Dr Cristian Moraru, an ophthalmologist with a great and long experience in the field, has revealed everything we need to know about eye surgery
Doctor of the day: What operations can currently be performed to correct visual impairment without ever wearing glasses or contact lenses? Is that possible?
Cristian Moraru: The problem is more complex. There is a special chapter in ophthalmic surgery. This type of surgery was invented about 20 years ago, is therefore a new procedure and is called refractive surgery. What exactly does it mean? It deals with the correction of refractive vices, such as myopia or hypermetropia.
- Are these defects of view a genetic inheritance, or do they appear as a result of several actions / factors?
- The eye is an optical complex, a series of lenses, optical media. First, we have the cornea, the first part of the eye, which has a very strong effect of concentrating the light rays to focus directly in the macular area, that is, in the central area of the retina. Cornea is like a magnifying glass. We then have the lens, practically the "lens" of the eye. It is a dynamic lens that changes its curvature depending on where we look – at a distance or near. Correlated with the cornea makes the rays of light unite in a single point on the retina. When this correlation is close to perfection, it is clear that the person in question does not need glasses or other means of correcting vision. However, if there are correlation differences, there are refractive errors, the images are no longer done where it is, in the retina. When the eye is too long, the image is formed in front of the retina, and this means myopia. If the eye is too short, anatomically speaking, and can not bring the image exactly where it is needed, hypermetropia appears on the retina. And there is a flaw of refraction linked to the axis of the eye; they must be approximately equal in horizontal and vertical plane (and between these planes). If they are not, or if the eye is more "flattened" in a shaft, astigmatism occurs, another defect in sight. It can be associated with both myopia – and this is called myopic astigmatism – and hypermetropia – and it is called hypermetropic astigmatism. Or it can be related to both, and then it's called mixed astigmatism. We have, more, some flaws of refraction.
- Which, as a rule, are corrected by glasses.
- However, these vices are generally discovered from early ages. After the age of three, parents have to take their child by the hand to take control, because an uncorrected vice can generate associated pathologies in which the child looks crucified – such as strabismus – or the phenomenon of "eye lazy "when one of the eyes has larger diopters than the other, which makes it weaker than the other eye.
First method: excimer laser – corneal grinding
- Now, according to the new trends, the glasses are no longer suited …
- Especially among youngsters, ladies. Based on this trend, refractive surgery appeared. What do we do to get rid of the world of glasses? There have been many attempts in the past, 50-60 years ago, to correct these vices by surgery. But the explosion to correct, with good and constant results, visual impairment occurred once with the laser called Excimer. Thanks to this method, you can get rid of your glasses or you can significantly reduce your dioptia.
- You can also get rid of contact lenses.
- And of them. Because you still talked about who did not want to wear glasses, contact lenses replaced them when the excimer laser method had not yet appeared.
- What exactly does this laser do? What role does a man / doctor have in all this delicate intervention?
- Although the technology is extremely advanced and the laser performs this operation with precision, however, the doctor certainly has a very important role, even determinant! As for the laser, it practically grinds the anterior part of the eye – the cornea. By means of procedures and special computer programs, the laser beam is guided so that it coats the layer and resolves the cornea. It shapes differently, depending on the refraction vice. In the case of myopia – thinning of the cornea is in the center. In the case of hypermetropia – this grinding is done at the periphery of the cornea, and in the case of astigmatism combinations are all kinds of software that head the eye until the deficiencies are right so that no need for glasses. The lasers have evolved. At first they were not so accurate. Now, however, the results are excellent. Okay, it's not just a laser, because it has some limits. There are patients with very high diopters. This thinning of the cornea is within certain limits, because we can not thin the cornea as much as we want. It has a thickness of 550-560 microns on average, and if we exceed the grinding limit, the cornea can suffer greatly, it can deform, leading to complications that may even require corneal transplantation. For this reason, at the beginning there were many rates. Doctors around the world quickly realized that the interest in this laser is enormous, and although technology was initially very expensive and the patient was paying a lot of money to get rid of glasses, more and more doctors began practicing these relatively simple interventions (at least, so it seemed at first). The patient put his eye on the laser, and the doctor pushes the …
- The doctor's role was reduced to a simple gesture …
- Apparently, yes. But after this boom of the beginning (we did not even have these types of interventions), when on one street in an American city you found five cabinets of this kind, it followed a period of complications, of misses. This boom has softened, so no surgeon anymore. The operation itself seems very simple, but it is not quite so. As I said, at some point, there were very serious complications, which generated many trials, many compensation payments, many problems for doctors. For this reason, things became important in a few years: now, the patient needs to be very well informed before, to know that not every patient fits refractive surgery and especially the laser method. He even has to sign consensus that shows he was informed about the surgical technique and possible risks or complications … Discussion with the patient before surgery is a particularly important moment. The doctor has to inform in detail, because it is, after all, an intervention at the patient's request. It is not, therefore, a medical emergency, but a situation where the patient can and must reflect. At Oculus Clinic, at preoperative consultation, we have a lengthy discussion with the patient, a discussion that must be understandable and an informed decision. This is the most important thing.
- What follows after informing the patient?
- Consultation, we need to determine what flaw of refraction exists. Depending on this defect, we choose the method. We talked about laser only so far, but, as I said, the laser is addressing a limited diopter beach. There are patients who have a myopia of -15, -20 or plus, +9, +10. For these types there are other methods, the Laser Excimer being neither safe nor stable over time.
The second method is "eyeglasses" – refractive implants
- How would it be?
- The introduction of a special lens – refractive lens implantation is called the method – either behind the cornea, or behind the iris, the color of the eye. They are, in fact, special lentils. Instead of wearing glasses, the patient wears the "glasses" straight into the eye! There are two categories of refractive lenses, some facing the pupil and others that sit behind the pupil (and the iris); we use the ones in the first category, which have dimensions that fit all patients, being strained and a much lower risk of cataracting over time. This compared to the other, the ones behind the pupil. The advantage of this laser operation is obvious, especially in patients with very large diopters. For example, it is a reversible intervention; laser intervention is irreversible. I mean, if we thin our eye and polish it, that's how it all lives. With thin, modified cornea; this may have consequences in the future if the patient is doing other diseases such as cataract – a thing often encountered, because there are very many people who have been operated at 20, 30, young, and now they have 50, 60 and, once with aging, cataract. Eh, cataract surgery uses artificial crystalline, which is measured with some special devices, but the measurements are done through the cornea, or, if the cornea is already polished with the laser, has modified bending radii and thus to our measurements for artificial crystalline, calculation errors may occur. Returning to refractive lenses, let's point out that their use is not irreversible. Depending on the increase in refractive defect or if cataract occurs and it needs to be operated, refractive lenses can be safely removed and replaced with others. Or, if necessary, we put an artificial crystal.
- Is there any disadvantage?
- Yes, if the patient does not follow certain postoperative indications (eg avoiding microtraumatism or even repeated eye strokes), the cornea may be affected – a situation where the refractive lens will need to be explanted.
The third method: Replacing the lens with an artificial one
- Is there any way of correcting outside the laser and the lenses in the eye?
- Yes, replacing the lens. I mean, remove the natural lens of the eye and put an artificial lens. Depending on the patient's dioptrie, it is calculated in such a way that vices can be corrected without the need for glasses. These three categories are differentiated according to the age of the patient. Replacement of lens, for example, is recommended for elderly people (over 40 years of age). We do not recommend removing the lens of a young man for 20-30 years and replacing it with an artificial lens, as it loses the natural ocular accommodation – which at this age is very good – to replace it with an artificial lens. Instead, after the age of 40, the natural lens gradually loses its elasticity and the accommodation starts to drop, so we can "dispense" the natural lens to replace it with an artificial diopter, specifically calculated so that the patient get away with glasses.
In conclusion, we can intervene for a patient not to have to wear glasses. However, the most appropriate method for each patient is to be set so as to give him the maximum chances of decreasing dioptrie, the stability of postoperative refraction by a safer operation for him.
The factors that determine the intervention
If you want to see well without wearing glasses, you can choose one of the three methods outlined by Dr. Cristian Moraru, mentioning that these surgical interventions are based on several determinants: "First of all, the refractive vices are taken into account – the type and value of diopters, then the age of the patient, and the job he practices. One is to be a driver driving the night, another one who needs a good view of the computer. One wants to see very well and without glasses in the distance, another wants the opposite … There are all sorts of combinations, and then a decision is made. "
Fixed engineers, artists and laser
Note that patients differ from person to person. "I feel him coming through the door. If he is an ultra-thin person, a bitter, perfectitious, even a fixist, I recommend that he do not do the laser surgery, because the intervention can not meet all his expectations; the patient may be unhappy, frustrated, even irritable. On the other hand, boomers, such as artists, have a different attitude. I look at them and, if they do not see the last row, they say they're okay, they're happy and so. Not like the other guy who, exaggerating and joking a little, threatens suicide if he does not even see the last point in the Universe. For this reason, the pre-operative discussion is very important. Not everyone is made to operate laser, "concludes Dr. Cristian Moraru.
The refractive vices must be stabilized
If you have chosen to operate to get rid of your glasses, you have to keep in mind the following: "It is very important that the patient's vagina wanting to get rid of the glasses is stabilized. Because myopia, for example, is a defect that has a gradual evolution. It starts at school, in high school … With 0.5, 1 … If we intervene with a laser on a myopia that is not stabilized, it is not good. This operation does not stabilize myopia, but it is valid for myopia at that time. People need to understand this very well. We do not know exactly when myopia stops, but anyway after 30 years it can be considered stabilized. So, we can only then work with the laser. Age is very important. Hypermetropia, in turn, is compensated for the young. Thus, the young patient does not even realize he has a defect, because inside the eye is the lens, which compensates for this vice by its elasticity and dynamism from this age. For example, a young man can even have +3, +4 dioptres, without being disturbed by it, precisely because of his lens, which carries the phenomenon called "accomodation." But this accommodation gradually decreases with age, so that, after 30-35 years, begins to feel the need for glasses. Basically, the lens begins to "tire". Therefore, by the fact that the arrangement compensates and "hides" a part of the diopter of a young man, to see the real dioptres, we must paralyze (temporarily, of course) this accomodation of the lens – something that is done with some special drops. Paralysis of accommodation is called cicloplegia and it is absolutely mandatory for a younger preoperative consultation, precisely because we need to know the real dioptres, not those apparent at some point, at the current age of the patient!
This operation (n.r. – laser) does not stabilize, but it is valid for myopia at that time. People need to understand this very well, "Dr Cristian Moraru, Oculus Clinic
Can complications arise?
"Complications, like any surgery, may exist, but they are quite rare; may be longer postoperative inflammation or even infections. Some may even be serious: for example, a post-operative infection such as corneal abscess or an intraocular infection can even lead to eye loss. There have been and are such situations, but, fortunately, rarity, "says Dr. Cristian Moraru.
"The critical age of the eye is 40-45 years"
"Everybody, after 40-45 years, starts to have trouble reading. The eye ages, a process called presbyopia. The lens of the lens works less after 40 years. Between 40 and 60, the lens loses its accommodation to zero! Therefore, patients between 40 and 60 years of age have to change their glasses about once every few years. "
Children can see even five centimeters, because the accommodation of their lens can go up to 23-30 diopters. I can also see from this distant distance thanks to the "youth" of the lens, "Dr. Cristian Moraru, Oculus Clinic
600 euros is the estimated price of an operation that can get rid of your glasses. The amount is valid for one eye
10-15 minutes takes a surgical procedure to correct refractive errors.
Mircea Cristian Moraru – primary ophthalmologist;
Date and place of birth: 5 December 1952, Targu Mures;
Education: St. Sava High School, Bucharest (1968 – 1971); Faculty of General Medicine Bucharest (1971-1977)
– Giurgiu County Hospital – head of ophthalmology department, ophthalmologist (1984-1990)
– National Institute of Geriatrics and Gerontology Bucharest – primary ophthalmologist (1990-1993)
– Opticontact Ophthalmology Center Bucharest (1993-1996)
– OCULUS Ophthalmology Center Bucharest (1996 – present)
– From a total of approx. 45,000 cataract operations, more than 35,000 were performed with artificial crystalline implant; the phacoemulsification technique since 1997; in the last 5-6 years, approx. 200 cataract operations per month.
– Since 1999 – approx. 12,000 refractive surgery operations, excimer laser and refractive implants
– Thousands of glaucoma operations, corneal transplantation and other anterior pole diseases, including ocular traumas