Cataracts
What is a cataract?
A cataract is a natural clouding of the lens. ( Cataract actually means waterfall!). The lens focuses light onto the retina to produce an image, just like a camera lens. With age the lens becomes less pliable and cloudy. This causes images to become blurred causing difficulty with reading , watching TV and seeing in the distance eg; the number on a bus. You may notice glare at night especially when driving.
When do I need surgery ?
Cataract surgery should be considered when your quality of life is affected .ie: when you have difficulty reading , driving or carrying out your hobbies. Just because your optician tells you, that you have a cataract, does not mean you have to have surgery , however cataracts do progress and the more advanced a cataract the higher the risk of complications from surgery. Also most patients are surprised at how poor their vision was once they have had cataract surgery.
How is cataract surgery done ?
Modern day cataract surgery is known as 'phacoemulsification' or small incision cataract surgery. This is performed using a special ultrasound that dissolves the lens allowing a small incision and invariably no stitches. A small plastic implant is placed where your natural lens was. There are a variety of implants available and new implants are being developed all the time.
Most patients have a local anaesthetic , that is an injection around the eye and thus can go home soon after the procedure.
What would happen if I decide to have cataract surgery ?
You would be given a date for surgery and will usually have this done as a day case under local anaesthetic. Before having surgery you will be measured for the lens implant. You will be given information on how to prepare for your surgery.
On admission you will have drops put in the eye to dilate the pupil. Later on you will be taken to the anaesthetic room where an anaesthetist will perform the injection. Once the anaesthetic has taken effect you will then be taken to theatre where the operation will take 10 - 15 mins. You will then be taken back to the ward for a drink and something to eat. Usually you can go home after an hour or so.
The whole process lasts approximately 3 - 4 hours.
If you would like to consider private cataract surgery and the benefit that private care offers please click on 'private eye care'
What happens after surgery ?
You will be asked to put drops in your eye to help the eye heal. This is done for 4 weeks. Your first post operative visit is usually 7 - 10 days. Following this you will be able to see your optician for an eyetest and discussion as to whether you need new glases or wwhether it is advised to have the other cataract done. Your second postoperative visit will be 1 month after surgery.
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Blepharitis:
This is an inflammation of the eyelids. It causes irritation and crusting of the lashes and lid margins. The eye may be red , sore and watery.
The best way to treat blepharitis is with ' lid hygiene' :
Lid hygiene:
1) Mix a solution of 4 drops of baby shampoo with a quarter cup of warm water ( boiled and then cooled).
2) Dip a clean cotton bud into the solution and use the tip to rub across the lid margin at the root of your eyelashes to remove any crusting.
There are a number of preparations on the market for lid hygiene eg; Blephasol lotion and Blephaclean wipes (Spectrum Thea) which make the process much simpler.
And /or warm compresses can be used: Soak a face cloth in warm water ( as warm as your eyelids can stand) Apply the face cloth to your eyelids for 5 - 10 mins. You may have to reheat the face cloth.
This can be done before cleaning with a cotton bud as it makes the crusts easier to remove.
Lid hygiene should be performed at least once a day. Once stopped the blepharitis will return.
Occasionally it may require treatment with antibiotics. Acne Rosacea is an associated condition resulting in blepharitis and a facial rash , classically across the cheeks and nose.
Most patients with blepharitis often have dry eyes. This combination can lead to recurrent conjunctivitis.
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Dry Eye:
This is a very common condition caused by a disturbance in the tear film. Tears are made up of water, oils, vitamins and mucous. If the balance is disturbed the tears are unable to coat the eye sufficiently. This causes the eye to dry out and become gritty, in turn the eyes become heavy and may ache. Also the eye may water, especially in the wind.
Artificial tears are very useful for restoring tear function. There are a variety of tear substitutes on the market for mild, moderate and severe dry eyes. It is often trial and error in finding ones that suit, all must be used at least four times a day for relief to be acheived. It is also worth remembering that most preparations are cheaper over the counter than on prescription!
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Watery Eye:
A watery eye may actually be a dry eye due to poor tear film constitution resulting in reflex watering due to irritation of the ocular surface. ( See dry eye for details)
Occasionally, the nasolacrimal duct may be blocked. This is the passage whereby tears flow from the eyelids to the nose. A simple, pain free, test called a sac washout can be done to find out if you have a blockage. Unfortunately the only treatment is surgery.
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Flashing Lights & Floaters:
We are born with a gel within the eye called the vitreous . This sits in the area behind the lens and is adherent to the retina. As we get older the vitreous starts to collapse in on itself as the proteins within it start to clump together, this forms floaters ( clumps of proteins within the vitreous). Eventually the vitreous becomes detached from the retina , as it does so the vitreous pulls on the retina and causes small flashes of light. Very occasionally if the vitreous pulls on an area where it is firmly attached to the retina it can cause a retinal tear.
Generally floaters are not a problem but more of a nuisance. Most patients get used to them. In extreme circumstances they can be removed surgically.
Flashing lights usually settle without consequences, but should your flashing lights not settle or become more frequent or are associated with a sudden increase in floaters, you should seek an expert opinion as soon as possible.
If your flashing lights and floaters are followed by a permanent shadow across your vision , that does not move, then you must seek an urgent opinion.
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Macula Degeneration:
The macula is a part of the retina that gives you your central vision ie: the ability to see faces, read and write. Macula degeneration or ARMD ( age related macula degeneration) is an ageing change at the back of the eye due to 'wear and tear of the macula'. This results in a grey / black blob or smear in the centre of your vision resulting in the inability to read or recognise peoples faces. It can also cause distortion, that is straight lines appear wavy.
There are two main types of ARMD - dry and wet.
The dry form is literally wear and tear ie the macula actually thins out. Of the two forms this is the less severe and more slowly progressive. There is however no treatment.
The wet form causes much more severe and rapid vision loss. It is due to scar tissue forming beneath the retina at the macula. This scar can leak or bleed resulting in disturbance and loss of function of the macula. Very occasionally a subset of this form ( classic wet armd) can be treated with a special dye called Visudyne and laser combined. This treatment is performed to prevent further loss of vision but will not restore vision. A more promising treatment has been developed using anti -veg f products such as Lucentis and Avastin. These drugs have been shown to halt progression of wet macula degeneration in up to 90% of patients with up to 30% gaining some vision. For further information try one of the links provided on the
LINKS page.
There are a number of promising treatments being developed for all forms of ARMD. Hopefully we will have more information in the future.
Nutrients and ARMD:
There has been a study called the AREDS study which showed that the use of mineral supplements could reduce the risk of development of ARMD in at risk groups.
Supplements available are ICAPS (Alcon) and Occuvite preservision (Bausch and Lomb). If you wish to find out more information then contact my secretary to make an appointment.
The IOL-Vip system:
This is an intraocular lens implant system that creates a magnified image and also deviates the image to another retinal point via a prismatic effect. This is achieved using two intraocular lenses which then act as a telescope within the eye. Reported results from Italy and early reports in this country have shown this to be a promising treatment for patients with moderate to severe vision loss. This procedure is presently only available privately. I am available to provide assessment of suitability at the Highfield hospital.
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Retinal Detachment:
What is a retinal detachment ?
Retinal detachment is caused by a hole or tear in the retina ( this is the film of the eye that processes images and gives us vision) which then causes fluid to accumulate beneath the retina. This in turn causes the retina to become detached from the wall of the eye.
What are the symptoms ?
Patients with this condition may have noticed flashing lights and floaters followed by a permanent shadow across the vision which progressively enlarges. Sometimes this is like a curtain coming down.
What happens if nothing is done ?
This is a blinding condition and requires surgery to prevent further loss of vision. Surgery does not guarantee restoration of vision.
What is involved in surgery ?
Surgery involves flattening the retina with an operation on the outside of the eye ( cryo/buckle) or on the inside of the eye (vitrectomy)
A vitrectomy is keyhole surgery of the eye whereby vitreous is removed using a special cutter. The retina is reattached using laser and a gas bubble. The gas bubble is used to float against the retinal hole / tear and therefore the head must be 'positioned' to get the bubble in the correct place. This is known as 'Positioning or Posturing'
A cryo/buckle involves stitching a small band of plastic to the eye wall to produce an 'indent' this allows the retina to reattach to the wall of the eye. Fluid is drained from beneath the retina via the wall of the eye. Sometimes it is necessary to put a gas bubble in the eye. Usually 'positioning' is not necessary but occasionally you may be asked to lie in a specific position after surgery.
Most retinal surgery is performed under general anaesthetic but can be performed if necessary under local anaesthesia. All surgery requires an overnight stay.
What happens after surgery ?
Once at home if you are r quested to posture this is performed for 2 weeks, 45 - 50mins per hour day and night.
You will be asked to put in eye drops and instructions will be given.
Vision is very blurred for at least 2 weeks. Vision improvement depends on the extent of the detachment and duration of the detachment.
Following surgery review takes place at 2 and 6 weeks then 3 and 6 months depending on progress
What is the success rate and what are the risks?
Success for reattachment with one operation is within the region of 80%, that means there is a 1 in 5 risk of needing further surgery. Other risks involved are:
infection < 1%
Bleeding < 1%
Blindness form the above < 0.1%
Cataract - very common after vitrectomy
Double vision , 1%
Remember, without surgery the eye will lose all it's vision.
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Macula Hole:
What is the macula ?
The macula is the area of retina at the very centre and is responsible for very fine vision, the macula gives you your central vision. Diseases of the macula cause what we call a scotoma ie a black / blurred area in the centre of your vision. It may also cause distortion ie wavy lines.
What is a macula hole ?
A Macula hole is a defect in the retina at the macula in the shape of a circle. The retina in this circle no longer works as it is missing. This means you may have difficulty recognising faces and also reading. You may not notice the problem with both eyes open.
What causes it ?
No one knows the exact cause but it is thought that the hole is caused by the vitreous gel pulling on the retina and causing a hole to form. This only affects the central vision and does not cause blindness.
It is more common in women and tends to affect only one eye. The risk to the other eye of developing a macula hole is 10-20%.
What can be done ?
Surgery for macula holes is very successful. Recent advances have enabled us to perform this procedure without prolonged face down positioning, I currently suggest 3 days . A recent audit of my results showed that over 90% of holes closed and 66% of patients gained vision.
What is involved in surgery ?
This entails a vitrectomy ( removal of the vitreous) and insertion of a gas bubble into the eye. The theory is that the traction from the vitreous gel is removed and the gas bubble floats against the hole to encourage closure.
What happens after surgery ?
In order for the gas bubble to press on the macula hole the patient is requested to 'position' face down ie with the nose pointing at the floor ( either sitting up with head on a pillow or lying face down) for 45mins per hour ie 15 mins rest per hour.
This positioning is done at home for 2 weeks
You will be asked to put drops in for at least 6 weeks and your vision will be blurred for at least 2 weeks.
The first post operative visit is at 2 weeks then 6 weeks, 3 and 6 months.
What is the success rate and risks ?
The success rate of surgery is approx. 80% but is dependent on many factors, mainly the size of the hole and how long it has been there. Once the hole closes approximately 2 /3rds of patients notice some visual improvement.
The risks of surgery are small, the main complication being:
detached retina < 5%
loss of vision < 0.1%.
Most patients develop a cataract and this is treated in the routine way.
However if you already have a cataract both operations can be done together.
For further information visit
www.maculardisease.org or
www.luteininfo.co.uk
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Diabetic Retinopathy:
This is a condition that can affect the retina in patients with any type of diabetes. It is associated with poor diabetic control in the past.
It is important that all diabetics have a regular retina or 'fundal' check either with their GP, Specialist, Optometrist or Ophthalmologist.
There are two types:
Maculopathy
Peripheral Diabetic Retinopathy
What is diabetic maculopathy?
This is caused by 'leakage' from blood vessels - we call this macula oedema or lack of blood supply at the macula - we call this macula ischaemia . Or a combination of both.
(see under macula hole for what the macula is)
This will cause 'blurring' or 'distortion' of your central vision, making reading and recognition of faces difficult.
Macula oedema can be treated with laser if detected early enough. There are new treatments under investigation at present such as steroid injections and vitrectomy, which may change the way we treat this condition.
What is peripheral diabetic retinopathy ?
This is due to ischaemia ( poor blood supply resulting in lack of oxygen to the retina).
The retina develops new blood vessels as a response but unfortunately these bleed , leak and cause fibrous tissue to form which ultimately produces a localised detachment of the retina.
The only treatment is to 'ablate' or destroy the affected retina to prevent this 'neovascular' response with laser. Several laser sessions are required to control this condition.
Occasionally surgery is required for the more advanced stages of the disease.
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Iritis:
What is iritis ?
Iritis or 'uveitis' is an inflammation of the eye.
The most common form usually affects one eye at any stage and is unassociated with any medical illnesses.
It causes a red eye which is painful, sensitive to light and causes blurred vision. It does not respond to antibiotic drops.
How is it treated ?
It is treated with steroid drops ( remember steroid drops should only be used under the supervision of an ophthalmologist)
Occasionally iritis can be quite severe affecting several parts of the eye and also both eyes at once. In these cases several investigations are performed to see if there are any associated illnesses.
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Conjunctivitis:
This is one of the commonest ophthalmological condition and is usually treated by your GP with antibiotic drops.
It may affect one or both eyes, it is not particularly painful but may cause slight blurring of vision. If it is a viral conjunctivitis it may not require treatment - the eye tends to be more watery than sticky.
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Retinal Vien Occlusion:
This is blockage of a vein within the retina causing localised haemorrhages or 'clots' . If the major vein is affected ie the central vein, then the vision may be severely affected. If only a smaller vein is affected this will only cause part of the vision to be blurred.
The treatment depends on the type of 'vein occlusion' and severity. Laser may be needed.
High blood pressure is probably the commonest cause.
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Retinal Artery Occlusion:
This is blockage of an artery within the retina. This causes the affected retina to lose it's blood supply and therefore causing loss of vision. The severity of the loss depends whether it is the main artery ie the central retinal artery or a smaller artery that is affected.
Very occasionally the blockage is only temporary. This causes transient loss of vision, like a curtain coming across the vision - we call this 'amaurosis fugax'
This condition could be a precursor of more life threatening conditions such as heart attack and stroke. The most common causative factors are smoking , high blood pressure and raised cholesterol.
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Glaucoma:
Glaucoma is a condition that causes restriction of the visual field ie: Tunnel vision. No one knows the exact way in which this happens but we do know that the pressure inside the eye ( the intraocular pressure) is an important contributory factor.
It can run in families. Your optometrist will be able to arrange a 'pressure check for you'. This is a condition that can only be picked up by a specialist as the patient is usually completely unaware of any problem.
The commonest form is chronic glaucoma
Treatment is usually with drops. Very occasionally surgery is needed.
Acute glaucoma is an emergency as it can cause very high pressure in the eye resulting in rapid visual loss. This requires admission to an eye ward.
Symptoms include severe eye pain, loss of vision and nausea.
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Presbyopia:
This is the eye getting old !!
With age the lens of the eye loses it's flexibility and becomes stiff. It is unable to change it's shape which is an important factor in focusing. So when you read you find that you have to move the print further away to a point where the lens can focus ie your arms become too short.
This is alleviated with reading glasses.
It is possible to have the natural lens removed and a special 'accomodating lens' inserted. This is a rapidly developing area within ophthalmology.
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A to Z of Eye Drops
Anti-infectives:
Chloramphenicol: antibiotic for conjunctivitis
Exocin: antibiotic for corneal infection
Fucithalmic: antibiotic for conjunctivitis
Genticin: antibiotic for corneal infection
Neosporin: anti fungal preparation
Soframycin: anti fungal preparation
Glaucoma:
Alphagan: glaucoma drop
Azopt: glaucoma drop
Betagan: glaucoma drop
Betoptic: glaucoma drop
Cosopt: glaucoma drop
Iopidine: glaucoma drop
Lumigan: glaucoma drop ( new generation)
Pilocarpine: glaucoma drop (less used now)
Propine: glaucoma drop (less used now)
Trusopt: glaucoma drop
Timoptol: glaucoma drop
Teoptic: glaucoma drop
Travatan: glaucoma drop ( new generation)
Xalatan: glaucoma drop ( new generation)
Xalacom: glaucoma drop ( new generation)
Anti - inflammatories:
Alomide: non steroidal used in allergies
Acular: non steroidal
Betnesol: steroid
Betnesol - N: steroid / antibiotic preparation
Emadine: non steroidal used in allergies
FML: weak steroid
Livostin: non steroidal used in allergies
Maxidex: strong steroid
Maxitrol: steroid / antibiotic preparation
Opatanol: non steroidal used in allergies
Opticrom: non steroidal used in allergies
Optilast: non steroidal used in allergies
Otrivine: non steroidal used in allergies
Pred Forte: strongest steroid
Predsol: weak steroid
Predsol - N: steroid / antibiotic preparation
Rapitil: non steroidal used in allergies
Sofradex: steroid / antibiotic preparation
Tobradex: steroid / antibiotic preparation
Vexol: weak steroid
Voltarol: non steroidal
Remember steroid drops should only be used under the supervision of an ophthalmologist.
Dry eye preparations:
Celluvisc severe dry eye (preservative free)
Gel tears moderate dry eye
Hypromellose mild dry eye
Hypotears mild dry eye
Ilube mild dry eye with excess mucous
Liquifilm mild / moderate dry eye
Lacrilube ointment for at night
Sno -tears mild / moderate dry eye
Tears naturale mild dry eye
Viscotears severe dry eye (preservative free avail)
Dilating drops:
Atropine: long acting post op drop
Cyclopentolate: used in iritis
Phenylephrine: used in clinic
Tropicamide: used in clinic
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