Retina Specialist St Louis | Diabetic Retinopathy St Louis, MO

Retina Treatments

The retina is a thin layer of tissue on the inside back wall of your eye, containing millions of light-sensitive cells and other nerve cells that receive and organize visual information. Your retina sends this information to the brain through your optic nerve, enabling you to see.

Retinal diseases can affect the area of the retina that serves your central vision (the macula and the fovea at the center of the macula). Many retinal diseases share common symptoms and treatments, but each has unique characteristics. The goal of retinal disease treatments is to stop or slow disease progression and preserve, improve or restore vision.

Pepose Vision is a retina specialist and a leader nationwide in the research, diagnosis and treatment of retinal diseases.

Chart Illustrating Different Parts of the Eye
Woman Having an Eye Exam

How do I know if I have a retinal disease?

Retinal disorders may cause symptoms such as blurred vision, floaters (usually fine objects that appear as debris obscuring the visual image), and flashes of light. However, many conditions affecting the retina do not cause noticeable symptoms in the early stages, but may lead to irreversible and sometimes severe loss of vision. Symptoms may indicate a disorder limited to the eye or may be related to a systemic condition, such as diabetes, high blood pressure, cardiovascular disease (“narrowing of the arteries”), autoimmune diseases, metabolic disorders, blood infections, and certain types of cancers.

If you have diabetes or certain other medical or eye conditions, your primary medical doctor or comprehensive ophthalmologist can help you to determine when and how often to see a retina specialist.

The diagnosis and monitoring of retinal diseases requires a complete eye examination where the pupils are dilated with eye drops. You may experience a temporary change in vision and sensitivity to light, so you may wish to bring a pair of sunglasses to wear after the visit. One or more tests may need to be performed to help your treating physician assess the retina and macula (the central portion of the retina).

Retina conditions Pepose Vision treats

Treating retina conditions is a very specialized practice within the field of opthalmology.  Pepose Vision is proud to be a leader in retinal services, and treats patients with a wide variety retinal conditions including the following.

Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is the leading cause of vision loss in the U.S., affecting individuals 50 years of age or older. As the baby boomers age, the disease is becoming a significant problem. The disease affects the part of the retina called the macula, which is responsible for central vision. Even though macular degeneration can cause visual impairment, the disease usually does not cause peripheral vision loss or lead to total blindness.

Types of Macular Degeneration

Chart Showing What It's Like to See With Normal Vision Vs What it's Like to See With Macular Degeneration

The two common types of macular degeneration are “dry” and “wet.”

“Dry” form – the most common form of macular degeneration is caused by aging and thinning of the tissues in the macula. It develops slowly and usually causes mild vision loss. As this form of the disease develops, people often notice a dimming of vision while reading.

“Wet” form – rare, and more severe. Wet AMD is less common than dry AMD, but with the potential to create a large blind spot in the center of the visual field. Wet AMD can progress rapidly, potentially leading to legal blindness.

The causes of macular degeneration are not completely understood, but there is a strong hereditary component. Genetic testing is available at the Pepose Vision Institute.

Symptoms of Macular Degeneration

  • A dark area in the center of vision
  • Blurred or wavy vision
  • Distortion

Treatment of Macular Degeneration

“Dry” form – There is no treatment for dry macular degeneration. Low vision aids can help maintain an excellent quality of life for those with visual impairment. High dose antioxidant vitamin therapy may slow the progression of disease in patients with moderate or severe disease. Anti-oxidant vitamins have not been shown to be beneficial for patients with no macular degeneration or early macular degeneration.
“Wet” form – a variety of therapies are available for wet macular degeneration. Intravitreal injections are the standard of care, with photodynamic therapy and laser photocoagulation rarely used.

Please visit our Age-Related Macular Degeneration page to learn more.

Central Serous Retinopathy

Central serous retinopathy is a disease that causes fluid to build up in the retina. This fluid leaks from blood vessels around the retina.


  • Dim or blurred spot in the center of vision
  • Distortion of straight lines
  • Objects appearing farther away

Diabetic Macular Edema

Diabetic macular edema causes blurred vision when the macula swells from fluid leaking from the blood vessels around the retina.

Diabetic Retinopathy

The cells in persons with diabetes mellitus have difficulty using and storing sugar properly. When blood sugar gets too high, it can damage the blood vessels in the eyes. This damage may lead to diabetic retinopathy.

Types of Diabetic Retinopathy

Background or nonproliferative diabetic retinopathy – blood vessels in the retina are damaged and can leak fluid or bleed. This causes the retina to swell and form deposits called exudates. Many patients may not notice any change in their vision when they develop the early form of the disease, but it can lead to other more serious forms of retinopathy that severely affect vision. Fluid collecting in the macula is called macular edema and may cause difficulty with reading and other close work.
Proliferative diabetic retinopathy – new, fragile blood vessels grow on the surface of the retina. These new blood vessels are called neovascularization, and can lead to serious vision problems, because the new vessels can break and bleed into the vitreous. When the vitreous becomes clouded with blood, light is prevented from passing through the eye to the retina. This can blur or distort vision and frequently causes sudden and severe loss of vision. The new blood vessels can also cause scar tissue to develop, which can pull the retina away from the back of the eye. This is known as retinal detachment, and can lead to blindness if untreated. In addition, abnormal blood vessels can grow on the iris (the colored part in the front of the eye), which can lead to severe glaucoma.

Treatment of Diabetic Retinopathy

Good control of diabetes with intensive management and control of blood sugar will delay, and possibly prevent, both the development and progression of diabetic retinopathy. Patients with diabetic retinopathy frequently need to have special photographs of the retina taken. This series of photos is called fluorescein angiography.

The type of retinopathy, as well as the patient’s general health and eye structure, will determine the kind of treatment needed and the type of anesthesia utilized, but these are common surgery options:

  • Laser photocoagulation
  • Vitrectomy surgery
  • Pharmacotherapy

Please visit our Diabetic Retinopahy page to learn more.


Distortion could indicate a problem in the macula, the center of the retina. If you close one eye and look at something straight, like the edge of a door, blinds on a window, or the grid shown below, you should not see distortion. It is important to check each eye independently.

The sudden onset of distortion in an elderly person could be due to macular degeneration. In a middle-aged person, distortion could be the result of a macular hole, a macular pucker, or macular edema. These are all conditions that would require diagnosis and treatment by Pepose Vision’s retina specialist.

Floaters and Flashes

Floaters and Flashes may be a sign of normal aging of the vitreous gel, or the first sign of a retinal tear or detachment. At birth, the vitreous gel is 100% gel. The gel liquefies with age. As the gel liquefies, it pulls away from the surface of the retina. As the gel pulls, one may see a quick flash of linear, arc-shaped light off to the side. Eventually the gel pulls completely free, and there should be no problem. However, if the gel pulls hard enough, it may pull tissue from the surface of the retina, producing hair-like or fly-like images that migrate with eye movement. These are floaters.

If the vitreous tugs abnormally on the retina while it pulls away, it can tear the retina. If you experience flashes and/or floaters, you should be evaluated immediately since a torn retina can be repaired with an office procedure, avoiding the need for hospital surgery.

A torn retina can lead to a retinal detachment if the fluid inside the eye moves through the tear to enter the space behind the retina, lifting it off the back of the eye. A symptom of retinal detachment is the sudden onset of peripheral (off to the side) vision loss seen as a curtain or darkness. Retinal detachment always begins in the peripheral vision and progresses centrally. To preserve central vision, this condition must be promptly evaluated and treated at Pepose Vision Institute.

Chart Illustrating How Floaters and Flashes Affect an Eye

Macular Edema

Occurs when fluid and protein deposits build up on or under the macula and causes it to swell. The swelling may distort vision.

Macular Hole

A macular hole is a small break in the macula, located in the retina.

Macular Pucker

A macular pucker is scar tissue on the macula. It is caused by age or can be triggered by eye diseases or disorders such as detached retina, uveitis, or diabetic retinopathy.


  • Blurry or Distorted Vision
  • Difficulty seeing detail or fine print
  • Gray area in center of vision

Plaquenil Toxicity

Side effects from the medication plaquenil (Hydroxychloroquine) may seriously effect the cornea and macula. Patients taking this medication are recommended to have regular exams, even when symptom-free.

Retinal Bleeding

Retinal bleeding can be caused by hypertension, a blockage of a retinal vein, or diabetes mellitus (which causes small fragile blood vessels to form, which are easily damaged). Retinal bleeding that take place outside of the macula can go undetected for many years, and may sometimes only be picked up when the eye is examined in detail with an ophthalmoscope.

Retinal Tear and Detachment

What is a retinal detachment?

As the vitreous gel in the back of the eye starts to liquefy, it can separate from the retina, a condition called vitreous detachment. If the vitreous gel adheres too firmly to the retina, a retinal tear can occur with a vitreous detachment. A retinal detachment occurs when fluid leaks through the tear and separates the retina from the back of the eye.

Symptoms of Retinal Tears and Detachments

Patients with retinal tear or detachment often, but not always, have flashes and floaters as their first symptoms. This occurs as the vitreous gel detaches from the back of the eye. Other patients may have very few symptoms. Patients may describe a “curtain” being drawn across the peripheral vision or decreased peripheral vision. If untreated, most retinal detachments will cause progressive loss of vision and eventually total blindness.

Treatment of Retinal Tears and Detachments

In most instances, retinal tears are treated with laser photocoagulation which acts to “spot weld” the retina to the back of the eye. In some cases pneumatic retinopexy is used to treat retinal detachment in the office without the need of surgery. In most cases, however, surgery is usually required. This consists of scleral buckling, vitrectomy, or a combination of the two procedures. These are usually performed as outpatient surgeries and may involve using a gas bubble to help push the retina back into position.

Retinal Vein Occlusion

Retinal vein occlusion is a blockage of the small veins that carry blood away from the retina.

Retinitis Pigmentosa

Retinitis pigmentosa is a group of genetic eye conditions that leads to incurable blindness. The condition starts with tunnel vision and is generally followed by night blindness, then legal blindness. Most will retain some sight all their lives, but some childhood cases causes total blindness.


Inflammation of the middle layer of the eye. It is estimated to be responsible for 10% of blindness in US patients.


A surgical procedure to remove some or all of the vitreous humor from the eye.

Vitreous Detachment

A condition of the eye in which the vitreous humour separates from the retina.

Frequently asked questions

A retina specialist is a doctor who has completed a 4-year medical school, a one-year hospital internship, a 3-year ophthalmology residency, and finally, a 2-year fellowship of specialty training in diseases and surgery of the retina and vitreous. A retina specialist focuses on diagnosing and treating diseases and surgery of the retina and vitreous.

Anyone with a retinal diagnosis given to them by their ophthalmologist or optometrist could potentially benefit from seeing a retina specialist. Such diagnoses include age-related macular degeneration, diabetic retinopathy, retinal detachment, trauma, macular hole, and epiretinal membrane. In addition, any one with unexplained blurred vision may benefit from a retinal evaluation.

Age-related macular degeneration (AMD) is the leading cause of legal blindness in the United States for persons aged 65 or older. It is an age-related degeneration of the macula, or center of the retina. (The macula allows for reading and driving vision.) AMD is described in 2 forms: Dry and Wet. In dry AMD, the retina will have age-spots called drusen in the macula. The drusen are compatible with good vision, but place an individual at risk for progressing to wet AMD. Wet AMD is a condition in which abnormal blood vessels grow underneath the macula and cause a bleeding and leakage (hence the term “wet”) that destroys central vision.

Every diabetic patient should have a yearly, dilated retinal examination by an eye care professional. Retina specialists are ophthalmologists specifically trained to diagnose and treat diabetic retinopathy. If diabetic retinopathy is diagnosed, follow-up examinations with a retina specialist would be needed more frequently than once a year. Diabetic Retinopathy is the leading cause of blindness in the United States for persons aged 65 or less. Much of the vision loss is preventable with early diagnosis and appropriate treatment.

Flashes and floaters may be due to normal aging of the vitreous gel inside the eye. They may also be the first signs of a retinal tear or retinal detachment. Therefore, anyone with those symptoms should have a dilated retinal examination by an ophthalmologist or a retinal specialist.

The process of posterior vitreous detachment causes flashes and floaters in the following way: When we are born, our vitreous gel is 100% gel. When we are 100 years old, it is nearly 100% liquid. So the gel gradually liquefies during one’s lifetime. The gel is attached to the surface of the retina everywhere. As one reaches “middle age” (approximately the mid 60’s, younger for nearsighted people) the gel starts to slosh around the inside of the eye with eye movement. As the gel moves, it pulls away from the retina. Each “tugging” on the retina produces a brief flash of light. If the process occurs normally (and this is part of normal aging in everyone) the gel should eventually pull free from the retina with no problems. However, if the gel pulls hard enough, it may pull tissue off the surface of the retina. This tissue is suspended in the otherwise clear gel and casts a shadow on the retina. This is seen as one or more floaters. If the gel is strong enough to pull tissue from the surface of the gel, it may be strong enough to pull a tear in the retina. Hence, any patient with flashes and floaters should be examined for retinal tears or retinal detachment.

The flashes of light should dissipate over time, but this could take weeks. If they persist for several months, a dilated retinal examination should be performed. The floaters are fragments of glial tissue pulled from the surface of the retina and left floating in the vitreous gel. Unfortunately, there is no exit from the eye. However, they are called floaters for a good reason: they tend to “float” out of view. This process can take weeks or months, however the floaters eventually become invisible for approximately 85% of people.

Floaters can be removed surgically by a procedure called vitrectomy in which the vitreous gel is removed from the eye and replaced with clear physiologic fluid. This procedure is performed in the operating room under local anesthesia. Although vitrectomy is a common, highly successful surgery, no surgery is without potential risks and complications. Generally, it is recommended that the floaters have been present for at least 6 months prior to considering surgical intervention. However, if floaters persist and are truly disabling (which occurs rarely), vitrectomy surgery may be considered on an individual basis.

No, if you have wet age-related macular degeneration (AMD), monthly shots are the standard of care for however long your doctor determines you need them. In the clinical trials that showed these shots were safe and effective for wet AMD, patients received 24 monthly shots with no adverse effects on the eye. Outside of the clinical trials, some patients have required more than 30 or 40 shots into one eye and have done well. However, if you have been receiving a lot of shots, you may wish to get a second opinion as there are other macular conditions that may mimic wet AMD that do not respond to shots.

Wet age-related macular degeneration (AMD) has a whole spectrum of severity. At the outset of treatment, neither the patient nor the doctor knows how many shots it will take to render wet AMD dry again (which is the goal of treatment). Some patients have wet AMD that resolves after a single shot. Some patients have recalcitrant disease and will receive monthly shots for an extended period of time, even years. Your retina specialist will put your affected eye through monthly testing in the office to determine if your macular degeneration is wet or dry. If it is wet, then your condition will continue to require shots. As stated above in answer 9, if you have concerns, you may wish to get a second opinion to make sure the condition being treated truly is wet macular degeneration.

Yes, that is the official recommendation arising from a national randomized prospective clinical trial on the treatment of wet AMD. This trial showed that monthly monitoring with shots as needed was not inferior to monthly shots (the previous standard of care), but stipulated the importance of both the doctor and the patient being compliant with the monthly visits for the best visual outcome.

A recent national prospective randomized clinical trial pitted Avastin against Lucentis in a head-to-head competition. Now famously referred to as the CATT Trial, the study found that Avastin was not inferior to Lucentis regarding visual outcome after 1 year when dosed in the same manner (There were 2 dosing regimens: mandatory monthly shots or monthly visits with shots as needed). There are two minor caveats: 1). Avastin may be associated with a higher incidence of systemic complications requiring hospitalization and 2). Lucentis may be slightly better at “thinning” the retina, a desirable anatomical outcome. However, these last two points require 2-year follow-up to see if the differences in the first year of the study hold true.

Avastin and Lucentis are closely related in that they are cousin molecules. They share the same grandparent molecule but have different parent molecules. Avastin is a larger molecule that was designed for stability in the blood stream, as it is FDA-approved for intravenous administration. Lucentis is a small molecule as it was designed to be injected into the vitreous cavity and penetrate into the retina. Both are drugs with anti-VEGF properties. The biggest difference between Avastin and Lucentis is price. Avastin can cost as little as $50. Lucentis costs roughly $2000.

VEGF stands for Vascular Endothelial Growth Factor. It causes abnormal blood vessels in the macula to grow and leak, essentially making wet macular degeneration “wet”. The purpose of treatment for wet AMD is to inject an anti-VEGF drug like Avastin or Lucentis into the eye in order to make the leaking blood vessels inactive and return the macula to being “dry”. It may take numerous injections to convert the “wet” form of AMD to dry again.

Yes, but not in the way that blond hair and blue eyes are hereditary. Macular degeneration is not autosomal dominant or recessive. Rather, DNA will carry variations that predispose a person to advanced forms of AMD. It has been determined that approximately 70% of a person’s risk for advanced forms of AMD are encoded in their DNA and that 30% is due to other factors like smoking, diet, and other environmental conditions. Currently, there are genes that have been identified, and are linked to advanced forms of AMD the same way smoking is linked to lung cancer.

Yes, there are two companies that offer genetic testing for AMD: Arctic Dx has a test called Macula Risk, and Sequenom has a test called Retna Gene. Both are offered at the Pepose Vision Institute. Both tests collect DNA by taking a gentle swab of the inside of the cheek. Both tests are covered by insurance if you have the diagnosis of AMD and a doctor orders the test. Both tests are thought to have an 83% positive predictive value for estimating an individual’s risk of developing advanced AMD by the age of 80.

An Amsler Grid is used to monitor the central 30 degrees of visual field for signs of distortion or visual abnormality that may signal the onset of wet macular degeneration. It is important to test each eye independently by covering one eye and then the other when using the Amsler Grid. With the Grid held reading distance away, look at the central dot and make sure all of the lines are straight and that the entire grid can be visualized. If straight lines become wavy or distorted, or a portion of the grid is missing, then you should call your ophthalmologist or retina specialist for an immediate evaluation. These changes will come on suddenly, even overnight, and merit urgent evaluation in someone with a known history of dry AMD.

The Foresee Home Device is a computerized, more sophisticated version of the Amsler Grid that has been FDA approved for early detection of wet AMD in patients who currently have dry AMD. It has been reported to detect early-onset wet macular degeneration before changes are evident on the amsler grid, visual acuity testing, or clinical examination by the doctor. It is well established that early detection leads to early treatment and a better outcome when treating wet macular degeneration.

The Foresee Home Device does not require a computer, but it does require familiarity with using a computer mouse. When using the device, a patient is asked to look into a monitor similar to the one used at the Department of Motor Vehicles when obtaining a driver’s license. The Foresee Home Device will flash a dotted line on to the screen. The dotted line will have a small distortion in it. The patient will use the mouse to click on the distortion. This is repeated multiple times. Each test takes about 2 minutes per eye. The information is sent via telephone to a central monitoring site that analyzes the test results on a daily basis. If the test results become abnormal, both the patient and the doctor are contacted to arrange an appointment.

Why choose Pepose Vision to treat your retinal conditions?

Our retina services are led by Dr. Nancy Holekamp, Pepose Vision Director of Vitreo-Retinal Disease and Center for Macular Degeneration. Dr. Holekamp is recognized nationally as a leader in her field.

Dr. Holekamp is the first in the bistate area to offer Susvimo, a novel drug delivery device that is surgically implanted and allows for continuous release of anti-VEGF, thereby reducing the frequency of intravitreal injections to only 2-3 times a year.

Pepose Vision uses the latest and most advanced technology to diagnose our patient’s retina conditions, and we create customized treatment plans. We are leaders in the research and application of new treatments of the retina, macula and vitreous.Should you be diagnosed with a retinal condition, we advise that the best way to ensure a successful outcome is to choose a highly experienced specialist who is involved in developing state-of-the-art treatments to enhance your vision outcome.

Patient Testimonials

I just wanted to let you know how much we still appreciate the fabulous work you did for Adam and I. Adam is a Sr. and will graduate May 19. He is #18 out of 350ish. He will attend the Univ. of Missouri and enter the Pre-Veterinary Medicine Scholars program. After finishing sixty hours he can enter vet school. He’s also very active in FFA. Without the surgery you did I don’t know that any of this would have been possible!

He would still be the same young man but achieving the goals he sets for himself would have been a lot harder if he couldn’t drive and see as well as he does.

Again thank you and may God shine His blessings down on you and yours.

-Gratefully, Marsha Birk

Thank you for the care, expert medical treatment, and concern you have provided me. Without your medical intervention, I would not have experienced the greatest joy of my life – seeing the face of my grandbaby. Kalynn Erin and my family thank you too!

-Renee M

I just wanted to take this moment to thank Dr. Holekamp sincerely for my Vitrectomy surgery success, locating the problems with the retina in that eye as well, the healing process and follow-up guidance. In addition, for the findings today of the other eye’s retina tears and I Iook forward to Thursday when I get through the in-office procedure to remedy as well.

Dr. Holekamp and her associate, Lisa, have been wonderful to me and make me feel safe in their hands. I am very happy that I trusted your opinion Dr. Pepose, and waited to see Dr. Holekamp. I am very, very pleased and just wanted to share that with you today.

Also, I cannot say enough about the team in your surgery center as I had the Vitrectomy. The nurses and the anesthesiologist were so good to me and likewise, made the experience more comfortable than I imagined could be.

As you know, the best advertisement is a good recommendation and I have been doing that to friends. I highly recommend the Pepose Vision Institute.

-Sincerely, Cindy Z

When I met with Dr. Holekamp, I was blind in my right eye. I did not know what was happening to me and was very concerned. Dr. Holekamp was able to provide an exact diagnosis on my initial visit – a detached retina – and perform immediate surgery to save vision for my eye. Also, during my initial visit , Dr. Holekamp discovered that my left eye was starting to detach from the retina. She performed a Cryo procedure, at my initial visit, to eliminate my left eye from having a detached retina and blindness.

I owe my eyesight to Dr. Holekamp and her dedicated and professional team at Pepose Vision Institute.

Thank you Dr. Holekamp!

-Chuck H

What’s your next step?

If you’ve been diagnosed by your eye doctor with a retinal disease, or think you might have one of the symptoms, please come see us right away. Our experienced doctors will use advanced diagnostics to determine exactly how to help you see your very best, patiently answer your questions and carefully explain all your options.

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