Institute of Ophthalmology-Clínica Girona (IOC) 
Juli Garreta, 13 2on pis · 17002 Girona
CIF B17356932
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Volume 1198
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Institut d'oftalmologia clínica girona
Refractive surgery
Refractive surgery
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Ocular Adnexa



Ectropion

Ectropion


Definition: Upper or lower eyelid that turns out and away from the eyeball. It is more common in the lower eyelid area being one of the causes of frequent tearing and red eye. It may be due for a traumatic cause or senile involution.

Treatments:
  1. Ectropion Surgery (14)



Entropion

Entropion


Definition: Upper or lower eyelid which is positioned inward. By altering the structure of the eyelid, it can create changes in the corneal area by rubbing eyelashes.

Treataments
1. Temporary: botulinum toxin and ocular lubricants (51)
2. Permanent: Entropion Surgery (15)


Lagophthalmos

Lagophthalmos


Definition: eye defect closure by facial paralysis or eyelid malposition (lower eyelid retraction) or proptosis of the eye.

Treatments:
  1. Temporary: botulinum toxin and ocular lubricants (51)
  2. Lateral tarsal strip, tarsorrhaphy, posterior lamellar graft + Mid Face Lift + tarsal strip, orbital decompression.



Eyelid Trauma, orbital and tear duct.

Eyelid Trauma, orbital and tear duct.


Definition: Eyelid: full or partial thickness laceration of the eyelid affecting or not outside it Orbitary: orbital fracture, orbital contusion. fractura orbitaria, contusión orbitaria. Tear Duct: canalicular laceration, inner side desinsertion, medial wall orbital fracture.
 
Treatments:
  1. Eyelid Repair Suture and/or flaps.
  2. Fracture Repair by orbital prosthesis.
  3. Tear Duct: Suture and canalicular intubation.
  4. Cantal Reintegration.
  5. Medial Wall Fracture Repair..



Blepharospasm

Blepharospasm


Definition: involuntary and repetitive contraction of the primary or secondary eyelids (dry eye)

Treatments:
  1. Botulinum toxin(51)
  2. Myectomy of the orbicularis muscle.
  3. Frontal suspension



Blepharitis

Blepharitis


Definition: it is acute or chronic inflammation of the lid margin creating eyelid hyperemia and a desquamation resulting in itching. Anterior blepharitis affects the outside of the eyelid where the eyelashes are located and posterior blepharitis affects the inner part where the meibonian sebaceous glands that when become infected and clogged, cause styes.

Treatments:
  1. Blepharitis is not contagious and is usually treated with eyelid cleaning and may also be treated with an antibiotic cream.



Eye Tumors (conjuntiva, intraocular, eyelid and orbit)

Eye Tumors (conjuntiva, intraocular, eyelid and orbit)


Definition: benign or malignant tumors affecting the eye or ocular adnexa

Treatments:
  1. Eyelid lumps: excisional biopsy + eyelid flap reconstruction and/or grafts.
  2. If malignancy can be associated with criotherapy, radiotherapy or systemic chemotherapy.
  3. If conjunctival pathology, excisional biopsy associated with topical chemotherapy and/or cryotherapy.
  4. If intraocular malignancy, evisceration or enucleation with orbital implant.(25, 26)
  5. In case of malignant orbital tumor, exenteration.(27)
  6. In cases of malignant tumors may be associated with cryotherapy, diathermy, plaque brachytherapy (ocular melanomas), external beam radiotherapy (orbital tumors), systemic chemotherapy (malignant orbit tumors). (19,20)




Orbit Infections and Inflammations

Orbit Infections and Inflammations


Definition: infection of orbital contents by bacteria, viruses, fungi or parasites; inflammation of the same content by vascular, inflammatory or neoplastic processes.

Treatments:
  1. Systemic antibiotic therapy, systemic corticosteroids, immunomodulators, chemotherapeutics. (51)



Exophthalmos

Exophthalmos


Definition: anterior displacement or protrusion of the eyeball

Treatments:
  1. Orbital Decompression (35)
  2. Eyelid Retraction Surgery (23)



Enophthalmos

Enophthalmos


Definition: Displacement or "retraction" of the eyeball.

Treatments:
  1. Orbital fracture repair with orbit implant, hyaluronic acid injection, fat or substances to increase the orbital contents.



Anophthalmic Cavity

Anophthalmic Cavity


Definition: absence of eyeball because of refractory pain to medical treatment, trauma or malignancy.

Treatments:
  1. Evisceration + Orbital Implant (26, 29)
  2. Enucleation + Orbital Implant (25, 29)
  3. Orbital Exenteration (27)
  4. Cul-de-Sac Reconstruction, dermograso graft, pericraneal graft, (30)

Anterior Segment



Dry Eye

Dry Eye


Definition: It is a multifactorial disease of the ocular surface that causes discomfort with sensation of grit, burning, itching, etc secondary to tear film instability with potential damage to the ocular surface. Altering the tear may be by fast evaporation or production deficit (being characteristic of Sjögren's syndrome).

Treatments:  
  1. A personalized treatment is applied depending on the cause and severity of dry eye. The treatment is medical with topical lubricants, anti-inflammatories, autologous serum..and in some severe cases oral treatment (tablets) is also given.(51)



Conjunctivitis

Conjunctivitis


Definition: Inflammation of the conjunctiva, mucous membrane that covers the white part of the eye (sclera) and the inside of the eyelids.This inflammation can be due to various causes, being the most frequent: infections (bacterial or viral conjunctivitis) and allergic (allergic conjunctivitis).

Treatments:
  1. Doctor, administering eye drops with anti-inflammatories, antibiotics or antihistamines depending on the cause and severity. (51)



Pinguecula / Pterygium

Pinguecula / Pterygium


Definition: Pinguecula is a conjunctival benign tumor related to the exposure to the sunlight. If it grows and affects the corneal surface, it is called pterygium and can cause astigmatism and affect the visual axis.

Treatments:
  1. Pterygium surgery with conjunctival autograft (4)



Keratoconus

Keratoconus


Definition: Progressive pumping (ectasia) of the cornea that typically begins in adolescence, causing a progressive loss of vision.

Treatments:
  1. In mild cases with no progression, checks are made or vision is corrected with semi-rigid contact lenses. In cases where the cornea is increasingly deformed, it is necessary further surgery: crosslinking (3a), intrastromal rings (3b) or DALK (3c).



Keratitis

Keratitis


Definition: It is a corneal inflammation. There are several causes, the most common is keratitis caused by dry eye, resulting in minor injuries in the cornea surface layer. It is also common after long sun exposure or severe conjunctivitis.

Treatments:
  1. Requires artificial tears and sometimes is needed to administer anti-inflammatories to improve symptoms. (51)



Corneal Ulcer

Corneal Ulcer


Definition: Wound of the cornea surface layer or layers, causing severe pain. The most common cause is secondary to trauma.

Treatments:
  1. We apply antibiotic and pain treatment. You also need to cover the eye for a few days, to facilitate the regeneration of the epithelium (surface layer of the cornea). (51)




Limbic Deficiency Syndrome

Limbic Deficiency Syndrome


Definition: Stem cells on the periphery of the cornea affectation, which are responsible for the regeneration of the epithelium (most superficial layer of the cornea). This destruction of epithelial stem cells can be congenital (birth) or acquired (by a burn, a conjunctival scarring ...)

Treatments:
  1. In mild cases, treatment is medical (tears and anti-inflammatory eye drops) (51) but in severe cases, it is necessary to resort to partial or total limbal transplantation.



Corneal Opacity

Corneal Opacity


Definition: Scarring (leukoma) in the cornea, causing a decrease in transparency with a consequent loss of visual acuity. It can be due to various causes: viral infections, burns, trauma...

Treatments: 
  1. The treatment is based on the cause. Sometimes improve with medical treatment (anti-inflammatory) (51) but sometimes it is necessary to use corneal surgery (3c, 5, 6, 8)



Corneal guttata

Corneal guttata


Definition: Alteration of the innermost layer of the cornea (endothelium). In severe cases, this endothelial alteration results in a loss of transparency of the cornea (edema) with vision impairment.

Treatments:
  1. Initially medical treatment (anti-inflammatory, anti-edema) is used (51) but if there is no improvent and vision is low, it is necessary to resort to surgery (endothelial transplant (6))



Cataract

Cataract


Definition: The human eye has two lenses that, acting together, focus light on the retina. The outer lens is called Cornea and internal Crystalline. Light rays that penetrate into the eye, first pass through the Cornea and then the Crystalline, to finally reach the retina. From the retina, these light rays are directed to the brain via the optic nerve in the form of electrical impulses. Crystalline is composed of water and protein. Almost everyone experiences, around age of 55-60 years, a progressive agglomeration of proteins. This process causes the lens to change color and go opaque. This clouding of the eye's natural lens (Crystalline) is called Cataract and, rather than a disease, should be considered as a natural process of aging.
Although cataracts can also be inherited or caused by disease, falls or trauma, age-related cataract is by far the most common.

Treatments:
  1. Cataract Surgery (1)

Posterior Segment



Dry AMD

Dry AMD


Definition: Macular degeneration is a age related disease in which central vision (also called "macula") is damaged. A degeneration of the central vision occurs. The macular degeneration is completely asymptomatic in the early and intermediate stages. Advanced forms usually affect central vision, ability to read or recognize the faces of people . There are two types of advanced forms: a) dry or atrophic that has a slow progression b) Wet form that has a very fast evolution.

Treatments:

1. Antiangiogenic Agent Intravitreal Injections for exuding advanced forms. (44)
2. Antioxidants have been shown to slow the progression in some groups of patients (51)




Floaters

Floaters


Definition: Normally they are seen by the presence of a posterior vitreous detachment. Vitreous humor is the gel that fills the eye socket, in myopic patients or with age, the vitreous humor can become more liquid and can be moved, sometimes detaching part of adhesions that bind it to the retina. This movement of the vitreous humor can be considered as a physiological event. Floaters can be seen and sometimes flashes of lightning. Se ven moscas volantes (miodesopsias) y a veces flashes o relàmpagos (photopsia). When a sharp movement of the vitreous humor occurs, with acute presence of floaters, is essential to study the retina, especially the peripheral zone to rule out holes, tears or retinal detachment.

Treatments:
  1. In the presence of floaters, no treatment is recommended, usually the symptoms disappear or decrease with the passage of months. Some severe cases may benefit from a pars plana vitrectomy and removal of floating bodies (9) vitrectomy pars (9).



Diabetic Retinopathy

Diabetic Retinopathy


Definition: It is the most common cause of blindness in young patients. It is characterized by affecting retinal vessels, especially small ones(capillaries) causing them to break or dilate. This causes that the blood does not properly arrive where it should, causing bleeding or serum out of the vessels. At the beginning, the disease is completely asymptomatic. In the long run causes severe visual impairment.

Treatments:
  1. At the beginning of the disease, only is required observation. The laser (37) or intraocular injections (44) may be needed when it starts to affect vision. In very advanced cases intraocular surgery may be required by pars plana vitrectomy. (9).



Macular Hole

Macular Hole


Definition: It consists of a total rupture of the retina layers in the central area of vision. Symptoms include distorted vision of straight lines (metamorphopsias), central vision spot (scotoma) and visual loss.

Treatments:
  1. 1. Macular hole treatment is primarily surgical, through pars plana vitrectomy (9), peeling of the internal limiting membrane and change by intraocular gas. Some cases of macular hole may benefit from intravitreal treatment with Jetrea (Alcon)(44).

 


Epiretinal Membrane or Macular Pucker (????)

Epiretinal Membrane or Macular Pucker (????)


Definition: It is characterized by the presence of abnormal tissue above the retina. It may be secondary as the cause of trauma, laser or tears in the retina, but often the cause is unknown. At the beginning it may be asymptotic, when the disease progresses, produces visual impairment and image distortion.

Treatments:
  1. It is treated by vitrectomy (9) and membrane peeling.




Retinal Vein Occlusion RVO.

Retinal Vein Occlusion RVO.


Definition: It is a disease where in the retina central vein, or in any branch, appears a thrombus and the venous blood can not flow normally. Is often associated with hypertension and also glaucoma has been associated with this disease. It produces central visual loss or loss in a vision field.

Treatments:
  1. The treatments that have proven most effective have been intravitreal injections (44), antiangiogenic agents or sustained release corticosteroids (51).



Retinitis Pigmentosa RP

Retinitis Pigmentosa RP


Definition: It is a progressive degeneration of the retina, usually related to genetic problems, it is characterized by progressive death of photoreceptors, especially rod cells, responsible for night and peripheral vision. The disease causes a loss of peripheral vision (gun-barrel vision) and night blindness.

Treatments:
  1. At present there are no treatments for this disease, control of possible complications or other associated problems such as cataracts or macular edema is recommended. It is also recommended genetic disease assessment.



Glaucoma

Glaucoma


Definition: Acquired Optic Neuropathy characterized by an optic nerve excavation increase that can cause visual field deficits in which the intraocular pressure is the major risk factor.
 
Treatments:
  1. Hypotensive topical or systemic treatment (51)
  2. Argon laser trabeculoplasty (TLA), Selective laser trabeculoplasty Nd: YAG (SLT) (40)
  3. Argon laser Iridoplasty, Laser iridotomy Nd: YAG (39)
  4. Peripheral Iridotomy
  5. Cataract Surgery (1)
  6. Trabeculectomy (11)
  7. Non-penetrating Deep Sclerectomy (12)
  8. Shunts (13)
  9. Cyclodiode, Cyclocryotherapy.




Uveitis

Uveitis


Definition: They are inflammations of the uvea (a structure formed by the iris, ciliary body and choroid). The uveitis group includes a heterogeneous spectrum of pathologies, according to their location and etiology. The main causes of uveitis are diseases that affect the rest of the body, especially infectious and autoimmune diseases. The most common symptoms are pain, decreased visual acuity and sensitivity to light. Uveitis usually requires a multidisciplinary approach, we perform together with internal medicine.

Treatments:
  1. Anterior uveitis is treated with anti-inflammatory eye drops (51)
  2. Noninfectious posterior uveitis is fought with cortisone administered orally or by injections around the eye (51)
  3. Uveitis associated with a chronic process may require the use of immunomodulatory drugs (51)
  4. Surgical intervention may be effective in solving associated complications such as cataracts (1) or glaucoma (affecting the anterior segment) (9*), retinal detachment (4*), vitreous opacity or macular edema (affecting the fundus)

Others



Hyperopia

Hyperopia


Definition
Refractive error caused mainly by a small length of the eye, causing a blurring of the image on the retina. People experience this visual problem in different ways according to age: a young person can compensate or suffer eyestrain, while an older person chan start with problems with near vision, and also at the end suffer difficulties in distant vision.

Treatments: 2a, 2b, 2c, 55


Myopia

Myopia


Definition:
Refractive error mainly caused by a large length of the eye, causing a blurring of the image on the retina. People who experience this defect have far blurred vision and good near vision.

Treatments: 2a, 2b, 2c, 54, 59


Astigmatism

Astigmatism


Definition: Refractive error caused by a non-sphericity of the ocular dioptrics, for example, a difference of curvature between two perpendicular meridians of the cornea. People who experience this defect have distorted vision at all distances. It is usually stable throughout life and can be accompanied by myopia or hyperopia.

Treatments: 2a, 2b, 2c, 52


Amblyopia or “Lazy Eye”

Amblyopia or “Lazy Eye”


Definition: Is the lack of development of vision that is not corrected with glasses. It is important to diagnose to make the first visit with children at 3 years of age, because if treated early, has a solution.

Treatments:

1. Correction of its cause (strabismus, refractive defect ...)
2. Force the lazy eye, preventing the vision of healthy eye.

 


Strabismus

Strabismus


Definition: Eye condition where the optical axes can not be directed to the same object, due to contraction or relaxation of one or more muscles of the eyeball. Each eye looks in a different direction, "twists an eye or both" inward, out, up or down. It can be congenital, from the first months of life to 3-4 years. It can also appear in adulthood.

Treatments:
  1. Glasses if needed. Always checking for refractive error (52,54,55)
  2. Occlusion-glued to the healthy eye (if lazy eye).
  3. Surgery to correct eyes (36)



Diplopia or double vision

Diplopia or double vision


Definition: You see the same image twice in a given visual field. The result of a bad binocular alignment (Strabismus) disappears when you cover one of your eyes. It can be monocular caused by disorders of the anterior segment (cataract, dry eye.)

Treatmentes:
  1. Occlusion
  2. Prismar
  3. Srabismus Surgery (36)



Facial Palsy

Facial Palsy


Definition: Bell's palsy is the most common facial neuropathy. It is manifested by the difficulty of occluding - close the eye (lagophtalmia). It can produce keratopathy, loss of vision.
 
Treatments:
  1. Topical artificial tears at regular intervals day and night with ointment.
  2. Occlusion especially at night, to keep the wet field.
  3. Tarsorrhaphy (23)
  4. Botulinum Toxin (51)
  5. Placing gold pieces on the upper eyelid



Aesthetic Problems and Signs of Aging

Aesthetic Problems and Signs of Aging


Definition: Dermatochalasis or excess of skin, ptosis or drooping eyelids, ptosis cejaa, prolapse of orbital fat or eyelid "bags", marked periocular grooves, periocular wrinkles.

Treatments:
  1. Upper / lower blepharoplasty (34)
  2. Canthoplasty (24)
  3. Ptosis Surgery (16)
  4. Eyebrow Surgery (direct / indirect plasty, coronal lifting / temporary)
  5. Orbital Lipectomy
  6. Botulinum Toxin (51)
  7. Chemical Peels (51)
  8. Fillers.