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Myopic degeneration/lacquer crack
I was recently diagnosed with myopic degeneration in my right eye, and told that I have a lacquer crack in that eye. I am 40 years old, and as a practicing attorney, am obviously concerned that my condition will either worsen in my right eye, or also develop in my left eye, thus rendering me essentially disabled.  Is there any treatment, therapy or surgery available for my condition? If not, what are the best preventative measures to take to ensure the condition does not progress in my right eye or begin develop in my left eye?  Lastly, what is the likelihood that the condition in my right eye will worsen, or that it will also develop in my left eye?  In other words, is it likely that I won't notice any significant decline in my condition over the next few decades?
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Interesting ... interesting ... here's a question - can a staphy be detected from a profile MRI image?  I had an orbital MRI done awhile back for another reason, but I went back and looked at the profile views of my head.  I can see the hollow globe of the eye, but it's perfectly round in the back of the eye.  There are a couple of images where there seems to be a very sharp, hook-shaped indentation, but I think that has to do with the optic nerve or some other connection from the eye to the head.  
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Oh yeah of course. It is probably the best way to do it I would have thought. Does this look familiar?

http://www.google.com/imgres?imgurl=http://www.radpod.org/wp-content/uploads/2008/07/staphyloma.jpg&imgrefurl=http://www.radpod.org/2008/07/30/staphyloma/&h=600&w=600&sz=51&tbnid=Q3XRRL9ye8RXhM:&tbnh=135&tbnw=135&prev=/images%3Fq%3Dposterior%2Bstaphyloma&hl=en&usg=__zagHR7g7YADe16O38KlhRQTHEFc=&ei=K5tFSqDrHZD7tgeWmKS8Bg&sa=X&oi=image_result&resnum=5&ct=image
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Well, the general image looks familiar - but are there staphys in those eyes?  How can you tell?
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Oh - those are anterior staphylomas
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I ran to the study to see if I had any top-down shots like that one - unfortunately, no.  But I do have the side-profile shots I mentioned.  I figure that those would show staphys too, since the eye is a spherical object and a staphy visible from top-down should be visible from the side as well.  I looked at the profile shots again and I see absolutely nothing - just a nice, smooth curve.  Let's hope it stays that way.
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There is a huge staphyloma in the eye on the right (as you look at it). That huge bulge you see in the back corner is the staphy. Looks kind of macular to me too. You would need to get the cross section absolutely perfect with this to see it.

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Thanks for info.With -22 and -17 dioptres and over 35 I try hard to not worry too much.
I do try to keep informed and the more I read on this forum the more I realize how
serious the lack of knowledge is in degenerative  myopia  and not only in Portugal  where I live. I

Its sad that only  existing procedure ( buckling) I've read about that has the potencial for reducing the complications of degenerative myopia is only done in the United States.If  crosslinking is ever used in  for myopia, I realize it will be in Europe, but it will probably be too late for me.

Best wishes,
Sophia
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Can't imagine why you'd have to get a perfect cross section - I would imagine that the staphy is at least big enough to be visualized at several cross sectional levels, no?
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You say that if there is not a significant staphyloma, you wouldn't have the surgery.

Is that because of the inherent risks associated with the procedure, or is it because -- in the absence of a staphyloma -- you wouldn't expect the condition to progress?
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You were right the second time, I just wouldnt expect it to progress. However, they can be difficult to spot if they are grade II or lower but at your age if it is not obvious now, it probably will not progress to anything too serious in the long term.

You didn't answer my question - how did Dr Ward know you did not have a staphy if he hasn't yet examined you?
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What he actually said was that if all four RS's I've seen said that there was no staphyloma, that I probably don't have one. Obviously he'll take a look, but when I described everything to him, including the fact that I'm "only" -8.5 in the right and that it really hasn't changed much in the past 10 years or so (it was maybe -7.5 ten yrs ago), on top of the fact that everybody I've seen said that I don't have one, he said that it sounds like that's the case, i.e., I don't have one.

I forgot to ask you, dukey: Did you have the procedure performed by Dr. Ward? If so, how was it? Too early to know whether it was a success, I assume, but I was just wondering what his post-surgery comments were, if anything.

One last thing, for anybody who knows: About a week ago, the "distorted vision" and "wavy lines" aspect of all this really increased. Everything looks like I'm seeing it underwater, or through a bubble. Dr. Ward and a local RS both said that it's common for this particular symptom to be temporary, and that after a few weeks or months, things should revert back to what they were before. Still defects, of course, but the wavy lines and distortions should diminish. Anybody know anything about this?
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Dukey just posted a lengthy narrative of his (her?) surgery on another part of this site - check it out.
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Hey I am little concerned. What exactly do you mean about the waviness increasing recently? If it is that bad and sudden, it could be something treatable like an active CNV which you should probably get checked out ASAP. Have you had an FA done?
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A couple days after I noticed the increased waviness and distorted vision, I saw an RS, and there was no leakage. He even did a dye test, and was certain that there was no exudation, CNV, etc.

Like I said, he and others (including Dr. Ward) have said that this is usually temporary, and I was just curious as to whether anyone else had experienced this.
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It is my understanding that any sudden change in vision such as increased waviness and distortion is likely due to a sudden event that is occurring in the retina (e.g., CNV or new lacquer crack).  However, another possibility is that visual defects of a milder nature have been present for awhile and perhaps you have now just become aware of them because you are more attune to your vision in each individual eye.  

A good practice is to use an Amsler Grid everyday or at least once a week to determine more objectively any new distortions that are present.  Any sudden change warrants and immediate evaluation.

I have distortions from lacquer cracks and the distortions are still present if I look for them.  However, due to neuroadaptation, I don't routinely notice them.
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The distortions are definitely new, but at least as of a couple days after they began, there was no CNV. It could just be the crack expanding, for which I assume nothing can be done.

Here's the time frame:

June 23 - The distortions/wavy lines increased.
June 24 - Saw one RS, who told me there was no leakage/CNV.
June 26 - Saw another RS, who told me there was no leakage/CNV, even after dye test.

So either both guys really missed it, or there is no CNV.

I have an appt. next week at Emory Univ. Eye Center in Atlanta, but I just got a call from an RS there who basically told me that they would probably just confirm what the other 4 RS's have told me, i.e., "nothing whatsoever can be done for your condition."
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I'm not sure that I buy that. A sudden increase in waviness is a sign that something is going on. Myopic CNV is not always easy to spot, even on an FA as many docs are more used to the more obvious ARMD type. It can be very occult but can cause some serious damage if not taken care of. An OCT scan would be very useful for you I think. My "CNV" was spotted on an OCT scan after several FAs. My doc was very undecided so consulted his colleagues and we all finally agreed the evidence indicated a CNV (based entirely on the OCT). With the very low risk of an Avastin shot, it seemed almost a no brainer that even if there was a hint of a CNV, I was going to have the injection.

Lacquer cracks progress very slowly (years) but, again, can be very difficult to spot even with FA and ICG. You could easily have an extensive LC under your fovea and not see it, which may account for your symptoms. They can literally form webs of cracks, not just a single line as is commonly believed. There are a number of articles on this. The result is that LCs have been underestimated in PM. Some think that 90% of high myopes have them.

I'm not sure what you mean by temporary. Nothing is temporary in PM. Yes some have indicated that the CNV will regress on its own but it is rare that it does this without inflicting some form of PERMANENT damage.

There is also a lot of merit in what kg17 said. Once you develop eye problems, it has a very large impact on your life and you become very tuned in to your eyes. I noticed things that were never there before and I could write a long list of mostly subjective symptoms that I have. The Amsler Grid is the ultimate test though. If there is waviness or spots on that, it is really there. Things can happen VERY fast with PM so be careful. Amsler grid everyday unless you get so depressed and then once a week is good. I find the black grids with white lines are the most revealing/frightening. Oh to have a clean Amsler grid!  
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This one is brutal. It will show ANY distortion.

http://www.vrmny.com/images/amsler_lg.jpg

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I'm not sure what an FA is (though I've probably had at least one), but I underwent an OCT last week, a few days after the distortions increased, and again, I was told that there is no CNV. On top of that, a dye test confirmed the same thing.

The way it was explained to me was that an examination of my eye after dilation would make them 98% sure that there was no CNV, and the dye test would push that # up to 100%.

So again, unless the people who are treating me are just completely incompetent, then as of last Thursday, a few days after the onset of the increased distortions, there was no leakage. And like I said, my local RS -- in addition to Ward -- said that these increased symptoms can be temporary.

Also, I have one lacquer crack. I saw it on the film that was produced as part of the dye test. The crack is "Z" shaped, and barely infringing on the macula.
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"So again, unless the people who are treating me are just completely incompetent, then there was no leakage."

Turns out they're incompetent.  Last Thursday the 25th, even though I told him the distortions had gotten worse, he said there was nothing he could do because he didn't see any leakage, never mind that any RS with a brain would give a shot of Avastin just to be safe.

Went back today, right after that last post, and there is a CNVM.  My vision in my right eye was 20/25 a week ago, and today it was 20/50.

Had an injection of Avastin, and I pray to God I regain some vision.
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I think the odds are in your favor.  You received the shot in a timely manner.  It's very wise that you have sought to educate yourself, and this forum is a good place to start.  I'm glad you went back and insisted to be checked again.  
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I'm pleased for you, but feel bad for you at the same time. I would expect the Avastin to clear it up quite easily. Be thankful, a few years ago this would not have been possible. Honestly, this stuff really isn't that complicated and it really amazes me how grossly negligent some of these docs are. Patholigcal myopia CAN and WILL progress quickly in certain people and requires specialist care. It can literally change overnight which is why monitoring and EARLY agressive treatment is so important.

I swear I could walk into any retina office and do a better job than 50% of these docs without even touching the patients. You order tests, look at the results, read the literature and away you go. It's a joke and it may cost you a few lines at vision. I guarantee you it was visible when you first started to notice symptoms. Myopic CNV can be extremely subtle. They should READ THE LITERATURE.

Oh well...........    
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"The way it was explained to me was that an examination of my eye after dilation would make them 98% sure that there was no CNV, and the dye test would push that # up to 100%"

There is your problem. That is ignorance and arrogance in my opinion.
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Just back from my 6 month retinal visit from the most reputable retinal specialist.  I have to concur with Dukey.  The biggest problem I see with healthcare, in general, is the ignorance of MDs - they really do fail to keep up on the research literature.  Perhaps it's because I had research crammed down my throat for 6 years of grad and 2 years post-grad, that I just don't understand how clinicians can treat without attending to the literature first.  But then again, an MD's income isn't based on any individual patient's outcome or knowledge of a relatively infrequent disease.  Additionally, accurate interpretation of available research isn't required either, whereas a scientist's entire career depends on it.

In my opinion, I believe that MD clinicians should not be paid more than the PhD/MDs who do the research.  Our system is far too lopsided.
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It's the laziness I have a problem with. I don't really care how much they get paid but they should do their best for the patient at all times. If you have a patient who walks in and you only have a basic understanding of the condition, you should either fess up and refer them to someone experienced or, even better, go out of your way to brush up on the area, even if that means going to the dreaded library. I do not think that is an  unreasonable expectation and if I was an MD, that is where I would get the most satisfaction.  

Science and medicine are linked unconditionally. They both need each other to move forward.  
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I think the money issue is relevant simply because it is a motivating factor for most people.  When reimbursement is based on the number of patients seen and procedures done, rather than the quality of the outcome, altruism merely becomes a footnote for many docs.  

It is a long-standing joke in med school (here in the U.S.) that those who can't practice, do research.  That perception is tied, at least indirectly, to the amount of money a practicing physician can make as opposed to the Ph.D researcher.
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Anybody have any idea how long it takes for the Avastin to take effect? It's been 2 days since the injection, and there's been no change.

The following 2 articles seem to bode well for me, but they don't say how long it takes to work.

http://www.lowvision.com/avastin-benefits-patients-cnv-myopic-egeneration/

http://www.myvisiontest.com/newsarchive.php?id=779
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Try not to worry, you are looking at weeks rather than days. The improvement has been shown to be exponential up to 12 weeks with the earliest detectable improvements being seen only at 2 weeks. The short term effects were part of the early studies on Avastin and myopic CNV. You are only at 2 days so you have a way to go. It may also take more than one injection but this is rare in myopic CNV.  
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This thread (and not just this one) has been really informative. Thank you all!
I am 33 ansd also a lawyer, so it was quite a disaster when I found out 1,5 months ago that I have CNV in my right eye). I had my first Avastin shot in the beginning of June and it took a week to notice the difference, after one more week everything was almost perfect (and it is "almost perfect" today also - only if I search for it I am able to detect some waviness).  Nevertheless, my RS says that she believes in aggressive treatment, so I got my second shot last week and there is one more coming. I hope for the best (don't we all :)), although last week I had a bad surprise - quite accidentally they discovered another crack in my "better eye" too. Noone knows whether they just didn't see it before or it is just something very new. Anyway, I'd better start waiting for CNV there also.
Best luck to you!
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Yeh this is a massive thread now! Glad it was of use.
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Quick update:

I went back to my local RS Monday the 6th (4 days post-injection), and my right eye had improved to 20/35.  Then yesterday the 7th (5 days post-injection) I went to Emory Univ. in Atlanta, and it was down to 20/25+.  So in 5 days, it went from 20/50 down to 20/25+, and hopefully will improve even more. In a nutshell, the Avastin worked.  (Amazing that when the local guy gave it to me, he said that only 40% of patients who receive the injection notice any improvement. That may be the case for AMD, but obviously not for PM, in which at least one study has shown a mean improvement of three lines.)

The RS I saw yesterday at the Emory Eye Center, which is a top 10 facility, was by far the most knowledgeable I've seen to date, and he echoed the opinion of all 4 local specialists I've seen who said that there is no staphyloma. It'll be interesting to see what Dr. Ward says on Aug. 6 when I see him.

Also, thankfully, the Emory RS said that the left eye looks "great," that there's no crack there, no sign of one, etc.

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Congrats, the success of Avastin in PM is much much higher than ARMD and usually only requires one injection. If you catch it early, you should reduce the chances of post-CNV scarring which is the real source of vision loss from CNV. There is some controversy as to whether Avastin can prevent this scarring but other factors such as original CNV size and location as well as the patients age are more important. Overall I think it looks good for you.

My feeling is that Lacquer cracks are no where near as dangerous now that Avastin is around, unless it passes right through your fovea and mechanically disrupts the vision. A few years ago with a subfoveal CNV, you would probably be down to 20/100 already and legal blindness in that eye would have been inevitable at some point.

I still think you have a staphyloma though. It is VERY rare to have myopic degeneration and not have one. Yours may not be too deep.  
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Wouldn't it be easiest to just order a CT or MRI to detect the staphyloma if they're so hard to detect on clinical exam?
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I've been diagnosed with myopic degenerataion in my right eye since last June when I first had symptoms. Have had multiple Avastin shots which brought me back to 20/20, now at 20/60 and had the laser treatment three weeks ago. I am also a lawyer, 39, and find it very interesting that in all the reseach on line, many of us, most of us it seems are lawyers who read every day.  My RS told me his daughter went from an anthropologist to lawyer so I could go to anthropologist when I complained about worrying how I was going to survive with this. He laughed, it was not funny.
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Quick update - I just had my second post-injection follow-up: Back to 20/20, and -- for now -- stable. Since the injection was only 26 days ago, and it's supposed to be effective for 2-3 months (according to my RS, at least), then I'll be going back in about 4 weeks for another follow-up, to see if I need another injection.

Barring any unforeseen developments, I'm leaning toward NOT having another injection. If the first one worked (and it did), then in my opinion, there's no sense in receiving another shot if I don't need it.

Hopefully I won't need it.
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I thought I posted a day or so ago but don't see it, I'm scheduled for the posterior pole buckling surgery Nov. 11 after consultation with Dr. Ward.  A bit, well, more than a bit -- nervous about it, but I feel pretty much OK with the decision in spite of the fact that my RS says don't do it, your vision is 20/25 now, why risk that?  Dr. Ward said with my axial length (and I have grade 3-4 staphy in right eye which is more degenerated than left and also longer than left) if my eyes were his he'd absolutely do this.  Also if I waited and didn't do this and wanted to do it later, and my husband lost his job and insurance, there is no way I could ever afford it, with insurance it's very affordable (for me).

I'm just apprehensive, really the only issue is my own fear and any risk, I really do think it's the right decision.  

Dukey, would you go through it again?

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Yes, I would without hesitation. If you like, we can exchange e-mails and/or talk over the phone. I would be more than happy to help. Just send me a PM.
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Great news! Super happy for you. I doubt you will need another injection and you are right to be hesitant.
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One more update - I saw Dr. Ward yesterday. Turns out my right eye (the bad one) is 28.2 mm, whereas the left one is 27.3 mm. He said he "wasn't impressed" with the staphyloma in the right, and that it was "very shallow." He said my eye was oblong, not "torpedo-shaped," which apparently is a good thing. He recommended the procedure, but they're booked through Christmas, so I suspect I'll be arranging it for next year.

Both eyes still 20/20, no more bleeds.
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It's been a while, so here's the latest:

On January 6, I underwent surgery (posterior pole buckle) in San Jose, CA, performed by Dr. Brian Ward.  Dukey has posted his experience with the surgery in detail, so I won't retread that same ground, but I will say that I'm glad I did it.

I'm currently almost 4 weeks post-op. A day after the surgery, I was 20/50, a week later, I was 20/30, and at 3 weeks post-op, I was back to 20/20 (minus 2 letters, but I'm wearing contacts with an eleven year old prescription).

I still have double vision, though it seems to be improving gradually. Also, the eye is still pretty red, though again, this appears to be getting better.  No more pain, though, as that was gone within about a week or so.  You have a pretty bad black eye at first, and there is a lot of discharge, but that goes away after a few days.

Like dukey, I had the surgery on a Wednesday, and after follow ups on Thursday and Friday morning, I flew out Friday afternoon, and was back at work on Monday. I will say this, though: I probably shouldn't have driven until at least a week post-surgery, as the double vision was pretty bad until then. Also, you can't wear contacts for 2 weeks after the surgery, so that compounded the issue as well.  You're supposed to sleep and shower with a patch (or tape) as well, which isn't very convenient or comfortable. On top of that, you can't exercise for 2 weeks, so by the time I started running again (17 days post-surgery) I was somewhat out of shape, not to mention still feeling the effects of the operation.

As far as the procedure itself, I checked in at 5:30, surgery was at 7:30, and I was back at the hotel at 11:00. The rest of that day is a blur, though, as the Darvocet knocked me out and made me nauseous. I stopped taking it that day. I had almost no appetite for about 4 or 5 days after the surgery, which I think is the result of the anesthesia and meds.

Anyway, all in all, it was pretty much what I expected. Insurance covered the hospital charges ($51k +) and doctor's charges, though unbeknownst to me, it did NOT cover the anesthesiologist's charges, which were about $1,000, so I'll be coming out of pocket for those.

And while I'm glad to be doing well, I can't say I hope to ever need the other eye operated on.
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Another setback.

Blind spot became more noticeable a few weeks ago, went to see RS on April 14, and since they didn't see anything (and I was still 20/20 or so), I was told they couldn't give me an injection of Avastin.

Since then, the distortions have increased even more, and I have an appt. tomorrow to see about getting that injection. My fear is that he'll refuse to do if he doesn't see a CNV, even though I know that things are getting worse.

Hard to know the cause and effect, but I'm starting to wish I didn't get the surgery with Dr. Ward in January. Everything was fine up until that point, and now this.

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It was a CNV.

I had an injection of Avastin yesterday (my second one, the first being 10 months ago), so hopefully this will rectify things.

Still 20/20, so they (we) hopefully caught it early enough to prevent any permanent damage.
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now you all have me scared.  I just generally trust the docs.  I don't seek out specialists.  I had a blind spot about 3 years and went to see the opthamologist who sent me to an RS.  I have always seen opthamologists.  I have worn glasses since age 4.  my eyes are OD -12 and OS -15.5 with astigmatism in both (+.75 and +1.25 respectively).  I wear gas perm lenses.  The RS found lacquer cracks in one eye but no cnv.  I haven't been back to the RS since that diagnosis.  Lately I've been seeing a lot more floaters than normal.  To the point that i have to wait for them to move so I can see sometimes.  thinking it might be time to go back to the RS...
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well, i went to my RS about what seemed like an increase in floaters and he said there was nothing.  no changes since i last saw him 4 years ago and that i didn't need to see him anymore unless something happened.  just see my regular eyeMD once a year.  

unfortunately 10 days ago something did happen.  i had leakage from a CNV that was near my lacquer crack.  the distorted area on an amsler is about the size of a penny or nickel.  he gave me a shot of avastin on thursday.  

really frustrated that there is such a lack of information.  my rs didn't talk to me very much but i heard what he was telling his assistant to write on my chart--peripapillary choroidal atrophy and i think retinal pigment epithelium atrophy.  the lacquer crack was discovered about 4 years ago when i noticed a very small blind spot in the se quadrant of my vision.  the new blind spot and distortion are in the nw quadrant of my vision.

also frustrated because i can't seem to find a doc that specializes in high myopes where i live here in TX
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Hi,

I have very high myopia -14 d in both eyes. I see wavy in both eyes. My right was good until 2 months ago, it also started wavyness. My RS said treatment is not going to help me. I assume its dry. Does posterior buckle surgery will prevent further dry macular degeneration? How is your vision with waviness? I am a pharmacist, afraid whether I would be able to work if waviness gets worse also I read a lot . Do you mind sharing your experience how waviness affects daily tasks . I had a CNV in left eye in march 2013, one avastin shot cleared the leak, But i still have waviness in left .M vision is 20/20. Thank you
Sri.
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Here we go again. After having no real problems since my last CNV/Avastin injection in May 2010, I noticed an increase in the size of a blind spot in Friday, September 19. On September 23 I went to my RS and got another injection of Avastin. (This is my 3rd since being diagnosed in May of 2009.) We'll see if it helps, or if the increased blind spot is a permanent change. The RS seems to think this was a CNV, because even though he could see any bleeds himself, the OCT seemed to pick up.

Still no problems at all in the left eye. Also, even as of yesterday, was 20/20 -1 in the right (bad) eye.

So the bottom line is that almost 5 years after the surgery, I'm still doing well, ASSUMING this latest setback was simply a CNV that will be dried up by the Avastin.

We shall see,
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I know that I'm late to this party but I'm going to say a few things.
first of all, don't give up hope. I am a 45 year old that was diagnosed with
macular degeneration at 42 years old. I also have been a practicing Registered Nurse since 1999. I've had to compensate some when using my technical skills, but overall things are still going ok. I receive Avastin
in each eye approx. every 30 days per eye. so it's a trip to the Eye doc every 2-3 weeks. Still going strong. this Former Army Combat Medic and Nurse is not giving up that's for sure.
Hang in there sir.
sincerely,
Michael Prescott MacArthur
RN
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Thanks very much. Turns out, the change was a CNV, as the blind spot decreased over the next few weeks. At 46 years old, I still have a long way to go. My biggest hope is that at some point in the future a "cure" is developed.
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I've had my first cnv due to myopic macular degeneration 4 weeks ago. I am 39 years old, married mom to 5 kids aged 1 - 10. I received an avastin injection 3 weeks ago and it did help but I still see the gray spot on the Amsler grid. I am looking for encouragement really and updates on everybody. This has been the hardest trial of my life.
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