A comprehensive eye exam involves evaluating the eyelids, the surface of the eye and the inside of the eye. In the case of some exams, it may be necessary to administrate eye dilating eye-drops. If they are used, vision may be blurred for about 2 hours. It is not safe to drive after having the eyes dilated.
It is a very detailed examination of vision in each eye separately, and in both eyes. During the examination, both near and distant vision are tested. An optometrist can prescribe glasses or propose other methods of correcting the visual impairment, including adequate contact lenses.
Gonioscopy is an examination of the angle which is responsible for the drainage of fluids out of the eye and, consequently, for maintaining an adequate eye pressure. Gonioscopy is typically performed in the case of glaucoma, intraocular hypertension or eye traumas, but it can be also carried out in any other case if it can help to make a diagnosis. Gonioscopy is performed using a special device under anaesthesia administrated in the form of eye-drops. Patient’s vision may be blurred for a couple of hours after the procedure.
Tonometry is performed to measure the eye pressure. It is one of the baseline eye examinations. It is especially important in the diagnostic procedure for advanced glaucoma. There are several techniques of performing tonometry including the contact ones and the non-contact ones. In the case of non-contact tonometry, the eye is anaesthetised with special eye-drops.
Perimetry, that is a visual field exam, is one of the baseline eye examinations. It measures the area of the eyesight of the patient. It also assesses the optic nerve head. It is a baseline examination in the case of glaucoma, but it is also widely used in the diseases of the nervous system.
Optical coherence tomography of the fundus of the eye (OCT) is an examination applied in the diagnostic procedure for retinal diseases, such as Age-Related Macular Detachment, diabetic maculopathy, macular oedema or macular holes. The examination shows the anatomy of the eye in details. It is a non-invasive procedure. Eye dilating eye-drops are normally used before the examination, so patient may complain of blurred vision and sensitivity to light for about 4 hours after the procedure. OCT examination also allows to assess the optic nerve head, similarly to the HRT or GDX examinations, as well as to examine the anterior segment, the angle and the anterior surface of the eye.
Fluorescein angiography is an examination of the blood vessels of the eye. In order to carry out this examination, a fluorescent dye is injected into the bloodstream. It passes through the blood vessels. Then, photos of the fundus of the eye are taken. The pupils are dilated with special eye-drops prior to the examination. The whole procedure usually lasts for about 1,5-2 hours with some breaks. Before the examination, patients are recommended not to have copious meals, because some of them may experience nausea and vomiting as a result of dye injection. After the examination, the skin, the conjunctiva and the mucous eye-membranes are yellow, the same with the urine of the patient. Some patients may develop an allergic reaction to the dye.
HRT examination is an optic nerve head assessment. In the course of the examination, the optic nerve head and the optic nerve pit are measured with an analyser. As the device is equipped with a database, so called “norms”, the result can be compared to these norms. HRT allows to diagnose patients for glaucoma.
Ultrasound examination (USG) of the eyes allows to assess the condition of the orbit, the eye muscles and, in particular, the eyeball. This examination is particularly useful if it is not possible to assess the inside of the eye due to the reduced transparency of the lens or the vitreous body. It can happen in advanced cataract, which makes it impossible to look into the eye, or in the case of an intense haemorrhage, that covers the fundus of the eye. Ultrasound examination can be also performed in any other case if it is recommended by an ophthalmologist. It is a painless procedure.
Ultrasound Biomicroscopy is a technique primarily used for imaging of the anterior segment of the eye using ultrasounds. It is used to assess the retina or the angle, among others. It can be very useful in the diagnostic procedure for glaucoma or when assessing tumour or other changes, for example, in the iris. UBM examination can be also used to assess the location of the lens in sublaxated glaucoma. The procedure is performed after administrating anaesthesia in the form of eye-drops.
Before any laser procedure eye is numbed with suitable drops. For more accurate laser implication eye doctor will put special lens on the eye. Vision after procedure is going to be worse for some time. After several hours it will get back to normal.
Laser treatment is used to treat a number of retinal diseases. Laser is frequently used in the case of changes that can lead to retinal detachment, that is, in peripheral retinal changes. Laser treatment consists of "welding" the retina to the surface so that it remains in place. An ophthalmologist specialised in treatment for retinal diseases should decide on using a laser treatment.
Pan-retinal photocoagulation is a type of laser treatment performed when the retina is damaged by diseases such as diabetes or retinal vein occlusion. It the retina is damaged by these diseases, it can emit some poisonous substances into the eye, leading to its further damage. In order to stop this process, photocoagulation of the retina has to be performed. This kind of laser can be used only in the parts of the eye that are not responsible for vision. It cannot be used, for example, in the macula. It is usually necessary to repeat the procedure. After PRP, some patients may complain of changes in the contrast sensitivity.
Laser Treatment For Glaucoma
It is a laser procedure applied in the case of glaucoma. It is aimed at lowering the eye pressure. It is usually performed in both eyes at once. SLT normally allows for lowering the eye pressure by about 20%. The procedure can be repeated if after some time, the eye pressure keeps increasing. It is a painless procedure.
Iridotomy is a laser procedure performed in angle closure glaucoma. In the case of this disease, eye fluids cannot flow freely inside the eye and may get trapped in some parts of the eye. Then, the eye pressure increases, leading to an episode of acute glaucoma. Such episode is not only very painful, but is can also cause a permanent damage to the vision. In order to avoid it, a hole in the iris, the coloured part of the eye, should be made with laser. The hole is small and thus, invisible. It is normally made in the part of the iris covered by the upper eyelid. It allows the water to flow inside the eye freely and thus, it reduces the eye pressure.
Other Laser Treatment
During the cataract surgery, an artificial lens in inserted into a special bag, which stays inside the eye permanently. It is a component of the lens and receives the name of posterior lens capsule. In 50-80% of the patients, the posterior lens capsule may be losing its transparency over time, becoming whitish, as matt glass. It leads to vision deterioration. It may resemble a recurrence of the cataract. A laser treatment involving “cleaning” of the posteriori lens capsule is then necessary. It leads to the improvement in vision, which can become as good as just after the cataract surgery. This procedure is performed only once in patient’s life, because the problem does not recur.
Intravitreous injections are injections into the eyeball. They consists of introducing an exact necessary amount of medicine directly into the eye. In the case of neovascular AMD, diabetes or retinal vein occlusion, anti-VEGF medication is administrated, in the case of diabetes – steroids and in the case of intraocular inflammation – antibiotics.
Anti-VEGF treatment consists of administrating anti-VEGF medication into the eye. Anti-VEGF stands for anti-vascular endotheliar growth factor – a substance that blocks vascular endotheliar growth factor. Anti-VEGF medication includes medicines such as Avantis, Lucentis and Eylea. There are used to treat a number of diseases including neovascular AMD, diabetic retinopathy, macular oedema in the course of the retinal vein occlusion and in patients with high short-sightedness. They stop the process of growth of abnormal blood vessels and, as a consequence, stop the progress of the disease.
Avastin (bevaxizumab) was the first anti-VEGF medication registered in the world. It has been used in ophthalmology since the turn of the years 2005 and 2006. Philip Rosenfeld from Badcom Palmer University in Florida was the first person who thought that Avastin could be used in the treatment for neovascular AMD. He correctly assumed that if Avastin could stop the growth of cancerous tumour by blocking the growth of its blood vessels, it could be as effective in the case of neovascular AMD, a disease caused by the uncontrolled growth of new blood vessels underneath the retina. The first attempts to use Avastin consisted in administrating the dose that were used in oncology intravenously. Currently, a significantly reduced dose (4000 times smaller) is used and administrated directly into the eye instead of into the vein. This prevents patient from suffering from adverse events. Avastin is owned by the company Genentech.
Lucentis (ranibizumab) was especially designed and registered to treat wet AMD. From the chemical point of view, it is a derivative of Avastin. It was produced by Genentech. After the success of Avastin, the company wanted to introduce a medicine developed specifically for ophthalmic use. The mechanism of action and adverse events of Lucentis and Avastin are similar. Clinical trials CATT/IVAN that have been carried out demonstrated that the effectiveness of Avastin and Lucentis is also akin. The same applies to the adverse events. The effectiveness is usually related to the regime of treatment and the experience of a doctor who performs it.
Eylea (aflibercept) is the most recent medicine that we use to treat wet AMD. Eylea is produced by Bayer. It is also a cancer medicine, which was tried out in ophthalmology. It turned out that it achieved very good results in retinal oedema and neovascular AMD. The mechanism of action of Eylea is slightly different from Avastin or Lucentis and some patients react better to the treatment.
Steroids are widely used in medicine due to their strong anti-inflammatory and anti-swelling properties. They also block the process of cell division. Currently, in ophthalmology, steroids are mainly administrated locally, that is exactly where they are needed, in order to achieve better medical results and avoid systemic complications. Generally, steroids are administrated if the defects in the eye are caused by systemic changes. It is because steroids have been reported to have numerous adverse events, such as diabetes, gastric ulcers or mood disorders. The eye diseases that can be treated with steroids include uveitis (inflammation of the middle layer of the eye), diabetic macular oedema or retinal vein occlusion. Among the most common medicines from this group, there are: Triamcinolone, Ozurdex and Illuvien.
Triamcinolone is a derivative of prednizolon. Triamcinolone has strong anti-inflammatory and anti-swelling action and blocks the process of cell division. In ophthalmology, it was among the first medicines to be administrated directly into the eye. It is administrated into the eye "off label" (for an unapproved route of administration), because it is registered as a medicine to be administrated intramuscularly. It is a very cheap and effective medicine. Its effects in the eye can last for about 4-6 months. Following this period, treatment usually has to be repeated. Triamcinolone is administrated into the eye in the form of suspension, so dark floaters may appear in the visual field during the first days after the injection. They disappear after a few days.
Ozurdex is a derivate of dexamethazon. It is an implant designed especially to be injected into the eye. It looks like a piece of white pencil load. Unlike Triamcinolone, it is does not cause floaters in the visual field after the injection. Its effects in the eye can last for about 4-6 months.
Illuvien is another implant with steroid medicine registered to inject into the eye. It has been originally created for patients with uveitis, but it can also be used to treat diabetic macular oedema. Its effects in the eye can last even up to 2 years! That is why it is very convenient in application. In Poland it is barely used.
Minor Surgical Procedures
Chalazion – a small lump that appears on the eyelid after a stye. It usually is not absorbed spontaneously; therefore, it has to be removed surgically. Removal of a chalazion is performed under local anaesthesia. No scares are left once the chalazion is removed, because the procedure is performed in the inside of the eyelid.
Warts and atheroma – minor changes around the eyes and on the eyelids, which are not dangerous from the medical point of view, but may cause inconvenience to patients. The procedure of the removal of warts and atheroma is painless, as it is performed under local anaesthesia. In some cases, it may be necessary to use stitches, which are removed after 7 days.
Xanthelasma – yellowish plaques that occur on the eyelids. They normally indicate that the level of cholesterol or fats in the system is too high. Removal of xanthelasma is performed under local anaesthesia. After the surgery, stitches are used and then, removed after 7 days.
As skin ages, it gradually loses its elasticity, which, in some people, may lead to changes in eyelid shape and position. The appearance of the eyelids may be improved by performing a cosmetic eyelid surgery, that is, a blepharoplasty. The surgery is also performed in the case of wrong positioning of the eyelids, for example, when the eyelid is folded to the inside or to the outside. The surgery is performed under local anaesthesia. After the procedure, stitches are used and then, removed after 7 days.
Cancer changes may occur on the eyelids or around them. This type of changes needs to be fully diagnosed and removed, and, on occasions, the eyelids may require reconstruction. The procedure is performed under local anaesthesia. After the procedure, stitches are used. The type of the surgery varies depending on the location and the size of the cancer change. A doctor, who qualifies a patient into a surgery, decides about the course of the procedure.
The procedure for ptosis consists of lifting the upper eyelid that is drooping. It is performed under local anaesthesia. Doctor decides about the type of procedure to be performed when qualifying the patient into a surgery.
Dry eye syndrome is one of the most common problems with which patients address an ophthalmologist. The symptoms include: burning, pinching, itching and feeling of a foreign body in the eye. In patient suffering from dry eye syndrome, the eyes are especially exposed to damaging factors, such as: wind, sunlight, dry air, air conditioning or hot air supplies. As a result of irritation, the eye starts producing too many tears; however, due to their incorrect composition, they cannot stay inside the eye. If the symptoms of dry eye syndrome persist despite the application of moisturizing eyedrops, it is indicated to close the tear ducts surgically. The procedure is performed under local anaesthesia.
A surgical method of treatment for excessive tearing. It consists of widening of the lacrimal points.
Excessive tearing can be reduced by performing an injection of botulinum toxin to the tear gland, which produces tears. It is an absolutely painless procedure. It temporarily stops the production of tears.
Cataract is a clouding of the lens, which leads to vision loss. Surgical removal of the clouding lens combined with insertion of an artificial lens in the same place, is the only available method of treatment for cataract. Procedure is performed using a special device, which can be compared to a small vacuum cleaner. Special equipment is introduced to the inside of the eye through a small (1.8 mm) hole. The lens is taken out using ultrasounds. Natural lens, removed during the surgery, is replaced with an artificial one. There are many different types of lenses. They differ not only in terms of price. Depending on the types of lens inserted into the eye, the patient will have to wear glasses or not. The type of lens should be determined based on individual patient’s needs.
There are specific cases of cataract, for example, subluxated cataract, in which the lens is not properly fixed inside the eye. It may make it more difficult to remove the lens and insert the new one. In such cases, a special type of lenses, that can be permanently fixed inside the eye, is typically used.
Complicated cataract refers to a condition secondary to other eye diseases. The procedure of complicated cataract removal is usually similar to the standard procedure of cataract removal; however, in some cases it may be necessary to use other techniques. On occasions, it is necessary to perform a glaucoma surgery at the same time if the patient suffers from glaucoma or to carry out a vitrectomy if complicated cataract coexists with retinal diseases. This kind of surgery should be performed by an experienced ophthalmic surgeon.
Scharioth macular lens is dedicated to patients with AMD or other macular diseases, who are not able to read small print. It consists of inserting into the eye a lens that acts as a magnifier in the eye so that the imagine is magnified and thus, more visible. The lens is inserted only into one of the eyes. As a consequence, one eye fares better in reading and the other one, in distant vision. The lens can be implanted even if the vision is very poor as long as a cataract surgery has been performed before. This procedures is not aimed at treating the disease that causes vision impairment, but at helping the patient to carry out daily activities. In most cases, it is necessary to carry out a further treatment for the main eye disease that the patient suffers from.
Glaucoma is a disease characterized with increased eye pressure. If it is not possible to control it using special eye-drops or laser treatment, it is necessary to perform a surgery. Surgery may be a good solution for patients who, for a number of reasons, do not use eye-drops, keep forgetting about them or do not have time to use them. There are several pressure-lowering procedures. Given that the eye pressure depends on the amount of the intraocular fluids, the majority of surgeries consists of making a new opening for the fluids to leave the eye or of reducing the amount of fluids produced inside the eye. Trabeculectomy, which involves creating a new channel that allows fluids to drain out of the eye, is the most common type of glaucoma surgery. An experienced surgeon is able to make a drainage channel tailored to the needs of the patient. ECP is carried out in order to reduce the amount of water produced inside the eye thus, lowering the eye pressure. This technique is more precise and safer than others, such as laser cyclophotocoagulation or cryotheraphy of the ciliary body, which cause an irrevocable damage to the eye.
Vitrectomy is a procedure in which an ophthalmic surgeon accesses the inside of the eye. It is performed to treat retinal detachment, macular holes, epimacular membranes, diabetes, haemorrhage to the vitreous body, macular oedema, inflammations, retinal vein occlusion, as well as in the case of more complicated cataract surgeries. Every vitrectomy is different, as there are no two identical eyes. In the course of the surgery, it may be necessary to carry out a number of procedures, including membrane removal, membrane staining or photocoagulation. In the case of vitrectomy, there are never two identical cases and it can be successful if it is tailored to the patient’s individual circumstances. For that reason, vitrectomy is a surgery that requires a surgeon to have a broad experience. After the surgery, a special substance, such as gas bubble or silicone oil, is inserted into the eye in order to unfold the retina. These substances normally cause vision deterioration, but they are removed at a later date and the vision improves.
The vitrectomy technique was developed in the United States over 40 years ago. In Poland, it is performed by a small group of ophthalmologists; therefore, the majority of doctors who work in ophthalmic clinics in Poland have little experience using this method. As recently as 15 years ago, vitrectomy was performed only in very difficult cases or as the last resort. Given that the experience of the surgeons, as well as the technique itself were not as developed as today, it was performed only when other treatments were not effective. Today, the situation has changed. Thanks to both the experience of the surgeon and the technological progress, vitrectomy is now a safe, reproducible method that gives a chance to restore vision. In view of the experience gained in the recent years, many conditions may be successfully treated by performing a vitrectomy. However, a frequent mistake is to perform it in the last possible moment. According to dr Nowosielska, patients should be referred to vitrectomy earlier than it happens now. Vitrectomy, when performed by an experienced surgeon, is not a means of last resort.