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The human Eye is one of the organs of the body that react to light and have a number of functions. As one of the sense organs, the human eye is responsible for vision and include special functions like color differentiation and depth perception. The components of the human eye that allow this level of specialization are the Rods and Cones, which are light receptors found in the Retina, the light sensitive inner coat of the eyeball. The human eyeball is not shaped like a perfect sphere, rather it is formed by the fusion of two components, namely the cornea and the sclera. The cornea is the more covered and outer transparent covering of the eye and the sclera is the white part of the eye which goes all the way around the eyeball. The cornea and the sclera are joined by a ring known as limbus. What one sees through the cornea is the Iris (part of the eye which imparts it its distinct color) and the pupil. Pupil changes its size with the help of the Iris’ dilator and sphincter muscles, which respond to intensity of light and modulate entry of light into the eye.
The path of light into the eye is through the cornea, then the pupil and then through the lens. The shape of the lens is controlled by ciliary muscles and this function of the lens allows in focusing objects near and far from the eye (this function is known as Accommodation of the Lens). Light then travels into the posterior chamber of the eye and falls on the light-sensitive cells of the retina. These light receptors then produce electrical signals that are carried to the occipital region of the brain by the optic nerves. Apart from vision which is the main function of the eyes, they are also responsible for regulating the melatonin levels in the body and for maintaining the body’s circadian rhythm.
Interestingly, an eye is composed of more than 2 million working parts, only 1/6th of the eye is exposed and of all the muscles in our body, the muscles that control our eyes are the most active. Also, each of our eyes have a blind spot in the retina, where the optic nerves attach to the eye. These blind spots are not at all photosensitive but we are not able to see these bind spots in our field of vision as both the eyes work together to compensate for the other’s blind spot.
According to WHO, the increase of diabetes among many population groups has caused diabetic retinopathy to be an alarmingly common cause of blindness, while glaucoma, a condition plaguing mankind for centuries, remains another common cause of vision impairment in the world. Age-related macular degeneration (AMD) ranks as the third leading cause of visual impairment globally. These conditions along with cataract, corneal opacities and childhood blindness are leading causes of blindness and vision impairment. According to North America’s National Eye Institute, the most common problems with vision include near-sightedness (myopia), far-sightedness (hyperopia), a defective curvature of the cornea in the eye (astigmatism) and age-related far-sightedness (presbyopia). Other conditions like amblyopia (also known as lazy eye) and strabismus (also called cross eyes) are known to affect vision, especially in children or at later age when they go clinically unattended.
The above conditions were associated with vision impairment but there can be a number of conditions which may lead to people approaching ophthalmologists for management. These include:
Blepharitis is the inflammation of the skin around the eye lashes and may be associated with styes (which are infections of the hair follicles of the eye lashes). It may occur due to bacteria, dandruff or skin allergies. The symptoms usually include eyelids being red, scaly, itchy or with crust formation. Sometimes eye lashes also fall out and one may complain of dryness or pain. In many cases, regular washing of the eyelids resolves the problem. The specialist may prescribe, anti-dandruff or medicated shampoo, anti-allergy medication or anti-biotics for associated co-infections.
Conjunctivitis is also known as Pinkeye and is a condition where the white of the eye turns red and is associated with watery discharge. It is caused by the inflammation of the conjunctiva, the clear mucous membrane over the eyeball. With inflammation this clear membrane becomes red and swollen. Other symptoms may include itching, watery discharge, swelling of the eyelids etc. It is mostly painless and a self-limiting condition. It lasts for 7-10 days and resolves without any treatment. It is very common and the infectious variety known as Viral Conjunctivitis is highly contagious and prevention of spread is the only precaution one needs to take. As this is common amongst school going children, it is paramount that a child suffering from pinkeye stays back home till conjunctivitis is fully resolved.
Floaters and Flashes are more of symptoms than conditions but are usually associated with certain ophthalmic pathology. Floaters are small specks moving in the field of vision. One sees them more clearly when looking at a plain background. They are actually tiny masses of gel inside the vitreous, which is the clear jelly-like fluid that is found in the posterior part of the eye behind the lens and in front of the retina. Floaters may present as different shapes, such as dots, clouds, circles, lines, or even like cobwebs. Mostly this is part of the ageing process, when the vitreous in the eye starts shrinking or thickening forming these artifacts inside the eye. During this shrinking, the vitreous may pull away from the back layer of the eye, leading to a condition known as posterior vitreous detachment. In some cases, this may further cause the retina to tear. This is a medical emergency and is known as retinal detachment. The manifestation of floaters can be disturbing and may be alarming, if they develop suddenly. One should consult an ophthalmologist right away if new floaters develop suddenly. Flashes are akin to lightening streaks or flashing lights and happen when the vitreous gel pulls on the retina. The sensation by many patients is defined as being hit in the eye and seeing "stars." These flashes may come and go for several weeks or months. As one ages, it is more common to experience flashes, but if one notices sudden appearance of flashes, an immediate visit to the ophthalmologist is mandated as it could mean a torn retina.
Strabismus, also known as cross-eyed, squint and walleye is a condition where the eyes do not move, focus or look at the same point at the same time. Simply put, there is loss of coordination between the two eyes’ movements. It develops during or in early childhood. In a normal individual, the extra-ocular muscles or the muscles responsible for eye movements for both eyes work in tandem to move eyes in the same direction simultaneously. In Strabismus there is a problem in this coordination and the muscles of the affected eye either are weak or too strong and lead to misalignment. This further leads to an impact in image formation in the brain and the images of the two eyes cannot merge leading to poor vision. The child suffering from Strabismus soon learns to accommodate and starts seeing with the working eye and blocks the use of the affected eye. A child with Strabismus will rarely outgrows it. Without treatment, it can cause permanent vision issues, known as Amblyopia or Lazyeye, which is known to occur if child is not treated till 5 years of age.
Cataracts, is a very common ailment of the eyes, where the lens of the eye becomes cloudy and eventually opaque, a condition known as Mature Cataract. The vision of those affected with cataract becomes blurred, duskier, and less vibrant or colorful. Some may even experience vision loss at later stages. As cataracts are usually caused by aging, and may become more common around the age of 50, they are bilateral. Cataracts can also be caused by trauma to the eye when they may be unilateral or systemic diseases like diabetes. The condition is usually painless and vision impairment is gradual.
Glaucoma is a group of eye ailments that damage the optic nerve, which transmits visual sensory information from the eye to the brain. With optic nerve damage, there is visual impairment and blindness. Glaucoma is one of the most common causes of legal blindness in the world, actually the second most common cause of blindness. Everyone is at risk of glaucoma and it may never show any symptoms, sometimes it is diagnosed so late that damage may be permanent. This is at times a very painful condition and may be present for long durations before it gets diagnosed. In the beginning, people affected with glaucoma start complaining of reduced vision in the periphery (peripheral vision). But, with time and leaving the condition untreated leads to worsening of vision impairment leading to permanent blindness over time. Glaucoma, presents an even greater health problem than cataracts, as the blindness it causes is irreversible. There are three types of glaucoma: Open-angle glaucoma (OAG) also known as Primary Open Angle Glaucoma (POAG) the most common form in Americas and Africa but less common elsewhere in the world. It usually is bilateral and affects both eyes simultaneously. In POAG, the channels draining fluid from within the eye become blocked, leading to rise in the pressure within the eye. Vision gradually worsens but it happens very slowly. In Closed-angle glaucoma (CAG) there is a build-up of fluid and pressure within the eye, but the onset is much more sudden compared to Open Angle Glaucoma. Symptoms may include headaches, severe pain in the eye and blurred vision. Asians are more likely to suffer from angle closure glaucoma. It usually affects one eye at time and can happen suddenly. Mostly it is reported as a medical emergency which requires immediate intervention. Congenital glaucoma is a rare form of glaucoma that afflicts some newborns. Some children and young adults can also get affected by this type of glaucoma.
Retinopathy is any disease of the retina, which is the nerve layer that lines the back of the eye. Many people with uncontrolled diabetes get retinopathy, which is known as Diabetic Retinopathy. Diabetic retinopathy is a cause of poor vision and even blindness. At first, the blood vessels in the eye get weak. This can lead to leaking of fluids into the retina from the blood vessels. This condition is known as non-proliferative retinopathy, most common retinopathy. Most people with this condition have no symptoms. If blood sugar levels remain uncontrolled and stay high, diabetic retinopathy worsens. New blood vessels grow on the retina, which are weak and break open very easily and spontaneously. This if happens then blood can leak into the middle part of the eye known as the Vitreous and coming in front of the retina, it affects the vision. This bleeding can also lead to scar tissue formation, which later can pull on the retina and cause retinal detachment. This is called Proliferative Retinopathy. Some people will be without symptoms until it is too late, which is a strong reason for regular eye examinations in diabetics. Retinopathy can also cause swelling of the macula, a condition known as macular edema. The macula is the region in the middle of the retina and is very important for sharpness and clarity of vision along with color perception. This condition can severely affect the vision and can lead to legal blindness.
Retinal Detachment is when a section or whole of the retina separates or detaches from the back of the eye. The retina is the sensory layer of the eye which normally detect light falling on it and upon stimulation it sends signals to the brain depicting what the eye visualizes. With retinal detachment, this process doesn’t work properly and leads to blurred vision or complete blindness. Retinal detachment is a medical emergency and requires immediate intervention by a Retinal Specialist. If timely eye surgery is performed, one can save the lost vision.
Cataract is irreversible and once mature requires surgical intervention for correction. The cataract surgery usually employs implantation of an artificial lens also known as intraocular lens implant (IOL) that corrects the individuals vision to a great extent. The cataract surgery separates the cataract or opaque lens from the lens’ capsule. If an IOL cannot be implanted, then contact lenses or eyeglasses are prescribed and must be worn for proper vision. Phacoemulsification and standard extracapsular cataract extraction (ECCE) are two surgical methods that remove the cataracts. In these surgeries, the posterior lens capsule is kept intact so that the IOL can be anchored properly and to keep the vitreous gel intact in the posterior chamber of the eye. The cataract surgery is usually done in an outpatient setting as a day surgery procedure. Phacoemulsification (small-incision surgery) is the latest and most common type of cataract surgery now performed by ophthalmologists worldwide.
The aim of glaucoma management is to treat the condition by lowering pressure in the eye known as intraocular pressure. Depending on the condition, type and response in individuals, the various options may include eyedrops, oral medication, laser treatment or surgery in some combination or alone.
Eyedrops: are the first line of drugs used to manage Glaucoma. These aim at decreasing intraocular pressure by improving drainage of fluid from the eye or by reducing the amount of fluid the eye produces.
Oral medications: If eyedrops alone do not provide adequate response, the specialist may prescribe an oral medication, usually a carbonic anhydrase inhibitor along with them. Possible side effects of this medicine include tingling sensation in the fingers and toes, depression, gastritis, frequent urination and kidney stones.
Eye Surgery and other therapies: Other therapies include laser therapy and number of surgical procedures. Additional or follow-up procedures may also be performed in case the intraocular pressure begins to rise again. The following therapies use techniques intended to improve the fluid drainage within the eye, lowering the intraocular pressure:
Photorefractive keratectomy, or PRK, is a new form of eye surgery in India which uses laser beams. PRK is employed to correct vision related problems namely, mild to moderate nearsightedness, astigmatism, and/or farsightedness. The goal of PRK like LASIK is to make the prescription glasses redundant.
The principle behind PRK is to reshape the curvature of the cornea, there by allowing images to form correctly by ensuring the light travelling is focused properly on the retina. PRK is an outpatient surgical procedure and gets done in approximately 10-30 minutes. During PRK, a specialist uses a laser to deliver a cool pulsing beam of UV light, at the surface of the cornea, as compared to LASIK where the Laser works underneath a thin flap of the cornea.
LASIK, which stands for Laser In-situ Keratomileusis, is a very popular surgery used to correct vision in people who are nearsighted, farsighted, or have astigmatism. The Laser deployed for this procedure is Excimer Laser, which is an Ultraviolet Laser. As mentioned earlier, all laser vision corrective surgeries aim at reshaping the curvature of the cornea, so that light traveling through it gets focused onto the retina so that proper images can form and vision is normalized to as much as possible. LASIK is one of the many different surgical techniques used to reshape the cornea, it may be one of the most sought after, popular and technically demanding surgery. In LASIK, field of surgery is under a very thin flap in the cornea, compared to PRK which is an identical laser vision correction procedure but is performed directly on the corneal surface. Both surgeries provide excellent outcomes and make glasses unnecessary for distant vision for nearly all patients.
Cataract is the result of the normal ageing process and leads to slow clouding of the eye lenses which eventually leads to impaired vision. The only available treatment for cataract is surgical removal of the cloudy or diseased lens. The method, technique and technology used for preforming this surgical step differentiates between the type of surgeries that exist. Primarily there are two forms of surgeries that exist as viable options for patients with mature cataracts, namely, Phacoemulsification (phaco) and Extra-Capsular Cataract Extraction (ECCE). Phacoemulsification is a newer form of surgery and is popularly known as suture-less surgery due to the very small size of the incision used in it. During ECCE, which is a surgery which was the mainstream surgery before phaco and is still a very popular surgery, employs a larger (10-12 mm) incision which requires sutures but a newer version of ECCE known as Manual small incision cataract surgery (MSICS), which is a evolved version and needs a smaller incision. Though Phacoemulsification is the norm in the Developed Nations but ECCE and MSICS are popular procedures along with Phaco in the developing nations. Luckily in India and especially in the leading Eye Clinics, Phacoemulsification has been the procedure of choice for years now with excellent clinical results.
Oculoplastic Surgery, also known as Oculo-facial Surgery, Ophthalmic Plastic and Reconstructive surgery or Eye Plastic Surgery in India, is a sub-specialty of Ophthalmology that manages the deformities and abnormalities of the eyelids, lacrimal (Tear Producing) gland system, orbit (or bony structure in which the eyeball are present) and the adjacent areas of the face. Some common oculoplastic procedures include Botox injections, Microdermabrasion, Endoscopic forehead and brow Lift, Blepharoplasty (Eyelid Surgery), TCA Peel, Laser Skin resurfacing, Fat Transfer, Neck lift and upper face lift (Rhytidectomy).
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