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Modern eye surgery

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Glaucoma

Glaucoma is a group of diseases characterised by a common trait of chronic progressive damage to the optic nerve, which manifests itself in changes of the optic nerve disc, accompanied by scotomas. The most frequent type of glaucoma is asymptomatic primary open-angle glaucoma, diagnosed in patients over 40 years old, which leads to irreversible blindness. The most important risk factors for this type of glaucoma include age, family history of glaucoma, and myopia. Primary closed-angle glaucoma is much less frequent. It is predominantly found in hyperopic eyes, with narrow filtration angle, in which this angle may be closed temporarily. If this happens, the intraocular pressure increases causing acute glaucoma attack, with such predominant symptoms as: acute eye pain and headache. A common type of glaucoma is secondary glaucoma concomitant with other ocular diseases, such as inflammations, injuries or diabetes.

 

 

 

Diagnostics

Diagnostics includes four basic examinations: optical nerve disc assessment, visual field test, intraocular pressure measurement, and filtration angle examination. Optic nerve disc assessment is part of basic ophthalmic examination and should be performed through stereoscopic observation with the use of a slit lamp and Volk lens. Another comparable and precise method of detecting scotomas is computerised perimetry.

 

There are various methods of measuring intraocular pressure. The most common one is the use of Goldmann applanation tonometer, which is the most comfortable application of a non-contact tonometer for the patient. We use Zeiss or Goldman goniometers to examine the filtration angle. It allows us to asses the risk of angle closure and detect any anomalies in its vicinity. Basic examinations may be supported by additional techniques to facilitate early glaucoma diagnosis. One of them is confocal scanning laser ophthalmoscopy of the optic nerve (HRT II). The device takes 32 photographs of the optic nerve at various depths. This provides a very precise measurement of a range of disc parameters, which can then be compared with normal values. Such comparisons can be used to detect even the smallest changes at subsequent tests. An important additional examination is corneal thickness measurement, which is a method of determining the actual intraocular pressure needed to assess the risk of glaucoma progression more precisely.

 

 

Healing


The objective of glaucoma treatment is the reduction of the intraocular pressure to such a level at which the progress of anomalies is stopped. Typically, it should remain below 18.0 mmHg. This can be achieved by administration of correct drops, which reduce production of aqueous humour or increase its outflow. If, despite administration of two different glaucoma medications, intraocular pressure continues to be above normal, and the disease progresses, it is worth considering a laser treatment or glaucoma surgery.

 

Laser trabeculoplasty is a procedure during which focal photocoagulation of trabeculation is performed, which increases outflow of aqueous humour from the eye. Advantages of this procedure include easy performance, low risk of complications and patient comfort – because it takes a short time and is done as an outpatient procedure. The main disadvantages are the fact that its effects are limited to eyes with a relatively small pressure increase, and the positive result is impermanent.

 


Trabeculotomy is the most common surgical procedure in glaucoma treatment. It is done by removing a section of trabeculation together with the Schelmm’s canal, and creating a pathway for the aqueous humour to flow between the anterior chamber and the subconjunctival area. Effectiveness of this treatment is very high, but it may cause numerous complications, including cataract. In order to reduce the risk of complications, it is possible in some cases to perform a non-penetrative procedure, that is one in which the eyeball wall is not fully open. The most frequent procedure of this type is deep sclerectomy with application of an absorbable implant (SK GEL). In the case of closed-angle glaucoma, it is necessary to perform laser iridotomy, which is done by making an opening in the iris to provide a pathway for the aqueous humour to flow from the posterior to anterior chamber. This minor procedure usually prevents further glaucoma attacks.

 

Preparation for a glaucoma procedure is similar to cataract surgery. One must remember that these procedures must be performed urgently.

 

Selective Laser Trabeculoplasty

(SLTSelective Laser Trabeculoplasty) is an advanced laser procedure, which effectively reduces intraocular pressure in about 80% of glaucoma patients. SLT uses the impact of laser beam which stimulates repair processes in certain filtration angle cells – those containing melanin, a natural pigment. This means that we can impact only these required cells and leave the surrounding tissues intact. SLT improves the flow of aqueous humour in the eyeball, which in turn reduces intraocular pressure. The SLT therapy is a treatment option suitable for the majority of glaucoma patients. Because of its non-invasive nature and safety as compared to the traditional laser treatment, an SLT procedure may be performed repeatedly to achieve lower intraocular pressure. Its effects are expected to last for several years. On average, SLT reduces intraocular pressure by 25% to 35% – over at least 2 years. The highest reduction is observed during the first 6 months and may equal up to 35% to 40% of baseline. With certain individual circumstances and expected target intraocular pressure, it may be necessary, and even desired, to repeat the procedure earlier. Depending on the stage of glaucoma and intraocular pressure, it is possible to eliminate or decrease the amount of drops following an SLT procedure. In the majority of patients, intraocular pressure reduction resulting from laser therapy is observed after several weeks.

An SLT procedure may be performed in patients with:


SLT is a highly safe treatment; however, some adverse symptoms may occur, but usually temporarily and without any effect on the final result.
- The following symptoms may occur in the first few days following the procedure:


How is SLT performed?
SLT is performed as an outpatient procedure. The patient sits by a slit lamp connected to a laser, just like during a standard eye examination. Prior to the procedure, anaesthetic eye drops are administered, and then a special lens is placed on the eye surface, enabling the doctor to precisely direct the laser beam to where the aqueous humour flows out in the filtration angle. The entire procedure lasts several minutes and is painless. During the procedure, the patient may see green light or flashes. At the end, an intraocular pressure check is performed. In order to asses the result, the patient must visit an ophthalmologist within the next few days, and then report for another follow-up, about 4 to 6 weeks after the procedure.