Eye Blog

Laser Eye Surgery - a patients diary

Mon, 07 Nov 2011 08:06:00 GMT

I started waring glasses when I was 11 years old. Three years later I opted for contact lenses and they have since been part of my daily life.

At 15 I was offered the opportunity to get a laser eye treatment in Belgium. My parents showed me a video on how the operation was done but it horrified me so much that I chose to stick to my contact lenses and I forgot about the chance on a perfect eyesight.

Many years later my husband and I moved to South Africa. As the climate is much dryer than the European climate, I got more and more issues with my contact lenses. My eyes were extremely dry and at times my contact lenses would fall out, just like that. I found out about disposable contact lenses but was blown away by the costs.

A couple of months passed and I talked to some people who had received laser eye treatment. Everybody seemed happy. They said that modern techniques had improved. “It’s a quick job, 20 minutes, in and out. Times have changed!”. I was promised a perfect eyesight the same day of treatment.
It is a lot of money but also a lot cheaper than in Belgium and I thought of it as a very good, once in a lifetime investment.

Dr.B convinced me. He goes to Europe on a regular basis to perform laser eye treatment there. So I decided to have the treatment done with Dr.B. The people at his practice and at the eye hospital were very friendly and very supportive and I pushed the memory of that old video far into the back of my mind… “Times have changed!” I reminded myself.

On the day of surgery, all the patients who came in for the eye treatment got two little stickers above their eyes. I felt like an alien in the queue to the big black vast of the unknown… but at the same time I felt strangely connected to my fellow patients. We were all in for the same deal.

They all “went in and came out” as different people… happy but different. As my husband and I, were escorted into the theater, we both got caps for our heads, aprons and socks to wear over our shoes. The lady who went in before me quickly took me by the hand and told me not to be afraid. “You must just concentrate very hard!” – she said.

As a feeling of terror overwhelmed me, one of the nurses took a welcome effort to calm me down by asking questions about Belgium, which I strangely enough was able to answer reasonably calm. Her actions had worked, even for only a couple of minutes she had succeeded in taking my mind of what was about to follow.

Everything people tell you about the laser eye treatment is true!

When I got up from the table I was asked to look at the clock on the wall and tell the time. As I realized that I was able to see and that I was ok, tears of joy ran from my eyes, and with the tears the feelings of terror left my body. It were the 20 most frightening minutes of my life but my life has changed forever!
When I left the theater I took a quick peek through my sensitive eyes… I could see the rimples in the curtains at the back of the hallway! Everything was good! I closed my eyes only to open them again the next day after a necessary and more than welcome rest of 18 hours.

Not a day goes by without me being grateful! Grateful for the means I had to pay for the treatment, grateful for the support of my husband and my parents, grateful for the hard work the doctor and nurses put into their studies enabling them to change people’s life’s, but most of all grateful for the courage I took to make the decision! If I would have to do it all again… I would!

Presbyopia or age related long-sightedness

Mon, 17 Oct 2011 07:26:00 GMT

Cause

The lens of the eye needs to change its length or shape to focus on smaller objects, or objects that get closer or further away. This is called the elasticity of the lens. This elasticity is slowly lost as people age. The result is a slow decrease in the ability of the eye to focus on nearby objects.

People usually notice the condition at around 45, when they realize that they need to hold reading materials further away in order to focus on them.

Presbyopia is a natural part of the aging process and it affects everyone.

Symptoms

- Focusing ability for near objects decreases
- Eyestrain
- Headache

Possible Treatment Options

- Multifocal Glasses
- Contact Lenses
- Monovision Lasik (Monovision LASIK surgery is the most recent development in presbyopia treatment. Rather than using glasses or contacts to achieve monovision, Lasik surgery can permanently correct one eye for distance vision and the other for near vision, allowing patients to reduce or eliminate their dependence on glasses and contacts.)
- Refractive lens exchange (view related Blog article in this newsletter for an insight into the procedure)

Where to find help

Call the ophthalmologist of your choice (see Cape Town list here: http://capeeyelaser.co.za/surgeons/index if you have eye strain or are less able to focus on close objects.

Prevention

There is no proven prevention for presbyopia.

Cataract surgery from 500bc until today

Wed, 14 Sep 2011 15:03:00 GMT

Being one of the oldest surgical procedures in medicine, cataract surgery has certainly came a long way from the procedures described in Sanskrit manuscripts dating from the 5th century BC by the ancient Indian surgeon Shusruta. In this procedures called “couching”, the lens was simply dislodged to the back of the eye and left there. The results were patients who could make out colours and shapes (if their eye sight wasn’t lost completely) – certainly much better than no vision at all!

In the 18th century surgeons started to remove the lens (with cataract formation) from the eye, it was only in the middle of the 19th century that anaesthesia were used for cataract surgery for the 1st time. Up till then the surgery were performed by pinning the patient down to the operating table or chair!

The initial lens removal surgeries were quite crude with complications seen very often. Incisions as big as 12 to14 centimetres were performed to remove the lens as a whole. That was followed by leaving the patient on his or her back with sandbags around the head to prevent any movement for at least 14 days (Since there were no sutures small enough to suture an eye, the eye had to heal on its own).

During the last 2 or 3 decades this part of the cataract surgery became much more elegant and predictable. Surgeries are generally done through an incision of around 2 mm using a sophisticated ultrasound probe to break the lens into small pieces and to extract from the eye – all while a constant pressure and low energy environment are maintained inside the eye. This procedure is called micro incision phaco-emulsification.

Rehabilitating the vision after removing the lens was a big problem and was only solved in the 1940’s by an English surgeon Sr. Harold Ridley. He acted on the knowledge gained in World War 2 where it was found, that glass penetrating the eyes of fighter pilots, showed little or no reaction inside the eye. In other words, the glass was not rejected by the body. This knowledge sparked the idea of implantation of a lens inside the eye. Sr. Harold designed the first lenses and implanted them with some success. This was the beginning of the concept of “intra-ocular lenses” (IOL’s).

IOL’s evolved very quickly into a multi-million dollar industry producing extremely accurate and technologically advanced lenses usually leaving patients with excellent vision after a cataract operation. The modern lens removal technology combined with the new generation of intra-ocular lenses that is implanted directly after the removal of the lens (through the same small incision) ensures a relatively pain free procedure with the patient able to continue with normal activity almost immediately after the procedure.

Pterygium surgery

Wed, 14 Sep 2011 15:03:00 GMT

HISTORY OF PTERYGIUM TREATMENT

PTERYGIUM has a long history of difficult treatment. THE word pterygium comes from the Greek word pterygos, which means ‘wing’.

SUSTARA (1 000 BC, Egypt) treated pterygium with pulverised salt and stimulation with a palmbranch. When the pterygium was inflamed and swollen, he tore it out with force and removed any remaining tissue with a flesh-stripping ointment. He also described the ease with which the lesion reappeared! HIPPOCRATES (469 BC) suggested the use of eye drops containing lead, zinc, copper, iron, bile juices, urine and maternal milk.
AMBROSE PARE (16th century) said, “You’ve learned that a pterygium is an illness that always recurs, even when you’ve done everything in your power to cure it.” This concept has remained true to the present day!

MANY TREATMENTS HAVE BEEN USED TO IMPROVE SURGICAL OUTCOMES:

1957 Topical radio-therapy with strontium 90 (Sr90)

1962 Use of antimitotics to prevent recurrence
1964 Use of amniotic membrane to repair the conjunctival tissue loss following excision of the pterygium
1985 Grafting autologous conjunctiva (own conjunctiva harvested from another area) over the open area

THE BASIC SURGICAL TECHNIQUES USED TODAY

Bare sclera : Stripping the pterygium and leaving the wound open to close naturally (an almost 30% recurrence)

Apposisional repair : Repairing the wound by suturing the edges together with vicryl, silk or nylon 8/0 (10-25% recurrence)
Torsional flap : Repairing the wound with a flap of adjacent healthy conjunctiva (5-10%recurrence)
Free flap : Use of autologous conjunctiva or amniotic membrane to cover the wound, sutured with 8/0 (5-10% recurrence)

Despite all efforts, surgical outcomes have remained indifferent.

UNTIL RECENTLY, OUTCOMES of pterygium surgery have been, to say the least, indifferent. The affected eye often remained red and inflamed, with visible scarring and a high rate of recurrence. But with a new technique that uses the tissue glue Tisseel, the cosmetic results have improved significantly, and the recurrence rate has dropped to less than 1% in the authors last 4 years of surgery.
Not all South African eye surgeons are currently performing the new procedure, which requires a bit of practice, but the results are so astonishing that it will soon gain ground.

The new technique still involves an autologous free conjunctival flap, usually harvested from the conjunctiva below the upper eyelid – but instead of sutures fastening the new flap over the bare area, Tisseel glue is now used.

WHAT IS TISSEEL?

It's a tissue glue that has been used extensively in general and neurosurgery. It simulates the final stage of the coagulation cascade to produce a biocompatible fibrin matrix clot that adheres to connective tissue like a natural blood clot. It contains concentrations of fibrinogen and thrombin that when mixed, duplicates clot formation with a high level of elasticity.

WHAT ARE THE ADVANTAGES OF TISSEEL OVER SUTURES?

The procedure is less time-consuming, saving almost half of the theatre time. There is also much less irritation or pain.

Inflammation is much less because the area is covered but there are no sutures that irritate the surrounding area. Less follow-up is needed (day one post-op and the 1 month later). In my hands the results are definitely far superior.

My experience with Tisseel surgery since 2007

– Where I used Tisseel I found the following:

There was no need for antimetabolites. Recurrences after previous conventional surgeries were successfully treated. The patient comfort was superior from day one. Cosmetic results were also superior.
In a retrospective questionnaire of my first 100 pterygium surgery patients done in 2007, we scored an average of 9/10 for subjective impression of success and cosmetic results.
-One of the 100 cases involved pterygium surgery performed on a bride-to-be only six weeks before her wedding. I would never have dreamt of attempting pterygium surgery using the ‘older’ techniques!!
With the low risk profile of Tisseel it is now safer to do pteryguim surgery on even the small cosmetically worrying lesions.

ABOVE LEFT: The eye a week before the procedure. ABOVE RIGHT: One month later

ABOVE LEFT: The eye of a bride, one day before surgery and six weeks before her wedding day. ABOVE RIGHT: A week before the wedding

Eye Laser – technology creating more predictable results

Wed, 14 Sep 2011 15:05:00 GMT

LASIK or Refractive Laser Surgery is certainly one of the most fascinating procedures in modern medicine. It is of the most accurate and successful surgeries performed in the world. But with good results comes great expectation! Advances in technology within laser refractive surgery are generally aimed at improving the predictability of the procedure. Improvements include:

The laser:
The laser used in LASIK surgery is an Excimer laser. This laser can remove as little as 0.25 micrometers of the cornea at a time, making it extremely accurate. The initial broad beam lasers are generally replaced these days with slit scanning or spot scanning laser beams. These lasers give a smoother laser surface and make wavefront correction possible.

Wavefront:
Wavefront aberrations are abnormalities in the focus system of the eye that cannot be corrected with spectacles. It is also referred to as 'Higher Order Aberrations'. Correcting these higher order aberrations can improve the quality of vision in certain patients. To detect the wavefront abnormalities, special equipment are used to create a customised map(see image on right) of each eye. This information is then used to adjust the laser specifically for each eye.

Eye Tracking:
To enable an accurate laser ablation, all modern refractive lasers have an eye tracking system. These systems identify an area of the iris or pupil and will adjust to tiny eye movements during surgery. If any big movements occur, the laser will stop automatically and resume treatment as soon as the eye has been aligned again. (see image on right)

Cutting the Flap:
Cutting the corneal flap during LASIK surgery is one of the most crucial steps during the procedure. Exact depth and size is most important and will impact a great deal on the final result. These days this step can either be done with Femtosecond Laser or modern Microkeratomes. Both of these systems give equal visual results with a very good safety and accuracy profile.

The Surgeon:
Although technology helps us a lot to make LASIK surgery safer and more predictable, the skill of the surgeon cannot be left out of the equation. Staying in touch with technology as well as understanding and mastering the “art” of refractive surgery by the individual surgeon will always carry most of the weight in determining the outcome of the surgery.

Latest Developments in Cataract Surgery

Tue, 06 Sep 2011 12:03:00 GMT

Cataract surgery is a wonderful operation that removes the lens when it has become cloudy.

In the past a large incision had to be made to remove the human lens, but nowadays the standard procedure is to make small incisions through which the lens is broken up into tiny pieces by phacoemulsification. This process utilizes high frequency ultrasound, the same as a dentist uses when he cleans your teeth, but on a much finer level.

It breaks up the cataract which measures 12mm in diameter and 4mm in thickness and removes the fragments by suction while fluid is infused into the eye. The size of the incision has also come down over the years to as small as 1,8mm, but usually varies from 3mm downwards.

A foldable lens implant has also become the standard of care. This step ensures that a person does not need to wear thick and heavy glasses after the operation as it was needed in the past. A small plastic lens is implanted which helps to focus the image in the eye. Most people do not even need glasses for distance vision after surgery. Depending on the type of lens used, some people might even be totally spectacle free. This lens has different zones that focus the image from different distances on the retina and thus causes multiple images. The up side of multiple images is that you may be able to read and see in the distance without any glasses. The down side is that you may be bothered by the multiple images.
Discuss this option with your doctor as not everyone is a candidate for this specific type of intra-ocular lens, but you might qualify. Other implants are also available that can correct astigmatism.

IS LASIK SURGERY WORTH IT?

Wed, 14 Sep 2011 15:09:00 GMT

LASIK ( laser refractive surgery) has gained word wide acceptance over the last twenty years. It is performed for example in the USA on air force pilots and active servicemen in the navy and army.

With between 16 and 20 million procedures already done worldwide it is considered one of the most successful elective (non emergency) surgical procedures. A worldwide review of the literature published in the very highly acclaimed journal, Ophthalmology, found the average rate of satisfaction after laser surgery to be 95.4%.

How long will it last?
The answer to that question depends on the severity of the prescription that was treated. People who were very near sighted before treatment (between -7 and -10) tend to regress a little over a ten year period. Though they become slightly more near sighted again, it almost always stays better than before the laser. Smaller and medium refractive errors tend to stay very stable beyond 10 years. Laser surgery can be repeated if regression occurs (provided the cornea is thick enough)- these re-treatments have been shown in the literature to be very effective and safe.

When older than 40 years old, reading becomes a problem due to presbyopia (the natural phenomena where the lens of the eye cannot focus on near objects.) reading spectacles is then often prescribed. When patients older than 40 present for laser surgery we often correct the one eye for near vision and the other eye for distance vision (mono-vision), although it takes some getting used to initially, this technique leaves the patient more spectacle independent.

When considering LASIK it is important to have realistic expectations, although around 90% of patients will end up with 20/20 vision without spectacles, 10% of patient may end up with thin spectacles to optimise their vision for driving at night etc. The main objective of the surgery is to give you better vision without spectacles than before.

The question still remains, is it worthwhile for you? That depends on your unique circumstances. If you are an individual with an active lifestyle and spectacles or contact lenses are impeding on the quality of your life, or if you are just tired of poor vision without them, LASIK is certainly a safe option to consider. For the price of about 3 pairs of fashionable spectacles LASIK can also make economic sense.

Operation Day Diary

Wed, 14 Sep 2011 15:05:00 GMT

This week a Cape Eye Laser patient, Jini B, was photographed while having Lasik Eye Surgery. See the photos in chronological order with her remarks below!

I arrive at the hospital and have 5 minutes to send some emails in their waiting room before my surgeon arrives.

My Ophthalmologist measures my "corneal aberration" with an OPD Wavefront scanner - I am told this is the latest technology ensuring that my refraction is corrected accurately.

10 Minutes later I am dressed and ready for surgery (Very excited and a bit nervous at this point!)

I have entered the Lasik theatre where my surgeon and the nurse cover me with a blanket while they explain the procedure.

Dr B positions the equipment, while keeping me relaxed with some dry humour (thanks Dr ;)

Anaesthetic drops are applied to my eyes, which numbed them completely within seconds.

Doctor inserted a clamp to keep my eyes open - This looks MUCH worse than it is - apart from some dryness, I didn't feel a thing.

A corneal flap is created with an instrument called a Microkeratome - This part scared me most pre-operation, but honestly I felt nothing, apart from very slight pressure.

The Corneal flap is lifted. After the flap was lifted, my vision went blurry.

The actual Laser pulses for a few seconds. This is what reshapes my cornea to correct my refraction. Again, felt nothing whatsoever.

Dr B closed the flap and removed the clamp - all done!

A protective shield is put over my eye. Dr B asked me to bring my sunglasses which protects my eyes from the sun.

Amazingly I could see almost perfectly at this point - only slight blurring. A day later I had 20/20 vision in my left eye and better than 20/20 in my right eye! Thank you so much Dr B and Cape Eye Laser. To find out if you are suitable, book a free consultation here>

What if I’m not suitable for LASIK?

Tue, 06 Sep 2011 12:45:00 GMT

Ten years ago you were simply told that you do not qualify for LASIK surgery – period.
That left you with the traditional options of either spectacles or contact lenses, quite disappointing for a young active person with a huge spectacle prescription and intolerance to contact lenses. Fortunately alternative options have evolved very quickly over the last few years.

Why would you not qualify?

People who most often do not qualify would be someone with a high refractive error (big spectacle prescription) and a thin cornea. To do safe LASIK surgery you need to leave at least 250um of the corneal bed intact, anything less than that can lead to long term problems like ectasia. Other reasons that will disqualify you include cornea diseases like keratoconus, Pellucid degeneration of the cornea, previous trauma etc. Minor eye ailment like dry eyes, blefaritis or simple infections will not disqualify you from LASIK but, it is important to have your eyes in optimal condition before laser surgery. Your ophthalmologist will therefore prescribe some treatment before commencing with the laser procedure.

Should you not qualify for LASIK your ophthalmologist will give you one of the following options tailored to your specific eye condition.

Phakic Intraocular Lenses:

Phakic Intraocular Lenses(PIOL) are lenses that is implanted inside the eye – either on or behind the iris(coloured part of the eye).The natural lens of the eye is kept intact with the PIOL adding or subtracting to or from the strength of the eye’s own lens system (almost like a contact lens only inside the eye).PIOL’s most often used in South Africa include: ICL(STAAR), Artisan/Artiflex(Ophtec) and Cachet(Alcon).
The big advantage of PIOL’s is that you can treat much higher refractive errors than with LASIK. Prescriptions of between +12 and -23 are treatable with the thickness of the cornea not playing any role. Astigmatism can also be addressed by some of the PIOL’s. The procedure is quick painless and safe and once the PIOL is inside the eye the patient is not aware of it. The accuracy is very comparable to LASIK surgery. A big advantage of the PIOL is that it is easily reversible by simply removing the lens surgically.

Bioptics:

Bioptics is the term used for combining Phakic Intraocular Lenses with Laser treatment. The reason one would consider Bioptics is to correct very high spectacle prescriptions( up to -35)
The PIOL procedure is done first followed by a laser treatment(either LASIK or PRK) to correct what is left of the refractive error.

Clear Lens Extraction:

Also called a Refractive Lens Exchange, Clear Lens Extraction refer to the removal of the eye’s natural lens to replace it with an artificial lens with better focus. This option is usually reserved for patients where LASIK or PIOL’s are not indicated. Best suited patients are usually farsighted (Hyperopic) individuals. The surgery is exactly the same as for cataract surgery and done through a 2.2mm self sealing wound(no sutures necessary), recovery is quick and relatively pain free. The artificial lenses implanted can be either monofocal (one focus point) or multifocal(two focus points, both for near and distance vision).

Conclusion:

Although LASIK treatment is still the best way to deal with most patient’s refractive problems, other options in refractive surgery are increasing by the day. This widens the opportunity, to be spectacle independent, to patients who would previously not have qualified for any treatment.

Lense of laser?

Tue, 06 Sep 2011 13:19:00 GMT