Eye Surgery

Please click on the links below to find out more about each subject:

• Cataract Surgery
• Glaucoma Surgery
• Eyelid Surgery
• Lacrimal Surgery
• Retinal Surgery
• Strabismus Surgery
• Laser Surgery in Ophthalmology

Also, feel free to visit our tutorial pages on eye anatomy and eye disease as well!

Cataract Surgery

If you have been told that you have a cataract, there is no reason to be overly concerned as you are not alone. Each year in the United States, more than 2.5 million people have cataract surgery. Thanks to advanced surgical procedures and technology, cataract surgery is not only one of the most frequently performed surgical procedures in the United States, but it is also one of the safest and most successful surgical procedures you can have. Cataract surgery is performed on an outpatient basis and usually only requires a few hours of your time from beginning to end.

What is a cataract?

A cataract is an opacity or cloudiness in the natural lens of the eye. It is still the leading cause of blindness worldwide and represents an important cause of visual impairment in the United States. The development of cataracts in the adult is related to aging, sunlight exposure, smoking, poor nutrition, eye trauma, systemic diseases, and certain medications such as steroids. A single study has suggested that use of oral vitamin C may help delay the progression of cataracts.

Just as a smudged or dirty camera lens may spoil a photograph, opacity in the natural lens of the eye can result in a blurred image. Patients with cataracts usually complain of blurred vision either at distance, near, or both. This may interfere with tasks such as driving or reading. Other common complaints include glare, halos, and dimness of color vision.

A diagnosis of cataract can only be made by a thorough eye examination including slit lamp (microscopic) evaluation. Other devices are sometimes used to determine if glare interferes with vision. If cataract surgery is being considered, an ophthalmologist will also examine the posterior aspect of the eye, which will include evaluation of the retina and optic nerve. If a cataract is mature (extremely dense) or hypermature (white), an ultrasound diagnostic device known as a B-scan may be used to rule-out retinal detachment and ocular tumors prior to proceeding with cataract surgery.

While the progression of cataracts is highly variable, they will invariably worsen in severity with time. Changing glasses may sometimes be useful in improving vision as the cataract progresses, since cataracts may induce relative nearsightedness. This is why some patients with hyperopia (farsightedness) will actually have better vision without glasses in the early stages of cataract development. For most patients, however, changing glasses has minimal impact on overall visual quality. Besides changing glasses, the only other option for treatment of cataracts is cataract surgery.

Cataract Symptoms and Signs

Cataracts are a progressive condition in which the lens of the eye becomes cloudy and grows increasingly opaque. They are usually white, but can be tinted yellow or brown. As a result, the symptoms vary, depending upon the type and severity of the cataract. When there is only a hint of cloudiness to the lens, the cataract is classified as "trace." As the cloudiness progresses, the cataract may be classified as "mild" to "moderate."

Once the cloudiness becomes very pronounced, the cataract is classified as "mature." As the cataract becomes progressively cloudy, it blurs and distorts vision to an increasing degree. Vision with a cataract is similar to peering through a dirty or frost covered window. As the dirt or frost on the window increases, it becomes more difficult to see a clear image. As the cataract grows more opaque, images become less recognizable. Ultimately, the cataract may become so dense that it blocks light from entering the eye, resulting in needless blindness.

Cataracts are not always white in color. If they assume a yellow or brown tone, they will affect the ways colors appear. This is similar to the way colored lenses in a pair of sunglasses alter colors.

Because cataracts develop at a slow pace, the changes they cause in vision occur slowly. Due to their progressive nature, the symptoms become more pronounced over time.

Common Systems

• A gradual deterioration in vision over time
• Objects may appear yellow, hazy, blurred or distorted
• Vision at night or in low light conditions may be dramatically reduced
• Vision in bright light or in the sunshine may be difficult due to glare
• Halos may appear around bright lights at night.

What Causes a Cataract?

The known causes of cataracts include

• Trauma
• Inflammation inside the eye
• Metabolic abnormalities
• Nutritional deficiencies
• Exposure to various types of radiation
• Use of certain medications
• Genetic predisposition
• Aging

Of these, aging and genetics probably are the most significant factors. There are no known ways to prevent a cataract from developing or to slow the progression of cataract growth.

Cataract Treatment

Initially, vision affected by cataracts can often be improved through either a new glasses prescription or stronger lighting. However, when cataract symptoms affect a person’s ability to do the tasks they want and/or need to do, cataract surgery becomes necessary. In addition, if the level of vision deteriorates too much or if a cataract interferes with the ophthalmologist’s ability to examine the other structures in the back of the eye, cataract surgery may be recommended.

Clear lens (top), Cataract lens (bottom)

The best way to treat cataracts is to remove the cloudy lens and replace it with a new, clear, artificial lens implant. The original cataract will never return. This implant will permanently stay clear and should never have to be replaced. The most advanced technique for this is called phacoemulsification, or phaco. This is the state-of-the-art procedure that we use.

In phaco surgery, a small ultrasonic probe is inserted into the lens of the eye. This probe breaks (emulsifies) the cloudy lens into tiny pieces and gently sucks (aspirates) those pieces out of the eye. Phaco requires a small incision of only 3.0 millimeters or less. Although lasers are being developed for removal of some cataracts, they are not very effective and have a very limited use. At this time, phaco remains the procedure of choice.

Anesthesia

Two types of anesthesia, local or topical, are used in most cataract cases. The most advanced technique, and our preference, is to use topical anesthesia which is administered by placing drops on the surface of the eye. This is the safest method and allows the eye to heal quicker. It eliminates any sensation of pain, but does not prevent your eye from moving around. The second technique, local anesthesia, uses an injection to eliminate any sensation and prevents movement of the eye during surgery. Unfortunately, there is a significant risk with this technique of puncturing the eye. Both types of anesthesia leave you awake during the operation.However, patients are given a relaxing medicine during the operation to make the surgery even more comfortable.

Incision

Phacoemulsification probe used to break up and remove cataract lens

In order to remove the cataract and replace it with a new lens, we make a microscopic incision in your eye. Where the incision is made depends on the technique your surgeon chooses for you.

Incisions can be made in either of two places in your eye - clear cornea or the sclera. The cornea is the transparent area of your eye over the iris and the pupil. The sclera is often referred to as the white part of your eye.

Our preferred technique is to make a smaller incision in the clear cornea. Smaller incisions usually result in less discomfort during and after surgery, do not require stitches, can aid in reducing astigmatism, and usually provide a faster recovery period

Replacement Lenses

Once the cataract (clouded lens) removal part of the procedure is completed, the doctor will replace it with a permanent, artificial lens called an intraocular lens implant, or IOL.

Intraocular lens implant (IOL)

The most advanced implants are foldable IOLs, lenses can be implanted through the same micro-incision that is created in the phaco procedure. These IOLs are made of a flexible material allowing them to be folded for implantation. Once inside the eye, the lens gently unfolds and returns to its original shape. Several different IOL materials are available today, such as silicone, acrylic, and collamer. All of these materials are biocompatible and there are no cases of a person “rejecting” an implant.

After Your Surgery

One of the benefits of today's small incision cataract procedure is the ability to return home soon after surgery. Before a patient leaves, they will be given written instructions on how to care for their eye, including information on any medications that may be required. Patients can resume normal activities shortly after their surgery.

IOL in place in eye

In time, improvement in vision will continue as the eye recuperates from surgery. The doctor will schedule follow-up appointments, as needed, to check on the visual recovery progress. Most patients will still need glasses for reading following cataract surgery. However, the need for glasses for distance vision may be eliminated following this procedure. In most cases, patients will be healed within two weeks of the surgery and can be given their glasses prescription at that time.

New Technology IOLs

In the past, when a surgeon performed cataract surgery, the only option was to implant a monofocal intraocular lens (IOL). The refractive power of this monofocal IOL was selected to provide good vision at distance, but the patient would still need glasses for good near vision. With advances in technology, ophthalmologists now have several new IOL options available that can reduce or eliminate a patient’s dependence on glasses for near vision. This new class of lenses includes both multifocal IOLs and toric IOLs.

The two multifocal IOLs available are the ReZoom lens (produced by Advanced Medical Optics), and the ReSTOR lens (produced by AcrySof). These two IOLs have concentric refractive zones which allow patients to see clearly at both near and far distance. As we age, the natural lens of the eye becomes less able to accommodate (change) from distance to near vision. Multifocal lenses address this problem by allowing the patient to have good vision at all distances.

Additionally, some patients have astigmatism, which is a condition where the surface of the cornea is shaped like a football rather than a sphere. For these patients, a new toric IOL (produced by AcrySof) offers the promise to restore good vision at all distances.

In addition to these new lenses is one that is monofocal in design, but which accommodates similar to a person’s natural lens. This lens is called Crystalens (produced by Bausch & Lomb). Crystalens is the only intraocular lens that uses the natural focusing ability of the eye.

Each of these lenses are designed to produce the same basic result, but do so in different ways. The one that’s right for you depends on a number of factors. Only you and your physician can decide which option is best for you. Patients choosing multifocal lens implants typically experience a greater overall freedom from glasses following cataract surgery, thus allowing them to participate in most everyday activities without dependence on, or the hassle of glasses.

Each of them costs more than a regular monofocal IOL, but with available financing they are now more affordable than ever. If you’re interested in learning more about these new IOL options, we invite you to attend our monthly Vision Correction Seminar. Call us at (530) 895-1727 for the date of upcoming Vision Correction Seminars.

Your Future Vision

Today, advancements in small incision surgery provide the most effective method of restoring vision in the treatment of cataracts. We use the latest state-of-the-art techniques, equipment, and intraocular lenses to provide a safe, fast and effective outcome.

The improvement in vision will not only provide safety and enhance a person’s normal lifestyle and activities, it will also add years of enjoyment to their life. You've got a lot to look forward to!

The first known cataract surgery was done in India in 5 BC by a surgeon named Susruta. He did a procedure called couching that pushed the cataract into the back of the eye permitting better, but by no means normal vision.

Phaco was first done in 1967 by American ophthalmologist Charles Kelman. He got the idea during a dental visit while undergoing a procedure with an ultrasonic probe.

Glaucoma Surgery

What is Glaucoma?

Glaucoma is a group of eye diseases in which the pressure inside the eye is too high for the  optic nerve to handle. Glaucoma can usually be treated medically with eye drops, but sometimes the condition requires laser surgery or a more complex operation. Since there are different types of glaucoma, there are different surgical treatments.

Types of Glaucoma and Their Treatments

Acute Angle Closure Glaucoma

Closed angle glaucoma

The natural drainage area (the angle) inside the eye suddenly becomes blocked. Pressure in the back of the eye builds up and pushes the iris (the colored part of the eye) forward blocking the angle. This is an emergency situation. Angle closure glaucoma almost always requires surgery to relieve the built-up pressure. A laser is used to painlessly create an opening in the iris allowing the pressure in the front and back of the eye to equalize. When done successfully, this lowers the pressure in the eye and re-opens the drainage angle. This is a rare condition.

Open Angle Glaucoma

Open angle glaucoma

The angle inside the eye slowly becomes blocked. The drainage area inside the eye appears to remain open, but the gradual increase in pressure leads to optic nerve damage. This can usually be treated with eyedrops. However, if optic nerve damage continues despite proper medical treatment, one of several procedures may be used to lower the eye pressure and better protect the optic nerve and vision. The most common procedures include the following. A laser trabeculoplasty is a procedure that stretches open the drainage area inside the eye. This is a fast, painless procedure. Although it is effective in nearly 80% of patients, the effect of this treatment usually only lasts 3 to 5 years. This procedure is done without entering the eye.

Trabeculectomy

A trabeculectomy is an operation that creates a small flap and opening inside the eye to help the internal fluid  drain out of the eye. This procedure is done in the operating room. Frequently after surgery, adjustments need to be made to try to regulate and fine tune the eye pressure.

Trabeculectomy is very effective and many times patients may eliminate some or all of their need for eyedrops.

Endo-cyclo photocoagulation (ECP) uses a special laser and fiber optic system to treat areas inside the eye (ciliary processes) behind the iris (colored part of the eye). This procedure decreases the amount of fluid produced inside the eye and thereby lowers the pressure inside the eye. Typically, this surgery is done in combination with cataract surgery. 

Eyelid Surgery

Eyelid surgery is usually performed on an outpatient basis using local anesthesia. If a patient is taking aspirin or aspirin-containing drugs, blood thinners, or has a bleeding problem, they need to inform their ophthalmologist prior to surgery. These may need to be stopped prior to surgery.

This surgery is generally safe; however, as with any surgery, there are certain risks. Although, the ophthalmic surgeon attempts to create a balanced result, no face is ever perfectly symmetrical. Due to differences in healing between the eyes, there may be some asymmetry following surgery. Although a "black eye" with bruising and swelling is common, it will resolve quickly. Keep in mind that the eyelid may feel dry after surgery. This irritation generally disappears as the surgery heals and serious complications are rare.

Your ophthalmologist will perform an eye examination and make recommendations. Photographs and visual field testing are often required by insurance companies before surgery. The improvements in comfort and appearance can be very gratifying.

Proper position and function of your eyelids are essential for your eye health and appearance. Excess eyelid skin, droopy eyelids or eyelids which curl inward or outward are common. Ophthalmologists are best qualified to evaluate and treat these problems, which can cause eye discomfort and even threaten vision. Fortunately, many such eyelid conditions are correctable by surgery.

Upper Eyelid Drooping (Ptosis)

Ptosis ("toe-sis") is apparent at birth (congenital) or develops with age (involutional). Congenital ptosis by itself rarely leads to poor vision. However, children should be examined by an ophthalmologist because they can have other associated eye problems. The type of surgery varies, depending upon the amount of droopiness.

Involutional ptosis develops with aging. It may worsen after other types of eye surgery or eyelid swelling. Ptosis may limit the field of vision and produce an unbalanced appearance. Surgical correction involves shortening and strengthening  the muscle which opens the eyelid.

Ptosis repair pre-op

Ptosis repair post-op

Excessive Eyelid Skin (Dermatochalasis)

Over time, many people develop excess eyelid skin. Eyelid skin is some of the thinnest skin of the body, making it very susceptible to stretching.

In the upper eyelid, this stretched skin may limit the field of vision, and may produce a sensation of heaviness and a tired appearance.

The excess skin in the upper eyelids can be removed surgically to improve the field of vision and other symptoms. If any fatty tissue is present, it may be removed at the same time.

Outward Turning of the Lower Eyelid (Ectropion)

Stretching of the lower eyelid with age allows the eyelid to droop downward and turn outward. Ectropion can cause dryness of the eyes, excessive tearing, redness, and sensitivity to light and wind. Surgery may restore the normal position of the eyelid, improving these symptoms.

Ectropian before surgery

Ectropian after surgery

Inward Turning of the Lower Eyelid (Entropion)

Entropion also occurs most commonly as a result of aging. When the eyelid turns inward, the eyelashes and skin rub against the eye creating a red, irritated eye sensitive to light and wind. If entropion is not treated, an eye ulcer may form. With surgery, the eyelid can be turned outward to its normal position, protecting the eye and improving these symptoms.

Entropian before surgery

Entropian after surgery

Lacrimal Surgery

These surgeries are used to correct problems with the tear drainage system of the eyes. Two surgeries are most commonly performed.

Many infants are born with a blockage of one or both tear systems. Usually, this will clear up on its own during the first 9 to 10 months of life. On those occasions when this persists, a surgical procedure is done to open the lacrimal system. This consists of passing a fine metal probe through the tear system to open it. This surgery is very successful if done prior to 13 months of age.

In adults, the tear system can become blocked over time, due to sinus problems, injuries or other causes. Sometimes medicines are adequate for control of this problem, but frequently a surgical procedure is needed. This is a more extensive surgery that requires creating a new connection between the tear sac and the nasal cavity.

Retinal Surgery

Several different retinal problems can arise that require a variety of surgical corrections. Many of these are treated with a laser at our offices. This is most commonly done for patients with diabetes, macular degeneration, or retinal tears or holes. However, certain conditions require surgery by a retinal sub-specialist. We will be happy to refer you to a qualified surgeon for these conditions.

Strabismus Surgery

This surgery is used to correct the alignment of the eyes. This can be used to correct eyes that turn in, turn out, or are raised up or down. This surgery can be performed at any age, but it is usually done during childhood.

Laser Surgery in Ophthalmology

What Is A Laser?

The word “laser” is an acronym for Light Amplified by Stimulated Emission of Radiation. A laser is a concentrated beam of light, created when an electric current passes through a special material, typically a gas or a crystal.

We use the following lasers:

• Argon gas: Blue-green light
• YAG (Yttrium-Aluminum-Garnet) Invisible Infrared Light
• Excimer: "Cold" Light
• ECP: Fiber optic laser for glaucoma treatment

How Does A Laser Work?

There are different ways that lasers are used to treat eye conditions.

Thermal lasers:

The light is converted to heat when it reaches the eye.
The heat is used to:

• Seal blood vessels (veins and arteries) that are bleeding or leaking fluid
• Destroy abnormal tissue, such as a tumor
• Bond the retina to the back of the eye to treat small retinal  tears or holes

Photo-disruptive lasers:

The light cuts or sculpts tissue, similar to a knife.
The beam of light is used to:

• Cut thin membranes inside the eye that are blocking vision
• Change the shape of the surface of the eye.

What Are The Advantages Of Using Ophthalmic Lasers?

Laser surgery of the eye has several advantages:

• There is no risk of infection from the laser light
• Laser surgery can be performed in an outpatient setting
• The surgeon has great precision and control

Which Diseases Can Be Treated With The Laser?

• Diseases of the retina
• Retinal tears or holes
• Diabetic retinopathy
• Macular degeneration
• Glaucoma
• After cataract surgery
• Refractive surgery

Types of Surgical Lasers Used In Ophthalmology

After Cataract Laser

YAG laser
This is a laser that removes/cleans the cloudy capsule in the eye following cataract surgery. The capsule is sometimes referred to as a "secondary cataract" or an "after cataract". In reality, the capsule is a support structure that helps the cataract implant heal in place during the first 1 to 2 months following surgery. It is not needed once the implant has fully healed in place. A patient MUST have had a regular cataract surgery BEFORE they can have this procedure.

Glaucoma Lasers

ALT (argon laser trabeculoplasty)
This is a laser treatment to lower the pressure in the eye. It works by stretching open the drainage are of the eye (the angle) to help allow more fluid to drain from the eye and therefore lower the pressure.

LPI or PI (laser peripheral iridotomy)
This is a laser that is used to equalize the pressure between the front and the back of the eye or to prevent this pressure imbalance from damaging the optic nerve. This treatment requires making a very small hole in the iris (the colored part of the eye), allowing the eye's natural fluid to easily flow from the back to the front of the eye.

ECP or Endocyclophotocoagulation
The latest development in glaucoma surgery, ECP uses a small fiberoptic probe inside the eye to reduce production of the eye's natural fluid. This helps lower the intraocular presure. It may done at the same time as cataract surgery or as a separate procedure. Chico Eye Center  was among the first in the state to become certified and own an ECP laser.

PRP (panretinal photocoagulation)
This laser treatment is used to prevent or shrink abnormal blood vessels growing in the eye. This laser treats the periphery of the retina inside the eye. It is NOT used in the central part of the retina. It can be done as a single treatment or several smaller treatment sessions. This treatment is primarily used in diabetics, but can be used in other situations.

Argon Focal Laser/Grid Laser
This laser is used to seal off blood vessels that are leaking blood, protein or fluid. This laser treats near the central part of the retina. This is a very delicate procedure. Sometimes this may improve vision, but it is primarily used to prevent the current problem from worsening. This treatment is used primarily in diabetics and wet macular degeneration.

Retinal Hole Treatment
This laser is used to help bond the retina to the wall of the eye to try to prevent a retinal hole from developing into a retinal detachment. This laser treats the areas around the retinal hole to form a ring of microscopic scars around the hole. As a result, it is very unlikely that the hole will enlarge and lead to a retinal detachment.

Excimer Laser/ Lasik/ PRK
This laser is used to improve a patient's vision without glasses. This laser works by changing the shape of the outer surface of the eye (the cornea). As a result, it makes people less dependent on glasses but is never a guarantee that glasses can be "thrown away". Also, people eventually will still need reading glasses at some point in their life.

Laser surgery has been one of the great advances in treating eye disease. The success of laser surgery depends on the type of eye disorder. In most situations, laser surgery helps prevent further loss of sight, but will not provide great improvement in vision. In a few situations, such as YAG laser surgery or LASIK, vision may be improved.