Surgical Procedures

A cataract is a progressive clouding of the human lens inside the eye. The cataract procedure is fast, comfortable and very successful.

If you have been told that you have a cataract, there is no need to be overly concerned as you are not alone. Each year in the United States, more than 2.5 million people have cataract surgery. Thanks to advanced surgical procedures and technology at Visiomed Eye Laser Clinic, cataract surgery is not only one of the most frequently performed surgical procedures, but it is also one of the safest and most successful surgical procedures that you can have. Cataract procedures are performed on an outpatient basis and usually only require a few hours of your time from beginning to end.

 

To begin the procedure, your eye will be treated with an anesthetic so that you will feel little, if any discomfort. A small incision will be made and a microscopic instrument will be passed through it. Using ultrasound from the tip of the microscopic instrument, the ophthalmologist will be able to gently break the cataract into pieces small enough to be washed away, drawn through the instrument and removed from the eye. Once your cataract has been removed, it can now be replaced by a new permanent Intraocular Lens Implant. The new lens is readily inserted and placed in position through the same incision at the outer edge of the cornea through which the cataract was removed.

After the procedure, you will rest for a short time at the clinic before going home. Usually we will arrange a visit to examine your eye within 24 hours after of your procedure. If necessary, your cataract surgeon may prescribe some eye drops for you to use and ask you to wear a protective shield, mainly at night to help you remember not to rub your eye. Although each patient heals a slight bit differently, most patients see well enough to return to their routine activities within a day or so after surgery.

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Restoring Vision

Below, we have detailed the major steps of the cataract procedure. This type of procedure is considered state-of-the-art for cataract surgery today. The procedure demonstrates basic principles only; however, eye surgeons use many variations of the general theme.

Our cataract FAQ may give you more insight.

		Cross-section of the eye:A cataract is a clouding of the lens of your eye that causes blurred or distorted vision. If left untreated it can cause blindness.
		Step 1 The pupil is dilated and the lens (behind the iris) is now exposed. A 1.8 – 2.3mm incision is made into the cornea. Due to the small size of the incision, the opening is generally self-sealing.
		Step 2A circular tear is made into the lens. The cataract is now exposed and ready to be removed.
		Step 3Ultrasonic vibrations are used to break the cataract into smaller fragments that are then aspirated from the eye with a customized suction device.
		Step 4After the cataract has been removed, a new lens is implanted. In most cases, a foldable lens is placed into an ‘injector’ and inserted through the incision previously made.
		Step 5As the foldable lens is inserted, it will automatically expand, open up inside the lens capsule, attach and secure itself to the lens wall with specially designed hooks, resulting in……..
		…….good, clear vision! Depending on the type of intra ocular lens inserted, you might only need a pair of spectacles either for distance or near vision, or no spectacles at all!

Cataract removal

Visiomed Eye and Laser Clinic offer a wide range of cataract replacement lenses to correct cloudy vision caused by cataracts. Our ophthalmologists are able to address distance and close-up vision and/or astigmatism complications at the same time.

What eye problems does cataract surgery address?

The Visiomed Eye and Laser Clinic cataract surgery procedure will address cataracts, nearsightedness, farsightedness, presbyopia and astigmatism.

What are cataracts?

The term cataract refers to a cloudy lens within the eye which is caused by proteins in the eye breaking down as we age. Most cataracts develop at 60 or 70 years of age, but other factors can influence the speed and severity of cataracts which include injury to the eye, diabetes, smoking, alcohol abuse and prolonged, direct exposure to sunlight.

As a cataract grows larger, it clouds more of your lens and distorts the light passing through. Symptoms of cataracts include impaired vision which is evident during driving, poor night vision, cloudy/blurry vision, double vision and glare/halo around lights.

In order to treat cataracts effectively the ophthalmologists at Visiomed Eye and Laser Clinic suggest regular eye examinations. If you are diagnosed with a cataract, the ophthalmologist is able to replace your lens. As cataracts are irreversible, surgery is the only proven way to get back to enjoying your family activities and all the adventures life brings without blurred, cloudy vision.

Visiomed Eye and Laser Clinic cataract treatment

Your ophthalmologist will make a small incision in your eye, through which the cataract will be removed. To remove it, your doctor will break it apart and extract it, a technique called phacoemulsification. An intraocular lens (IOL) will then be inserted through the same tiny incision into the lens capsule of your eye.

The IOL will be used to replace your cataract-affected natural lens. The lens is made of a material that is flexible, which allows the ophthalmologist to fold and insert it through the small incision.

Once the cataract is removed, and the IOL is in the proper position, light can once again travel unimpeded to the back of your eye. You will begin to notice an immediate improvement in your vision. Patients are typically able to heal very quickly with little to no discomfort as the cataract treatment procedure is performed through a small incision.

The cataract procedure comprises of six steps:

Life after Cataract surgery

At Visiomed Eye and Laser Clinic, your post-op care is very important to us. We therefore schedule visits with our ophthalmologists periodically after your treatment.

The first 24 hours after cataract surgery

• The ophthalmologist will perform a post-op check-up and you will be given a pair of protective glasses that you will need to wear for several hours after the surgery.
• Ensure you organise a driver home.
• The artificial tears provided by your doctor will help ease any irritation you may experience after the Cataract surgery.
• If you experience any irritation it is important not to rub, poke or touch your eyes.
• Follow your doctor’s instructions on using your steroid and antibiotic eye drops.
• Use this time to rest and relax.
• Do not strain your eyes through reading, computer work or watching TV.

One week after the cataract surgery

• You will experience significant improvement to your overall vision.
• You may read, use the computer and watch TV, but keep your eyes well lubricated and rest them if they feel strained.
• Be sure to keep sweat out of your eyes and avoid all lotions, creams and eye makeup for seven days.

One month after the cataract surgery

• Your eye will be close to fully healed and you will notice continued improvement to eyesight.

Three months after cataract surgery

• Typically, your Visiomed Eye and Laser Clinic ophthalmologist will request that you attend a post-op appointment between one and three months after your cataract surgery.
• In some cases, after three months, your doctor may request an additional 90-day post-op check.
• Vision stability will be realised in most patients at approximately three months.

Cataract FAQ

What is a cataract?

A cataract is a progressive clouding of the human lens inside the eye. The lens is a transparent oval structure situated just behind the iris (coloured part of the eye).

How does a cataract affect vision?

An eye with a cataract views the world as through a bathroom window. Glare becomes a problem especially in bright sunlight and during driving at night.

What causes a cataract?

The most common cause of cataracts is ageing. The lens looses transparency over a period of months to years and the patient experiences a gradual decrease in visual perception.

When is cataract surgery necessary?

Regular eye examinations by your optometrist and opthalmologist are recommended so that the health of your eyes can be monitored.

When a cataract starts interfering with your daily activities, your optomotrist will refer you to an eye specialist.

What is the recovery rate after the procedure?

Your vision should already be a pretty good the first day after the procedure. Temporarily, over the counter reading glasses may be used to cope with reading for the first few weeks. Your eye may be tested for prescription glasses about 4 to 6 weeks after the procedure if needed, by your optometrist.

What are implantable contact lenses (ICL)/Artisan

Implantable contact lenses (ICL) or Artisan surgery is one of the best alternatives to LasikHD surgery. An ICL corrects your vision much like a contact lens with the exception that it is permanent. The ICL/artisan surgery does not require regular maintenance and is undetectable to the wearer and onlookers. Thanks to the ophthalmologists at Visiomed Eye and Laser Clinic, you can now enjoy clearer vision if LasikHD or PRK surgery is not right for you.

What eye problems does ICL surgery address?

The Visiomed Eye and Laser Clinic ICL/Artisan surgery procedure will address nearsightedness, farsightedness and astigmatism.

Who are ideal ICL/Artisan candidates?

• Patients not suitable for PRK or LasikHD.
• Patients with more than 1.5 diopter astigmatism.
• Patients suffering from nearsightedness (myopia)
• Patients under the age of 40.

What is the difference between ICL/Artisan surgery and LasikHD surgery?

While LasikHD surgery is performed on the surface of your eye using a cool laser beam to permanently reshape the cornea, the Implantable Contact Lens (ICL)/Artisan procedure does not reshape your cornea. Instead, a synthetic lens is gently placed inside your eye where it functions just like a contact lens without the need to ever remove it. ICL/Artisan is designed to permanently correct your vision and the lens can be simply removed and/or replaced if necessary.

What benefits does ICL/Artisan surgery have over wearing traditional contact lenses?

• Overall better quality vision is achieved.
• Sharper, clearer and more vivid vision is evident.
• Your vision will have greater depth and dimension than what glasses or contact lenses are able to provide.
• No dryness, irritation or discomfort often associated with wearing contact lenses.
• The procedure is suitable for mild to severe nearsightedness.

What are the benefits of ICL surgery at Visiomed Eye and Laser Clinic?

• Comfort
  ICL/Artisan offers the very best in implantable contact lens technology. Made to be biocompatible with the eye and therefore not seen as a foreign object to the body.
• Protection
  The collamer material that makes up the ICL/Artisan contains a UV blocker that prevents harmful UVA and UVB rays from entering the eye. This can prevent future eye problems such as cataracts.

The ICL/artisan procedure comprises of five steps:

Life after ICL/Artisan procedure

At Visiomed Eye and Laser Clinic, your post-op care is very important to us. We therefore schedule visits with our ophthalmologists periodically after your treatment.

The first 24 hours after the ICL/Artisan procedure

• The ophthalmologist will perform a post-op check-up and you will be given a pair of protective glasses which you will need to wear for several hours after the surgery.
• Ensure you organise a driver home.
• The artificial tears provided by your doctor will help ease any irritation you may experience after the ICL surgery.
• If you experience any irritation it is important not to rub, poke or touch your eyes.
• Follow your doctor’s instructions on using your steroid and antibiotic eye drops.
• Use this time to rest and relax.
• Do not strain your eyes through reading, computer work or watching TV.

Two weeks after the ICL/Artisan procedure

• Your vision will stabilise to its full potential after two weeks with an Implanted Collamer Lens in place.
• After your initial ICL/Artisan is completed, the two-week point is typically when your ophthalmologist will complete the procedure on your other eye.

One Month after the ICL/Artisan procedure

• One month from your initial ICL/Artisan procedure at Visiomed Eye and Laser Clinic, both eyes will have undergone treatment and your body will be nearing completion of the healing process.
• Vision stabilisation is complete. Your Visiomed Eye and Laser Clinic team will perform a series of check-ups to ensure everything is progressing as expected before releasing you from care after around three months.

A few years after the ICL/Artisan procedure

• With aging, you may develop cataracts which will need to be addressed by Visiomed Eye and Laser Clinic ophthalmologists.
• The ICL/Artisan procedure causes no interference with the cataract removal procedures.
• The ICL/Artisan is built to last a lifetime but can be removed in order for cataracts to be addressed.

What is Photorefractive Keratectomy (PRK) surgery?

Similar to the LasikHD surgery, PRK surgery corrects the way light enters the cornea in order to give you clearer vision. LasikHD surgery uses a laser to prepare the cornea for treatment while during PRK surgery the tissue is gently wiped from the cornea.

PRK surgery requires a slightly longer recovery time, but results are the same as with LasikHD surgery.

Following the PRK procedure, a soft contact lens is placed on the eye to act as a bandage. This allows patients to see and function while the corneal tissue regenerates and heals beneath it during the days immediately following the PRK treatment. Vision may be blurry during this initial recovery time and you may experience brief periods of discomfort or irritation.

Prescribed anti-inflammatory and lubricating drops will minimize post-procedural discomfort and speed up the healing process. As with LasikHD surgery, the result is always clearer vision.

Thanks to our ophthalmologists’ PRK technique at Visiomed Eye and Laser Clinic, PRK can offer distinct benefits to patients who clinically do not qualify for LasikHD due to thin corneas.

What eye problems does PRK surgery address?

The Visiomed Eye and Laser Clinic PRK surgery procedure will address nearsightedness, farsightedness and astigmatism.

Who are ideal PRK surgery candidates?

• LasikHD candidates with thin corneas. Your Visiomed Eye and Laser Clinic ophthalmologist will perform a series of diagnostic tests to determine corneal thickness.
• Patients who suffer from chronic dry eye.
• Patients with extremely active lifestyles or professions.

The PRK surgery procedure comprises of four steps:

Life after PRK surgery

At Visiomed Eye and Laser Clinic, your post-op care is very important to us. We therefore schedule visits with our ophthalmologists periodically after your treatment.

The first 24 hours after PRK surgery:

• The ophthalmologist will perform a post-op check-up and you will be given a pair of protective glasses that you will need to wear for several hours after the surgery.
• Ensure you organise a driver home.
• The artificial tears provided by your doctor will help ease any irritation you may experience after the PRK Laser surgery.
• If you experience any irritation it is important not to rub, poke or touch your eyes.
• Follow your doctor’s instructions on using your steroid and antibiotic eye drops.
• Use this time to rest and relax.
• Do not strain your eyes through reading, computer work or watching TV.

Five days after PRK surgery:

• A 5-day post-op consultation with your Visiomed Eye and Laser Clinic doctors is required to remove the protective contact lens.
• Most patients are able to drive to their follow-up appointment however if you do not feel comfortable, please ask someone to drive for you.
• You are now free to pursue any hobbies or activities that were part of your normal routine before the PRK procedure.
• Continue following your doctor’s recommendations regarding eye drops and be sure to keep water, soap and shampoo out of your eyes when showering.
• You may read, use the computer and watch TV, but keep your eyes well lubricated and rest them if they feel strained. Be sure to keep sweat out of your eyes and avoid all lotions, creams and eye makeup for seven days.

Two weeks after PRK surgery:

• A two-week post-op consultation with your Visiomed Eye and Laser Clinic doctor is required to closely monitor your recovery.
• As your cornea heals (typically a 14-day process) you will begin to notice additional clarity in your vision.

One Month after PRK surgery:

• A post-op consultation with your Visiomed Eye and Laser Clinic doctor is required between one and three months after your PRK treatment. With a clean bill of health, you will be released from care.

Epi-LASIK is a refractive Lasik Eye Surgery technique designed to reduce a person’s dependency on glasses and contact lenses. The technique is basically an automatic LASEK without alcohol.

Epi-LASIK is considered a better option for some patients who will probably not do very well with LASIK. These include people who have thin corneas, with not enough tissue for a good LASIK flap.

A device similar to a microkeratome (called epi-keratome) slides over the surface of the cornea, just underneath the epithelial layer of cells while suction is applied.

The this kind of Lasik Eye Surgery results is a hinged sheet of epithelium that is at least partially viable, which is reflected out of the way so that the ablation can take place.

The sheet is repositioned and a bandage soft contact lens is placed on the eye.

Have a look at the 5-step process below and the LASIK FAQ for more information.

Precision Laser Surgery

Step 1You will be placed onto a comfortable bed from where your laser surgery will be done. Anaesthetic drops will be instilled to numb your eye. A special ring will be placed into your eye to keep your eyelids apart.
Step 2Your surgeon will create a corneal flap on the surface of your cornea.
Step 3The ‘hinged’ corneal flap is carefully pulled back and a small area of your cornea is exposed.
Step 4The Excimer laser beam is applied to reshape the exposed corneal area, removing certain parts of the tissue with high precision. This corrects your refractive error.
Step 5The corneal flap is then pushed back into place. The flap forms a natural ‘bandage’ and enhances the healing process after surgery.
	Pictures sponsored by PDTSA: www.pdtsa.co.za   tel. 0861 123 738

What is LasikHD surgery?

The LasikHD surgery procedure involves the use of cool pulses of light to prepare the cornea for treatment. Immediately following corneal preparation, the cornea will be reshaped using a cool ultra-violet laser to evaporate a small amount of corneal tissue, which is thinner than that of a human hair.

Our highly qualified ophthalmologists at Visiomed Eye and Laser Clinic have unprecedented training and experience enabling them to professionally correct your vision using 100% bladeless laser technology.

Why choose LasikHD at Visiomed Eye and Laser Clinic?

The wait for better quality vision is finally over for millions of South Africans. Visiomed Eye and Laser Clinic has pioneered a new era in laser vision correction giving patients in South Africa the opportunity to free themselves from glasses and contact lenses. Many patients were once told that they do not meet the criteria to be a candidate; Visiomed Eye and Laser Clinic offers technological advances in laser vision correction making the procedure applicable for just about anyone.

• No reading glasses or contact lenses
  Most patients adjust quickly to this procedure, thus eliminating their need for glasses or contacts.
• Painless procedure
  Both eyes will be completely numbed using anaesthetic drops, so you will experience minimal to no discomfort.
• Leading surgeons
  Leading eye surgeons at Visiomed Eye and Laser Clinic, together with world-class technology ensures personal, complete client satisfaction with numerous vision correction procedures.
• Technology
  World leading laser technology will fine-tune the way light is interpreted or refracted by the eye by gently adjusting and reshaping the cornea. Visiomed Eye and Laser Clinic is one of the first facilities to offer industry’s most recent advancements, the WaveLight EX500 Excimer laser technology. This technology yields better outcomes for vision correction surgery.
• Addressing unique eye problems
  Until quite recently, eye laser refractive surgery was based on the assumption that all eyes with the same amount of short or long sight and astigmatism required exactly the same laser treatment. This assumption is incorrect. While two eyes may have the same degree of short sight and astigmatism, there are other optical errors present in both eyes that will not be the same.In the human eye, these differences are called optical errors and are known as “Higher Order (HO) aberrations”. If these HO aberrations are not corrected when doing refractive surgery, the eye may not reach its full visual potential.Visiomed Eye and Laser Clinic has recently acquired the latest laser technology to measure these Higher Order aberrations in the human eye. It is now possible to download your specific correction of HO aberrations electronically into the WaveLight® EX500 Excimer laser platform. This makes it possible for ophthalmologists to maximise the visual potential of your eyes, and to reduce the chances of less than optimal outcomes after surgery.
• Advanced diagnostics
  During your personal consultation at Visiomed Eye and Laser Clinic, your ophthalmologist will use advanced diagnostics allowing them to fully map your eye. The surgeon plans patient specific surgical algorithms in precise locations and adjusts your treatment based on small changes or aberrations on your eye. This is what allows Visiomed Eye and Laser Clinic to revolutionise your vision.

LasikHD at Visiomed Eye and Laser Clinic successfully achieves high-quality vision correction for patients by personalising treatment to their individual refractive errors.

“Wavefront Optimized” and “Wavefront Guided” treatments allow for complete customisation for the patient’s individual eye.

The high definition diagnostic capabilities of the WaveLight® Topolyzer™ VARIO™ has been optimized to further enhance the patients’ refractive range and customized laser vision correction on the WaveLight® EX500 Excimer Laser’s platform.

The advanced design and built-in flexibility of the WaveLight® EX500 Excimer Laser allows surgeons at Visiomed Eye and Laser Clinic to expand their treatment capabilities by customising for all types of vision disorders (myopia, hyperopia, and astigmatism).

This will result in better quality vision in demanding situations such as poor lighting.

As part of the WaveLight® Refractive Suite at Visiomed Eye and Laser Clinic, the WaveLight® EX500 Excimer Laser has been ergonomically optimised to combine with the Ziemer® Z6 Femto second Laser and other WaveLight® diagnostic devices. By utilising the WaveNet™ Computer Network, surgeons can accurately transfer all patient data, treatment and diagnostic information directly to the lasers. The result is improved data flow throughout the procedure and enhanced patient experiences with a simplified surgical procedure. As the data is automatically transferred through the WaveNet it prevents manual uploading of patient data that reduces the possible chances of human error.

Bladeless technology
The first step in the LasikHD procedure involves the creation of a small flap in the eye’s outer corneal tissue. While traditional procedures use a blade for flap creation, Visiomed Eye and Laser Clinic is one of the first facilities in Johannesburg to adopt femtosecond laser technology. The Ziemer Z6 laser is the most advanced and accurate way to create the corneal flap before the Lasik procedure. The laser flap is more precise than traditional hand-made blade flaps and allows the eye to heal more quickly. The Z6 has many advantages:

• Comfort for the patient due to a shorter procedure.
• Faster visual recovery due to a smoother flap and 500 Hz operation.
• Reduced dry eye due to less laser energy use.
• Less inflammation and light sensitivity.
• Innovative engineering that reduces flap shrinkage and stromal dehydration of the cornea.
• Wavefront Optimized and Wavefront-Guided treatments for complete customisation for each patient.
• 1050 Hz-type multi-dimensional eye tracking for optimal precision and safety.
• Reduces the potential for nighttime glare.

Which eye problems does LasikHD surgery address?

The Visiomed Eye and Laser Clinic’s LasikHD surgery procedure will address nearsightedness, farsightedness and astigmatism.

Who are ideal LasikHD surgery candidates?

• You are at least 18 years of age.
• You are in good general health.
• You have had a stable vision prescription for at least one year.
• You are not currently pregnant and have not been nursing in the past six months.

Initial eye exam at Visiomed Eye and Laser Clinic

Life after LasikHD surgery

At Visiomed Eye and Laser Clinic, your post-op care is very important to us. We therefore periodically schedule visits with your ophthalmologists after your LasikHD treatment.

The first 24 hours after LasikHD surgery:

• The ophthalmologist will perform a post-Lasik check-up and you will be given a pair of protective glasses that you will need to wear for several hours after the surgery.
• Ensure you organise a driver home.
• The artificial tears provided by your doctor will help ease any irritation you may experience after the LasikHD surgery.
• If you experience any irritation it is important not to rub, poke or touch your eyes.
• Follow your doctor’s instructions on using your steroid and antibiotic eye drops.
• Use this time to rest and relax.
• Do not strain your eyes through reading, computer work or watching TV.
• Wear your protective glasses to bed for one week to avoid accidentally touching your eyes in your sleep.

One day after LasikHD surgery:

• After surgery, your doctor will schedule a follow up consultation at Visiomed Eye and Laser Clinic for the next day.
• Most patients are able to drive to their follow-up appointment, however if you do not feel comfortable please ask someone to drive you to your appointment.
• Remember to keep your eyes well lubricated while using the computer and watching TV and rest them if they feel strained.
• Continue following your Visiomed Eye and Laser Clinic doctor’s recommendations regarding eye drops, and be sure to keep water, soap and shampoo out of your eyes when showering.
• Approved activities include reading, computer/tablet usage, watching television, returning to work and light exercise.
• Avoid face lotions/creams, eye makeup, strenuous exercise, contact sports, swimming, Jacuzzi’s, strenuous activities or any activity where dust or debris could get into your eyes such as gardening or yard work.

One Week after LasikHD surgery:

• A 1-week post-op consultation with your Visiomed Eye and Laser Clinic doctors is required to monitor your healing.
• You may now sleep without wearing your protective glasses and can resume the use of lotions and creams.
• Approved activities include exercise at normal rate and the use of eye makeup.
• Avoid strenuous exercise, contact sports, swimming and Jacuzzis.

Two Weeks after LasikHD surgery:

• You are now able to resume all the activities you enjoyed prior to LasikHD surgery with the benefit of clearer vision.

One Month after LasikHD surgery:

• For most patients, one last Visiomed Eye and Laser Clinic post-op consultation with their ophthalmologist is required at this stage.
• All normal activities may be resumed.
• In some cases, your doctor may request a 90-day post-operative check. Be sure to check with your doctor at Visiomed Eye and Laser Clinic for specific instructions.

Epi-LASIK is a refractive Lasik Eye Surgery technique designed to reduce a person’s dependency on glasses and contact lenses. The technique is basically an automatic LASEK without alcohol.

Epi-LASIK is considered a better option for some patients who will probably not do very well with LASIK. These include people who have thin corneas, with not enough tissue for a good LASIK flap.

A device similar to a microkeratome (called epi-keratome) slides over the surface of the cornea, just underneath the epithelial layer of cells while suction is applied.

The this kind of Lasik Eye Surgery results is a hinged sheet of epithelium that is at least partially viable, which is reflected out of the way so that the ablation can take place.

The sheet is repositioned and a bandage soft contact lens is placed on the eye.

Have a look at the 5-step process below and the LASIK FAQ for more information.

Precision Laser Surgery

Step 1You will be placed onto a comfortable bed from where your laser surgery will be done. Anaesthetic drops will be instilled to numb your eye. A special ring will be placed into your eye to keep your eyelids apart.
Step 2Your surgeon will create a corneal flap on the surface of your cornea.
Step 3The ‘hinged’ corneal flap is carefully pulled back and a small area of your cornea is exposed.
Step 4The Excimer laser beam is applied to reshape the exposed corneal area, removing certain parts of the tissue with high precision. This corrects your refractive error.
Step 5The corneal flap is then pushed back into place. The flap forms a natural ‘bandage’ and enhances the healing process after surgery.
	Pictures sponsored by PDTSA: www.pdtsa.co.za   tel. 0861 123 738

Intacs is the trademark name for micro-thin prescription inserts which were previously used as a form of refractive surgery in the treatment of low levels of myopia or nearsightedness, but has recently received FDA approval for keratoconus.

Intacs are thin plastic, semi-circular rings inserted into the mid layer of the cornea. When inserted in the keratoconus cornea they flatten the cornea, changing the shape and location of the cone. The placement of Intacs remodels and reinforces the cornea, eliminating some or all of the irregularities caused by keratoconus in order to provide improved vision. This can improve uncorrected vision, however, depending on the severity of the KC, glasses or contact lenses may still be needed for functional vision.

FDA Approval

Intacs were approved under a Humanitarian Device Exemption (HDE) by the FDA in July 2004, allowing Intacs to be used for treating keratoconus. As part of the HDE approval, Addition Technology, the manufacturer of Intacs, has implemented an extensive training program in which each surgeon will be required to participate.

What is a Humanitarian Device Exemption (HDE)?

The humanitarian device regulations were first established in October 1994. Humanitarian Use Devices (HUDs) are medical devices specially designated by the FDA for use in the treatment of fewer than 4000 patients per year with rare medical conditions. CPT Code is: Category III CPT code 0099T

Intacs received a Category III CPT code 0099T from the American Medical Association. Category III CPT codes are temporary codes to designate emerging technologies and are not assigned a value. It is up to the insurance company to determine the amount to be paid. A Category III code has 5 years to become mainstream, whereupon it may be promoted to a permanent Category I code.

The Procedure

This procedure involves placing the plastic inserts just beneath the surface of the eye in the periphery of the cornea. The procedure itself takes approximately 15 to 20 minutes usually in the doctor’s office. Topical anesthetic drops are used to numb the eye, and a clamp is used to hold the eye open throughout the procedure to prevent blinking.

There are 3 basic steps to the procedure:

Step 1: A single, small incision is made in the surface of the cornea. Instead of using mechanical cutting, some surgeons may use a laser to make the incision.

Step 2: A centering guide is placed on the surface of the eye for several minutes to help stabilize the eye and ensure proper alignment of the Intacs insert. During this time, the corneal layers are gently separated in a narrow circular band on the outer edge where the Intacs will be placed.

Step 3: The Intacs inserts are placed. Once this insertion is completed, the small opening in the cornea is closed with a suture.

Follow-up visits will be required to monitor the healing process and to evaluate the visual benefits of the procedure. Even after a successful procedure, glasses or contacts may be required.

As with any surgical procedure, there are some risks, including infection. Some patients experience visual symptoms including difficulty with night vision, glare, halos, blurry and fluctuating vision.

Penetrating Keratoplasty (PKP)

The cornea is the clear, living tissue on the front part of the eye. Light passes through the clear cornea on its path toward the retina in the back part of the eye. Sometimes, the cornea is referred to as the “window” to the eye. Occasionally, either through disease or injury, the corneal tissue is damaged to a point where light can no longer effectively pass through it, resulting in reduced vision. When other methods of treatment have failed to save the cornea, or if vision has been lost in the affected eye, a corneal transplant procedure may be indicated. The procedure involves replacement of the damaged cornea with a healthy and clear donor cornea.

Deciding When to Have a Corneal Transplant

A corneal transplant, also known as a corneal graft, or as a penetrating keratoplasty, involves the removal of the central portion (called a button) of the diseased cornea and replacing it with a matched donor button of cornea. Corneal grafts are performed on patients with damaged or scarred corneas that prevent acceptable vision. This may be due to corneal scarring from disease or trauma.

A common indication for keratoplasty is keratoconus. The ophthalmologist must decide when to recommend keratoplasty for the keratoconic patient. This is often not a simple, straightforward decision. Keratoplasty for keratoconus is highly successful; however, there is a long recovery period and a risk of severe ocular complications. A number of factors must be considered in deciding when to do a keratoplasty. One of the most important is the patient’s functional vision. If the best acuity with their contact lenses prevents them from doing their job or carrying out their normal activities, a transplant must be considered. The actual measured visual acuity may be quite different for different patients. One patient may find that he/she cannot do his or her job with 20/30 acuity while another patient may be very satisfied with 20/60 acuity.

Very careful contact lens fittings are necessary before recommending a corneal transplant. One study found that 69% of keratoconics, most referred for transplant, could be successfully fit with contact lenses if special lens designs were used (Smiddy). Thus, prior to  eye transplant surgery every effort should be made to optimally fit the patient with contact lenses, especially if there is not significant corneal scarring affecting vision.

However, a few patients become intolerant to contact lenses, and require a transplant earlier than otherwise would be necessary. If the patient has a large area of thinning, a very decent red cone or significant blood vessel growth into the usually clear cornea, called neovascularisation, a transplant may be performed earlier than otherwise indicated by the visual performance, as these factors may require a larger than normal transplant button size and/or increase the chance of rejection if allowed to advance too far.

The healing process following transplant is long, often taking a year or longer. The time from surgery to the removal of the stitches is commonly 6 to 17 months (Kirkness et al 1990; Troutman and Lawless 1987). The patient may be on steroids for months. Initially following surgery, the donor button is swollen and even following healing the button is usually thicker than the corneal bed in which it rests.

Graft rejection reactions occur in 11% to 18% of the patients (Kirkness et al 1990; Troutman and Lawless 1987). Signs of graft rejection include ciliary flush, anterior chamber flare, keratic precipitates, Khodaoust line and Krachmer’s spots. Signs of graft rejection are reported to occur from one month to five years following surgery (Kirkness et al 1990). The rejection rate for bilateral grafts is higher than if only one eye is grafted. In the bilateral cases, when a rejection reaction occurs it is commonly in both eyes. If the second eye is to be grafted, there is usually a period of at least a year between grafts. If signs of rejection occur, aggressive treatment with steroids is begun. Usually the reaction is overcome and the graft remains clear. Over 90% of the corneal grafts are successful with some studies reporting 97% to 99% success rates at 5 and 10 years (Kirkness et al 1990, Troutman and Lawless 1987, Epstein).

Large amounts of astigmatism are common following keratoplasty. One study found an average of 5.56 DC with a range from 0 to 17 D following suture removal (Kirkness et al 1990), with other studies showing an average of 5.4 DC (Troutman and Lawless 1987) and 4.5 DC (Smiddy).

The patient’s spectacle prescription may fluctuate for some months following surgery. Refractive changes and keratometry or corneal topography can be used to follow the healing process.

Contact Lenses After Surgery

Most transplants have significant astigmatism and often some distortion requiring correction with contact lenses made of rigid materials. Many factors make fitting contacts after transplant a challenge. It is common for the edge of the transplant to be slightly raised with respect to the surrounding cornea. The graft is usually steeper than the normal cornea, and may be tilted with respect to the surrounding tissue. To combat high amounts of astigmatism, some of the sutures may be removed early. Following healing a relaxing incision or a wedge resection may be done to decrease the astigmatism. In any case, there is usually some distortion of the transplant and most patients will obtain better vision with a rigid contact lens. Rigid corneal lenses, scleral (haptic) lenses, and the SoftPerm lens are all viable options.

If a contact lens is required following keratoplasty, it is customary to wait at least three months after the surgery and preferably until after the sutures are removed, which may be up to a year, before fitting contact lenses.

Due to the irregularity of the cornea after transplant, soft contact lenses seldom give satisfactory vision. In addition, hydrogel lenses, scleral lenses and the SoftPerm lens may encourage vessel invasion into the graft. Therefore, rigid gas permeable corneal lenses are usually the lens of choice. Keratometer readings are seldom of any significant value in determining the base curve of the lens to use, but may be useful for baseline values to determine if any changes are occurring. Corneal topography with a computerised topographer can be of some value in determining the shape of the transplant and surrounding cornea. However, diagnostic lenses must be used to fit these eyes.

Due to the size and shape of the button and the transition area between the button and the host cornea, it is often best to use a larger diameter lens to maintain lens centration. In the rare instance that a corneal transplant is placed off-center, rigid corneal lenses are nearly impossible to properly fit. In these few cases scleral or SoftPerm lenses may be the only viable option.

Parameters of the lenses are assessed using the fluorescein pattern. The power of the final rigid lens is determined by an accurate refraction over the diagnostic lens. A lens material with good oxygen permeability should be used to minimize corneal swelling.

The corneal transplant patient should be followed closely, especially during the first year or two following surgery to be sure corneal integrity is not compromised and that graft rejection is not occurring.

The Transplant Procedure

This is an extremely delicate microsurgical procedure. The procedure first involves removal of a round, button-shaped shaped portion of the damaged cornea. This diseased cornea is removed with a special round cutting tool called a trephine. Then, a clear donor cornea, prepared to the same size, is replaced within the round opening. Finally, this donor cornea is stitched into place with extremely fine sutures.

The surgery itself is painless and usually done on an outpatient basis. First, you are given eye drops or medication to help you relax. Then, a local or general anesthetic is used to prepare the eye. A patch is usually worn over the eye immediately following surgery. Other procedures may be performed at the time of corneal transplant surgery if necessary.

Post-operative

A corneal transplant takes many months to heal. Often, the stitches are not removed until six to nine months after surgery. During that time, medicated eye drops are used to make sure the transplant heals properly.

Possible Complications

As with any surgical procedures, complications and/or side effects may occur. One of the risks of any transplant is the possibility of rejection. Our body is able to sense things that are not natural parts of it. The body’s defense system tries to destroy these foreign tissues. Thus, it is natural for the body to try to destroy a transplant that is foreign because it comes from another person’s body. This is the process called transplant rejection. If a corneal transplant rejects, it loses its clarity and swells.

When rejection of the cornea occurs, the patient usually experiences the following:

Deterioration of vision when compared to the postoperative period.

Glare and glittering of light.

Redness of the eyes.

Significant change in refractive error (increased myopia and corneal astigmatism).

Often, corneal transplant rejection can be stopped with medication, but rejection is always a possibility for the rest of the patient’s life. If a transplanted cornea is rejected, another transplant may be done.

Donor Tissue

Donor corneas come from healthy patients who donate their eyes after death. Ophthalmologists work closely with their local Eye Banks to obtain fresh tissue, which is kept in sterile preservative culture media until use. If you are interested in becoming an eye donor, you can simply check off a form when you get your next driver’s license in most states revision for South Africa.

Presby LASIK, also known as multifocal LASIK is a surgical technique for presbyopic visual correction using Excimer laser ablation.

As we get older, our eyes become less accommodating (less able to adjust their focus). You may know people who never wore glasses before suddenly having to wear glasses to read or work on the computer. This is a condition called presbyopia. This happens to most people as we move into our mid forties. Unfortunately, once accommodation is gone, it cannot be regained.

For those who are nearsighted, reading without glasses or contacts may not be a problem but with glasses or contacts, their up-close vision may be blurry. LASIK does the same thing as glasses. It can give the nearsighted patient clear vision for distance, but because of lost accommodation (presbyopia), the close vision will be blurry.

See diagram below:

 

Normal eye	Keratoconus eye

Corneal Cross Linking is a very promising new treatment for some patients suffering from Keratoconus. Keratoconus is a disease of the cornea that causes a weakening of the cornea leading to a gradual outward bulging of the eye. Instead of having a rounded cornea the shape of a soccer ball, the cornea becomes the shape of a rugby ball when developing Keratoconus.

Most often, this bulging is in the lower half of the cornea and first presents as astigmatism. (Astigmatism means ‘without a point.’) This prevents the cornea’s ability to converge the light rays into one focusing point, thereby producing moderate to severe blurriness of vision. However, not all astigmatism is due to Keratoconus. In mild or early stages of Keratoconus, (Forme Fruste Keratoconus) glasses or soft contact lenses may correct the astigmatic vision and produce clear vision. It might be advisable to consult an ophthalmologist during the early development of Keratoconus.

The image on the left is a cross section of the eye. The irregular cornea is the outer section left bulging downwards and prevents light entering the eye to focus on one central point in the back of the eye on the retina.

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Corneal Cross Linking Treatment detail

During the treatment, custom-made Riboflavin (Vit.B2) eye drops are applied to the cornea, which is then activated by ultraviolet light.

This amazing simple process has been shown in laboratory and clinical studies to increase the amount of cross linking of collagen fibres in the cornea , which are the natural ‘anchors’ within the cornea and are responsible for preventing the cornea from bulging out and becoming steep and irregular.

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Other treatments

As Keratoconus advances, rigid-gas-permeable, scleral and other contact lenses now available on the market for keratoconic patients  might be the only surgical way to achieve clear vision. Discuss your options with an optometrist who is well skilled in this field..

What happens on the day of your treatment?

Corneal Cross Linking can be done in a theatre. If you are a candidate for this procedure, you will lie down on a bed, made comfortable, and music of your choice will be played. The preparation and treatment last about ½ hour per eye, of which the cross linking procedure will take only 5 minutes. Before the treatment is commenced, you will receive a sedative and local anaesthetic drops will be instilled into your eyes. You will experience no discomfort or pain during the procedure.

When the treatment is complete, you will go home immediately afterwards. The doctor will prescribe eye drops and analgesic medication, for your eyes might feel quite sensitive after the local anaesthetic has worn out. This will last only for a few days.

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