Common procedures done at Angel Eyes

Nd YAG Laser Peripheral Iridotomy (A)

Laser Peripheral Iridotomy (LPI) is a surgical procedure that is performed on the eye to treat angle closure glaucoma, a condition of increased pressure in the front chamber (anterior chamber) that is caused by sudden (acute) or slowly progressive (chronic) blockage of the normal circulation of fluid within the eye. LPI eliminates pupillary block by allowing the aqueous to pass directly from the posterior chamber into the anterior chamber, bypassing the pupil. LPI can be performed with an argon laser, with a neodymium: yttrium-aluminium-garnet (Nd:YAG) laser or, in certain circumstances, with both. Laser iridotomy was first used to treat angle closures in 1956.

In acute angle-closure glaucoma cases, surgical iridectomy has been superseded by Nd:YAG laser iridotomy, because the laser procedure is much safer. Opening the globe for a surgical iridectomy in a patient with high intraocular pressure greatly increases the risk of suprachoroidal haemorrhage, with potential for associated expulsive haemorrhage. Nd:YAG laser iridotomy avoids such a catastrophe by laser created hole in the iris, which facilitates flow of aqueous humour from the posterior to the anterior chamber of the eye.

Purpose

The purpose of a laser iridotomy is to allow an equalization of pressure between the anterior (front) and posterior (back) chambers of the eye by making a hole in the superior peripheral iris. Once the laser iridotomy is completed, the intraocular fluid flows freely from the posterior to the anterior part of the eye, where it is drained via the trabecular meshwork. The result of this surgery is a decrease in IOP.

When laser iridotomy is performed on patients with chronic angle closure, or on patients with narrow angles with no history of angle closure, the chances of future pupillary blocks are decreased.

Indications

Indications for LPI include the following:

• Acute angle-closure glaucoma
• Chronic angle-closure glaucoma
• Fellow eye of acute angle-closure glaucoma
• Narrow/occludable angle
• Miscellaneous conditions, including phacomorphic glaucoma, aqueous misdirection, nanophthalmos, pigmentary dispersion syndrome and plateau iris syndrome

In patients with acute angle-closure glaucoma, LPI should be performed after intraocular pressure (IOP) and intraocular inflammation are controlled. The aim is to prevent another attack of acute angle-closure glaucoma or progression to chronic angle-closure glaucoma. In patients with chronic angle-closure glaucoma, IOP may remain the same or be lowered after LPI, depending on the extent of peripheral anterior synechiae.

The fellow eye in a patient with acute angle-closure glaucoma or chronic angle-closure glaucoma has a 50% chance of developing acute angle-closure glaucoma. Therefore, if an occludable angle is noted on examination, LPI should be performed.

Certain patients, especially hyperopic patients, are at increased risk of having narrow angles. Therefore, gonioscopy should be performed. If narrow/occludable angle is noted on the examination, LPI is recommended.

LPI has been performed in phacomorphic glaucoma, aqueous misdirection, and nanophthalmos to relieve pupillary block. In pigmentary dispersion and plateau iris syndrome, LPI is used to confirm the diagnosis.

Contraindications

Contraindications for LPI include conditions that cause poor visualization of the iris, angle closure due to synechial closure of the anterior chamber angle, and a patient who is unable to cooperate.

• Conditions causing poor visualization of the iris include the following:
• Corneal edema
• Corneal opacity
• Flat anterior chamber

• Conditions causing synechial closure of the anterior chamber angle include the following:
• Neovascular glaucoma
• Iridocorneal endothelial (ICE) syndrome

• Patients who are unable to cooperate include the following:
• Patients who cannot sit comfortably at the laser table
• Patients who cannot keep the head still

Patient Education/Informed Consent

Initially, informed consent for laser peripheral iridotomy (LPI) is obtained. The indications for the procedure, its benefits, and its complications should be discussed in detail with the patient.

Equipment

To perform LPI, a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser is needed.

Neodymium:yttrium-aluminum-garnet (Nd:YAG)

Additionally, using a contact lens makes the procedure easier. The advantages of doing so include the following :

• The laser energy is concentrated at the level of the iris
• The number of corneal epithelial burns is minimized because the lens acts as a heat sink
• The target structure is magnified with less loss of depth of field than occurs if magnification is simply increased with the slit lamp controls
• The lens acts as a speculum; keeping the eye open minimizes fine eye movements

Patient Preparation

Before laser peripheral iridotomy (LPI) is performed, intraocular pressure (IOP) and anterior segment inflammation must be controlled. Topical anaesthesia with proparacaine 0.5% is usually adequate for performing LPI. The patient must be comfortable at the laser table, as when a patient is examined at the slit lamp.

Because postlaser IOP spike is a common complication of LPI, the eye should be pretreated with topical proparacaine, pilocarpine 1%, and either apraclonidine (0.5% or 1%) or brimonidine (0.1%, 0.15%, or 0.2%); the use of apraclonidine or brimonidine significantly reduces the risk of this complication. Pilocarpine is used to stretch the peripheral iris, making it thinner and easier to penetrate. Higher concentrations of pilocarpine are not recommended, because they can cause paradoxical angle closure.

Monitoring and Follow-up

At 1 hour after completion of LPI, the intraocular pressure (IOP) should be checked to make sure that it did not increase significantly (ie, that IOP has not increased by 8 mm Hg or more and that IOP does not exceed 30 mm Hg). Topical prednisolone acetate 1% is given 4 times a day for 5-7 days. At 1 week, the patient is seen to monitor IOP, to confirm the patency of the iridotomy site, and to check for any significant intraocular inflammation.

At 1 month, the patient is seen again for a complete examination that includes IOP measurement, slit-lamp examination, gonioscopy, and dilated fundus examination. IOP is also measured after dilation. If IOP rises by more than 8 mm Hg, the anterior chamber angle is still occludable, and the patient must be evaluated for other causes of angle closure (eg, plateau iris).

Complications of Procedure

Complications of laser peripheral iridotomy include postoperative IOP spike, intraocular inflammation, iris bleeding and hyphema, focal cataract, posterior synechiae, visual symptoms (eg, blurred vision, haloes, lines, glare, and diplopia), corneal decompensation, and miscellaneous complications.

• Postoperative intraocular pressure spike

Elevation of IOP after LPI is common. Typically, the increase is transient, lasting less than 24 hours. When an IOP spike occurs, it is usually in the first hour after LPI (as many as 70% of cases) or, less commonly, in the second hour (as many as 40% of cases). A rise in IOP greater than 6 mm Hg occurs in as many as 40% of patients, and an IOP higher than 30 mm Hg is noted in as many as 30%.

To prevent postoperative IOP spike, a drop of topical apraclonidine (0.5% or 1%) or brimonidine (0.1%, 0.15%, or 0.2%) is placed on the eye before LPI. The IOP should be checked within an hour after LPI.

• Anterior uveitis

Anterior segment inflammation is another common complication of LPI. It is thought to be due to the release of prostaglandins. The inflammation is usually mild and can be successfully treated with topical steroids. Prednisolone acetate 1% 4 times a day for 5-7 days is prescribed.

• Iris bleeding and hyphema

Because the Nd:YAG laser is a photodisruptive device, bleeding is common with its use, occurring in as many as 50% of patients. However, iris bleeding is uncommon with the use of the argon laser, which causes photocoagulation. Usually, iris bleeding can be controlled by applying pressure on the globe with the contact lens. In severe cases, the iris bleeding can lead to hyphema.

• Focal cataract

Lens opacities can develop if the iridotomy site is too close to the pupil. Cataract formation is attributable to heat buildup during argon laser use and direct tissue disruption during Nd:YAG laser use.

• Posterior synechiae

Synechiae may occur between the iris and the lens at the pupillary border or at the iridotomy site. Formation of posterior synechiae can be reduced by using postoperative topical steroids; any synechiae that form can be broken up by means of early postlaser dilation.

• Visual symptoms

Different visual symptoms can present after LPI. Transient blurred vision may occur in the immediate postlaser period. Possible causes include pigment dispersion, inflammation, and retained methylcellulose from contact lens placement.

• Miscellaneous complications

The following complications are rare but have been reported in the literature:

• Aqueous misdirection
• Recurrent herpetic keratouveitis
• Retinal and subhyaloid hemorrhage
• Choroidal and retinal detachment after argon LPI
• Stage I macular hole

Closure of the iridotomy site is rare, especially when the Nd:YAG laser is used; however, it is common in patients with uveitis that requires LPI.

Alternative Procedure to Laser Iridotomy

An alternative to laser iridotomy is surgical iridectomy , a procedure in which part of the iris is removed surgically. This was the procedure of choice prior to the development of laser iridotomy. The risks for iridectomy are greater than for the laser iridotomy, because it involves an incision through the sclera, the white tunic covering of the eye that surrounds the cornea. The most common complication of an iridectomy is cataract formation, occurring in more than 50% of patients who have had a surgical iridectomy. Since an incision in the eye is required for surgical iridectomy, other procedures, such as filtration surgery—if needed in the future—will be more difficult to perform. Studies comparing the visual outcomes and IOP control of laser iridotomy with surgical iridectomy show equivalent results.

In the case of acute angle closures that occur because of reasons other than, or in addition to pupillary block, argon laser peripheral iridoplasty is performed. During this procedure, several long burns of low power are placed in the periphery of the iris. The iris contracts and pulls away from the angle, opening it up and relieving the IOP.

PUNCTAL PLUGS (B) 

 Punctal plugs are tiny, biocompatible devices inserted into tear ducts to block drainage. This increases the eye’s tear film and surface moisture to relieve dry eyes.

Also known as punctum plugs, lacrimal plugs or occluders, these devices often are no larger than a grain of rice.

Punctal plugs usually are considered when non-prescription or prescription eye drops fail to relieve your dry eye condition.

Types of Punctal Plugs-

Two general types of tear duct plugs are:

• Semi-permanent, typically made of long-lasting materials such as silicone.
• Dissolvable, made of materials such ascollagen that the body eventually absorbs.

Temporary or dissolvable punctal plugs usually last from a few days to as long as several months. These types of plugs would be used in circumstances such as preventing dry eyes after LASIK, if you choose to have refractive surgery.

Dissolvable, temporary punctal plugs sometimes are used to determine if the treatment works for your dry eye condition. If so, then semi-permanent punctal plugs might be considered.

Location-

Punctal plugs fall into one of two groups:

• Punctal (or punctum) plugs, which are placed at the tops of the puncta. The tops of these plugs are often visible to the patient looking carefully in a mirror. Generally speaking, the advantage of punctal plugs is ease of removal, with the accompanying disadvantage that they may more easily lost.
• Intracanalicular plugs, which are inserted into the canalicula. Most plugs of this type cannot be seen after insertion. They cannot be removed in the way punctal plugs can, though they may be flushed out with irrigation.

In practice often all types of plugs collectively are referred to as punctal plugs. Both types of plugs may cause some slight discomfort, especially when turning the head all the way to one side. If a punctal plug is too loose,

Material-

Materials used to make punctal plugs include silicone, collagen, hydrophobic acrylic polymer, polydiaxonone and hydrogel. Some punctal plugs are coated with a “slick” surface for easier insertion.

Soft, pliable punctal plugs made of these common materials can increase comfort and help the devices conform more readily to the shape of the tear drainage channels.

• “Temporary” plugs are usually made of collagen and are designed to last long enough to determine whether a patient can benefit from plugging.
• Extended duration temporary plugs are typically made of synthetics such as PCL.
• Punctal plugs are generally made of silicone.

• Intracanalicular plugs are now available made from several different materials. Siliconeplugs remain popular, although there are thought to be some risks of them migrating in places they shouldn’t go, particularly if there is an attempt to irrigate them out.

• More recent entrants in intracanalicular plugs category include the SmartPlug, made of athermodynamic acrylic polymeris solid at room temperature but melts on contact with body heat so that it can conform to the space it’s in and finally rests in the drainage channel in a semisolid state much like gelatin.

• Another type of soft intracanalicular plug is made of hydrogel material that, once it is inserted into the lacrimal punctum, hydrates until it completely fills the cavity. Form Fit (Oasis Medical) is an example of this type of punctal plug and is thought to carry lower risk if it has to be irrigated out.

• Older people particularly can benefit from soft punctal plugs because — with aging — orifices such as tear drainage channels enlarge and muscular lining becomes less elastic. In this case, softer punctal plugs are more likely to stay in place than harder ones.

Design-

For such a teeny bit of material there is a surprising range of shape designs for plugs, in terms of the shaft, cap (if punctal), and overall concept. Punctal plugs have many designs and shapes, including:

• These types do not “disappear” into the tear duct, making them easy to spot and remove if necessary.
• This design exerts extra force horizontally to help keep the punctal plug in its proper place.
• A hollowed interior can help the punctal plug adhere to the shape of the eye’s tear duct.
• This style captures and holds tears, which helps reduce foreign body sensation and increase comfort.
• Slanted or low profile cap.This design can help maintain comfort, while providing extra stability.

Some noteworthy innovative designs include:

• Smartplugs, which change shape when warmed up to body temperature and become shorter/fatter to fill the space;
• Oasis FormFit plugs, which hydrate after insertion and expand to fill the space; and
• Eagle “Flow Controller” plug and FCI “Perforated” plug, designed for people who experience overflow (epiphora) if full occluded

Size-

The range of sizes available for a given plug varies considerably. In general sizes range from 0.2mm diameter to over 1mm but the majority of plugs are avaiable in the 0.3 to 0.5 or 0.6 range.

Procedure of Punctal Plugs Insertion in Tear Ducts –

Depending on the type of punctal plug selected, your eye doctor first may use a special instrument to measure the size of your tear duct openings (puncta). This helps determine the proper size of the punctal plug needed to block drainage within the channel and to keep it securely in place.

Many eye doctors need only a lighted, close-up examination of your eye to determine the size and type of punctal plug you need. In some cases, a one-size-fits-all style of punctal plug may be used.

To prepare you for the procedure, some eye doctors use a local anesthetic before inserting the punctal plug. In many cases, no anesthetic is needed.

Each eyelid has one punctum, located at its inner margin near the nose. Punctal plugs can be inserted in the puncta of the lower lids, the upper lids or both. An instrument may be used to dilate the tear duct opening for easier insertion.

Many punctal plugs are prepackaged with disposable devices that help your eye doctor insert the plug.

Inserters are available in different designs, such as a forceps style that is squeezed to push the plug into place. Narrow, syringe-style inserters also can be used. Your eye doctor may use other instruments such as forceps to help place the punctal plug in your eye’s tear duct.

Some punctal plugs are inserted just into the puncta so they still can be seen and mechanically removed if necessary.

Other punctal plugs are inserted deeper into the canaliculus, where they are out of sight. These types of tear duct plugs — technically called intracanalicular plugs — do not protrude from the punctum. They are not seen or felt, and automatically conform to the shape of the cavity.

In the uncommon case where removal is needed, intracanalicular plugs are extracted by flushing them out.

Other than slight initial discomfort, you should not feel the punctal plug once it is in place. Immediately after the procedure, you should be able to drive yourself home and resume normal activities.

Punctal plugs can be placed in drainage channels of the upper and lower eyelids.

Punctal Plugs Side Effects and Problems –

Usually, punctal plug insertion is uneventful and rarely involves serious side effects or problems.

Excessive tearing (epiphora) and watery eyes can occur when the punctal plug does its job too well. In this case, you may need to visit your eye doctor for removal of the plug or replacement with a different type to better control the amount of tears on your eye.

Plugs as Drug Delivery Devices

Displacement or loss of the plug is common and can occur for many reasons, such as when people rub their eyes and accidentally dislodge the device. Hard types of punctal plugs in particular are more likely to become dislodged and fall out. Again, you will need to visit your eye doctor to receive a replacement punctal plug.

Eye infections may occur, though rarely, in association with the devices. Canaliculitis results from a rare reaction to punctal plugs, with symptoms such as swelling and yellowish secretions from the tear duct. Such infections may result from upper respiratory infections where blowing the nose under pressure may force germs from the nasal cavity backward into the canaliculus.

In these cases, you may need treatment with topical antibiotics, oral antibiotics and/or removal of the punctum plug.

Other uncommon complications can occur when the plug unexpectedly migrates outside the target area and deeper into the eye’s drainage channels. This can create blockages leading to conditions such as dacryocystitis, with swelling, pain and discomfort.

Soft types of punctum plugs generally can be removed by flushing them out (irrigation). However, surgery might be needed when a hard type of punctum plug migrates into the eye drainage canal. Because of the nail-shape head of current hard plugs, however, entrapment within the tear drainage canal is rare.

With rigid types of punctum plugs, some extra tissue formation may occur as a reaction and cause the channel to narrow (stenosis). If necessary, your eye doctor can simply remove the punctal plug. However, the punctal plug’s purpose is to slow the exit of tears, so extra tissue can be beneficial because it helps achieve that goal.

Removal of Punctal Plugs – 

While semi-permanent punctal plugs can last indefinitely, they also are easily removed.

If you feel discomfort or suspect you have an eye infection or other complication, be sure and notify your eye doctor.

If removal is considered necessary, your eye doctor may use forceps to grasp and extract the plug. Another method of removal involves flushing with a saline solution, which forces the punctal plug to exit into the nose or throat where tear ducts drain. 

Routine Eye surgeries at Angel Eyes

1. Specs Removal

Refractive surgery (also known as specs removal procedures), are methods to correct one’s spectacle power. These procedures utilize highly precise laser systems to reshape the curvature of your cornea (clear round dome at the front of your eye) in order to focus the light clearly on Retina (light sensitive layer behind the eye). Other types of procedures involve implanting a lens inside your eye over the natural lens or exchanging the natural lens with an artificial lens of appropriate power. Angel Eyes offers all the latest procedures for specs removal such as:

• ICL (Implantable Collamer Lens) – Spherical & Toric
• SBK LASIK with Custom Q
• SBK (Thin Flap) LASIK
• Aspheric LASIK
• Standard LASIK
• Refractive Lens Exchange
• Surface Ablation Procedures

2. Cataract

A cataract is a condition where the natural lens in the eye becomes cloudy and hard and is usually a part of normal aging process. Sometimes these can also occur in young or paediatric age groups. If the blurred vision due to cataract is disturbing your daily lifestyle, the cataract may need to be removed. The only way to get your cataract removed is surgery. Angel Eyes offers all the latest procedures for Cataract surgery such as:

• Micro Phaco Cataract Surgery
• Regular Phaco Cataract Surgery

3. Cornea & External Eye Disease

The cornea is the transparent, dome-shaped tissue covering the front of the eye. Replacing the damaged or opaque cornea with a clear, healthy cornea from a donor is referred to as corneal transplant, corneal graft or Penetrating Keratoplasty (PK). There are many different types of corneal transplants depending on the part of Cornea damaged. All types of corneal transplants are performed routinely in our hospital. Keratoconus is an eye condition where the clear front of the eye, the cornea, gets thin and bulges outward into a cone shape. This spoils the quality of the image projected into the eye, and the vision becomes progressively blurred. Angel Eyes offers all the latest treatments for Cornea such as:

• Corneal Transplant Surgery (PK – Penetrating Keratoplasty)
• Lamellar Corneal Transplants (DALK, DSEK, DMEK)
• Corneal Collagen Crosslinking (C3R)
• Keratoconus Treatment
• Intacs and Intra Corneal Rings
• Keratoprosthesis
• Pterygium surgery
• Amniotic Membrane Transplant
• Dry eye treatments

4. Glaucoma

Glaucoma is the most serious eyesight threatening condition of the eye. It usually manifests as a painless gradual loss of vision. The lost vision can never be recovered. However, medical or surgical treatment can prevent or retard further loss of vision. Many a times it can be confused with a cataract which also manifests as a painless gradual loss of vision. The difference is that in the case of cataract, the loss of vision is fully recoverable by means of a simple surgery. Our eyes contain a clear fluid called aqueous humour, which is continuously produced in the eye to bath and nourish the structures inside it. The fluid normally drains out of the eye through drainage canals in a fine mesh work located around the edge of the iris (the coloured part of the eye that surrounds the pupil). In people with glaucoma the fluid fails to drain due to some defect and thus increases the pressure inside the eyes called raised Intraocular Pressure (IOP) (or Tension). In most cases of glaucoma, the patient is not aware of the gradual loss of sight until vision is significantly impaired. Angel Eyes offers the latest diagnostic and surgical treatments for glaucoma such as:

• Glaucoma Drainage Valves
• Glaucoma Surgery
• Glaucoma lasers
• Visual Fields Analysis
• Cyclodestructive Procedures

5. Retina

Retina is like the film of the camera which sends the image to the brain for processing. A damaged retina can lead to significant visual disturbances many of which may become permanent if not treated in time. Angel Eyes offers all the latest procedures in Retina such as:

• Retinal Detachment Surgery
• Diabetic Retinopathy Treatment
• Retinal Lasers
• Retinopathy of Prematurity
• Hypertensive Retinopathy
• Retina Vascular diseases
• Retinal holes
• Retinal and macular degenerations
• Eye Ultrasound
• Cryo Procedures
• Intra-Vitreal Injections/ Anti-VEGF
• Retinal Angiography
• OCT Imaging
• Vitrectomy Procedure

6. Squint and Paediatric Ophthalmology

Eyes of children are different from adults and require specialized treatment. At Angel Eyes, we have dedicated team of Paediatric Ophthalmologists specially trained to take care of the little ones. We offer all the latest procedures in Squint and Paediatric Ophthalmology such as:

• Squint Surgery
• Paediatric Eye Surgery – Glaucoma, Cataract, cornea, globe, lids, NLD Obstruction, Syringing/ Probing etc

7. Oculoplasty and Cosmetic Enhancement

Oculoplastics or oculoplastic surgery or eye plastic surgery includes a wide variety of surgical procedures that deal with the orbit (eye socket), eyelids, tear ducts and the face. It also deals with the reconstruction of the eye and associated structures. We offer all the latest procedures in Oculoplasty and Cosmetic Enhancement such as:

• Naso Lacrimal Duct Blockage (NLD Block)
• Watering Eye Treatment Procedures
• Ptosis (drooping eyelids)
• Ectropion / Entropion (out-turned/in-turned)
• Botox/ fillers
• Eyelid Reconstruction Surgery
• Eye socket reconstruction
• Orbital implants and artificial eye
• Ocular tumour
• Enucleation/ Evisceration

8. Eye Trauma

An eye damaged by trauma requires extensive planning for restoration of vision and aesthetics. We have a team of highly specialized doctors in the field of eye plastic surgery and reconstructive procedures to provide the best to our patients.

• Repair and Reconstruction
• Orbital Fractures
• Chemical Injuries
• Globe Injuries
• Lid Injuries
• Intra Ocular Foreign Body Removal