Ophthalmology and Laser Center

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Ophthalmology and Laser Center

Vision is one of the most important elements that connects people to life. For this reason, regular eye examination is one of the most important steps to be taken for a healthy life. It should not be forgotten that vision defects and diseases in the eye can only be revealed by the ophthalmologist.

An adult over the age of 40, whether wearing or not wearing glasses, should be examined once a year, even if there are no complaints. This period in children according to the doctor's recommendation may be every 6 months, or even more frequent in some special cases. It is ideal for initial eye control in a 3-year-old child with no complaints. The eye examination at the Türkiye Hospital is carried out meticulously and in great detail by the latest technological devices and an expert staff.

Treatments;

  • Elimination of refractive errors (myopia, hypermetropia, astigmatism)
    • Smile Laser
    • PRK
    • Lasik
    • I Design
  • Cataract & Phaco
  • Pediatric Eye Diseases and Strabismus
  • Medical Retina
  • Surgical Retina & Vitrectomy
  • Contact Lenses
  • Glaucoma (High eye pressure)
  • Photodynamic Therapy
  • Eye plastic surgery operations
  • Cornea & Eye Transplant

What is cataract?

A cataract is the blurring of our clear lens located inside our eye that provides visual acuity. The clear lens located in the pupil allows the rays reaching the eye to focus on the yellow spot. If the lens loses its clearness, the rays cannot reach the yellow spot, and vision loss develops. If this loss of vision restricts a person's daily activities, it should be treated with surgical intervention.

Causes of cataract

Cataract is a disease that often occurs with advanced age. However, it may develop in every age group depending on various reasons. Risk factors in cataract formation;

1. Diabetes

2. Medicine use, especially cortisone medicines

3. Eye traumas

4. Long-term exposure to ultraviolent rays (Solar) and X-rays (such as Radiotherapy)

5. Smoking

What complaints does cataract cause?

Cataract development can occur over a period of years or in a short period of time, such as 6 months depending on the type of cataract. Cataracts usually develop in two eyes and their intensity may be different. 

  1. Blurred vision (especially pronounced in long-distance vision)
  2. Dazzling in eyes in bright light and sunny weather
  3. The difficulty that occurs especially at night when driving a car
  4. Cloudy vision in colors, especially in blue

 

 

Cataract treatment

The only option for cataract treatment is surgery. It is not a disease that can be treated with medication!

When should the operation be performed?

Treatment is unnecessary in those with mild cataracts. However, if the person has decreased vision that disrupts their daily activities (such as driving a car, reading a book), an operation should be planned. Cataract surgery is not urgent, expect in rare cases. In very advanced cataract patients, more important problems may occur during surgery. That is why it is not right to wait for the cataract to progress.

Is cataract surgery difficult?

From the point of view of patient comfort, it is not difficult thanks to advanced surgical techniques. However, as with any surgery, various problems may arise, especially infection, in such cases, the duration of surgery may be prolonged or additional surgery may be required.

The surgical process

The aim of cataract surgery is to replace the blurred lens in the eye with a clear lens. The operation is performed with the help of a microscope, while the patient is in the supine position, looking at the light on top. Except in special cases, it is performed while the patient is awake. The most commonly used method all over the world is PHACO. An incision of about 3 mm is made near the anterior of the eye and the cataract is cleaned with ultrasound waves. Later, an intraocular lens can be inserted into the lens membranes. 

Features of intraocular lenses inserted during operation can be

used lenses "monofocal and multifocal (smart lens)". After inserting monofocal lenses, it is necessary to use glasses to see up close clearly. The use of smart lenses has increased in recent years, it is possible to see far and near without glasses.  Such lenses are used in cases where the patient and their physician will decide jointly.

Risks of cataract surgery

The primary risks are infection and intraocular bleeding during the operation. In addition, problems such as cataract falling behind the eye, and shifting of the lens placed in the eye may develop. For this reason, cataract surgery should be performed by an experienced ophthalmologist and in centers where problems that may occur can be corrected.

Does cataract recur?

Cataract does not recur, however, over time, blurring may develop in the membrane behind the lens placed inside the eye. This condition, popularly known as "secondary cataract" or "opacification of the lens", can be easily eliminated with a quick laser procedure without surgery. 

OPTIC LASER TREATMENT AND NEXT GENERATION METHODS

 

These are the operations known as 'getting rid of glasses with laser' and are treatments in which refractive defects such as myopia, hyperopia, and astigmatism are corrected.

 

How Can You Tell If Your Eyes Are Suitable For Laser Treatment?

Examination for your degree of vision, vision ratio determination, eye pressure measurement, biomicroscopic inspection are performed. After that, the pupils are dilated with eyedrops, the eye numbers are determined again with administered eyedrops, and a detailed examination of fundus (retinal vascular structure and optic nerves) is performed. Since the pupils will be dilated with eyedrops during the examination, there may be discomfort from the light and blurred vision, and this condition may last for 24 hours. Those who are going to drive should take this condition into account. In addition to the detailed optic examination, corneal topography, pachymetry, and pupillometer are performed. The shape and thickness of the corneal layer are assessed with these tests.

 

What Should Be Paid Attention to Before Laser Treatment?

Those who wear contact lenses should stop wearing their contact lenses 1 week in advance. On the Day of the Laser Operation, do not apply makeup and lotion on your eyelids before the operation. You don't need to be fasting on the day of treatment. You can be full in such a way that it does not bother you. The operation is performed with anesthetic eyedrops. You can return home immediately after the operation. It is beneficial to spend a few hours resting after the operation. It is harmful for you to rub, press on, and scratch your eyes. You will need to use the prescribed eyedrops as recommended.

 

What Will Change in Your Life with Laser?

You will completely get rid of the discomfort caused by glasses and lenses. You will be able to see the time easily in the mornings or at night when you wake up from your sleep. You will get a natural look and vision without glasses and lenses. You will achieve comfort and higher success in sports activities. You will be less bothered by weather and climate events such as wind and rain. You will get rid of such situations such as losing your contact lenses and breaking your glasses.

 

WHAT ARE TREATMENT METHODS WITH LASER?

 

Superficial Treatment (PRK-LASEK)

In the PRK technique, a laser is applied after removing the corneal epithelium, the frontmost transparent layer of the eye. Epithelial tissue heals on its own in 3 days. In the LASEK technique, the corneal epithelium, the frontmost transparent layer of the eye, is softened with diluted alcohol and removed, and laser is applied to the remaining lower part. Then the epithelium is again placed in its previous position. Recovery occurs in 3 days.

 

Here it is necessary to mention a method that has recently been updated and is being introduced as 'No-Touch'. This method is actually a superficial treatment method that we medically call 'Trans-PRK'. This method is not a new technique, as mentioned, it has been used since 1995. In this method, the surface layer is removed by laser instead of alcohol and the rest continues as in PRK. The results are also similar to the PRK method, it does not have any superiority.

 

Femto LASIK

In this method, a corneal flap is created in the transparent part of the eye with a femtosecond laser and the corneal surface is shaped with excimer laser. With Femtosecond Laser, the corneal flap is created completely under computer control and without the use of a sharp surgical instrument. The advantage of this method over PRK is that the patient's comfort after surgery is higher and the return to daily life is quick.

 

I-Design (Personalized treatment)

I-Design is a personalized treatment method that is carried out through a unique corneal map, just like a person's fingerprint. Thanks to this, the quality of vision in the dark increases to higher levels than other standard laser methods. Since the characteristic structure of each eye is different from one other, the difference of this treatment from others is that it is a special treatment for the person themselves.

What is keratoconus? 

Keratoconus is a progressive eye disease that is accompanied by thinning and tapering in the corneal layer in the anterior part of the eye, leading to irregular astigmatism and myopia, resulting in a decrease in vision. 

What are the symptoms? 

The most common symptoms are the increasing degree of myopia and astigmatism in a short period of time and, accordingly, frequent change of glasses, inability to see well despite glasses, a decrease in night vision, an increase in light sensitivity.

Who experiences it and why does it occur?

It is observed in both men and women without gender difference.  Repeated trauma related to eye scratching and genetic factors have been blamed as the cause. It is often observed in people with allergic eye diseases, which leads to excessive itching in the eyes. In addition, it may also be associated with genetically transmitted diseases such as retinitis pigmentosa (night blindness), Down syndrome, and some connective tissue diseases. Today, it is known that keratoconus is a multi-factorial disease, it occurs when environmental factors such as trauma due to eye scratching come into play in people with a genetic predisposition.

How is the course of the disease?

Keratoconus usually begins in adolescence or in the twenties and progresses at a pace that varies from person to person. This progression stops around the age of 35-40 and the disease becomes stable. Although the disease affects both eyes, it is not symmetrical and often shows more pronounced deterioration in one eye.

How is keratoconus diagnosed?

An experienced ophthalmologist can recognize advanced keratoconus patients through a standard eye examination. However, in addition to eye examination in suspicious and early cases, diagnosis is made by evaluating with special examination devices (corneal topography and corneal thickness measurement). Corneal topography is also used for the follow-up of keratoconus and the evaluation of the result of the treatments applied. In this method, three-dimensional mapping is performed, steepness and flatness are determined.

What are the treatment methods?

The first step in the treatment of keratoconus is to try to stop the progression if the disease is in a progressive period. The rate of disease progression varies from person to person, and progression is usually observed in young people. Examinations are repeated with an interval of 4-6 months to understand whether there is progress or not. If there is progress, the treatment applied is collagen cross-linking treatment. Other methods applied to improve the visual acuity of patients with progressive keratoconus are contact lens applications, intra-corneal ring  placement, intraocular lens application and corneal transplantation.

• Collagen cross-linking treatment: The only proven method to stop progress for our day is the "cross-linking (CCL)” method. However, in order for the CCL method to be applied safely, it is necessary that the diagnosis is not delayed, that is, the cornea is not excessively thinned. In the CCL method, riboflavin drops are dripped into the patient's eye and ultraviolet light is applied to the eye. With the photochemical reaction formed in this way, the hardness of the cornea is increased and strengthened.

• Contact Lenses: Keratoconus patients, whose vision with glasses is not satisfactory, may benefit from specially manufactured hard contact lenses or hybrid contact lenses (soft and hard together) for this condition. Contact lenses are not suitable for advanced-stage patients whose cornea is very thin.

• Intracorneal Ring Method: In the ring method, semicircular prostheses made of polymethylmethacrylate or acrylic polymers are placed in laser-prepared tunnels in the cornea. In order for the ring method to be applied, the cornea must not be too thinned and not too steepened. The rings placed on the cornea in the suitable eyes provide an increase in the best corrected visual acuity by flattening the cornea.

• Intraocular lens application: If keratoconus patients cannot benefit from contact lens and ring treatments, another treatment option to eliminate myopia and astigmatism is the application of intraocular lenses. These lenses are placed on the person's own clear lens or on the colored iris layer. In order for such an application to be performed, it is required that the number of internal corneal layer cells of the patient is sufficient. 

• Corneal transplantation: Since other methods cannot be used, corneal transplantation is usually performed as a last resort in neglected patients with advanced keratoconus, whose corneas are very thin.

 

UNCONTROLLED GLAUCOMA MIGHT MAKE YOU BLIND

The disease, with the medical name of glaucoma, accompanied by high eye pressure and related eye symptoms, is one of the most important causes of blindness in the world.

Glaucoma is a disease that often occurs at advanced ages and may lead to insidiously progressing blindness. It is not diagnosed only with machines that measure eye pressure with numerical values. In the detailed evaluation carried out by the physician, it is especially significant for the diagnosis to notice the thinning or weakening of the optic nerve during the examination. Then, the diagnosis is finalized by performing further examinations such as pachymetry, OCT (optic coherence tomography), visual field.

The normal values are considered between 10-22, though the upper limit may vary depending on the eye structure of the person. In other words, an eye pressure value of 24 for a patient does not cause disease, while a pressure value of 16 for another patient may cause disease.

What are the symptoms?

It is usually asymptomatic, so, it does not cause any symptoms. The patients do not consult a doctor with any complaints with blood pressure values of 20-30, which we often encounter. Glaucoma patients whose intraocular pressure is below 30 have no complaints at the beginning, however, they apply to us stating they feel as if their vision has been decreasing day by day recently. Unfortunately, it is not possible to restore the lost vision except for the treatments that will preserve the existing vision during this period. If the eye pressure is 30 and above, they may have symptoms with complaints such as eye pain, however, we see these values much more rarely, and it is easy to diagnose since the patients apply with complaints.

At what age does glaucoma occur?

Age is very important for the disease, and development of the disease is common after 40 years of age.

Do Babies or Children have glaucoma?

We encounter postpartum glaucoma with a very rare frequency, such as 1 in 10000 births. However, this is a different disease that we call congenital glaucoma. It is a syndrome that is accompanied by pterygium and watering in eye. Again, we can also encounter high eye pressure in a syndrome we call juvenile glaucoma around the age of 10, which is a very rare condition. But since these two syndromes are very rare, and they visit the doctor with different symptoms; it is more significant to evaluate them with a general examination rather than measuring eye pressure in these patient groups in order to make a diagnosis.

Who is at risk?

Since glaucoma is an insidious disease, routine eye screenings are crucial for diagnosing this disease.

Groups at risk;

  • Patients over the age of 40,
  • Those with a family history of glaucoma,
  • Those who have had eye trauma or eye surgery,
  • Patients with high myopia or hypermetrope,
  • Patients with migraine,
  • Smokers,
  • Those with chronic diseases such as diabetes and hypertension disease,
  • Patients on long-term cortisone medication,
  • Patient groups on medications that may increase their eye pressure (such as some prostate medications)

Glaucoma should be excluded through a detailed eye examination of this group of patients. We recommend an annual examination of glaucoma after the age of 40. The frequency of the examinations for other groups at risk may vary on the recommendation of the physician, depending on the patient's condition.

How can I take precautions?

  • Precautions can only be taken by screening with the examination of an ophthalmologist. Other than that, you cannot take precautions for the disease by paying attention to nutrition (such as eating low-salty food, carrots).
  • We can say that some of the things known among people are meaningless. For example, factors such as eating salty food, drinking too much water, gaining and losing weight quickly are not directly related to glaucoma.
  • Glaucoma does not cause blindness in 1 day.
  • The high numerical value of glaucoma on the machine does not always mean that there is a disease. Maybe your cornea is thick, and the machines measure it higher than the actual value. The gold standard is the examination of a physician.
  • Glaucoma in babies and children is an extremely rare condition, and unlike adult patients, it is diagnosed independently of the machines by the findings of the examination of the ophthalmologist.

As a result, glaucoma is an insidious disease and an eye screening examination is very important for the diagnosis. We recommend 1 eye examination a year, especially after the age of 40. Further examination of the patient groups at risk before the age of 40 is also important in order not to miss the disease.

EVERYTHING ABOUT EYE ALLERGIES

When the eyes come into contact with certain substances, they react. These substances are allergic for the eyes. These are called allergens. This is a similar type of reaction to those seen in hay fever, eczema and asthma. Redness in one or both eyes, itching under the eyelids, watering, sensitivity to light, and often a feeling of inability to open the eyelids due to sticking in the morning are observed. Eye itching is the most common symptom of eye allergy.

What causes eye allergies?

Eye allergy is usually more common in people with hay fever, asthma or allergic nature. Sometimes the allergy is limited only with the eyes or one eye. Polens of various plants, pet hair, dust, some medications, and contact lens cleaning solutions are the most common causes of eye allergies. Many activities and chemical products can complicate allergies. Working intensively in front of a computer screen, spending a long time playing computer games or watching television, exposure to sunlight for a long time without taking precautions, and some chemical products used at home are among these reasons. A person can find out this reason by observing themselves and their environment.

Are there any types of eye allergies?

Allergy is a condition that occurs as a result of a response to any external or internal factor that the body's defense system recognizes as foreign. Basically, although 4 types of hypersensitivity reactions are encountered in eye allergy, many allergy cases are considered to be Type I reactions. The early type reaction occurs within seconds and minutes after the encounter with the antigen (causative agent of the allergy) and lasts about 30-60 min. Following this, a late-type reaction may occur, which lasts longer and is more uncomfortable.

Clinically, there are 5 types of eye allergies:

  1. Seasonal or permanent allergic conjunctivis
  2. Vernal keratoconjunctivitis
  3. Atopic keratoconjunctivitis
  4. Giant papillary conjunctivitis
  5. Contact allergy

Although these clinical forms are distinguished from each other by some symptoms and features, itching, redness, burning and discharge are observed in all of them. In keratoconjunctivitis, the transparent layer of the eye (cornea) is also affected, causing discomfort from light and blurred vision. Atopic keratoconjunctivitis can also cause the transparent layer to taper (keratoconus), leading to vision problems that are difficult to treat.

Is eye allergy common?

Eye allergy is increasingly observed in industrialized countries. The reason for this is not only the presence of allergen substances. The increase of many factors related to modern life, such as wall-to-wall carpeting becoming more widespread, going to the countryside more often, pets becoming more popular, and air pollution, lead to eye allergies with increasing frequency.

Is an eye allergy a serious condition?

If the eye allergy recurs or persists for a long time, it may be more disturbing. Initially, it is often felt as a slight discomfort. If the treatment is started immediately, there will be no problem. Otherwise, the eye's reaction to the allergen will worsen, discomfort will settle and progress. It may leave permanent problems in the eye.

What are the symptoms of eye allergy?

Itching is the first symptom of the allergy. Along with redness, watering, burning, swelling of the conjunctiva and eyelid are common signs. Mostly both eyes are affected. A clear-mucous discharge can be encountered. As there may be a family history of allergies, it shows relapses, especially in the spring season. It causes round swelling (papillae) that line up like pebbles on the mantle of the eyelid (tarsal conjunctiva). Itching occurs due to stimulation of nerve endings.

Is eye allergy easy to diagnose?

If the symptoms and the course of the disease are well explained to the doctor, it becomes easier to diagnose. The doctor should be told about when the first symptom of discomfort began, how many times a year and when it occurs, and the history of allergic discomfort in the patient or their family. All the details should be mentioned from lifestyle, job, hobbies, the layout and furnishing of the house to medications used due to another illness. The doctor makes a diagnosis after carefully listening and a full ophthalmological examination. Sometimes skin tests are performed or the amount of lgE in the blood serum can be checked.

 

How is the treatment of eye allergy?

 

Allergen avoidance is the first step in treatment. If the allergen causing the disease can be detected or known, it should be avoided. As a precaution against flower pollens and plant seeds in seasonal allergies, it is necessary not to stay in green and flower areas for a long time during the pollen season, and if possible not to go outside on windy days. When going out, sunglasses with UV filters should be used. 

The second step is to resolve complaints.  For this, artificial tear drops, cortisone drops or ointments, antihistamine medications that the ophthalmologist will recommend are used. Artificial tears give the eye a feeling of comfort by hydrating the eye. It is necessary to use cortisone medications in a controlled manner with a doctor's recommendation due to their stronger effects and potential side effects. If bacteria also multiply on the background of allergies and become inflamed, antibiotic drops should also be used. In recurrent and prolonged cases, especially if an upper respiratory tract allergy is also involved in the picture, desensitization vaccines can be performed by performing skin tests.

 

The doctor should be supported in the treatment of eye allergy!

 

In order for the prescription prescribed by the doctor for treatment to be completely effective, all dosage instructions must be followed. Drops for allergies are able to relieve discomfort within a week. But despite this, the treatment should be continued until the time recommended by the doctor. Inadequate treatment will facilitate the disease to become longstanding.

INTRAOCULAR INFLAMMATIONS: UVEITIS

 

 

The eye is in a very exclusive place in the body compared to other organs due to its transparency and the fact that most of its tissues do not contain vessels. The absence of a vascular layer in most eye tissues protects these tissues from the reach of microbes and makes it difficult for the immune system to reach them.

 

The immune system reaches the eye through the vascular layers of the eye. These layers are called uvea. These vascular layers include the colored part of the eye, the iris (the pupil is located in the middle of it), the ciliary body that secretes intraocular fluid, and the choroid coat just below the nerve layer of the eye. Inflammation of these layers is called uveitis.

 

These intraocular inflammations can be caused either by the activation of the immune system due to microbial infection or by the disorderly aggression of the immune system due to rheumatic disease. The first stage in the treatment of these diseases is the detection of the underlying disease.

 

When the uveitis affects only the anterior layers (iris and ciliary body) of the eye, it is called "anterior uveitis". This condition is accompanied by redness of the eyes, very intense light sensitivity, pain and slightly blurry vision. Although this is a picture that we can often see in patients with ankylosing spondylitis among rheumatic diseases, many infections may also occur together with infections or rheumatic disease, especially those caused by the herpes virus.

 

There is an egg white-like gel texture that starts from just behind the eye lens and fills the space inside the eye. The uveitis conditions, in which this tissue called vitreous is affected, are called intermediate uveitis. This condition, on the other hand, can be caused by multiple sclerosis from neurological diseases, sarcoidosis which is a type of rheumatism of the lungs, and tuberculosis disease from infections. Redness in the eyes, highly intense light sensitivity, and pain accompanied by various levels of blurred vision are also observed in these patients.

 

Uveitis conditions, in which the nerve tissue (retina) located in the backmost layer of the eye and the vascular tissue (choroid) behind it are affected, are called posterior uveitis. All uveitis conditions have the potential to cause serious damage to the intraocular tissues. However, especially since posterior uveitis affects the nerve tissue, the damage they cause may be irreversible. In these patients, a decrease in vision is observed more often than in other types of uveitis, and therefore the type of uveitis that worries us the most is posterior uveitis.

 

Although there may be many diseases that can cause posterior uveitis; Behcet's disease and sarcoidosis disease are relatively and frequently observed among rheumatic diseases in our country. Among the microbial infections that cause posterior uveitis, Toxoplasma parasite transmitted from cats, Herpes virus infections (herpes viruses, shingles viruses, etc.) and tuberculosis are relatively common inflammatory causes.

 

 

How are the treatment and progress?

 

In uveitis caused by rheumatic diseases, inflammation is suppressed with medications that contain cortisone, and then treatments that suppress or readjust the immune system are provided. In the treatment of uveitis due to infection, treatment for the underlying infection is required, and some cortisone can be added to the treatment to prevent the immune system from destroying a tissue as sensitive as the eye.

           

It is especially important for individuals with rheumatic disease to be vigilant that they may have uveitis when they have redness in their eyes, abnormal light sensitivity, pain, and blurred vision. It is important for these patients to consult an ophthalmologist without delay in order to prevent permanent vision loss in their eyes. In the treatment of these patients, it is important that the ophthalmologist and the rheumatologist work closely together. 

 

It is also important to treat uveitis due to infections without delay in order to prevent permanent damage to the tissue. Just as ophthalmologists can sometimes treat these patients alone, it is important for them to work together with infectious disease specialists in some severe infections.

 

Since uveitis is a relatively troublesome disease to treat and will require long-term follow-up, it is important that these patients be followed up by experienced centers and experienced physicians in this field. The inflammatory condition inside the eye caused by uveitis can cause cataracts to form in the lens of the eye, sticky eyes and pupils, glaucoma, and tears in the retinal tissue. Cataract surgery, glaucoma surgery or retinal surgery may also be required from time to time in the treatment of these patients. In such a case, it is very important that the uveitis doctor and the doctor who will perform the surgery are in close contact.

 

Thanks to advances in the treatment of rheumatic diseases caused by abnormal immune system responses, it has been possible to use these medications in uveitis patients as well. At times when these medications were not present, blindness due to uveitis was common. However, thanks to the modern treatments we have now, blindness is extremely rare in patients who use their medications properly and come to their check-ups regularly. Therefore, in our age, if a conscious patient is under the supervision of an experienced doctor in this field, there is no need to worry as in the old days.

 

ANSWERS TO FREQUENTLY ASKED QUESTIONS ABOUT DIABETIC RETINOPATHY

 

Diabetes is a metabolic disease caused by the absence of the insulin hormone or the inability to use it adequately in tissues. An increase in blood sugar leads to damage to all the vessels in our body and many organs along with it. Diabetes is one of the most important health problems of today. There are about 11 million diabetes patients in our country and this number is increasing rapidly. Uncontrolled diabetes causes the most serious damage to the retinal layer of the eye.

 

Signs of Diabetic Retinopathy

 

Diabetes leads to many eye diseases including cataracts, glaucoma, double vision with eye muscle involvement, optic nerve inflammation and retinopathy. Diabetic retinopathy is important since it is the most common cause of blindness.

 

Retinopathy, which occurs with damage to the vessels in the retina of the eye, is mainly examined in two stages.

 

1. Edema and leakage period (Non-proliferative stage): At this stage, hemorrhages, enlargements called aneurysms in the vessel wall, edema caused by leaks, and fluid accumulations formed by lipid accumulation can be observed. The most important vision loss at this stage is due to edema that occurs in the visual center called the macula.

 

2. The stage of vascular damage and formation of new vessels (Proliferative stage): At this stage, vascular occlusions develop. Some substances released into the eye from these areas with no blood flow cause the formation of new vessels in the retina. These vessels are very thin-walled structures that can bleed easily and cause the release of fibrin. At this stage, severe vision loss is experienced with sudden developing large intraocular hemorrhages. As a result of the accumulation of a clot-forming substance called fibrin on the surface of the retina, membranes form and lift the retina from its place, causing it to separate.

 

As the duration of the disease increases, the incidence of retinopathy increases. Approximately 75% of patients with diabetes for 15 years have retinopathy. In diabetic patients, the presence of hypertension, high cholesterol levels, anemia, pregnancy, infections and kidney failure are the factors that affect the course of retinopathy as much as glucose levels.

 

Diagnostic Methods of Diabetic Retinopathy

 

All patients diagnosed with diabetes should definitely have a retinal examination once a year. In case of detection of signs of retinopathy in the examination of the fundus, some tests may need to be performed. Among the most commonly used tests are Optical Coherence Tomography (OCT) and FFA (Fundus Fluorescein Angiography).

 

1. Optical Coherence Tomography (OCT): It is a test in which the macula and the optic nerve are evaluated. Due to its easy applicability, it has become the most frequently used test method in follow-ups. The presence of edema in the macula, hemorrhages, membranes and retractions on the surface of the retina can be detected. The amount of these is measured and the treatment methods are determined.

 

2. Fundus Fluorescein Angiography (FFA): In this test, the retinal vessels are rendered visible thanks to the medication injected intravenously. Whether there is leakage from the vessels, vascular occlusions, the presence of ischemic areas with no blood flow, and new vessel formations on the retinal surface in the advanced stage are detected.

 

 

Treatment of Diabetic Retinopathy

 

The first point to be considered in the treatment is the regulation of blood sugar. Increasing or decreasing attacks cause a weaker response in the treatment of retinopathy. The main methods used in the treatment:

 

1. Intravitreal antiVEGF agents and steroids (drugs with cortisone):

 

Macular edema is the most common cause of blurred vision complaints. Anti-VEGF agents and steroids applied to the eye are the most effective method of treating edema. Injections should be administered initially with monthly periods. With the decrease in macular edema, the application intervals are extended. Intraocular hemorrhages due to new vessel formations observed in more advanced stages cause serious vision loss. Intraocular drug injection is also performed in order to clean these hemorrhages and prevent their recurrence.

 

2. Laser photocoagulation:

 

Laser is still considered the gold standard in the treatment of diabetic retinopathy today. In the treatment of resistant macular edema, grid/focal laser treatments should be applied as well as intraocular drug injections. Laser treatment of ischemic areas that develop as a result of vascular occlusions will protect the eye from complications that may develop in the future. In cases where new vascular formations are detected, laser treatment should be applied to prevent serious intraocular bleeding.

 

3. Vitreoretinal Surgery:

 

In cases where treatment is delayed, laser or intraocular injections are not sufficient for the treatment of retinopathy. In these cases, while hemorrhage in the eye is cleaned with a method called vitrectomy, retinal detachment, which develops as a result of membranes and retraction on the retinal surface, is treated with this surgical method. The development of instruments and techniques used in vitreoretinal surgery helps to obtain satisfying results after the surgery.

 

In diabetic retinopathy, which is an important public health problem, eye examinations should not be neglected in order to prevent vision loss and to perform early diagnosis and treatment.

 

Vitrectomy - Overview of Retinal Surgery

The shape of the eye that allows us to see is, as we know, in the form of a sphere. In the anterior part of the eye, which is also visible from the outside, there is a transparent corneal tissue and iris tissue behind it, which gives the eye its color. Just behind the iris is the lens of the eye. The inner surface of the eyeball contains retinal tissue that perceives images (picture 1). The image from the outside world falls on the retina, focused on by the cornea in front and the lens slightly behind it. The part of the retina that allows us to see most precisely and clearly is called the yellow spot (macula). The transparent tissue that fills the inside of the eyeball is vitreous, which has a jelly-like structure.

In general, the eye can be compared to a camera. The anterior part (cornea and lens) focuses on the external image of an object and enables it to fall on the retina at the back. When the image of the object we are looking at is focused on the yellow spot, which allows us to see precisely, we see clearly. Thanks to the lenses in the front part of the camera, the images of the objects are focused and reflected on the film in the back part (nowadays mostly in electronic chips ). Of course, the important difference is that the perception of the image that comes to the eye of the human is thanks to the images reaching the retina reach the brain via the optic nerve.

The retinal layer on which the images are focused has a number of diseases that can be treated with medications. The treatment of some retinal diseases can only be surgical. Surgical procedure performed by entering the eye is called “vitrectomy”. The history of this surgery, which is performed by entering through three holes opened in the anterior part of the eye, dates back to the beginning of the 70s. Before this date, many retinal diseases, especially retinal detachment, which is the separation of the retinal layer from its place, or important eye diseases such as intraocular hemorrhages due to diabetes, resulted in blindness. The efforts of Dr.  Robert Machemer, (picture 2 ) a German ophthalmologist living in America, on “how to empty the inside of an egg through a very small hole“, which he started amateurishly in the garage of his house in the 60s, have yielded results (picture 3 ). The device, which reached a point where it can treat people in the early 70s, has been a ray of hope for a large number of people to be able to see. Again, in the 70s, in our country, Prof.Dr. Demir Başar in Istanbul and Prof.Dr. Cahid Örgen in Ankara started performing eye surgeries with vitrectomy technique.

 

Vitrectomy, in other words “vitreoretinal surgery” as it describes many surgical procedures performed today better, is a process that requires the use of extremely complicated devices (picture 4) and requires a long educational process to learn. One of the important reasons for this lies in the retinal tissue itself. As we have already stated, the structure of the retina, which covers the inner surface of the eyeball, is highly soft, and its thickness is about a third of a millimeter. Therefore, the retina, which has dislocated as a result of a retinal tear and is positioned in the liquefied vitreous, as in the elderly or advanced myopia patients, requires a lot of care and experience to be placed back in place without damaging this tissue. At the end of this procedure, the laser is applied to the torn parts of the retina and the intraocular space is filled with special gases or silicone oil to support it from the inside for a while ( internal tamponade) ( picture 5 ). While the gases are absorbed spontaneously within 3 – 6 weeks and moved away from the eye, it is necessary to remove the silicone oil with a second surgical procedure after leaving it in the eye for a certain period of time, depending on the patient's condition.

Today, cannulas are inserted into the holes made in the eye for vitrectomy, and surgical instruments are inserted into and removed from the eye through these cannulas ( picture 6 ). Thus, tissue damage from the insertion and removal of surgical instruments to/from the eye is eliminated. In addition, the diameter of surgical instruments used is decreasing every day. The diameter of the surgical equipment used in the first vitrectomy operations was about 1.5 mm, later it was reduced to 0.9 mm. The diameter of modern surgical instruments is now about 0.4 – 0.5 mm ( picture 7 ). The surgical procedure performed with thinner instruments both shortens the duration of the operation and accelerates the patient's recovery after surgery ( picture 8 ).

Vitrectomy is used in the surgical treatment of many retinal diseases. The first of these is the treatment of retinal detachment, which develops as a result of a ruptured retina.  It is not possible to restore the patient's vision without performing vitrectomy – vitreoretinal surgery, especially in cases with large ruptures, caused by a large number of tears, or when the patient is late in applying a physician ( pictures 9.1, 9.2 ).

Diabetes is observed in approximately 14% of the adult population in Türkiye. This naturally makes diabetes a highly important social problem. Although diabetes itself and the complications caused by it in the eye are treated better with each passing day, in some cases, the only way to treat severe bleeding and more severe complications caused by the disease in the eye is vitrectomy ( pictures 10.1, 10.2 ). Very thin scissors and pliers are used to remove the newly formed membranes from the delicate retinal tissue inside the eye ( pictures 11.1, 11.2, 11.3 ).

With the development of diagnostic methods, the diagnosis of a number of diseases, the cause of which cannot be determined exactly, can be easily made today. One of the most important of these is a device called optical coherence tomography. Thanks to this device, it is possible to detect almost transparent, very thin ( 5 – 8 microns ) membrane formations that lead to a decrease in vision related to the sensitive visual region of the eye. With vitrectomy surgery, these membranes are removed and damage to the yellow spot ( macula ) is prevented ( pictures 12.1, 12.2 ). Sometimes it is observed that these membranes lead to the formation of holes in the yellow spot ( macular hole ). Again, in this case, vitrectomy and peeling of the membranes on the surface of the retina, filling the eyeball with a tamponade gas can prevent the patient's vision loss.

In case of eye injuries and foreign body penetration into the eye, the integrity of the eye is ensured first. Then, with vitrectomy surgery, the foreign body in the eye, if any, is removed and the damage caused in the eye is repaired ( picture 13 ). The resulting intraocular hemorrhage is eliminated, the membranes that may have formed are peeled off, laser is applied to reattach the retinal tissues to their place. In such cases, internal tamponade and silicone oil are often resorted to.

Vitrectomy, vitreoretinal surgery in its advanced form, is used in a large number of retinal pathologies, apart from the conditions listed above. As in advanced stages of neonatal retinopathy, as well as in cases where intraocular inflammations do not respond to medication. Advances in technology significantly affect the results of success. The effect of the patient's early access to the physician on the results is unquestionably very important.