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role and the position of the retina are easy to understand if we compare it
to a film in a camera. If the film is ‘damaged’, the quality of picture will
not be good, regardless of how perfect the optics of the camera is (concerning
the cornea, the anterior chamber, pupil – aperture, lens and the vitreous
body). A ray of light (a signal) travels through these elements on their way
to the receptors on the retina.
Retina is a part of the eye’s ‘nervous system’ and is made of a fantastic
net of nervous cells – photoreceptors, which collect visual information and
send them to the ‘processing centre’ in the occipital part of the brain. All
of these segments are important for having good quality of a picture and its
recognition.
Retinal detachment happens when the neural part of the retina, consists from
photoreceptors, separates (ablates) from its foundation-retinal pigment epithelium,
and the fluid from vitreous accumulate under the retina. The retinal pigment
epithelium has an important metabolic and protective role. Therefore, in case
of detachment, photoreceptors die, what leads to loss of vision.
This is an -ACUTE- condition and requires an -URGENT- surgical intervention.
Complains of the patients prior to having retina detached, usually are feeling
of sudden, spontaneous ‘flashes’ or ‘lightening’. That is because of a strong
pulling of the vitreous body, or forming one or more retinal defects-breaks,
so-called ruptures that precede the detachment. If the patient immediately
after first signs visits the ophthalmologist, the ruptures as the potential
cause of possible detachment could be discovered and laser barrage as prevention
could be done. But, if retina has already been detached, laser barrage is
of no use any more. The surgery is the only way to reattach retina and preserve
visual acuity.
As a sign of retinal detachment. the patient could notice a small or a big
‘curtain’ or a ‘shadow’ in the visual field, most frequently in its lower
area, since the retinal rupture usually develops in the upper retinal area,
which is projected as a reverse picture. A certain number of patients does
not pay attention to the first symptoms and thinks they will not last for
a long time, especially when the vision of the other eye is intact. However,
if retinal detachment strikes the better eye, the patient soon takes it seriously
and seeks help.
Detachment usually progresses fast, and if not operated immediately it can
also take hold on macula, and consequently further loss of vision, to the
stage of only light perception and movements recognition, and complete blindness
at last stage. .Macula (yellow spot) is the most sensitive area. Its functional
damage is extremely fast because even this area is very small, of only 5mm2
, it is very important for vision function with largest concentration of the
photoreceptors. So, when macula is detached, its nourishment ceases and the
cells are dying.
Full visual acuity can only be preserved if macula is not detached. For this
reason, as soon as the first signs of the disease (‘the curtains’) appear,
an -URGENT SURGICAL INTERVENTION- has to be performed, if possible within
24 hours.
Before the operation, the patient has to lie on his back to postpone or prevent
macular detachment. If macula is already detached, the intervention can be
done within 3-7 days. If, however, the intervention is delayed for a while,
the irreversible changes in retina and especially in macula appear. Recovery
of visual function will not be complete in the case of very delayed surgery,
regardless the technical success of the operation.
According to the mechanisms of retinal detachment appearing, mostly it is
due to retinal break - rupture, so-called rhegmatogenous retinal detachment.
The rupture can become during vitreous detaching process, in case of very
strong adhesive power between retina and vitreous body, causing retinal tear
at the site of a significant vitreoretinal adhesion. In that condition fluid
from vitreous cavity can easily pass through the break in retina into subretinal
space and cause separation of the neural retina from the underlying retinal
pigment epithelium-RPE.
A higher risk for that could be expected in some cases-e.g. in near-sighted
people or as a part of the aging process, and as a result of a sudden trauma
to the vitreous body in case of an eye injury or its increased mobility.
On the other hand, a large number of eyes with a retinal rupture never develop
detachment, because in the absence of strong adherence between the vitreous
body and retina, the physiological forces in the choroids and pigment epithelium
manage to keep the re
tina
in its place. Retinal breaks (holes, tears, dialyses) in these eyes are discovered
by chance during an ophthalmic examination; because these patients do not
have the typical complains.
The other large group of retinal detachment are tractional, caused by the
traction of retina due to the presence of the retinal membranes, most frequently
in cases of a long-lasting not operated retinal detachment or the presence
of the membranes with blood vessels in the vitreous body attached to retina,
e.g. in advanced diabetes.
The third group of detachment are those with the fluid effusion below the
retina as in, for example, eye tumor, choroid inflammation and inherited anomalies.
-THE TREATMENT-
Treatment of retinal detachment is only surgical. The aim of the treatment
is to close the rupture, by provoking the cicatrix round the break between
the retina and underlying choroid. This is treated with either cryopexy (
local freezing of ruptured places) or barrier laser photocoagulation. In order
to achieve that, the rupture has to be drawn near the choroid either from
the outside with scleral buckling, silicon sponge, and puncturing the fluid
below the retina or from the inside using gas tamponade. Prior to injecting
the gas the vitreous body is removed. This intervention is called VITRECTOMY
and is being used more frequently than the classic scleral buckling and puncture
operation. Thus, by removing the vitreous body the possibilities of forming
another ruptures and redetacments are less, and the eye length is not changed
as it is not the case with scleral buckling and silicone sponge.
Vitrectomy is also used as the only surgical approach in retinal detachments
due to the presence of the retinal membranes, in diabetic patients and long-lasting
retinal detachments. During the operation, these structures are totally removed,
enabling a sustained retinal attachment. In these complicated cases , silicone
oil can be used instead of a gas tamponade. Its advantages over the gas are
that the patient can see immediately after the operation. Therefore, it is
always used in case of the last eye, but requires an additional intervention,
i.e. extraction of the silicone oil, approximately two-three months after
the first operation. It is used in more damaged eyes.
In very complicated retinal detachments, like trauma or long lasting retinal
detachment, even after uneven, brilliant previous surgery, is expected the
formation of new membranes, as normal healing process . In such cases , one
or more additional operations are required.
-THE SUMMARY-
It is important to recognize the signs of the developing retinal break and
to use e laser photocoagulation to PREVENT the detachment. If the detachment
is already present, the permanent loss of the visual acuity has to be prevented
by an -URGENT- surgical intervention within 24 hours, in the centers where
this surgery is performed, before the macula becomes detached. If this does
not happen, it is necessary to prevent the further progressive loss of vision
and the development of other more serious forms of detachments by an EARLY
intervention within not more than 7 days. The longer the period from the onset
of symptoms and the operation, the less functional result is, regardless the
complete anatomical reattachment of the retina.
Untreated case leads to definite blindness within a year.
-Special Hospital SVETI VID cherishes the high-quality contemporary vitreoretinal
surgery. Dr Zoran Tomic, a distinguished vitreoretinal surgeon, meritorious
for the development of the modern vitreoretinal and macular surgery, leads
the team for the posterior eye segment.
The frontiers of operability are stretched towards the highest potential,
with the precision of surgical techniques and an exceptionally top- equipped
hospital with the devices of the latest, advanced technology.-
DIABETES
AND THE EYE-
Diabetes represents a metabolic problem, with the inability or reduced ability
of a cell to use the blood glucose, while the level of glycemia in the blood
is high due to the complete cessation or a reduction of insulin secretion
by pancreas. This hormone is secreted in pancreas and helps the cell to use
glucose. With the lack of insulin, the blood level of glucose is high, while
at the same time cells are unable to have it in. So, we have situation with
high glucose levels in the blood, and at the same time its deficiency in the
cell what is called , hyperglycemia. Consequently, a mosaic of changes develops
in the body: on the blood vessels generally, in the heart, the kidneys, the
brain, the nervous tissue and the eye. Specific changing are easily observed
while looking into fundus of the eye through the dilatated pupil. Frequently,
it is actually an ophthalmologist who first suspects the diabetes, before
the clinical picture is clearly revealed.
Specific biochemical processes develop in the situation of increased blood
level of glucose, and its lack in the cells, with big changing in the quality
and permeability of the walls of blood vessels. Lack of adequate tissue nutrition(ischaemia
) makes suitable conditions for forming unfunctional, easy breakable new vascularisation
. Mainly on the place of ischaemia appear so-called growth factors which are
the stimulus for the development of these new-formed blood vessels .
All these reflect on patient’s decline of vision, due to the posterior repeated
bleeding and membrane formation with tractional effect on retina causing retinal
detachment at the end which means blindness if not operated in time.
Argon laser photocoagulation regularly done can delay this moment and postpone
the operation. This is a demand prior to vitreoretinal surgery, but only vitreoretinal
surgery can save and conserve the functional vision.
Macular
degeneration is a process of degenerating of macula)yellow spot)-special part
of retina responsible the central vision. It appeared in two main forms, non-neovascular
(dry) and neovascular (wet) macular degeneration. Dry macular degeneration
appears more frequently( 80 percent), and has slow progression, while wet
form is quite aggressive, leading to a rapid loss of central vision. The spatial
orientation remains (the retinal periphery remains intact). Around 10-20 percent
of the dry forms can develop into the wet one.
There were many attempts directed at finding the ways to stop further progression
of the neurosensor retina and preserve the vision. Visudyne and photodynamic
therapy are now at the main place in treatment of wet form of macular degeneration..
Basis of wet form of the macular degeneration is choroidal neovascularisation
(CNV),as pathological finding of new formed and abnormal choroid blood vessels
(the layer just below retina). Due to its fragility, these blood vessels permeate
the blood and the fluid under the macula and inside the macular space as well.
Detachment of the pigment epithelial tissue or the neurosensory cells of retina,
with fibrovascular scar forming at the end, leads to the loss of the macular
function (see the yellow spot chapter). These changes are irreversible.
Choroid neovascularisation (CNV) in wet macular degeneration is the most common
cause of the central vision lost among the people over 50 years of age. CNV
also appears among the young population as part of the pathological near-sightedness,
as well as in the cases of the ocular histoplasmosis (fungal intraocular chronic
inflammation induced by Histoplasma capsulatum and endemically present in
some areas ).It is , however, less frequent in the case of angioid streaks,
trauma or uveitis.
Regardless the cause, the outcome of CNV is always the same: the loss of the
central vision. And still only a small percentage of the population (2 percent)
in an international study was familiar with the burning situation concerning
macula.
Before photodynamic therapy with Visudyne had started, there had been impossible
to influence the dramatic macular damaging to subdue the progression. Classic
Argon laser-photocoagulation was the only choice but not for the central subfoveal
neovascularisation because of the harmful , non-selective effect of termal
lasers. Side effects of such thermal lasers are damaging the healthy tissue
nearby the selecting aiming part as well , which was the desired effect of
therapy.
That is not happening with the use of nonthermal laser , the one used in PDT.
-Photodynamic therapy or the PDT-
It represents the selective apply of non-thermal laser on the are of neovascularisation,
without destructive effects on the surrounding healthy retinal tissue.The
photoactive substance – Visudyne (verteporfin) is injected intravenously in
its inactive form, and then selectively activated by the non-thermal laser.
The therapy is aimed at arresting the diagnosed changes in their further destructive
attempts and to PRESERVE the vision by destruction of neovasculariisation
. Especially is used to treat subfoveal and juxtafoveal CNV in its classical
form of expression and combined occult/classical membrane but with predomination
of classic type of changes.
-This type of therapy in Serbia is only performed in SVETI VID, where special
attention is given to the problem of the macular degeneration.-
Before decision of the therapy, it is mandatory to do angiography and distinguish
the two subforms: classic and the occult neovascular membrane.
On the day of performing the procedure, intravenous infusion line is installed
and application of Visudyne starts with the duration of 10 minutes. The substance
is transported through circulation bound to a serum low density lipid molecules
and selectively attached to LDL receptors in pathological neovascular blood
vessels. Than fifteen minutes after starting the infusion laser light is applied.
Substance is photosensitive and is activated when exposed to a light of 698nm
of wavelength. Activated in aiming place, which is actually under the macula
–in choroids, it leads to destruction of neovasculare membrane due to photo-effect
of the therapy, without thermal burns. Photoreceptors of macula remain intact.
The entire procedure takes about 30 minutes and is painless. It is done on
an outpatient basis.
Following the surgery, the patient has to be placed under special conditions,
protected from the intensive, especially focal light, and has to follow special
protective instructions. Each patient is given written instructions about
the protective measures after the surgery: protective glasses wearing, for
up to 5 days following the surgery, staying in condition of indirect lighting
without direct sun or focal light exposing (neon, halogen), to avoid solariums,
dentist lighting, or cosmetic and not to stay by the window. Creams with a
high protective factor is applied for the first 5 days after the procedure
or if necessary to go out. After 5-7days the patients are allowed to go out
in the late afternoons, without the protection, depending on the intensity
of outdoors’ light.
In the first five days complete darkness is not desirable. The light of TV
is permitted as well as the indirect light from the other room. Thus, the
elimination of active substance would be safely enabled. The medical check-up
is conducted three months after the surgery, when the fluorescein angiography
has to be performed.
Special
Hospital SVETI VID has introduced in Serbia the ultrasound cataract operation
(phacoemulsification), method present in world’s ophthalmology since 1971
and today brought to perfection. Nowadays, the highest level of this surgery
is present just here, in SVETI VID, giving to people of Serbia and from abroad
the highest quality of surgery with big comfort in performing.
Phacoemulsification allows cataract surgery to be performed in the earliest
stage of the disease, at the very onset of the first symptoms, instead of
troublesome waiting for cataract to be mature .Waiting for cataract to be
mature is actually passing through the dark period of ‘ temporary blindness’
This is unavoidable in the old classical surgical approaches that are still
deep-rooted within the Serbian ophthalmology. Furthermore, mature cataract
by itself, is a risk of inducing possible complications-glaucoma, or inflammatory
reactions due to disintegration of altered human lens materials (uveitis),
or make difficulties in discovering serious diabetic changes in posterior
segment of the eye, such as bleeding or retinal detachments
It is not unusual that patients their loss of the vision connect only with
the cataract, without idea of other possible causes, from posterior segment,
and that is why early operation is of great importance.
It has been very difficult and demanding task to explain to both the patients
and the ophthalmologists here the advantages of ultrasound cataract surgery
in compare to an old approach still deeply rooted here , even not present
in contemporary ophthalmology for decades.
Phacoemulsification means small incision surgery, today less than 2 mm, use
of ultrasound power in emulsifying the lens material and aspiration ,applying
a foldable lens in the place of capsular bag through a small incision, and
therefore finishing surgery without stitches, except in children where the
stitches steach is demanded. The choice of the lens type depends of the case,
special patient’s need, wish for correcting refractive error or special ophthalmic
problem. Patients are particularly happy with a selection of the multifocal
implants, which provides comfortable far distance and intermediate vision
, independent of glasses. Special advantage of multifocals is comfort in looking
the objects from every side with the same quality of given picture, not as
in multifocal spectacles an effort to find picture under the certain angle.
The aim of refractive surgery to beat the presbyiopia has finally been achieved
, mainly in presbyopic hyperopic patients.
For the patients with the damaged macula the intraocular lens with blue filter
is specially suggested for protecting from harmful blue light.
Just opposite from mentioned above, the old, classic approach require mature
cataract, what means completely blurred lens, with functional “blindness”
prior to operation and a large incision, great mechanical trauma for the eye,
many sutures at the end. That could lead to accompanying problems in some
cataract cases combined with glaucoma, or diabetic changes posteriorly, or
big changes in macula, what mostly made “classic doctors “ to announce such
cases as inoperable having fear of making situation worse with the classical
approach to surgery. Since there are enormous number of combined problems
in the eye, the safer surgical approach was required and that is why phacoemupsification
was born.
The idea of a great innovator Dr Chareles Kelmman from 1967 of using ultrasound
for cataract surgery, became reality in 1971.
Developed countries began to realize that it was more expensive to treat the
complications of the traditional surgery than to introduce a new method. The
ultrasound cataract operation became the GOLD STANDARD in the official ophthalmology.
For beginners, however, even the most basic steps of performing this surgery
is very difficult and might be great disaster if done without a close supervision
by experienced surgeon, what is a demand. But, unskilled surgeons are prone
to take unseriously the high demands of the surgery and completely new technology,
and blindly run into complications, without necessary knowledge.
The point is that the refining and perfecting the surgical technique needs
virtuosity in performing the surgery, and such skilled surgeons dictate the
guidelines for modeling of the technique. Therefore, owing to one of them,
who won special awards and merits for his contributions to the modern ophthalmology,
Prof.Dr Pavel Rozsival (who has also introduced the method in Serbia), we
now have the opportunity to follow the phenomenal possibilities of the phacoemulsification
nowadays. This method has already entered the new epoch of existing, now in
completely new appearance and new instrumentation, with three different energy
platforms integrated in one device, INFINITY. Now we have three different
types of a probes, to be used in specific case each. One is completely new
approach without the use of ultrasound-at all- AQUALASE. Aqualase became a
new term in refractive lens exchange procedures where ‘gentle lens rinsing’
is achieved by water-jet phenomenon without a roughly mechanical impact. It
is ideal for the minimally blurred lenses or clear lens exchange in refractive
corrective procedures.
The other two platforms are refined, more balanced ultrasound and neosonix-ultrasound
and oscillatory energy in one platform, far more powerful in the cases of
‘hard, mature’ cataracts, with an exceptional degree of control and shorter
apply of ultrasound energy.
This new technology requires the great knowledge of technique of phacoemulsification,
the experts in this method, and currently exists only in the few leading world
centers, performed by the best surgeons of great experience in phacoemulsification.
One of them is Prof. Dr Pavel Rozsival and owing to him and Special Hospital
SVETI VID, this top-quality surgery is here in Belgrade.
Special
Hospital SVETI VID has introduced in Serbia and Montenegro the surgical and
laser procedures for the correction of refractive errors such as myopia, hyperopia
and astigmatism – REFRACTIVE SURGERY. This subspecialised field of ophthalmology
has been existing in the contemporary ophthalmology since 1980s, and has finally
become available in this area due to SVETI VID eye hospital.
-WHAT IS THE REFRACTIVE SURGERY?-
The refractive surgery refers to a series of procedures – surgical and laser
– used for correcting the refractive errors – far-sightedness, near-sightedness
and astigmatism. It eliminates the dependence on the conventional accessories
such as contact lenses and spectacles . With the foundation of Special Hospital
SVETI VID, these methods officially present in the world’s ophthalmology for
many years, finally became our reality as well.
The potential of refractive surgery is enormous, for both small and large
optical aberrations including astigmatism as well, by selecting the most adequate
method.
Excimer laser is certainly the most popular and the least invasive method.
It represents a computer guided and well controlled appliance of a laser beam
– actually the high frequency ‘flying’ laser spots, used to reshape the corneal
surface according to a desired one and therefore change its refractive power
into a desired one. The dioptric range planned to be "taken" off
by a laser is defined in advance by the specific parameters established during
an examination. Very important is the corneal thickness , its shape and stability
prior the laser procedure. It is used for correction of a low- and medium
level of near-sightedness , up to – 10 diopter (with astigmatism) in the case
of normal corneal thickness, and lower level in thinner corneas. For far-sightedness,
these values are round plus 2, with small astigmatism.
This is an essential condition for the safety of the procedure. For the higher
range of dioptria, the suggestion is surgical treatment regarding following
possibilities:
a) Surgical procedure with refractive intraocular lens implants, without the
removal of the natural, biological lens, with accommodative power saved. That
is so-called PHAKIC INTRAOCULAR LENS (IOL) for high myopia and high hyperopia
and PHAKIC TORIC IOL for mentioned sphere aberration combined with a certain
(high) range of astigmatism. The method is applied on patients that still
have the accommodation, up to 35-40 years of age. Currently, the quality of
these lenses is exceptional, and the aberration field covered with this surgery
is wide: for the near-sightedness up to – 25Dsph and far-sightedness up to
plus 10 /plus 12 Dsph, with the cylindrical correction of up to plus 7 D,
depending on the type of the lens. There are different types available – angle
support and iris – claw lens , flexible for small incision implantation. The
results are brilliant.
b) In older myopic or hyperopic patients , when the natural human lens lost
its accommodative power and therefore another spectacle dependence is needed,
well known as “reading glasses”, the method of choice would not be laser,
or phakic iol implantation, but LENS EXCHANGE surgery with the type of the
lens implant especially selected to fit the patient’s needs, and professional
or other requirements. A large number of patients are extremely happy with
the selection of the multifocal foldable intraocular lens with a comfort of
near vision for close objects (imitation of accommodation), medium distances
(computer) and far distances vision.
Thus a multifocal foldable lens practically removes the double dependence
on spectacles, giving opportunity of having good quality of vision at different
distances (imitation of accommodation). All procedures require appropriate
surgical skill and performance, since surgical precision is a very IMPORTANT
premise, in order to use the best potential of the refractive surgery. Therefore,
it is very important that the surgeon who performs refractive surgery is an
expert in this field, and offers the maximum to his patients.
Refractive surgery is a crown of the surgical skill and the queen of ophthalmology.
It is not yet present at our University.
The beginners and those with no experience in new surgical approaches do not
hold a license to work in this surgical field and it could be dangerous. Lack
of knowledge and experience in the field of refractive procedures, might lead
to misunderstanding and might be the source of the deceptions and fear related
to this way of correction of diopter. But in fact, these procedures are official,
very good if done by an expert in this field, giving satisfactions to those
who had it.
-HOW CURRENT IS THIS PROBLEM IN THE CONTEMPORARY OPHTHALMOLOGY, HOW LONG HAS
IT EXISTED AND WHAT RESULTS HAS IT ACHIEVED?-
The very beginnings of the refractive surgery date far back, more than half
a century ago, from the pioneering steps by Baraquer, Sateau, Fiodorov, in
their attempts to correct a diopter surgically. These first steps, though
far from the final goal, certainly were very important for the further development
of the contemporary refractive surgery. From round two and a half decades
ago to nowadays , refractive surgery developed into a new subspecialist field
of ophthalmology. Many congresses were organized, and many journals and books
were written on this topic. For many years students and young ophthalmologists
have been listening the lectures from this field in ophthalmology in the normal
developed courtiers, but not here in Serbia, unfortunately.
The use of Excimer laser in ophthalmology began in the 1980s. These were the
first, now abandoned, hardware lasers, and the predecessors of the modern
ones. Today Excimer laser is a software type, with the advantages of adjusting
the procedures to each individual eye. It has reached its developmental culmination.
A long time ago assigned aim has finally been achieved. A dream of the millions
has become a reality! Precision, predictability, safety and satisfaction of
the millions of patients underwent the operation worldwide influenced the
highest authorities of ophthalmology to make the laser procedures official.
-THE GOLDEN AGE OF THE REFRACTIVE SURGERY IS NOT STARTING, IT CONTINUES. This
is the age of stable results, where the aims that were set a long time ago
are now being achieved. Owing to SVETI VID, this recently UNTOUCHABLE field
of the ophthalmology, has become our REALITY as well.-
-HOW MUCH REFRACTIVE SURGERY IS PRESENT IN MINDS OF OUR PEOPLE?-
More and more, but not sufficiently unfortunately…
Though present in the contemporary ophthalmology for a long time as a unique,
subspecialised branch ,refractive surgery still is not normally included in
program of studying at our University. That is why it’s easy to understand
the confusion made in domestic ophthalmology society which would for sure
last for a while longer. Unfortunately this problem and confusion of our society
is transferring to younger generations, the hope of our future, and further
to the patients seeking for help.
-WHAT IS THE GOAL OF REFRACTIVE PROCEDURE?-
The goal of refractive surgery is to provide a comfortable, functional visual
acuity without contact lenses or spectacles, and to quit the dependence on
the conventional helping devices.
-WHAT MAKES PEOPLE TO ASK FOR SUCH CORRECTION OF DIOPTRY?-
Mainly it is discomfort caused by the use of conventional devices especially
present in certain professions, or a normal everyday life. Young people usually
have negative feeling about the spectacles or simply could not bear contact
lens and feel uncomfortable with them. Not rarely that might be a source of
the greater problems in communications and closing inside. Therefore their
motivation to find solution in refractive surgery is great.
The other reason for choosing refractive surgery is impossibility to correct
the refractive error with spectacles , because of the type of error or big
diopter differences between both eyes( anisometropia), even if they have nothing
personally against the glasses.
Financial aspect is of great importance. Refractive surgery is done ones for
a life, while the contact lenses are a lifelong dependence.
-WHO ARE THE CANDIDATES FOR THE EXCIMER LASER?-
People over 18 years of age, with a stable dioptry. Certain age is a desired
condition.
Cornea is to be healthy. Its quality and thickness, as well as the size of
the pupil, measured under dark conditions define the dioptric range suitable
for treatment. These parameters set the safety limits of laser correction.
In the case of large refractive difference between the eyes(anisometropia),
refractive surgery is of great importance , as well as for need of only one
eye correction.
For younger than18 years of age, laser can be used in case of a stable dioptry,
in the last three years, with a strong motivation due to the dedication to
sports or fine arts, where the classic adjuncts are not the best solution.
Large difference in dioptry not corrected in time , or presence of astigmatism
is the reason for amblyopia from young age. The place of excimer laser here
is to help correcting the refractive error in the best way and prevent strong
amblyopia if used properly in certain age.
EXCIMER laser is successfully used not only for refractive procedures , but
also for therapeutic treatments-for better healing in cases of recidivant
(‘repeated’) erosions of cornea – the PTK method.
-WHAT DOES THE LASER PROCEDURE LOOK LIKE, HOW LONG DOES IT TAKE, WHICH ANESTHETIC
IS USED?-
The task of the computer-controlled apply of a ‘cold’ laser beam is to change
the refractive power of cornea into a desired one by remodeling the cornea.
This can be achieved by direct effect of the laser beam on the surface of
the cornea ( PRK method) that lasts for 1-2 minutes, for the purpose of creating
an erosion zone on the cornea. During the epithelisation of this eroded area,
the patient wears a therapeutic contact lens in order to protect the cornea
and reduce the discomfort caused by the targeted ‘erosion’. This discomfort,
which is usually expected the next day following the intervention, is a common
reaction and is overcome successfully with given eye drops and pills .Immediately
after the intervention, the patients notice a dramatic improvement of vision,
in spite of the temporary blur that lasts for a few days.
Another modality is LASIK, a combination of the microsurgical and the laser
procedure. Lifting the epithelial flap is achieved using a microkeratom (a
special instrument), and is then followed by the laser treatment of deeper
layers, after which the epithelial flap returns to its position. This method
is more invasive. The healing period of the cornea lasts longer than for the
PRK, although the discomfort is here reduced to only a few hours following
the intervention.
In both cases, the anesthesia is topical , with drops, and the patient returns
home immediately after the intervention, and can go back to work in 5-6 days.
The other modalities of the basic principles are Lasek and Epi lasik (variants
between the PRK and Lasik).
-HOW SHOULD THE EXAMINATION BE PLANNED IN CONTACT LENS WEARERS?-
If the patient is a contact lens wearer, it is required to stop with the lens
before the laser procedure in order to give time for cornea to ‘reconfigure-
between 10 and 15 days for soft, and 4 -6weeks for GP lenses-approximately
one month of stopping for 10 years of wearing. Corneal topography can plastically
showed what happened with cornea under contact lens- an ‘imprint’ of the contact
lens on cornea can be seen.
-WHO PERFORMS THE LASER PROCEDURES IN THE SVETI VID?-
All refractive procedures are performed by Prof. Pavel Rozsival, the renowned
member of the biggest European and the worlds’ ophthalmologic associations,
who was voted by the leading authorities as one of the most meritorious and
outstanding people of the ophthalmology of the 20th century.
Owing to him, with the adequately equipped hospital and education of personnel,
we have managed to introduce the refractive surgery in Serbia and make it
available to all people, to the patients and the doctors. The surgery performed
here, represents the highest level of ophthalmic surgery.
-WHAT IS THE CONTACT WITH THE PATIENT AFTER THE INTERVENTION LIKE?-
There are continuous follow up and regular contacts with patients prior to
and following the intervention. In one place in your country, you can get
an answer to all the questions and a detailed explanation of your problem
and the possible solutions. Through the detailed examination and consultation
we are finding the method of choice , which is the best and the safest solution.
-This is not the beginning of the refractive surgery, but the methods approved
and officially accepted ,through many years of use with positive results worldwide.
It will take time to accept the fact that something what was unreachable and
far outside this country’s borders is now very close and available in Special
Hospital SVETI VID. Hiding this fact has the great negative impact to patients
and the whole society ,intending to pull back the society to the past and
thus deliberately enhancing the survival of old obsolete methods and views.-
This is not the beginning of the golden age of the refractive surgery, but
the continuation instead. These are the times of stable results, when the
past goals are being achieved. Owing to the SVETI VID, this inviolable field
of ophthalmology has become our reality.
LOW
VISION Centre in SVETI VID is a unique in this area. The idea was to give
a chance for reading and space orientation to those with badly impaired vision
when neither surgery nor other therapy could help. It could be achieved by
special devices with certain magnification for visual rehabilitation.
These are special electronic telemonitor systems with magnification options
between 7 to 40 times, in fixed (home) or a mobile (outdoor) variant.
The CCTV represents a home telemonitoring system with a mobile board in two
directions- of x-y axis. It is used for reading texts, writing or drawing.
The contrast and magnification are options that patient could choose individually,
as required.
Following the remote text, for example on TV or a school board, is provided
by a special additional camcorder. This is particularly of interest for visually
impaired children for home and school education.
Mobile electronic telemonitoring instruments provide outdoor comfort, on journeys,
in restaurants, in banks, etc.
A pocket variant of such mobile electronic device (pocket viewer) offers to
the user the freedom of movement outside his/her home. It enables him/her
to see the numbers on mobile phone or the time on the wrist watch, as well
as the names on an interphone while going to visit friends.
Hypercorrective glasses are different sort of aid then electronic devices.
They are specially made, with new design and with large range of magnifications
of the optics that gives better quality of pictures compared to the earlier
variants. For the protection of macula, which is mainly the basis of these
impairments special filters are used depending on the indoor or outdoor lighting.
The use of telescopic glasses enables a sort of distance viewing.
It was an enormous necessity for our country to have this sort of center,
especially because of very old and unsuccessful way of treatment underlying
problems and a lot of unhappy people for that reason. Owing to SVETI VID that
time really went to the past.
The
Hospital is situated in the very center of Belgrade, in Dobracina Street No.
27, near the Republic Square and the National Theatre. It covers an area of
800 m2 with a few consulting and waiting rooms, numerous diagnostic cabinets
for basic and accompanying diagnostics, an operation block, a laser center,
an in-patient department for comfortable accommodation after general anesthesia
, optic shop with fashionable sun and corrective glasses, contact lenses,
low vision center unique at this area with large choice of devices for magnification,
as help for patients with damaged macula and optic nerve .
Working hours: every day and Saturday from 8.00 a.m. to 8.00 p.m.
-ACTIVITIES-
Special Hospital SVETI VID was founded in 1997, starting a new epoch of the
Serbian ophthalmology. The idea was to improve Serbian ophthalmology and to
exceed the emptiness that for decades were dominan in the Serbian ophthalmology
circles. By opening the possibilities for new and appropriate and useful solutions,
and not “Surgery for the sake of surgery only”, Sveti Vid has become an institution
and a synonym for the highest quality and up - to - date ophthalmology. Thus,
instead of looking for good treatments abroad, the modern high-rate ophthalmology
has become the reality in the heart of Belgrade.
From the very first moment of its founding, Special Hospital SVETI VID has
been introducing the most recent, high-quality technology and the leading
surgical and diagnostic methods for the treatment of eye problems.
Thus, the new, modern views and standards for treatment the ophthalmic problems
are imposed on Serbian ophthalmology, with much better effects on preserving
the vision. Therefore, the new guidelines for the development of the Serbian
ophthalmology are set.
Here, in a small piece of Europe, in the heart of Belgrade, there is now a
hope for the long streams of young ophthalmologists to see the potentials
of the contemporary eye surgery today, which is not only a picture from a
foreign textbook, but the real surgery, in order to abandon the burden of
the inherited, outdated views.
-DIAGNOSTICS-
In several first class equipped consulting rooms, our pleasant staff will
welcome you and recommend the best solution to your problem. A comprehensive
ophthalmic examination involves an access to all eye structures, both the
anterior and the posterior segment, in order to view the problem entirely.
-The special cabinets-
-Ultrasound diagnostic cabinet – for discovering changes of deeper eye structures,
in vitreous body, retina and orbit (bleedings, retinal detachment, tumor changes
etc.), especially in the conditions of non-transparency of anterior media,
such as cataract, or bleeding in the anterior chamber, which prevents good
viewing into posterior structures.
- Pachymetry and the computerized corneal topography cabinet - This is a contemporary
diagnostic approach for defining the corneal problems: an early discovery
of keratoconus or other degenerative corneal disorder, and changes caused
by contact lenses wear, as well. Such examination is demand prior to refractive
procedure.
- Cabinet for early glaucoma detection- the first asymptomatic changes in
the nerve fiber layers-GDx.
- Computerized visual field cabinet, with special tests for examining the
function of the optic nerve or the macula – the yellow spot.
- Cabinet for intravenous angiography –Fundus camera – for recording the fundus
blood vessels with contrast applied intravenously. This is inviolable procedure
for defining the fundal diabetic changes which are to be treated by the laser
photocoagulation, as well as the macular changes (yellow spot), before the
photodynamic therapy is applied (PDT).
Fundus camera also helps in recording the changes on the papilla of optic
nerve in order to monitor and control the glaucoma changing objectively, and
evaluate the effects of the applied therapy.
- Laser cabinet :
– laser-photocoagulation- treatment of the diabetic changes on fundus,
- Yag- laser capsulotomy (laser opening of the fibrous posterior lens capsule).
- laser iridotomy for the particular types of the glaucoma.
-Child ophthalmology and strabology
-OPTICS-
There is a modern optics that gives the exceptional precision of processing
the finest corrective glasses.
Modern lines , attractive dioptric and sun glasses: Vogue, Valentino, Escada,
Dior, Roberto Cavalli, Vivien Westwood, Simpsons, Seventeen…
Contact lens cabinet- offers good quality contact lenses, colored as well.
-LOW VISION CENTRE-
Equipped with the new generation of devices for low vision improvement, magnifying
glasses, telescopic systems. mobile and for home use, of different degree
of magnification, devoted to those to whom reading and space orientation is
troublesome because of damaged macula or optic nerve. Presentation and demonstration
as well as teaching people to use the rest of the vision is organized in the
place of Optic. There is a place and time for choosing the appropriate option
individually.
This is a great help especially for school children with impaired vision.
--THE CENTRE FOR THE EMPLOYMENT OF THE PHOTODYNAMIC THERAPY – THE PDT-
--THE SURGERY-
SVETI VID is changing and updating the old and exceeded views deeply rooted
in the Serbian ophthalmology. It has introduced contemporary surgical methods
which became official in world’s ophthalmology today, against the back warded
ways closely round the Special Hospital SVETI VID. This influenced the domestic
ophthalmic field positively and is of great importance for changing the old
attitudes round the country.
This contribution to the Serbian ophthalmology is present in the field of
the cataract (phacoemulsification, aqualase) and the glaucoma treatment, the
refractive surgery (the Excimer laser, many sorts of implantable lenses including
multifocal implants ), vitreoretinal surgery. Furthermore, Photodynamic therapy
(PDT) with Visudyne for some forms of choroid neovascularuisation gave a special
impact to changing view of macular disorders. Amazing reconstructive procedures
for repairing previously done inadequate treatment in anterior segment surgery,
as well as secondary lens implantation, glaucoma surgery, strabismus surgery,
etc, are only a slight survey of large program of SVETI VID.
-The Sveti Vid is one of only the few centers in the world where a maestral
surgery of the ‘artificial cornea’ implantation is performed on patients following
a trauma, when transplantation is inadequate due to the danger of the corneal
tissue rejection (among the first 250 operations in the world).
The special hospital SVETI VID from the very beginning of its work has made
efforts to educate the population, as well as doctors and patients, believing
that by changing the attitudes, development of terminal conditions could be
prevented. Consequently, the incidents of needlessly developed blindness in
the Serbian population would be reduced.-
Vitreoretinal
surgery – operation in the posterior eye segment – on retina and vitreous
body- is performed in collaboration with a Swedish University in Uppsala,
lead by dr Zoran Tomic, who is a regular member of the medical team of the
SVETI VID Hospital. Dr Zoran Tomic is one of the leading European vitreoretinal
surgeons.
The patients who undergo this kind of surgery are mostly diabetic patients,
the patients with long lasting retinal detachment and patients with injuries
to the eye, as well.
This surgery can be considered as a kind of the “neurosurgery” of the eye.
It is very complex and demanding, dependent on technological conditions and
support of an experienced and skilled surgeon.
In contemporary ophthalmology in developed countries vitreoretinal surgery
experienced very dynamic period of development, while it stagnated in our
country, staying far away from ophthalmic society and the patients. Those
who were in better position, had been operated abroad. For others it was a
time of hopelessness and desperation.
Therefore, it was a moral pressure and obligation to give to our people the
same condition and quality of surgery, like there were in the leading ophthalmology
centers in the world for the vitreoretinal, as it was for anterior segment
in SVETI VID. And now, SVETI VID became one of the leading European center
in both, anterior and posterior eye surgery.
Not only the quality of surgery and complete treatment, but some other advantages
like the lower operation costs, without the additional costs of traveling
and escorting, continuous checking and following up the patients after operations
are the large advantage of having SVETI VID here.
Usually after being operated abroad they never saw their doctor again.
Like it was in anterior segment surgery (cataract and refractive), the vitreoretinal
surgery also tremendously developed to the today’s possibilities in smaller
incision (23 and 25 gauge ) without stitching. Visualization of the posterior
eye segment is advantage of new generations of devices, as well as precision
of cutting the vitreous membranes with vitrectoms - small rotary high speed
cutting disposable instruments of 2500 cuttings per minute is amazing. Modern
vitrectomy today is far above the past standards and gives to those who underwent
this surgery the new quality and faith in life.
SVETI VID gave to the people this new approach to vitreoretinal surgery, with
the positive postoperative results, very much different than the outdated
surgery in surroundings. Only the name remained the same. And not only diabetic
cases considered as inoperative in domestic surroundings, but macular disorders
as well, macular hole for eg., within the limited framework of the Serbian
ophthalmology is still considered as inoperable, although it has been successfully
treated for a long time, which is confirmed by the results in the SVETI VID.
If operated in time, this problem could be solved.
The other importance of SVETI VID for this area is the introduction of combined
procedure, phacovitrectomy, which is combination of two operations performed
simultaneously in one surgery: cataract –phacoemulsification +vitreoretinal
when the cataract is present with membrane proliferations and retinal detachment
all together. This enables a faster and better rehabilitation of the visual
function.
And many more complicated cases are treated here in SVETI VID, as referential
and educational center.