New-Age Eye Care

Specialist charts treatment advances for common eye conditions.

Eyesight is precious, so when it’s threatened, people promptly seek answers that solve the problems. Two common eye conditions that can negatively affect vision are glaucoma and cataracts. In recent years, there have been technological advances in treatment for both disorders that increase surgical precision and improve outcomes.

Dr. Ana-Maria Oliva talks about cataracts and glaucoma and the advancements in treating them, including the iStent inject® device for glaucoma.

Ana-Maria Oliva, MD

The National Institutes of Health (NIH) report that about 2.3 million Americans suffer from glaucoma, which is the second leading cause of blindness in the world. The NIH estimates that another two million Americans have the disease but don’t know it. Glaucoma is an insidious disease that causes damage to the sensitive optic nerve, leading to a gradual loss of sight.

“Glaucoma is a disease in which the pressure in the eye is elevated, and as a result, patients can lose their peripheral vision,” describes Ana-Maria Oliva, MD, a board-certified ophthalmologist at Florida Eye Specialists & Cataract Institute’s Brandon and Sun City locations.

“In some cases, patients don’t realize increases in pressure and glaucoma are occurring until they ultimately lose central vision. By that time, it’s typically too late. This loss of vision can lead to blindness. The only way to accurately diagnose glaucoma in its early stages is by seeing an eye care professional who can test the eye pressure, optic nerve and visual field.”

There are different types of glaucoma, including open-angle glaucoma, also called wide-angle glaucoma. This is the most common type and represents about 90 percent of cases in the US. Other, less common types include closed-angle glaucoma, normal-tension glaucoma, congenital glaucoma and secondary glaucoma.

“With open-angle glaucoma, the pressure builds up in the eye when there’s a back-up of the eye’s natural fluid,” explains Dr. Oliva. “This fluid, which is called the aqueous humor, flows between and nourishes the lens and cornea. It then drains into the bloodstream through a honeycomb of channels called the trabecular meshwork. This drainage system allows the pressure to maintain a certain level.

“When the aqueous is unable to drain or drains too slowly, there’s a build-up of fluid in the eye. Too much fluid increases the pressure in the eye, which can then damage the optic nerve and affect vision.”

Closed-angle glaucoma, also called narrow-angle glaucoma, occurs when there’s a blockage in the eye, causing a sudden rise in eye pressure. Closed-angle glaucoma is an emergency and requires immediate medical attention to prevent permanent damage to the optic nerve and vision loss.

The cause of normal-tension glaucoma is not completely understood, but is thought to be related to reduced blood flow to the optic nerve. Congenital glaucoma is hereditary and is often diagnosed in very young children. It results when the eye does not form properly during development. Secondary glaucoma is the result of another condition, such as diabetes.

Diminutive Device

Traditionally, the primary treatment for glaucoma has been pressure-lowering medications. These include drops that are placed directly into the eyes.

“There are several classes of medications that can be used, and we typically try them before we move on to another level of treatment,” reports Dr. Oliva. “There are also lasers that can be used and surgeries to reduce pressure to healthier levels.

“The latest in the treatment of glaucoma is microinvasive glaucoma surgery, or MIGS. That’s a procedure we are actually able to perform during cataract surgery. Twenty percent of the population that has cataract surgery also has mild to moderate glaucoma.”Dr. Ana-Maria Oliva talks about cataracts and glaucoma and the advancements in treating them, including the iStent inject® device for glaucoma.

MIGS is done while the patient is already in the operating suite and prepped for surgery. It is performed immediately following the cataract surgery, after the replacement lens is implanted, and takes less than five minutes to complete.

A new device is used during MIGS called the iStent inject®. The iStent inject is used in adults with mild to moderate open-angle glaucoma as well as cataracts who are currently using glaucoma medication. The iStent inject creates new pathways in the drainage system for better aqueous flow out of the eye.

“The iStent inject uses two small stents, whereas before, we only inserted one stent,” relates Dr. Oliva. “With two, there’s even more pressure reduction.

“During MIGS, I place the two stents into the trabecular meshwork. They help to bypass the standard mechanism of outflow and allow for better flow of the aqueous. This helps it to drain out more readily, which decreases the amount of fluid in the eye and, therefore, eye pressure.”

The iStent inject is tiny. It’s the smallest medical device known to be implanted into the human body. It’s about the size of a third of a grain of rice. Once the stents are placed, they can’t be seen or felt. They are made of titanium, so they are MRI-compatible.

Studies done on the iStent inject show it reduces eye pressure seven points, or seven millimeters of mercury. What’s considered high varies per patient, but physicians typically begin investigating when eye pressure reaches 20 points.

“The iStent inject has been shown to stabilize eye pressure in the long term, as well,” notes Dr. Oliva. “In one study, patients’ pressures remained at the level of their initial drop three years post-surgery.”

Glaucoma patients have traditionally been committed to a lifetime of eye drops, which can be difficult to take long term because issues with compliance are significant. Older patients sometimes have difficulty remembering to take the drops. The iStent inject is a major advantage for people with glaucoma, as it can potentially reduce or eliminate eye drop medications.

“This result of MIGS with iStent inject is a huge benefit for our patients,” says Dr. Oliva. “It can eliminate issues of compliance with medication. Studies have shown that one year after surgery, patients were still able to eliminate one to two eye drop medications from their glaucoma treatment plan.”

Clearing Cloudy Vision

There’s no escaping it. Everyone develops cataracts as a natural part of the aging process. While not everyone is troubled enough by symptoms to seek treatment, all adults should be aware of the nature and course of this common disorder, which, if not treated, can slowly steal their clear, crisp vision.

“Cataracts are a clouding of the clear lens in the eye that leads to a progressive loss of vision,” informs Dr. Oliva. “All light entering the eye passes through the lens, which is made mostly of water and protein.

“As a person ages, the proteins can begin to clump together, and the lens becomes cloudy. This clump can grow larger over time, eventually interfering with the light reaching the retina and, ultimately, the sharpness of vision.”

People with cataracts might experience murky or blurry vision. They might notice more glare than usual, especially at night, with halos or starbursts around car headlights and lamps. Colors may seem faded or have a yellowish or brownish tint to them. Reading may become more difficult, as it becomes harder to distinguish the contrast between the letters on the page and the background. Frequent prescription changes to eyeglasses or contact lenses might also signal the presence of cataracts.

“The only treatment that provides a cure for cataracts is surgery,” discloses Dr. Oliva. “Cataract surgery is one of the safest, most predictable surgeries, but any surgery has minimal risks. Cataract surgery is a totally elective procedure.

“Once I give the patient all of the information about the surgery and its potential risks, including infection, bleeding and swelling, as well as my recommendation, he or she can then make an informed decision. But, ultimately, it’s always the patient’s choice.”

Once a patient has decided to have cataract surgery, the patient and doctor discuss the patient’s desires and expectations for their vision following surgery. This helps in determining the appropriate type of replacement lens to use.

“During cataract surgery, the doctor removes the cloudy, natural lens and replaces it with a clear, replacement lens,” educates Dr. Oliva. “There are several types of replacement lenses available.

“The most commonly used monofocal lens corrects for one focal range, which is typically the distance vision. This results in excellent vision for driving and most daily activities, but people may require reading glasses for very small print. One of the ways of getting around that is the monovision approach, where the doctor corrects one eye for distance and one eye for reading.

“Then there’s the Toric lens, which is made to also correct corneal astigmatism, which causes blurry vision,” she continues. “Additionally, there are multifocal lenses available that can help the patient be less dependent on glasses after cataract surgery. Multifocal lenses provide a range of vision, correcting, to a degree, for far, intermediate and reading distances.”

Laser Precision

Surgery is an art form, and surgeons spend years perfecting their techniques. Surgeons, like all artists, are always striving to improve upon their craft. For the surgeons at Florida Eye Specialists & Cataract Institute, advancing with new technology is one way they refine their creative skills.

An example of this advancement is the LENSAR® Laser System for use during cataract surgery. LENSAR is on the leading edge in femtosecond laser technology. Its added functions and precise laser incisions enable surgeons to remove the cataracts with increased safety and position the replacement lenses with greater accuracy. These innovations lead to better vision following surgery.

The LENSAR automates certain aspects of cataract surgery that were traditionally done by hand. The surgery is more efficient, more effective and safer as a result.

“The laser makes the initial incision into the eye,” offers Dr. Oliva. “It can also create the capsulotomy, which is an opening into the thin, fragile membrane that holds the cataract, and it does so with exceptional precision.

“A capsulotomy done by hand can be less than perfect. The importance of having a perfect capsulotomy is that the replacement lens can then sit in a more optimal position, which ultimately gives the patient better vision.”

The LENSAR is useful in other ways, as well.

“To correct astigmatism, we make what are called limbal relaxing incisions, which are tiny cuts in the cornea to reshape it,” describes Dr. Oliva. “The corneal reshaping done by the LENSAR can reduce astigmatism and help people see more clearly after surgery.”

Dr. Ana-Maria Oliva talks about cataracts and glaucoma and the advancements in treating them, including the iStent inject® device for glaucoma.

“The iStent inject has been shown to stabilize eye pressure in the long term.” – Dr. Oliva

The LENSAR imaging platform, Augmented Reality™, enables the surgeon to view the inside of the eye in great detail. After imaging the eye in high resolution, it creates a 3-D reconstruction of the lens, allowing the surgeon to tailor the surgery to the patient.

Toric Technology

Another advancement to the femtosecond laser at Florida Eye Specialists & Cataract Institute enables even more precise placement of replacement lenses following cataract removal. This innovation is specifically designed for use with Toric lenses.

“Using this technology, doctors are now able to put markings on the actual capsule, the thin, clear membrane that covers the natural lens, to better align the Toric lens,” states Dr. Oliva. “This provides even more precise placement of the lens for correcting the astigmatism.”

Dr. Oliva points out that the laser performs the most crucial portions of the surgery within seconds with the click of a button, and it does them with unmatched precision. It is a nice adjunct to the surgeon’s skills and expertise.

“Cataract surgery can be life-changing for patients,” she reports. “That’s one of the things I find so satisfying and rewarding about what I do. I’m happy to be able to restore clear sight to patients with such a quick and easy surgery. And as more technology has evolved, we’ve been able to minimize patients’ need for glasses in more and more cases.”

Technology has advanced for the treatment of astigmatism apart from cataract surgery as well. With new technology, doctors are able to perform imaging on the operative eye in the office using corneal topography and use the image as a guide on the day of surgery.

“We take a picture of the eye, then superimpose it on the eye during surgery and apply our measurements that way,” observes Dr. Oliva. “When patients lie down, their eyes rotate, but using this technology, we can adjust for any rotation. This technology enables more precise limbal relaxing incisions to correct the astigmatism.”

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