COMMON EYE DISORDERS

What is 'dry eyes'?

Dry eyes refers to a condition whereby the moisture and lubrication of the eye(s) is inadequate, leading to surface dryness. It is possibly the most common complaint and is often accompanied by blepharitis (an infection of the lid margin, which needs to be treated also). Proper functioning of the tear system ensures normal moisture and lubrication, which may be disturbed due to several reasons.

What are the symptoms of dry eyes?

  • irritation
  • blurring of vision
  • foreign-body sensation (feels like sand)
  • itching
  • redness
  • light sensitivity
  • excessive watering (over-compensation of dryness)
  • headache

What causes dry eyes?

There can be several reasons for dry eyes, including:

  • anatomical (e.g. tear film quality or quantity, eye lids that do not close fully)
  • environmental (e.g. hot/dry weather, air conditioning, dust, smoke)
  • ocular diseases (e.g. Sjögren's syndrome)
  • systemic illnesses (e.g. diabetes, systemic lupus erythematosus, rheumatoid arthritis, thyroid disorders)
  • contact lens use
  • hormonal changes (menopause, pregnancy, contraceptive pills)
  • excessive screen time (e.g. phone, tablet, laptop)
  • medications (e.g. antihistamines, antidepressants)
  • after eye surgeries (especially laser vision correction)
  • dehydration

How is dry eyes diagnosed?

Dry eyes can be diagnosed at your visit to the ophthalmologist (or in some cases optometrist) by full patient's history and symptoms as well as clinical examination. The most common tests used by ophthalmologists include:

  • fluorescein staining (a drop of dye is placed on the eye, which stains dry areas temporarily)
  • tear break-up time (a drop of fluorescein is placed on the eye and observed under the microscope for the number or seconds it takes for a dry spot to appear in the tear film)
  • Schirmer's test (a small strip of filter paper is placed under your eye lid that collects tears over 5 minutes and is then measured)

How can dry eyes be managed?

There are several methods to manage dry eyes and new ones are continuously being researched due to the commonness of the condition. Some of these options are:

  • eye drops or ointment (artificial tears, preferably preservative-free, in severe cases temporary cortisone drops may be prescribed)
  • punctal plugs (temporary or permanent plugs to close the tear drainage ducts)
  • increased dietary intake of fish oil and Omega-3
  • blinking more often
  • sunglasses or other glasses to protect from the elements (light, wind)
  • increased water intake
  • reduce/break screen-time or reading (20-20-20 rule: every 20 minutes, look at something 20 feet away for 20 seconds)

What is glaucoma?

Glaucoma is a disease that causes damage to the optic nerve and can result in irreversible loss of vision, starting from peripheral vision then central vision. Commonly, though not always, the cause for damage is elevated intraocular pressure (IOP). Although the exact mechanism is still unknown, it is considered to be a fluid exchange issue inside the eye. Glaucoma is the second leading cause of blindness and any vision loss that takes place will be permanent and cannot be recovered, which is why early diagnosis and treatment is essential.

What is considered a high IOP (intraocular pressure)?

 

Each patient and each eye is different and therefore it is difficult to determine a general range for 'normal IOP'. Usually, an IOP between approximately 10-20 mmHg is cited as 'normal' but it is important to note that for some patients even a low or normal IOP can be 'too high' and vice versa for some patients a 'high IOP' may not cause glaucomatous changes. Please note that IOP is different from systemic blood pressure (BP) although there may be a correlation between the two.

What are the symptoms of glaucoma?

Glaucoma is often called "the silent thief of sight" since it can develop without any signs or symptoms until damage has already happened, which cannot be reversed - vision loss is permanent. With very high IOP vision may become blurry. In extreme cases, a dangerously high IOP ("closed-angle glaucoma attack") can lead a patient to the emergency room with complaint of vomiting and stomach pain. Eventually, untreated glaucoma leads to irreversible narrowing of the visual field and loss of vision.

Who is at risk for glaucoma?

There are associations between the glaucoma and the following risk factors:

  • Family history
  • Race (African descent)
  • Systemic hypertension
  • Systemic hypotension (especially at night time)
  • Steroid use
  • High myopia
  • Hyperopia (due to small dimensions of the eye)

 

Can glaucoma be prevented?

Although it may not be possible to prevent glaucoma entirely, the following have been linked to better eye health and reduced IOP:

  • Healthy diet
  • Exercise - 40 minutes of walking 4 times per week can significantly reduce IOP
  • Reduce/avoid stress
  • Quit smoking

 

How is glaucoma diagnosed?

Since elevated IOP is a common factor for glaucomatous changes, the first check is a simple IOP measurement. As mentioned before, however, an IOP measurement is not the only indication because of individual differences and the complex nature of glaucoma. A thorough ophthalmological examination by your ophthalmologist should be done, including the optic nerve as well as any anatomical irregularities. It is advised to have your IOP checked even if you do not belong to any of the risk groups due to the "silent" nature of development. If glaucoma suspicion is raised, further evaluation will be advised accordingly. Please note that glaucoma can develop from a young age.

At Finland Eye Center, we have the tools to diagnose and follow-up glaucoma, including:

  • IOP measurement
  • Pachymetry (corneal thickness)
  • Gonioscopy
  • Optic disc assessment (OCT, fundoscopy)
  • Visual field investigation
  • Full ophthalmological examination

 

How can glaucoma be treated?

There are several options for glaucoma treatment from medication to surgery, depending on the patient's condition and circumstances. The aim of glaucoma treatment is to lower IOP, usually by a 20% reduction at least. At Finland Eye Center, we offer a range of options:

  • Lifelong medication (eye drops or tablets)
  • ExPress tube - FEC proudly offers this surgical technique as the first in Oman
  • Laser (different from vision correction)
  • Trabeculectomy
  • Iridectomy
  • Drainage valves

 

Your ophthalmologist will discuss your treatment options with you and decide on the most appropriate method for your individual needs. In general, medication (eye drops or tablets) used to be the first line of treatment. It is a non-invasive option to reduce IOP. However, it must be understood that glaucoma medication is a daily medication that needs to be continued for the rest of your life with regular follow-up to ensure appropriate dosage. Currently, the trend is moving towards surgical options earlier, which offer long-term results without daily concerns or compliance issues (i.e. patients who do not use their medications as prescribed). For example, the latest surgical technique is the ExPress tube - a mini shunt placed in the eye for drainage - which was brought to Oman first by FEC. For patients needing both cataract surgery and glaucoma surgery, a combination procedure can be done in one session.

Note: If glaucoma has advanced too far, vision loss and blindness can occur regardless of treatment due to the previously mentioned irreversibility of glaucomatous changes. In such cases, any treatment would be ineffective.

What are the risks and side effects of treatment?

Lifelong glaucoma medication may cause dry eyes, foreign body sensation, redness, itching, or allergy. Changes in iris colour towards more brown (even in blue-eyed patients) and strengthening of eye lashes is common. Shortness of breath can occur, which can worsen asthma or lead to an asthma attack (in patients who are asthmatic). Rarely, systemic effects are possible such as bradycardia or irregular heartbeat. Glaucoma medication must be used as prescribed with regular follow-up. If the IOP does not reduce to an acceptable level with medication, surgical options will be considered.

As with all surgeries, glaucoma surgeries carry risks and side effects from anaesthesia to intra-operative complications and post-operative recovery. Your anaesthesiologist will examine you and decide the best anesthesia option for you (local, general) based on your health status. Should circumstances arise during surgery, which require immediate decisions, your surgeon has the right to change the surgical plan intra-operatively for the best of the patient. Post-operative risks include temporary blurred vision, foreign body sensation, redness, infections (immediate or late), and temporary vision reduction (should improve within a few weeks). Follow-up is essential to monitor and remove sutures and treat any post-operative complications as soon as possible. In some cases, the healing of tissues is 'too fast' and revision of the surgery site may be needed. It is possible that the chosen method proves ineffective at reducing the IOP to an acceptable level despite successful surgery. In these situations further treatment may be needed (simultaneous medication, further surgeries).

Note: Glaucoma diagnosis, treatment and follow-up involve many steps. Each of these steps requires care and co-operation from all involved. While all effort is made to ensure successful surgery (should surgery be decided), it is important to make an informed decision, before signing the consent form.

Through the following information guide, Finland Eye Center would like to explain to you the benefits and potential risks associated with pterygium surgery.

Before consent, kindly read the following:

Pterygium excision surgery is an outpatient surgery that is relatively safe, and usually performed upon patient request when it becomes cosmetically bothersome or it causes persistent discomfort. Occasionally, it may become large enough to threaten vision. At Finland Eye Center, we can perform the excision under local anaesthesia with many techniques, depending on doctor's plan, such as bare sclera technique, autograft, rotation flap technique, mitomycin technique or with amniotic membrane graft.

As with any surgery, you should understand that risks and side effects are possible. These include irritation, burning, prolonged redness, the need for prolonged use of lubricant eye drops and sunglasses, and recurrence of the pterygium, which may need re-operation.

Serious complications like infections, eye perforation or restrictive eye movement are extremely rare.

Finland Eye Center will provide the patient with treatment for the first week and follow-up visit for the next 3 months. If further procedures are needed, additional charges may apply.

As with any surgery, you should understand that risks and side effects are possible. These include irritation, burning, prolonged redness, the need for prolonged use of lubricant eye drops and sunglasses, and recurrence of the pterygium, which may need re-operation.

Serious complications like infections, eye perforation or restrictive eye movement are extremely rare.
 

Finland Eye Center will provide the patient with treatment for the first week and follow-up visit for the next 3 months. If further procedures are needed, additional charges may apply.

What is squint (strabismus)?

Squint (also known as strabismus) is a misalignment of the eyes that arises due to an imbalance of the muscles that move the eyes, faulty nerve signals to those muscles or high uncorrected hyperopia (farsightedness). Most common forms of squint present as horizontal (inward or outward deviation) and vertical (upwards or downwards deviation), as well as more complex forms. Squint can be apparent all day or only at times such as when tired.

Squint can technically occur at any age. A baby can be born with a squint or develop one soon after birth. Most commonly, squint develops early on but it is possible for a teenager or an adult to develop the condition as well. Other conditions such as accidents and tumours can lead to squint also.

Why is squint a problem?

When the eyes are misaligned, they send two different images to the brain. A child can ignore one of those images but this can lead to the eye not developing properly and causing amblyopia, or lazy eye. An adult with misaligned eyes, however, will find it difficult to ignore and may see double. This can become not only frustrating but potentially hazardous in situations such as traffic.

Especially for children, it is important to seek professional advice quickly as proper visual alignment is important for depth perception, good vision and to avoid double vision, amblyopia and head tilts. Many children with squints have poor vision in the affected eye and the sooner treatment is started the better the results.

What are the treatment options for squint?

The first part is a thorough examination and evaluation of the squint. Depending on the age of the patient, different methods are available with the aim to restore or preserve vision, realign the eyes and finally to restore binocular vision if possible. Glasses, occlusion therapy in children (covering the 'good' eye and forcing the lazy eye to work), and surgical intervention are options for treating squint. The key to non-surgical options is co-operation between the patient and doctor and especially the family of a young patient. It should be noted that squint will very rarely resolve itself without treatment i.e. a child will usually not 'grow out of it'. Squint surgery is an option for cosmetic reasons as well. A squint specialist determines the timing of surgical intervention.

How is squint surgery done?

Squint surgery involves a carefully planned recession or resection (or a combination) of relevant muscles depending on the type and degree of squint to allow the muscles to work more physiologically. The surgeon, based on pre-operative assessments and calculations, operates individual muscles surrounding the eye to shorten, loosen or reposition the muscle(s), thus allowing the eyes to move in unison. Fixed or adjustable sutures can be used; adjustable ones allowing the surgeon to fine-tune the result within a day or so if needed. Depending on the surgeon's decision, one or both eyes can be operated either under local or general anaesthesia. For children or babies general anaesthesia is necessary.

What are the results, risks and side-effects?

As with all procedures, results may vary and risks and side effects exist.

Redness will be noted after squint surgery but this will clear with time. Itchiness, foreign-body sensation (usually due to sutures, which will be removed within a few weeks) and some discomfort are likely to be experienced but should resolve in a short time and can be alleviated with drops or sometimes oral painkillers. Itching and rubbing should be avoided. Double vision is also possible at the beginning but should resolve soon. Prescribed medications (eye drops or oral medications) must be used as advised to ensure safe, infection-free recovery.

Normal vision activities (such as reading) can and should be resumed as soon as possible to get the eyes working. For children, playing with sand, face paints etc. should be avoided for at least 2 weeks and care should be taken to avoid any product getting into the eyes. Swimming should be avoided for at least 1 month. For adults, driving permission will be given by your ophthalmologist when appropriate.

It is possible that further surgeries are needed to attain the best possible result, especially if the surgery is performed on a very young patient. Intra-operative complications are possible though rare and do not usually risk visual acuity (such as sclera tearing or incorrect muscles being operated). Eye globe perforation is extremely rare. Post-operative complications include slipped muscle/loose sutures, which require re-suturing, and infections, which are likely avoidable with proper use of medications and aftercare.

If recommendations are made for glasses and/or patching treatment after surgery, make sure they are followed as this will be essential especially for normal eye development in youngsters. If an eye is already amblyopic, squint surgery is likely not to improve the visual acuity. Parental co-operation with child patients is essential especially with post-operative care to avoid infections and encourage glass-use to attain best rehabilitation. Regular follow-ups are necessary.

Note: Squint surgery involves many steps from pre-operative examination to anaesthesia, squint surgery itself to post-operative care and follow-up. Each of these steps requires care and co-operation from all involved. While all effort is made to ensure successful surgery, it is important to make an informed decision, before signing the consent form.

What is diabetic retinopathy?

Diabetes (both Type I and Type II) can lead to a multitude of complications, including often forgotten eye-related complications, which are significant. One of the main ways in which diabetes can affect the eyes is diabetic retinopathy. This condition includes all manners of retinal disorders related to diabetes. The retina – the light-sensitive inner lining at the back of the eye – begins to deteriorate as the fine network of blood vessels is damaged leading to scarring of the retinal tissue, blocked vessels, growth of new fragile vessels, leaks, and swelling. Eventually these begin to impair vision.

Diabetic retinopathy vs. diabetic maculopathy

It should be noted that in general, the term used to encompass all retinal conditions related to diabetes is 'diabetic retinopathy'. However, diabetic conditions specifically affecting the macula – the central part of the retina, which is responsible for sharp vision – are officially referred to as 'diabetic maculopathy'. Diabetic maculopathy can be divided into the subtypes of oedematous (accumulation of fluids and exudates in the macular region) and ischaemic (occlusion of macular blood vessels).

What are the symptoms of diabetic retinopathy?

Worryingly, early changes in the retinal functioning may not cause noticeable symptoms for the patient. Due to this, it is imperative that anyone diagnosed with either type of diabetes have regular eye checks (yearly usually) to detect and diagnose changes at the earliest possible stage and initiate treatment when appropriate. Once the symptoms appear, they include blurred vision, sudden loss of vision, floaters in your vision, or missing/dark patches on images.

What are the stages of diabetic retinopathy/maculopathy?

Diabetic retinopathy is a progressive condition, which can be broadly classified into the following stages:

  • Background retinopathy
  • Non-proliferative retinopathy
  • Proliferative retinopathy
  • Oedematous maculopathy
  • Ischaemic maculopathy

What causes vision loss in diabetic retinopathy?

There are two main triggers for vision loss in this condition; macular oedema and neovascularization. Macular oedema occurs when fluid and blood leaks from microaneurysms in the network of vessels. These leaks can cause swelling in the macula, which is responsible for sharp and colour vision. Neovascularization occurs when signals are sent from the retina to start growing new blood vessels to replace damaged vessels. Unfortunately, these new vessels are very fragile and have thin walls, which can leak blood and cause severe vision loss as well as lead to scarring that can pull the retina away from the back of your eye.

Who is at risk of diabetic retinopathy?

Anyone with either type of diabetes is at risk of developing diabetic retinopathy. The severity or progression of the condition can vary from one diabetic to the next, but the longer you are diabetic, the higher the risk becomes. High blood pressure and elevated cholesterol levels can exacerbate the condition, so beware and make sure your eyes are checked regularly. If you are diabetic and are or become pregnant, you should have a comprehensive dilated ophthalmological examination as soon as possible and follow the guidelines and possible further evaluations recommended by your ophthalmologist.

How is diabetic retinopathy diagnosed?

Diagnosis can be done only by an ophthalmologist during a complete ophthalmological examination. Finland Eye Center offers a 'Diabetic Retinopathy Assessment Package', which includes the following:

  • Complete ophthalmological examination
  • Optical coherence tomography (OCT) test
  • Fundus fluorescein angiography (FFA) examination

Finland Eye Center is equipped with a fully functioning laboratory for all laboratory investigations including blood sugar level tests.

How can diabetic retinopathy be managed?

Strict control of blood sugar, blood pressure and blood cholesterol – to reduce the risk factors – is essential. Depending on the severity and progressional trajectory of your diabetic retinopathy, several options are available at Finland Eye Center to manage the condition.

  • Regular eye examinations – to detect issues as early as possible
  • Intravitreal Anti-VEGF injections, which are administered as an injection inside the eye to bind to and remove excess growth factor (causing new vessels to grow) from the eye
  • Intraocular steroid injection – to reduce the amount of fluid leaking into the retina
  • Laser treatment –to treat macular oedema and to reduce the growth of abnormal new vessels
  • Vitrectomy – usually for advanced proliferative diabetic retinopathy, to remove gel-like substance from your eye to reduce the pull on the retina and/or to remove blood that has leaked and is disturbing your vision

Your ophthalmologist will inform and advise you of the best option (or combination of options) for your situation. It is important to understand that treatment may need to be repeated and that curing the condition is not possible as the risk of new bleeding always exists since diabetes is a chronic disease.