Ophthalmic Consultation
WHO SHOULD GET AN EYE EXAMINATION
Everyone should have routine eye examinations. How often you should see your ophthalmologist or eyecare specialist depends on your age, your general health and whether you have any ongoing eye disorders.
If you are in good health and have no known eye problems and no vision problems, an exam every two to four years is adequate. The elderly should have eye examinations at least every two years because cataracts and other eye problems may develop as we age. For people with special health problems, such as diabetes, yearly eye examinations are necessary to maintain good eye health. Finally, anyone with known eye problems, such as glaucoma, will need to see their ophthalmologist on an ongoing basis. Because vision is so related to learning, children also should have yearly eye examinations.
WHAT HAPPENS DURING AN EYE EXAMINATION
During a routine eye examination, your ophthalmologist will test your eyesight and the health of your eyes. At this time, you should discuss any chronic illnesses you have and any medications or dietary supplements you may be taking. Even if you feel your eyesight is good, it is always helpful to have an open discussion about your family history, health problems, profession and lifestyle because these things may have an impact on your eyes now and in the future.
Your eye doctor will test your visual acuity, which is the clarity of your vision. You will probably be asked to read the letters on an eye chart. These letters vary in size, becoming increasingly smaller as you read from row to row. At some point, you will probably tell the doctor that you can't see clearly or at all. Based on this test, the doctor will be able to determine whether your visual acuity is normal or whether you are nearsighted (myopic) or farsighted (hyperopic).
The doctor will also examine your eyelids and use various lights and instruments to look into your eyes, on the eye surface and even behind the eye. Just as you have your blood pressure taken at your primary care physician's office, the ophthalmologist will use a device that measures the pressure inside your eye to check for glaucoma. At some point in the exam, your doctor will also check the muscles of your eyes.
None of the tests used during a routine eye examination are painful or uncomfortable. There is a possibility that the doctor may use eyedrops that will dilate (widen) your pupils, which may make it difficult for your eyes to focus properly for several hours after the exam.
Ocular Emergencies
Seek emergency care if you believe your eyesight is in jeopardy, if you are in severe pain, or if you have any of the following symptoms:
- Sudden vision loss
- Pain in or around the eye
- Redness accompanied by pain in the eye
- New floaters (e.g., spots, strings, cobwebs)
- Bulging of the eye or swelling of eye tissue
- Flashes or streaks of light
- Double vision
- Sudden crossed, turned, or "wandering" eye
- Discharge, crusting, or excessive tearing
- Eyelids stuck together
- Sudden blurring of vision that persists
Paediatric Ophthalmology
Children can be afflicted by many eye diseases. They may be born with or may develop cataracts, glaucoma, retinal and orbital tumors, or other problems. More commonly, children may need glasses to see more clearly or intervention for misaligned eyes (strabismus) or poor visual development in one eye (amblyopia). The management of eye problems in children requires special knowledge and skills. Even before a child can speak, pediatric ophthalmologists can tell what a child sees, if he or she needs eyeglasses or contact lenses, and if any problems exist with the eyes. Children are not miniature adults, and their eye problems require diagnostic and treatment methods that are usually different from those used in the older age group. Fortunately, most eye problems can be treated without surgery, but about 1,000 children per year undergo surgical correction of their eye problems.
Amblyopia
Amblyopia (lazy eye) is another frequent condition, occurring in about three or four of every 100 children. When a child is born with normal eyes, he or she has the potential for good vision in both eyes, but must learn to see with each of them. If for some reason, the child prefers to use one eye more than the other, the preferred eye learns to see well but the other suffers from lack of use. It does not learn to see as well, even with glasses. The non-preferred eye is said to be lazy or have amblyopia. This vulnerable period of visual development ends around age eight or nine.
One common cause for lazy eye is strabismus. When the child's eyes are pointed in different directions, the child has to use one eye at a time to avoid seeing double. If he or she uses one eye more than the other, the other eye becomes lazy.
Children without strabismus can also develop a lazy eye. Even though their eyes are straight, one eye is preferred more than the other. The non-preferred eye becomes lazy and does not learn to see.
Amblyopia does not bother the child because there are no symptoms. It is found only by checking the vision in each eye. This can be done fairly accurately in any child three years or older. For this reason, all children should have their vision tested by age four.
The treatment for amblyopia involves forcing the lazy eye to be used more often. Usually this is accomplished by temporarily blurring the preferred, or good, eye. This can be accomplished with patching or drops. This treatment may have to be continued for several months until each eye sees equally well. Fortunately when caught at an early age, it is usually successful in restoring good sight. Sometimes the patching must be continued intermittently until age nine. If the lazy eye is out of focus, eyeglasses may be require, in addition to patching the good eye to obtain the best sight.
Esotropia in Children
The most common type of strabismus is esotropia, which occurs when either one or both eyes turn in toward the nose. Some children are born with this condition. Alternatively, it can start at about age two and a half. When esotropia occurs in these older children, eyeglasses can often help to treat the condition by correcting the child's vision for farsightedness or hyperopia. This can reduce or eliminate the crossing by changing the child's need for excessive focusing.
Exotropia
Exotropia is the second most common kind of strabismus. In this condition, one or both eyes turn out away from the nose. It usually starts at age two or three. In the beginning, the eye may drift out only for a few seconds when the child is tired or ill. It typically occurs when the child looks far away. Closing one eye in bright sunlight when playing outside is also a common early sign.
Diagnostic Examinations
Diagnosis is a key step in medical practice and that means we are offering each patient the most suitable personalized treatment. Our clinic has the most technologically advanced equipment and works in a coordinated manner, covering the widest range of specific tests for the detection of the eye’s condition. Our diagnostic examinations are:
- Refractometry and Keratometry
- Aplanation/Goldmann tonometry
- Direct and Indirect Gonioscopy
- Corneal pachymetry
- Corneal topography
- Ultrasounds:
- A scan biometry with or without IOL calculations
- B scan ultrasonography
- Optical Coherence Tomography
- Visual fields:
- Goldmann Visual Field
- Esterman Visual Field
- Photography:
- Fundus and optic nerve photography
- Slit lamp photography
- Fundus autofluorescence
Medical Services
A wide range of clinical and imaging services to optimize your eye-care.
Glaucoma
What is glaucoma?
Glaucoma is a chronic irreversible optic nerve disease due to many reasons, the most important risk factor of which is high intraocular pressure (IOP).
It is the second cause of blindness in the western world and 50% of people suffering from it in the developed world are unaware of it.
We speak of glaucoma when we find that the optic nerve (which acts as a conductor of information from the eye to the brain) is affected. However, we talk about ocular hypertension when IOP alone is high, without any optical nerve defect.
IOP is determined by the production of aqueous humour (the liquid responsible for the eye's tone) and the resistance and difficulty involved in its drainage.
There is a wide variety of types of glaucoma although in general terms we can classify them according to their origin (primary and secondary) and angle width (open- or closed-angle).
Symptoms
The majority of those affected do not usually show symptoms until the advanced stages of the diseases, when the eye damage is then significant.
This happens because of a loss of lateral vision, which the patient does not notice because the brain has the ability to compensate for the lost vision and fill in the blind spots by combining the images in both eyes to give a complete image.
This is why it is called 'the silent thief' and early detection is crucial.
How is it diagnosed?
- With an IOP (intraocular pressure) measurement
- With the visual field
- With an optical coherence tomography (OCT)
Diagnosis is vitally important given that it is a chronic disease that hardly has any symptoms until it is at a very advanced stage, when the patient has tunnel vision.
Glaucoma risk factors
- Ocular hypertension
- Over the age of 40
- Family history
Factors that may condition the progression of glaucoma
- High blood pressure or vascular diseases
- Myopia
- Diabetes
Treatment
The majority of treatments are aimed at increasing drainage and, in some case, reducing the production of aqueous humour.
There are three main treatments, described herein from least to most invasive:
Medical-drug treatment
- Hypotensive eyedrops
- Tablets
Outpatient laser treatment
- Laser iridotomy
- Trabeculoplasty
- Transscleral diode laser cyclophotocoagulation
Surgery
- Microinvasive surgery (MIGS)
- Invasive surgery for more advanced cases
- Filtering surgery (trabeculectomy and a non-penetrating sclerectomy
- Drainage devices (Ahmed and Baerveldt valves)
Early detection and timely treatment considerably improve the visual prognosis and prevent it progressing towards blindness.
Uvea
What is it?
Uveitis is inflammation of the inside of the eye which affects one or more of the three parts of the uvea: the iris (which gives the eye its colour), the ciliary body (behind the iris, where the aqueous humour is produced) and the choroid (behind the retina). It is responsible for 10-15% of the cases of blindness in developed countries and may occur at any age. It is most common in young to middle-aged patients.
Types
Types of uveitis are classified according to their anatomical localisation:
- Anterior uveitis: This is the most common form, it affects the iris (iritis) and, on occasions, the ciliary body (iridocyclitis). In this case, inflammation is prevalent in the anterior chamber of the eye.
- Intermediate uveitis: It affects the ciliary bodies and structures close to it, therefore inflammation is predominantly localised in the vitreous gel.
- Posterior uveitis: It affects the choroid (choroiditis), although it often affects the adjacent retina as it is in direct contact with it (chorioretinitis).
- Panuveitis: Sometimes the three parts of the uvea are compromised, leading to panuveitis.
Symptoms
The types of uveitis have different symptoms depending on the localisation. Anterior and intermediate uveitis present with redness, eye pain, tearing, photophobia (intolerance to light) and blurred vision. On the other hand, posterior uveitis usually presents with myodesopsia (perception of floaters), and a loss of vision which varies depending on the size and location of lesions.
Inflammation can occur in only one eye or both (simultaneously or separately in time). It can manifest itself acutely and suddenly or chronically with a more gradual and longer onset. Relapses or recurrences may be common.
Causes
The origins of intraocular inflammation may be very diverse. Uveitis may be the reflection of a disease occuring in other part of the body that has perhaps gone unnoticed, becoming a warning sign.
We can divide the causes of uveitis into infectious and non-infectious. The infectious agents that may cause intraocular inflammation include viruses (such as herpes), bacteria (such as tuberculosis, syphilis) or parasites (such as toxoplasmosis).
Toxoplasmosis is the most common infectious cause. This parasite, ingested in contaminated meat or vegetables, embeds itself in the retina and causes chorioretinitis which, once cured, leads to the appearance of a scar. When this occurs in the macula (the central part of the retina), the loss of vision is severe.
Non-infectious uveitis may affect the eye only or be related to general illnesses like idiopathic juvenile arthritis, ankylosing spondylitis, Behcet's disease, an inflammatory intestinal disease or sarcoidosis, etc.
We must remember that almost 35% of patients never get to the bottom of the cause or exact origin of the inflammation, so these are considered cases of idiopathic uveitis.
Treatment
Treatment for uveitis depends on the cause of the inflammation, and should be started as soon as possible. In those of infectious origin, antibiotic treatment can cure it.
In most patients, corticosteroids are the mainstay of treatment in the acute phase, in form of eye drops, injections around or in the eye, or by systemic route (oral, intramuscular or intravenous).
In some cases of uveitis that are immunological, chronic and difficult to manage or have complications arising from the use of corticosteroids, it might be necessary to use immunomodulatory drugs to control inflammation (for a prolonged time or even lifelong). Some of these drugs might have side effects that require close monitoring.
In other cases, a surgical procedure with diagnostic purposes may be necessary in order to treat some of the complications associated with intraocular inflammation (especially in chronic forms), such as cataracts, glaucoma, persistent opacity of the vitreous body, intraocular bleeding, or retinal detachment.
Surgical Services
The latest operating techniques to maximize the surgical outcome.
Cataract surgery
What does the treatment involve?
Cataract surgery involves extracting the content of the opacified crystalline lens using ultrasounds and replacing it with a custom-made intraocular lens (IOL).
When is this treatment indicated?
With regard to incipient cataracts, palliative measures can be taken such as the use of sunglasses to avoid glare or prescription glasses if you've experienced a change in refraction. But the definitive treatment for cataracts is still surgery.
Cataracts may appear at any age. They may even be congenital, although in general, cataracts generally appear during old age. As soon as the patient starts to notice a loss of visual acuity and is no longer comfortable, cataract surgery can be proposed and performed.
Chalazion surgery
Surgery
Surgical treatment may be considered in case of unresolved chalazion or large and symptomatic
chalazion. Incision and curettage is the treatment of choice.
Local anaethestic agent is injected to the area surrounding the lesion. Eyelid is then everted with
special clamp and incision is made through conjunctiva. Contents of chalazion are curetted, and
tarsus may be minimally resected if indicated. Since the operation is done at the inner side of eyelid,
no scar will be seen over the anterior aspect of the lid.
Preferably, specimens obtained during the procedure should be sent to pathology.
Surgical follow up
Patient may be seen again in several weeks, or follow-up as required. The inflamed lid may still take
several weeks to completely resolve.
Complications
Large chalazia can occasionally exert mass effect on cornea and result in astigmatism and blurred
vision; Acute secondary infection leading to pain that may require incision and curettage.
Steroid injection may lead to local skin depigmentation or atrophy of skin.
Prognosis
Excellent prognosis is expected. Untreated chalazion can resolve spontaneously in weeks.
Corneal Cross-linking
Introduction
Corneal collagen crosslinking (CXL) is a minimally invasive procedure used to prevent progression of corneal ectasia such as keratoconus and post-LASIK ectasia.
Background
Cross-linking of collagen refers to the ability of collagen fibrils to form strong chemical bonds with adjacent fibrils. In the cornea, collagen cross-linking occurs naturally with aging due to an oxidative deamination reaction that takes place within the end chains of the collagen. It has been hypothesized that this natural cross-linkage of collagen explains why keratectasia (corneal ectasia) often progresses most rapidly in adolescence or early adulthood but tends to stabilize in patients after middle-age.
While crosslinking tends to occur naturally over time, there are other pathways that mean lead to premature crosslinking. Glycation refers to a reaction seen predominantly in diabetics that can lead to the formation of additional bonds between collagen. In the pathway most relevant to this topic, oxidation has been shown to be able to trigger corneal crosslinkage through the release of oxygen free radicals.
The bases for the currently employed corneal collagen cross-linking techniques were developed in Europe by researchers at the University of Dresden in the late 1990s. UV light was used to induce collagen cross-linking in riboflavin soaked porcine and rabbit corneas via the oxidation pathway. The resultant corneas were shown to be stiffer and more resistant to enzymatic digestion. The investigation also proved that treated corneas contained higher molecular weight polymers of collagen due to fibril crosslinking. Safety studies showed that the endothelium was not damaged by the treatment if proper UV irradiance was maintained and if the corneal thickness exceeded 400 microns.
Human studies of UV-induced corneal cross-linking began in 2003 in Dresden, and early results were promising. The initial pilot study enrolled 16 patients with rapidly progressing keratoconus and all of the patients stopped progressing after treatment. Additionally, 70% had flattening of their steep anterior corneal curvatures (decreases in average and maximum keratometric values), and 65% had an improvement in visual acuity. There were no reported complications.
In late 2011, orphan drug status was awarded by the FDA to Avedro for its formulation of riboflavin ophthalmic solution to be used in conjunction with the company's particular UVA irradiation system. Corneal collagen cross-linking using riboflavin and UV received FDA approval on April 18, 2016.
In 2015, a Cochrane systemic review analyzing CXL for treating keratoconus revealed that the evidence for the use of CXL in the management of keratoconus is limited due the lack of properly conducted Randomized Controlled Trials.
Basic Concepts
The main components of CXL are a photosensitizer, a UV light source, and the resulting photochemical reaction.
Riboflavin
A photosensitizer is a molecule that absorbs light energy and produces a chemical change in another molecule.
In CXL, Riboflavin is used as the photosensitizer. It is safe systemically and can be adequately absorbed by the corneal stroma topically. It has an absorption peak at 370 nm.
UV Light
As the absorption peak of riboflavin was noted to be 370 nm, UV-A light was found to be ideal for CXL, while at the same time protecting the other ocular structures. The total fluence required was found to be 5.4J/cm2.
The Bunsen Roscoe law states that the photochemical effect should be similar if the total fluence remains constant. Based on this, various protocols have been devised with different combinations of the intensity and duration of UV-A exposure. However, it has been noted that CXL fails to be effective once the energy intensity exceeds 45mW/cm2.
Photochemical Reaction
Once exposed to UV-A light, the riboflavin generates Reactive oxygen species, which induce the formation of covalent bonds both between collagen molecules and between collagen molecules and proteoglycans.
Corneal Laser Refractive surgery
What is corneal laser refractive surgery?
We talk about corneal laser refractive surgery when we are referring to the group of surgical techniques that use a laser to modify the curvature of the cornea and correct refractive errors of the eye (myopia, hypermetropia and astigmatism) and thus eliminate, or at least reduce, the patient's dependence on glasses and/or contact lenses.
Because of its reliability and safety, refractive laser surgery is the most commonly used method for correcting mild and moderate refractive defects.
Refractive errors
Astigmatism is characterised by the fact that the eye is unable to form a clean image of an object because the power of the optical system varies between the highest and lowest degrees of power.
In hypermetropia, objects in the distance are focused behind the retina, this makes close objects look blurred.
Myopia is a change in refraction whereby objects in the distance are focused in front of the retina and not on it, causing blurred farsight.
Surgical techniques (PRK, LASIK, SMILE)
PRK (Photorefractive Keratectomy)
- Laser can be applied directly to the corneal epithelium. To a large extent, it respects the cornea's architecture and physiology, as it acts in a superficial way.
- It is a quick procedure performed all at once.
- It causes pain for a few days and visual recovery is slow.
- Indicated in patients with fine corneas and also in those who, because of their profession or hobbies, may receive impacts to the eyes.
LASIK (Laser-Assisted in Situ Keratomileusis)
- To avoid a lesion to the epithelium, a fine flap is lifted, the laser is applied to the interior (also known as the corneal stroma) and the flap is put back in position.
- Irritation is minimum and vision is quite good the next day.
- Treatment is performed in two sessions, with a break of a few minutes between each one. It ends up having a deeper effect on the cornea and may affect the architecture and corneal nerves.
SMILE (Small Incision Lenticule Extraction)
- It modifies the curvature of the cornea by cutting out an internal lenticule that is extracted using a very small incision.
- The epithelium remains intact, meaning that post-operative pain is almost inexistent.
- The superficial layers remain intact and the corneal nerves are affected to a lesser degree, the risk of ectasia and dryness is low.
- It is performed all at once.
- It is largely dependent on the surgeon's skill and vision is recovered somewhat slower than in the case of LASIK.
It is important to conclude that there are neither better or worse techniques in this field, given that the most important factor is to determine which technique best suits each patient. A proper diagnosis is key.
Practical aspects of the procedure
The pre-operative period
- In the first visit, your current prescription and the state of your eye health will be assessed. An examination will be carried out to determine the main parameters of the cornea.
- Depending on the results, the most advisable type of operation will be determined in each individual case: superficial laser surgery (PRK), laser lenticule extraction surgery using a small incision (SMILE) and intrastromal laser surgery (LASIK).
- The patient should stop using contact lenses at least 15 days before the operation.
- The day before the operation, a series of complementary tests will be performed to confirm the previous data and determine suitable treatment parameters.
The operation
- It is an outpatients surgery, although the patient will have to remain in the clinic for a few hours.
- Anaesthetic drops are applied before the operation.
Glaucoma surgery
The primary way to treat glaucoma, and prevent or slow the progression of vision loss, is by decreasing eye pressure. This can be often be achieved by medications; however, in some patients, glaucoma laser or surgery is needed to lower the eye pressure to a safer range.
This page describes the most common laser and surgical options. The type of surgery that is best suited for a particular patient is based on many factors such as the type of glaucoma, eye pressure goal, shape of the eye, and prior eye surgeries, amongst other factors. Therefore it is best to discuss whether you are a candidate for a particular type of laser or surgery with your doctor.
High myopia surgery
What does the treatment involve?
Firstly, we would like to clarify that there is currently no surgical treatment that can stop the advancement of myopia (short-sightedness). Therefore, the treatment aims to correct the refractive error, that is to say, the number of dioptres the patient has, once it is stable, and thus reduce or, in many cases, avoid dependence on glasses.
There are also surgical techniques that prevent or treat the complications of myopia magna, such as retinal tears, neovascular membrances, cataracts or retinal detachment.
In terms of refractive error treatment, that is to say, the elimination of dioptres, surgery will greatly depend on the degree of myopia and the characteristics of the cornea.
Simple myopia, (less than 6 or 7 dioptres) can usually be treated with laser surgery which modifies the surface of the cornea in a very simple way.
With higher degrees of myopia, the changes caused by the laser might put the structural integrity of the cornea at risk because of the high number of dioptres to eliminate. For this reason, after an exhaustive feasibility study, we should opt for other surgical techniques that do not change the corneal structure.
These techniques involve intraocular lens implants.
There are basically two types of intraocular lenses:
- Phakic or ICL lenses: These lenses are similar to contact lenses. They are smaller in size and they are placed on the inside of the eye on the surface of the crystalline lens, behind the pupil, instead of on the cornea like the conventional contact lenses that we all know.
- Lenses that substitute the crystalline lens: These lenses are a similar size to those above and are put in place of the crystalline lens, that is to say, they replace them. The surgical technique used to implant these lenses is the same as the technique used in cataract surgery. For this reason, they are implanted in older patients whenever they have cataracts or are close to having them.
On the other hand, as mentioned before, there are surgical techniques that do not aim to correct the dioptres but rather treat the possible complications of myopia magna, such as:
- Laser photocoagulation in the case of retina tears.
- Intravitreal injections in the case of neovascular membrane haemorrhages.
- Vitrectomy in the case of haemorrhages, retinal detachment or macula problems.
When is this treatment indicated?
As intraocular implant surgery does not stop the advancement of myopia, it must be performed when the myopia is stable, that is to say, when we think that it will not increase significantly. For this reason, where high myopia with a more prolonged development is concerned, it is usually performed over the age of 25, provided no changes in the prescription have been detected in the preious year.
Does this mean that your myopia will definitely not increase after the operation? The answer is no, but the likelihood that it continues to advance is much lower than in younger people who get the same operation.
Phakic or ICL lenses are normally implanted under the age of 40 given that it is important to respect the role of a crystalline lens which works properly until this age.
From the age of 50, the crystalline lens is not able to focus on nearby objects like it used to. For this reason, an ICL implant does not make much sense and it would be more appropriate to extract the crystalline lens and implant a lens to substitute it, with the additional advantage that if we implant a multifocal intraocular lens, we can also correct presbyopia, which also exists at this age.
How is it performed?
The phakic lens or ICL implant is a relatively simple surgical technique performed under local anaesthesia and involves making a small incision in the periphery of the cornea as the entry point for a cannula where the lens is injected. It subsequently unfolds behind the pupil and will settle properly on the surface of the crystalline lens, signalling the operation's completion.
In the case of lenses that substitute the crystalline lens, this operation is also performed under local anaesthesia, and just like cataract surgery, the nucleus of the crystalline lens should be aspired, leaving its surrounding capsule ready for the insertion of the intraocular lens, this time inside the crystalline lens capsule itself and not on top of it, as we would do with the ICL implant.
Results
Visual recovery is practically immediate, although for the first few hours your vision might be slightly blurry because of a minimal inflammation of the entry incision, but it recovers in a short time.
The visual results are excellent and are comparable to wearing glasses or contact lenses. The precision of the correction is usually very good, in the majority of cases the resideual error is lower than the average dioptres.
Possible risks
Although the probability of complications with this kind of operation is very low, under no circumstances are you exempt from them.
The possibility of an infection is latent in any surgery, although due to the little manipulation required in this surgery and as it is a very short operation (less than 10 minutes), the incidence rate of infections is even lower than with cataract surgery, in other words, unlikely.
Depending on the characteristics of each patient, greater postoperative inflammation in one eye than the other cannot be ruled out meaning functional recovery may take longer although, in general, there are no long-term consequences.
The eye with the higher level of myopia is more likely to suffer retina complications, a problem that a lens implant cannot solve.
A myopic patient is more likely to suffer cataracts at a younger age than the general public. Wearing a phakic lens may even accelerate their appearance in a small percentage of cases, which would, in the future, mean they have to change the phakic lens for a crystalline lens substitute lens, which would correct their myopia, as we stated before.
Intraviteral injections
What does the treatment involve?
It is a simple surgical procedure, the purpose of which is to inject drugs directly into the eyeball (vitreous cavity).
This enables very high concentrations of medication to enter at intraocular level that would not reach via another route (oral or intravenous) as the eye is an organ isolated from the rest of the organism and that makes it difficult for drugs not administered by intravitreous route to reach high enough concentrations inside in the eye.
When are intravitreal injections indicated?
They are used as treatment for retina or vitreous issues. Depending on the indications, we can chose different kinds of intravitreal drugs: anti-angiogenics, corticoids, antibiotics, etc.
At present, the injections that are most commonly used are anti-angiogenics, of which we have 2 drugs, Ranibizumab and Aflibercept, which have been used for intraocular use and a third, Bevacizumab, which is only for compassionate use and in exceptional cases, where other medications have not been effective enough for controlling the disease.
The administration of these drugs is widespread for exhumative or wet age-associated mascular degeneration, and for the treatment of choroidal neovascular membrane secondary to other causes (for example, myopia magna). They are also the treatment of choice for cases of macular oedema (swelling of the central retina) associated with vascular diseases of the retina (for example, retinal vein obstruction, diabetic retinopathy, etc.).
We are currently participating in various state-of-the-art anti-angiogenic studies, with greater efficacy in the control of these diseases and a lower frequency and number of injections.
In the near future, we will also begin clinical trials to administer intravitreal injections in order to slow or even stop the evolution of atrophic senile macular degeneration.
A special mention must be made of intravitreal corticoids, such as the dexamethasone intravitreal implant, the effects of which last 4 to 6 months and the indications for which include treatment of vascular macular oedema and inflammatory oedema, in the context of either ocular inflammation (uveitis) or after intraocular surgery (cystoid macular oedema).
For a short time now, we have also had a Fluocinolone intraocular implant for very select cases of refractory diabetic macular oedema (which recurs after multiple treatments), the pharmacological effects of which may last up to 3 years without requiring reinjections.
Another disease for which we use intravitreal injections is endophthalmitis (an infection of the intraocular content), in this case with antibiotics. The choice will depend on the micoorganism causing the disease.
Although they are not medications themselves, intraocular silicone, gas and air can be used to treat very select cases of retinal detachment.
How is it performed?
For the safety and comfort of patients, intravitreal injections should be administered in an operating theatre or clean room, and, therefore, under strict sterility conditions.
No pre-operative period is required and it is an outpatients technique (no hospital admission needed). It is simple to administer: under topical anaesthetic (use of anaesthetic drops). It is well tolerated by patients.
Possible risks
The risk of complications is extraordinarily low if we follow these intructions.
The patient will barely feel any irritation during or after the injection, but if they do, it is limited to a feeling of grit in the eye, stinging and a slightly red eye.
On few occasions, a small red spot may appear in the place of the injection (hyposphagma) which is reabsorbed on its own. Seeing black bubbles after the injection is not uncommon, they could be leftover air; they usually disappear in 24 to 48 hours without any effect on the treatment.
The most feared complication, and luckily it is very uncommon, is endophthalmitis. To prevent it, the patient should apply antibiotic drops on the days after the procedure.
Laser iridotomy for glaucoma
The primary way to treat glaucoma, and prevent or slow the progression of vision loss, is by decreasing eye pressure. This can be often be achieved by medications; however, in some patients, glaucoma laser or surgery is needed to lower the eye pressure to a safer range.
This page describes the most common laser and surgical options. The type of surgery that is best suited for a particular patient is based on many factors such as the type of glaucoma, eye pressure goal, shape of the eye, and prior eye surgeries, amongst other factors. Therefore it is best to discuss whether you are a candidate for a particular type of laser or surgery with your doctor.
Pterygium surgery
What does the treatment involve?
Sutureless pterygium surgery involves removing the pterygium without applying sutures. As there is an area without any cells, we must put healthy tissue in its place. The simple removal of the ptergygium may cause a relapse, the pterygium reappears, therefore a graft is always required.
When is this treatment indicated?
When the pterygium starts to grow, it may cause an astigmatism. It may, in turn, cause the cornea to opacity, in which case it has to be removed.
How is it performed?
During the surgical procedure, performed under local anaesthesia, we remove the pterygium in the whole part invading the cornea, and in the part of the conjunctiva. We clean the whole fibrous tissue forming over the years, leaving the area as clean as possible.
It is usually an area of 6 x 8mm, depending on the size of the pterygium.
This whole area will be covered with a graft, which is taken from the eye itself, from the conjunctiva, normally from the superior temporal quadrant, under the upper eyelid.
A small square of tissue approximately 1cm thick, or a little less, depending on the size necessary, is cut with scissors, and is placed in the area from where we have removed the pterygium.
It is important to preserve the orientation of the tissue. Sutures are not used to hold it in place, but rather a fibrin-based biological adhesive that sticks to the tissue perfectly.
Once the surgery is finished, an antibiotic oinment, a dressing, and a compression bandage are applied to keep the graft in position, which would normally be well fixed with the fibrin for 24 to 48 hours until a good level of healing is attained.
In the postoperative period, the eye may be red for a few days or you may experience discomfort. The patient needs corticosteriod treatment, antibiotics and plenty of topical lubrication with ointments, gels and artificial tears so that the graft takes and starts to attach to the surrounding tissue.
Results
The use of this technique means we attain a very low percentage of recurrences. We do not use sutures, which are always uncomfortable for the patient during their postoperative period.
In general, the result is very satisfactory as it is a very simple operation when undertaken by experts. The cosmetic result is usually excellent.
Possible risks
There are few complications. One of them is inadvertent detachment, if the graft does not remain adhered and is lost in the postoperative period.
It is an extremely rare complication that can be seen as soon as the bandage is removed on the first day. A new graft from the same eye or the other eye would be required.
Recurrence is perhaps the most common complication of pterygium surgery. It may be around 5% although it also depends on the patient's individual circumstances, like repetitive sun exposure and race.
It is more common in patients from countries in the equatorial strip, due to the higher level of sun exposure. If the pterygium has not relapsed in the first months, has not recurred, then it will now no longer come back during your lifetime.
The astigmatism caused by the pterygium after removal normally goes away. Otherwise, the patient will need to use glasses or will require cornea surgery to correct it.
YAG laser capsulotomy
What does the treatment involve?
Cataract surgery involves removing the eye's natural lense or the opacified "crystalline lens" without damaging the "capsular bag" in which it is found.
This capsular bag must be polished and left transparent before finalising the surgical operation, given that this is when the artificial intraocular lens is implanted to substitute the eye's natural crystalline lens.
Months or years after cataract surgery, the patient may notice reduced vision. This is due to an opacification of a part of the capsular bag called the "posterior capsule". A posterior capsule opacity, known in the past as a "secondary cataract", is treated quickly and simply via a procedure called a Nd:YAG laser posterior capsulotomy.
Treatment involves restoring transparency to the posterior capsule by making an opening in it with a Nd:YAG laser without the need for incisions.
How is it performed?
To perform a capsulotomy, the pupil is dilated using eyedrops around 30 minutes before the procedure. Then some anaesthetic drops are applied and the laser is applied. This is painless and usually lasts a few minutes.
Very rarely, in cases where patients do not cooperate adequately, a lens is put on top of the eye. Once the procedure is finished, anti-inflammatory and anti-hyperintensive eyedrops are applied and the patient is discharged after checking that everything is in order.
It is an outpatients treatment and does not require any prior preparation by the client. It is advisable that you are accompanied by someone as you may experience passing glare due to the light of the microscope used to carry out the procedure. You can usually resume your daily activities the day after the operation.
After a few days during which anti-inflammatory eyedrops should be used, an eye check-up is performed to monitor the patient's progress and the final results.
Results
An obvious improvement is usually noticeable just a few hours after as long as the patient does not have any eye issues that would impede proper visual recovery.
People frequently report that they see "floaters" for the first few days after treatment, a phenomenon that passes in a few days but may occasionally last for a little longer.
Possible risks
The Nd:YAG laser posterior capsulotomy is a non-invasive and very safe procedure. Occasionally, the intraocular pressure of some patients increases temporarily, which usually happens during the first few hours after the treatment is performed.
To avoid this complication, anti-hypertensive eyedrops are applied immediately after the laser. Furthermore, to counteract the postoperative inflammatory repsonse, anti-inflammatory drops are prescribed for a few days as mentioned before.
Cosmetic Periocular Surgery and Rejuvenation
Our eyes say so much about us. They reveal what we think and they express what we feel. But sometimes, because of heredity or the aging process, our eyes do not convey the full range of human thoughts and emotions.
"Tired" eyelids or droopy eyebrows can make a person look constantly sad and worn out. An injury to the eyelid or orbit or certain health conditions, such as Graves' disease may cause an abnormal appearance as well as damage to the function of the eye. In addition to aesthetic concerns, heavy eyelids and eyebrows can obstruct vision, creating an unnecessary limitation.
Any number of eye conditions can be corrected through cosmetic plastic surgery in which the appearance of the eye can be improved to produce a younger, brighter, less tired look. Cosmetic eye surgery at Tirana Eye Clinic consists of plastic surgery of the upper eyelids, lower eyelids and eyebrows.
During your initial consultation, our consultants will advise you as to whether or not you are a candidate for cosmetic eye surgery. Complications are rare but your physician will discuss these with you in detail, as well as your expectations. Cosmetic eye surgery is performed in an outpatient operating room. Before the procedure begins, you will receive local anesthesia administered by a physician so that you are comfortable and do not feel any pain during surgery. Following surgery, you will be prescribed medication to reduce any pain. A regular follow-up examination will be scheduled. Following surgery, most patients are able to return to work within one week.
Botox
What does the treatment involve?
Botulinum toxin, commonly known as Botox, is a toxin produced by a bacteria that causes botulism, causing temporary muscle paralysis.
This toxin was purified in its day so it could be used for therapeutic purposes. It is used in various specialist areas of medicine, such as neurology, aesthetics and ophthalmology.
When is this treatment indicated?
In the field of ophthalmology, we use it in certain pathologies, such as cases of strabismus, blepharospasm (a condition where the eyes close involuntarily) and in cosmetics to rejuvenate the appearance by treating wrinkles in the periocular area, on the forehead and between the eyebrows.
Regarding strabismus, it is used in acute ocularmotor palsy to minimise the antagonistic muscle contracture of the affected eye and in chronic phases in cases where there is a small residual deviation of the eye. In surgical operations for strabismus, it is also used as a complement in some cases.
Blefarospasm is a chronic condition, the cause of which is not quite known. Patients cannot prevent their eyelids from closing as if it were a "tic" and cannot open them until this "tic" is over. Often they last seconds in which the patient cannot see and therefore cannot go about their normal life. This affects them not only for those moments of "blindness", but it also affects their family, social- and working-relationships with others. Botulinum toxin administration is the treatment of choice in these cases.
In cosmetic surgery, Botulinum Toxin acts on the dynamic wrinkles, which are those that are most noticeable when the muscLes are contracted: crow's feet, between the eyebrows and on the forehead.
How is it performed?
Botox treatment is a very simple procedure.
In cases of blepharospasm, cosmetic treatment and oculomotor palsy, it is an outpatients treatment. It involves Botulinum Toxin injections in the targeted muscle, distributed according to the case and pathology.
The procedure is painless because an anaesthetic cream is applied to the targeted areas of the skin in the case of blepharospasm and cosmetics. Anaesthetic drops are applied for cases of paralysis. The botox injection is administered in under five minutes and the patient leaves the doctor's office by themselves when it is complete.
In cases where Botox is required as a complement to strabismus surgery, depending on the complexity of the case and the age of the patient, local or general anesthesia can be given. These are both outpatients treatments.
Results
The effect of botox can be seen after one week and, like any other medication, it has an average life span of 3 to 6 months, depending on each case.
Due to this, patients who get Botulinum Toxin must see an ophthalmologist to have it administered two or three times per year.
Possible risks
Botox treatment is contraindicated for patients who are hyper sensitive to toxin or have an infection in the area to be injected. In addition, pregnancy, if the mother is breastfeeding, or if the patient is taking any kind of medication interfering with neuromuscular transmission are considered to be relative contraindications (not advised).
It is a very safe drug that does not usually have any adverse effects. It may cause side effects that are local and temporary, but they are very uncommon and easy to solve, such as redness or slight inflammation in the area injected. In this case, the local application of something cold will suffice.
If there are any undesired side effects of toxin, they are temporary.
In light of the foregoing, we can say that it is a safe and effective procedure both for the treatment of the described pathologies as well as for cosmetic purposes.
Lower blepharoplasty
Blepharoplasty is the treatment of choice for bags under the eyes. It is an outpatients surgery with excellent results and minimum inconvenience for the patient. After a short post-operative period—just a few weeks—the effect of the surgery is very apparent and appearance improves visibly and, in many cases, quite spectacularly.
