Author: Thind Eye Hospital

A cataract is a cloudiness or opacity of the eye’s natural clear lens. It obstructs the passage of light to the retina (parda) of the eye and impairs vision. When the lens develops cloudiness to the point that it impairs vision, it is called cataract. It is like looking through a frosted glass.

How is cataract diagnosed?
The ophthalmologist examines the rest of the eye so as to predict the visual results of the surgery. The pressure of eye is recorded so as to rule out glaucoma. If possible, the retina is also examined, otherwise ultrasound scanning is performed.

What are the symptoms?
Progressive and painless blurring of vision is the commonest symptom. The blurring of vision may be more marked in bright light. Brightness and contrast of the image decreases in early cataract. Some individuals experience glare in night driving. Colors may become less district. Later on the vision deteriorates and interferes in day to day activities. Seeing two or more moons poyopial at night also suggests cataract. Pain, itching, redness or watering are not symptoms of cataract. Cataract usually develops in both the eyes, but may progress at different rates.

Is there a cure?
Although research is currently underway, no preventive measures are known for cataract that develops with age. No diet, drugs or medicine have been proven to delay or cure the cataract. The only treatment is surgical. Cataract surgery is a safe surgical procedure, with the appropriate lens implant, has restored sight for millions.

Phacoemulsificatlon or Phaco

Phacomulsification                                                            Conventional Surgery

1.2 mm to 1.8 mm long Incision                                             7 mm to 9 mm long Incision

It is a no stitch small incision cataract surgery. IOL is implanted and the surgery is completed without any stitch. The Incision is only 1.8mm – 2.2mm long.

A computer controlled ‘Phaco’ machine with tiny ultrasonic probe is used to remove cataract. Phaco uses ultrasound energy to liquify lens and suck it out with a titanium probe, vibrating forty thousand times a second. The lens is implanted through the smallest possible opening in the eye. The minute (2.2mm or smaller) incision is self sealed and needs no suture or stitch to close it. The patient is back to normal activities within a few days, including attending office or even doing heavy manual work. Phacoemulsificatlon was started for the first time in Jalandhar at THIND EYE HOSPITAL. At present this technique is used for all cases undergoing Cataract surgery at our hospital. To retain the maximum benefit of the miniature 2.2mm or smallest incision, a foldable IOL is used. The foldable IOL made of transparent silicone or acrylic polymer to be inserted inside the eye in a fine tube and it unfolds to It’s full size once inside the eye.

Diabetes Mellitus is a condition which impairs the body’s ability to use and store sugar. The past two decades have seen an explosive increase in the incidence of Diabetes in India, which has the largest number of diabetics in the world today. The increased incidence of Diabetes Mellitus and its complications have been attributed to changes in life style caused by increased urbanization, high calorie diet, decreased physical activity and stress. Another cause for concern is that Diabetes Mellitus has been striking at an early age among the urban population. Diabetics are at a higher risk of developing blindness, getting a stroke, suffering from myocardial infarction, developing kidney disease or undergoing amputation. It is a common disease with serious ocular complications and one of the leading causes of blindness in the world. Diabetics are at high risk for eye complications, the most common being Diabetic Retinopathy. Certain studies have shown that the development of Diabetic Retinopathy depends greatly on the duration of Diabetes Mellitus. Other associated factors that increased the chances of this disease were hypertension, smoking & presence of renal diseases. Diabetes Mellitus does not just affect the retina. It has been found to promote cataract formation, an increased incidence of open angle Glaucoma, etc. Unfortunately, it is mainly the effect of Diabetes Mellitus on the retina that causes blindness.

What is Diabetic Retinopathy?

It is a stage of the disease process in which the blood vessels in the retina are damaged and leak fluid or blood. It has been seen that 25 % of all diabetics develop this complication after 10 years of developing Diabetes and 50 %develop it after 20 years of developing diabetes. People with Type 1 Diabetes [Diabetes since childhood] are more likely to develop diabetic retinopathy at a younger age. Diabetics also have a higher incidence of cataract and glaucoma and those with poorly controlled blood sugar and blood pressure are at a higher risk of losing vision.

What are the symptoms of diabetic retinopathy?
Early Diabetic Retinopathy usually has no symptoms. Gradual blurring of vision may occur if fluid leaks in the central part of the retina [the macula]. In late diabetic retinopathy [proliferative stage], new abnormal blood vessels begin growing on the surface of the retina or the optic nerve. These vessels have weak walls and leak blood into the retina and vitreous [jelly that fills most of the eye]. Presence of blood in the path, from where the light enters the eye, blocks vision.

How is diabetic retinopathy diagnosed?
Complete eye examination is required for the detection of diabetic retinopathy. The retina of the eye is examined using an instrument called the indirect ophthalmoscope after dilating the pupils. If diabetic retinopathy is detected, a special test called Fluorescein Angiography may be performed where a dye is injected in the vein of the arm and serial photographs of the retina aretaken. Optical Coherence Tomography (OCT) is another test used for detection and evaluation ofDiabetic Macular Edema(DIVIE) which is swelling and fluid accumulation in the most important area of the retina.

How is diabetic retinopathy treated ?
The first step is that all diabetics must maintain strict control of blood sugar and blood pressure and follow a regular exercise regime and healthy diet. In early cases only regular follow-up may be necessary. [Vlore advanced cases require treatment to control the damage of Diabetic Retinopathy and improve sight in the form of lasers, injections or surgery.

I. LaserTreatment:
here are two types of laser treatments done for DiabeticRetinopathy:

a) Focal Laser:
Focal laser is done for swelling of the macula due to leakage from damaged blood vessels. There is usually no pain from this laser and there will be some slight blurring of vision initially after treatment.

b) Peripheral Laser or Pan Retinal:
Photo coagulation (PRP): This type of laser is done for severe diabetic retinopathy which has developed new vessel for mationor bleeding into the vitreous gel. This type of laser may lead to loss of peripheral vision, decreased night vision and may be painful with the need to give an injection on around the eye ball for anesthesia.

II. Vitrectomy Surgery:
In the event of the patient presenting with very advanced Diabetic Retinopathy, a microsurgical procedure known as Vitrectomy is recommended. Blood-filled vitreous gel of the eye is replaced with a clear solution to aid in restoring vision. Sometimes the retina may also be’ detached. Vitrectomy surgery is thenperformed to reattach the retina.

III. Intraocular Injections:
Newer modility of treatment include use of intraocularinjections(AntiVEGF&Steroids) for diabetic macular edemas as a pre operative tool to reduce the incidence of bleeding during Vitrectomy Surgery. How to prevent visual loss in Diabetes ? Early detection of diabetic retinopathy and timely laser treatment is the best protection against loss of vision. Diabetics must have their eyes examined regularly. Our diabetic clinic is designed towards providing regular preventive care as well as fo I low—up for patients with established diabetic retinopathy. Additionally, all diabetics must maintain control of blood sugar and blood pressure and follow a regular exercise regime and healthy diet.

The Diabetic Retinopathy Treatment at THIND EYE HOSPITAL:

• Diabetes needs regular follow-up since the condition can lead to a dramatic loss of vision if poorly treated orneglected.
• Various factors govern the rate of progression of your condition. It is therefore necessary to review your eye condition periodically even after the present condition has been treated
• The patients receive specialized care provided by our diabetic retina specialists.
• At each visit to THIND EYE HOSPITAL, we check your vision & intraocular pressure, do a slitlamp biomicroscopy and perform a detailed retinal examination with dilated pupils using an indirect ophthalmoscope. We record images and maintain records of your eye condition for comparison on the following visit. We also monitor factors that control the progression of your eye condition such as diet, blood sugar levels, exercise, blood pressure etc.
• We Perform special procedures like Fluorescein Angiography, Optical Coherence Tomography, Laser Photocoagulation and Ultrasonography, if required.

All diabetics must have their eyes examined regularly with dilated pupils. Juvenile diabetics must have their eyes examined at least once a year after the age of 12 years because diabetic retinopathy is rarely known to occur before puberty. Those with Diabetes at an older age must have the eye examination done once at the time of diagnosis and then at least every year thereafter. If Diabetic Retinopathy has been diagnosed, they should have the eyes examined as often as recommended by their eye doctor.
At Thind Eye Hospital Your eye health is our prime concern. If you have any queries regarding Diabetic Retinopathy or its treatment, please feel free to contact us either personally or telephonically. Our team of doctors, counselors and staff will ensure that your experience of treatment of Diabetic Retinopathy, at our centre, is a leasant and memorable one.

Unfortunately, people seldom notice these small blind areas until they enlarge which is why glaucoma is often called the silent thief of vision. When the entire nerve is destroyed permanent blindness results. Special tests are the only way to identify these early defects. Early detection and treatment are the keys to prevent optic nerve damage and blindness from Glaucoma (Kala Motia).

About Pressure
A clear fluid called the ‘Aqueous Humor’ circulates continuously within the eye. This fluid is not a part of the tears on the outer surface of the eye. Produced behind the Iris (The brown part of the eye), it flows forwards through the pupil and drains out of the eye through intricate drainage channels. Normally, fluid production and outflow are balanced. As a result the pressure inside the eye remains stable and within the safe range. If the drainage of this fluid is hampered, the pressure within the eye increases to a level that damages the cells in the optic nerve. This is Glaucoma (Kala Motia).

About Rise in pressure
The drainage portion of the eye, called the ‘drainage angle’ is like a sieve and can be blocked in different ways.
a) It may get blocked suddenly by the iris that closes the drainage angle. Eye pressure increases rapidly, resulting in a sudden loss of vision, severe eye pain and headache, rainbow halos around light accompanied by nausea and vomiting. This is called “Acute Angle Closure Glaucoma” and if not treated as an emergency it leads to permanent blindness.
b) In the second type of Glaucoma, the out flow sieves get blocked by debris. This leads to a slow rise in pressure, known as ‘Primary Open Angle Glaucoma’. Vision is lost so gradually and painlessly that a person is unaware of until the optic nerve is badly damaged. What makes it dangerous is that has no symptoms. This type of Glaucoma is much more common.
c) Glaucoma can also occur after an injury, inflammation of eye, drugs, cataract etc. Glaucoma may rarely be present at birth. The parents may notice their baby’s eye enlarging due to the increase in pressure. The cornea becomes cloudy, with watering and increasing sensitivity to light. This needs an urgent eye examination .

Range of Normal Pressure
The average Intra-Ocular Pressure (IOP; the pressure within the eye like the air pressure in tyre of a car) in adult is 16 mmHg. The actual upper limit of normal pressure, however, is difficult to pinpoint. If the 10P is consistently above 21mmHg, the chances of eye damage are probably around 10%. When the 10P is above 26mmHg, the likelihood increases to about 50%. What constitutes normal 10P is an individual matter for each person. For example, some persons with an 10P of 16mmHg may need surgery while, others with an 10P of 30mmHg may be kept under observation only. The 10P is different and independent of blood pressure. Don’t confuse it with the pressures of day to day life!

Common in all type of Glaucoma
All types of Glaucoma have three features in common. These form the basis to diagnose Glaucoma, measure the extent of damage, and monitor its progression. a) Increased 10P: The pressure inside the eye is measured with Goldmann applanation tonometer. A prism with blue lights touches the eye to accurately check 10P. There are however some types of glaucoma where damage may occur even with a normal pressure, called Normal Tension Glaucoma. b) Cupping and atrophy of the Optic Nerve: It is the drying up of the optic nerve (the nerve of sight) as it suffers damage due to high pressure inside the eye. It is assessed by examination of the fundus of the eye. c) Retinal Nevre fibre layer (RNFL) defects and Visual Field Defects: The slow death of nerve fibers is the earliest change to occur in Glaucoma. This nerve fibre layer damage is picked by a specialized instrument called OCT. Visual Fields defects are missing areas in the field of sight, though the person may be seeing well otherwise. This is measured with an instrument called a perimeter. The modern perimeter is computerized to measure; analyse, compare and report the defects.

Symptom
Unfortunately there are no symptoms in early stages. A person with Chronic Glaucoma is usually unaware of the disease. Like the hands of a clock, Chronic Glaucoma moves so slowly that its progress is not noticed. It is a silent thief of vision.
On the other hand, Acute Glaucoma, in which the pressure rises rapidly, causes severe symptoms which compel the patient to consult a doctor. Symptoms that suggest the presence of Chronic or Acute Glaucoma include are shown in above table.

Early Detection
Getting an annual eye examination at Thind Eye Hospital is the best way to detect Glaucoma. During a complete work up for Glaucoma, we will be asure your Int ra-Ocular Pres sure (Tonometry), the central corneal thickness (Pachymetry) inspect the drainage angle of the eye (Gonioscopy), evaluate for optic nerve head damage (Ophthalmoscopy), test the visual field of each eye (Perimetry) and measure the thickness of your retinal nerve fibre layer (OCT examination).
All of these tests may not be necessary for every person. But it is very important that these tests be repeated on a regular basis to monitor the progress of disease and to detect glaucoma at the earliest possible stage.

Risk Factor
People with high 10P have a higher risk of developing optic nerve damage. Other important risk factors include advancing age, severe myopia (near sighted), and a family history of Glaucoma, presence of Diabetes, past injury to the eye, surgery, or history of severe anaemia or shock.
We will weigh all these factors before deciding whether you need treatment for Glaucoma or not. If your risk of developing Glaucoma is higher than normal but there is no optic nerve damage, you will be monitored periodically as a ‘Glaucoma suspect’.

Medical Treatment
Eye drops to lower your 10P are the first line of treatment. They act to decrease eye pressure either by reducing the production of fluid within the eye or by improving the outflow through the drainage angle. It is very important to use the drops regularly at the prescribed timings.

Sometimes pills may also be required. Some medicines may occasionally result in unwanted side effects. They may sting, redden the eye and cause blurring of vision or headaches. Such side effects usually disappear after a few days. Rare side effects may be changes in your heart rate and breathing. Inform us immediately if you think you are experiencing side effects it is very important to consult your ophthalmologist before starting, stopping or changing your medication.. Frequent eye examinations and tests are the only way to monitor any changes in your Glaucoma.

Laser surgery is effective for some types of Glaucoma. In a laser surgery known as trabeculoplasty used in chronic open angle Glaucoma, the drain itself is treated In another laser surgery known as Laser iridotomy used in angle-closure Glaucoma, a hole is made in their is 0 to restore the free flow of aqueous fluid. These laser surgeries help to reduce the need for eye drops and pills to control your pressure.

In advanced cases, surgery known as trabeculectomy is necessary to control Glaucoma. We use specialized instruments to create a new drainage channel for the fluid to leave the eye, thus lowering the pressure in advanced cases. If surgery fails, special Glaucoma valves can be implanted. Fortunately, glaucoma surgery today is very safe and serious complications of modern are rare. Surgery for Glaucoma would be recommended only if the medicines or lasers fail to prevent damage to the optic nerve.

Whatever may be the approach, the objective of the treatment is to lower the eye pressure to a level at which optic nerve damage does not develop or worsen. Although eye pressure is important, the condition of your optic nerve and peripheral vision are equally or more important. It is very important to understand that achieving a normal pressure does not mean that glaucoma has been cured. It only means that the treatment is effective and would help prevent further damage to your vision. However regular eye examinations are very important while you are on treatment as glaucoma behaves differently in every patient and more aggressive treatment is often needed in some patients. This would involve reducing the pressure even further since the threshold at which pressure can cause damage is different for each individual.

The success of your treatment depends entirely on the team work put in by you and the Thind Eye Hospital team. On your part is therefore important to communicate with us and to remember to keep the follow-up appointments. If you don’t, glaucoma could be stealing your sight without your knowledge.

Management
Glaucoma is a lifelong diagnosis and treatment. Strictly speaking Glaucoma cannot be cured but it can be controlled to slow or halt optic nerve damage. The key to preventing blindness from Glaucoma is early diagnosis and treatment. This is why we emphasize regular checkups to detect glaucoma, especially if you have family history of glaucoma. If glaucoma is detected at an early stage and effective treatment is started we can prevent it from causing ANY vision loss. However achieving this goal requires a lifelong commitment to treatment and regular visits to Thind Eye Hospital.

Suggested Screening

• People with high intra-ocular pressure (IOP): Need a baseline glaucoma work up including pressure check, central corneal thickness measurement, gonioscopy, fundus examinations OCT and Perimetry. Regular follow-up visits to monitor !OP and optic nerve damage are required every six months.
• People over the age of forty years with no previous glaucoma: At least once every two years, especially whenever there is a change of reading glasses.
• Family history of Glaucoma: Regular screening form a young age for people with parents or close relatives suffering from glaucoma.
• People having high minus or plus numbered glasses: Once a year checkup.
• Other high risk factors like diabetes, eye injuries, a major eye surgery, prolonged steroid use etc., need more frequent screening

Causes of Squint?
Squint may be caused by any of the following:

• Weakened muscles or abnormal nerve impulses to the eye muscles
• Heredity
• Blurred or poor vision ‘Conditions inside the eye such as cataract

Symptoms of squint
Main complaint of patient is that the eyes are not straight. Sometimes, a youngster will squint or close one eye in bright sunlight. Faulty depth perception may be present. Some children turn their face or tilt head in a specific direction in order to use their eyes together.

Treatment
Patient often gets the false impression that child may “outgrow” the problem. If a child has two eyes pointed in different directions, eye examination by ophthalmologist is necessary to determine the cause and to begin treatment. The goals of treatment are to preserve vision, straighten the eyes and to restore binocular vision. Treatment of squint depends upon the exact cause of the misaligned eyes. It can be directed towards unbalanced muscles or other conditions, which are causing the eyes to point in two different directions. After a complete eye check-up, including detailed study of the inner parts of the eye, an ophthalmologist can recommend appropriate optical, medical and surgical therapy.

Non Surgical Treatment
Some squints are caused because of refractive errors. For such cases, wearing prescribed glasses can correct squint completely.

Surgical Treatment
Most patients require surgical corrections. Surgery is done
under anaesthesia, in children and under local anaesthesia in adults.

Facts about Squint Surgery

• Squint involves both eye, It may be obvious only in one eye
• Surgery is done on eye muscles situated out side the eyeball.
• Muscles are adjusted to correct the position of eye in straight gaze
• One or more muscles may be operated depending upon type and severity of squint
• Surgery is done either on both eyes simultaneously or one eye at a time
• Squint surgery can be done in any eye
• Other eye surgery may be required later
• Surgery does not worsen the patients sight
• Most of the surgeries are for “cosmetic” reasons
• Patient may experience double vision temporally after surgery. This usually resolve in few days. Personalize Your Vision – We Make Great Vision Affordable
• Patient should be free of any general illness
• Parents should inform doctors of systemic disease especially cardiac problems and fits
• Routine blood investigations and X-rays are required before surgery
• Patient undergoing general anaesthesia should not consume water or solids foods at least four hours before surgery.
• Anaesthetist fitness should be obtained before receiving anaesthesia
• Eye is bandaged for one day after surgery.
• Patients are usually freed from hospital same day when the effect of anaesthesia wears off
• Eye drops are used for one month after surgery
• Oral medicines are used for first few days after surgery
• First follow—up is on next day, after one week and after one month of surgery.
• Further follow-up depends upon patients requirement for additional treatments for Amblyopia or refractive errors etc.
• Patients can start normal activities form next day of surgery
• Patient should avoid water entering the eyes for at least a week after surgery
•  

In case of doubt please consult our doctors. Child with squint do not outgrow the condition child with squint usually has defective vision which can be corrected by proper treatment if initiated early in life treatment for squint may be non-surgical which include glasses or patching of eyes surgical treatment of eye if indicated should be at the earliest possible age; this allows better surgical results and binocular function.

Causes :
Overuse of the eyes does not cause or worsen refractive error. The causes of the main types of refractive error are described below:

Myopia(close objects are clear, and distant objects are blurry)
Also known as nearsightedness, myopia is usually inherited and often discovered in childhood. Myopia often progresses throughout the teenage years when the body is growing rapidly.· Hyperopia (close objects are more blurry than distant objects)
Also known as farsightedness, hyperopia can also be inherited. Children often have hyperopia, which may lessen in adulthood. In mild hyperopia, distance vision is clear while near vision is blurry. In more advanced hyperopia, vision can be blurred at all distances.

Presbyopia (aging of the lens in the eye)
After age 40, the lens of the eye becomes more rigid and does not flex as easily. As a result, the eye loses its focusing ability and it becomes more difficult to read at close range. This normal aging process of the lens can also be combined with myopia, hyperopia or astigmatism.

Astigmatism
Astigmatism usually occurs when the front surface of the eye, the cornea, has an asymmetric curvature. Normally the cornea is smooth and equally curved in all directions, and light entering the cornea is focused equally on all planes, or in all directions. In astigmatism, the front surface of the cornea is curved more in one direction than in another. This abnormality may result in vision that is much like looking into a distorted, wavy mirror. Usually, astigmatism causes blurred vision at all distances.

Causes of Amblyopia
The most common problem is poor focusing due to myopia (nearsightedness), hyperopia (farsightedness), or astigmatism (irregularity of the focus) and Anisometropia.

Strabismus (a squint or turning eye)
Strabismus will sometimes cause amblyopia. If, for example, there is an in-turning of the eye, and it is always the same eye that turns in, then this eye will become amblyopic.

Visual deprivation
Anything that interrupts the passage of light into the eye, such as a scar on the cornea (surface of the eye), a cataract (an opaque lens in the eye), or a very droopy eyelid can lead to amblyopia.

Treating amblyopia
Treating amblyopia relies on making a child use the poorer eye in order to build the vision up again. Patching is the mainstay of amblyopia treatment. Amblyopia treatment only treats the vision and does not make a turned eye become straight.