Adult Squint Surgery

To enable the eyes to work together, in some cases to relieve double vision and to improve appearance by making the squint less obvious.
While you are waiting for the operation, the orthoptist may wish to see you to monitor your condition.

About two weeks before your operation you will be sent an appointment to attend the Pre-Assessment Clinic at the Hospital.  At the clinic you will be seen by a staff nurse who will perform a nursing and medical assessment.  Depending on your age and general health, it may be necessary for the following procedures to be undertaken:

• Blood sample
• Heart tracing (ECG)
• Chest x-ray

Any medication you are taking will be discussed and it may be necessary to discontinue this prior to surgery.  The nurse will also explain about the anaesthetic and the operation and you will have the chance to ask any questions.
 
After your visit to the ward you will be seen by the orthoptist who will assess your vision and measure the degree of squint before consultation with the doctor to plan your surgery.

The surgeon involved in your operation will discuss your case and examine your eyes. Once the operation is agreed with you, the consent form is signed by yourself and your surgeon.

Make sure you bring your glasses to the appointment.

Argon Laser Treatment

A laser is a machine which is attached to a slit-lamp microscope which emits a highly concentrated beam of light.  Laser treatment is given to prevent deterioration in your eye condition, and occasionally to cure it.

The Argon laser is used in the treatment of glaucoma, diabetic eye disease, and sometimes holes and tears in the retina.

Laser treatment will involve the following:

• A vision test:  The nurse may instil drops into the eye in order to dilate (enlarge) the pupil.  These usually take 30 to 40 minutes to work.
• The doctor will instil anaesthetic drops into the eye before commencing the treatment, to stop any discomfort.
• Next, a contact lens will be gently placed on your eye which may feel odd but will not hurt.
• You will then be required to sit still at the slit-lamp while the treatment is being undertaken. When the laser treatment starts, you will see flashes of light.  Occasionally a sting may be felt but it is essential that you do not pull away. 
• Very occasionally, particularly if you are having a second treatment, you may feel a slight pain.  If this should become severe, the doctor can give a painkilling injection below the eye.  A treatment session can last between 5 to 45 minutes depending upon the amount of treatment required.
• After the treatment you are free to go home but please remember that you will be unable to drive so it is advisable to make alternative arrangements for your journey. You will usually be asked to make a follow-up clinic appointment.

Artificial Eye Fitting

In all cases, a clear ‘shell’ or ‘proformer’ is fitted at the time of surgery.  This will be replaced by a temporary artificial eye, individually fashioned some six to eight weeks after surgery.  A permanent artificial eye will be supplied later. If drilling and post fitting follows, further modification to the artificial eye will be required.

Enucleation - post-operative advice

To remove your shell

• Wash your hands
• Look up, and using a finger, pull down your lower lid. With a finger from your other hand, flip out the shell by pressing down on the bone. This may be easier using a plastic rod.  Then look down, and the shell should easily flip out
• Once the shell is removed, bathe the eyelids with boiled water that has been cooled and cotton wool

To insert your shell

• Look down and put the shell, with the notch upwards and nearest to your nose, underneath your upper lid
• Slide the shell upwards, and at the same time pull down on your lower lid. The shell should easily flip into place.

Your lids and surrounds will appear bruised and red; the socket itself will also appear swollen and red. This is normal.  If however the eye becomes more painful, swollen and starts to discharge please contact your nurse.

Remember that the shell is a temporary measure.  You will be sent an appointment for a false eye fitting which will take place about six weeks later.

You will only need to remove your shell twice a day after your surgery.  When the socket starts to heal (about 6 weeks) this can be reduced to once a day.

Blepharitis

This is an inflammatory condition affecting the edge of the eyelids. The cause is often unknown and prolonged treatment may be required to be effective. Despite this the condition may recur.

Signs and symptoms

• Red, inflamed eyelids
• Crusting around the eyelashes
• Itching and discomfort
• Treatment

Heat treatment for Blepharitis 

The purpose of heat treatment

• It helps soothe your eye, making it feel more comfortable
• It allows the natural oils in the skin and eyelid to flow more freely helping to reduce the size of any cysts in the eye-lids and prevent any further swelling
• It can be used as a sort of ‘first aid’ treatment if you are unable to get to the Eye Hospital (e.g. if you are on holiday)
• It is effective and very easy to do.

• You will need some hot water, a bowl and some cotton wool.  It will help if you can find a quiet place where you won't be disturbed.
• Put some hot water in a bowl. It should be fairly warm but not so hot that it will burn you
• Soak the cotton wool, then gently squeeze out the excess water. You now have a hot compress
• Close your eye and place the compress on your closed eye until the compress is cool
• Repeat this several times for approximately 25-30 minutes
• By gently removing the compress while it is on your eye, you will massage your eye at the same time
• Carry out this procedure two to three times a day. You must not open your eye with the compress on.

Chalazion

This is a common condition and is caused by a blockage in one of the small glands in the eyelid.  A small lump develops as the normal contents cannot escape.  Although it is unsightly, it is easy to treat and should not cause you any major problems with your vision.

As a first step in treatment, you will be prescribed antibiotics to reduce the inflammation in the eyelid. Heat treatment with hot compresses can also help and may actually release the contents of the cyst which means that further intervention is not needed.

If it has not resolved on this treatment, it can be removed surgically.   
Treatment

Your eyelid will need to be numbed by an anaesthetic injection to the area which will sting initially but the lid will soon become frozen.

The cyst is removed from the inside of the eyelid - no stitches are necessary and no scar will be visible. Antibiotic ointment will then be applied followed by an eye pad.

The pad may be removed after two hours, or left overnight for comfort, if felt necessary.  You may be given ointment to use in the eye for three - four subsequent days.

Often the lid is bruised following the procedure which is normal and will resolve within two weeks.

Some people are prone to getting these lumps again.  You can help prevent them from reoccurring by using hot compresses on the lids and massaging them in the morning.

Chlamidyal Conjunctivitis

Chlamydia is a germ which infects the genitals and sometimes the eyes and throat. In men it causes inflammation of the urethra, and in women it affects the cervix.
 
Conjunctivitis is an infection of the conjunctiva - the mucous membrane covering the sclera, the white part of the eye.

The infection is passed on through sexual intercourse with an infected person or hand to eye contact with an infected person.
Signs and symptoms in the eye

Usually only one eye is affected. Your eye will become red with a sticky discharge - especially in the mornings.

Women

You may also notice discharge or extra moisture in the vagina because the infection can inflame the cervix.  There may be pain or stinging sensation when passing water.  If left untreated, Chlamydia can lead to pelvic inflammatory disease which can lead to infertility.

If you are pregnant, or trying to get pregnant, Chlamydia can be passed on from a mother with an infection to a baby during its birth which can cause the baby to have an eye or lung infection.

Men

You may also notice a burning or stinging sensation when passing water as the Chlamydia affects the urethra.

Treatment

The nurse or doctor will take a swab from your conjunctiva by wiping the inside of your lower lid firmly. You will be given antibiotic eye ointment to use frequently.

The doctor will refer you to your local Genito-Urinary Medicine clinic for further tests which include a urine sample test and possibly more swabs.  The  Genito-Urinary Medicine clinic doctor will prescribe antibiotic tablets and ask you to take them for seven to 14 days.

Conjunctivitis

Conjunctivitis is an inflammatory condition of the conjunctiva, the clear transparent membrane which covers the white of the eye and lines the eyelids.  There are several causes, but the two most common are bacteria and viruses.  

Signs and symptoms

Sore, gritty, red eyes and a discharge which may be watery or sticky depending on the cause.  This makes the eyes sticky in the mornings.

Treatment

The nurse may need to take swabs to determine the cause of the conjunctivitis.  The results of take a few days but in special cases may take several weeks. 

Bacterial conjunctivitis is easily treated with antibiotic drops or ointment. There is no direct treatment for viral conjunctivitis which will gradually clear up on its own, but the doctor may prescribe antibiotic drops or ointment to prevent a secondary bacterial infection occurring.

Conjunctivitis is infectious so it is important to follow these rules:

1. Keep your face flannel separate from those of the rest of the family.
2. Wash your hands thoroughly after touching your eyes.
3. Use tissues, should you need to wipe your eyes, and dispose of them immediately afterwards.
4. Under no circumstances allow anyone else to use your eye drops or ointment. Throw them away when your treatment is finished. Never keep used bottles.

Corneal Graft

The cornea or ‘window’ of the eye is a clear structure at the front surface of the eyeball.  It is made up of five very delicate layers and is highly important in the process of vision.  Any damage to it will cause poor vision, which can often be treated by eye drops, but will also occasionally require corneal grafting or transplantation.

Common reasons for corneal grafting

• Keratoconus - a conical shaped cornea
• Long standing corneal disease or degeneration, when the clarity of the cornea is damaged

The aim of corneal grafting

This is to replace the damaged cornea or part of it with healthy corneal tissue.  The new cornea is obtained from donated corneas which undergo thorough testing before being used for transplantation.

Before the Operation

A visit to the Pre-Assessment Clinic will be arranged about two weeks prior to the planned date of surgery.  This will mean a full health check and another thorough examination of your eye.  As the operation is usually performed under a general anaesthetic it is possible that some blood tests and a heart reading will be performed depending on your age. 

On the day of the operation drops will be put into the eye to make the pupil small.  The aim of this is to protect the underlying structures of the eye during the operation.  You may also be given medications to make you sleepy before the anaesthetic is given.
 
The Operation

The operation which will take from one - two hours consists of removing the damaged cornea and replacing it with a new one which will be held in place by very fine stitches.  These stitches often need to be removed after six - twelve months and will require attendance at the hospital, usually as an out-patient. 

After the Operation

The eye will be covered with an eye pad which stays in place until the next morning.  You are likely to stay in hospital for one - two days afterwards.  You will have eye drops put into your eye once the pad has been removed.  These are quite frequent initailly and will continue for six weeks or more.  The drops are important for many reasons:

• To reduce swelling or inflammation
• To prevent infection – antibiotic
• To keep the pupil of the eye enlarged

It is worth noting that the vision of the eye following a corneal graft may remain blurred and very light sensitive, certainly whilst having the drops.

DCR

You may be having a DCR because a part of the tear drainage system of your eye (the lacrimal system) is blocked and, therefore, the tears are not draining away as they should.  You will undoubtedly have been suffering from watery eyes, possibly a sticky discharge from the part of your eye nearest the nose and recurrent infections.

Do’s and Don’ts after the operation:

• Don't rub or touch the eye
• Do aim to avoid smoky and dusty rooms which can cause irritation
• Do wear sunglasses if the eye is light sensitive and your normal glasses if you wear them
• Don't play contact sports and swimming. Ask your nurse or doctor if you are unclear about which sports you should avoid
• You will need at least two - four weeks off work, but this will be discussed with you
• Avoid driving until the doctor tells you otherwise.

The risks of rejection of your graft is low however, the following signs may indicate that you should return to the A & E Department for an extra check-up.

• Increased pain
• Increased redness
• Increased watering or discharge
• Further reduction in the vision

Donor Cards

Every corneal graft operation requires graft material which has been provided by donors and this material is in constant short supply.  We aim to encourage as many people to carry donor cards as possible to help provide material.  You may wish to encourage your friends and family to carry donor cards themselves once you have had your operation.

Dry Eyes

The tear film that covers the surface of the eye is made up of three layers secreted by glands in the eyelids and around the eye.  Its function is to keep the surface wet thus preventing damage and to inhibit the growth of bacteria.

Deficiency in any one of the three layers will lead to dry eyes.  There are many causes such as age-related changes, dry or dusty working conditions and central heating.

Signs and symptoms

• Gritty, scratchy or foreign body sensation
• Itching
• Burning
• Discomfort or pain
• Often the eye is completely normal to look at

Treatment 

This consists of artificial tear drops to use during the day and ointment to use last thing at night.  Different types of artificial tear drops can be bought over the counter at a chemist without a prescription which are often less expensive than a prescription charge so you need never run out of drops.

You will be told to use the drops quite often at first, then the frequency can gradually be decreased to just a few times a day to keep your eyes comfortable.  You will eventually be able to judge how often you need to use them.

As the drops are used to relieve the symptoms and are not a cure for the condition you will probably need to use them for a long time.
Plugs may be placed in the drainage tubes which preserve the tears in the eye.

Ectropion

This is a condition that commonly affects the lower eyelid causing it to turn outwards.  If the lower eyelid is not resting comfortably next to the eye, the tears cannot flow into the tear duct resulting in watering and soreness of exposed inner eyelid. 

The condition is also cosmetically unpleasant. The most common cause of ectropion is the muscles of the eyelid become less elastic due to ageing but this may also happen if you have a facial palsy or scarring of the eye-lids.

Lubricating ointment may be used for comfort while waiting for surgery.  

Treatment

This involves a minor operation under a local anaesthetic to turn the lid inwards again to its normal position.  The operation usually takes 30 minutes and is performed as a day-case so you do not have to stay in hospital overnight.

Entropion

This is a condition that commonly affects the lower eyelid causing it to turn inwards resulting in the eyelashes rubbing on the front of the eye.
This causes discomfort, redness and sometimes a sticky eye.  If left, it can lead to corneal ulcers.

Treatment

This involves a minor operation to turn the lid outwards to its normal position. As a temporary measure tape can be used to keep your eyelid turned outwards.

Method for placing tape to treat Entropion:

• First wash your hands
• Using a piece of wide Sellotape, approximately 3 cms long, apply one end to the skin of the lower lid, just underneath the eyelashes
• Secure the other end of the tape to the cheek.  The tension will pull the eyelid outwards back into its normal position
• Do not use too much tension - if the lid is pulled too far outwards, it will result in a watery eye.  Use the position of the eyelid in the other eye to judge how much tension to use 
• Change the tape as often as you need to, i.e. when it loses its tension and the lid starts to turn inwards again

Enucleation

The removal of an eye is a major event in the life of any individual.  However, many people have adapted to the loss of their eye and succeed in living a normal life following their surgery.

This information leaflet is designed to provide the factual information needed to support you through the decision to have your eye removed.

• The main reasons for removing an eye are
• To provide relief from a painful blind eye
• To create a better cosmetic appearance following an injury to an eye

Removing a tumour

The procedure will involve either:
 
The removal of the contents of the eye leaving the conjunctiva (clear outer layer covering the eye ball and lids) and sclera (white layer under the conjunctiva covering the whole surface of the eye ball). 

This is called evisceration.
or:
The removal of the eye ball as a whole (enucleation).

The operation to remove an eye and insert an implant is usually performed with a general anaesthetic and can take up to one and a half hours to perform.

Orbital implants

It is common surgical practice to replace the removed eye with an orbital implant which is inserted to replace volume in the orbit so that the artificial eye fitted later will give a better result.

Over the past ten years, implants have been developed to allow for the in-growth of naturally occurring tissues and blood vessels.  This reduces the risk of the body rejecting the implant at a later stage which has in the past been a problem due to the introduction of artificial material into the body.  It also allows for better eye movement and position of the false eye.

However, some patients are not suited to such implants when their socket tissue has shrunk due to injury, disease or previous radiotherapy treatment.

The advantage of such an implant is that in some cases better artificial eye movement can be achieved by ‘drilling’ a hole in to the implant into which a post can be inserted.  The protruding end of the post is fashioned to form a rounded head which in turn is fitted to a specially modified artificial eye.  The cosmetic outcome can be particularly successful.  The drilling process is not always necessary and some patients achieve excellent results through the insertion of the implant alone.

If it is judged necessary, the drilling procedure which is performed under a local anaesthetic and takes only a matter of minutes from up to six - twelve months following the initial operation to remove the eye. This whole process can take several months to complete.

Post Operative Care

It is normal for a pressure dressing to remain over the eye for 48 hours after the operation.  This is to reduce the risk of hemorrhage, bruising and swelling.  During this first two days, anti-inflammatory pain relieving tablets will be given to you on a regular basis to help reduce swelling and pain.

If an orbital implant has been used you will be given a course of oral antibiotics. Once the dressing has been removed, the eye lids are cleaned and a shield or sunglasses are worn to protect the eye and help with adjusting to the change in the appearance of the eye.  It is normal for the eye lids to look bruised and swollen, and to weep blood stained tears.  If the lids are parted the tissues will look like the inside of the mouth.

On day three no other treatment is attempted other than lid cleaning. On day four, shell removal and insertion is taught carefully to avoid disturbing the tissues surrounding the implant.

The timing of hospital discharge is discussed with each individual according to progress.  Sports, swimming and strenuous exercise is not recommended for at least one month.  Driving is permitted with one eye (provided DVLC requirements are met) but is not advisable within 48 hours of a general anaesthetic.  Returning to work will vary depending on the nature of employment, but can be anything from two - four weeks.

It is usual to make a couple of return visits to the hospital to see the surgeon; the first of these will be two weeks following surgery.  Reviews by the prosthetist (who fits the artificial eye) will require additional visits.  

Episcleritis

The front, white part of the eye called the sclera is covered by transparent membrane called the conjunctiva.  Between these is another transparent layer called the Episclera.  When this is inflamed it is known as Episcleritis.

Causes

The cause is unknown in most cases although some people suffering from gout may be more prone to Episcleritis which normally affects only one eye.

Symptoms

• Redness
• Pain
• Sensitivity to light
• Tenderness in the eye
• Watering of the eye

Treatment

Episcleritis is easily treated by drops prescribed by the doctor and usually resolves in about two weeks. The doctor will want to check the drops are helping to treat the Episcleritis which can recur and if it does, you should come to the Eye Clinic.

Fluorescein Angiography

This is a diagnostic test where special photographs are taken to outline the blood vessels of the retina at the back of the eye.
Prior to the procedure drops will be instilled into your eyes in order to dilate the pupils which usually takes 30 to 40 minutes.

You then stare at the camera whilst a series of colour photographs are taken of your eyes after which a yellow dye is injected into an arm vein whilst more photographs are taken.

After the Procedure

Your skin will become slightly yellow in colour. This is temporary and will disappear in about 12 hours. The dye is passed out of your blood into the urine which will also become yellow.

It will be necessary for you to remain in the hospital for 30 minutes after completion of this test to allow time for recovery from the dye injection.

Your vision will remain blurred for the rest of the day so it is advisable not to drive to your appointment but to make other arrangements. A pair of dark glasses may be helpful.
 
You will usually be asked to make a follow-up appointment at which time the results of this test will be explained and advice given as to treatment.

It is important to tell the nurse if you know of any allergies to medicines, food or animals, are taking any medication or suspect you maybe pregnant. 

Glaucoma

The eye produces a nourishing fluid called the aqueous humour which circulates around the tissues of the eye and drains away through outflow channels.

‘Normal’ eye pressure is when the amount of fluid produced is balanced by the amount of fluid draining away.  If the fluid in the eye does drain correctly then the pressure inside the eye becomes raised - Glaucoma.  Glaucoma, if untreated, causes damage to the optic nerve at the back of the eye, ultimately resulting in loss of vision.

Signs and symptoms

Glaucoma can cause damage to your field of vision.  This means that the edge of your peripheral vision can start to disappear causing your vision to narrow.  If treatment is delayed, these defects can severely affect your vision.

Importance of early diagnosis

The pressure in the eye will gradually increase over months, or even years because the gradual increase in symptoms may go unnoticed.

Treatment can prevent the damage from becoming worse but it cannot reverse damage that has already happened.

Glaucoma is slightly more common in people who are short-sighted or people who have diabetes.  It also tends to be hereditary. If there is a history of glaucoma in your family you are entitled to a free eye test but one eye test is not enough.  Regular eye checks are essential and ideally everyone over the age of 40 should have an eye test for glaucoma.

Tests for Glaucoma

Pressure check

A local anaesthetic drop will be placed in both eyes.  The effect of these drops lasts for two –three minutes, then a small instrument is placed gently against the eye to measure the pressure inside the eye.

General examination

The examiner can look into the eyes to see if the optic nerve is damaged.

Field Test

A test can be carried out to check the peripheral vision.
ALL TESTS ARE VERY SIMPLE AND PAINLESS.

Treatment

The treatment aims to reduce the pressure in the eye either by helping the fluid to drain away or by reducing the amount of fluid produced. The usual treatment is with eye drops.

IF YOU ARE PRESCRIBED EYE DROPS THEY MUST BE TAKEN REGULARLY AND IT IS IMPORTANT NOT TO MISS ANY DOSES.

Herpes Eye Infections

You have been diagnosed as having an eye infection caused by a herpes virus.  These viruses are normally responsible for a wide range of conditions including chickenpox, cold sores and shingles.

Symptoms can include some or all of the following on the side of the affected eye:

• Head and facial pain
• A rash and ulcers
• Swollen eyelids
• A red, painful eye
• Crusting of the eyelids
• Visual disturbances

Treatment

As this condition lasts two - three weeks, the eye usually responds very well to treatment.  Eye drops and creams, and, very occasionally tablets may be given to help your eye to heal.

On rare occasions, a herpes infection can take several months to clear up but this is not common.

It is important to continue all treatment and to attend the hospital as instructed until the eye doctor is happy that your eye is healing.

Hyphaema

You have a condition of the eye known as Hyphaema. This means that there is a small bleed inside the front chamber of your eye in front of the iris (the coloured part of your eye).

The following guidelines are intended to help the condition resolve quickly.

What to do when you get home

Rest

This is very important!  The small amount of blood is very quickly absorbed and if you move around it will swirl about and may take slightly longer for your eye to get better. It can also cause your eye to bleed some more.  You must take life easy.  No sports, bending or lifting.  You should not go back to work until instructed to do so.

Drops

The prescribed eye drops are to help your eye to heal and it is important to take them at the correct time.  You must be careful not to poke your eye when putting the drops in.

Return appointment

It is necessary for your eye to be checked to ensure the blood is clearing.  Please come back to the Eye Clinic when you are asked to.
 
Sometimes the eye can re-bleed. If this happens, the vision will suddenly become reduced or blurred and the eye might be painful.

What to do if this happens:

You should return to the Eye Casualty department at once or telephone the Hospital and ask for advice.

Iritis

This is an inflammatory condition affecting the iris (the coloured part of your eye).  It can be associated with other inflammatory conditions of the body for example arthritis, but in most cases the cause remains unknown.

It is a common condition which tends to recur, and although it usually only affects one eye at any one time, but it can affect either eye.

Signs and Symptoms

An aching, painful red eye with a small pupil, blurred vision and sensitivity to light.

Treatment

It is important that this condition is treated at an ophthalmic casualty department as it can be difficult to diagnose without certain equipment which is usually not available at your doctor's surgery.
The doctor will prescribe anti-inflammatory drops which may be used frequently at first, then gradually tailed off.  You must not suddenly stop using the drops or the Iritis may recur.  You may also need to use an anti-inflammatory ointment last thing at night.

You will be given drops to dilate your pupil.  This will cause blurring of vision and difficulty in focusing, and may also increase your sensitivity to light, but it is a vital part of the treatment for Iritis. 

If the pupil is not dilated, the inflamed iris will stick to the lens, which can lead to complications.  You may require intensive pupil dilating drops in casualty to ensure your pupil is dilated before you go home.
Should you have a future attack of Iritis it is essential that you seek early treatment at an ophthalmic casualty department to prevent complications.

The sooner treatment is commenced the easier Iritis is to treat and the quicker the inflammation subsides.

Lacrimal Drainage System - DCR

Tears are drained away from the eye through tiny holes called puncta on the upper and lower eyelids, near to your nose.  From there the tears pass into the canaliculi and into the lacrimal sac. 

Why isn't my drainage system working?

The blockage from your tear drainage system may have been caused by a previous injury or chronic infections.

So what exactly is a DCR?

The operation can take up to a couple of hours and requires a general anaesthetic.  A small incision is made on the skin between your eye and your nose.  The surgery involves joining the lacrimal sac directly onto the lining inside the nose thereby bypassing any obstruction in the sac or naso-lacrimal duct.  Sometimes a very fine plastic tube may be left in the new tear duct with the ends emerging inside the nose.  These are often trimmed the morning after the operation.  This tube is left in place for several months while healing takes place and then will be removed.  The surgeon will explain whether you need these tubes when you see him before the surgery.

What can I expect after the surgery?

You will stay in hospital for the night following surgery to ensure that there is no bleeding from the operation site or from your nose and that there are no signs of infection.  The one sign of your surgery will be a small line of stitches on the side of your nose.  These will be removed five - seven days following the operation, either by your GP or at the Eye Clinic. 

It is important that you do not blow your nose for two weeks or bend down too much to prevent the risk of bleeding.  If you develop a nose bleed at home you should contact your doctor and return to the hospital.  You may have bruising and swelling around the operation site which will gradually resolve over a few days. 

A painkiller such as Paracetamol will help with any discomfort.  You will be given a follow-up appointment to see your doctor in the eye clinic two weeks following surgery.  You will also be given some eye drops to prevent inflammation and infection which will need to be instilled four times a day for four weeks.

Will this surgery resolve my symptoms?

The success rate for this operation is high and your symptoms should be alleviated straight away - about 95% of the operations are successful.  However, if a tube has been left is place the eye may continue to water until this is removed.

Laser Treatment

A laser is a machine which emits a highly concentrated beam of light.  This is attached to a slit-lamp microscope, similar to the microscope that the doctor used to examine your eye in the clinic.
This type of laser is used to cut and divide thickened membranes after cataract extraction, and in the treatment of certain types of glaucoma.

This will involve the following:

• A vision test
• The nurse may instil drops into the eye in order to dilate (enlarge) the pupil.  These usually take 30 to 40 minutes to work. The doctor will instil anaesthetic drops into the eye before commencing the treatment, to stop any discomfort
• A contact lens will be gently placed on your eye which may feel odd but will not hurt.
  You will then be required to sit still at the slit-lamp while the treatment is being undertaken. The treatment is painless and takes up to 10 minutes to perform. You may feel dazzled for a while afterwards. The doctor may prescribe drops and tablets for you to take for up to 3 days after the treatment
• As you will be unable to drive after the treatment it is advisable to make alternative arrangements for your return journey. Do remember to allow enough time for your visit to the clinic. You may be asked to make a follow-up clinic appointment.

Following your treatment

Your vision will be blurred for a few hours and you may need to use a course of eye-drops.

Local Anaesthetic for Eye Surgery

If you are having your eye surgery under a local anaesthetic you will remain awake during the operation. This will be administered with eye drops and an infusion when you get to the operating theatre.  This technique is called surgeon administered sub-tenon's anesthesia and will freeze or numb the eye.  There is some initial stinging, but this will soon wear off.  The injections will also stop your eye moving and the lids blinking during the operation.  You will NOT receive a painful injection into the eye or the eyelid.

During the operation you will need to lie still for about 20-30 minutes. Your head will be supported by a special pillow and you may be aware of a bright light above you. This is the microscope light which aids the surgeon's visibility and does not harm the eye. You may see pretty lights during the operation.

The theatre nurses will make sure that you are lying comfortably before surgery begins. You must not move or talk whilst the operation is in progress.  During this stage a theatre nurse will sit next to you and hold your hand.  If you experience any discomfort, you will be able to communicate by squeezing the nurse's hand.

In order to keep the surgical area 'sterile', it is usually necessary to cover you with a theatre drape.  So that you will not feel hot and stuffy under this drape, the nurses will place a 'funnel' under your chin to blow some cool fresh air around your nose.

There will be background music to help you relax!

Because you are having a local anaesthetic you can have a light meal and can drink normally beforehand; you will not have to stay in bed afterwards.

You will only have to undress from the waist up. Your ward nurse will help you into a theatre gown and you can put your dressing gown or woolly cardigan over this to keep warm.  You may dress fully as soon as you return to the ward.

Your ward nurse will accompany you to and from theatre and when it is all over will make you some refreshments.

All medications should be taken as normal on the day of the operation.

You will need time to sleep and recover from the anaesthetic.  Most adults stay overnight but if you have recovered sufficiently you may be able to go home in the evening following the operation.  However, you will need to return to the ward early next morning to see the orthoptist and surgeon.

Your eye may be bloodshot and may be sore post-operatively.  You can be given pain-killers if necessary. The morning after surgery you will be advised to instil eye drops or ointments, and the nurse will give you these and show you how to instil them before you leave the ward.

Preparing for your Operation

Your surgery will be in the morning, so you must not eat or drink after 2.00 am on the morning of your operation.  You should take your normal medications with a small amount of water unless you were advised otherwise at the Pre-Assessment Clinic.

You will need to arrive on the ward at 7.30 am in order to see the anaesthetic doctor.  He will ensure you are fit for a general anaesthetic.

Optimising Phakodynamics

The Millennium phako machine can utilise a Microflow needle that has been reported to reduce energy utilisation and reduce the chance of wound burn. Reducing the amount of energy used in cataract surgery reduces the trauma to the eye. 

However increasing the vacuum will lead to increased chance of complications as well as chamber instability and post-occlusion surge.  It is hypothesised that if the amount of energy used is the same for conventional compared to dual linear control then the amount of vacuum will be less for dual-linear.

Posterior Vitreous Detachment

The vitreous is a transparent gel substance filling the back of the eye ball.  With age, the vitreous gel shrinks and separates itself from part of the retina.

Signs and Symptoms

You may notice black ‘floaters’ in your vision which move with the eye and then settle as the eye rests.  You may also be aware of flashing lights, like little flickers in the periphery.  To look at, the eye will appear normal.

Treatment and diagnosis

• There is no treatment required for posterior vitreous detachment
• The floaters will gradually disappear but this may take some time
• The flashing lights should gradually settle down over the next few days or weeks.

Occasionally a posterior vitreous detachment may be the start of a retinal detachment.  Retinal detachments are much more serious and may lead to permanent loss of vision. 

Warning signs of a possible Retinal Detachment

• A sudden increase in the number of floaters in your vision
• New floaters
• A portion of your visual field missing
• A curtain coming across the vision

This may be a warning of a retinal detachment and you should see a specialist as soon as possible.

Ptosis Surgery

Ptosis is the medical term for a drooping of the upper eyelid. 

• Congenital Ptosis which will have been apparent since birth.  Usually it is due to abnormal development of the levator muscle which pulls the eyelid up
• Acquired Ptosis tends to become apparent in later life and may be caused by ageing changes, lid trauma, eye surgery, neurological or muscular conditions

Lid measurements will be taken to accurately measure the degree of lid drooping and amount of muscle function so that plans can be made for the best mode of treatment which often involves an operation.

Treatment

The timing of this can vary.  In children if there is no sign of the development of Amblyopia (lazy eye) then an operation is often delayed until the age of three or four years.

In most cases the operation will involve strengthening the levator muscle in the eyelid.  In very severe Ptosis surgery on the muscles above the eyebrow is performed.  This will involve using either sutures or tissue from the leg to form a connection between the muscles in the eyelid and eyebrow.

In nearly all cases of Ptosis in adults, surgery is performed with a local anaesthetic.

A stitch is often left in the lower lid until 48 hours after surgery to keep the eyelid closed to prevent the eye becoming exposed after the operation.  It is usually removed when the pads are removed 48 hours after surgery but may remain for a few days more.

Skin sutures are normally removed after approximately two - six weeks depending on the type of operation performed.

After the operation a "pressure dressing" normally consisting of eye pads and Elastoplast is firmly applied and left in place for 48 hours to minimize post-operative swelling and bruising.

It is normal for antibiotics in either drop or ointment form, and lubricating drops to be used after the operation.

As the local anaesthetic starts to wear off it is quite common for the eyelid to ache.  This requires mild painkillers such as Paracetamol or Co-Proxamol.

Initially the eyelids are often bruised and swollen.  This can take up to 2 - 3 weeks to completely clear up.  It is often too early to judge the final outcome immediately after surgery, although every attempt is made to achieve the best cosmetic outcome for each individual.

Recurrent Corneal Erosion

This is a fairly common condition which can occur months or even years after an injury or scratch to the cornea. It is due to imperfect healing at the time of the original injury, which leaves a loose area in the cornea. This area can become dislodged by the eyelids when you open your eyes in the morning.

Signs and Symptoms

Severe pain on waking or in the night, redness, watery eye and light sensitivity.

Treatment

This condition should be treated in an ophthalmic department as it is difficult to diagnose without certain equipment.

The erosion is initially treated with an antibiotic ointment and a firm eye pad to keep the eyelids closed. This allows the cornea to heal within 2 - 3 days without the process being interrupted by blinking.
A lubricating ointment is used last thing at night for several months to prevent another erosion occurring. By keeping the cornea and inner surface of the eyelid lubricated in this way friction is prevented which dislodges the loose area and causes the erosion.

If this is not sufficient then the surface of the cornea can be helped to heal using either a small series of abrasions called 'Micropuncture', the Excimer laser or with an operation.

Retinal Detachment Surgery

The retina is a membrane inside the eye transmits images to the brain similar to a camera film.

Retinal Detachment

This is when there is a separation between the two main layers of the retina which occurs when there tension pulling on the retina tears and then allows fluid to seep in and collect between the layers.   People who are short-sighted are at a slightly higher risk of retinal detachment due to thinner retinal layers.

Symptoms

• Flashes of light
• Floaters
• Shadows or a curtain across the vision
• Any loss in vision may be at the edge of the visual field and may not be immediately noticed.  If the centre of the retina that allows detailed vision becomes detached there will be a sudden loss of vision and;
• Pain is not usually associated with retinal detachment as the retina has no pain nerve fibres

Treatment

An operation under general anaesthetic is usually necessary to re-attach the retinal layers.  This is done by attaching a small sponge to the outside of the eye and sometimes a bubble of gas on the inside, bringing the layers of the retina together.

If the jelly in the centre of the eye (the vitreous) is removed (vitrectomy) gas or fluid may also be injected to maintain the correct pressure.  Any fluid that has collected between the layers will be drawn off.

The other eye will be examined thoroughly whilst you are asleep and any weak areas of retina sealed to prevent further retinal detachments.
 
After the Operation

Your eye might feel sore and your lids slightly swollen, this will ease over a couple of days and you will be given pain-killers.  You may also feel quite tired for a couple of weeks after the general anaesthetic.
 
If you have had gas or air inserted you will have to rest with your head on your side or front until the retina looks properly re-attached.  You may have to continue this at home for up to a week or 10 days after your operation.

You may need to stay in hospital for more than one night depending on the extent of the detachment and surgery.  On going home you should ask your doctor about returning to work or driving.

Your eye drops usually continue for four weeks and you should avoid any strenuous activity for about four - six weeks. You will be given an appointment for clinic follow-up for about a fortnight after the operation.
 
Results of Surgery

In the majority of cases the retina can be repositioned with one operation but in some cases further procedures may be required.   Some people have good vision with a retinal detachment because the central part of the retina is still in place.  After surgery vision may be initially worse because of the surgery.  You may also need to change your glasses once the eye has healed to get best vision.

Some people do not have good vision with a retinal detachment either because of bleeding or because the central part of the retina has been detached. Blood will slowly clear or may be removed with a further operation.  If the central part of the retina is involved, vision takes some time to improve and may not return fully to normal.

Sub-Conjunctival Haemorrhage

The front, white part of the eye known as the sclera is covered by a transparent membrane called the conjunctiva; the conjunctiva has a rich blood supply.  A sub-conjunctival hemorrhage occurs when these tiny blood vessels leak causing a small amount of blood to gather between the sclera and conjunctiva.  Because these membranes are transparent this condition looks very serious but it is not and will not interfere with your sight.  This is the same process which causes bruising, which is a small bleed in between the layers of the skin.

Symptoms

The eye will look very bloodshot and you may have a feeling of ‘tightness’ in the affected eye.

Causes

• Coughing, knocking your eye, or rubbing it extremely hard
• Diabetes or high blood pressure
• Aspirin or Warfarin
• Practically all sub-conjunctival haemorrhages occur for no reason. 

In most cases it does not mean you have an illness or eye condition

Treatment

Treatment is not required and apart from an eye examination, we will also check your blood pressure and give you a routine test for diabetes. The bloodshot appearance should go in seven to fourteen days.

Purpose:  A prospective, 1 year, randomised trial to compare the surface cytology of three types of single piece acrylic pseudophakic intraocular lens (IOL) using in-vivo specular microscopy to identify small cells (SC), lens epithelial cells (LEC) and giant cells (GC) on the anterior surface of the IOL as a marker for biocompatibility. 

Trabeculectomy

The front part of the eye contains fluid called 'aqueous humor.'  This normally drains away through a sieve-like structure inside the eye called the trabecular meshwork.  If this becomes clogged up for any reason, the fluid cannot escape and pressure will build up inside the eye, pressing on the optic nerve. As a result of this sight in the eye is permanently lost through a disease is called 'glaucoma'.

Glaucoma can be treated with eye drops, which have to be instilled every day. If treatment with eye drops fails to control the pressure in the eye, an operation may be necessary. In other cases an operation may not be essential, but may be offered as an alternative to instilling eye drops constantly.

This operation is performed to treat glaucoma (high pressure in the eyes).  The operation entails forming a small channel through the white part of the eye under your upper eyelid.  This channel will allow the fluid made naturally in the eye to drain away more easily into a small pocket.

Will the operation improve my sight?

Unfortunately, the operation cannot bring back any sight that has been lost.  After the operation, your sight may be blurred and seem worse.  This is only a temporary situation, and is to be expected after an operation on the eye. Your eye will need time to heal and settle down following surgery.  This generally takes about 8 weeks.

How successful is the operation?

It is a very successful operation which will save the remaining sight of the eye.  Following surgery, in 80% of cases no further treatment is necessary.  In 15% of cases drops to reduce pressure will still be needed.  In 5% of cases a further operation or treatment is necessary.
 
There is a small risk of bleeding in the eye at the time of surgery but this will gradually clear. There is also a small risk of over drainage so the pressure is too low.  This usually settles but may need extra treatment. There is a very rare risk of late infection so if the eye becomes red and painful please return to the Hospital urgently.

Vitrectomy

A vitrectomy is an operation to remove the vitreous humor, a clear transparent jelly from inside the eye.  The vitreous humor is situated behind the iris, the coloured part of the eye and in front of the retina, at the back of the eye). It has no real function other than providing packaging inside the eye.

Why is a Vitrectomy necessary?

• Retinal Detachment
• Diabetic eye conditions where blood vessels from the retina leak and bleed into the clear vitreous jelly greatly reducing the vision
• Trauma; to allow removal of any foreign body (e.g. metal) lodged inside the eye in the vitreous jelly or retina
• Biopsy purposes, usually in the case of serious infections to enable the source of infection to be identified and treated.

How is the vitreous jelly removed? 

It is usually necessary to perform surgery under full or general anaesthesia although in some instances it may be performed under local anaesthesia.  The vitreous jelly is removed through small holes made in the sclera - the white of the eye.  The jelly is broken up and sucked away very gently to avoid any damage or further damage to the retina.  The procedure can take one - two hours depending on the reason for surgery.  Once the jelly is removed the retina is repaired (if necessary), any foreign bodies removed and, in the case of diabetics, any leaking blood vessels are sealed.
 
After the Operation

Expect your eye to be sensitive, swollen and red due to the nature of surgery.  This is normal and you will be given specific instructions and advice. You will be prescribed a combination of eye drops to instil at home to help prevent infection and reduce inflammation; you must also rest the eye.

If gas or oil has been inserted into the eye, usually for retinal detachment surgery, you will be advised to tilt your head downwards.  This helps ensure that the gas or oil is lying against the area of retina which has detached encouraging it to heal in the correct place.  You will be required to follow this instruction for 50 minutes out of every hour during the day for at least seven - ten days. 

At night whilst in bed we advise you to lie on your front as much as possible.

You will attend the eye clinic one - two weeks after surgery in the out-patient department of Eye Hospital and will be assessed.  Further appointments will normally be necessary.