What is Cataract Surgery/Phacoemulsification?

Modern cataract surgery usually involves an incision in the cornea followed by fragmentation of the cloudy lens (cataract) by ultrasound (phacoemulsification) and removal by aspiration.

The cataract is broken up with ultrasound, and the pieces are removed under suction. Once the lens has been removed, an artificial lens is inserted through the small incision. This lens unfolds inside the eye into the correct position. The small incision then seals itself or is closed with one or two sutures which are usually removed in the post-operative phase.

How do I decide whether to have cataract surgery?

Your decision on whether to undergo cataract surgery will depend on your answers to the following two key questions:

  • Does your vision limit your activities?
  • Are you willing to have an operation?

The Doctors will examine your eyes and determine how much the cataract is contributing to your loss of vision and decide whether there would be benefit in removing your cataract.

Pre-operative care

Pre-operative care for patients with cataract includes an assessment of your general health, medications, and allergies as these factors will affect the decision to proceed with surgery and the type of anaesthesia required. Prior to surgery, an ultrasonic scan will be performed to calculate the required power of the artificial lens to be inserted during the operation. The aim is to achieve clear vision for the desired distance. Glasses may be required.

Post-operative care

Following surgery, the eye will be padded overnight. You will be reviewed the following day and the pad will be removed. The vision will initially be blurry but it should clear over the following days and continue to improve over the next month to two months.  New spectacles are prescribed at two months following the surgery, if required.

Once the pad has been removed, the eye may be left opened and sunglasses or other spectacles may be worn to protect the eye.  A plastic eye shield should be worn at night for the first two weeks following surgery to prevent any trauma to the eye. You should keep the eye clean and dry and take care when showering to avoid getting water in the eye for the first two weeks. You should also avoid prolonged coughing, straining, bending, or heavy lifting for one month following surgery.  Swimming should be avoided for at least two months following surgery. You may walk about and perform your usual daily activities after a few days as long as care and hygiene is maintained.

You will be required to use eye drops and, in some cases, tablets to control the intraocular pressure following surgery.  The eye drops are usually required for one to two months following surgery.

The eye may feel irritated for the first week following surgery due to the small stitches and the surgery. Severe pain may indicate that the pressure in the eye is elevated or that an infection may be developing.  A reduction in vision may suggest an infection, inflammation or development of retinal problems such as retinal detachment. These complications are however rare.  Should any complications such as severe pain or loss of vision occur, it is advisable to contact City Eye Centre as soon as possible.

What is Vitrectomy Surgery?

Vitrectomy surgery involves microsurgery in the eye using very small incisions (less than a millimeter wide) into the eye for many retinal conditions.

These retinal conditions include:

Retinal Detachment Macular Hole Epiretinal Membranes Vitreous and Retinal Haemorrhages Diabetic Retinopathy Penetrating Eye Injuries Intraocular Foreign Bodies Severe Vitreous Opacities Complex Cataract Surgery Dislocated Lenses Severe Eye Infections (Endophthalmitis) Rare types of Glaucoma Retinal Vein Occlusions

Vitrectomy surgery can clear blood and scar tissues from the vitreous cavity as well as floaters and debris in the vitreous.  It is also used in repair of severe eye injuries and in retinal detachments.

Once the vitreous is cleared by vitrectomy, other additional treatments may be required:

Laser: to seal breaks in the retina and also prevent further retinal bleeding.

Cryotherapy: to seal breaks in the retina and help prevent retinal detachment.

Gas: gas bubble is often injected to hold the retina in place and prevent further bleeding until the laser and cryotherapy treatment sticks the retina down. It may take from 1 week to 8 weeks to clear depending on the type of gas used.  While the gas is clearing the vision will be poor and often you will have to posture face down for certain lengths of time depending on your condition.  You must not fly in a plane till the gas bubble clears as the pressure in the eye will increase due to high altitude. As the gas bubble clears you will notice a line of gas in your vision and the vision above the bubble will gradually get better over the time.

Silicone oil: this is used in certain cases of retinal detachment or other retinal problems which require longer term support than when gas is used. Patients can fly in a plane after surgery where silicone oil is used. The oil may be left in the eye for a period of time depending on your condition.  In severe retinal detachments it is often left in for years.  Other cases the oil may be removed around 6 months to a year later.

Heavy liquid (perfluorooctane): this is a special heavy liquid used in vitrectomy surgery.  It may be just used during the operation, or left in the eye for a few weeks to hold the retina in place, in cases of giant retinal detachments. The heavy liquid will need to be removed by a further vitrectomy surgery.

Cataract surgery: this may be performed concurrently with vitrectomy if the patient has a cataract or there was difficulty in removing the lens at cataract surgery.  An intraocular lens may be inserted.

Vitrectomy surgery usually takes around ¾ to1 hour. This is usually performed under twilight anaesthetic or general anaesthetic. Twilight anaesthetic is safer, giving quicker recovery, and less nausea.  The anaesthetist will assess you prior to the surgery.

Patients may be required to posture face down ½ – ¾ hour in each hour for 1-2 weeks after the operation to position the gas bubble. A face-down positioning chair is available for hire at City Eye Centre.

Vitrectomy surgery may be performed as an overnight stay or day surgery depending on your condition. Recovery from vitrectomy may be slow and may take several weeks for the eye to settle.

Vitrectomy is a safe and commonly performed procedure. Risks are rare and they include infection, haemorrhage, loss of vision, retinal detachment, anaesthetic risks, and other eye sympathy.  If complication develops then further surgery may be required.

Cataract surgery is often required 6-12 months following vitrectomy surgery.

What is a Corneal Transplantation/Graft?

Corneal graft surgery aims to replace the hazy cornea with a clear donor cornea.  The aim of this is to provide improved vision and/or a stable eye surface.

Donor cornea

The cornea graft is from another person who has kindly donated their tissue for transplantation.  All material has been cleared by the Queensland Eye Bank for transmissible diseases such as Hepatitis B & C, AIDS, syphilis.

The Operation

Corneal surgery can be performed under a local or general anaesthetic.  A round blade called a trephine is used to cut the patient’s diseased cornea.  The donor cornea is then harvested from the donated eye and stitched into the patient’s eye with a very fine Nylon suture one tenth of a human hair.  This suture usually remains for 12 months after which the suture will need to be removed.

Post-Operation

You will be on 2 types of medications – a steroid and an antibiotic.  Initially you will be using it quite frequently eg every 2-3 hours during the day for the first month.  The drops are then tapered according to recovery over the next 2 months.  Some patients may require longer term drops, particularly if they have had previous graft surgery

Complications

Generally graft surgery is very good, however with any surgery there are always risks.  These include infection, bleeding and reduced vision.  Specific to graft surgery there is the risk of rejection of the corneal graft, as it is tissue from a donor.  If this occurs, treatment in the form of drops need to be commenced as soon as possible.  Generally it is possible to reverse the rejection, however if rejection recurs multiply, it can result in failure of the graft which turns cloudy.  In this circumstance the graft will need to be replaced.  Astigmatism (irregular curvature of the cornea) occurs in all grafts to a varying degree.  This can be corrected with glasses or contact lenses.  It will change when the suture is removed after 12 months.

Recovery

Most corneal graft patients take 2-3 weeks off post-operation, depending on the type of occupation they perform.  Bending, lifting heavy items and straining should be avoided in the first 2 weeks.  Swimming should be avoided whilst on the steroid drops, as there is an increased risk of eye infection.  The visual recovery is gradual over the first few months.  The final visual outcome will occur about the sutures are removed at 1 year.  Most patients will require glasses and occasionally contact lenses to achieve best vision.

Sclerocorneal graft

Corneal graft

For more information please click here to download the Corneal Transplantation booklet

What is a Trabeculectomy?

A trabeculectomy is drainage surgery used in the management of glaucoma.

The term Trabeculectomy refers to making a hole in the drainage area of the eye, to allow fluid from inside the eye to be released, thereby lowering the intraocular pressure.

Why do I need a Trabeculectomy?

Most glaucoma is treated by medical therapy in the form of eye drops.  In most cases the eye pressure is sufficiently lowered by the eye drops to reduce the risk of vision loss from glaucoma.  In some cases the pressure lowering is not sufficient and requires further treatment.  The current options are tablets, laser or drainage surgery.  Generally, tablets are only used in the short-term for pressure control as they are associated with side-effects.  Laser, also, does not generally have a long-term effect and is utilised mainly if surgery is not safely possible.

What is involved with Trabeculectomy?

Trabeculectomy is performed as Day Surgery and does not require overnight admission.  It is necessary to stop aspirin, warfarin, anti-inflammatories, fish oil or any other blood thinning medications 7 days prior to surgery.  Local anaesthesia with sedation is preferred as it is safer for the patient and provides more rapid recovery.  A general anaesthesia can be performed in certain patient indications.  The procedure takes one to one and a half hours, depending on the complexity of the glaucoma.

The aim of the surgery is to create a one-way flap valve from the inside of the eye to under the conjunctiva of the eye.  The fluid subsequently passes from this small reservoir (bleb) back into the blood vessels of the conjunctiva.  It does not result in more tearing from the eye as there is no external drainage of the fluid.  During the operation anti-scarring agents such as Mitomycin C are used to optimise the long-term drainage of the fluid from the eye.

What happens after the operation?

A pad/shield is worn on the first night.  As the eye can be uncomfortable due to the nature of the surgery, it is advised to rest and take oral analgesia if required.  It is advised to sleep slightly elevated on two to three pillows during the first night to prevent overdrainage of fluid.  No eye drops need to be administered on the first night.

The next day your eye will be reviewed.  The eye pad will be removed, the eye cleaned and the trabeculectomy site checked.  If you bring your post-operative eye drops, the first dose will be put in for you.

The first 3-4 weeks are critical in establishing the flow through the trabeculectomy site.  I will be seeing you twice a week during that period in order regulate the flow.  This may involve massaging your eye and possibly removing sutures.

It is expected that your vision will fluctuate in the first few weeks, due to the variable drainage of fluid, but will eventually stabilise.

What are the side-effects of Trabeculectomy surgery?

For any eye surgery there is the risk of infection, bleeding, loss of vision and the potential for retinal problems.  Trabeculectomy surgery, in particular, is associated with problems of under or over drainage following the surgery either due to loosening of the sutures or wound leak.  Occasionally, if the drainage is not controlled, then the trabeculectomy may need to be revised, which involves going back to the operating theatre.  This does not occur frequently but if required, it is in the best interest of your eye.

Patients generally have 2-3 weeks off work depending on how the eye is healing and the nature of their work.  More physical work (lifting more 10kg or involving prolonged bending over), especially in dusty or dirty conditions, should be avoided in the first three weeks.  It is wise to wear sunglasses during the day and a shield at night.

The ultimate goal of trabeculectomy surgery is to reduce the pressure in the eye to a level that will slow the vision loss. Due to the progressive nature of glaucoma no current treatment cures the condition, however, achieving lower stable eye pressures gives you the best long-term chance to maintain a functional level of vision.

What is Panretinal Photocoagulation (PRP) Laser Surgery?

Panretinal photocoagulation laser surgery is performed in proliferative diabetic retinopathy to prevent severe vitreous haemorrhage. The laser causes regression of the abnormal blood vessels which grow at the back of the eye on the retina in diabetic patients.

Each session takes approximately five to ten minutes and multiple sessions (3-4 per eye) are usually required to treat the proliferative diabetic retinopathy.

There is some discomfort during the procedure and analgesics such as Nurofen or Panadol may be taken before the laser session.

The eye may be irritated and blurred for a few days following the laser surgery.

With time, you may notice some decrease in night vision and peripheral vision.  This occurs due to the laser treatment, but is necessary in order to control the proliferative diabetic retinopathy.

Focal laser may be performed for in cases of diabetic maculopathy to seal the leaking blood vessels that cause reduced vision.

What is SLT/YAG Laser Capsulotomy Surgery?

1.  SLT: Selective Yag Laser Trabeculoplasty

SLT laser is a new innovation in glaucoma treatment to reduce the need for glaucoma eye drops or as adjunctive therapy. It reduces the eye pressure by selectively widening the drainage mechanism in the eye.

Usually two treatments are required per eye.

2.  Yag Laser Capsulotomy for Post Cataract Capsule Opacity

Yag laser surgery may be required to clear scarring which develops behind the intraocular lens implant. This often develops over time following cataract surgery.

The laser surgery itself usually takes ten to fifteen minutes and are performed in the consulting rooms.

The vision will be blurred initially for a few hours after treatment due to the bright lights.  Following that, the vision should improve over the subsequent weeks.

Normal duties can be commenced the day after the laser surgery. The eye may feel irritated and scratchy at first, but should settle over the subsequent days.

If the eye has persistent severe pain following treatment or if the vision deteriorates, you should contact City Eye Centre urgently on 3831 6888  or 3345 7111, as there is a small risk of inflammation, increased pressure in the eye, or retinal detachment and lens dislocation (with capsulotomy).

What is a Cyclodiode Laser?

Cyclodiode is the use of a laser to treat high pressures in the eye. It works by placing small burns in the ciliary body – the structure that makes the fluid inside the eye.

Procedure

The eye to be treated will be made numb using a freezing injection. A metal clip will be placed to hold your eyelids open. The laser probe will be applied to the surface of your eye. You will feel a pressure, but should not be painful. While the laser is on, you will hear a beeping noise – each beep represents one burn. The procedure lasts around 15 to 20 minutes. A steroid injection into the conjunctiva (skin of the eye) will be given on completion of the laser. An eyepad will be put on the eye.

Instructions after the laser

When the freezing injection has worn off, the eye will have an aching feeling. Take oral pain relief and rest, preferably with your head slightly raised on a pillow.

The next day, remove the eyepad. Your eyelids may be swollen and the eye slightly red. This is usual, however if the eye is particularly painful or if you have any concerns, please contact the hospital or Dr Lee through the rooms on 07 3831 6888.

You are to use Prednefrin forte drops 4 times per day for 1 week, as well as any glaucoma medications as instructed. An appointment will be made to see you in one week. If after one month the pressure has not been controlled, further treatments can be undertaken.

Advantages

Ease of application Good pressure lowering Low risk of hypotony (excessive low pressure) – 1/100

Disadvantages

Often will need to continue glaucoma medications. May require multiple applications to achieve desired effect. Long term control may require repeat laser application Other uncommon risks include: inflammation, bleeding, perforation, retinal detachment, and loss of vision

Alternatives to Cyclodiode

Chlorpromazine injection Filtering surgery eg trabeculectomy Drainage device eg Baerveldt tube

What is Intravitreal Therapy?

City Eye Centre specializes in the latest intravitreal treatments for Age-related Macular Degeneration (ARMD), Retinal Vein Occlusion and Diabetic Macular Oedema. We are also equipped with the latest diagnostic technology such as high resolution OCT scanning and Optos ultra wide-field angiography to promptly diagnose your condition.

We endeavour to deliver sight saving therapy utilizing Eylea, Lucentis, Avastin (these are termed Anti-VEGF drugs) and Triamcinolone, and have had many years of experience in this. Diagnosis involves OCT scanning, fluorescein angiography and in some instances ICG angiography.

Macular degeneration (ARMD)

Early diagnosis and prompt treatment of macular degeneration with Eylea or Lucentis can be potentially sight saving. This is performed at the City Eye Centre using topical / local  anaesthetic to make the procedure as pain free as possible. Generally treatments are performed monthly until the ARMD subsides (an initiation/induction phase), then treatment is extended to around 6-8 weeks. Every patient however is treated with an individualized dosing strategy as part of your treatment plan. Long-term treatment is essential to maximize visual potential and maintain your vision (a maintenance phase).

Retinal Vein Occlusion (RVO)

Retinal Vein occlusion is a thrombosis of the retinal vein causing loss of vision and macular oedema. Prompt treatment with Anti-VEGF therapy has replaced the previously adopted “wait and see” approach. We have noted excellent results in accordance with recent clinical trials, and often a finite endpoint to treatment. It is also important to have a GP monitoring your blood pressure which can be associated with RVO. We treat all types of RVO including central and branch retinal vein occlusions.

Diabetic macular oedema (DME)

Diabetic maculopathy is a common cause of vision loss due to fluid retention in the macula.  Recent clinical trials have proven that these cases respond well to Anti-VEGF treatments, and sometimes triamcinolone. Proliferative diabetic retinopathy is a severe form of diabetic retinopathy requiring PRP laser surgery and/or a vitrectomy.