Surgical treatment of cataracts
Phacoemulsification technique (PHACO)

• Size of the incision from 1 to 2.75 mm.
• A probe is used to break the lens in microscopic pieces, which are then gently vacuumed up.
• It does not require sutures (“stitch-free” cataract surgery).

For patients over 40 to 45 years old with high degrees of refractive errors or with some degree of cataracts, the most recommendable surgical technique is extraction of the lens using the phacoemulsification technique and then implanting an intraocular lens.

The extraordinary evolution in the design of modern intraocular lenses, which incorporate biocompatible material, provides surgeons with an array of options that enable excellent clinical results to be obtained and make it possible for many patients to recover reduced dependence on glasses for seeing different distances.

• The cornea is the transparent and curved part of the eye that performs two-thirds of the eye’s focusing tasks.
• It refracts or curves rays of light when they enter the eye, which makes it possible to focus them toward the retina.
• If the clarity or the curvature of the cornea is affected by injury or disease, vision can be drastically affected.

Cornea transplant (also known as keratoplasty) is advisable when vision has diminished to a certain degree and is irreversible.
It is the organ transplant procedure with the highest success rate, greater than 90%.
The affected cornea is extracted using a microscope and microsurgical instruments; then, the new cornea is sutured in its place.
A new technique has recently been incorporated that makes it possible to delay transplanting the cornea when the pathology causing diminished vision is Keratoconus. It is the intraocular ring implant technique (Keraring, Ferrara, INTACS).

Who can it affect?
Glaucoma affects over 3% of the population and it is, together with diabetes, the main preventable cause of blindness in Spain. It primarily affects people over 40 and those with a family history of glaucoma.

Symptoms
The pain felt by a patient varies depending on the type of glaucoma that he/she has.

Chronic glaucoma is the most frequent type, and in its beginning phases no sort of pain is felt. If the pressure continues to be high for a prolonged period of time, the optic nerve is affected and peripheral vision deteriorates slowly. In advanced stages, vision is reduced to the central area of the visual field, making the patient feel as though he/she were looking through a tube, and it may lead to total vision loss.

Acute glaucoma is much less frequent. It is characterised by intense pain, which suddenly begins around the eye area, and by a decrease in vision. In some cases, it can be accompanied by headaches, nausea and vomiting. If you have these symptoms, you should immediately call/visit an ophthalmologic specialist.

Detection of glaucoma
Intraocular pressure can be measured using quick and painless tests. The condition of the retina and optic nerve can also be evaluated in a non-intrusive manner.

In the event of a family history of glaucoma and/or when such procedures show some sort of anomaly, a computerised perimetry test should be carried out.

Treatment
The best treatment for glaucoma is early diagnosis in those situations in which intraocular pressure is high and/or the optic nerve is beginning to be damaged. Due to the fact that most cases of blindness caused by glaucoma occur without symptoms and that it can be prevented, it is essential to perform checks every one or two years in any person over 40.

Therapeutic options
Medical treatment
The most common way to treat glaucoma is by applying drops. The aim is to decrease intraocular pressure. If the treatment is done correctly, in most cases it is possible to stop glaucoma from getting worse.

Laser
If the pressure is not controlled with medical treatment, the next option is to use a laser. This procedure aims to help ocular fluid leave the eye and thus reduce intraocular pressure.

Surgery
This is the last step in the treatment of glaucoma. It consists of expanding the zone where intraocular fluid leaves the eye by making an exit valve or by implanting an artificial drain valve.

The surgery is performed using local anaesthesia. When glaucoma is associated with the presence of cataracts, the two procedures can be done at the same time.

What happens afterward?
It is not possible to know if the glaucoma is controlled according to how the patient sees or feels, since there is no type of pain that indicates such information. Making periodic visits to the ophthalmologist is the only way to know if the glaucoma is correctly controlled.

Nonetheless, once glaucoma has been detected and treated and the pressure on the eyeball returns to normal levels, deterioration of the optic nerve is not very common.

Until today, all lens implants were rigid, so it was necessary to make a wide incision (5-6 mm) to implant them and then to use two or three sutures to close the incision. In addition, this practice also made it necessary to use local or general anaesthesia, which induced astigmatism and slowed visual recovery.

Since 1997, the procedure has been carried out in Spain using flexible epicapsular lenses (Implantable Contact Lens – ICL) that are placed between the crystalline lens and the iris.

The ICL are implanted using a 3 mm incision that is not necessary to stitch, which makes it possible to correct refractive errors with causing astigmatism. Other important advantages include the fact that it is performed using topical anaesthesia (drops), it lasts about 15 to 20 minutes and it is not necessary to be admitted or to cover the eye after the surgery, so visual recovery is practically immediate. The ICL make it possible to correct up to 18-20 dioptres of myopia and 9-10 dioptres of hyperopia.

• Eyeglasses in the first stage.
• Contact lenses when eyeglasses are no longer effective.
• Cross Linking: cross linking is the only process able to create new unions or bridges between the corneal collagen fibres in order to significantly increase the rigidity of the cornea. This makes it so the cornea resists ocular pressure and does not deform, thereby detaining visual deterioration.
• Intracorneal rings: when it is evident that the keratoconus has progressed. The rings used may be keraring, ferrara, corneal ring or intacs.
• Cornea transplant, necessary in the most advanced stages when other options will not cause improvements. (Corneal scars, very advanced keratoconus, holes.)

This type of surgery aims to eliminate or reduce sight problems (Myopia, Hyperopia, Astigmatism) in order to achieve good vision without the need to wear glasses or contact lenses.

To do so, and depending on the dioptre to be corrected, the visual acuity and the patient’s age and the condition of his/her eyes, it is possible to use techniques the Excimer Laser or with lens implants.

Corrective surgical procedures

Ptosis surgery
Dropping of the upper eyelid.
The edge of the eyelid is too low and partially blocks vision.
Causes are congenital, due to injury, due to neuromuscular disease or due to the effects of gravity when ageing.
During the corrective surgery, the muscle that lifts the eyelid is shortened so that the upper eyelid is raised.

Entropion surgery
It is defined as the inward turning of the upper or lower eyelid.
When this happens, the eyelashes and skin rub against the cornea causing irritation, redness and pain.
If it is not treated, it can lead to infections, abrasion of the cornea or eye ulcers.
Correction involves rotating the edge of the eyelid to its normal position and strengthening the muscles.

Ectropion surgery
It is defined as the outward turning of the lower eyelid, which causes excess tearing, mucous discharge, eye irritation and chronic conjunctivitis.
It is caused by the displacement of the tear duct, which is located in the lower corner of the eye.

Aesthetic surgical procedure
Blepharoplasty
Also known as eyelid lift surgery. Over time, bags form on eyelids and eyelids sag because the skin becomes more compact and fat deposits become more prominent.
The procedure eliminates excess skin and fat from the upper eyelids and excess fat from the lower eyelids.
It is usually caused by ageing, but it can also be due to hereditary factors.
It can be combined with an eyebrow and check lift.

An eye problem that is not diagnosed early can stop vision development and leave defects that continue throughout life.

When to take children to the ophthalmologist

There are two different situations in which children should be taken to the ophthalmologist: when a child complains or has eye pain and routine visits that should be carried out even if a child does not have eye problems.

The most common reasons that make it necessary for a child to visit the ophthalmologist are:

• Getting too close to the television or paper when they read or write.
• Squinting eyes when looking at far objects.
• Headache after straining sight.
• Common occurrence of red eyes.
• Deviation of the eyes.
• Differences in vision when covering one eye or another.
• White or greyish pupil (leucocoria).

Regarding routine visits by the ophthalmologist, the following checks are recommended:

• During the first month of life: rule out serious eye diseases or malformations (glaucoma or congenital cataracts).
• At seven months old: diagnosis of strabismus.
• At 18 months old: diagnosis of retinoblastoma (most common malignant tumour in childhood).
• At four years old: visual acuity and refractive errors.
• Every two years until reaching 14 years old.

Refractive errors
They are commonly referred to as eyeglass defects. In a normal eye, rays of light converge on the retina and create a sharp image. Refractive errors make it so objects are not seen with clarity. There are three types: hyperopia, myopia and astigmatism.

It is important to detect them early on, since they can lead to poor performance at school. They must be corrected using eyeglasses or contact lenses and, after 20, when degrees of error are stabilised, it is possible to operate with a laser. A baby can be visited to check for these errors, even if he/she is not able to talk.

What strabismus is and how to treat it
It is the abnormal deviation of one or both eyes in one or more sight positions. It can be a horizontal deviation (the eye deviates inward or outward) or a vertical deviation (the eye deviates upward or downward).

All children that deviate an eye intermittently should be visited when they are six to seven months old. Children that have a permanent deviation should be visited even before this age.

Strabismus can be corrected using eyeglasses, surgery or both. Surgery isolates the muscles responsible for the eye’s mobility and it positions them in another place in order to weaken or strengthen their effect. General anaesthesia is required for children.

What is lazy eye?
Amblyopia or lazy eye is the eye that didn’t develop properly during childhood and, consequently, has worse vision than the other eye.

Amblyopia affects 4% of children and can only be treated before eight to nine years of age; otherwise, it can cause a severe and irreversible visual defect.

It is usually detected in routine vision checks by a paediatrician or by a paediatric ophthalmologist, since it causes very few symptoms and usually goes unnoticed by parents.

Its most common causes are strabismus, refractive errors and, less commonly, eye diseases that prevent light from reaching the retina in a normal way (cataracts).

Treatment consists of forcing the child to use the lazy eye by patching the good eye.

Lacrimal obstruction
Tears normally lubricate the surface of the eye and drain through the lacrimal points toward the nose.

Lacrimal obstruction is when the tear path from the eye to the nose is obstructed. In children, it causes tearing and secretion (rheum) from birth.

Ninety percent of the time, the problem is solved spontaneously during the first six months of a child’s life. Antibiotic eye drops and massaging the lacrimal sac are beneficial. If the condition is not cured in this way, it is necessary to carry out a tear duct probe.