Cataract surgery is one of the most commonly performed surgeries in the United States with over 90% of patients reporting improved vision afterwards. This surgery is performed on an outpatient basis using local anesthetic and generally takes an hour or less to complete. Cataract surgery involves removal of the cloudy lens and replacement with a permanent, artificial lens known as an intraocular lens. Most patients will notice improved vision within a few days after surgery. Full recovery generally takes less than eight weeks. Two separate surgeries are performed 4-8 weeks apart for those patients requiring surgery on both eyes.
There are two types of cataract surgery: Phacoemulsification and Extracapsular Extraction.
Phacoemulsification is the most common cataract surgery. A small incision is made on the side of the cornea and a probe is inserted that uses ultrasound waves to break up the lens. The surgeon removes the diseased lens and implants an intraocular lens.
Extracapsular extraction is generally used to remove larger, more advanced cataracts. A longer incision is made on the side of the cornea, which allow the surgeon to extract the cloudy core of the lens in one piece and to implant an intraocular lens. Unlike contact lenses which must be removed and cleaned, intraocular lens (IOLs) require no care and become a permanent part of the eye. There are two kinds of IOLs and your doctor will assist you in deciding what lens is best for you.
Limbal Relaxing Incisions
Astigmatism is a common refractive disorder in which the cornea and the lens of the eye have an irregular curvature. Eliminating corneal astigmatism results in better overall vision following cataract surgery and the implant of an intraocular lens (IOL). The most commonly used procedure to correct mild to moderate astigmatism is a surgical procedure known as Limbal Relaxing Incisions (LRIs). A pair of incisions is made at the corneal limbus which induces changes in the corneal astigmatism by varying the length, depth and location of the incisions. This procedure takes only a few minutes and is performed at the same time as cataract surgery. There is an almost immediate recovery of vision and healing time is reduced.
Toric Lens Implants
Toric Lens Implants are intraocular lenses (IOLs) designed to correct moderate to high astigmatism. The toric lens implants are made of a soft plastic material that can be folded and inserted into a small incision during cataract surgery.
While a typical monofocal lens corrects vision for only one distance, toric intraocular lens are designed with two powers, one to correct astigmatism and the other to correct nearsightedness (myopia) or farsightedness (hyperopia). Glasses or contacts are still required for a full range of vision.
Toric lens implants can be used in combination with Limbal Relaxing Incisions (LRIs) and/or Laser Enhancement Surgery. They can also be used in patients with lenticular astigmatism, a less common form of astigmatism in which there is an irregularity in the shape of the natural crystalline capsule.
Laser Enhancement Surgery is effective in treating high astigmatism. In combination with Limbal Relaxing Incisions (LRIs) and/or Toric Lens Implants, Laser Enhancement Surgery helps patients achieve optimal vision following their cataract surgery. This surgery has many advantages in the treatment of astigmatism such as superior precision, correction of high astigmatism, and offering an alternative for patients who want multifocal intraocular lenses. However, it must be performed six weeks after cataract surgery which is an additional cost. The benefit of enhanced vision outweighs the cost for many patients.
The cornea is the outmost lens of the eye and is made up of five layers of smooth, transparent material. It acts as a protective shield for the eye, keeping it free from germs and other foreign material, and it controls and focuses light entering the eye. If an injury or infection is confined to the outer layers of the cornea, treatment can generally be effective with no permanent impact on vision. If inner layers are affected, however, there is a greater risk of permanent damage such as corneal scarring and vision loss. In such instances, a corneal transplant may be necessary to restore vision.
Full Thickness Cornea Transplant
In full thickness corneal transplant surgery (Penetrating Keratoplasty) or corneal graft, the damaged or diseased cornea is removed and replaced with a donor cornea. Common reasons for a cornea transplant include:
To improve optical quality and enhance vision in cases such as replacement of an opaque and scarred cornea or one that has been distorted by severe astigmatism due to keratoconus.
To reconstruct the anatomy of the cornea to preserve the eye in cases in which the cornea has been injured or perforated.
To preserve the eye by treating diseases that are not responding to medications or other forms of therapy, such as a severe fungal cornea ulcer or ruptured bullae keratopathy.
Conditions such as Fuchs’ corneal dystrophy, keratitis, corneals stromal dystrophies may also warrant a corneal transplant.
Corneal Transplant Surgery
Corneal transplant surgery is the most commonly performed transplant surgery in the United States. In full thickness corneal transplant surgery, the damaged or diseased corneal tissue is removed and is then replaced with a precisely matched donor corneal graft that is anchored to the surrounding host tissue by tiny hair-thin sutures. The surgery is generally performed with general or local anesthetic on an outpatient basis.
Following surgery, eye shields are worn to prevent damage to the eye from possible trauma such as bumping, hitting or rubbing of the cornea. Topical antibiotics are used for several weeks, and topical corticosteroids are used for several months to reduce possible infection or graft rejection. The surgeon will monitor the cornea shape through corneal topography and in some cases a patient may need to wear a rigid, hard contact lens over the corneal transplant to reduce astigmatism. Lifting, bending and other strenuous activities must be avoided for several weeks. Recovery from corneal transplant surgery takes about six months to a year depending on healing time, refraction changes and corneal astigmatism.
Complications of corneal transplant surgery can include:
- Graft rejection or failure
- Intraocular bleeding
- High refractive error (astigmatism or myopia)
- Recurrence of disease, such as corneal stroma dystrophy
Medications such as antibiotics and corticosteroids and careful monitoring throughout the recovery period can reduce the risk of these complications.
Partial Thickness Cornea Transplant
Partial thickness corneal transplants are becoming the preferred method of corneal transplant surgery for those whose disease or injury is confined to specific layers of the cornea. Advances in corneal transplant procedures now allow surgeons to remove and replace just the damaged or diseased corneal tissue rather than the entire cornea in cases in which only one or two layers of the cornea are affected. This procedure is known as a partial thickness cornea transplant.
Two primary partial thickness corneal transplant procedures are DSAEK, Descemet stripping with automated endothelial keratoplasty, and DALK, deep anterior lamellar keratoplasty.
Only the two innermost layers of the cornea, the Descemet’s membrane and the endothelium, are removed and replaced with a donor cornea in DASEK surgery. This partial thickness corneal transplant has proven useful for patients with Fuch’s corneal dystrophy and this less invasive procedure offers some advantages over full thickness transplants such as a smaller incision, fewer sutures, and a faster healing time. DSAEK is generally an outpatient procedure using local anesthetic and takes only about 45 minutes to complete. The risks include possible graft displacement, graft rejection, hemorrhage, swelling and infection.
Anterior Lamellar Keratoplasty (DALK)
Deep anterior lamellar keratoplasty, or DALK, is a partial thickness corneal transplant procedure used to treat disease or injury confined to anterior layers of the cornea including the epithelium, Bowman’s layer and stroma.
In this procedure, the surgeon separates and removes the anterior layers of the cornea from the innermost layer, and then after the diseased layers are removed, a donor cornea that has been stripped of the Descemet’s membrane and endothelium is sutured in. DALK is used to treat keratoconus and corneal scarring. And like other partial thickness corneal transplant procedures, it has some advantages over traditional PK surgery such as fewer post-operative complications, a faster recovery, and a decreased risk of graft rejection and damage or infection in other parts of the eye
DALK is generally performed on an outpatient basis using local anesthetic. Because it is a technically precise procedure, perforation of the Descemet’s membrane can occur, sometimes necessitating a full thickness PK procedure. Infection inflammation, suture-related problems and graft rejection are other possible complications.
Laser Assisted Corneal Transplant
Laser assisted corneal transplantation (laser assisted keratoplasty) is a corneal transplant technique using laser technology to prepare the corneal graft and to remove the diseased recipient cornea. The laser assisted wound may have faster vision recovery, reduction of postoperative astigmatism and improved strength due to the increased surface area of contact between the corneal graft and recipient cornea.
Artificial Cornea Transplant
Implantation of an artificial cornea (keratoprosthesis) offers hope to patients who have either rejected donor grafts or who are not good candidates for natural grafts. There is little risk of rejection since only host tissue is used, however, artificial corneas are only indicated for those patients who cannot tolerate natural grafts. Complications are similar to those of traditional transplantation surgery including glaucoma, infection and possible retina detachment.
Photorefractive keratectomy (PRK) is a type of laser eye surgery that permanently changes the shape of the cornea, improving the way it focuses light on the retina. PRK was the most commonly used form of refractive surgery before LASIK. Though the two procedures have similarities, each is performed differently and has its own advantages and disadvantages. PRK is also used to correct myopia, hyperopia and astigmatism by reshaping the cornea. It is used on the surface of the cornea only, unlike LASIK, and requires no incisions thus leaving intact the structural integrity of the cornea. In PRK the thin outer cell layers (epithelium) of the cornea are removed with an excimer laser, reshaping the cornea and correcting the refraction error.
Following surgery, a patch or a bandage contact lens is placed on the eye for protection. Some discomfort may be experienced by the patient for the first few days after surgery, and vision will be blurry from three days to a week. Best vision may take a month to achieve. Eye drops may also be required for an extended period.
Possible complications of PRK include undercorrection, overcorrection, poor night vision and corneal scarring. 95% of eyes were corrected to 20/40, the legal limit for driving without corrective lenses in most states, according to an FDA study. Permanent vision loss is extremely rare from PRK.
PRK still remains the preferred method of refractive eye surgery for patients with thin corneas and large pupils, for those who are extremely nearsighted, and for those who are not good candidates for LASIK.
LASIK surgery offers an alternative to eyeglasses and contacts for correcting vision in those with refractive errors. LASIK is the most commonly performed refractive surgery in the U.S and has helped improve the vision of millions of people with myopia (near-sightedness), hyperopia (far-sightedness), and astigmatism (a cornea with unequal curves). The ideal candidate for LASIK has a stable refractive error within the correctable range, is free of eye disease, is at least eighteen years old, and is willing to accept the potential risks, complications and side effects of LASIK.
LASIK is usually performed as an outpatient procedure using topical anesthetic drops and takes only about fifteen minutes to complete. Using an automated blade and laser, the surgeon permanently reshapes the cornea, allowing light to focus directly on the retina to produce clearer vision. A flap in the cornea is created and lifted to the side. Then the cool beam of the excimer laser is used to remove a layer of corneal tissue, permanently reshaping the cornea. The flap is folded back into its normal position and sealed without sutures. A shield is used to protects the flap for the first 24 hours following surgery. Vision is generally clear by the next day and there is usually less pain than with other methods of refractive surgery. Eye drops can be used for pain, if needed, for a few days. 90% of patients who undergo LASIK achieve between 20/40 and 20/20 vision, and 95% of LASIK patients report satisfaction with the procedure and their results.
After LASIK, some people experience poor night vision and the surgery may result in undercorrection or overcorrection, requiring a second surgery. Though rare, other serious complications include a dislocated flap, epithelial ingrowth and inflammation underneath the flap. These complications can be managed without any loss of vision. Permanent vision loss is very rare.
This investigational surgical procedure is designed to improve near vision without reading glasses or with a decreased need for them. Typically, after the age of 40, people must hold things further away in order to read them, and most usually purchase reading glasses to make print appear larger, clearer, and easier to read. Through Reading Enhancement Surgery, Dr. Damiano’s patented Reading Enhancement Device (RED) is permanently sutured to the sclera (white part) of the dominant eye to decrease or avoid the need to use reading glasses.
85% of patients participating in Dr. Damiano’s research after having this procedure gained two or more lines of near vision, and 25% of patients gained three or more lines. None of the patients lost their best corrected distance or near vision. This surgery has been performed for about 7 years. All surgery has some risk, but these risks have been minimal in over 50 years of similar detachment scleral buckling procedures.
Alternative treatments to allow people to read at a generally comfortable distance include reading glasses and conventional bi-focal lens glasses, tri-focal lens glasses (two near distances and one far distance), multi-focal lens glasses (no line bi-focal lens with gradual power changes). Contact lens are also an option with both multi-focal contact lenses and monovision contact lenses. Other surgeries such as Laser vision correction and incisional sclerotomy can also be discussed with your ophthalmologist.
Radial keratotomy (RK) is an eye surgery procedure to correct myopia (nearsightedness) in which the cornea is flatten, reducing its optical power. Incisions are made in the cornea similar to the spokes in a bicycle wheel, thus the term radial. Hyperopia (farsightedness) following RK can be a significant problem, either immediately following surgery or years later. The mechanism causing hyperopia after RK is apparently the weakening of the peripheral cornea beyond a critical point, perhaps caused by intraocular pressure and by years of external lid pressure from blinking, sleeping, and eye rubbing.
Dr. Damiano and his associates developed peripheral interrupted or purse-string sutures which can steepen the central cornea after RK and appears to enhance wound healing. Using this procedure, hyperopic (farsighted) patients following RK who were unhappy with their uncorrected vision and not satisfied with either contact lens or spectacle correction, underwent this intrastromal corneal purse-string suturing. Most patients gain significant visual acuity following the procedure.
Amniotic Membrane Transplantation
A very thin layer of the placenta known as the Amniotic Membrane (AM) is used in treating a wide range of ocular surface conditions. Among these are stromal ulcer, chemical burns, persistent non-healing epithelial defects, pterygium, and autoimmune ocular surface disorders such as Stevens-Johnson syndrome, toxic epidermal necrolysis, and ocular cicatricial pemphigoid. AM is transplanted on to the surface of the eye to enhance healing and restore ocular surface, providing a natural surface and nutrition for growth of the epithelium, the surface layer of the cornea and conjunctiva.
Limbal Stem Cell Transplantation
Corneal limbal stem cells are special cells that have the ability to continuously produce new epithelial cells and maintain a healthy corneal surface. There are many ocular disorders such as chemical burn, aniridia, and autoimmune diseases such as Stevens-Johnson syndrome, toxic epidermal necrolysis, ocular cicatricial pemphigoid, in which stem cells may become permanently damaged to a degree that they no longer function. This leads to a compromised ocular surface, irritation, redness and decreased vision. Limbal stem cell grafts can be harvested from a donor and transplanted onto the ocular surface of a patient to treat this state of limbal cell deficiency. The donor graft can be harvested from the patient’s other eye or from a relative, another living donor with healthy ocular surface, or a cadaver.