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Medical Ophthalmology Center

Blepharitis is a common and persistent inflammation of the eyelids. Symptoms include irritation, itching, and occasionally, a red eye. This condition frequently occurs in people who have oily skin, dandruff or dry eyes. Blepharitis can begin in early childhood, and continue throughout life as a chronic condition, or develop later in life. Bacteria reside on the surface of everyone's skin, but in certain individuals they thrive in the skin at the base of the eyelashes.


The resulting irritation, sometimes associated with over-activity of the nearby oil glands, causes dandruff-like scales and particles to form along the lashes and eyelid margins. For some people the scales or bacteria associated with blepharitis produce only minor irritation and itching, but in others they may cause redness, stinging or burning. Some people may develop an allergy to the scales or to the bacteria which surround them. This can lead to a more serious complication, inflammation of the eye tissues, particularly of the cornea. Many medications are available for the treatment of blepharitis, including antibiotics and steroid preparations in drop or occasional ointment form. This process which may take several weeks includes a daily cleansing routine instructed by Dr. Adam Koenigsberg, and is essential.

Cataracts are a common cause of visual impairment in older adults. Cataracts are considered an inevitable part of aging, and are relatively common among adults older than 55 years of age. In fact, half of all Americans have them, or have had cataract surgery, by age 80.

Cataract Chart

Cataract surgery is performed when your quality of vision affects your quality of life. When you are unable to enjoy daily routine activities such as working, driving, reading, hobbies, etc., because of cataracts, one should consider cataract surgery.

Diabetes affects many parts of the body, including the eyes. Those with diabetes, or an elevated risk of diabetes, should have an annual dilated eye examination. This should be done even though they may not be experiencing problems with their vision.

Diabetic Eye Care

Diabetic eye disease refers to a group of eye problems that often accompany diabetes. These include cataract (clouding of the eye's lens), glaucoma (increase of fluid pressure inside the eye leading to optic nerve damage and loss of vision), and diabetic retinopathy (the most common diabetic eye disease).

Diabetic retinopathy damages the tiny blood vessels in the retina, the light-sensitive tissue that lines the back of the eye. Symptoms may include blurred vision. Retinopathy is a silent condition. Symptoms may not appear until the disease becomes more severe, but the damage is still occurring in the eyes. Having diabetes makes one at high risk for eye disease. Good diabetes control may help prevent eye disease. The only way to diagnose early signs of diabetic eye disease is through a dilated eye exam at least once a year. This should be done even though one is not experiencing problems with their vision.

Double vision diagnosis and treatment is a very large part of this practice specialty. Many other eye care providers refer their double vision patients to us for further evaluation.

What is double vision? Essentially it is seeing two images, but sometimes patients may complain only of image blur, headache or the perception of images/objects "running together." It is also called "diplopia." The diagnosis of eye disease and medical problems associated with double vision is long and difficult, but very important. Certain patients may have to undergo MRI or CT scanning of the brain and orbits to evaluate for important neurologic diseases associated with double vision. Equally important at times are blood work-ups, and other specialists which can include neurologists and cardiologists. Occasionally, strokes and tumors of the brain and orbits can result in double vision. Thyroid disease is another clinical problem that can result in double vision.

Once diagnosis is made, treatment is directed toward the disease itself. In many cases, the double vision can also be alleviated or eliminated with eye muscle surgery, or with special glasses that contain "prism", a visual tool that neutralizes the double vision that is perceived. When glasses with prism are worn, an individual will be able to see everything as"one image" again. The same can be true of surgery. Depending on the situation, some patients may require glasses with prism, eye muscle surgery, or both. Diagnosis and treatment of a patient with double vision is highly complex and specialized, and can be very rewarding for the physicians as well as the patients who present with this problem. Dr. Adam Koenigsberg is a double vision specialist, as part of his role as a pediatric and adult eye muscle specialist.

Dry eye is also a frequent problem in the hot and humid environment of Northeast Florida. During warmer weather, our tears evaporate more frequently, causing dry eye. Similarly in the mid-winter, the lower humidity and use of heat indoors can cause dryness. Many patients complain that their eyes are "tearing" and are surprised to learn that "tearing" is one of the signs of dry eye. This is because the tearing is a reflex to the dry surface of the eye itself.

Dry Eye

There are many treatments for dry eye which we can tailor to your needs. These can include over 20 different brands of lubricant drops which come in different strengths and thicknesses, which coat and protect the eye and improve comfort. There are now prescription drops (Restasis) which can also increase the amount of tears that a patient makes, to reduce dry eye symptoms. Finally, there are minor procedures which can be performed in the office including punctal plugs' placement. This is a painless procedure where a tiny plug, less than a millimeter in size is placed on the surface of the punctum, a dot on the inner corner of the eyelid where tears drain down the nose. By stopping or slowing drainage of your tears, they remain on the surface of the eye longer, making you much more comfortable.

Eye allergy is a very common problem here in Northeast Florida. In fact, since we have very little true winter with a long growing season, there is constant fluctuation of pollen in the outdoor air that can cause eye irritation and burning. Sometimes our patients also experience these symptoms of irritation and burning from indoor allergies to dust, pet dander and carpeting. There are many ways to treat eye allergy, which is called allergic conjunctivitis. The symptoms can be helped with a variety of prescription and non-prescription topical antihistamines, and sometimes topical steroids. Topical steroids do have a low risk for development of cataracts and glaucoma, therefore they require regular monitoring. It is best to have Dr. Koenigsberg evaluate your condition so he can recommend the exact treatments and/or medications that may correct your condition.

Click here to read Eye Muscle Problems in Children & Adults: A Guide to Understanding. This book is useful for parents with children and for adults.

The purpose of eye muscle surgery, otherwise known as strabismus surgery, is to correct the malpositioned ocular appearance. Many patients are under the assumption that the inability of the eye or eyes to appear or remain straight is muscular in origin. In fact, in most cases, the problem is usually neurologic, genetic or secondary to some external factor. Children who are born with crossed eyes, or have eyes which drift for example, do not have a particular problem with a muscle. Rather, the brain, for reasons which are not clear, did not learn to understand how to use the eye or eyes together for various reasons. The neuronal connections or "wires" which connect the brain or "master organ" with the eyes do not work correctly and therefore the eyes do not move in unison, or individually in the correct fashion, in the direction in which one would expect them to. In some cases, the matter is genetic and some patients similarly are born or acquire a problem where the eyes do not work properly individually or together and similarly the problem usually rests with the brain and its connections to the eyes. Finally, in some situations, an eye position abnormality may rest with an outside source such as a stroke, aneurysm or brain tumor, or after a traumatic event such as a serious accident.

Therefore, the purpose of eye muscle surgery is to correct the improper movement of the eye or eyes, but as you will now understand the problem is only rarely a true problem of the eye muscle itself. Since the key is in understanding the complicated nature of the problem in the innervation of the muscle, patients will understand the benefits as well as the limitations of what eye muscle procedures can accomplish. In essence, the surgeon attempts to repair the position of the eyes via muscular procedures in an effort to "re-teach" the brain how to use the eye or eyes correctly. In some ways, it is an elegant form of peripheral neurosurgery, working on the endpoint of the brain's control, namely the eye muscle or muscles.

What can eye muscle surgery do for a patient? It can restore normality in appearance, help to enable the eyes to work together better, and in some cases reduce or eliminate double vision from their malposition. Since the problem is not the end point or eye muscle itself, the chance of repeat surgery, namely, a second or third procedure is 25% in the USA. This is due to the fact that the clinical problem is related to the "wiring" or "neuronal connections."

The surgeries themselves are very straightforward and usually performed in an outpatient surgery setting. They can be performed under local (where is patient is relaxed but awake) or general (the patient is "asleep") anesthesia. This is often left to patient preference. The selected muscles of the eyes are visualized under a mounted microscope which the surgeon wears, much like a very high power microscope that a jeweler would use to evaluate a gem under high magnification. The muscle in question can be isolated with special hooks and then detached from the eye, and gently moved into a new position and sewn with self-dissolving stitches into the new, desired position. Muscles can be shorted and tightened (resected) to strengthen their effect, or relaxed and lengthened (recessed) to weaken their effect.

Patients sometimes fear the eye will be removed during surgery. This is not the case. The surgery is elegant and sophisticated, and only the muscles are gently manipulated while the eye remains in perfect position in the socket. The procedure is not painful, and the post-operative discomfort is moderate and lasts usually 1-3 days and can be controlled with Tylenol® or sometimes stronger prescription pain medication if needed, depending on the patient and the procedure involved. During the first week or two the eyes will appear red and irritated. This disappears by 3-4 weeks. Most patients return to work or school within 3-4 days easily. Healing typically takes approximately one month, during which the brain learns how to use the eye or eyes in their new positions. Within one month it is difficult to tell that surgery has occurred. Some exceptions occur for patients who are undergoing complex revisions of prior procedures done during earlier times in their lives. In this situation, the eyes can remain irritated longer.

Eye muscle surgery can be performed additionally under a special technique, depending on patient preference, in which the muscles are "adjusted" via a special sliding stitch several hours after the procedure to maximize the appearance and position of the muscle. This approach has its benefits and disadvantages, and we discuss each approach and type of procedure in this practice thoroughly prior to making a final decision.

Eye muscle surgery therefore remains both an art and science. Its predictability can be excellent, and most patients are extremely pleased with their new appearance and in some cases, the elimination of significant problems that occur with poorly positioned eyes. This includes elimination of the psychological and social problems inherent with looking "different." As mentioned previously, it can also reduce or eliminate double vision, improve depth perception (3-dimensional vision) depending on the age and patient situation, and also sometimes improve "binocular" vision or the vision with both eyes open at the same time. Finally, eye muscle surgery can reduce the complicated appearance of eye muscles that can occur after strokes and trauma additionally. We hope this information is helpful and we encourage you to ask as many questions as you like should you visit our office. Eye muscle surgery, when the proper clinical situation is chosen, can be an enormously powerful tool in restoring normal appearance and eliminating significant medical and psychosocial problems for our patients.

Glaucoma is a serious eye disease which is silent. It is one of the most significant eye diseases in Ophthalmology because for the most part it is silent without any symptoms. Patients gradually lose their peripheral vision without notice, and sometimes then their central vision. Since there are no symptoms and you cannot tell that you have it, it is important to have an M.D. Ophthalmologist assess your risk for glaucoma. There are a number of risk factors including family history, race, age over 40, and the presence of other systemic diseases such as Diabetes Mellitus. On examination we have a number of ways that can help us determine if you might have glaucoma. This includes a thorough eye examination, and measuring of the intraocular pressure which is often elevated in patients with glaucoma. Our office has very sophisticated computer technology that can measure the thickness of the optic nerve down to microns or one-hundredth of a millimeter. We also have computer equipment that can assess whether or not peripheral vision has been lost, another sign of glaucoma.


Many patients worry that glaucoma is a doom and gloom sentence to blindness. However, this is not necessarily true, especially if the patient comes for regular eye exams and follows treatment protocols carefully. There are many treatments for glaucoma. Although different forms of glaucoma exist, the most common is called primary open angle glaucoma. In this form, the pressure in the eye is too high, and we can lower the eye pressure via many methods, including eye drops. There are currently over 6 different types of drops that can be used to lower eye pressure and each works differently. For patients who still have an elevated IOP (Intraocular pressure) after attempting glaucoma treatment through medication, Dr. Koenigsberg may recommend either laser or traditional surgery. About three million Americans have open angle glaucoma, and laser therapy is a safe and effective alternative to eye drops. It can be repeated multiple times, and its effect can last from 3-5 years or longer depending on the patient.

Age-related macular degeneration (AMD) is a progressive disease of the retina whereby the light sensing cells in the central area of vision (the macula) stop working and eventually die. The disease is thought to be caused by a combination of genetic and environmental factors, and it is most common in people who are age 60 and over. AMD is the leading cause of visual impairment in senior citizens. An estimated fifteen million people in the United States have it.

AMD occurs in both "dry" (non-neovascular) and "wet" (neovascular) forms. Macular degeneration can make it almost impossible to read or recognize particular objects or faces, but enough peripheral vision remains in order to perform daily activities.

Macular Degeneration

"Dry" AMD is the most common form of the disease. It is diagnosed when yellowish spots (drusen) accumulate from deposits or debris from deteriorating tissue, mostly around the macula. The most common symptom of Dry AMD is slightly blurred vision. Additional light may be necessary for reading and other tasks, as well as recognizing faces.

"Wet" AMD, which is less common, occurs when abnormal blood vessels behind the retina start to grow under the macula. The new blood vessels tend to be very fragile and often leak blood and fluid. The blood and fluid raise the macula from its normal place at the back of the eye. Damage to the macula occurs rapidly. An early symptom of Wet AMD is when straight lines appear wavy. A grid is often dispensed to our macular degeneration patients to use at home for daily monitoring and detection of changes in AMD.

Whether you are experiencing symptoms of "Dry" or "Wet" AMD, you are strongly encourage to schedule an appointment with Dr. Koenigsberg for a comprehensive dilated eye examination of the macula and retina.

Around four of every 100 young children exhibit amblyopia, sometimes referred to as "lazy eye". This common visual condition leads to loss of vision in otherwise healthy eyes. Complete vision loss can be permanent in some cases unless identified and treated by our specialists at Deerwood Ophthalmology.

Amblyopia most commonly occurs as a result of strabismus (misaligned eyes), uncorrected refractive error, or blockage of the vision pathway as may occur with infant cataracts or ptosis (droopy eyelid). It may co-exist with strabismus, but is not synonymous for strabismus. Amblyopia may be present even when the eyes are straight.

Pediatric eye disorders can have lasting impact into adulthood. For example, misalignment of the eyes, or strabismus, is where an eye may turn in or out. If left untreated, strabismus may result in a lazy eye, or amblyopia, a common adult reason for blurred vision.

Deerwood Opthalmology's Medical, surgical and therapeutic treatments for strabismus may translate into improved study habits, better visual attention, refined ocular coordination for sports, and reduced dependency on eyeglasses through adulthood.