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Pterygium

SIGNS AND SYMPTOMS
In most cases, routine ocular evaluation reveals pterygia in asymptomatic individuals or in patients who present with cosmetic concern about a tissue "growing over the eye." In some instances, the vascularized pterygium may become red and inflamed, motivating the patient to seek immediate care. In other cases, the irregular ocular surface can interfere with the stability of the precorneal tear film, creating a symptomatic dry eye syndrome. Rarely, the pterygium may induce irregular corneal warpage, or even obscure the visual axis of the eye, resulting in diminished acuity.

Clinical inspection of pterygia reveals a raised, whitish, triangular wedge of fibrovascular tissue, whose base lies within the interpalpebral conjunctiva and whose apex encroaches the cornea. The leading edge of this tissue often displays a fine, reddish-brown iron deposition line (Stocker's line).

The vast majority of pterygia (about 90 percent) are located nasally. These lesions are more commonly encountered in warm, dry climates, or in patients who are chronically exposed to outdoor elements or smoky/dusty environments.

Pterygia must be distinguished from pingueculae, which are more yellow in color and lie within the interpalpebral space but generally do not encroach beyond the limbus. Pingueculae also lack the wing-shaped appearance of pterygia, the former being more oval or ameboid in appearance.

PATHOPHYSIOLOGY
Ultraviolet light exposure (both UV-A and UV-B) appears to be the most significant factor in the development of pterygia. This may explain why the incidence is vastly greater in populations near the equator and in persons who spend a great deal of time outdoors. Other agents that may contribute to the formation of pterygia include allergens, noxious chemicals and irritants (e.g., wind, dirt, dust, air pollution). Heredity may also be a factor.

Whatever the etiology, pterygia represent a degeneration of the conjunctival stroma with replacement by thickened, tortuous elastotic fibers. Activated fibroblasts in the leading edge of the pterygium invade and fragment Bowman's layer as well as a variable amount of the superficial corneal stroma. Histologically, pterygium development resembles actinic degeneration of the skin.

Pterygia often persist after surgical removal; these lesions appear as a fibrovascular scar arising from the excision site. These "recurrent pterygia" probably have no relationship to ultraviolet radiation, but rather may be likened to keloid development in the skin.

MANAGEMENT
Because pterygia appear to be linked to environmental exposure, manage asymptomatic or mildly irritative cases with UV-blocking spectacles and liberal ocular lubrication. Advise patients to avoid smoky or dusty areas as much as possible. Treat more inflamed or irritated pterygia with topical decongestant/antihistamine combinations (e.g., Naphcon-A) and/or mild topical corticosteroids (e.g., FML, Vexol) four times daily in the affected eye.

Surgical excision of pterygia is indicated only for unacceptable cosmesis and/or significant encroachment of the visual axis. The treatment of choice involves dissection and removal of the fibrous tissue down to the level of Tenon's capsule. Free conjunctival flaps are then grafted over the bare sclera. Postoperative adjuvant therapy with b-radiation, topical thiotepa, mitomycin-C and other antimetabolic agents may diminish the chance of recurrence. In cases that involve significant corneal scarring, lamellar or penetrating keratoplasty may be indicated.

CLINICAL PEARLS
bulletA pterygium is a benign clinical entity in most cases. Distinguish between the potentially progressive pterygium and the less threatening pinguecula-large pingueculae may be difficult to differentiate from pterygia.
bulletConjunctival intraepithelial neoplasia (CIN), a precursor of conjunctival squamous cell carcinoma, is another clinical entity that must be ruled out in the diagnosis of pterygia. This lesion is generally unilateral, elevated and gelatinous, with deep irregular vascularization and an ameboid shape. CIN is an invasive ocular cancer that can inflict significant morbidity. Obtain a biopsy if CIN is suspected.
bulletPterygia can affect vision if left unchecked. The corneal degradation may extend beyond the leading edge of the lesion. This means that the pterygium need not cover the visual axis to inflict significant visual compromise. Surgery must be performed before vision is affected.
bulletFollow up on medium- to large-sized pterygia at least once or twice yearly, and include a manifest refraction, corneal topography, slit lamp evaluation with measurement of the pterygium, and photodocumentation if possible.

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Strabismus

Evolution of Two-eyed Vision

RabbitTwo Eyes to the Side
Nature has given animals the physical attributes necessary for survival. Lateral placement of the eyes is essential to the survival of hunted animals or herbivorous animals (e.g., horse, rabbit, cow) as it allows them to increase side or peripheral vision.

Side vision (increased by lateral placement) is a sensitive detector for motion or movement. Peripheral vision allows creatures to effectively scan for danger. The rabbit must be constantly aware of its natural enemies while it eats your garden greens. At the first sign of danger, peripheral vision, the motion detector system, alerts the rabbit that there is danger. The immediate reflexive response is for the rabbit to run.

Tiger

 

Two Eyes in Front
Faster moving carnivorous hunters do not need as much peripheral vision as the hunted. It is more important for hunters to locate their prey and accurately determine the distance from themselves to that prey. Therefore, animals that hunt (carnivorous or meat eating animals, e.g. lion, cat) as well as humans have frontal placement of the two eyes in order to determine the exact location of their prey. The hunters sacrifice the large peripheral motion detection system afforded by side placement of the eyes in favor of the incredibly accurate depth perception system created by frontal placement of the eyes. To make up for the loss of peripheral vision, most carnivorous animals have also developed a sophisticated, pivoting system which extends the range of side vision...that is, the neck.

The Benefits of Two Eyes in Front
Frontal placement of the eyes allows for a remarkable visual phenomenon called stereopsis. Stereopsis is the 3D perception that occurs as a result of both eyes working together to create relative depth perception.

Many of you have experienced exaggerated demonstrations of stereoscopic depth by viewing I-Max 3D movies or old stereoscopes. Or, perhaps, you have seen photos of theatergoers in the 1950's wearing special Polaroid glasses in order to view 3D movies.

What is Stereopsis?
Stereopsis results from the combination of the two images received by the brain from each eye. Each eye views the world from a slightly different vantage point (See Fig 1).

Stereopsis
Figure 1

The fusion of these two slightly different pictures from our two "cameras" (the eyes) gives us the sensation of strong three-dimensionality or relative depth.

At near, there is a greater difference in what the two eyes view as compared to far. Thus, stereopsis is strongest and most important at near distances. At near is where man uses accurate hand-eye coordination to make tools and other items!

The Benefits of Stereopsis
Stereopsis has been very important in human development. Keen and accurate two-eyed depth perception has allowed man to develop tools and the manufacture of goods, a central aspect of modern civilization. Stereopsis plays a role in many other human activates, such as, catching a ball, parking a car, threading a needle, performing surgery, or any other activity that requires accurate depth perception at close distances.

Man with stereoscope

Animals that have lateral position of the eyes and individuals who have constant strabismus (eye turn) lack stereopsis. This does not mean that they have absolutely no depth perception. There are many one-eyed (monocular) depth perception cues that allow us to make reasonably accurate depth judgments. These monocular depth perception cues may be familiar to you and include: perspective, overlay, shadowing, aerial perspective (color of the sky), relative motion, relative size, etc.

Binocular vision cues (from two eyes), such as stereopsis and parallax, are dependent on accurate alignment of the eyes and appropriate unification of the two images by the brain. People with only monocular or one-eye depth perception skills can do fine in many situations. However, they are not allowed to fly a rocket ship, drive the trains in New York city subways, and they definitely should not be surgeons. They may have trouble catching a fly ball or becoming a NBA point guard. However, many jobs do not require stereopsis and thus the lack of stereopsis does not preclude a successful life.

Stereopsis does enhance quality of life and life choices, however! Some eye doctors might tell you that it is a luxury, but it is part and parcel of our evolution and human potential. 3D vision is a human skill we all want and deserve. Every attempt should be made to develop this visual-motor skill in a child [and it's not too late for many adults!]

What is the "critical period?"
In the early 1960's, two Nobel Prize winners from Harvard , Hubel and Weisel, did research on the development of vision. They studied monkeys and cats who have stereoscopic vision similar to humans. This led to conclusions regarding a "critical period" of development for stereopsis.

What is the "critical period" and what does it mean in regards to you or your child and your treatment options. Explore this controversial topic by reading the following two articles by Dr. Jeffrey Cooper and Dr. Paul Harris, two different experts on strabismus. Dr. Harris refers to the famous 1960s Hubel and Weisel study as well as later studies by Hubel and Weisel and others. Many of the more recent studies call into question the idea of a finite "critical period." Dr. Cooper explains the Hubel and Weisel study and its implications in detail.

The Myth of the Critical Period
by Dr. Paul Harris

Development of Vision (Critical Periods)
by Dr. Jeffrey Cooper

Why does my eye doctor say it is "too late?"
Whenever an eye doctor tells you that it is "too late" to treat your child's loss of binocular vision (or eye turn or "lazy eye"), he or she is probably referring to his or her earlier education regarding the "critical period." He or she might even be directly or indirectly referring to the aforementioned research dating from the 1960s.

Remember, a great deal has been learned about the human brain since the 1960s! For example, a new ground-breaking study on the brain's plasticity (its ability to change and grow) was released to broad media fanfare in the year 2000.

When is it too late to treat strabismus or lazy eye?
It is often asked at what age should treatment no longer be attempted. The answer is, everyone deserves a chance! Age should not be a deterrent, though treatment under age 6 (especially before 2) is ideal and allows better results than later treatment. After age 6, age is not important.

"... every attempt should be made to improve strabismus and lazy eye."

 


The best chance of success in eliminating the effects of the most difficult conditions, amblyopia or constant strabismus, occurs before the age of two. However, this does not preclude excellent success in many older patients and at least partial success in most patients older than 6 years of age. There are numerous studies that demonstrate that treatment after the age of 6 is very successful. One study compared treatment before age 6 to treatment after age 6. They found no statistical difference between the two groups. As a matter of fact, loss of an eye in patients over the age of 65 who were never treated for their amblyopia experienced a spontaneous improvement in vision in over one-third of the cases.

Thus, every attempt should be made to improve strabismus and lazy eye, though treatment might not be as effective after the age of six, and definitely requires more work. Also, remember that if an eye turn occurs only some of the time (intermittent), the cells of the brains do not develop the changes associated with the more challenging cases of constant eye turns.

"It is never too late to try!!"

 


An analogy to understanding the relationship of age in regards to the treatment of eye muscle anomalies would be to consider the relationship of one's age in learning to speak a second language. During the period of neurological development, around the first year of life, language development is natural and spontaneous. Children raised in families that speak two languages from birth automatically learn both languages. However, if the second language is introduced in later school years, language development takes a longer time and is more arduous. Yet, remember, people learn languages well into their sixties and seventies. The very same is true of visual development. It is easier to develop normal vision during the critical period, but with work, many people can develop normal binocular vision in later years.

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Cataracts and Cataract Surgery

A cataract is a clouding of the eye's natural lens, which lies behind the iris and the pupil. The lens works much like a camera lens, focusing light onto the retina at the back of the eye. The lens also adjusts the eye's focus, letting us see things clearly both up close and far away.

The lens is mostly made of water and protein. The protein is arranged in a precise way that keeps the lens clear and lets light pass through it. But as we age, some of the protein may clump together and start to cloud a small area of the lens. This is a cataract, and over time, it may grow larger and cloud more of the lens, making it harder to see.

Cataracts are classified as one of three types:

bulletA nuclear cataract is most commonly seen as it forms. This cataract forms in the nucleus, the center of the lens, and is due to natural aging changes.
 
bulletA cortical cataract, which forms in the lens cortex, gradually extends its spokes from the outside of the lens to the center. Many diabetics develop cortical cataracts.
 
bulletA subcapsular cataract begins at the back of the lens. People with diabetes, high farsightedness, retinitis pigmentosa or those taking high doses of steroids may develop a subcapsular cataract.

Cataract Symptoms and Signs

A cataract starts out small, and at first has little effect on your vision. You may notice that your vision is blurred a little, like looking through a cloudy piece of glass or viewing an impressionist painting. A cataract may make light from the sun or a lamp seem too bright or glaring. Or you may notice when you drive at night that the oncoming headlights cause more glare than before. Colors may not appear as bright as they once did.

Blurred or hazy vision may indicate a cataract.

Hazy or blurred vision may indicate a cataract.
 

A cataract is a clouding of the eye's natural lens. Click here for animation. Click here for animation of how a cataract affects vision.

A cataract is a clouding of the eye's natural lens.

Cataracts affect vision by scattering incoming light.

The type of cataract you have will affect exactly which symptoms you experience and how soon they will occur. When a nuclear cataract first develops it can bring about a temporary improvement in your near vision, called "second sight." Unfortunately, the improved vision is short-lived and will disappear as the cataract worsens. Meanwhile, a subcapsular cataract may not produce any symptoms until it's well-developed.

If you think you have a cataract, see an eye doctor for an exam to find out for sure.

What Causes a Cataract?

No one knows for sure why the eye's lens changes as we age, forming cataracts. Researchers are gradually identifying factors that may cause cataracts — and information that may help to prevent them.

Many studies suggest that exposure to ultraviolet light is associated with cataract development, so eyecare practitioners recommend wearing sunglasses and a wide-brimmed hat to lessen your exposure. Other types of radiation may also be causes. For example, a 2005 study conducted in Iceland suggests that airline pilots have a higher risk of developing nuclear cataract than non-pilots, and that the cause may be exposure to cosmic radiation. A similar theory suggests that astronauts, too, are at risk from cosmic radiation.

Other studies suggest people with diabetes are at risk for developing a cataract. The same goes for users of steroids, diuretics and major tranquilizers, but more studies are needed to distinguish the effect of the disease from the consequences of the drugs themselves.

Some eyecare practitioners believe that a diet high in antioxidants, such as beta-carotene (vitamin A), selenium and vitamins C and E, may forestall cataract development. Meanwhile, eating a lot of salt may increase your risk.

Other risk factors include cigarette smoke, air pollution and heavy alcohol consumption. A small study published in 2002 found lead exposure to be a risk factor; another study in December 2004, of 795 men age 60 and older, came to a similar conclusion. But larger studies are needed to confirm whether lead can definitely put you at risk, and if so, whether the risk is from a one-time dose at a particular time in life or from chronic exposure over years.*

Cataract Treatment

When symptoms begin to appear, you may be able to improve your vision for a while using new glasses, strong bifocals, magnification, appropriate lighting or other visual aids.

Think about surgery when your cataracts have progressed enough to seriously impair your vision and affect your daily life. Many people consider poor vision an inevitable fact of aging, but cataract surgery is a simple, relatively painless procedure to regain vision.

Cataract surgery is very successful in restoring vision. In fact, it is the most frequently performed surgery in the United States, with over 1.5 million cataract surgeries done each year. Nine out of 10 people who have cataract surgery regain very good vision, somewhere between 20/20 and 20/40.

This intraocular lens or IOL is used to replace the cataract patient's clouded natural lens.

An intraocular lens (IOL) is implanted in the eye in place of the patient's clouded natural lens. Shown is Alcon's new AcrySof Natural IOL; the lens material is yellow because it filters out blue light, which may be harmful to eyes.

During surgery, the surgeon will remove your clouded lens, and in most cases replace it with a clear, plastic intraocular lens (IOL). New IOLs are being developed all the time to make the surgery less complicated for surgeons and the lenses more helpful to patients. One example is a new IOL that lets patients see at all distances, not just one. Another new IOL blocks both ultraviolet and blue light rays, which research indicates may damage the retina (see illustration).

Facoemulsification:

Different methods of cataract surgery are available, but they all have the same objective: the replacement of the opaque lens by an intraocular lens to achieve an adequate vision.

The surgeon will chose the most suitable method, according to the patient's need.

The facoemulsification is the most modern and effective technique. The opaque crystalline is liquefied and aspired through a vibrating end. The incision in the eye must be only of the size necessary to allow the passing of the facoemulsificator needle. This incision, performed with a small diamond seals automatically, therefore it does not require stitches, or, at the most, one or two.

Through this incision the intraocular lens is inserted, as shown step by step in these images. To the right, a model of an intraocular lens can be observed. These are made of biocompatible elements.

The facoemulsification is performed under local anesthesia or with eye drops, it is therefore considered an ambulatory surgery that does not require the hospitalization of the patient.

Post operating Care

The patient can go home, and within two days perform regular day to day activities.
The visual recovery is almost immediate, but the healing process will be complete almost six weeks after the surgery.
During this period the patient must follow the doctor's indications:

bulletFulfill the post operating indications.
bulletDo not perform group sports in order to avoid the risk of receiving a blow in the eye.
bulletUse sunglasses.
Any visual effort performed does not alter the result of the surgery.

Refractive Possibilities:

The patient with cataracts, with a previous refraction vice (myopia or hyperopia), has with this surgery an additional advantage.

When having surgery, and their crystalline lens being removed, we can, in the power calculus of this lens, compensate the refraction vice.

It may happen, that after several months or even years after surgery, the capsule (bag where the intraocular lens was placed) may become opaque, being this common in a 17% of the patients.

When this happens, it is corrected performing an incision with a technique called posterior capsulotomy with Yag Laser , a simple procedure done in the doctor's office.

The decision to operate:

Both the patient and the doctor must agree, according to the need to improve the eyesight, as well as the quality of life.

Santa Cruz Clinic uses the latest equipment and techniques 100_1296.jpg (86258 bytes)

Click here for a Patient's View

 

 

 

 

 

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Surgery for Glaucoma

What is the purpose of glaucoma surgery?
Glaucoma surgery reduces eye pressure. The purpose of reducing intraocular (within the eye) pressure is to prevent further vision loss from glaucoma. Glaucoma surgery usually does not improve vision.

Why is surgery performed for glaucoma?
Medicine — usually in the form of eye drops — or glaucoma laser can lower pressure and treat glaucoma. However, sometimes these do not adequately lower the intraocular pressure. In addition, some patients have side effects from the eye drops while others cannot afford their medicine. Glaucoma laser is quicker, easier, more convenient, and safer than surgery. However, it does not always adequately lower the pressure, and its effects might wear off months or years later.

For some, glaucoma surgery is the best option. Surgery reduces intraocular pressure to lower levels than can be achieved by medicine or laser, and might also reduce or eliminate the need for long-term glaucoma medicine. The lower pressure achieved by surgery has been shown to provide a greater chance of preventing further loss of vision from glaucoma.

Is there more than one type of glaucoma surgery?
The most common glaucoma surgery performed in the United States is called a "trabeculectomy." During this operation, a partial thickness channel is created on the upper part of the eye, through the sclera (white part of the eye). This creates a fluid-filled pocket, sometimes called a "glaucoma filtering bleb," that allows the fluid from the eye to spread outward around the eye, reducing eye pressure.

Full-thickness filtering surgery was an earlier form of glaucoma surgery. It was found to be highly effective, but tended to cause a greater number of side effects from the pressure becoming too low. Occasionally, it is performed for selected patients.

In the late 1990s, some glaucoma sub specialists advocated non-penetrating filtering surgery. This has the advantage of reducing the risk of the intraocular pressure becoming too low immediately after surgery, but seems to have a disadvantage in that there is a higher failure rate and need for repeat surgery for glaucoma.

What is a glaucoma implant?
There are several types of implants for glaucoma treatment. Glaucoma implant surgery is a somewhat longer and more technically involved procedure compared to trabeculectomy. Glaucoma implants have two components:
bulletA small tube that is placed in the front or back of the eye to collect fluid
bulletA plate connected to the tube that forms a natural chamber of tissue to collect and release the fluid from your eye

It is generally reserved for cases of severe glaucoma due to more unusual conditions, such as abnormal vessels in the front of the eye of some people with diabetes, and glaucoma caused by ocular inflammation. Implant surgery is also used in some individuals who have previously had a trabeculectomy that was not successful.

What is the recovery period after glaucoma surgery?
Immediately after surgery you can use your eyes. There will be some blurring in the operated eye. We recommend that people wear their glasses during the daytime and tape an eye shield over their operated eye at bedtime. Most people are able to engage in normal activities, but it is recommended that patients avoid heavy straining or lifting for a few days, and avoid bumping or rubbing the eye.

Are there risks of glaucoma surgery?
Any eye surgery has some risk. The glaucoma operation might fail and require glaucoma medicine or another operation. Frequently, the eye pressure becomes very low. This is usually harmless over a short period of time. However, over a long period of time, this might cause vision changes. Occasionally, there is a leak from the surgery, which often closes naturally. Any eye surgery has the risk of bleeding in the eye or infection, but the risk is usually less than one percent (1%), and precautions are taken to reduce that risk.

However, these risks must be compared to the risks of uncontrolled glaucoma, which can lead to a total, permanent loss of vision, if the pressure cannot be controlled with eye drops, laser, or surgery.

What can be done to prevent failure of glaucoma filtering surgery?
In the last two decades, two medicines have been used to reduce scarring after glaucoma surgery. One is 5-fluorouracil and a second is mitomycin C. Both are medicines that were initially developed for cancer treatment and have been found to reduce the scarring after surgery, particularly in higher risk cases. 

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LASIK and other refractive surgeries: Say good-bye to eyeglasses

Considering surgery to correct your vision? Explore three procedures that can restore your eyesight.

If you wear glasses or contact lenses, you might be interested in surgery to correct your vision. Keep in mind, though, that as much as you might like to toss out your glasses or put an end to the daily ritual of inserting and removing your contact lenses, surgery to correct vision problems isn't for everyone.

Familiarize yourself with the procedures eye doctors use to correct vision problems and the risks and benefits of each. Then discuss your options with your doctor to help you decide whether refractive eye surgery is for you.

What is refractive eye surgery?

Eye Anatomy:
Eye anatomy

Your eye is a complex and compact structure measuring about 1 inch in diameter.

Refractive eye surgery is a surgical procedure to change the way your eye refracts light. As light rays enter your eye, your cornea and lens bend (refract) the rays to focus them on the back of your eye — your retina. If you have a refractive error, your eye is shaped in such a way that light rays aren't sharply focused on your retina.

During refractive surgery, your cornea is reshaped. Your cornea can be flattened or steepened based on your specific vision problems. Refractive surgery is usually considered an elective surgery — which means it isn't vital to your health and well-being. For this reason, Medicare and most insurance companies won't cover the cost of the surgery.

Who can have refractive eye surgery?

Refractive eye surgery is for people with certain refractive errors in their vision, such as:

bulletNearsightedness (myopia). Nearsightedness is the most common refractive error. It generally occurs when your eye is slightly larger than the average-size eye. It can also be caused by a cornea that is too curved. Nearsightedness causes light rays to focus in front of your retina, rather than right on it, causing blurry distant vision.
bulletFarsightedness (hyperopia). Farsightedness affects near vision. It generally occurs when your eye is slightly smaller than the average-size eye. It can also be caused by a cornea that's too flat. Farsightedness causes light rays to focus beyond the retina, rather than right on it, causing blurry vision.
bulletAstigmatism. Astigmatism makes it difficult to see objects at any distance. It's caused by a cornea that's uneven — curving and flattening in different spots on your eye.

Refractive surgery can't correct or prevent presbyopia — a type of refractive error that is common as you age. Most people in their 40s have some signs of presbyopia, including difficulty reading or doing up close work. If you're approaching your 40s or if you already have presbyopia, keep in mind that refractive surgery may give you clear distance vision, but it might make it even more difficult for you to see objects close up.

To avoid this, you might choose to have your vision corrected to give you monovision. With monovision, one eye is corrected to see objects far away and your other eye is corrected to see close objects. Some people can adjust to this whereas others can't. You can also choose to wear glasses solely for reading or other close up work. Ask your eye doctor about your options if you have presbyopia.

Your eye doctor will likely recommend that you try other ways of correcting your vision before you turn to surgery. Glasses or contact lenses are usually your first option. Some people might have only mild refractive errors that don't require vision correction.

What might disqualify you from having refractive surgery?

Not everyone with a refractive error is a candidate for refractive surgery. Whether surgery is right for you is also based on:

bulletYour general health. Certain diseases or conditions might make it difficult for your eyes to heal after surgery. Diseases that affect your immune system, such as autoimmune and immunodeficiency diseases, affect your ability to heal. One example is rheumatoid arthritis.
bulletYour eye health. Eye diseases and conditions that make your eyes dry can make it difficult for your eyes to heal after surgery. Examples include Sjogren's syndrome and rheumatoid arthritis. Abnormally shaped corneas may make surgery more difficult to perform.
bulletThe stability of your vision. The degree of refractive error in your eye must be stable. If your vision is fluctuating or progressively worsening, you may not be eligible for refractive surgery. Women who are pregnant or breast feeding, for example, usually have fluctuating degrees of refractive error.
bulletOther factors. Your eye doctor will take into account additional factors. For example, deep-set eyes may make the surgery more difficult and risky.

To determine whether you're a candidate for refractive surgery, your eye doctor will conduct an in-depth eye exam to determine the degree of your refractive error, the shape of your corneas and the general health of your eyes. Talk with your eye doctor about certain aspects of your eyes that might influence whether you're eligible for refractive surgery.

What types of refractive eye surgery are available?

Several surgical procedures are available if you have a refractive error in your vision. What type of surgery you choose will depend on the type and degree of refractive error that you have. Get to know the common types of refractive surgery and discuss your options with your eye doctor.

Laser-assisted in-situ keratomileusis (LASIK)
LASIK is the most common refractive eye surgery. You might choose LASIK if you're nearsighted or farsighted, with or without astigmatism. LASIK is performed using a laser programmed to remove a defined amount of tissue from your cornea. With each pulse of the laser beam, a tiny amount of corneal tissue is removed. The laser allows your eye surgeon to flatten the curve of your cornea or make it steeper.

During the LASIK procedure, your eye surgeon uses a special blade or special cutting laser to cut a hinged flap about the size of a contact lens away from the front of your eye. Folding back the flap allows your doctor to access the tissue in your cornea that needs reshaping. Using a laser, your eye surgeon then targets specific parts of your cornea. The flap is then folded back into place and usually heals on its own without stitches.

Your eye doctor determines which specific areas of your cornea need to be flattened or curved during your eye exam. This allows your eye doctor to chart your eye and remove tissue from your cornea very precisely.

You will receive an anesthetic to numb your eye during the LASIK procedure, which helps ensure you'll experience little pain. You may be given medication or eyedrops after the procedure to soothe any pain you might have for several hours after your surgery. Your eye doctor might also ask you to wear a shield over your eye at night until your eye heals. You might have the option of having LASIK on both eyes on the same day.

Typically you're able to see the day of your surgery, but your vision won't necessarily be better right away. Expect your vision to improve over the next two to three months. Most people who have refractive surgery will have vision that is close to 20/20. Your chances for improved vision are based, in part, on how well your eyes saw before surgery.

Laser epithelial keratomileusis (LASEK)
LASEK is similar to LASIK and might be an option if you aren't eligible for LASIK. During a LASEK procedure, a much thinner layer of your cornea is folded back to allow the laser to focus on parts of your cornea that need reshaping. The flap is then replaced.

If you have very thin corneas, you might choose LASEK because the procedure allows your doctor to cut out less of your cornea. People who play sports or have jobs that carry a high risk of eye injuries might also prefer LASEK because a thinner flap means less damage to your vision should the flap be torn before it can heal. As with LASIK, the LASEK procedure can be done on both eyes on the same day. Expect your vision to take time to recover — it may take several months.

Photorefractive keratectomy (PRK)
PRK is sometimes used if you have a low-to-moderate degree of nearsightedness or farsightedness, or if you have nearsightedness with astigmatism. With PRK a thin layer on the surface of your cornea is removed. Unlike with a LASIK or LASEK procedure, this layer isn't replaced during PRK. Your eye surgeon uses a laser to flatten your cornea or make its curve steeper.

The raw surface of your cornea repairs itself, assisted by a contact lens you wear as a bandage over your eye for three or four days after surgery. You might have eye pain for a few days until your cornea heals. It generally takes up to a week for your eye to regenerate the surface tissue that was removed. During this time you'll notice changes in your vision. It may take three to six months before your vision improves completely. Most people undergoing PRK have one eye done at a time. After your first eye has healed, you might consider having surgery on your other eye.

PRK has become less common in recent years because more eye surgeons prefer the LASIK procedure. Healing after LASIK is more predictable and usually involves less discomfort and scarring.

Other types of surgery
Other types of refractive surgery exist, although LASIK, LASEK and PRK are the most popular. Talk to your doctor about what types of refractive surgery are available to you. If you have severe refractive errors, your eye doctor may propose more than one type of surgery to help you regain your vision.

What are the risks and benefits of refractive eye surgery?

Refractive surgery can offer you improved vision without the hassle of glasses or contact lenses. In general, you have a very high chance of achieving 20/40 vision or better after refractive surgery. About 85 percent of people who've undergone refractive surgery no longer need to depend on their glasses or contact lenses most of the time.

Your results will depend on your specific refractive error and other factors. People with a low grade of nearsightedness tend to have the most success with refractive surgery. People with a high degree of farsightedness along with astigmatism have the least predictable results.

As with any surgery, refractive surgery carries risks, including:

bulletUndercorrections. If the laser removes too little tissue from your eye, you won't get the vision results you were hoping for. Undercorrections are more common for people who are nearsighted. It may require another refractive surgery within a year to remove more tissue.
bulletOvercorrections. It's also possible that the laser will remove too much tissue from your eye. Overcorrections may be more difficult to fix than undercorrections.
bulletAstigmatism. Astigmatism can be caused by uneven tissue removal. This sometimes occurs if your eye moves too much during surgery. It may require additional surgery.
bulletGlare, halos and double vision. After surgery you may have difficulty seeing at night. You might notice glare, halos around bright lights or double vision. Sometimes these signs and symptoms can be treated with an eyedrop that contains a type of cortisone, but sometimes a second surgery is required.
bulletDry eyes. As your eyes regenerate the nerves cut during surgery, your eyes might feel dry for the first six months or so. Your eye doctor might recommend that you use eyedrops during this time. More severe cases of dry eye may require special plugs for your tear ducts to prevent your tears from draining away from the surface of your eyes. Keeping the tears on the surface of your eyes for a longer time will help keep them moist and more comfortable.
bulletFlap problems. Flaps folded back during surgery and then replaced after surgery can cause complications, including infection, tearing and swelling. The flap removed during PRK may grow back abnormally.

Talk to your doctor about your concerns. He or she can explain the risks that are most likely to affect you.

Considering refractive eye surgery

As you make your decision whether to have refractive eye surgery, consider the benefits and the risks. Also consider the cost of surgery. Most importantly, discuss your decision and your concerns with your eye doctor. He or she can help you decide if refractive surgery is right for you.

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