Refractive lensectomy or clear lens extraction is the technique of removing the natural lens and replacing it with an intraocular lens which gives improved focus.  This technique is based on the same principles as modern day cataract surgery.

A cataract is the clouding of the natural lens which results in impaired vision.  For people over 40 years of age who are considering refractive surgery and are beginning to show signs of cataract development, this is the most logical procedure for correction of refractive error.

For higher levels of nearsightedness (myopia) and longsightedness (hyperopia) corneal refractive surgery techniques (LASIK, PRK and RK) are associated with poorer results and greater potential for vision threatening complications.

The risk of intraocular haemorrhage is very low due to the short surgical time.  Because no needles are used around or behind the eye, there is no risk of haemorrhage behind the eye. Central retinal vein/artery blockage is a very rare complication, but can occur to people with hypertension, diabetes or other predisposing conditions.

What are the side effects of the procedure?

Townsville - A surgical technique for glaucoma, developed in South Africa but now used regularly here, effectively lowers intraocular pressure (IOP) without removing any of the trabecular meshwork or incurring the risks often associated with filtration blebs in conventional trabeculectomy.

Viscocanalostomy is a technique pioneered by Robert C Stegmannm MD, in private practice in Pretoria, South Africa. Although designed by Dr Stegmann as a single    glaucoma procedure, it can be combined with cataract surgery.

“Currently, this technique is used by only a handful of surgeons because it is a delicate procedure, and it si demanding and time consuming, but its benefits outweigh these drawbacks,” spokesman for the North Queensland Day Surgical Centre said “Its efficiency has me convinced that it will soon be in widespread use, and that it is a procedure that warrants widespread clinical evaluation.”

Viscocanalostomy begins, much like a conventional scleral trabeculectomy, with the creation of a 4-mm-by-3-mm flap, penetrating about half the scleral thickness.

Underneath that flap, the surgeon creates a second, smaller 3-mm-by-2-mm flap. When that flap is carefully peeled back, Schlemm's canal is “unroofed.” Delicate    dissection of the second flap is continued anteriorly, into cornea, until it reaches the level of Descement's membrane.  This process creates a window  where Descemet's   membrane is the only tissue separating the wound and the anterior chamber. The second flap is then excised, so that when sutured shut Descement's membrane is    exposed to the posterior surface of the initial flap. Into either side of the exposed portion of Schlemm's canal (the lake) is deposited a highly cohesive viscoelastic,    such as Healon GV (sodium hyaluronate, Pharmacia & Upjohn).

The reason for the viscoelastic is to keep out refluxing serum, plasmoid aqueous or anything else containing fibrim that could create or promotes scar tissue, (no    antimetobolities are used during viscocanalostomy.)  Once the lake is filled with viscoelastic, the superior flap is sutured shut.  Several days after surgery the viscoelastic is absorbed, clearing the way for unimpeded aqueous drainage.

The theory goes that the window of Descemet's membrane created by this procedure acts as an osmotic filter. Aqueous diffuses across Descemet's membrane, into the   lake, and then has access to the exposed ends of Schlemm's canal, where the viscoelastic had been.

Following surgery, patients remain on pressure control medication until IOP is stable. Once stable, they are weaned from medication.

At the time this article was written, Dr Gimbel has performed 34 viscocanalostomies. Dr Stegmann, who developed the procedure more than 4 years ago, had performed   195.  Six-month follow-up data show that patients maintained pressure of between 11mm Hg and 14 mm Hg, experiencing an average decrease of 7.3 mm Hg. Some of the patients have been taken off medication completely, while others have had their medications reduced.

Dr Stegmann, who presented recent viscocanalostomy outcomes at the 15th Congress of European Society of Cataract and Refractive Surgeons in Prague, said that 158 of 195 patients were considered successful cases because they achieved their target pressures following surgery. of the successful cases, patients experience an average decrease in IOP of 62%.

Viscocanalostomy is a relatively complications-free procedure, providing the delicate dissection of the second flap for Descement's membrane can be accomplished    without damaging the underlying tissue.

Combining viscocanalostomy with cataract surgery, is no problem, and involved doing the viscocanalostomy procedure, by completing the first and second flaps until   after phacoemulsification and IOL implant is complete. When the cataract portion of the procedure is finished, the second flap is excised, viscoelastic is injected and the outer flap is sutured shut.

Viscocanalostomy avoids the risk associated with trabecular glaucoma surgery - overdrainage with hypotomy and choroidal effusions flat anterior chambers
  -  Hypheama
  -  Bleb infections
  -  not an intraocular procedure

Strabismus

Strabismus refers to misaligned eyes. If the eyes turn inward (crossed), it is called esotropia. If the eyes turn outward (wall-eyed), it is called exotropia. Or, one eye can be higher than the other which is called hypertropia (for the higher eye) or hypotropia (for the lower eye). Strabismus can be subtle or obvious, intermittent (occurring occasionally), or constant. It can affect one eye only or shift between the eyes.

Strabismus usually begins in infancy or childhood. Some toddlers have accommodative esotropia. Their eyes cross because they need glasses for farsightedness. But most cases of strabismus do not have a well-understood cause. It seems to develop because the eye muscles are uncoordinated and do not move the eyes together. Acquired strabismus can occasionally occur because of a problem in the brain, an injury to the eye socket, or thyroid eye disease.

When young children develop strabismus, they typically have mild symptoms. They may hold their heads to one side if they can use their eyes together in that position. Or, they may close or cover one eye when it deviates, especially at first. Adults, on the other hand, have more symptoms when they develop strabismus. They have double vision (see a second image) and may lose depth perception. At all ages, strabismus is disturbing. Studies show school children with significant strabismus have self-image problems.

Amblyopia, or lazy eye, is closely related to strabismus. Children learn to suppress double vision so effectively that the deviating eye gradually loses vision. It may be necessary to patch the good eye and wear glasses before treating the strabismus. Amblyopia does not occur when alternate eyes deviate, and adults do not develop amblyopia.

Strabismus is often treated by surgically adjusting the tension on the eye muscles. The goal of surgery is to get the eyes close enough to perfectly straight that it is hard to see any residual deviation. Surgery usually improves the conditions though the results are rarely perfect. Results are usually better in young children. Surgery can be done with local anesthesia in some adults, but requires general anesthesia in children, usually as an outpatient. Prisms and Botox injections of the eye muscles are alternatives to surgery in some cases. Eye exercises are rarely effective.

Detached and Torn Retina

A retinal detachment is a very serious problem that almost always causes blindness unless treated. The appearance of flashing lights, floating objects, or a gray curtain moving across the field of vision are all indications of a retinal detachment. If any of these occur, see an ophthalmologist right away.

As one gets older, the vitreous, the clear gel-like substance that fills the inside of the eye, tends to shrink slightly and take on a more watery consistency. Sometimes as the vitreous shrinks it exerts enough force on the retina to make it tear.

Retinal tears increase the chance of developing a retinal detachment. Fluid vitreous, passing through the tear, lifts the retina off the back of the eye like wallpaper peeling off a wall. Laser surgery or cryotherapy (freezing) are often used to seal retinal tears and prevent detachment.

If the retina is detached, it must be reattached before sealing the retinal tear. There are three ways to repair retinal detachments. Pneumatic retinopexy involves injecting a special gas bubble into the eye that pushes on the retina to seal the tear. The scleral buckle procedure requires the fluid to be drained from under the retina before a flexible piece of silicone is sewn on the outer eye wall to give support to the tear while it heals. Vitrectomy surgery removes the vitreous gel from the eye, replacing it with a gas bubble, which is slowly replaced by the body's fluids.

- Performed under general anaesthetic
- Procedure takes approximately 40 – 60 minutes

Eyelid surgery is a common method of treatment for entropion (inward turning of the eyelid), ectropion (outward turning of the eyelid), ptosis (drooping of the eyelid), and some eyelid tumors.

Eyelid surgery is usually an outpatient procedure with local anesthesia. Risks of surgery are rare, but include asymmetry of the eyelids. Differences in healing between the eyes may cause some unevenness after surgery.

After eyelid surgery, a black eye is common but goes away quickly. It may be difficult to close your eyelids completely, making the eyes feel dry. This irritation generally disappears as the surgery heals. Serious complications are rare but include vision loss, scarring, and infection. To most people, the improvement in vision, comfort and appearance after eyelid surgery is very gratifying.

Ectropion

Ectropion is an outward turning of the lower eyelid, most commonly caused by aging, although eyelid burns or skin disease may also be responsible.

Normally, the eyelids help lubricate and cleanse the eye during blinking. An eyelid that is drooping and has lost contact with the eye can cause dry eyes, excessive tearing, redness and sensitivity to light and wind.

Surgery can be performed to tighten the eyelid and return it to its normal position. The eyelid can then protect and lubricate the eye properly, so that irritation and other symptoms subside.

Eyelid surgery to repair ectropion is usually performed as an outpatient procedure using local anesthesia. After surgery, an eye patch is usually worn and antibiotic ointment is prescribed.

Entropion

Entropion is an inward turning of the eyelid and lashes toward the eye, usually caused by relaxation of the eye muscles and tissue due to aging.

Entropion usually affects the lower lid. The skin and eyelashes rub against the eye and cause discomfort and tearing. The irritated eye can produce mucous, and become red and sensitive to light and wind. If entropion is not treated, rubbing of the skin and eyelashes can cause infection or scarring of the eye, which can cause vision loss.

Surgery can be performed to tighten the eyelid and return it to its normal position. The eyelid then protects the eye properly, and irritation and other symptoms subside.

Eyelid surgery to repair entropion is usually performed as an outpatient procedure using local anesthesia. After surgery, an eye patch is usually worn and antibiotic ointment is prescribed.

Blepharoplasty

As we age, the delicate skin around the eyes can appear puffy or saggy. Eyelid skin stretches, muscles weaken, and the normal deposits of protective fat around the eye bulge. The surgical procedure to remove excess eyelid tissues (skin, muscle, or fat) is called blepharoplasty.

Blepharoplasty can be performed on the upper eyelid, lower eyelid, or both. The surgery is performed for either cosmetic or functional reasons. Sometimes excess upper eyelid tissue obstructs the upper visual field or can weigh down the eyelid and produce tired-feeling eyes. Most often, people choose blepharoplasty to improve their appearance by making the area around their eyes firmer. When blepharoplasty is performed to improve vision, rather than for cosmetic reasons only, it may be covered by insurance.

Blepharoplasty for the lower lid removes the large bags under the eyes. It is unusual for third party payers to cover lower lid blepharoplasty.

The surgery is usually performed on an outpatient basis and can take one to three hours. Upper lid incisions are made in the natural crease of the lid, and lower lid incisions are made just below the lash line. A procedure for lower lid blepharoplasty, called transconjunctival blepharoplasty, removes excess fat through an incision inside the lower lid. Incisions are closed with fine sutures.

Swelling, bruising and blurry vision are common after blepharoplasty. Stitches are removed three to five days after surgery, except in the case of transconjunctival blepharoplasty where the self-dissolving sutures require no removal.

Possible complications associated with blepharoplasty include bleeding and swelling, delayed healing, infection, drooping of upper or lower eyelid, asymmetry, double vision, and dry eye. It is important to note that the puffiness of the fat pockets may not return, but normal wrinkling and aging of the eye area will continue.

Browlift (or Forehead Lift)

Sun, wind, and gravity affect the skin and muscles of the face over time. One of the most noticeable aspects of aging is a progressive drooping of the eyebrows. This can cause wrinkling of the forehead from raising one's eyebrows, as well as vertical wrinkles or furrows between the eyebrows. Sometimes the eyebrows or excess eyelid tissue can obstruct vision.

A browlift or forehead lift elevates the brow and smooths forehead skin, and can remove vertical lines between the eyebrows. Incisions are made in inconspicuous places, either behind the hairline, in one of the forehead wrinkles, or immediately above the eyebrows. If an endoscope (a small tube with a fiberoptic light) is used, the incisions can be very small. After the muscles are tightened and excess skin is removed, the incision is closed with sutures. The operation is usually an outpatient procedure that can take several hours.

Swelling and bruising, common after a browlift or forehead lift, begins to subside in seven to 14 days. Numbness and itching are common during the healing process. Sutures are removed within seven to ten days after surgery. Incisions in the hairline may damage hair follicles and result in some hair loss.

Refractive surgery involves a number of procedures which off an opportunity to decrease or eliminate your dependency on spectacle correction.   Unfortunately, from the ages between 40 to 50 years of age, presbyopia begins to occur.  Presbyopia is where the lens in the eye no longer has the ability to accommodate or focus for near vision.  As such, for anyone aged within this range or above, if the refractive error is corrected for distance vision, they will require near spectacles.  If your are shortsighted you will be able to take your spectacles off and read.  Correcting your distance vision will mean you need a reading correction.

Monovision offers an opportunity to decrease your dependence on near spectacles.  In this situation, one eye is fully corrected for distance vision and the other eye is corrected for reading.  It is worthwhile noting that the eye corrected for near vision will be blurred in the distance, but with the two eyes working together compensate this slight compromise to your vision.

Not everyone is suitable for the monovision correction.  Monovision has been shown to have a small effect on driving performance, with regards to depth perception.   We recommend a trial with contact lenses to simulate monovision prior to surgery to assess how you cope visually with your day to day activities and driving.  If you have a commercial vehicle licence requiring good distance vision in both eyes, you will not be a candidate for monovision.  If you are actively involved in sporting activities requiring very good general vision and/or depth perception, monovision is also not an option for you.

The strength of the monovision or the near vision eye is specifically chosen to suit your needs.  For example, some people may wish to keep reasonable distance vision in the near eye and have only limited near focus for situations such as reading a menu at a restaurant or grocery shopping without the need for near spectacles.  These people would still require near spectacles for general prolonged reading or fine print.  Alternatively, some people may wish to be capable of reading very fine print.  Your visual tasks and general lifestyle are very important in determining the monoision strength.

For some people with monovision, night driving spectacles may be required.  In the dim illumination, the pupil size increases which causes a decrease in the depth of focus for the eyes.  This means that you can notice some blur with your distance vision and could include such situations as night drive, theatre, or movies.  Spectacles in this situation is dependent on how the patient feels they are coping.