Ophthalmologic surgery is a surgical procedure performed on the eye or any part of the eye.
Surgery on the eye is routinely performed to repair retinal defects, remove cataracts or cancer, or to repair eye muscles. The most common purpose of ophthalmologic surgery is to restore or improve vision.
Patients from the very young to very old have ocular conditions that warrant eye surgery. Two of the most common procedures are phacoemulsification for cataracts and elective refractive surgeries.
Cataract surgery is the most common ophthalmic procedure. More than 1.5 million cataract surgeries are performed in the United States each year. The National Eye Institute (NEI) recently reported that more than half of all United States residents age 65 and older have a cataract.
Elective refractive surgeries, especially laser in-situ keratomileusis (LASIK) , attract younger patients in their thirties and forties. Recently, the American Academy of Ophthalmology (AAO) estimated that 95% of the 1.8 million refractive surgery procedures performed in a year were LASIK.
The surgeon, operating room nurses, and an anesthesiologist are present for ophthalmologic surgery. For many eye surgeries, only a local anesthetic is used, and the patient is awake but relaxed. The patient's eye area is scrubbed prior to surgery, and sterile drapes are placed over the shoulders and head. Heart rate and blood pressure are monitored throughout the procedure. The patient is required to lie still and for some surgery, especially refractive surgery, he or she is asked to focus on the light of the operating microscope. A speculum is placed in the eye to hold it open throughout surgery.
Common ophthalmologic surgery tools include scalpels, blades, forceps, speculums, and scissors. Many ophthalmologic surgeries now use lasers, which decrease the operating time as well as recovery time.
Surgeries requiring suturing can take as long as two to three hours. These intricate surgeries sometimes require the skill of a corneal or vitreo-retinal specialist, and require the patient to be put under general anesthesia.
Refractive surgeries use an excimer laser to reshape the cornea. The surgeon creates a flap of tissue across the cornea with an instrument called a microkeratome, ablates the cornea for about 30 seconds, and then replaces the flap. The laser allows this surgery to take only minutes, without the use of stitches.
Trabeculectomy surgery uses a laser to open the drainage canals or make an opening in the iris to increase outflow of aqueous humor. The purpose is to lower intraocular pressure in the treatment of glaucoma.
Laser photocoagulation is used to treat some forms of wet age-related macular degeneration. The procedure stops leakage of abnormal blood vessels by burning them to slow the progress of the disease.
Patients complaining of any ocular problem that requires surgery will receive a similar initial examination. A complete patient history is taken, including the chief complaint. The patient needs to disclose any allergies, medication usage, family eye and medical histories, and vocational and recreational vision requirements.
The diagnostic exam should include measurement of visual acuity under both low and high illumination, biomicroscopy with pupillary dilation, stereoscopic fundus examination with pupillary dilation, assessment of ocular motility and binocularity, visual fields, evaluation of pupillary responses to rule out afferent pupillary defects, refraction, and measurement of intraocular pressure (IOP).
Other examination procedures include corneal mapping, a keratometer reading to determine the curvature of the central part of the cornea, and a slit lamp exam to determine any damage to the cornea and evidence of glaucoma and cataracts. A fundus exam also will be performed to check for retinal holes, and macular degeneration and disease.
The patient's overall health must also be considered. Poor general health will affect the ophthalmologic surgery outcome. Surgeons may request a complete physical examination , in addition to the eye examination, prior to surgery.
Patients having ophthalmologic surgery usually must stop taking aspirin , or aspirin-like products, 10 days before surgery unless directed otherwise by the surgeon. Patients taking blood thinners also must check with their physician to find out when they should stop taking the medication before surgery. A number of pain relievers may affect outcomes, making it important for patients to disclose all medication. The patient might have to ask about alternative medications if the surgeon requires that he or she stops taking the usual regime before the procedure. Some prescription medicines have been known to cause postsurgical scarring or flecks under the corneal flap after LASIK.
To reduce the chance of infection, the surgeon may request that the patient begin using antibiotic drops before surgery. Depending on the procedure, the patient may also be advised to discontinue contact lens wear and stop using creams, lotions, make-up, or perfume. Patients may also be asked to scrub their eyelashes for a period of time to remove any debris.
Patients are advised not to drink alcoholic beverages at least 24 hours before and after the ophthalmic procedure.
Patients must usually avoid eating or drinking anything after midnight on the day before the surgery; however, some patients may be allowed to have clear liquids in the morning. It is important for patients to ask their physician for a list of foods and medications permitted on the morning of surgery. Some patients may take morning medications (with physician approval) with the exclusion of diuretics , insulin, or diabetes pills. Patients are advised to dress comfortably for the surgery, and wear button-down shirts that will not have to pass over the head.
Presurgical tests sometimes are administered when the patient arrives for surgery. For refractive surgeries, this ensures the laser is set for the correct refractive error. Before cataract surgery, measurements help determine the refractive power of the intraocular lens (IOL). Other tests such as a chest x ray, blood work, or urinalysis may also be requested depending on the patient's overall health.
Most ophthalmic surgeries are done on an outpatient basis, and patients must arrange for someone to take them home after the procedure.
Before surgery, doctors will review the presurgical tests and instill any dilating eye drops, antibiotic drops, and a corticosteriod or nonsteroidal anti-inflammatory drops as needed. Anesthetic eye drops also will be administered. Many ophthalmologic surgeries are performed under a local anesthetic, and patients remain awake but in a relaxed state.
After surgery, the patient is monitored in a recovery area. For most outpatient procedures, the patient is advised to rest for at least 24 hours until he or she returns to the surgeon's office for follow-up care. Over-the-counter medications are usually advised for pain relief, but patients should check with their doctor to see what is recommended. Some pain relievers interfere with surgical outcomes. Patients may also use ice packs to help ease pain.
Some patients may experience slight drooping or bruising of the eye. This condition improves as the eye heals. Severe pain, nausea, or vomiting should be reported to the surgeon immediately.
After surgery, patients may be advised not to stoop, lift heavy objects, exercise vigorously, or swim. Patients may also be required to wear an eye shield while sleeping, and sunglasses or some type of protective lens during the day to avoid injury. Wearing make-up may be prohibited for weeks after surgery. The patient may be restricted from driving and air travel.
Patients usually have their first postoperative visit the day after the eye surgery. Subsequent exams are commonly scheduled at one, three, and six to eight weeks following surgery. This schedule depends on the patient's healing, and any complications he or she might experience.
Some patients will be required to instill eye drops for a number of weeks after surgery to prevent infection, pain, and to lessen inflammation. Eye drops also are used to lower intraocular pressure. In some cases, correct eye drop usage is critical to a successful surgery outcome.
Complications may occur during any surgery. Ophthalmologic surgery, however, is usually very safe.
Some risks include:
- Undercorrection or overcorrection in refractive surgery. Undercorrected refractive surgery patients usually can be treated with an enhancement, but overcorrected patients will need to use eyeglasses or contact lenses.
- Debilitating symptoms. These include glare, halos, double vision, and poor nighttime vision. Some patients may also lose contrast sensitivity. These symptoms may be temporary or permanent.
- Dry eye. Some patients are treated with artificial tears or punctal plugs.
- Retinal detachment. The retina can become detached by the surgery if this part of the eye has any weakness when the procedure is performed. This may not occur for weeks or months.
- Endophthalmitis. An infection in the eyeball is a complication that is less common today because of newer surgery techniques and antibiotics .
Other serious complications that may occur are blindness, glaucoma, or hemorrhage.
Normal results include restored or improved vision, and a much improved quality of life. Specific improvements depend on the type of ophthalmologic surgery performed, and the type of ocular ailment being treated.
Morbidity and mortality rates
Death from ophthalmologic surgery is rare. However, complications can still arise from the use of general anesthesia. With most ophthalmic surgeries requiring only local anesthetic, that risk has been widely eliminated.
Blindness, which was sometimes caused by serious infection, has also been reduced because of more effective antibiotics.
Some medications can be used to treat certain ophthalmic conditions. For example, surgery for glaucoma is performed only in patients who do not respond to medication. Patients with myopia (nearsightedness), hyperopia (farsightedness), or presbyopia, can wear contact lenses or eyeglasses instead of having refractive surgery to improve their refractive errors.
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American Optometric Association. 243 North Lindbergh Blvd., St. Louis, MO 63141. (314) 991-4100. <www.aoanet.org>.
American Society of Cataract and Refractive Surgery. 4000 Legato Road, Suite 850, Fairfax, VA 22033-4055. (703) 591-2220. E-mail: firstname.lastname@example.org; <www.ascrs.org>.
National Eye Institute. 2020 Vision Place Bethesda, MD 20892-3655. (301) 496-5248. <www.nei.nih.gov>.
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WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Ophthalmologists and optometrists may detect ophthalmic problems; however, only an ophthalmologist can perform surgery. An ophthalmologist has received specialized training in diseases of the eye and their surgical treatment. Some ophthalmologists further specialize in certain areas of the eye, such as corneal or vitreo-retinal specialists. Depending on the severity of the disease, the general ophthalmologist may refer the patient to a specialist for treatment.
An anesthesiologist may be on hand during surgery to administer the local anesthetic. Surgical nurses will assist the ophthalmologist in the operating room, and assist the patient preoperatively and postoperatively.
Most ophthalmic surgery is performed on an outpatient basis. Ambulatory surgery centers designed for ophthalmologic surgery are commonly used. Surgery may also be performed in hospital operating rooms designed for outpatient surgeries.
QUESTIONS TO ASK THE DOCTOR
- If both eyes are diseased, will they be treated simultaneously?
- Will the eyes need to rest after surgery? Will protective lenses be required following the procedure?
- Will eyeglasses be needed eyeglasses?
- How many times has the surgeon performed this specific procedure?
- Should the physician be contacted if pain develops after the surgery?
- When can normal activities be resumed? What about driving?
Bekker, Mary. "Ophthalmologic Surgery." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. 2004. Encyclopedia.com. (July 25, 2016). http://www.encyclopedia.com/doc/1G2-3406200322.html
Bekker, Mary. "Ophthalmologic Surgery." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. 2004. Retrieved July 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3406200322.html
Scleral buckling is a surgical procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of a retinal tear to push the sclera toward the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. It also prevents fluid leakage which could cause further retinal detachment.
Scleral buckling is used to reattach the retina if the break is very large or if the tear is in one location. It is also used to seal breaks in the retina.
Retinal detachment occurs in 25,000 Americans each year. Patients suffering from retinal detachments are commonly nearsighted, have had eye surgery, experienced ocular trauma, or have a family history of retinal detachments. Retinal detachments also are common after cataract removal. White males are at a greater risk, as are people who are middle-aged or older. Patients who already have had a retinal detachment also have a greater chance for another detachment.
Some conditions, such as diabetes or Coats' disease in children, make people more susceptible to retinal detachments.
Scleral buckling is performed in an operating room under general or local anesthetic. Immediately before the procedure, patients are given eye drops to dilate the pupil to allow better access to the eye. The patient is given a local anesthetic. After the eye is numbed, the surgeon cuts the eye membrane, exposing the sclera. If bleeding or inflammation blocks the surgeon's view of the retinal detachment or hole, he or she may perform a vitrectomy before scleral buckling.
Vitrectomy is necessary only in cases in which the surgeon's view of the damage is hindered. The surgeon makes two incisions into the sclera, one for a light probe and the other for instruments to cut and aspirate. The surgeon uses a tiny, guillotine-like device to remove the vitreous, which he then replaces with saline. After the removal, the surgeon may inject air or gas to hold the retina in place.
After, the surgeon is able to see the retina, he or she will perform one of two companion procedures.
- Laser photocoagulation. The laser is used when the retinal tear is small or the detachment is slight. The surgeon points the laser beam through a contact lens to burn the area around the retinal tear. The laser creates scar tissue that will seal the hole and prevent leakage. It requires no incision.
- Cryopexy. Using a freezing probe, the surgeon freezes the outer surface of the eye over the tear or detachment. The inflammation caused by the freezing leads to scar formation that seals the hole and prevents leakage. Cryopexy is used for larger holes or detachments, and for areas that may be hard to reach with a laser.
After the surgeon has performed laser photocoagulation or cryopexy, he or she indents the affected area of the sclera with silicone. The silicone, either in the form of a sponge or buckle, closes the tear and reduces the eyeball's circumference. This reduction prevents further pulling and separation of the vitreous. Depending on the severity of the detachment or hole, a buckle may be placed around the entire eyeball.
When the buckle is in place, the surgeon may drain subretinal fluid that might interfere with the retina's reattachment. After the fluid is drained, the surgeon will suture the buckle into place and then cover it with the conjunctiva. The surgeon then inserts an antibiotic (drops or ointment) into the affected eye and patches it.
For less severe detachments, the surgeon may choose a temporary buckle that will be removed later. Usually, however, the buckle remains in place for the patient's lifetime. It does not interfere with vision. Scleral buckles in infants, however, will need to be removed as the eyeball grows.
Retinal detachment is considered an emergency situation. In the case of an acute onset detachment, the longer it takes to repair the detachment, the less chance of successful reattachment. Usually the patient sees floating spots and experiences peripheral visual field loss. Patients commonly describe the vision loss as having someone pull a shade over their eyes. In extreme cases, patients may lose vision completely.
An ophthalmologist or optometrist will take a complete medical history, including family history of retinal detachment and any recent ocular trauma. In addition to performing a general eye exam, which includes a slit lamp examination, examination of the macula and lens evaluation, physicians may perform the following tests to determine the extent of retinal detachment:
- 3-mirror contact lens/panfunduscopic
- scleral indentation
Small breaks in the retina will not require surgery, but patients with acute onset detachment require reattachment in 24–48 hours. Chronic retinal detachments should be repaired within one week.
Because scleral buckling is usually an emergency procedure, there is no long-term preparation. Patients are required to fast for at least six hours before surgery.
Immediately following the surgery, patients will need help with meals and walking. Some patients must remain hospitalized for several days. Many scleral buckling procedures however are performed on an outpatient basis.
After release from the hospital, patients should avoid heavy lifting or strenuous exercise that could increase intraocular pressure. Rapid eye movements should also be avoided; reading may be prohibited until the surgeon gives permission. Sunglasses should be worn during the day and an eye patch at night. Pain and a scratchy sensation as well as redness in the eye also may occur after surgery. Ice packs may be applied if the conjunctiva swells. Patients may take pain medication, but should check with their physician before taking any over-the-counter medication.
Excessive pain, swelling, bleeding, discharge from the eye or decreased vision is not normal, and should immediately be reported to the physician.
If a vitrectomy was performed in conjunction with the scleral buckling, patients must sleep with their heads elevated. They also must avoid air travel until the air bubble is absorbed.
After scleral buckling, patients will use dilating, antibiotic or corticosteroid eye drops for up to six weeks to decrease inflammation and the chance of infection. Best visual acuity cannot be determined for at least six to eight weeks after surgery. Driving may be prohibited or restricted while vision stabilizes. At the six-to-eight week postoperative visit, physicians determine if the patient needs corrective lenses or stronger prescription lenses. Full vision restoration depends on the location and severity of the detachment.
Complications are rare but may be severe. In some instances, patients lose sight in the affected eye or lose the entire eye.
Scar tissue, even pre-existing scar tissue, may interfere with the retina's reattachment and the scleral buckling procedure may have to be repeated. Scarring, along with infection, is the most common complication.
Other possible but infrequent complications include:
- bleeding under the retina
- cataract formation
- double vision
- vitreous hemorrhage
Patients may also become more nearsighted after the procedure. In some instances, although the retina reattaches, vision is not restored.
The National Institutes of Health reports that scleral buckling has a success rate of 85–90%. Restored vision depends largely on the location and extent of the detachment, and the length of time before the detachment was repaired. Patients with a peripheral detachment have a quicker recovery then those patients whose detachment was located in the macula. The longer the patient waits to have the detachment repaired, the worse the prognosis.
Morbidity and mortality rates
The danger of mortality and loss of vision depends on the cause of the retinal detachment. Patients with Marfan syndrome, pre-eclampsia and diabetes, for example, are more at risk during the scleral buckling procedure than a patient in relatively good health. The risk of surgery also rises with the use of general anesthesia. Scleral buckling, however, is considered a safe, successful procedure.
Severe infections that are left untreated can cause vision loss, but following the prescribed regimen of eye drops and follow-up treatment by the physician greatly minimizes this risk.
Vitrectomy is sometimes performed alone to treat retinal detachments. Laser photocoagulation and cryopexy also may be used to treat less serious tears. The more common alternative, however, is pneumatic retinopexy, which is used when the tear is located in the upper portion of the eye. The surgeon uses cryopexy to freeze the area around the tear, then removes a small amount of fluid. When the fluid is drained and the eye softened, the surgeon injects a gas bubble into the vitreous cavity. As the gas bubble expands, it seals the retinal tear by pushing the retina against the choroid. Eventually, the bubble will be absorbed.
The patient is required to remain in a certain position for at least a few days after surgery while the bubble helps seal the hole. Pneumatic retinopexy also is not as successful as scleral buckling. Complications include recurrent retinal detachments and the chance of gas getting under the retina.
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WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Scleral buckling can be performed by a general ophthalmologist, an M.D. who specializes in treatment of the eye. Even more specialized ophthalmologists, vitreo-retinal surgeons who specialize in diseases of the retina, may be called upon for serious cases.
The surgery is usually performed in hospital settings. Because of the delicacy of the procedure, sometimes an overnight hospital stay is required. Less severe retinal detachments can be treated on an outpatient basis at surgery centers.
QUESTIONS TO ASK THE DOCTOR
- How many scleral buckling procedures have you performed?
- Could other treatments be an option?
- Will I have to stay in the hospital?
- Will my sight be completely restored?
- What is the probability of having another retinal detachment in the same eye?
- Am I likely to have a retinal detachment in my unaffected eye?
Bekker, Mary. "Scleral Buckling." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. 2004. Encyclopedia.com. (July 25, 2016). http://www.encyclopedia.com/doc/1G2-3406200399.html
Bekker, Mary. "Scleral Buckling." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. 2004. Retrieved July 25, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3406200399.html