Eye Diseases and Treatment

Anophthalmos - Loss of one eye

Due to various causes such as injury, infection or diseases one can lose an eye. If a patient is diagnosed with a tumor inside the eye or has a painful blind eye due to some incurable condition, the eye may have to be removed. Very rarely a child is born with an eye missing. When surgery is performed to remove a damaged eye the operation is called enucleation. The space resulting from removal of the eye needs to be filled with an implant to ensure adequate and symmetric growth of the bones of the face. On top of that a prosthetic eye is placed to restore normal appearance.

Implants

Implants can be made from several different materials. Common materials currently used include:

  • Hydroxyapatite, a calcium phosphate hydroxide compound which is derived from marine coral
  • Porous Polyethylene

Both these are porous and allow blood vessels to grow around and into them, so that the implant essentially becomes part of the eye socket.

  • Silicone
  • Medical Grade Acrylic
  • Grafts of fat from elsewhere in the body

Astigmatism

When the front part of the eye, cornea, is not entirely spherical and has different curves in different areas, the condition is known as astigmatism. In this condition the rays of light entering the eye are bent unequally, bringing them to a focus at different points within the eye and causing blurred, distorted images, both for far and near.

Astigmatism can be found either alone, or along with myopia or hyperopia. It can be treated with laser eye surgery.

Blepharitis

Persistent inflammation of the eyelids giving rise to symptoms like watering, irritation, itching, and occasionally a red eye.

Predisposing Factors:

  • Individuals with oily skin
  • Dandruff or
  • Dry eyes

It can begin in early childhood or develop later in life and continue as a chronic condition.

Blepharitis occurs in two forms:

  • Anterior blepharitis affects the outside front of the eyelid, where the eyelashes are attached. The two most common causes of anterior blepharitis are bacteria (Staphylococcus) and scalp dandruff.
  • Posterior blepharitis affects the inner eyelid (the moist part that makes contact with the eye) and is caused by problems with the oil (meibomian) glands in this part of the eyelid. Two skin disorders can cause this form of blepharitis: acne rosacea, which leads to red and inflamed skin, and scalp dandruff (seborrheic dermatitis).

Complications From Blepharitis include:

Stye: A red tender bump on the eyelid that is caused by an acute infection of the oil glands of the eyelid. Chalazion: This condition can follow the development of a stye. It is a usually painless firm lump caused by inflammation of the oil glands of the eyelid.

Chalazion can be painful and red if there is also an infection.

Problems with the tear film: Abnormal or decreased oil secretions that are part of the tear film can result in excess tearing or dry eye. Because tears are necessary to keep the cornea healthy, tear film problems can make people more at risk for corneal infections.

Treatment

Treatment for both forms of blepharitis involves keeping the lids clean and free of crusts. Warm compresses should be applied to the lid to loosen the crusts, followed by a light scrubbing of the eyelid with a cotton swab and a mixture of water and baby shampoo. Because blepharitis rarely goes away completely, most patients must maintain an eyelid hygiene routine for life. If the blepharitis is severe, an eye care professional may also prescribe antibiotics or steroid eye drops.

When scalp dandruff is present, a dandruff shampoo for the hair is recommended as well. In addition to the warm compresses, patients with posterior blepharitis will need to massage their eyelids to clean the oil accumulated in the glands. Patients who also have acne rosacea should have that condition treated at the same time.

Additional medications might be needed in some cases like:

  • Artificial tears may be used to relieve symptoms of dry eye.
  • Steroid eye drops may be used short-term to decrease inflammation.
  • Antibiotic ointment may be used to decrease the bacterial content of the eyelids.
  • Antibiotic tablets may be used to decrease the oil production from the meibomian glands.

Blocked Tear Ducts

Tear Film is the source of both nourishment and protection to the front surface of the eye. Tears are produced in the Lacrimal Glands and are spread across the surface of the eye by the wiper like action of the blinking eyelids. Tear Film is constantly renewed and old tears drained away through a series of channels starting in the inner corner of the eye called The Canaliculi, Tear Sac and Nasolacrimal Duct (Tear Duct) into the nose.

10-15 percent of babies are born with blocked tear ducts resulting in watering and mucoid discharge in the eye. Since this condition can resolve spontaneously in most children, daily massage over tear duct in the recommended fashion is the first line of treatment. If it doesn't get better by 8-10 months of age a small procedure called TEAR DUCT PROBING may be required to open it.

Tear Duct blockage in adults results most commonly following infection. It is generally progressive and patients become symptomatic only when the obstruction is complete. In most cases it has to be treated by creating a bypass channel to the block in an operation called Dacryocystorhinostomy (DCR).

Cataracts

Cataracts are the clouding of the normal crystalline lens of our eye. Most often they are a part of the ageing process of the eye (Senile) and do not signify any disease. Cataracts cause a partial or total decrease in vision but this loss is totally reversible. Recent advances in technology as well as micro-surgical techniques give remarkable results in terms of recovery of vision as well as restoration of quality of life. THE MOST EFFECTIVE TREATMENT FOR CATARACTS IS SURGERY. The timing for surgery is not fixed but when the reduced vision starts to interfere in your daily lifestyle it is time to give the situation some thought.

What are cataracts?

The Lens in our eye works like the lens of a camera focusing objects on the retina to produce a sharp image. Any process resulting in making this lens opaque causes decrease in the quality of vision. This opaque lens is called a Cataract. The process of opacification is usually gradual over the period of months to years. Clouding of the lens normally follows ageing with degradation of the protein components of the lens. Some of the other causes of cataract are:

  • Secondary cataract: Cataracts can form after surgery for other eye problems, such as glaucoma. Cataracts also can develop in people who have other health problems, such as diabetes. Cataracts are sometimes linked to steroid use.
  • Traumatic cataract: Cataracts can develop after an eye injury, sometimes years later.
  • Congenital cataract: Some babies are born with cataracts or develop them in childhood, often in both eyes. These cataracts may be so small that they do not affect vision. If they do, the lenses may need to be removed.
  • Radiation cataract: Cataracts can develop after exposure to some types of radiation.

Cataract Myths Dispelled

  • A cataract is not a layer or mass on the surface of the eye.
  • It is not caused from excessive crying or straining of the eyes.
  • Continuing daily activities and using eyes once you have cataract does not make it worse.

Symptoms

In the early stages there will be no symptoms to indicate that you have a cataract. As it progresses you might become aware of one or more of following symptoms:

  • Decreased vision at night and in other situations with poor lighting
  • Increased sensitivity to glare or bright sunlight
  • Difficulty with night driving - often due to headlights appearing too bright
  • Impaired depth perception
  • Color distortion (some people describe this phenomenon as colours appearing washed out)
  • Hazy or cloudy vision
  • Frequent changes to the prescription in your glasses
  • Better near vision for a while
  • Double vision - often occurs even with one eye closed

Diagnosis

A complete eye examination with an ophthalmologist is required for the diagnosis of cataract. It will involve checking for changed glass prescription though if cataract is advanced changing glasses will not improve your vision. The next step in the evaluation is to put drops to dilate the pupils which enable the doctor to assess the stage of the cataract as well as condition of structures at the back of the eye such as Retina, Optic Nerve and Macula. Sometimes a special test called Retinal Acuitymetry (RAM) is done to predict the amount of improvement in vision by cataract surgery. Other tests are done to check the eye pressure, curvature of cornea (keratometry) and length of the eyeball (A-Scan Biometry). The last two help in determining the power of the intraocular lens (IOL) to be placed at the time of operation.

Treatment

In early stages of cataract, change of glasses and close observation is all that is needed. Eventually as cataract progresses surgery is the only effective treatment to restore vision.

Conjunctivitis

The inside of the eyelids as well as the white of the eye (Sclera) are lined by a thin, transparent membrane called Conjunctiva. Any inflammation of this layer is called as Conjunctivitis. This is by far the most common cause of "Red Eye".

What Causes Conjunctivitis?

  • Infections: Bacterial, Viral and rarely parasitic infections are a very common cause of conjunctivitis. In the presence of infection, redness of the eye is associated with watering and excess mucoid discharge which can cause matting of eyelashes and sticking together of eyelids.
  • Allergy is another common cause of conjunctivitis. The main symptom of allergic conjunctivitis is itching but in some long standing cases only redness may persist in the absence of any itching
  • Irritants in the environment like noxious fumes, smoke etc. can act as stimuli to produce conjunctivitis. These cases are aggravated if an underlying dryness is present in the eye.

As cases of infective conjunctivitis are contagious, strict personal hygiene by the patient is important to prevent rapid spread of organisms within the family and community members. Some important things to remember are:

  • The patient should not touch the other eye
  • Tissues/ disposable napkins used to wipe the discharge from the eye should be promptly discarded.
  • If cloth is used, then care should be taken to wash it separately
  • Patient should avoid touching commonly shared things like remote control, phone etc.
  • Eye drops should be instilled regularly as advised and with total cleanliness.

Other causes of red eyes:

Though conjunctivitis mostly runs a mild course and responds to treatment with eye drops red eye can be associated with more critical conditions which can result in permanent reduction of vision or even blindness. Therefore any patient with red eye having additional symptoms like pain, decreased vision and extreme sensitivity to light should get themselves checked by a competent ophthalmologist to rule out serious conditions like Glaucoma, Corneal Ulcer and Iridocyclitis (inflammation inside the eye).

Corneal Abrasion & Erosions

Corneal Abrasion

Any injury to superficial layer of cornea (epithelium) resulting in a defect is called an abrasion. The following type of trauma is likely to result in a corneal abrasion:

  • Contact Lens mishandling
  • Foreign Body
  • Fingernail injury

Since cornea has a rich supply of sensitive nerves abrasions result in severe pain and photophobia (sensitivity to light).Most abrasions heal spontaneously due to their superficial nature. Use of lubricating drops and ointment during this period adds to the comfort of the eye.

Treatment:

If the abraded area is large or if it is relatively deep, eye is patched. This helps by:

  • Giving mandatory rest to the eye
  • Avoiding constant blink movement interfering with the healing process
  • Preventing dust and other infective particles from entering the eye thereby reducing the risk of infection
  • Giving relief from disturbing symptoms of pain and photophobia

Smaller abrasions are allowed to heal without patching but an antibiotic drop and/or ointment is prescribed for those days to avoid infection. Patient is advised not to rub the eyes vigorously to void damaging the newly formed delicate epithelium.

Corneal Erosion

If a defect occurs in the corneal epithelium in the absence of any external factors it is termed as Erosion. Some patients have a tendency for repeated spontaneous corneal erosions due to faulty adhesion mechanism of the superficial layers of the cornea. The complaints associated with erosion are similar to an abrasion. Recurrent erosions frequently occur in the morning on sudden forceful eye opening upon waking. Dry Eyes are more prone to this.

Treatment:

Smaller erosions can be treated just by lubricating drops and ointment whereas sometimes a protective (bandage) contact lens can be placed in the eye to prevent eyelids rubbing on the cornea and interfering with the healing.

Recurrent erosions may require to be treated by surgical modalities like micro puncture of the epithelium and stroma underneath with a needle or excimer laser. Sometimes the damaged epithelium is removed with chemicals like alcohol and healthy epithelium is allowed to grow back.

Cystoid Macular Oedema

Cystoid macular oedema (CME) is formation of fluid filled spaces (cysts) in Macula, central portion of retina responsible for the central, sharpest vision. this accumulation of fluid results in reduced vision.

Most commonly it follows cataract surgery, where a small percentage of patients even aftr an uncomplicated surgery can suffer CME due to unknown cause. It has also been associated with Diabetes, Retinal Vein Occlusion and Uveitis (inflammation inside the eye).

Symptoms:

The most common symptoms of cystoid macula oedema is blurred or decreased central vision (cystoid macula oedema does not affect peripheral or side vision).

How can cystoid macula oedema be treated?

Signs of retinal inflammation are usually treated with anti-inflammatory medications, including cortisone-like drugs (steroid drops, tablets or local injections) or anti-inflammatory drugs. Diuretics such as Diamox may help to reduce the swelling in some cases.

If the vitreous (the clear, gel-like substance that fills the center of the eye) is believed to be the source of the problem, laser surgery might be recommended.

Another procedure called a vitrectomy can be used to suction the vitreous out of the eye and replace it with a clear solution.

A great deal of research is presently being conducted to determine the causes of cystoid macula oedema. Hopefully, this research will lead to more exact prevention and treatment measures in the near future.

Diabetic Retinopathy

Diabetes mellitus is emerging as a major public health problem in India. It is a multisystem disorder which affects the heart, kidneys, peripheral nerves and the eyes. Involvement of the retina is called diabetic retinopathy, and can lead to blindness. In patients with more than twenty years of diabetes, nearly all patients with type I diabetes (insulin-dependent) and more than 60% of those with type II diabetes (non-insulin dependent) will have some degree of retinopathy. This also depends on how well the disease has been controlled.

Sadguru Netra Chikitsalaya offers comprehensive facilities for the medical and surgical management of diabetic retinopathy.

What is diabetic retinopathy?

Diabetic retinopathy is an eye problem that can be caused by either type 1 or type 2 diabetes mellitus. Retinopathy occurs when diabetes damages the tiny blood vessels in the retina. The weakened blood vessels may leak fluid and blood.

Who are at risk for developing diabetic retinopathy?

Those with poorly controlled blood sugar levels are at a high risk of developing diabetic retinopathy. In addition, high blood pressure, high cholesterol, anemia, kidney disease and pregnancy can all place a patient at greater risk of suffering from diabetic eye disease.

How frequently should I get my eye examined?

If you have diabetes, you should get a yearly examination by your ophthalmologist. Once you develop diabetic retinopathy, your ophthalmologist may advise further investigations or treatment. A periodic follow up as advised by your ophthalmologist is mandatory. The frequency of these follow up visits is decided based on the severity of the disease.

What are the symptoms of Diabetic Retinopathy?

There may be no symptoms in the early stages, especially when the central portion of the retina is not involved. As the retinopathy progresses, you may have:

  • Blurred vision
  • Floaters, which can look like black spots, little threads, or cobwebs
  • Bleeding in the eye causing sudden loss of vision
  • Temporary or permanent loss of vision.
  • Pain is not a common feature of the disease.         

What are the types of Diabetic Retinopathy?

There are two forms of diabetic retinopathy: non-proliferative (NPDR) and proliferative (PDR). Non-proliferative diabetic retinopathy refers to the early stages of the disease, while proliferative diabetic retinopathy refers to the severe, progressive stage.

Macular edema: The fluid and exudates collect in the macula, the central part of the retina that helps us in fine central vision.

What is laser treatment? Will I regain my vision after laser treatment?

The aim of this treatment is to protect central vision. It does not restore lost vision, but it can prevent further deterioration, which is why early diabetic retinopathy diagnosis through periodic eye examination is imperative.

Laser photocoagulation involves tiny burns to seal the capillaries. This may cause small spots to appear in your field of vision after the procedure. These spots generally fade and disappear with time. Some patients may experience difficulties in dim illumination and while reading following multiple sittings of laser treatment.

How many sittings of laser treatment are required?

With the PASCAL® (Pattern Scan Laser), the entire session can be completed on sitting. It may however vary from patient to patient. The severity of diabetic retinopathy plays an important role in deciding the number of sittings required.

What are Anti VEGF agents, and what is their role in managing diabetic retinopathy?

Anti VEGF agents (Lucentis, Avastin and Macugen) are emerging as the new modality of treatment for various stages of diabetic retinopathy. These agents are injected into the eye (intravitreal injection). They are commonly used in diabetic maculopathy and proliferative diabetic retinopathy. They may also be used as an adjunct before surgery for diabetic vitreous hemorrhage and retinal detachments.

Droopy Eyelids (Ptosis)

Also known as Ptosis, it is a downward displacement of the upper eyelids and/or eyebrows. Commonest causes are developmental defects in the eyelid muscle (seen from birth), diseases of the nerve supplying the muscle (Diabetes, Trauma, Brain tumors), disorders of the junction of the nerve and muscle (Myasthenia Gravis) etc.

Severe drooping of the eyelids in childhood can cover the visual axis thereby arresting visual development of the eye leading to Lazy Eye. Ptosis of old age also obscures peripheral vision. Ptosis is also a major cosmetic blemish and makes your eyes look sleepy and tired.

Most cases of ptosis require surgical correction. Some cases like Myasthenia may be treated with medication while some are given "Ptosis Prop Glasses" if surgery cannot be done for some reason.

Ectropion

Ectropion is a medical condition in which the lower eyelid turns outwards. It is one of the notable aspects of newborns exhibiting congenital Harlequin-type ichthyosis, but ectropion can occur due to any weakening of tissue of the lower eyelid. The condition can be repaired surgically.

Causes

  • Congenital
  • Aging
  • Scarring
  • Mechanical
  • Allergic
  • Facial nerve palsy
  • Anti-cancer treatments such as erlotinib, cetuximab, and panitumumab, which block the function of EGFR (the epidermal growth factor receptor).

Entropion

Entropion is a medical condition in which the eyelid (usually the lower lid) folds inward. It is very uncomfortable, as the eyelashes constantly rub against the cornea and irritate it. Entropion is usually caused by genetic factors and very rarely it may be congenital when an extra fold of skin grows with the lower eyelid (epiblepharon). Entropion can also create secondary pain of the eye (leading to self-trauma, scarring of the eyelid, or nerve damage). The upper or lower eyelid can be involved, and one or both eyes may be affected. When entropion occurs in both eyes, this is known as "bilateral entropion." Trachoma infection may cause scarring of the inner eyelid, which may cause entropion. In human cases, this condition is most common to people over 60 years of age.

Symptons of Entropion

Symptoms of entropion include:

  • Redness and pain around the eye
  • Sensitivity to light and wind
  • Sagging skin around the eye
  • Epiphora
  • Decreased vision, especially if the cornea is damaged

Treatment

Treatment is a relatively simple surgery in which excess skin of the outer lids is removed or tendons and muscles are shortened with one or two stitches. General anesthesia is sometimes used before local anesthetics are injected into the muscles around the eye. Prognosis is excellent if surgery is performed before the cornea is damaged.

Causes

  • Congenital
  • Aging creating loose skin and stretched and loose ligaments and muscles.
  • Scarring
  • Spasm

Eyelid Skin Cancer

Skin cancer can occur on the skin of the eyelid or area surrounding the eye. Usually, the cancers appear as painless elevations or nodules. There may be ulceration of the involved area, along with bleeding, crusting and/or distortion of the normal skin structure.

What Causes Eyelid Skin Cancer?

As with all skin cancers excessive exposure to sunlight is the most important factor associated with eyelid skin cancers. They are also more common in fair skinned people. Skin cancers may be hereditary.

Types of common eyelid skin cancer:

  • Basal cell carcinoma (this type tend not to spread to distant parts of the body)
  • Squamous cell carcinoma (this type tend not to spread to distant parts of the body)
  • Sebaceous gland carcinoma (This is a more serious type of skin cancer because it may spread to other parts of the body)
  • Malignant melanoma (This is a more serious type of skin cancer because it may spread to other parts of the body)

Treatment

Complete removal of the tumour is necessary to minimize the possibility that it may recur. A pathologist will examine the tumour to make sure it has been completely removed. Once the tumour has been removed, reconstructive surgery is often necessary.

Glaucoma

Glaucoma is a group of diseases that can damage your eye's optic nerve and result in vision loss and blindness. It is one of the leading causes of blindness in Australia, affecting approximately 3% of the population.

It is more common with advancing age, and in women. Nearly half of people with glaucoma do not even know they have the disease.

While there is no cure for glaucoma, the good news is that if diagnosed early, the disease can usually be controlled with ongoing treatment (eye drops, laser and surgery) and blindness can be prevented.

Types of Glaucoma

There are two main types of glaucoma:

Open-angle Glaucoma. Also called wide-angle glaucoma, this is the most common type of glaucoma. The structures of the eye appear normal, but fluid in the eye does not flow properly through the drain of the eye, called the trabecular meshwork.

Angle-closure Glaucoma. Also called acute or chronic angle-closure or narrow-angle glaucoma, this type of glaucoma is less common but can cause a sudden buildup of pressure in the eye. Drainage may be poor because the angle between the iris and the cornea (where a drainage channel for the eye is located) is too narrow.

Symptoms of Glaucoma

For most people, there are usually few or no symptoms of glaucoma. The first sign of glaucoma is often the loss of peripheral or side vision, which can go unnoticed until late in the disease. Detecting glaucoma early is one reason you should have a complete check-up with an eye specialist every one to two years. Occasionally, intraocular pressure can rise to severe levels. In these cases, sudden eye pain, headache, blurred vision, or the appearance of halos around lights may occur.

If you have any of the following symptoms, seek immediate medical care:

  • Seeing halos around lights
  • Vision loss
  • Redness in the eye
  • Eye that looks hazy (particularly in infants)
  • Nausea or vomiting
  • Pain in the eye
  • Narrowing of vision (tunnel vision)

Herpes Simplex of the Eye

Herpes simplex is a virus that infects the skin, mucous membranes, and nerves. There are two major types of herpes simplex virus (HSV). Type I is the most common and is responsible for herpes simplex eye disease and the familiar cold sore or fever blister. Type II is responsible for sexually transmitted herpes, and it rarely causes eye disease.

An original infection with HSV Type I occurs in 90 percent of the population, usually during childhood or adolescence. The infection, sometimes only a mild sore mouth or throat, comes from close personal contact with an infected person, and it usually passes without notice.

After the original infection, the virus goes into a quiet or dormant period, living in nerve cells that supply the skin or eye. Occasionally, the virus reactivates and causes a recurrent cold sore or fever blister.

What is herpes simplex eye disease?

The most common herpes simplex eye disease caused by HSV Type I is a recurrent eye infection of the cornea, the clear front window of the eye, which can potentially threaten sight. The infection varies in duration, severity and response to treatment, depending in part on which of several different strains of HSV Type I caused the original infection.

The disease usually begins on the surface of the cornea. The eye turns red, and it is sensitive to light. For most people this will be the only episode. Unfortunately, one out of four people who have a corneal infection are likely to have a recurrence within two years. The process may go deeper into the cornea and cause permanent scarring or inflammation inside the eye. Chronic ulcers, which are sometimes very difficult to heal, may also develop on the cornea.

Herpes simplex eye disease usually occurs in only one eye and rarely spreads to the other eye. Spreading the infection to another person is unlikely. In people with poor immunity, the herpes simplex virus may infect other parts of the eye or body, such as the retina or brain, but this occurs infrequently.

It is important to remember that herpes simplex eye disease is not usually caused by HSV Type II, the sexually transmitted herpes. While possible, sexual transmission of herpes eye disease is extremely rare.

Treatment

Treatment depends on the extent of the disease. Anti-viral eye medications are commonly used and may need to be applied frequently. At times it may be necessary to scrape the surface of the cornea, to patch the eye, or to use a variety of medications. These may need to be continued for many months. Occasionally therapeutic excimer laser treatment is required and, in cases of severe scarring and vision loss, a corneal transplant may be required.

Hyperopia - Long Sightedness

Hyperopia is caused by one or a combination of the following:

  • Flat cornea
  • Short eyeball

Consequently light rays are focused behind instead of on the retina.

Long sighted people are able to see images in the distance more clearly than they can see images at close. Though most hypermetropic people are unable to see at either distance clearly without their glasses. Laser surgery corrects hyperopia by making the cornea steeper so the rays of light are refocused on the back of the eye.

There is a limit on the degree of hyperopia that can be fully corrected, approximately 6 dioptres. If you are above the level of treatment it is still worthwhile coming for a consultation. The doctors may be able to give you less dependence on glasses and contact lenses, or outline other treatment options available to you.

Injuries

Orbital trauma is a general term used to describe injuries to the bones surrounding the eye (orbit), the tissues surrounding the eye or the eye itself. The following injuries can be categorized as orbital trauma:

  • Orbital foreign body
  • Orbital penetrating injury
  • Blow-out fracture
  • Traumatic optic neuropathy

Orbital Foreign Body

Sometimes foreign objects such as metal, dust, wood and others can hit and become embedded in the eye or orbit. If your symptoms and the circumstances in which they arose are suggestive of a foreign body your ocular plastic surgeon will ask a number of questions to try to determine the type and size of the object, as well as its speed and angle at impact.

What is it? Where is it?

The surgeon will thoroughly examine the eye looking for any damage to the eye or surrounding tissues. f there is a possibility that the foreign object is deep within the eye, X-rays or a CT scan may be needed to determine its location. A CT scan will also show whether there are associated fractures and if the object has penetrated into any deeper structures, such as the brain. If the foreign body is wooden it may not be seen on X-ray or CT, and an MRI scan may be necessary.

Treatment

These tests are all necessary to determine whether the foreign body should be surgically removed. Following removal of the foreign body, antibiotics will be prescribed to avoid any infection.

Orbital Penetrating Injuries

A penetrating eye injury means an object has pierced the tissues surrounding the eye or the eye itself.

How can you tell if the eye has been penetrated?

When a facial injury involves the eye area and causes significant skin trauma, penetrating injuries to the eyelid, eye, eye muscle, bone or even the brain may not be immediately obvious. A complete eye examination is necessary to exclude injury to these structures. If the object has penetrated into the area of the brain, a neurological examination may also be necessary.

What treatment will be necessary?

Once the extent of the damage has been determined, the ocular plastic surgeon will concentrate on surgically repairing the damaged tissues.

Orbital Blow-Out Fractures

The bony, pear-shaped socket that surrounds and protects the eye is called the orbit. When an object larger than the size of the orbital entrance hits the eye but doesn't penetrate, the force can literally cause a "blow out" of part of the orbit. The bone that forms the floor of the orbit is particularly prone to this type of fracture, known as a blow-out fracture. Blow-out fractures often occur when a fist or ball, or the dashboard of a car during a motor vehicle accident, strikes the eye.

A possible complication of orbital floor fracture is that the eye may partially drop down into the maxillary sinus, which is directly beneath the orbital floor, trapping some of the muscles that move the eye.

Diagnosing orbital blow-out fracture

Warning signs of orbital blow-out fracture include bruising around the eye, double vision, protrusion of the eye and/or numbness in the cheek and upper teeth areas. The ocular plastic surgeon will examine the eye carefully whether it has been damaged. A CT scan will also be performed to assess the extent of the fracture.

Based on the complete evaluation, your ocular plastic surgeon may recommend surgery. Factors influencing the timing of surgery include persistence of double vision, enophthalmos (the eye appears shrunken in the orbit as the swelling subsides), any limitation of eye movements and the size of the fracture.

Keratoconus

Keratoconus, sometimes called conical cornea, is a condition causing poor vision and it affects many young Australians. This condition varies from extremely mild (with little or no effect on vision) to quite severe with a marked reduction in vision.

In keratoconus, the cornea becomes increasingly thin and uneven over time. So, instead of maintaining an even curve (like the side of an orange), over a period of time it starts to bulge and become uneven (more like the side of a pear).

As the condition progresses, vision deteriorates, sometimes rapidly. However, it does not cause blindness. Keratoconus usually starts to develop in the teenage years but it is sometimes only picked up when a person has a consultation for laser eye surgery later in life. The progression of keratoconus usually lasts 10-20 years before stabilizing.

How is your keratoconus treated?

The treatment for keratoconus depends on the severity of the disease.

If you have mild keratoconus you may have minor symptoms and there may be no consequence other than being unsuitable for laser eye surgery. Milder forms of keratoconus can commonly be corrected with prescription glasses.

As the keratoconus progresses, glasses are unable to correct the increasing distortion in your cornea. Hard contact lenses are commonly used, although some patients find these lenses difficult to tolerate.

Mild to moderate keratoconus can be treated by re-shaping the abnormal corneal shape with small, thin crescents of plastic, called corneal rings. Using a special laser, a circular channel is created within the cornea without touching the outside surface. Then, through a tiny incision, the corneal rings are inserted into the cornea. The corneal rings flatten the cornea and return it to a more natural shape. They are designed to stay permanently within the eye.

The progressive changes in the shape of the cornea which occur in keratoconus can be slowed or stopped by performing collagen cross-linking. This technique uses a combination of specialized eye drops and ultraviolet light to increase the stiffness of the cornea. This treatment has the dual effect of stopping further shape changes and, to a lesser extent, improving vision by stabilizing the shape of the cornea. Collagen cross-linking is only available on individual application through the TGA Special Access Scheme.

In severe cases of keratoconus, where the cornea is very thin and distorted, a corneal transplant is usually performed. This can either be a full thickness corneal transplant, or in younger patients a corneal transplant where the patient's own corneal inner lining is retained to help prevent rejection of the transplanted cornea. Although corneal transplantation is a very successful procedure, the recovery time may be prolonged (several months to years) and because of rejection issues, a transplant will typically last for only 10-15 years.

Lagophthalmos

Lagophthalmos is inability to fully close the upper eyelid with diminished ability to blink and impairment of the tear duct pumping system. Normally each blink spreads the tear film over the eye's surface, allowing a continuous layer of moisture. If the eye is not closing properly, its surface can dry out, damaging the cornea.

What causes lagophthalmos?

Various conditions can cause partial or complete paralysis the muscle controlling upper eyelid movement. Rarely, lagophthalmos is present at birth. More commonly it is associated with paralyzing conditions such as Bell's palsy or stroke. It can also occur after head trauma, head surgery, infections and tumours.

What treatments are available?

Treatment depends on how long the lagophthalmos is expected to last. In some cases it will be long-standing or permanent but often the goal is to keep the eye healthy while the condition resolves on its own.

Medical (short-term) treatment is aimed at keeping the eye moist to protect the cornea. This is done via frequent instillation of ointments or drops. Ointments tend to be more effective; however, they may cause blurry vision for a while after they are applied.

Surgical (longer term) treatment is aimed at closing the eyelids to prevent corneal dryness. Several surgical procedures can be used:

  • Lateral tarsorrhaphy is the usual method. It involves stitching the outer edges of the upper and lower eyelids together. It can limit side vision.
  • Medial tarsorrhaphy is generally used as a last resort, as it is more disfiguring than lateral tarsorrhaphy The eyelids are joined at the inner corners

Tarsorrhaphy can be temporary or permanent.

  • The lower eyelid can be elevated using a face lift or an implant
  • A light weight can be inserted into the upper eyelid, allowing it to close more easily.

Myopia - Short Sightedness

Myopia is caused by one or a combination of the following:

  • Steep cornea
  • Long eyeball
  • Powerful lens

Consequently, light rays focus in front of the retina, instead of directly on it.

Short-sighted people are able to see close up objects clearly, but objects in the distance are blurry and indistinct. People with moderate to high levels of myopia are unable to recognize things beyond arm's length without their glasses on. Laser surgery corrects myopia by making the central cornea flatter, thereby refocusing light rays onto the retina.

There are different degrees of myopia. They are classified as:

  • Low = 0 to -4
  • Moderate = -4 to -8
  • High = -8 and above

All of the above can be improved, but those in the higher range of myopia, may still need to wear a small prescription for certain activities. The laser is used to treat up to about 10 diopters of myopia.

Nystagmus

Nystagmus appears as an involuntary constant movement of the eyes. The eyes appear to 'dance', 'shake' or 'jump' around. Nystagmus usually means that there is a problem with the eyes or the brain. It may be present at birth or shortly after (congenital) or it may occur later in life (acquired).

Congenital Nystagmus

Two types are seen:

  • Nystagmus due to poor vision is noticed typically between two and four months of age. Generally, the worse the vision, the more movement of the eyes. Possible reasons why a baby may have poor vision are cataract, albinism, optic nerve abnormalities and disorders of the retina. It is important that children with nystagmus be examined by an ophthalmologist to see if the underlying cause can be treated.
  • Nystagmus due to eye muscle problems is present at birth or soon after. It occurs when the normal balance of eye movements is disrupted. People with this kind of nystagmus may turn their heads or cross their eyes to slow the nystagmus, thus improving their vision.

Acquired Nystagmus

Older children or adults may develop nystagmus for various reasons including neurological disease, head injury, inner ear disease and stroke.

Treatment of Nystagmus

Nystagmus due to poor vision does not usually improve even if the vision can be corrected. Treatment options for other types of nystagmus depend on the cause of the problem.

Paediatric Eye Problems

Paediatric Cataract

Cataract (opacification of the lens) is not only a disease of adult but it can also occur in children.

Pediatric cataracts can occur in one eye (unilateral) or both eyes (bilateral). They can be complete or partial and can be present at birth or occur sometime after birth. Peadiatric cataract requires early treatment to prevent irreversible amblyopia (lazy eye) and better prognosis.

Maternal infection, maternal malnutrition, genetic inheritance, trauma are some of the common causes of pediatric cataract.

White reflex in eye, deviation of eyes, nystagmus, unable to see objects are common complaints in peadiatric cataract.

Not all pediatric cataracts require surgery. A small, partial or paracentral cataract can be managed by observation. If the cataract is felt to be visually significant, cataract extraction and IOL implantation surgery is the only option.

Cataract surgery in children is done under general anesthesia. Cataract extraction with or without intraocular lens (IOL) implantation is a procedure of choice. IOL is not implanted below 1 year of age in bilateral cataract.

The use of aphakic glasses or contact lenses continues to be the treatment of choice for congenital cataracts in these neonates; An IOL is preferred for children over one year of age. Primary posterior capsulorrhexis with anterior vitrectomyis done to ensure the clarity of the central visual axis in children below 8 years of age to prevent 'after cataract' (collection of inflammatory cells and fibrous tissue) formation which may reduce vision. After 8 years of age if ‘after cataract’ formation occurs it can be treated surgically or by laser capsulotomy.

Postoperatively, the child will require glasses even after the IOL implantation. Occlusion therapy may be required to treat amblyopia.

Lifelong follow up of a child is necessary for changing refraction and development of glaucoma.

Squint (Strabismus)

Squint is deviation or misalignment of eyes, which not only poses cosmetic disfigurement but also impairs visual, social and psychological development in a child.

Misalignment can be intermittent ( few hours in a day ) or constant ( 24 hours ). Intermittent deviation may eventually turn constant at later stage. Deviation of one eye hampers depth perception necessary for day to day activities. Delay in alignment causes irreversible loss of vision (amblyopia).

Squint correction in optimal age not only helps in recovering the vision and binocularity but also builds self-confidence.

Eye may turn inward (esotropia ), outward (exotropia), upward (hypertropia) or downward (hypotropia).

Common symptoms are squinting constantly or in bright light, Tilt head or turn face to use their eyes together,double vision in case of acquired squint.

Squint can be corrected with Glasses, Prisms incorporated in glasses, Orthoptic Exercises, Injections – botolinium toxin, Surgery for unbalanced muscles, Surgery for the cause eg- cataract, ptosis.

Covering or patching the strong eye is often necessary to improve amblyopia.

Paediatric Glaucoma

Glaucoma is a group of diseases characterized by damage to the optic nerve that often occurs when the eye pressure is elevated and can result in severe vision loss.

Glaucoma is more common in the elderly but can develop at any age. Infants and children with glaucoma typically have different signs and symptoms than adults. The subtypes of pediatric glaucoma are based upon the age of onset congenital glaucoma occurs in Infants from the time of  birth and juvenile glaucoma occurs in children.

Most cases of pediatric glaucoma have no specific identifiable cause and are considered primary glaucoma. Secondary glaucoma is typically associated with systemic conditions (Axenfeld-Rieger syndrome, Sturge-Weber syndrome, and neurofibromatosis), medication use (steroids), trauma or previous eye surgery (cataract surgery as a child).

Enlargement of eye(buphthalmos), cloudiness of cornea, inability to open eyes in light (photophobia) watering are common complaints in congenital glaucoma. If a baby is suspected of having glaucoma, an examination under anesthesia is necessary. Juvenile glaucoma tends to develop without any obvious symptoms, similar to adult glaucoma.

Pediatric glaucoma is treated by lowering the intraocular pressure (IOP) via medical and/or surgical means. Most cases of pediatric glaucoma are treated with surgery which creates a bypass route for the aqueous out of the eye.  Nerve damage caused by raised intraocular pressure is irreversible. Control of the glaucoma often requires multiple procedures and examinations with or without  anesthesia for IOP measurement, refraction and amblyopia treatment. One to several medications may be necessary to control the IOP, even after surgery.

Paediatric glaucoma requires lifelong follow up.

Ocular Trauma

Ocular trauma is more common among children than adults.

The trauma can be caused by stone, woodenstick, bow and arrow, needle, fire cracker, chemicals. The injury can be closed or open globe.

The clinical picture may vary from mild irritation to total blind eye and any or all the ocular structures may be involved. The clinical presentation may in the form of black eye, lid tear, sclero corneal tear, hypheama/vitreous hemorrhage (blood in eye), glaucoma (raised intraocular pressure), cataract, retinal detachment, retinal edema, optic nerve damage.  Any ocular injury needs immediate referral to ophthalmologist. The fellow eye can be affected even if it has no impact of trauma (sympatheticophthalmitis).In children it may lead to amblyopia (lazy eye) if not treated timely.The eye is managed accordingly to the clinical presentation. Visual prognosis is always guarded in case of eye trauma. Eye injuries can occur from chemicals like alkali (lime) and acids. The first aid to any chemical injury is immediate and copious eye wash with fresh tap water and presenting to the nearest ophthalmologist.

More than 90% eye injuries are preventable. So keep children away from chemicals and sharp objects. Children should be monitored while playing or lighting firecrackers.

Paediatric Corneal Diseases

The cornea can easily be damaged by a foreign object, bacteria and/or hereditary diseases. Common corneal Disorders in children are Xerophthalmia (Vitamin A deficiency), vernal keratoconjunctivitis (Allergic Eye Disease), Infective keratitis (Corneal ulcer), corneal tear, corneal foreign body, corneal opacity (Scar), and Keratoconus and Corneal dystrophies. All corneal peadiatric diseases are diagnosed and managed in children eye care centre with the help of cornea services.

Paediatric Retinal Disorders

The diagnosis, evaluation and medical and surgical treatment of all pediatric retinal diseases like retinal detachment, retinopathy of prematurity, retinitispigmentosa, congenital anomalies are done with the help of Retina Services.

Presbyopia

Presbyopia occurs in all adults after 40 years as part of the ageing process. It signifies an inability to focus on near objects. This occurs due to reduction of the accommodative power of the eye resulting in shifting away of the nearest point at which the patients can focus. To bring this point to the original place reading glasses are required.

Patients who have no glasses for far and those who have Plus power glasses for far require Bifocal or Progressive spectacles but those with near sightedness can manage to read without glasses.

Various surgical techniques have been devised to correct presbyopia some of which are:

  • Monovision
  • Conductive Keratoplasty
  • Presbyopic Lens Exchange (Prelex)

Pterygium

A pterygium is a form of scar tissue with blood vessels, which grows towards the cornea, then into the cornea. It can be a source of irritation and redness, which can flare up from time to time, it can be a cosmetic problem, and occasionally it can lead to visual distortion by altering corneal shape. In doing this it can cause irregular corneal astigmatism. For a pterygium to become bad enough to cause visual distortion is unusual, as they mostly never proceed to this level. Sometimes a pterygium can be confused with a type of low grade skin cancer, which can occur and look a little like a pterygium.

How is Pterygium treated?

Pterygium is kept under observation in majority of cases till it threatens to or invades the cornea. Supportive management is given I the form of lubricant drops, sun and wind protection and decongestant drops.

Surgical treatment involves complete removal with grafting of the bare area with patient's own conjunctival graft to prevent recurrence.

Strabismus - Squint or Turned Eye

Normally, both eyes work together to look at the same object. The brain then fuses the two pictures into a single three-dimensional image, giving us a sense of depth. Strabismus or Squint is a condition in which the eyes are misaligned and point in different directions. Whilst one eye may look straight ahead, the other eye may turn inwards (esotropia), outwards (exotropia), upwards (hypertropia), or downwards (hypotropia). Strabismus is present in about 2% of children and occurs equally between the sexes.

Why is Strabismus a problem?

When the eyes are misaligned, two different pictures are sent to the brain. In an adult this causes double vision. In a young child the brain learns to ignore the image of the misaligned eye and sees only the image from the good eye. The child then loses depth perception. Babies who have a strabismus after the age of six months should be seen by a Paediatric Ophthalmologist as there is a risk of developing amblyopia (decreased vision in one or both eyes).

What causes Strabismus?

Strabismus can be caused by a refractive error, unequal pulling of the muscles controlling eye movement or paralysis of these muscles. Children with a family history of strabismus are at increased risk of having strabismus themselves. A pediatric ophthalmologist can determine the nature of the strabismus and can treat the cause appropriately.

How is Strabismus recognized?

An obvious sign of strabismus is an eye that is not straight or does not appear to be looking in the same direction as the other eye. Sometimes children will squint one eye in bright sunlight or tilt their head to use their eyes together. Children who have had strabismus since birth or soon afterwards do not often complain of double vision. However, any child who does complain of double vision should be seen by a doctor promptly. All children should have their vision checked by a paediatric ophthalmologist at an early age, especially if there is a family history of strabismus or amblyopia.

Infants and young children often look cross-eyed. This is because they tend to have wide, flat noses with folds of skin in the inner corners of their eyes that can make the eyes appear uneven. This appearance of strabismus goes away as the child grows. However, a child will not outgrow a real strabismus. An ophthalmologist can tell the difference between true and false strabismus.

Treatment for Strabismus

Treatment for strabismus works to preserve vision, straighten the eyes, and restore binocular vision. These treatments are only to be prescribed by a paediatric ophthalmologist who, after examining the child, can recommend appropriate treatment and monitor progress.

Glasses: When the strabismus is caused by a refractive error wearing glasses to normalise vision may completely straighten the eyes, or at least make an improvement to eye position.

Occlusion/Patching: If the child has a strabismus with amblyopia he or she can be forced to use (and thus strengthen) the weaker eye by covering the good eye with a patch. Patching should be started as early as possible and continued for as long as your doctor recommends. After about the age of 8 it is generally too late to use patching treatment as vision is fully developed. Patching does not cosmetically straighten the eyes.

Surgery: An operation on the muscles that control eye movement is often necessary to make the eye appear straight. Before considering an operation the child is treated with glasses (if necessary) and patching to give the best possible vision. The child will need further visits to the ophthalmologist after the operation to check progress and continue treatment.

Tumours of the Eye

A wide variety of tumours (masses) are encountered in the orbit. They can arise from orbital structures like bone, muscles, soft tissues, blood vessels and nerves or from the eyeball itself. They can also invade orbit from surrounding areas like nose, sinuses, and brain. They are seen in all ages and sexes and are mostly benign.

How are orbital tumours diagnosed?

Displacement of the eyeball forward should arouse suspicion of a mass behind it. Other symptoms to watch out for are: Pain, Loss of Vision, Double Vision, Restriction of Eye Movements and a mass which is seen or felt. In many instances additional tests like CT Scan or MRI is required to confirm the diagnosis.

Are there any other causes of a bulging eye?

The commonest cause of a bulging eye in adults is Thyroid Related Eye Disease. In this a increase in the bulk of fat behind the eye as well as increase in the size of eye muscles causes the bulging.

The commonest cause of a bulging eye in children, on the other hand, is Orbital Cellulitis, an infective condition of orbit most commonly following spread of infection from surrounding sinuses.

Tumours in children

Tumours in children are usually the result of developmental abnormalities. The most common types of benign tumours in children are:

  • Dermoids: cysts in the lining of the bone
  • Haemangiomas: tumours of the blood vessels

Malignant tumours are unusual in children but any rapidly growing mass is a cause for concern.

Tumours in adults

Benign tumours in adults are:

  • Haemangioma: blood vessel tumour
  • Lymphangioma: lymphatic vessel tumour
  • Arteriovenous malformation: a tangled mass of arteries and veins
  • Schwannoma: nerve cell tumour
  • Lipoma: fatty tumour
  • Mucocele: tumour in the sinuses

Of these tumours, the most common are the blood vessel tumours.

The most common malignant orbital tumours in adults are lymphomas (lymph gland cancers). These are often confined to the orbit and do not spread to other parts of the body. Cancers from other organs, such as the breast and prostate gland, can also spread to the orbit. Other malignancies arising from the tissues surrounding the orbit are less common.

Treatment of orbital tumours

Surgery, radiotherapy or other treatment may be undertaken, depending on the type of tumour.

Retinal Detachment

What does retinal detachment mean?

The retina is the light-sensitive layer of tissue that lines the inside of the eye and sends visual messages through the optic nerve to the brain. When the retina detaches, it is lifted or pulled from its normal position. If not promptly treated, retinal detachment can cause permanent vision loss.

Who is at risk for retinal detachment?

A retinal detachment can occur at any age, but it is more common in people over 40 years. It affects men more than women.

A retinal detachment is also more likely to occur in people who:

  • Are extremely nearsighted (high myopes)
  • Have had a retinal detachment in the other eye
  • Have a family history of retinal detachment
  • Following cataract surgery, there is a 1% to 2% chance of developing a retinal detachment.
  • Have other eye diseases or disorders, such as retinoschisis, uveitis, degenerative myopia, or lattice degeneration
  • Have had an eye injury

What are the alarming symptoms of retinal tear and detachment?

  • Floaters which are little "cobwebs" or specks that floats about in your field of vision
  • Light flashes in the eye
  • Sudden blurry vision
  • An area of dark vision, like a curtain or a veil coming from above or below or from the sides
  • Floaters are a common symptom in otherwise normal individuals. However if these are accompanied by persistent flashes, they could be symptoms of a retinal tear or detachment

What are retinal holes / tears?

Holes are small circular defects in the retina. Tears are due to a flap of retina being pulled off as the vitreous shrinks.

What do you mean by laser and cryo therapy?

Laser therapy (Diathermy): Laser is a beam of light that is converted to heat when it hits the retina. This welds the retina to the underlying choroid.

Cryo treatment: Cryotherapy refers to a cold probe that freezes the tissue around the tear causing the retina and choroid to stick together.

 

Vitrectomy

The vitreous is removed, therefore the name “Vitrectomy”. The lack of vitreous does not affect the functioning of the eye.

Sadguru Netra Chikitsalaya has the latest and the most sophisticated surgical equipment’s. Micro incision and sutureless (23/25 gauge) vitrectomy (MIVS) is performed using the CONSTELLATION® machine. The advantages of this surgery are the absence of stitches in the eye; hence the post-operative recovery is faster.

The surgeries performed in our department are as follows:

  • Scleral Buckling
  • Vitrectomy for retinal detachments, epiretinal membrane, macular hole,vitreomacular traction, vitreous hemorrhage, parasitic cysts, dislocated nucleus, dislocated intra ocular lens
  • Vitrectomy for diabetic retinal detachment
  • Scleral fixated IOLs
  • Surgery for trauma-related conditions
  • Sub retinal surgery
  • Surgery for intra ocular infections
  • Pneumoretinopexy