Routine eye exams are a key component to maintaining eye health. By keeping your visits consistent, your doctor has a better chance of diagnosing, monitoring, and treating eye diseases like retinal detachments and diabetic retinopathy.
Our vitreoretinal specialists, Dr. Craig Lemley and Dr. Steven Saraf primarily treat the portion of the eye from behind the lens, which includes the vitreous gel and the retina itself. There are a variety of diseases that can affect these areas of the eye, and Drs. Lemley and Saraf work directly with patients to find the best possible outcomes for you. Medicare and most health insurance plans will cover the treatment of retinal disease.
Retinal tears or detachments can cause significant vision loss, and are most common in people over age 50. As we reach middle age, the clear, jelly-like fluid that fills the eye may start to liquify and shrink. The vitreous gel can eventually pull away from the back of the eye, causing a detachment. Injury to the eye, or ocular trauma, can also lead to retinal detachment. This condition can manifest with “floaters” or the appearance of flashing lights. Your doctor can determine whether the floaters and flashes of light are caused by a retinal detachment and determine the best treatment.
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OPTICAL COHERENCE TOMOGRAPHY
MEET DR. LEMLEY
Dr. Lemley is a board-certified ophthalmologist with advanced fellowship training in vitreoretinal diseases and surgery. He has extensive experience in the treatment of ocular conditions including age-related macular degeneration, diabetic retinopathy, retinal vascular disorders, macular hole, epiretinal membrane, retinal tear, and detachment.
Dr. Lemley’s training includes a vitreoretinal fellowship at the Medical College of Wisconsin, where he instructed ophthalmology residents, medical students, and surgical staff. He also served as Staff Physician at the Clement J. Zablocki Veterans Administration Hospital in Milwaukee, Wisconsin, and served as a clinical instructor/volunteer at the Oregon Health and Sciences University in Portland, Oregon.
He has made contributions to medical literature by authoring book chapters and peer-reviewed journal articles and has presented at national ophthalmology conferences. He has also been a contributing investigator in numerous clinical trials investigating novel treatments of vitreoretinal diseases.
A member of the American Society of Retinal Specialists, the American Academy of Ophthalmology, and the Association for Research in Vision and Ophthalmology, Dr. Lemley also served on the Continuing Education Committee of the Oregon Academy of Ophthalmology.
Dr. Lemley has donated his time to offer complex and expensive surgical procedures to treat diseases of the retina and vitreous in low-income and uninsured patients served locally by La Clinica. For more information, visit the La Clinica website.
When away from the office, Craig enjoys spending time with his family. He is also an avid skier, bicyclist, hiker, and speed skater.
Education and Training
Vitreoretinal—Medical College of Wisconsin
Ophthalmology—University of Washington
Internal Medicine—University of Washington
Medical School, 2001
University of Washington, Seattle
MEET DR. SARAF
Dr. Steven Saraf was raised in southern Washington but has traveled widely throughout his career. He specializes in the retina, vitreoretinal surgery, and uveitis. He completed two ophthalmology fellowships, the first in uveitis at Bascom Palmer Eye Institute in Miami, Florida, and the second in retina and vitreoretinal surgery at the University of Washington in Seattle, Washington. He completed his internship and ophthalmology residency at Henry Ford Hospital in Detroit, Michigan. He obtained his medical degree at the University of California, Los Angeles, and a bachelor’s degree at Cornell University in Ithaca, New York.
Upon completing his ophthalmology training, Dr. Saraf was recruited by the University of Washington to serve as faculty, where he was appointed assistant professor. He provided valuable training and mentorship to fellows, residents, and medical students. He has won multiple teaching awards. He served as the medical director of the Karalis Johnson Retina Center at the University of Washington. This busy referral center provides higher-level care for Washingtonians and patients traveling from Alaska, Idaho, Montana, Wyoming, and others. His experience during these years proved invaluable in allowing him to care for a wide breadth of challenging clinical problems.
Dr. Saraf specializes in the care of medical and surgical problems in the retina including retinal detachments, epiretinal membranes, macular holes, age-related macular degeneration, diabetic retinopathy, central serous chorioretinopathy, retinal vascular occlusions, and ocular trauma. He provides advanced care for patients with uveitis, offering advanced immunomodulatory therapies and surgical interventions for inflammatory eye conditions.
Dr. Saraf is an established researcher, having authored over 20 articles in peer-reviewed journal articles and contributed multiple book chapters. He has helped conduct clinical trials and his work has been featured at national and international conferences.
Outside of work, Dr. Saraf enjoys playing ice hockey, exploring the outdoors, cooking, drinking coffee, playing chess, and traveling the world.
Education and Training
Retina and Vitreoretinal Surgery Fellowship, University of Washington
Uveitis—Bascom Palmer Eye Institute, University of Miami
Ophthalmology—Henry Ford Hospital, Department of Ophthalmology
Medical Degree, 2012
David Geffen School of Medicine at UCLA, Los Angeles, CA
Bachelor of Arts, Biological Sciences and English
Cornell University, Ithaca, NY
- Are you experiencing vision loss or distortion of your central vision?
- What about a curtain or veil over a portion of your vision?
- Have you recently developed small specks or clouds moving in your field of vision?
- Do you notice the sudden appearance of light flashes or stars?
- Do you have diabetes and vision changes?
Retina eye care encompasses a variety of diseases in the eye. A retina care specialist primarily treats the parts of the eye from behind the lens, which includes the vitreous gel, and retina. The retina is a thin layer of light-sensitive tissue on the back wall of the eye. The vitreous is a clear gel that fills the back of the eye. The optical system of the eye focuses an image of what you are seeing on the retina, similar to the way an image is focused on the film of a camera. The retina then translates that focused image into neural impulses and sends them to the brain via the optic nerve. Patients who need retina care may suffer from:
- Macular Degeneration
- Diabetic Retinopathy
- Retinal Tears and Retinal Detachment
- Ocular Trauma – Injury to the Eye
- Retinal Vein Occlusion
- Retinal Artery Occlusion
- Macular Hole and Epiretinal Membrane
The majority of people who learn they have retinal disease are referred by their regular eye doctor. If you are diagnosed with a retina eye disease, our fellowship trained retina specialists will work hand-in-hand with you to determine the best possible course of action. We work closely with other eye doctors in the region and we will send a report to your referring physician. Medicare and most health insurance plans will cover the treatment of retinal disease.
Learn more about retina diseases, testing and treatments in the pages at the right, or feel free to call our offices in Medford or Grants Pass and schedule an appointment. We’re here to answer your questions.
Despite ongoing medical research, there is no cure yet for ‘dry’ macular degeneration. Based on clinical studies, some nutritional supplements may slow progression of macular degeneration. This is based on the Age Related Eye Disease Study (AREDS) that showed that a certain formula of vitamin A, vitamin C, vitamin E, zinc and copper reduced the chance of progression from intermediate to late stages of macular degeneration by about 25%. Treatment of advanced forms of ‘dry’ macular degeneration focuses on helping a person find ways to cope with visual impairment.
The most frequently used treatment for ‘wet’ macular degeneration is injection of a medicine that halts new blood vessel growth and causes them to regress. Despite advanced medical treatment, however, many people with age-related macular degeneration still experience some vision loss.
Occasionally, ‘wet’ macular degeneration can be treated with other procedures, including laser surgery. It may also be treated with photodynamic therapy (PDT), in which a light activated chemical is injected into the blood stream and activated in the eye with a low energy laser.
To help you adapt to lower vision levels, your doctor can prescribe optical devices or refer you to a low-vision specialist or center. A wide range of support services and rehabilitation programs are also available to help people with macular degeneration maintain a satisfying lifestyle. Because side vision is usually not affected, a person’s remaining sight is very useful. Often, people can continue with many of their favorite activities by using low-vision optical devices such as magnifying devices, closed-circuit television, large-print reading materials, and talking computerized devices.
Types of Macular Degeneration
The two main categories of age-related macular degeneration are ‘dry’ (atrophic) and ‘wet’ (exudative):
‘Dry’ or Atrophic Macular Degeneration
Most people have the ‘dry’ form of macular degeneration. It is caused by aging and thinning of the tissues of the macula. Vision loss is usually gradual.
‘Wet’ or Exudative Macular Degeneration
The ‘wet’ form of macular degeneration accounts for about 10% of all macular degeneration cases. It results when abnormal blood vessels form underneath the retina at the back of the eye. These new, abnormal blood vessels leak fluid or blood and blur central vision. Vision loss may be rapid and severe.
Macular Degeneration Symptoms
Macular degeneration can cause different symptoms in different people. The condition may be hardly noticeable in its early stages. Sometimes only one eye loses vision while the other eye continues to see well for many years. But when both eyes are affected, the loss of central vision may be noticed more quickly. The following are some common ways vision loss is detected:
- Words on a page or faces look blurred
- An empty area appears in the center of vision
- Straight lines look distorted
Visit the American Academy of Opthalmology’s webpage on Macular Degeneration.
How is diabetic retinopathy diagnosed?
A medical eye examination can find changes inside your eye. An eye care specialist can often diagnose and treat serious retinopathy before you are aware of any vision problems. Your doctor dilates your pupil and looks at the inside of your eye.
If your eye doctor finds diabetic retinopathy, he or she may order color photographs of the retina and a special test called fluorescein angiography to find out if you need treatment. In this test, fluorescent dye is injected into a vein in your arm and your eye is photographed as the dye passes through the blood vessels in the back of the eye.
Treatment of diabetic retinopathy
The best treatment for diabetic retinopathy is to prevent it’s development. Strict control of your blood sugar will significantly reduce the long-term risk of vision loss from diabetic retinopathy. If high blood pressure and kidney problems are present, they need to be treated.
Laser surgery is often recommended for people with macular edema, PDR and neovascular glaucoma. For macular edema, the laser is focused on the macula to decrease the fluid leakage. The main goal of treatment is to prevent further loss of vision. It is uncommon for people who have blurred vision from macular edema to recover normal vision, although some may experience partial improvement.
For PDR, the laser is focused on all parts of the retina except the macula. This panretinal photocoagulation treatment causes abnormal new vessels to shrink and often prevents them from growing in the future. It also decreases the chance that vitreous bleeding or retinal distortion will occur. Recently, eye injections have become a useful tool in the management of diabetic retinopathy.
Multiple eye injections or laser treatments over time are sometimes necessary. These procedures do not cure diabetic retinopathy and does not always prevent further loss of vision. Sometimes, in severe cases, a patient may need to see a retina specialist to discuss more involved surgery.
Vision loss to diabetic retinopathy is largely preventable.
If you have diabetes, it is important to know that today, with improved methods of diagnosis and treatment, only a small percentage of people who develop retinopathy have serious vision problems. Early detection of diabetic retinopathy is the best protection against loss of vision. You can significantly lower your risk of vision loss by maintaining strict control of your blood sugar and visiting your eye care specialist regularly.
When to schedule an examination.
In general, you should have your eyes checked promptly if you have visual changes that:
- Affect only one eye.
- Last more than a few days.
- Are not associated with a change in blood sugar.
People with diabetes should schedule examinations at least once a year. More frequent medical eye examinations may be necessary after the diagnosis of diabetic retinopathy. Pregnant women with diabetes should schedule an appointment in the first trimester because retinopathy can progress quickly during pregnancy.
If you need to be examined for glasses, it is important that your blood sugar be in consistent control for several days when you see your doctor. Glasses that work well when the blood sugar is out of control will not work well when blood sugar is stable. Rapid changes in blood sugar can cause fluctuating vision in both eyes, even if retinopathy is not present.
When people reach middle age, the clear jelly-like fluid that fills the inside of your eye may start to liquify and shrink. The vitreous gel will eventually pull away from the back wall of the eye, causing a posterior vitreous detachment (PVD). This condition naturally occurs when people reach their late 50s or early 60s, but sometimes earlier or later in life. It can happen earlier in people who:
- Are nearsighted
- Have had cataract surgery
- Have had laser surgery
- Have had inflammation inside the eye
PVDs often cause symptoms of new floaters in the vision and flashing of lights. Sometimes these symptoms can indicate problems such as retinal tears or detachments.The appearance of flashing lights or floaters may be alarming, especially if they develop suddenly. While not all floaters and flashes are serious, you should have a medical examination by an eye care specialist to make sure there has been no damage to your retina.
Retinal Tear Overview
Retinal Detachment Overview
What causes the flashing lights?
When the vitreous gel pulls on the retina, you may see what look like flashing lights or lightning streaks. The flashes of light can appear off and on for several weeks or months. If you notice the sudden appearance of unexplained light flashes, however, you should visit your eye care specialist immediately to see if your retina has been torn.
What causes floaters?
Sometimes you may see small specks or clouds moving in your field of vision. They are called floaters. You can often see them when looking at a plain background, like a blank wall or blue sky. Floaters are actually tiny clumps of debris inside the vitreous, While these objects look like they are in front of your eye, they are actually floating inside. What you see are the shadows they cast on the retina, the nerve layer at the back of the eye that senses light and allows you to see. Floaters can have different shapes: little dots, circles, lines, clouds or cobwebs. Many people have subtle floaters for most of their lives. If you suddenly develop new or more prominent floaters, however, it can indicate a problem and should be evaluated by an eye doctor.
Trauma to the eye can sometimes lead to vision threatening complications. Injuries can lead to scratches on the cornea (corneal abrasion), bleeding in parts of the eye (hyphema or vitreous hemorrhage), high pressure in the eye (glaucoma), clouding of the lens in the eye (cataract) or retinal detachment. Trauma to the eye that is substantial—or if it causes temporary or ongoing vision loss, eye pain, floaters or flashes—should be promptly evaluated by an eye specialist. Treatment may be needed to help restore or preserve vision.
More severe trauma to the eye can sometimes break or cut the wall of the eye. High velocity impacts that can occur with grinding tools, hammering, and landscaping equipment such as weed-whackers may cause objects to enter the inside of the eye. This can lead to problems such as severe bleeding, infection, retinal detachment, permanent vision loss and/or loss of the eye. With these serious injuries, surgery is often required promptly to maximize the outcome. With more serious trauma, one or more surgical procedures may be required to treat the injured eye.
Retinal Vein Occlusions (RVOs) occur when small veins in the retina suddenly close off for a period of time. This leads to a sudden increase in blood pressure in the affected area of the retina that causes blood to spill out of the veins into the retinal tissue, often damaging part retina. RVOs can vary greatly in their severity. Sometimes vision is not affected, other times it can be severely affected.
Vision loss with RVOs can occur due to the blood vessels in the retina closing off permanently (ischemia). Vision may also be affected by blood vessels becoming leaky. Serum (clear fluid within the blood) can leak from these blood vessels into the retina making it thick and swollen and allowing proteins and fats to accumulate in the retina. When this retinal swelling occurs in the center of the retina, it can make the vision very blurry (macular edema). Macular edema can often be treated with eye injections or with laser.
Sometimes abnormal blood vessels can start growing in the eye after an RVO. This complication is termed neovascularization. It can lead to bleeding in the eye or even high eye pressure (termed neovascular glaucoma) that can lead to severe vision loss or pain. If this condition is diagnosed in the early stages treatments with laser or eye injections can often limit further damage to the eye. If you have developed an RVO, your eye should be evaluated regularly, especially for the first year in order to detect and treat neovascularization.
Patients who develop RVOs are more likely to have other conditions in the rest of their body such as diabetes, high blood pressure or heart disease. Patients with RVOs should be see their primary care provider to check their general health and assess for these possible conditions, if this has not been done recently.
Retinal artery occlusions (RAOs) occur when small blood vessels in the retina suddenly close off for a period of time. This leads to severe damage in the affected area of the retina often causing sudden vision loss that is usually painless. RAOs can affect the entire retina leading to loss of both central and side vision. RAOs can also affect only a portion of the retina causing loss of a section of the central or side vision.
Sometimes abnormal blood vessels can start growing in the eye after an RAO. This complication is termed neovascularization. It can lead to bleeding in the eye or even high eye pressure (termed neovascular glaucoma) that can lead to even more severe vision loss or pain. If this condition is diagnosed in the early stages treatments with laser or eye injections can often limit further damage to the eye. If you have developed an RAO, your eye should be evaluated regularly, especially for the first year in order to detect and treat neovascularization.
Patients who develop RAOs are more likely to have other conditions in the rest of their body such as diabetes, high blood pressure or heart disease. They may also have conditions in their carotid artery (the artery that brings blood to the head) or heart that could lead to another RAO or even a stroke. Patients with RAOs should be see their primary care provider to check their general health and assess for these possible conditions, if this has not been done recently.
On occasion a small hole can spontaneously occur in the very center of the retina. This is called a macular hole. Because it affects the very center of the retina (termed the macula), it can cause distortion and a blank spot in the center of your vision. Once the macular hole reaches a certain point, it is unlikely to improve on its own.
Macular Hole Overview
Surgery can be performed to close the macular hole. The procedure is called vitrectomy. During this surgery the gel that fills the eye (called vitreous) is removed and replaced with saline (salt water). A small membrane is often removed from the retinal surface in the area of the hole to encourage the hole to close. Near the end of the surgery a gas bubble is placed in the eye. After surgery, the bubble gently presses on the hole to encourage it to close. In order to get the bubble into the correct position over the macular hole the patient often needs to sit or lay face down for part of the day for up to a week. The gas bubble slowly absorbs into the body over a couple weeks. Your ability to travel by airplane or to higher altitude will be limited during the period of time that the bubble is in your eye.
Once the macular hole is closed, there is often (but not always) an improvement in the vision, including better ability to read and improved distortion and blank spot in the central vision. When vision does improve, it can take several months.
Macular Hole Treatment Overview
Occasionally a small film of tissue, like cellophane, grows on the center of the retina. This condition is called an epiretinal membrane (ERM). The ERM can contract and distort the retina leading to blurring and distortion of the vision. ERMs can be very subtle and may not significantly affect the vision for long periods of time. Other times they can progress more rapidly and cause bothersome visual symptoms.
When ERMs are affecting the vision, surgery can be performed to remove the membrane. The procedure is called vitrectomy. During this surgery the gel that fills the eye (called vitreous) is removed and replaced with saline (salt water). The ERM is then removed from the retinal surface with very fine instruments placed into the eye. Afterwards, the vision often (but not always) improves, with improved central vision and reduction of distortion.
Eye Injections for retinal disease
We perform eye injections for a number of retinal disease including Age Related Macular Degeneration, Diabetic Retinopathy and Retinal Vein Occlusion. Several of the medications, termed anti-VEGF agents, work by causing abnormal blood vessels to shrink and regress or by reducing abnormal leakiness of blood vessels. Examples include Avastin, Lucentis and Eylea. Other medicines injected into the eye include steroids, which work by reducing inflammation in the eye.
Having an eye injection is usually not as bad as it sounds. We numb the eye with anaesthetics first and clean the eye with an antiseptic. The antiseptic can feel like having shampoo in the eye, which is often the most uncomfortable part of the procedure. Once the eye is numb, the injection with a very small needle through the white part of the eye usually produces minor discomfort. Xipere is a new injection treatment for Uveitis. It is a steroid injection into the eye, but into a different part of the eye called the suprachoroidal space. It has some advantages over our other steroid injections and in most cases poses less problems with eye pressure elevations and treatment effect can last several months longer than traditional injection treatments.
After the eye injection, the eye may be red from irritation or a limited amount of blood that accumulates near the injection site like a bruise. This can be very minor or very noticeable. It will fade over a week or two. The eye may be irritated and scratchy for the first day, but usually is much improved by the day after the procedure. If the eye becomes more painful or the vision becomes more blurry following the day of the injections you should call the office and may need to be evaluated. Very rarely, vision threatening issues such as severe infection can occur and requires prompt evaluation and treatment.
Laser Surgery for retinal disease
A number of laser procedures are used in treatment of retinal disorders. Lasers can be used for conditions such as Age Related Macular Degeneration, Diabetic Retinopathy, Retinal Vein Occlusion as well as to treat retinal tears.
Laser procedures are usually performed in the office. Most laser procedures are painless or only minimally uncomfortable. Occasionally the laser procedure can be more uncomfortable. Sometimes an injection of an anesthetic is used to make the eye comfortable for the procedure.
Sometimes a laser procedure will be done in one visit, other times it may be performed over several visits.
Vitrectomy Surgery for retinal disease
The primary surgery used in the treatment of retinal disease is vitrectomy. In this procedure, the gel from the center of the eye is removed and replaced with saline (salt water). Once the gel is removed, natural saline fluid that is continuously being made inside the eye takes the place of the gel. Sometimes a temporary gas bubble is placed into the eye at the end of surgery. Rarely a silicone oil is place into the eye that helps to hold the retina in place. Silicone oil is often removed with and additional surgery 3 to 6 months later.
Vitrectomy surgery is utilized for a large number of retinal disorders. For example, blood and scar tissue can be removed from patients with advanced diabetic eye disease. Other disorders treated with vitectomy include removal of epiretinal membranes, closure of macular holes and treatment of retinal detachments.
Vitrectomy surgeries are currently performed at Ashland Community Hospital, where the very specialized equipment needed for this type of surgery is located. Several clinic appointments are required after surgery and these are usually performed at the Medical Eye Center. You will need to take eye drops for a month or more after surgery. If a bubble is placed in your eye during the surgery, you may need to position face down for part of the day for the first week or so after the surgery. Because severe pressure problems can occur if you travel to higher altitude with a bubble in the eye, you must not fly in an airplane or drive to higher altitude without specific instructions from your surgeon. Once the bubble is gone, no altitude restrictions apply.
If you require vitrectomy surgery, your surgeon will give you more information about what to expect.
What to expect at your exam
An initial retina care examination may last 2-3 hours, depending on the tests required. When Dr. Lemley examines your eyes, your pupils will be dilated with eye drops. During this examination, he will carefully observe your retina and vitreous. Methods of diagnostic testing of the retina and vitreous include:
- Optical Coherence
- Fundus Photography
- Ocular Ultrasound
What to expect after your exam
Because your eyes have been dilated, you may need to make arrangements to have someone drive you home afterwards. If you are from out of town, we partner with local hotels that offer discounted rates for our patients. If you need accommodations we will be happy to assist you.
Your comfort and safety is our priority
If your procedure requires anesthesia, our Certified Registered Nurse Anesthetists (CRNA’s) will be with you through your entire procedure to monitor your vital functions and modify your anesthesia to help ensure your maximum safety and comfort.
CRNA’s are anesthesia specialists that are board certified and highly trained to help keep you comfortable and safe before, during and after your procedure.
Before your procedure, your CRNA will assess your health and responsivity to anesthesia, taking into account any health conditions, current medications, and allergies to create a customized approach depending on your individual needs.
New monitoring technologies, improved anesthetics, and advanced education for providers have made the administration of anesthesia safer and more effective than ever before.