Corneal Disease Treatment

Keratoconus

In keratoconus, there is thinning of the cornea which later bulges out. It gradually acquires the shape of a cone.

The patient usually present with blurry vision which gradually worsens without treatment. There is increased sensitivity to light and glare at night which causes difficulty in driving. There may be frequent a change of glasses. Patient may have recurrent episodes of sudden cloudy and decreased vision (ACUTE HYDROPS)

The patient need to see an ophthalmologist at the earliest. A detailed ocular examination with refraction and corneal imaging is performed.

Initial treatment comprises of prescribing contact lenses especially rigid contact lenses and regular follow up.

In more advanced cases, a technique of COLLAGEN CROSS LINKING (C3R) is performed. In this, ultraviolet light and a photosensitizer is used to strengthen the covalent bonds in the cornea. This reinforces the weak cornea and halts the progression of the disease. This procedure is done by giving anesthetic drops and is usually completed within 1 hour. Thereafter, bandage contact lens is applied. Since, it is an OPD procedure, patient is then sent home. The treated eye experiences some pain for 3 to 5 days. It takes usually 1 week to recover, though it may be prolonged in some cases.

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Collagen cross linking is a very successful treatment with the success rate of 95%. In the remaining 5% patients, where there may be progression, second sitting may be required.

The cost of a single sitting of collagen cross linking in India is 1200-1500 USD.

Another mode of treatment in Keratoconus is placement of intracorneal rings (INTACS). They are thin, plastic semi circular rings which are placed in the mid layer of cornea. They basically flatten the cornea and change the location and shape of the cone. They are basically preferred in mild and moderate keratoconus who are intolerant to contact lens. They may be offered as an alternative to keratoplasty for visual rehabilitation especially with clear optical zone. However they cannot halt the progression of the disease. The procedure is performed as a day care under local anesthesia. Regular follow up with corneal imaging is done to monitor the disease. The cost of INTACS in India for one eye is around 1500 – 2000 USD.

Also, if the need be, then INTACS can be safely removed from the eye.

OCCULOPLASTY

PTOSIS

Ptosis is the condition in which there is drooping of the upper lid. This drooping may be mild or it may be so severe that the upper lid may completely cover the pupil and affect vision.

The cause of ptosis can be congenital, paralytic and other neurological causes, after injury, muscular causes.

When ptosis affects one eye , it is known as unilateral and when it affects both the eyes then it is known as bilateral ptosis. It may present in newborn babies as well as old individuals.

Children with ptosis can have multiple problems. They need to elevate their eyebrows, lift their chin and neck to see. This may cause problems in the neck muscles. Also if the ptosis is very severe, then the children may have problem in vision and may have low vision in the affected eye ( amblyopia). A child with ptosis may have other abnormalities like squint ( cross eye), eye muscle related problems, tumours or other problems.

Ptosis in adults can be due to separation of levator muscle from its attachment or injury to it or after certain surgeries or due to neurologic causes , tumours etc.

In both the cases a consultation from an ophthalmologist is must. The cause of ptosis will be ascertained by the doctor and thorough eye examination will be performed. Also, relevant blood tests and imaging tests might need to be conducted.

PTOSIS SURGERY IN CHILDREN.

The factors determining the type of Ptosis surgery are –

The amount of ptosis
Unilateral or bilateral
Whether able to close the eyes properly
The height of the eyelid
The strength of the eyelid’s muscle
Eye movements

If the child has squint then that needs to be treated first. The surgeries recommended are

Either tightening of Levator muscle by performing Levator resection

Or attaching the eyelid to other muscles that can lift it. (Frontalis sling surgery)

If the child has amblyopia , that needs to be treated by patching the other eye. A regular and good follow up is needed in ptosis patients.

ADULT PTOSIS SURGERY – the cause of ptosis needs to be ascertained in adults first and the management mainly depends on the cause. Ptosis surgery in adults is usually an outpatient procedure and performed under local anesthesia. The surgery mainly comprises of reattaching or tightening the Levator muscle of the eyelid.

Usually after surgery there is some swelling and mild pain in the operated lid which is taken care of by oral NSAIDS. The usual recovery time is around 1 to 2 months.

Usually the ptosis correction is permanent , however rarely ptosis can recur after surgery in some cases and re surgery may be required.

The cost of ptosis surgery in India is around 1500-2500 USD

SQUINT SURGERY

Squint is the condition in which there is misalignment of the eyeball. One eye is either rotated inwards, outwards, upwards or downwards.

It can either be constant or intermittent.

It can affect any age group from child to an old person and the cause has to be found out.

In a child ,early diagnosis is very important as because of squint the child is not able to look at one point from both the eyes simultaneously. This leads to loss of depth perception.

Also presence of a constant squint can lead to development of Amblyopia which if not treated can lead to permanent decrease in vision in the affected eye.

You need to consult an ophthalmologist for the squint who will do a detailed ophthalmologic examination including refraction. Refractive error and amblyopia always need to be treated before squint surgery.

Some kinds of squints improve dramatically after correction of refractive error and for them, the child is prescribed glasses.

In other kinds of squint surgery may be needed.

The type of surgery depends on the type of the squint.

For adults, it is usually an outpatient procedure performed as a day care surgery.

The squint surgery usually involves tightening certain muscle or weakening others.

Even after squint surgery has been performed, sometimes, the squint doesn’t resolve completely.

Also, squint surgery does improve not vision. If squint has developed due to loss of vision in one eye then even after performing squint surgery (cosmetic squint surgery) and correcting the squint, the eye may again develop squint after some time.

Even after surgery, regular use of glasses may be needed and regular follow up should be done meticulously.

The cost of squint surgery in India is around 1500-2000 USD.

OCULAR TUMOURS

Retinoblastoma – is a rare malignant tumour which arises from the immature cells of the retina.

Usually seen in children, usually less than 7 years of age, however may affect elders also rarely.

It may affect one eye (unilateral) or both the eyes ( bilateral).

It may also be transmitted genetically and may affect siblings, though rarely. Hereditary retinoblastoma is passed from the parent to offspring in autosomal dominant fashion which means that if any one parent has the abnormal gene then it has 50% chances of occurring in children. Also it occurs at an earlier age.

The most common presenting feature is white reflex in the center of the black part of the eye .( LEUCOCORIA)

It may also present as cross eye ( SQUINT), painful red eye, with rapidly progressive forward protrusion of the eye ( PROPTOSIS)

Any of these abnormalities indicate an urgent consultation by an ophthalmologist. A detailed ophthalmoscopic examination and relevant investigations are carried out. Examination by RET CAM, ultrasound, MRI to see the detailed view of the tumor and its extension into the brain, PET scan to look for metastasis will be required.

An aggressive treatment approach is followed these days with more emphasis to preserve the eye. Small , local tumours which have not gone beyond the eye are treated by cryotherapy ( treatment with cold), thermotherapy, laser photocoagulation or plaque Brachytherapy ( localized radiation given to the tumour).

For larger tumours chemotherapy followed by surgery ( which may involve removal of the affected eye) and external beam radiotherapy is usually done.

Sometimes, there are recurrences of the tumour despite aggressive management. Also some secondary form of cancers like Osteosarcoma may occur years after treatment with radiotherapy.

A very regular follow up is needed along with periodic investigations to rule out recurrences after the treatment. Also, rehabilitation is carried out after the eyeball has been removed by giving prosthesis to the child.

The cost of Retinoblastoma treatment depends on the mode of treatment received , brachytherapy, radiotherapy, chemotherapy or surgery, or further reconstruction surgery if performed. The cost of retinoblastoma treatment in India is much lower than the UK & the USA and other pioneer countries dealing in medical tourism.

Other ocular tumors –

Other ocular tumors like Rhabdomyosarcoma , Choroidal Melanoma , Lacrimal Gland malignancies can also be treated by a multimodality treatment approach comprising of extensive imaging, biopsy, chemo reduction , surgery and radiotherapy. Rhabdomyosarcoma is the tumor of children. Choroidal melanoma and lacrimal gland malignancies affect the adult, particularly middle age and elderly population. This is being performed at many hospitals of India with treatment options being considerably cheaper than the US ,UK and other pioneer countries.