Glaucoma Surgery and MIGS

Glaucoma Surgery and MIGS

by | Mar 1, 2019

Glaucoma Laser

A selective laser trabeculoplasty (SLT) and argon laser trabeculoplasty (ALT) are both very similar laser procedures to reduce the eye’s pressure. This is done in the office by placing a special contact lens on the eye. The laser is then focused through this lens to the angle of eye (trabecular meshwork). The laser helps improve aqueous outflow which in turn helps reduce the eye’s pressure.

Goniotomy

A Goniotomy is a Minimally Invasive Glaucoma Surgery (MIGS) which can lower intraocular pressure by improving the outflow dynamics of the eye. It was originally used to treat Glaucoma in children, but has been adapted to treat mild to severe Glaucoma in adults.

A Goniotomy opens the eye’s natural fluid drainage pathway by removing part of the trabecular meshwork. By opening the eye’s natural fluid drainage pathway, the intraocular eye pressure should decrease. There is no need for a stenting device with this procedure. A Goniotomy can be performed with or without Cataract Surgery. The post-operative care and follow-up is similar to Cataract Surgery.

The most common instrument to perform a Goniotomy is a KDB Glide. Below is a diagram demonstrating the removal of the trabecular meshwork.

Treating Your Glaucoma with an iStent

The iStent® is yet another way to treat mild to moderated glaucoma. The FDA requires this procedure to be performed in conjunction with cataract surgery.  If you have already had cataract surgery you are not a candidate for this procedure.

If you have glaucoma, over time your eye’s natural drainage system becomes clogged. iStent® creates a permanent opening through the blockage to improve the eye’s natural fluid outflow. By improving the outflow of fluid in your eye, iStent® is designed to lower and control the pressure within your eye.

The iStent® Trabecular Micro-Bypass Stent is 20,000 times smaller than the intraocular lens (IOL) your doctor will use to replace your cataracts. By increasing your eye’s ability to drain fluid, this technology is designed to improve the aqueous outflow to safely lower your eye pressure.

If you are a candidate for the iStent® then your surgeon can implant it during your cataract surgery procedure. Once implanted, the iStent® will begin working to safely and effectively manage your eye pressure.

See How iStent Works

What is a Trabeculectomy?

A trabeculectomy is a glaucoma surgery that creates a small hole in the anterior chamber of the eye to allow drainage of the aqueous fluid toward the outside. Trabeculectomy surgery starts with making an incision through the conjunctiva. Underneath the scleral flap, a surgeon cuts a small hole into the anterior chamber, which allows the drainage of aqueous fluid through the scleral flap and into the sub-conjunctival space. An iridectomy (hole in the iris) is performed at this point to allow the scleral opening to stay open without being blocked by the iris tissue. The scleral flap is then tied down with stitches, that are loose enough to allow continuous drainage of the aqueous fluid. Finally, the overlying conjunctival tissue is closed with stitches to allow formation of a bleb or an elevation of conjunctival tissue formed by the aqueous fluid, which is being filtered out of the scleral flap (trapdoor) underneath. The filtering bleb is usually located in the superior aspect of the eye and covered by the upper lid.  It is not readily noticeable by a casual observer. The aqueous fluid from the filtering bleb is then slowly absorbed by the conjunctival and episcleral (on the surface of the sclera) blood vessels and drain into the orbital venous system.

What is a Seton Implant?

The seton implant is similar to a trabeculectomy, in that the goal is to decrease the eye’s pressure, by creating a pathway for the fluid inside the eye (aqueous fluid) to drain to the outside.  A tube is inserted into the anterior chamber so the aqueous fluid can drain into the seton implant and out of the anterior chamber of the eye.   The implant is sutured into a conjunctival pocket and the aqueous is absorbed naturally.

The diagram below shows the step-by-step insertion of a Ahmed Valve ® which is one of the most common seton implants.

The pictures below show the step-by-step insertion of a Ahmed Valve ® which is one of the most common seton implants.

Trab # 1

Trab # 2

Trab # 3

Trab # 4

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Retinal Surgery

Retinal Surgery

by | Mar 1, 2019

What is the Retina

The retina is a thin sheet of nerve tissue in the back of the eye where light rays are focused and transmitted to the brain via the optic nerve. Tiny blood vessels supply the retina with oxygen and other nutrients. Arteries deliver the blood, and veins carry it out.

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Common Retina Issues

Retinal Vein Occlusion

There are numerous treatments for a retinal vein occlusion from laser to intravitreal injections. Sometimes one of these arteries hardens or swells and presses on a nearby vein. The vein can then become blocked, or occluded, making it difficult for blood to leave the eye. This is called a retinal vein occlusion. The restricted circulation leads to high pressure in the eye, which can in turn cause swelling, bleeding, growth of abnormal blood vessels, and partial or total vision loss.

Retinal vein occlusions are the second most common cause of blood vessel-related vision loss (the first is diabetic retinopathy). The condition occurs most often in men and women over the age of 50, particularly those in their 60s and 70s. Risk factors include atherosclerosis (hardening of the arteries), high blood pressure, high cholesterol, diabetes, smoking, glaucoma, and, in rare cases, blood clotting and inflammatory conditions.

Treatment and prognosis depend on the severity of the blockage and the location of the occluded vein. If the largest vein leaving the eye is affected, the condition is known as a central retinal vein occlusion, or CRVO; otherwise, it is called a branch retinal vein occlusion, or BRVO. Retinal vein occlusions do not cause a change in physical appearance, and BRVOs often occur with no pain or noticeable loss of vision. For these reasons, it is important to have routine eye exams and also to check one’s own vision by closing one eye at a time.

There is no cure for retinal vein occlusions, so emphasis is placed on risk management, treatment of symptoms and prevention of further vision loss. It is critical to control high blood pressure, high cholesterol, diabetes and other health conditions that increase the risk of vascular hardening, narrowing and blood clotting.

Macular Hole

The macula is at the back of the eye, situated in the middle of the retina. It is a light-sensitive layer, which converts light into signals that tell the brain what we are looking at. The macula enables us to see sharp, clear images. A hole is caused when the vitreous, the gel-like substance in the eye, shrinks and starts to come away from the retina.

In severe cases, a hole in the macula can cause loss of central vision and the ability to see finely detailed images. A macular hole can also be called a retinal hole, a macular cyst, or retinal perforation. Macular holes are more prevalent in women than men.

It is important to point out that a macular hole is not the same as macular degeneration. Macular degeneration is a different eye-related condition that also affects elderly people.  Treatment for a macular hole usually requires surgery called a vitrectomy.  In this type macular hole surgery, a gas bubble is also placed in the eye and the patient usually needs to keep their head down for a period of time.

Retinal Detachment

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Retinal detachments are a very serious problem that almost always causes blindness unless it is treated. As a person’s normal eye ages, the vitreous gel contracts and becomes more liquid. As the vitreous gel becomes more liquid, it may pull on the retina and create a retinal tear (and then tear.) When fluid passes through a tear, it will lift the retina from the back of the eye, creating a retinal detachment.  Surgery is usually required.

Retinal Detachment Risk Factors

  • Extreme Nearsightedness (myopia)
  • Family history of retinal detachments
  • Age
  • Previous injury to the eye

Macular Edema

Macular Edema is also called Cystoid Macular Edema or (CME). Macular Edema sets in when blood vessels leak into the eye and form cysts and swelling that obstruct central vision. CME can be seen from a diagnostic vision testing with optical coherence tomography (OCT), fluorescein angiography (FA), and several other testing modalities.

Causes of Macular Edema

  • Cataract surgery or repair of retina detachment
  • Macular degeneration
  • Medication side effects
  • Diabetes
  • Blocked or clogged veins of the retina
  • Eye injuries

Diagnosing Macular Edema

During routine dilated eye exams, our eye doctors may detect central yellow spots. Depending on the amount of fluid that has leaked, these spots may be easy or hard to detect.  Optical coherence tomography (OCT) is a picture taken in the back of the eye without a dye injection.  Fluorescein angiography(FA) procedure is conducted where sodium fluorescein dye is injected into an arm or hand and then retina photographs are taken. If there are any abnormalities on the retina, the dye will usually reveal them by leaking, staining or by its inability to get through blocked blood vessels.

Macular Edema Treatment

We will provide expert treatment options to deal with macular edema. The treatment type will depend on the severity and progression of the macular edema. Some of the treatment options include:

  • Intraocular injections to make blood vessels less leaky and decreases macular edema.
  • Ocular steroid injections are used to stabilize the retinal barrier and decrease vascular growth within the eye.
  • Anti-inflammatory eye drops (steroid based) are used to reduce the inflammation of the retina.
  • Vitrectomy Surgery removes vitreous gel and membranes to allow the retinal to flatten again.

Macular Pucker

Numerous words and phrases have been used to describe the same medical condition. Macular pucker is the most common term but epiretinal membrane, cellophane maculopathy, wrinkling of the retina have all been used. There is a film on the retina that causes a pucker or wrinkle. A vitrectomy is done to remove this membrane. Gas may be placed in the eye to help reduce retinal swelling. The patient may need to keep their head down 90 degrees to help with the healing.

Vitrectomy Surgery

Vitrectomy Surgery removes vitreous gel and membranes to allow the retina to flatten again. It is a microsurgical procedure in which specialized instruments and techniques are used to repair retinal disorders. These types of retinal disorders were previously not operable.

The first step in this procedure is usually the removal of the vitreous gel through very small (˜1.4mm) incisions in the eye wall, hence the name “vitrectomy.” The vitreous is removed with a miniature handheld cutting device and replaced with a special saline solution similar to the liquid being removed from the eye. A high level intensity fiberoptic light source is used to illuminate the inside of the eye while the surgeon works. The ophthalmic retinal surgeon uses a specialized operating microscope and contact lenses, which allow a clear view of the vitreous cavity and retina at various magnifications. A vitrectomy is performed in an operating room under local or general anesthesia.

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Keratoconus & Corneal Cross Linking

Keratoconus & Corneal Cross Linking

by | Feb 20, 2019

What is Keratoconus?

Keratoconus, often referred to as ‘KCN’, is a non-inflammatory eye condition. Typically the cornea progressively thins and weakens causing the development of a cone-like bulge and optical irregularity. This causes distortion of your vision and can result in significant visual impairment.

Symptoms

Keratoconus typically first appears in individuals who are in their late teens or early twenties and may progress for 10-20 years. In the early stages of keratoconus, people might experience:

  • Distortion of vision
  • Increased sensitivity to light
  • Can result in significant vision loss
  • May lead to corneal transplant in severe cases

In the past, KCN was only corrected with surgery.  Many patients needed to undergo a corneal transplant.  Now newer and less invasive surgery is available.  Epi-off crosslinking (CXL) is a Food and Drug Administration (FDA) approved treatment for progressive KCN.  Epi-off refers to epithelial removal treatment.  This is a less invasive treatment for KCN compared to a corneal transplant. 

FDA clinical trials are currently being conducted for Epi-on crosslinking.  Dr. Haverly is a principal investigator for the on-going Epi-on clinical trials.  Contact Laser Eye Surgery of Erie if you have KCN and are interested in treatment and/or enrolling in the Epi on clinical trial.

You can find more information from the National Keratoconus Foundation at www.NKCF.org

>>>Watch Dr. Haverly’s feature on Erie News Now as he discusses Keratoconus treatment here<<<

 

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What is Corneal Cross-Linking?

We are now offering procedures using the KXL® System, the first and only FDA-approved therapy for progressive keratoconus. The machine, created by Avedro, was approved in 2016, along with Avedro’s Photrexa® Viscous and Photrexa® solutions, and is being used in about 100 facilities nationwide. Cross-linking is a minimally invasive outpatient procedure that combines the use of UVA light and riboflavin eye drops to add stiffness to the corneas which have been weakened by disease.

Riboflavin

Riboflavin (vitamin B2) is important for body growth, red blood cell production and assists in releasing energy from carbohydrates. Under the conditions used for corneal collagen cross-linking, riboflavin 5’-phosphate, vitamin B2, functions as a photoenhancer which enables the cross-linking reaction to occur.

Ultra-Violet A (UVA)

UVA is one of the three types of invisible light rays given off by the sun (together with ultra-violet B and ultra-violet C) and is the weakest of the three. UVA light is applied to irradiate the cornea after it has been soaked in the photoenhancing riboflavin solution. This cross-linking process increases the number of molecular bonds, or cross-links, in the collagen.

Is cross-linking right for me?

Patients over the age of 14, who have been diagnosed with progressive keratoconus should ask their doctor about corneal cross-linking. Our practice is proud to offer patients the first and only FDA approved therapeutic treatment for progressive keratoconus.

For information on the FDA approved corneal cross-linking procedure for the treatment of keratoconus and corneal ectasia following refractive surgery, visit www.glaukos.com/int/cornea/cross-linking

Dr. Haverly is a principle investigator conducting a FDA clinical trial for Epi-on crosslinking.   New enrollment for the present study, GLK-202-02, closed 04/20/2023.  If you are interested in participating in a future clinical trial for CXL contact us below:
 
schedule today

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Glaucoma

Glaucoma

by | Feb 20, 2019

What is glaucoma?

Glaucoma is a disease that causes damage to the optic nerve. The optic nerve, which acts as a messenger for information between the eye and the brain, is in the back of the eye. When the nerve is damaged, a loss of vision is likely to occur.  Initially, people with glaucoma will lose their peripheral (side) vision. If the disease remains untreated, vision loss will likely get worse. This can lead to total blindness over time.

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The two basic glaucoma types

Glaucoma often presents with no symptoms to warn you. Detecting and treating the disease early is important to prevent blindness. Treatments are available and early detection is critical. 

Open-Angle Glaucoma

Open-angle glaucoma is the most common form of the disease. The risk of developing open-angle glaucoma increases with age. It has no symptoms in its early stages and vision is normal. As the optic nerve becomes more damaged, blank spots begin to appear in your field of vision. Patients can experience:

  • Gradual loss of side or peripheral vision
  • An inability to adjust the eye to darkened rooms
  • Rainbow-colored rings or halos around lights

Closed-Angle Glaucoma

Closed-angle glaucoma (also called angle-closure glaucoma) is more rapid symptoms. Patients may experience:

  • Blurred vision
  • Severe eye pain
  • Rainbow-colored halos around lights

Narrow-angle glaucoma can precede closed-angle glaucoma.  Treatment for both closed-angle and narrow-angle glaucoma include a laser peripheral iridotomy or a iridectomy. The treatment creates an alternate route for the fluid in the eye flow and prevents pupillary block so the eye pressure does not increase.  Risk factors for closed-angle glaucoma include:

  • Hyperopia (far-sightedness)
  • Cataracts
  • Over the age of 55

Research has shown that cataract surgery can treat and reduced the risk of narrow-angle and closed-angle glaucoma.

 

Glaucoma Risk Factors

Regular medical eye exams can help prevent unnecessary vision loss. People who are at a greater risk for glaucoma usually have the following conditions:

  • Age: You’re at higher risk if you’re older than 40.
  • Ethnic Background: Certain ethnicities, such as African-Americans, are at risk of developing the disease at a younger age and are more likely to experience permanent blindness as a result.
  • Family History: Glaucoma may have a genetic link; therefore, if you have a family history, you are at a greater risk of developing the condition.
  • Medical Conditions: Diabetes, heart disease, high blood pressure and hypothyroidism are several conditions that may increase the risk of developing this disease.
  • Other Eye Conditions: Eye tumors, eye inflammation, lens dislocation and retinal detachment could increase the risk of glaucoma. Certain types of eye surgery and being nearsighted or farsighted may also increase your risk.
  • Injury: Increased eye pressure is sometimes a result of severe eye injuries; therefore, trauma can increase the risk of developing this disease.
  • Long-term Corticosteroid Use: Corticosteroid medications (e.g. some eye drops) over a long period of time may increase the risk of developing glaucoma.

Early Detection is Key

Comprehensive eye exams are necessary to diagnose glaucoma.  We will measure your eye pressure, dilate your pupils to evaluate your optic nerve and perform a visual field test to measure your peripheral vision.  Initially, eye drops are usually used treat glaucoma, but sometimes laser would be considered first.  Resistant and severe glaucoma may need surgery.  See the “glaucoma surgery” link for more information.

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See if lasik is right for you

Glaucoma Laser

A selective laser trabeculoplasty (SLT) and argon laser trabeculoplasty (ALT) are both very similar laser procedures to reduce the eye’s pressure. This is done in the office by placing a special contact lens on the eye. The laser is then focused through this lens to the angle of eye (trabecular meshwork). The laser helps improve aqueous outflow which in turn helps reduce the eye’s pressure.

contact us

Goniotomy

A Goniotomy is a Minimally Invasive Glaucoma Surgery (MIGS) which can lower intraocular pressure by improving the outflow dynamics of the eye. It was originally used to treat Glaucoma in children, but has been adapted to treat mild to severe Glaucoma in adults.

A Goniotomy opens the eye’s natural fluid drainage pathway by removing part of the trabecular meshwork. By opening the eye’s natural fluid drainage pathway, the intraocular eye pressure should decrease. There is no need for a stenting device with this procedure. A Goniotomy can be performed with or without Cataract Surgery. The post-operative care and follow-up is similar to Cataract Surgery.

The most common instrument to perform a Goniotomy is a KDB Glide. Below is a diagram demonstrating the removal of the trabecular meshwork.

Treating Your Glaucoma

The iStent® is yet another way to treat mild to moderated glaucoma. The FDA requires this procedure to be performed in conjunction with cataract surgery.  If you have already had cataract surgery you are not a candidate for this procedure.

If you have glaucoma, over time your eye’s natural drainage system becomes clogged. iStent® creates a permanent opening through the blockage to improve the eye’s natural fluid outflow. By improving the outflow of fluid in your eye, iStent® is designed to lower and control the pressure within your eye.

The iStent® Trabecular Micro-Bypass Stent is 20,000 times smaller than the intraocular lens (IOL) your doctor will use to replace your cataracts. By increasing your eye’s ability to drain fluid, this technology is designed to improve the aqueous outflow to safely lower your eye pressure.

If you are a candidate for the iStent® then your surgeon can implant it during your cataract surgery procedure. Once implanted, the iStent® will begin working to safely and effectively manage your eye pressure.

contact us

See below step-by-step Trabeculectomy.

The basic goal behind trabeculectomy is to create a small hole in the anterior chamber of the eye to allow drainage of the aqueous fluid toward the outside. Trabeculectomy surgery starts with making an incision through the conjunctiva. Underneath the scleral flap, a surgeon cuts a small hole into the anterior chamber, which allows the drainage of aqueous fluid through the scleral flap and into the sub-conjunctival space. An iridectomy (hole in the iris) is performed at this point to allow the scleral opening to stay open without being blocked by the iris tissue. The scleral flap is then tied down with stitches, that are loose enough to allow continuous drainage of the aqueous fluid. Finally, the overlying conjunctival tissue is closed with stitches to allow formation of a bleb or an elevation of conjunctival tissue formed by the aqueous fluid, which is being filtered out of the scleral flap (trapdoor) underneath. The filtering bleb is usually located in the superior aspect of the eye and covered by the upper lid.  It is not readily noticeable by a casual observer. The aqueous fluid from the filtering bleb is then slowly absorbed by the conjunctival and episcleral (on the surface of the sclera) blood vessels and drain into the orbital venous system.

Seton Implant

The basic goal of a seton implant is to decrease the eye’s pressure.  A tube is inserted into the anterior chamber so the aqueous fluid can drain into the seton implant and out of the anterior chamber of the eye.   The implant is sutured into a conjunctival pocket and the aqueous is absorbed naturally.

The diagram below shows the step-by-step insertion of a Ahmed Valve ® which is one of the most common seton implant.

Laser Eye Surgery of Erie

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