Center for Advanced Eye Care

BLEPHAROPLASTY Blepharoplasty (eyelid surgery) is a plastic surgery procedure for correcting sagging or drooping eyelids. The eyelid, because its skin is much thinner than that in other parts of the face, is often one of the first facial areas to exhibit signs of aging. Eyelids that sag or droop can affect peripheral vision, making daily activities such as driving more difficult. Blepharoplasty may become necessary when various factors, which include aging, sun damage, smoking and obesity, cause the muscles and tissue that support the eyelids to weaken. Reasons for Blepharoplasty Blepharoplasty tightens the eyelid‘s muscles and tissue, and removes excess fat and skin. Blepharoplasty eliminates the drooping of skin into the visual field, greatly improving peripheral vision. It is also performed for strictly cosmetic reasons. Functional Blepharoplasty If the eyelids begin sagging into the field of vision, a functional blepharoplasty may be required. The procedure may be covered by medical insurance if it is deemed medically necessary. A determination of how much vision is affected is done by checking the peripheral visual field with an instrument called the Humphrey Visual Field (HVF) Analyzer. Cosmetic Blepharoplasty Blepharoplasty can be performed on either the upper or lower eyelid, or on both, for cosmetic purposes. For a lower eyelid that needs fat rather than skin removed, a transconjunctival blepharoplasty is performed. During transconjunctival blepharoplasty, an incision is made inside the lower eyelid, so there are no visible scars, and the fat is removed. This procedure has no effect on vision, but results in a person‘s looking younger and more refreshed. It is important for a patient to have realistic expectations before undergoing cosmetic blepharoplasty. Although the procedure can enhance appearance and improve self-confidence, it does not radically alter the face. Candidates for Blepharoplasty The best candidates for blepharoplasty are those who are in good overall health, do not smoke, do not have any serious eye conditions, and have healthy facial tissue and muscle. People with eye disease, including glaucoma or retinal detachment, thyroid disorders, diabetes, cardiovascular disease or high blood pressure are not good candidates for blepharoplasty. The Blepharoplasty Procedure Blepharoplasty is typically performed as an outpatient procedure requiring local anesthesia and sedation. General anesthesia may be used for anxious patients. Patients can choose to have this procedure on their upper or lower eyelids, or both. The procedure can take anywhere from 45 minutes to 2 hours, depending on whether both the upper and lower eyelids are operated on. If the upper eyelid is being operated on, an incision is typically made along its natural crease. Once the incision is made, fat deposits are repositioned or removed, muscles and tissue are tightened, and excess skin is removed. For the lower eyelid, an incision is usually made just below the lash line so that excess skin can be removed. After the procedure, the incisions are closed with sutures, tissue glue or surgical tape, and usually loosely covered with gauze so the area can heal. Recovery After Blepharoplasty After blepharoplasty, patients may be advised to apply lubricating drops/ointment and cold compresses to aid in healing and minimize side effects. Most patients return to work within a few days to a week, but should avoid exercise and strenuous activities for at least 2 weeks. Stitches are usually removed after 3 or 4 days. Most swelling and other side effects typically subside within 2 weeks. Contact lenses and eye makeup may not be worn for 2 weeks after surgery. Patients are typically advised to wear dark sunglasses outside or in bright light for 2 weeks to protect their eyes from sun and wind. Risks of Blepharoplasty Although there may be swelling and bruising around the surgical site, they will subside on their own, and the eyelids will improve in appearance for up to a year. Uncommon side effects include infection, reaction to anesthesia, and double or blurred vision. Eyes may be irritated and dry due to a temporary change in tear distribution. Side effects such as uneven healing and permanent scarring are rare but, if they occur, may require surgical correction. The scars from blepharoplasty are well-concealed, and usually fade with time until they are virtually undetectable. Although the eyelids are still subject to aging, blepharoplasty produces long-lasting results.

CANALOPLASTY Canaloplasty is an advanced surgical procedure used for patients with open-angle glaucoma, the most common type of glaucoma. It causes the fluid in the eye to drain too slowly through the eye‘s network of tiny drainage channels, resulting in an increased pressure within the eye. Canaloplasty is a minimally invasive treatment that can substantially reduce eye pressure. During a canaloplasty, the surgeon will make a tiny incision to insert either a microcatheter or thin, flexible tube into the eye. The tubing is directed to the natural drainage canal of the eye, known as the Schlemm‘s Canal, which is where healthy eyes naturally drain. A sterile, surgical material called viscoelastic is introduced to the drainage channels in order to expand them. The tubing is removed and a suture is then placed in the canal and tightly tied, which serves to maintain the canal in an open position. The entire procedure typically lasts about 45 minutes. After a canaloplasty, most patients‘ dependence on glaucoma medication is greatly reduced. Patients will be permitted to return home soon after the procedure. Most activities can typically be resumed a few days later. This safe treatment method provides a faster recovery period and lower risk of complications than traditional glaucoma procedures such as a trabeculectomy.

CATARACT SURGERY A cataract is a clouding of the lens of the eye; cataract surgery is performed to improve vision by replacing the clouded lens with an artificial one. Cataracts affect millions of people in the United States each year. Most cataracts are the result of aging, though some form as a result of genetic factors, disease or injury. Cataract surgery is common, and considered safe and effective. Reasons for Cataract Surgery Cataracts can cause blurry vision, and increase the glare from lights. In their early stages, cataracts usually are not troublesome but, as they thicken, surgery to remove them may be required. Typically, surgery is needed because cataracts are interfering with everyday activities, or the treatment of another eye problem. Candidates for Cataract Surgery Cataracts caused by aging develop gradually, and patients may not notice the early vision changes they cause. It is only when their cataracts start interfering with vision that patients may become aware of them. An ophthalmologic examination will detect cataracts, and rule out other causes for vision issues, such as glaucoma or macular degeneration. Patients who become aware of visual difficulties related to cataracts usually experience, especially at night, clouded, blurred or dim vision. Benefits of Cataract Surgery Cataract surgery‘s benefits are many, greatly enhancing the quality of life. They include the following: Improved quality of vision (sharper images, brighter colors) Less difficulty with routine tasks (particularly night driving) Decreased dependency on eyeglasses Greater independence, regardless of age or disability Greater safety Research indicates that the improved vision provided by cataract surgery reduces the risk of falls, making exercise, sports and hobbies safer. This, combined with the improved ability to read, recognize faces, and perform everyday activities with greater ease, results in improved physical health, increased sociability and longer life expectancy. The Cataract Surgery Procedure After the pupil is dilated, and the area in and around the eye is numbed with anesthesia, a tiny incision is made to insert an ultrasonic probe. The probe emulsifies (breaks up) the cloudy lens into tiny pieces that are then suctioned out of the eye. Once the cloudy lens has been removed, an artificial lens is implanted. The new lens, known as an intraocular lens (IOL), is often inserted through the original incision. Some varieties of IOLs serve multiple purposes, such as blocking ultraviolet light or working as bifocals. Depending on the type of IOL used, sutures may or may not be needed. Surgery is usually performed on an outpatient basis in a doctor‘s office, takes only 20 to 30 minutes, and is relatively painless. A very high percentage of patients demonstrates improved vision after the procedure. Risks of Cataract Surgery Although cataract surgery is a common procedure and considered quite safe, any surgery poses risks. In the case of cataract surgery, there is a slightly increased risk of retinal detachment, a painless but dangerous condition. Other risks of cataract surgery include bleeding and infection. The risk of complications after cataract surgery is greater if the patient has another eye disease or serious medical condition. Danger signs of complications after cataract surgery include increased pain in or redness of the eye, light flashes or floaters, diminished vision, nausea, vomiting or intense coughing. Recovery from Cataract Surgery Immediately after surgery, an eye patch is worn; some doctors advise wearing a protective shield, even when sleeping, for several days. Vision may be blurry at first, but improves within a few days. Some itching and discomfort are also present for a few days, but it is important that a patient not rub or exert pressure on the treated eye. Heavy lifting should be avoided. Eye drops to prevent inflammation and infection, and control eye pressure are prescribed. Even though full healing can take up to 2 months, because cataract surgery is performed on one eye at a time, daily activities can be resumed in a few days. Most patients need to wear eyeglasses, for at least some tasks, after surgery. If the other eye also has a cataract, which is usually the case, the second surgery is scheduled a month or two after the first.

LASIK LASIK, an acronym for Laser-Assisted In Situ Keratomileusis, is a refractive procedure that reshapes the cornea to correct nearsightedness, farsightedness and astigmatism. It is the most common type of refractive surgery. Using targeted laser beam energy, the LASIK procedure reshapes the cornea so that light rays are focused more precisely on the retina, producing clear, sharp vision. Candidates Eligible for LASIK LASIK is considered a safe procedure, yet it is not ideal for everyone. A thorough medical evaluation of the patient‘s eyes must be performed to determine whether the LASIK procedure is appropriate. Good candidates for LASIK are patients who: Are over 18 years old Not pregnant or nursing In general good health Have had stable vision for at least 6 months Have healthy corneal tissue, thick enough for a flap Have refractive errors that fall within the treatable range It is also important for patients to fully understand the details and risks of the procedure, and to maintain realistic expectations for the outcome. Benefits of LASIK One of the primary benefits of LASIK is that patients immediately experience improved vision after surgery. For many people, laser eye surgery can correct their vision sufficiently to permit them to perform all, or most, of their daily activities without eyeglasses or contact lenses. Approximately 90 percent of patients who have undergone LASIK achieve 20/20 to 20/40 vision as a result of the procedure. LASIK has the advantage of being a short procedure that results in permanent vision improvement. Most patients who choose to undergo LASIK achieve clear vision without corrective lenses while also benefiting from minimal downtime and only mild post-operative discomfort. The LASIK Procedure LASIK is performed on an outpatient basis using only numbing eye drops to reduce any potential discomfort. The entire surgery takes less than 5 minutes to perform, although patients can expect to spend a few hours at the doctor‘s office. If requested, patients can receive an oral sedative prior to surgery to reduce any anxieties about the procedure. During the LASIK procedure, the patient lies down in a reclining chair as the doctor positions the laser precisely over the eye. A speculum is used to keep the eye open while the eye is cleaned and anesthetic eye drops are administered. A corneal flap is created with either a blade or a laser. The surgeon gently lifts the surface of the cornea aside, enabling the excimer laser to reshape the curvature of the cornea. The excimer laser delivers customized pulses of light energy based on each patient‘s prescription. The measurements for customization are determined prior to surgery, with the precise positioning confirmed prior to the start of the procedure. The second eye is treated immediately after the first. Following the surgery, the patient is provided with a protective shield to protect the eyes from bright lights. Risks of LASIK Any surgical procedure carries some risks, and patients should be aware that changes to the cornea made during LASIK cannot be reversed. Nonetheless, LASIK is considered safe for most eligible patients. While rare, complications may occur after the procedure, including: Undercorrection or overcorrection of vision Astigmatism Dry eyes Flap complications Postsurgical infection Increased sensitivity to light Visual problems, such as halos or night glare Fluctuating vision Only 1 percent of patients undergoing LASIK experience complications. Recovery After the LASIK Procedure After LASIK, patients rest in the ophthalmologist‘s office for a short time before having someone else escort them home. Medication may be prescribed to relieve any discomfort experienced during the first 24 to 48 hours after surgery, but most patients tolerate this procedure well. The doctor will likely recommend a few hours of rest after treatment. Most patients are able to return to work and other regular activities the very next day. Patients who have undergone LASIK are instructed to avoid strenuous activities for at least a week. Typically, patients experience a significant improvement in their vision immediately after the procedure, but the full benefits of LASIK may not be apparent for several months. While patients can achieve clear vision from LASIK, this procedure does not prevent the development of presbyopia, the age-related vision changes that occur after the age of 40. Many patients will need reading glasses for this condition, but their distance vision will remain clear.

MONOVISION LASIK Monovision LASIK surgery corrects one eye for distance and the other eye for near vision, eliminating or reducing the need for patients with presbyopia to rely on glasses or contacts. Patients retain both near and distance vision after LASIK surgery. For those patients, age 40 and older, who wear bifocals or reading glasses, monovision LASIK may be an option. The ability to focus the eyes on objects at different distances, also known as accommodation, changes with the aging process. The lenses of the eyes lose their flexibility and begin to harden as a part of the process called presbyopia, making accommodation more difficult to achieve. People with symptoms of presbyopia often need bifocals or two different pairs of glasses; one for distance and the other for near vision. Because LASIK does not treat presbyopia, patients who undergo conventional LASIK may still need glasses after the procedure. LASIK reshapes the cornea which does not affect the lens. Monovision LASIK preserves near and distance vision without the need for corrective eyewear. The LASIK procedure optimizes one eye for distance sight and the other eye for near sight. With practice, patients are able to adjust their vision to accommodate between distances.

PHOTOREFRACTIVE KERATECTOMY PRK Photorefractive keratectomy, or PRK, is a laser vision correction procedure that reshapes the cornea to correct mild to moderate conditions of myopia (nearsightedness), hyperopia (farsightedness), and astigmatism. It is the second most common type of laser eye surgery after LASIK. While during LASIK a flap is created to access the cornea, during PRK the entire epithelial layer of the cornea is removed and later allowed to grow back. During both processes, the cornea is reshaped to provide vision correction. Advantages of PRK Compared to LASIK, PRK provides the surgeon with greater control over the location and amount of tissue being removed, which permits more precise results. PRK gently sculpts the cornea rather than cuts, maintaining corneal strength while providing impressive vision correction. Other advantages of the PRK procedure include: Less depth of laser treatment No corneal flap complications Ability to be performed on thin corneas The PRK procedure offers distinct benefits to individuals whose activities put them at elevated risk of eye injury (boxers, for example) and for patients whose corneas are too thin, or whose pupils are too large, to permit LASIK. PRK also avoids not only the complications from corneal flaps, but a serious complication of LASIK known as corneal ectasia, which can result in distorted vision and even permanent vision loss. Disadvantages of PRK While PRK may be a preferable to LASIK surgery for some patients, there may be disadvantages to the procedure as well, including: More discomfort for the first few days after surgery Longer recovery period Greater risk of postsurgical eye infection Greater risk of temporary or permanent haziness of the cornea Both LASIK and PRK have comparable rates of vision improvement and carry some of the same risks, so a serious consultation with the ophthalmologist is necessary to determine which surgery will be most beneficial to the individual patient. The PRK Procedure Before the PRK procedure begins, the eyes are numbed with anesthetic eye drops. The surgeon then uses an excimer laser, with targeted laser energy, to reshape the cornea. The surgeon has complete control over the laser throughout the procedure, for a highly precise and customized result, designed to give each patient the best vision possible. The entire procedure takes only a few minutes to perform. Because of the potential for blurred vision for a time after PRK, the surgery is often performed on only one eye at a time, with the surgeon waiting to schedule the second eye until the vision in the first has adequately cleared. After the procedure, the eyes are bandaged with a soft contact lens to protect the cornea. New cells will grow back over the next few days to replace the cells that were removed. The contact lens will be removed by the surgeon in a follow-up examination. Recovery After the PRK Procedure After the PRK procedure is completed, patients are instructed to rest before returning home. They may required to wear eyeglasses after the procedure until their vision has stabilized. The surgeon prescribes eye drops to prevent infection and keep the eyes moistened. While vision may improve immediately after the PRK procedure, full results may take several days or weeks to become apparent. Strenuous exercise should be avoided for at least a week because this can interfere with the healing process. Patients will likely be able to see well enough to drive a car after 2 to 3 weeks. Results After the PRK Procedure The results of PRK are considered comparable to those of LASIK. Some patients may experience only 20/40 vision and may still need glasses or contact lenses after their procedure. PRK does not correct presbyopia, a natural change in the eyes that affects people over the age of 40. Patients who require glasses for reading will continue to need them after surgery. It is important for patients to maintain realistic expectations of the results of any laser surgery if they are to be satisfied with the results. Risks of PRK As with any type of surgery, there are certain risks associated with the PRK procedure, including: Postsurgical infection Adverse reaction to anesthesia Inaccurate vision correction Sensitivity to light Problems with night vision, such as halos Hazy vision Dry eyes Many of the complications that may arise after PRK are similar to those that may occur after any type of refractive surgery.

TYPES OF IOLS A wide range of replacement lenses are available to cataract patients, each offering different advantages for post-surgery vision. The most effective lens to use depends on the patient‘s individual preferences and goals for their vision. The lenses eliminate the need for glasses or contacts after cataract surgery, providing most patients with convenient, effective results for their specific vision conditions. Multifocal IOLs Multifocal IOLs allow for full vision correction at near, intermediate and far distances, completely eliminating the need for eyeglasses or contact lenses for most patients. Some IOLs can also correct astigmatism. The procedure to implant a multifocal IOL is performed at the conclusion of cataract surgery. These choices were not always available for cataract patients. In the past, cataract surgery only involved monofocal lenses, which could only focus on objects near or far, but could not adjust to accommodate varying distances. These patients still had to rely on glasses or contact lenses after surgery in order to see clearly at all distances, especially for those older patients suffering from presbyopia. Accommodative IOLs Crystalens is the only FDA-approved presbyopia correcting intraocular lens (IOL) that corrects vision through accommodation. The Crystalens IOL is made with flexible silicone that has hinges on each side allowing it to move with the eye muscle, flexing and accommodating seamlessly so you can focus on the objects around you at any distance. In other words, it dynamically adjusts to your visual needs. Accommodation is the ability to shift focus between nearby and distant objects, providing sharper vision at multiple distances in order to minimize the use of glasses. Other IOLs are unable to accommodate and those patients may require additional vision correction with glasses or contact lenses. Toric IOLs Intraocular lenses are used during cataract surgery to replace the damaged lens of the eye with an implant that clears up and corrects vision, oftentimes leaving patients with little to no dependence on glasses. Up until now, patients with astigmatism did not have the same opportunities that other cataract patients have had in correcting their condition with the types of IOL lenses that were available. Typically, the astigmatic patient would need an additional surgical procedure, such as refractive surgery or LASIK, to correct their vision after the procedure. If the patient did not want to undergo another surgical procedure, the only option for correction would be the use of either contact lenses or glasses to address their astigmatism. Toric IOLs are able to accommodate for the condition of astigmatism. Toric IOLs are specially designed to correct astigmatism along with overall vision during cataract surgery, offering complete vision correction.