Keeping Patients in Sight

By Amy Geiszler-Jones
Monday, February 19, 2018

Grene Vision Group ophthalmologists Alan R. Hromas, MD, and David M. Chacko, MD, PhD, are fellowship-trained retina specialists.

Grene Vision Group retina specialists David M. Chacko, MD, PhD, and Alan R. Hromas, MD, are always on call.

The two doctors, based in Wichita, rotate on-call duties every other day, as well as weekends, offering emergency services 24/7, 365 days a year for patients in a large part of Kansas.

“If someone has loss of vision or any other retinal issue, we will take the call and handle the emergency,” Dr. Chacko says.

That’s because of the time-sensitive urgency of diagnosing and treating retinal conditions to prevent permanent vision loss.

Most patients referred to Grene Vision Group’s retina service have been seen by their optometrist or general ophthalmologist and diagnosed with potentially sight-threatening emergencies. Frequently these are emergency patients or add-ons to the GVG physicians’ schedule, and the patients may have retinal detachments, Dr. Chacko says.

“The key is a thorough examination of the patient to make a proper diagnosis,” he says.

It’s not uncommon for the pair to treat five or more retinal detachments a week. Depending on the severity of the tear or detachment, some patients may need treatment immediately, while others can be treated as much as a week later. When the retina is pulled, torn or detached from its normal position in the back of the eye, it separates from the blood vessels that provide needed oxygen and nourishment, according to eye experts.

Nearly all retinal detachments start with a tear, notes Dr. Hromas.

The tear can be the result of age (as the vitreous gel attached to the retina begins to shrink and pull on the retina), genetics or eye trauma. Dr. Hromas cited the news-making case of Minnesota Vikings head football coach Mike Zimmer in late 2016, in which a scratch to his eye worsened to the point that he required retinal surgeries to repair a detachment and remove scar tissue.

“If we catch it when it’s a tear, we can do a five-minute laser treatment in the office, and the patient never has to go to the operating room,” Dr. Hromas says. “Once it becomes a full detachment, in most cases it has to be treated in the operating room.”

Symptoms such as experiencing floaters or flashes of light can indicate a potential tear.

“At that point, it might just be a tear, but if a patient waits to be seen, it could become a detachment,” Dr. Hromas says. “I saw a patient today who had started seeing floaters two weeks ago. If we had seen her at that time, we likely could have prevented a detachment. By the time it’s curtains, it’s detached.”

Characteristically, patients with a detached retina will notice what can be likened to a dark gray curtain closing in on their vision from the outside to the middle, moving inward from either side or from the bottom up. The most dangerous movement is that from the bottom up, Dr. Chacko says.

The availability of wide-field fluorescein angiography (FA) means earlier detection and more accurate staging of various ocular diseases. Although the fundoscopic exam above appeared relatively benign, FA demonstrated significant ischemia of the peripheral retina due to diabetic retinopathy.

Wide-field fluorescein angiography allows for the precise localization of pathology, as in this patient with proliferative diabetic retinopathy. Accurate localization facilitates a more targeted treatment, which is potentially less invasive and traumatic than compared to traditional approaches.

Fluorescein angiography demonstrates active choroidal neovascularization, the hallmark of wet age-related macular degeneration. Early recognition, diagnosis and treatment are essential to preserve maximal vision.

Age-related macular degeneration (AMD) and diabetic retinopathy caused by complications from diabetes are two other critical conditions that affect the retina and can lead to permanent vision loss.

According to the American Society of Retina Specialists, diabetic retinopathy is the most common cause of irreversible blindness in working-age Americans. The condition occurs in more than half of people who have either Type 1 or Type 2 diabetes.

According to the National Eye Institute, AMD, which destroys macula of the eye, is the leading cause of vision loss in the U.S. By 2050, the estimated number of people with AMD is expected to more than double from 2010 figures to 5.44 million Americans. AMD always starts with dry-form degeneration. In wet form, fluid leaks under the retina and can cause scar tissue and more damage.

Both conditions require compliant monitoring with annual eye exams because changes are often subtle and undetectable by the patient, according to Drs. Chacko and Hromas. Often by the time a patient becomes aware of symptoms, the situation can be advanced and lead to vision loss.

Advances in treatments and diagnostic tools for both AMD and diabetic retinopathy are helping preserve and slow down the loss of vision.

“When I first started practicing, in 1991, we saved less than 1 percent of the eyes of patients with wet macular degeneration,” Dr. Chacko says. “Now about 50 percent of my patients can retain functional vision of 20/50 or better and continue to drive or read, if we approach it diligently.”

One monitoring advancement is an ultrawide retinal imaging system by Optos, which is “used to discover, diagnose, document and treat ocular pathology,” according to the manufacturer. Two years ago, Grene Vision Group invested in two such machines. With Optos’ fluorescein angiography, the physician can view up to 80 percent of the retinal surface at one time, with a 200 degree range, as opposed to the 30 degree range of conventional imaging.

For more information about retinal conditions, or to make a referral, contact Grene Vision Group at 316-684-5158 or visit