Ophthalmologic surgery is a surgical procedure performed on the eye or any part of the eye.
Purpose
Surgery on the eye is routinely performed to repair retinal defects, remove cataracts or cancer, or to repair eye muscles. The most common purpose of ophthalmologic surgery is to restore or improve vision.
Demographics
Patients from the very young to very old have ocular conditions that warrant eye surgery. Two of the most common procedures are phacoemulsification for cataracts and elective refractive surgeries.
Cataract surgery is the most common ophthalmic procedure. More than 1.5 million cataract surgeries are performed in the United States each year. The National Eye Institute (NEI) recently reported that more than half of all United States residents age 65 and older have a cataract.
Elective refractive surgeries, especially laser in-situ keratomileusis (LASIK), attract younger patients in their thirties and forties. Recently, the American Academy of Ophthalmology (AAO) estimated that 95% of the 1.8 million refractive surgery procedures performed in a year were LASIK.
Description
The surgeon, operating room nurses, and an anesthesiologist are present for ophthalmologic surgery. For many eye surgeries, only a local anesthetic is used, and the patient is awake but relaxed. The patient's eye area is scrubbed prior to surgery, and sterile drapes are placed over the shoulders and head. Heart rate and blood pressure are monitored throughout the procedure. The patient is required to lie still and for some surgery, especially refractive surgery, he or she is asked to focus on the light of the operating microscope. A speculum is placed in the eye to hold it open throughout surgery.
Common ophthalmologic surgery tools include scalpels, blades, forceps, speculums, and scissors. Many ophthalmologic surgeries now use lasers, which decrease the operating time as well as recovery time.
Surgeries requiring suturing can take as long as two to three hours. These intricate surgeries sometimes require the skill of a corneal or vitreo-retinal specialist, and require the patient to be put under general anesthesia.
Refractive surgeries
Refractive surgeries use an excimer laser to reshape the cornea. The surgeon creates a flap of tissue across the cornea with an instrument called a microkeratome, ablates the cornea for about 30 seconds, and then replaces the flap. The laser allows this surgery to take only minutes, without the use of stitches.
Trabeculectomy
Trabeculectomy surgery uses a laser to open the drainage canals or make an opening in the iris to increase outflow of aqueous humor. The purpose is to lower intraocular pressure in the treatment of glaucoma.
Laser photocoagulation
Laser photocoagulation is used to treat some forms of wet age-related macular degeneration. The procedure stops leakage of abnormal blood vessels by burning them to slow the progress of the disease.
Diagnosis/Preparation
Patients complaining of any ocular problem that requires surgery will receive a similar initial examination. A complete patient history is taken, including the chief complaint. The patient needs to disclose any allergies, medication usage, family eye and medical histories, and vocational and recreational vision requirements.
The diagnostic exam should include measurement of visual acuity under both low and high illumination, biomicroscopy with pupillary dilation, stereoscopic fundus examination with pupillary dilation, assessment of ocular motility and binocularity, visual fields, evaluation of pupillary responses to rule out afferent pupillary defects, refraction, and measurement of intraocular pressure (IOP).
Other examination procedures include corneal mapping, a keratometer reading to determine the curvature of the central part of the cornea, and a slit lamp exam to determine any damage to the cornea and evidence of glaucoma and cataracts. A fundus exam also will be performed to check for retinal holes, and macular degeneration and disease.
The patient's overall health must also be considered. Poor general health will affect the ophthalmologic surgery outcome. Surgeons may request a complete physical examination, in addition to the eye examination, prior to surgery.
Pre-surgery preparation
Patients having ophthalmologic surgery usually must stop taking aspirin, or aspirin-like products, 10 days before surgery unless directed otherwise by the surgeon. Patients taking blood thinners also must check with their physician to find out when they should stop taking the medication before surgery. A number of pain relievers may affect outcomes, making it important for patients to disclose all medication. The patient might have to ask about alternative medications if the surgeon requires that he or she stops taking the usual regime before the procedure. Some prescription medicines have been known to cause postsurgical scarring or flecks under the corneal flap after LASIK.
To reduce the chance of infection, the surgeon may request that the patient begin using antibiotic drops before surgery. Depending on the procedure, the patient may also be advised to discontinue contact lens wear and stop using creams, lotions, make-up, or perfume. Patients may also be asked to scrub their eyelashes for a period of time to remove any debris.
Patients are advised not to drink alcoholic beverages at least 24 hours before and after the ophthalmic procedure.
Patients must usually avoid eating or drinking anything after midnight on the day before the surgery; however, some patients may be allowed to have clear liquids in the morning. It is important for patients to ask their physician for a list of foods and medications permitted on the morning of surgery. Some patients may take morning medications (with physician approval) with the exclusion of diuretics, insulin, or diabetes pills. Patients are advised to dress comfortably for the surgery, and wear button-down shirts that will not have to pass over the head.
Presurgical tests sometimes are administered when the patient arrives for surgery. For refractive surgeries, this ensures the laser is set for the correct refractive error. Before cataract surgery, measurements help determine the refractive power of the intraocular lens (IOL). Other tests such as a chest x ray, blood work, or urinalysis may also be requested depending on the patient's overall health.
Most ophthalmic surgeries are done on an outpatient basis, and patients must arrange for someone to take them home after the procedure.
Before surgery, doctors will review the presurgical tests and instill any dilating eye drops, antibiotic drops, and a corticosteriod or nonsteroidal anti-inflammatory drops as needed. Anesthetic eye drops also will be administered. Many ophthalmologic surgeries are performed under a local anesthetic, and patients remain awake but in a relaxed state.
Aftercare
After surgery, the patient is monitored in a recovery area. For most outpatient procedures, the patient is advised to rest for at least 24 hours until he or she returns to the surgeon's office for follow-up care. Over-the-counter medications are usually advised for pain relief, but patients should check with their doctor to see what is recommended. Some pain relievers interfere with surgical outcomes. Patients may also use ice packs to help ease pain.
Some patients may experience slight drooping or bruising of the eye. This condition improves as the eye heals. Severe pain, nausea, or vomiting should be reported to the surgeon immediately.
After surgery, patients may be advised not to stoop, lift heavy objects, exercise vigorously, or swim. Patients may also be required to wear an eye shield while sleeping, and sunglasses or some type of protective lens during the day to avoid injury. Wearing make-up may be prohibited for weeks after surgery. The patient may be restricted from driving and air travel.
Patients usually have their first postoperative visit the day after the eye surgery. Subsequent exams are commonly scheduled at one, three, and six to eight weeks following surgery. This schedule depends on the patient's healing, and any complications he or she might experience.
Some patients will be required to instill eye drops for a number of weeks after surgery to prevent infection, pain, and to lessen inflammation. Eye drops also are used to lower intraocular pressure. In some cases, correct eye drop usage is critical to a successful surgery outcome.
Risks
Complications may occur during any surgery. Ophthalmologic surgery, however, is usually very safe.
Some risks include:
Undercorrection or overcorrection in refractive surgery. Undercorrected refractive surgery patients usually can be treated with an enhancement, but overcorrected patients will need to use eyeglasses or contact lenses.
Debilitating symptoms. These include glare, halos, double vision, and poor nighttime vision. Some patients may also lose contrast sensitivity. These symptoms may be temporary or permanent.
Dry eye. Some patients are treated with artificial tears or punctal plugs.
Retinal detachment. The retina can become detached by the surgery if this part of the eye has any weakness when the procedure is performed. This may not occur for weeks or months.
Endophthalmitis. An infection in the eyeball is a complication that is less common today because of newer surgery techniques and antibiotics.
Other serious complications that may occur are blindness, glaucoma, or hemorrhage.
Normal results
Normal results include restored or improved vision, and a much improved quality of life. Specific improvements depend on the type of ophthalmologic surgery performed, and the type of ocular ailment being treated.
Morbidity and mortality rates
Death from ophthalmologic surgery is rare. However, complications can still arise from the use of general anesthesia. With most ophthalmic surgeries requiring only local anesthetic, that risk has been widely eliminated.
Blindness, which was sometimes caused by serious infection, has also been reduced because of more effective antibiotics.
Alternatives
Some medications can be used to treat certain ophthalmic conditions. For example, surgery for glaucoma is performed only in patients who do not respond to medication. Patients with myopia (nearsightedness), hyperopia (farsightedness), or presbyopia, can wear contact lenses or eyeglasses instead of having refractive surgery to improve their refractive errors.
BOOKS
Berkow, Robert, ed. The Merck Manual of Medical Information. Whitehorse Station, NJ: 1997.
Columbia University College of Physicians & Surgeons Complete Home Medical Guide 3rd Edition. New York, NY: Crown Publishers, 1995.
Daly, Stephen, ed. Everything You Need to Know About MedicalTreatments. Springhouse, PA: Springhouse Corp., 1996.
ORGANIZATIONS
American Academy of Ophthalmology. PO Box 7424, San Francisco, CA 94120-7424. (415) 561-8500. <www.aao.org>.
American Optometric Association. 243 North Lindbergh Blvd., St. Louis, MO 63141. (314) 991-4100. <www.aoanet.org>.
American Society of Cataract and Refractive Surgery. 4000 Legato Road, Suite 850, Fairfax, VA 22033-4055. (703) 591-2220. E-mail: ascrs@ascrs.org; <www.ascrs.org>.
National Eye Institute. 2020 Vision Place Bethesda, MD 20892-3655. (301) 496-5248. <www.nei.nih.gov>.
University of Michigan Kellogg Eye Center Department of Ophthalmology and Visual Sciences. 1000 Wall Street, Ann Arbor, MI 48105. (734) 763-1415. <www.kellogg.umich.edu>.
"Surgical Procedures for Glaucoma." Your Medical Source. [cited April 12, 2003] <www.yourmedicalsource.com/library/glaucoma/GLC_surgery.html>
Mary Bekker
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Ophthalmologists and optometrists may detect ophthalmic problems; however, only an ophthalmologist can perform surgery. An ophthalmologist has received specialized training in diseases of the eye and their surgical treatment. Some ophthalmologists further specialize in certain areas of the eye, such as corneal or vitreo-retinal specialists. Depending on the severity of the disease, the general ophthalmologist may refer the patient to a specialist for treatment.
An anesthesiologist may be on hand during surgery to administer the local anesthetic. Surgical nurses will assist the ophthalmologist in the operating room, and assist the patient preoperatively and postoperatively.
Most ophthalmic surgery is performed on an outpatient basis. Ambulatory surgery centers designed for ophthalmologic surgery are commonly used. Surgery may also be performed in hospital operating rooms designed for outpatient surgeries.
QUESTIONS TO ASK THE DOCTOR
If both eyes are diseased, will they be treated simultaneously?
Will the eyes need to rest after surgery? Will protective lenses be required following the procedure?
