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A new scientific treatise from Paschalides Medical Publications.
Read the foreword for the Greek Edition written by Dr. G. Chronopoulos.
A few years ago, the phrase “knowledge is power” still retained its originality and freshness. Today it is a belief among all educated people that, especially in issues of health and disease that are lived by everyone every day, albeit unconsciously, this saying holds even more gravity.
Ophthalmic Surgery admittedly possesses a pioneering position in medicine. Impressive achievements in all its branches, but especially Refractive Surgery during the second half of the 20th century, gave it new prestige and affected its course substantially. During the last decade of the century, Refractive Surgery started to accept strong influences from the progress in biomedical sciences and technology, which moves forward with an explosive pace. Rapid advancements in the technology of Excimer lasers, as well as the increasing applications of Femtosecond lasers in the creation of the flap have brought Refractive Surgery to great crossroads and tend to change its physiognomy, to a point that it is unknown what its course will be in the 21st century in which we currently liveTraditional complications such as under-/overcorrections, incomplete, decentered flaps or “button hole” flaps tend towards extinction with the introduction of new pioneering technologies in the practice of corneal surgery. However, the increase of the frequency of refractive surgery created new issues, such as new forms of persistent inflammations, the need to calculate the strength of IOL in cataract surgery after corneal surgery or the loss of endothelial cells, all of which are complications that worry all refractive surgeons in their everyday practice. For these reasons, the doctor's continuous education is more necessary than ever before and needs to be achieved with all available means, like conventions, conferences, round tables and magazines, but also with treatises, where the knowledge given is responsible and crystallized.
This book concerns both the Resident doctor and also the experienced Ophthalmologist. For the former it is a detailed and informative source of knowledge on Refractive Surgery, while for the latter it plays the part of a modern reference book. Its exclusive goal is to provide current and future surgeons with the most recent information on the pathogenesis of possible complications in Refractive Surgery and offer an approach to their prevention and treatment.
The resident, the general ophthalmologist and the surgeon are always in need of approachable and rich in content treatises that are a source of quick reference in a given time, when the doctor considers necessary to bring certain knowledge back to memory. I believe that Jorge L. Ailo and Dimitri T. Azar succeeded in full by avoiding details that are not essential in the development of a surgical issue.
It is a successful and dense presentation of 19 chapters on how to treat the most common and difficult complications, which, in the writers' opinion, but also in the opinion of this foreword's author, belong in that list of subjects whose knowledge is essential for the ophthalmologist, but also for the young surgeon that is learning the art of refractive surgery.
Notable merits are its clarity, its method, its elegance and the rich illustrations of excellent quality.
To translate the individual chapters, colleagues that have dedicated their lives to the service of a certain expertise were recruited, in order for us to give to the beginning of the new century a completely modern treatise of refractive ophthalmic surgery for the first time in a Greek edition. I would like to thank them for the special care they have shown to faithfully translate the text, even if, in some cases, paraphrasing was de factoFinally, I would like to thank the publisher, Mr. P. Paschalides, for his efforts on this complete edition. I am sure that “Treatment of Complications in Refractive Surgery” will gain from its medical readers the recognition and appreciation that an important text deserves and that it will be an especially useful tool of knowledge and, at the same time, an important incentive for further study and deeper research in the world of knowledge.
George Chronopoulos
Consultant Ophthalmic Surgeon
Information on Refractive Surgery
Refractive surgery has brought a revolution in myopia, hyperopia and astigmatism correction. We are already in the third decade of laser use and we can really observe that precision and safety are already here. With the use of this impressive technology, we can forever eliminate our dependence on corrective glasses or contact lenses.
There are two methods of effective correction of high or low degrees of myopia, hyperopia and astigmatism: PRK and LASIK (conventional LASIK, where the creation of the flap is done with a mechanical microkeratome and FEMTO-LASIK, where it is done with a femtosecond laser). The difference between these two methods lies in the fact that, in the first, the correction occurs on the surface of the cornea, while in the second in its interior. In PRK there is some minor discomfort the first 2-3 days, while in LASIK the discomfort is insignificant and eyesight restoration happens almost immediately, on the very first day. The final result is the same in both cases. An important role in the patient's decision to do away with glasses and contact lenses plays the trust and relationship between doctor and patient. The most important part of a refractive surgery is thorough preoperative tests, which will show us if the patient is eligible for a procedure in that particular area. Detailed and thorough preoperative tests ensure the success of the procedure. Timewise, the procedure lasts only a few minutes and it is never longer than 5 or 6 minutes for both eyes. The doctor uses local anesthesia and the patient feels no pain. It is important to note that the correction is permanent and in the very few cases where some degrees of the condition remain, then an additional laser procedure can be done to achieve full correction. An important role in the patient's decision to do away with glasses and contact lenses has the trust and relationship between doctor and patient. The 25 years of laser use allow us to say that the possibility of serious complications is negligible. Even those rare complications can be treated. We are in a position to say with absolute certainty that the chances of infection from contact lenses are more than the possible complications of refractive surgery.
Keratoconus is a non-inflammatory disorder of the cornea, which is characterized by the presence of a progressive deformation of its surface. The cornea gradually takes a “conical” shape (it expands by creating an extrusion), deforming the reflection formed in the fundus of the eye. A progressive thinning can also be observed, as well as scarring, and finally opacity in the area where the cone has formed. Despite ongoing research, the causes of keratoconus are essentially unknown. It is generally considered a genetic disease caused by multiple factors, mainly irregularities in the structure or the metabolism of various segments of the cornea. It used to be considered a rare disorder, perhaps because there weren't any diagnostic means to detect it in the early stages. Today we know that keratoconus is not so rare. There are more than 20,000 people in Greece with keratoconus (approximately 1 for every 2,000 people). It usually appears in adolescence and progresses relatively fast, while later the rhythm of deterioration decreases and stops at around 35 years of age. Physical examination does not always provide evidence for a positive diagnosis. However, keratometry can give altered parameters. The patient presents an irregular progressive astigmatism that previously did not exist. In more advanced stages, the diagnosis is easier and with the help of a slit lamp, the cornea can present the known conical form, as well as thinning and haze of its central area. Nonetheless, positive diagnosis occurs with the help of an electronic device and a test called “corneal map” (corneal topography). In this test, a 2D image of the corneal topography is taken and, based on that, we can diagnose even the subclinical forms (those that haven't presented any symptoms). It is strongly believed today that the riboflavin method can substantially delay or even stop the development of keratoconus, saving the patient from a potential corneal transplant. This method is still evolving and is called C3-R (Corneal Collagen Crosslinking with Riboflavin). Through lab tests and clinical examinations, it has been proven that it reinforces the inner structure of the cornea, stabilizing its architecture and, specifically, strengthening the bonds of the corneal collagen fibers, which are one of the basic ingredients for maintaining its structure.
C3-R treatment can be done at the clinic and lasts about 60 minutes. During the treatment, drops of a riboflavin (B2) mix are instilled, which are then activated with UV rays.
Cataract is a haze of the natural lens inside the eye. This lens, which is found behind the iris (the colored part of the eye) is capable of moving and changing shape, so that it can function exactly like the lens of a camera, by focusing bright images on the retina, which, in turn, sends them to your brain. The human lens, consisted mainly of protein and water, can present some haze, in such a degree that the light and images are not allowed to reach the retina. Eye damage, certain disorders or even some medicine can cause this haze. In more than 90% of the cases, however, this haze is cause by the aging process. Cataract isn't a deposition in the eye and cannot be removed with diet or laser. The best way to treat cataract is to remove the old, hazy lens and to replace it with an artificial one. Cataract can be the cause of the blurring of clear images, the dimming of bright colors or a decrease in vision at night. It is also possible that it is the reason why reading or bifocal glasses that used to help you read or perform simple tasks, cannot help you any longer. Unfortunately, it is not feasible to prevent cataract, but only to remove and replace it with an artificial lens which can restore your vision and significantly improve quality of life. The proper time to remove cataract is when the quality of your vision starts causing restrictions in your activities and your enjoyment of life.
Glaucoma is a group of ocular disorders that share as a symptom the destruction of the optic nerve. The optic nerve consists of nerve fibers and is responsible for the transfer of images from the eye to the brain. Glaucoma is a disorder that leads to loss of vision without warning. It is possible that there are no symptoms in the early stages of the disease and that patients with glaucoma don't know they have it. Loss of vision starts with peripheral or side vision. This loss might be compensated by the unconscious turn of the head towards the corresponding side, which results in the patient not realizing his condition until there is a significant loss of visual acuity.
For this reason, early diagnosis is important and can prevent major damage. All people above forty years of age and especially those with a family history of glaucoma should be examined once or twice a year.
Diabetic Retinopathy is a disorder at the small (capillary) vessels of the retina. Diabetic retinopathy concerns every diabetic patient either insulin dependent (Type 1) and of young age or non-insulin-dependent (Type 2) and the disease has appeared later in life. The diabetic patient should know that the most important thing he needs to do for his condition is to keep his blood sugar under control. Blood sugar not under control causes a more rapid progress of diabetic retinopathy. He should also control his hypertension, his hyperlipidemia (cholesterol and triglycerides), if such exists, and limit smoking and alcohol. Patients with diabetes should be examined by an ophthalmologist once every 6 months. It is important to know that today, with the improved methods of diagnosis and treatment, only a small percentage of patients develop retinopathy and face serious eyesight problems.
Age-related macular degeneration, is the most common cause of irreversible blindness in the western world. This disorder affects the central area of the fundus, which is also the most important. The consequence? A gradual deterioration of our central vision with no other symptoms. Several studies have calculated that 6% to 10% of people among the ages of 65 and 74 years old and 19% to 30% of people above 75 years old have this disorder. As we can see, it is related to the elderly and for this reason it is called age-related macular degeneration. Age-related macular degeneration is caused by many factors. These risk factors may include age, heredity, light-colored irises, smoking, cardiovascular diseases, as well as sunlight. The most important factor is, of course, the aging process.
What can we do to prevent it?
Wear sunglasses with UV filter, to protect our eyes.
You can take dietary supplements, multivitamins and zinc products. Even though it is difficult to prove those products' preventive action, several studies have shown that they can help delay the disease. Dosage should be indicated by the ophthalmologist in cooperation with the pathologist, in case of contraindications.
You should regularly check your eyes after 40 years of age and visit your ophthalmologist as soon as you observe changes in your eyesight, especially scotomas related to your central vision. Special diagnostic tests like OCT and Fluoroangiography are quite often valuable in the treatment of the disease.
You should reduce or, better yet, quit smoking.
Regulate your blood pressure, your cholesterol and consult with a cardiologist, in case it is needed.
Published in the magazine Dimosios Tomeas, volume 286, July-August 2011
Normal Vision Vision with Hemianopia / Hemianopsia
Normal Vision Vision with Floaters
Floaters are black spots that look like “flies” and appear to move in our visual field, especially under bright lights or in front of a white background. These floaters are small concentrations inside the vitreous humor, a gel found inside the eye that keeps the eyeball in its spherical shape. As those concentrations move inside the vitreous humor, they cast a shadow on the retina, under bright conditions, and thus appear as black spots.
Floaters are usually caused by a posterior vitreous detachment. Since those same symptoms can hide other more serious conditions, like retinal detachment or tears, it is advisable to visit our ophthalmologist urgently for early diagnosis and possible treatment.
Learn more about Floaters.
Normal Vision Vision with Photopsias
Photopsias are called the "glares or “flashes”" that appear in our visual field, especially in the dark or in low-light conditions. These photopsias are caused by tractions of the vitreous on the retina. Those flashes can disappear or reappear for weeks or months.
Since those same symptoms can hide other more serious conditions, like retinal detachment or tear, it is advisable to visit our ophthalmologist urgently for early diagnosis and possible treatment.
Learn more about Photopsias.
Normal Vision Vision with Metamorphopsia
Metamorphopsia is called the change of the shape of the reflection we're looking at. This condition results in the deformation of our central vision. Reflection deformation, which is usually perceived during reading, is caused by a pathology of the macula. The macula is the central area of the retina, responsible for our clear vision. The ability to recognize objects, e.g. a person's face or the written page, is dependent on its integrity. When the macula malfunctions, the central vision is decreased and often appears deformed (metamorphopsia).
Age-related macular degeneration is probably the most common cause of our patients' central vision deformation. It is usually the wet (exudative) degeneration that indicates fluid accumulation under the macula which is followed by metamorphopsia.
Other disorders that deform central vision are:
Macular hole
Epiretinal membrane
Macular edema (e.g. due to diabetes, or retinal vein occlusion)
Central serous chorioretinopathy.
Normal Vision Vision with Retinitis Pigmentosa
Normal Vision Vision with Scintillating Scotoma
Some people with migraines (less than one in four) may present “aura”, which sometimes precedes the headaches. Usually, people with migraines falsely call “aura” an indistinct and non specific sense that a migraine crisis is coming. The term “aura”, however, refers to something completely different: “Aura” in migraines is some particular neurological symptoms (of the vision, the senses, movement or speech) that usually precede pain.
The most common aura consists of visual symptoms (visual aura). The person with visual aura might often see bright lines, lights that flicker or blurry segments in his visual field (these symptoms are merely indicative, since there are many types of visual aura). It is usual that the symptoms coexist: a line, bright or not, that may flicker has on one of its sides an area that is not clear (this is called “scintillating scotoma”). The symptoms of visual aura can be found in part of the visual field (right or left), something that makes the person who has them think that they are in one eye (right or left). The visual aura symptoms move within the visual field, more often from the center to the outside. If they can be found in half the visual field, it is often described as “faces and objects seem half”. This lasts less than an hour and often for only 15 or 20 minutes. Migraine headache usually follows the aura, but in some cases it may come before or at the same time.
Besides visual symptoms, some people have sensory aura (“pins and needles”) in one part of the body. Sensory aura usually includes the hand and the head on the same side. Other people experience speech problems as part of their aura (they can't find words or even speak).Even though the aura symptoms can be (at least, initially) scary for some people, they are generally harmless and people with migraines and aura may experience them many times in the course of their lives. However, such symptoms should be reported, in any case, to a neurologist to make sure that they are not caused by something else.
EyeClinic
64, Vass. Sofias Av,6th floor, Athens
Laser Astigmatism
Phone number: 210 7295000 - Fax: 210 3622245
Laser Hyperopia
Ophthalmological Research Center
64, Vass. Sofias Av.6th floor
Phone number: 210 7295000
Fax: 210 3622245
info@eyeclinic.com.gr