadol is needed for a day or two to relieve any discomfort.
  • You will have eye drops to use for a few weeks following surgery. Generally there is an antibiotic and an anti-inflammatory drop to be used 4 times a day. You will be advised of exact details following surgery.
  • Vision gradually improves over a number of weeks.
  • It is important to recognize that the gas bubble inside the eye (injected when the jelly is removed) will block out all useful vision straight ahead - this is not a complication. Gradually the gas bubble will dissipate and may even break up into smaller bubbles as it goes. You will not be able to see clearly when you look through the gas bubble.

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Macular Hole Surgery

Surgery for macular holes is one of the great advances in Vitreo-Retinal surgery over the last decade. This condition was previously untreatable, but now substantial visual improvement is achieved in most patients.

Macular holes develop within the area of sharp central (reading) vision. This small area - no more than half a millimetre across – is the most delicate part of the retina.

The hole develops due to tightening of the vitreous gel. This usually occurs after the age of 60 or 70. Rarely macular holes follow trauma where tension pulls a hole open. As these holes are in nerve tissue, a tenth of a millimetre thick, it is not possible to stitch or glue tm back together. Instead gas is used to fill the eye and is left inside the eye for a couple of weeks to support the hole while it is healing.

The gas bubble supports the healing hole in much the same way as a plaster cast supports a broken bone.

In general, the sooner the hole is closed the greater the visual improvement. This is not an urgent thing on a day to day basis rather the difference is noted on a month to month basis.

The microsurgery concentrates on removing some of the abnormal vitreous (Jelly) within the eye and then peeling off scar tissue on the surface to release any tension pulling the hole open.

Closure of the hole is achieved in over 90% of cases with one operation. Further surgery increases the chance even higher.

Complications are uncommon apart from potentially rapid cataract development. If there is already substantial cataract present, vitreous surgery for the macular hole can be combined with cataract surgery to deal with both problems at once.

Serious complications such as retinal tears or retinal detachments occur in much less than 5% of cases. Other rarities such as damage from the bright light, haemorrhages, severe glaucoma and peripheral vision loss can also occur. There is between a one - three in ten thousand risk of infection.

After the surgery

  • The patient must look down towards the floor. This allows the floating bubble within the eye to press the hole edges together as they heal. This positioning is generally performed for 5 days after surgery.
    This is most important - if this positioning is not done the chance of success is reduced considerably.
    This is not as difficult as it seems. It is important to look down towards the floor – more towards the heels than the toes – for roughly 45 minutes each hour of the day (when awake). When sleeping try to look face down or at least roll on the side looking towards the floor. This is particularly critical in the first few days after the surgery.
  • The eye should be comfortable. Panadol should provide sufficient relief from any discomfort.
  • The gas bubble gradually gets smaller. This creates a crescent of vision that gradually increases from the top. It is similar to wearing a diving mask with water in the bottom that sloshes around. It is quite normal for the bubble to move around and sometimes to break into smaller ones.
  • Vision generally improves considerably. There may still be a small amount of distortion that takes quite a while to settle. Some distortion may remain. It is important to recognize that macular holes may leave some irreversible damage to the area of sharp central vision.
  • It is important to recognise that the gas bubble inside the eye blocks all useful vision straight ahead and this is not a complication. Features such as hands or feet can be seen when looking straight down through the bubble but there will be only very blurred shapes and light looking straight ahead. This is normal until the bubble dissipates.

It is critical not to fly or rapidly drive up a mountain while the bubble is present.
It is also vital that you tell the anesthetist if an urgent operation is needed with general anesthesia.

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Branch Retinal Vein Occlusion (BRVO)

Branch retinal vein occlusion is a process where hardening of the arteries causes a compression or notching of a vein within the retina. It will only affect one eye. Vision may be blurred or a ‘blackout’ area of vision may be experienced.

How does BRVO occur?

The retina is part of the brain and forms a thin nerve tissue lining within the eye. The retina functions like the film in a camera. The retina, like all other parts of the body needs a blood supply to keep it functioning.

The retinal veins drain the 'used' blood from the retina to take it back to the heart, while the arteries take the blood supply into and around the retina at high pressure. The blocking off, medically called 'occlusion' of a retinal vein occurs when a retinal artery crosses over a vein and compresses it, thus occluding it. This can be imagined like you stepping down on a hose and blocking off or occluding its flow of water.

What does the blockage cause?

When blood flow through the vein is restricted, fluid builds up as it cannot drain from the eye. Some blood then leaks out into the retina blocking areas of vision. Fluid can also leak out of the blood and water log the eye causing central swelling, medically called 'oedema'. This results in a reduction in clarity and blurred vision. The site of the blockage determines the degree or extent of the vision affected.

What are the risk factors?

The eye is unusual in that the arteries and veins travel through the retina alongside each other and occasionally, as a random event during development, they can cross over allowing the occlusion to happen.

The artery is most likely to do this if:

  • Hypertension (high blood pressure)
  • Diabetes
  • Cholesterol
  • Cardiovascular disease
  • Smoking & obesity

It is essential to optimise the cardiovascular risk factors by insuring that the blood pressure, cholesterol and diabetes are optimally control.

How is BRVO diagnosed?

Diagnoses and then management of BRVO involves a thorough eye assessment including checking the pupils response to light, measurement of intraocular pressure and examination of the retina.

A Fluorescein Angiogram is performed to assess the circulation and the degree of the blockage. This procedure is where a dye is injected into the hand and then the eye is photographed over a period of five minutes as the dye flows through.

An OCT (Ocular Coherence Tomography) determines the degree of retinal swelling by scanning the eye with an ultrasound. This takes a very short time and is non-invasive.

What are the treatment options?

BRVO is a condition that can be significantly helped with modern treatment. The choice of what treatment is best can only be made on an individual basis where the clinical pattern and duration of the problem are assessed and then the options discussed in light of all the findings.

Management can range from a period of observation through to surgery.

Types of Treatment

Observation

In many patients, observation is the best approach for a couple of months to determine whether the occlusion will begin to resolve itself by creating ‘bypass channels’ so the blood can flow out of the eye again. Sometimes the kinking/blockage can be reduced if high blood pressure is controlled.

Laser

Laser is the traditional treatment option which "prunes" areas of poor circulation just like one would trim a plant that is not doing well. This ensures that the nourishment goes to the key parts of the plant rather than trying to supply everything - with the consequence that nothing is well supplied. Laser treatment involves a procedure where a bright flashing light is used to cauterise leaking blood vessels and to facilitate drying of the leaking fluid by making little outflow channels. Laser treatment can be very effective in simple branch vein occlusion particularly if there is not too much retinal bruising. Retinal bruising or haemorrhages prevents the laser working. As such, sometimes it is necessary to defer laser treatment until the haemorrhages diminish. This, unfortunately, leaves poor vision for a longer time and also increases the prospect of permanent visual reduction. The good thing about laser treatment is that it can be delivered in my consulting room and has virtually no direct side-effects. It is, however, effective in only a small group of patients with a branch vein occlusion.

Triamcinolone

Very effective therapy where the predominant problem is retinal swelling 'macular oedema'. The anti-inflammatory properties of the Triamcinolone reduce the swelling and allow the blood vessels to start repairing. The side-effects of this injection are potential infection (perhaps two per thousand developed an infection called endophthalmitis), approximately 40% will have a mild elevation of the intraocular pressure but only approximately 20% would require drops to control the pressure for several months. A very common side affect is increased speed of cataract formation. A cataract is cured by a routine operation. This drug is injected into the eye in our consulting rooms.

Avastin

A new drug that is predominantly used for Macular Degeneration. It is very effective in reducing the retinal swelling 'macular oedema'. There have not been long term studies on this drug but it has been routinely used by Dr Heriot and across the world for over two years now with no known long-term side effects. The only side affect has been inflammation in the eye lasting a week to ten days. The vision may be blurred or fogged out during this time. The drug is injected into the eye in our consulting rooms.

Surgery

A breakthrough in management is a procedure called vitrectomy with or without “sheathotomy" whereby the artery crimping/blocking the vein is released surgically so that the blood flow through the vein can recommence allowing the retina to start recovering. The major long-term side effect of the surgery is cataract formation in older people. Other risks such as infection, etc. are very low and occur in 1:5000. Retinal tears can develop where the instruments are introduced into the eye in less than 5% of cases and are usually easily addressed with a small procedure where some spot welding using the laser is performed in conjunction with a gas bubble. This is a procedure in the operating theatre performed under local anaesthetic with sedation.

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Central Retinal Vein Occlusion (CRVO)

Central retinal vein occlusion causes very poor vision because the circulation within the eye slows down. The effects can range from slightly blurry vision through to a blind painful eye.

How does CRVO occur?

The retina is part of the brain and forms a thin nerve tissue lining inside the eye. The retina functions like the film in a camera. The retina has its own blood supply: the arteries bringing fresh blood in and the veins channelling the 'used' blood out. The smaller vein branches join together and exit the eye within the Optic Nerve as the Central Retinal Vein.

If the central retinal vein is kinked/blocked, for example by a hardened artery, the blocked venous drainage causes the circulation to stagnate which is medically called an ‘occlusion’.

What does the blockage cause?

Unfortunately with a CRVO your sight is usually always affected. This may range from mild to severe blurred vision. Internally, haemorrhaging (where blood leaks out of the occluded vein) occurs but the vision is blurred because the retina gets ‘water logged’ when fluid is forced out otf the vessels due to the high pressure. This leakage is medically called ‘oedema’ and this damages your sight. In severe or untreated cases the circulation is so static that retinal tissue starts to die off and triggers new blood vessel growth that can fill the eye cavity with blood causing dense vision loss, and also the pressure in the eye may also increase (Rubeotic Glaucoma) which can be painful and blinding.

What are the risk factors?

The risk factors that make people susceptible to CRVO are:

  • Increasing age
  • Hypertension (high blood pressure)
  • Cholesterol or triglyceride problems
  • Glaucoma
  • Diabetes

Less commonly the blood can become thick and sticky from a variety of causes including:

  • Too much protein in the blood which causes circulation to slow down
  • Hormone supplements, particularly affecting women.

How is CRVO diagnosed?

Diagnoses and management of central retinal vein occlusion involves a thorough eye assessment including checking the pupil’s response to bright light, measurement of intraocular pressure and examination of the retina.

A Fluorescein Angiogram is performed to assess the circulation and the degree of blockage. This procedure is where a dye is injected into a vein in your hand and the eye photographed over a period of five minutes as the dye runs through.

An OCT (Ocular Coherence Tomography) determines the degree of retinal swelling by scanning the eye like an ultrasound. This takes a very short time and is non-invasive.

General Health

It is always essential for the blood pressure to be monitored and diabetes to be excluded so you will be encouraged to check with your local GP regarding your general health. Further blood tests may be necessary depending on each individual circumstance.

What are the treatment options?

Treatment options vary depending on the severity of the CRVO from laser, an injection into the eye or surgery. The benefits and potential complications of these different treatments need detailed discussion after the thorough initial assessment of the eye. In most cases, some benefit can be achieved with treatment options.

Types of treatment

Triamcinolone

Is an injection into the eye performed in the clinical rooms. The anti-inflammatory properties of the Triamcinolone reduce the swelling and allow the blood vessels to start repairing. The side-effects of this injection are potential infection (perhaps two per thousand developed an infection called endophthalmitis), approximately 40% will have a mild elevation of the intraocular pressure but only approximately 20% would require drops to control the pressure for several months. A very common side affect is increased speed of cataract formation. A cataract is cured by a routine operation.

Avastin

A new drug that is predominantly used for Macular Degeneration. It is very effective in reducing the retinal swelling 'macular oedema'. There have not been long term studies on this drug but it has been routinely used by Dr Heriot and across the world for about 2 years with no known long-term side effects. The only side affect has been inflammation in the eye lasting a week to ten days in about 1% of cases. The vision may be blurred or fogged out during this time. The drug is injected into the eye in our consulting rooms.

Choroidal Anastamoses bypass

A high powered laser creates a connection between the retina and a deeper (choroidal) circulation within the eye. This can also be achieved surgically in some cases that are not suitable for laser.

In severe longstanding cases where the circulation is very poor, there is a high risk of the eye becoming totally blind and painful from a severe type of glaucoma called Rubeotic Glaucoma. Laser or Avastin treatment is essential to prevent this disaster.

Radial Optic Neurotomy (RON)

An operation done in an operating theatre. This is where an incision is made around the optic nerve rim to decompress the veins and allow blood flow and drainage. As with any operation there are risks involved. Dr Heriot will discuss these at length with you if this surgery is indicated.

Follow up

It is crucial with CRVO that the eye is checked at regular intervals to detect and control any further deterioration. These visits are critically important to prevent the eye becoming totally blind and painful and to preserve as much sight as possible.