Institute of Ophthalmology-Clínica Girona (IOC) 
Juli Garreta, 13 2on pis · 17002 Girona
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Institut d'oftalmologia clínica girona
Refractive surgery
Refractive surgery
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SURGICAL TREATMENTS



Cataract Surgery

Cataract Surgery


The only current treatment for cataracts is the removal of the clouded lens and replacing it with a clear intraocular lens of your eye required optical power. To remove the opaque lens, the surgeon uses a technique called phacoemulsification. This technique starts with a microscopic incision that will close by itself and through which instruments are introduced to break softly the cataract and afterwards suck the tiny fragments. Once the surgeon has removed the contents of the crystalline lens respecting its curvature (lens capsule), introduces a foldable intraocular lens placed within the capsular bag that previously housed the crystalline lens.
 
 Crystalline lens surgery, phacoemulsification, is currently a technique:

1. Very quick and painless.
2. Doesn't need general anesthesia. A few drops of anesthetic eye drops are enough.
3. With a fast visual recovery.
 
Current technology in the design and manufacture of intraocular lenses allows, in selected cases, implantation of multifocal lenses i / or toric lenses taking advantadge of the lens extraction surgery.  The Toric Multifocal Intraocular Lenses are designed to allow a vision without glasses both far and near. They are now regarded as one of the safest, most precise and predictable surgery techniques for the treatment of presbyopia or tired eyes. Your ophthalmologist will tell you if they are indicated in your case. 


Refractive Surgery

Refractive Surgery


Techniques to go without glasses or contact lenses.
Next we will detail and explain the most common options, which depend on some variable factors in each person:
1. Defect graduation, its value and time stability
2. Age.
3. Corneal Thickness
4. Diopter Power of the Cornea.
5. Depth of the anterior chamber.
6. Number of corneal endothelial cells.
7. Tear Absence.
8. Existence of cataract or other eye disease or eyelids.
 
Common Defects,
Hyperopia does not increase. It is normal in childhood and usually decreases till the age of  12.
Myopia does not decrease. It increases when the eye grows, and the most common is to do it half diopter per year. A person is stable when during two years or more has not raised the diopter graduation. In high myopia (more than six diopters) the possibility of eye growth beyond two years is higher than in low myopia, and can do so after age of 10-15 years and up to 45 years. Myopia does not increase during pregnancy unless the two conditions coincide, it is rare nowdays because women have children at ages when myopia hardly worsens.
 
Congenital Astigmatism (existing at birth) corresponds to 95% of astigmatism cases and hardly changes during life. When astigmatism changes in a child or adolescent a corneal disease must be seek.
 
Before surgery we measure the value of the refractive error (default graduation) after the patient has been without wearing contact lenses for about five days and put drops of cycloplegic (eye drops that paralyzes the ciliary body of the eye and therefore accommodation ). This makes that the patient looks bad for 12-24 hours after the visit because he/she can not focus properly. The thickness and power of the cornea of a normal person remain stable throughout life.
 
The depth of the anterior chamber gradually decreases with age. The number of endothelial cells of the cornea decreases naturally with age.It also decreases if there is trauma or surgery of the eye. These cells are responsible for maintaining the corneal tissue dehydrated to be transparent. They must be in good condition and have a minimum number in order to implant an intraocular lens although today we can transplant.
 
We measure the amount of tear that occurs and the tear film before LASIK or PRK.
Refractive surgery by definition is done in an eye having myopia or hyperopia or astigmatism or presbyopia but not in any other disease. If you have any defects such as high-pressure, lens opacity or a deformed cornea or too thin one, surgery may be contraindicated.
The visit, to decide whether a person can be intervened with refractive surgery and which technique we may choose, can last one or two hours or even more than one visit may be needed. A well-operated eye rarely causes problems, but because of its high sensitivity and optical precision surgery must be perfect. Pre-operative visit is as important as the surgery itself. We must explain what goal we want to achieve and not promise results that are not real. Patient expectations must be achieved.
To correct the graduation defects we can modify the natural lens of the eye, the cornea (with LASIK or PRK), or add another in the anterior, posterior chamber of the eye (surgery with phakic lenses) or replacing the crystalline lens (Clear Lens Surgery).
 

Laser Surgery LASIK and PRK

We've been doing Lasik Surgery for 20 years. It is the most common surgery worldwide. The term LASIK is an acronym that comes from Laser Assisted in Situ Keratomileusis, and means modification the curve of the anterior surface of the cornea with a laser. Its main objective is to change the diopter of the cornea and focus the image properly on the retina.
Considerations:
  • It is not a reversible process, the removed tissue can not be replaced.
  • Normally we operate both eyes in the same session since 2008.
  • When the laser energy volatilize the molecular bonds of the corneal tissue during surgery you can smell burning, what is normal.
  • If the eye, after surgery, grows, we may need an optical correction for myopia starting again from scratch.  
  • We can treat successfully up to 8 diopters of myopia, 6 of astigmatism and 3 of hyperopia  with the machine we have today. Higher values have more undesirable effects of poor night vision and halos around lights.
  • The number of diopters to treat depends on the thickness and the radius of the cornea and the pupil size in the dark.
  • Years ago we had to re-operate more than 15% of patients because graduation was not sufficiently accurate. Currently only two or three a year. The accuracy has dramatically improved and complications have decreased.
  • During surgery we injure corneal nerves and that produces less tear because of lack of stimulation on the surface. The secondary dry eye usually lasts between one and three months but can be more persistent.
  • We measure the amount of tear with Schirmer test after anesthetic instillation before surgery. We measure the quality of the tear film with the test BUT (Break Up Time, breaking time teardrop). We dye tear with fluorescein and determine how many seconds it takes to break the film.
  • A variation of Lasik is PRK (Photorefractive Keratectomy, removal of corneal tissue with photons with refractive purpose). It is indicated in dystrophies of basal epithelial membrane, superficial opacities or people with high risk of corneal trauma (boxers). It is used the same laser but without the microkeratome. Visual results for two or three months are the same. The recovery is slower.
  • After surgery, therapeutic conctact lenses may be prescribed, you wear them several days without remove them at night and they serve as a reservoir of medication and act as transparent protector.
  • Complications from the microkeratome (a device that cuts the corneal lenticule 90 to 120 microns thick) have also diminished with new models. In some cases of extreme measures of some parameters, we suggest the convenience of using the femtosecond laser although it is a more expensive procedure.
  • The profiles of the optical zone that the current laser forms, are aspherical and optically better, and therefore have less night vision aberrations and are clearer. The refraction stabilization is achieved after two months after surgery.
  • Treatment with anti-inflammatory eyedrops, antibiotics and artificial tears without preservatives is essential to achieve a good result.
  • To prevent displacement of the lenticule, you dont have to rubb the eyes for 6 weeks after surgery.
  • It is essential to wash and perfectly remove makeup before surgery.
  • No one in the laser room can carry perfume, colognes or cosmetics containing alcohol. It evaporates and the laser beam does not reach the cornea to collide with air particles: this means that not all scheduled diopters are corrected
  • It is very important to keep the time of surgical steps to prevent evaporation of water from the cornea. This causes drying and thinning and makes the laser more effective than desired what ends in different results in diopters than expected.
  • During the application of mechanical microkeratome or femtosecond we provoke a suction effect that raises the eye pressure for a few seconds. During this period the patient sees nothing but fully recovers his vision when suction is removed.



Arcuate Incisions:
 
Widely used until twelve years ago, when we were doing a pulse with calibrated diamond scalpels, now returns femtosecond laser for its simplicity and accuracy.  To its credit, with these incisions the visual axis and the optical wide area is not touched. They serve mostly for mixed astigmatism. Lasik devices also treat these astigmatism.
 


 

Surgery with phakic lenses (ICL, Artiflex ...)

Artisan or Artiflex, Ophtec of iridian support, which serve to all refractive defects less presbyopia.




ICL (Staar) placed in front of the lens and behind the iris, usually treats myopia and astigmatism. It is not visible when the pupil is normal.


 

Clear Lens Surgery

Lenses that are implemented within the capsular bag, once emptied the contents of the lens. We can correct all defects included presbyopia.  Usually they are implanted when exists a cataract, after age of 50, in people with graduation defects from far and near, or emmetropic (that do not require optical correction by far) by presbyopia. They are the most used ones and there are many models and types of different materials.






Keratoconus Surgery

Keratoconus Surgery


A. Crosslinking

Surgery in which a substance is applied on the cornea plus some ultraviolet radiation, allowing strengthen it and preventing its deformation. It is a quick and safe process that is performed on an outpatient basis.

B.     Intrastromal Corneal Rings

Outpatient surgery consisting of implanting rings into the cornea when it is deformed, and thus regularizing its shape.

C.     Corneal Transplantation anterior stroma (DALK)

Outpatient surgery in which the anterior portion of the cornea is replaced, keeping the innermost layer (the endothelium). It takes place during the pathology, affects only the surface layers of the cornea (keratoconus deformations, corneal scarring), with less risk of graft rejection, since it does not substitute the endothelium.
 


Keratoplasty o lamellar or penetrating corneal transplantation

Keratoplasty o lamellar or penetrating corneal transplantation


Outpatient surgery in which all the patient's cornea is replaced with a donor's cornea. A great improvement in visual acuity is achieved by recovering the transparency of the cornea.




DMEK (Descemet's Membrane Endothelial Keratoplasty)

DMEK (Descemet's Membrane Endothelial Keratoplasty)


Outpatient surgery in which the innermost layer of the cornea (endothelium) is replaced, keeping the outer layers. It is indicated when the only affected layer is the endothelium, as in the case of uncompensated guttata corneas or corneal decompensation following cataract surgery (bullous keratopathy).


Arcuate Keratotomy

Arcuate Keratotomy


Outpatient corneal surgery performed in corneas with high astigmatism. Corneal incisions are made in the join steep axis allowing partial or total reduction of the cornea deformation secondary to astigmatism.


Amniotic Membrane Transplantation

Amniotic Membrane Transplantation


Outpatient surgery in which a sample of amniotic membrane (tissue derived from the inner layer of the maternal placenta) is implanted. This tissue has important anti-inflammatory and healing effects. Above all it is used as graft or coating when there are corneal injuries, but can also be used to reconstruct conjunctival disorders.


Vitrectomy

Vitrectomy


It is the main technique for surgery of retinal problems. It is a sort of endoscopy in the eye socket. Using very small tools and making very small wounds (sometimes not even stitches are needed to close) to access the eye socket. Once inside, the technique can be combined with performing laser or withdrawal of epiretinal membrane, facilitate macular hole closing or intraocularly gas exchange. Surgery is usually performed under local anesthesia with mild sedation and can be ambulatory.


Scleral Buckling

Scleral Buckling


This is the technique that for many years has been used to solve retinal detachments. It involves placing a silicone belt around the eye, sometimes may be only part of the circumference. Surgery is usually performed under local anesthesia with mild sedation and can be ambulatory.


Trabeculectomy

Trabeculectomy


It is the most common surgical procedure in the world to control glaucoma. Glaucoma may be performed open or closed angle. It is performed under local anesthesia (retrobulbar) and sedation. It involves establishing communication between the anterior chamber and the subconjunctival space through a surgical fistula regulated by a sutured scleral permitting the flow of aqueous humor. Antifungal drugs (mitomycin, 5-fluorouracil) and anti-VEGF drugs are used to prevent excessive scarring of the fistula and maintain regular filtration over time. Variations of this technique have incorporated associated implants such as Express.




Non-Penentrating Deep Sclerectomy

Non-Penentrating Deep Sclerectomy


Alternative Surgical procedure to trabeculectomy for the treatment of open-angle glaucomas, developed in the last decade. It is characterized as a less aggressive procedure regarding potency in reducing intraocular pressure and in the immediate response in postoperative complications (ocular hypotony). It requires the application of an intrascleral implant (Snopper, t-Flux ...). Postoperatively it may require a YAG laser goniopuncture in the trabeculodescemetic membrane in order to achieve low long term intraocular pressure.


Drainage Devices or Valves

Drainage Devices or Valves


They are used for the treatment of complex or secondary glaucomas or complex when conventional techniques (trabeculectomy, deep sclerectomy) fail and the eye is still viable. They are implanted under local anesthetic and sedation. The most used are the Molteno implant and Ahmed valve.


Ectropion Surgery

Ectropion Surgery


Outpatient surgery to correct the eyelid eversion and is performed under regional anesthesia and it is to make a tarsal strip that involves the replacement and adjustment of the eyelid with a suture side edge. 
  1. Involutive Ectropion Surgery : tarsal strip, Kuhnt-Szymanowski, Lazy-T, repairCirugía de Ectropión Involutiu: tira tarsal, Kuhnt-Swymanowsky, Lazy-T, retractors repair with sutures investors, spindle medial, lateral or medial canthopexy.
  2. Mechanical ectropion Surgery: excision tumor injury.
  3. Paralytic Ectropion Surgery: tarsal strip +/- midface lifting +/- posterior lamella graft. Scar: skin graft + tarsal strip +/- half facelift    



Entropion Surgery

Entropion Surgery


In presenting the anomalous position of the eyelid inward, it can cause discomfort and corneal injury due to contact of the tabs on the ocular surface so, under regional anesthesia,  ambulatory surgery of Quickert eversing sutures for the replacement of the eyelid is performed.
 
Other surgeries:
  1.  Eversing Sutures + tarsal strip.
  2.  Anterior or posterior via of retractors replacement.
  3. If case of scar cause:  tarsal fracture + terminal rotation, lamellar division with posterior lamella anteposition +/-  tarsal strip  +/- buccal mucosa graft.



Ptosis Surgery

Ptosis Surgery


Procedure under local anesthesia (and in some cases, general anesthesia in case of congenital ptosis in children) in which either transcutaneous or transconjunctival repair and / or resection of the levator muscle and / or muscle Muller tarsus is made. In case of making the front suspension, a communication between the frontalis muscle and above stroke through the insertion of a biocompatible material (fascia lata, temporalis fascia autologous or synthetic material such as PTFE, Goretex ...) occurs.      


Exophthalmos Surgery

Exophthalmos Surgery


Eye reduction to its natural position within the orbit by fat removal decreasing orbital contents and / or removal of the orbital walls to increase the continent. It is characterized by a high complexity and is performed under general anesthesia. 


Orbiculectomy

Orbiculectomy


Surgery of the orbit applied to the repair orbital fractures, orbitaries diagnostic biopsies and / or therapeutic or exophthalmos surgery. Highly complex surgery under general anesthesia. 


Benign and Malignant Tumor Surgery

Benign and Malignant Tumor Surgery


It involves the excision of the tumor and reparation of static palpebral either directly or through flaps or grafts. The piece surgical-biopsy is sent for histopathologic analysis to confirm complete removal of the malignant tumor.


Orbital Volume Restoration Surgery

Orbital Volume Restoration Surgery


In anophthalmia and orbital fractures associated with enophthalmos. It is to set the orbital volume using autologous implants (fat, bone, cartilage ...) or heterologous (Goretex, PTFE, silicone ...). It is performed under general anesthesia and is a highly complex process.


Midface Lift Surgery

Midface Lift Surgery


It consists of the elevation of the skin and subcutaneous tissue of the malar region in order to treat lower eyelid eyelid retraction. Its main indications are facial paralysis and complications of transcutaneous lower blepharoplasty, as well as cases of periocular rejuvenation.


Thyroid Orbitopathy Surgery

Thyroid Orbitopathy Surgery


Term for exophthalmos surgery (orbital decompression may be just fat or bone, in this case segment of the inferior, medial and / or lateral are removed in order to reduce the exophthalmos walls ) for the lid retraction or strabismus associated with thyroid associated orbitopathy.


Eyelid Retraction Surgery

Eyelid Retraction Surgery


Procedures used in order to reduce its vertical interpalpebral indent in diameter and thus decrease the corneal exposure. It may be associated with the use of autologous / heterologous materials (tarsus, auricular cartilage, PTFE, Gore-Tex, ...).


Canthoplasty

Canthoplasty


Eyelid lateral or medial edge surgery in order to get a better static and palpebral functionalism. The most used is the side canthoplasty treating involutive ectropion and facial paralysis.


Enucleation

Enucleation


The enucleation is the total removal of the eyball.  During the operation, the surgeon removes the patient's eyeball and introduces an implant of the same size in its place to prevent that the ophthalmic cavity has no volume.


Evisceration

Evisceration


Evisceration is a surgical procedure consisting of removing the internal contents of the eye maintaining the sclera and its muscles.  During the operation, the surgeon removes the patient's eyeball and introduces an implant of the same size in its place to prevent that the ophthalmic cavity has no volume.


Exenteration

Exenteration


Exenteration is a surgical procedure consisting of removing the orbital contents (either partially or fully) depending on the location of the intraocular and eyelid tumor. During the operation, the surgeon removes the patient periocular and orbital content.


Orbital Reconstruction

Orbital Reconstruction


Reconstruction of orbital volume and position of the eyeball mainly associated with orbital trauma.
It may involve the use of autologous or heterologous implants and fillers. Highly complex surgery under general anesthesia.


Secondary Orbital Implant

Secondary Orbital Implant


In cases of complications within anophthalmia (exhibitions, infections, insufficient volume because of implant defects). It involves the placement of a sphere to correct the existing volume defect.The implant can be silicone, poliethylen, hydroxyapatite bioceramics. Highly complex surgery under general anesthesia.


Cul-de-Sac Reconstruction

Cul-de-Sac Reconstruction


Associated procedure in cases of anophthalmia, especially before a syndrome that does not allow the adaptation of an extrinsic ocular prosthesis.


Eyelid Reconstruction

Eyelid Reconstruction


Associated with eyelid trauma and surgery of malignant eyelid tumors (benign in some cases)


Jones' Tube

Jones' Tube


They are used associated with conjunctival dacryocystorhinostomy, standard surgical procedure in the treatment of obstruction of the upper lachrymal canaliculus scale (canalicular obstructions). They can also be used in the treatment of epiphora in case of absence of lacrimal sac or failure of dacryocystorhinostomy.


Dacryocystorhinostomy

Dacryocystorhinostomy


Standard procedure for the treatment of obstruction of the lower lachrymal. It can be made via transcutaneous, endonasal or transcanalicular.
It is to make a permanent communication between the lacrimal lake eye and the nostril by performing a rhinostomy.It may be associated with canalicular or intubation and the use or not of antimitotic.


Blepharoplasty

Blepharoplasty


Generic eyelid surgery, but in reality this term applies to cosmetic eye surgery for removal of skin excess in the upper eyelid (dermatochalasis) or lower eyelid bags. It may be associated with ptosis surgery, surgery of the eyebrow, periocular lipectomy, canthoplasty / canthopexy, Piling chemical, etc.


Orbital Decompression

Orbital Decompression


Surgical procedure for exophthalmos reduction or eye anterior protrusion reduction. Its main indication is associated with thyroid orbitopathy by corneal exposure, optic neuropathy or inflammatory orbitopathy not well controlled. It is always performed under general anesthesia and can be just of fat or bone with orbital lipectomy; in the latter case, one, two or three orbital bone walls are extracted in order to position the eye into the orbital cavity. It is a highly complex process.


Strabismus Surgery

Strabismus Surgery


It is to strengthen or weaken a muscle.
Resection: remove a segment of muscle to strain it and thus reinforce the action.
Retroinsertion: moving back muscle attachment to weaken it.


THERAPEUTIC TREATMENTS



Laser Photocoagulation

Laser Photocoagulation


Laser photocoagulation on the retina is a very safe technique performed on an outpatient basis, it is mainly used for the treatment of proliferative diabetic retinopathy and to treat tears or holes in the retina. Sometimes this technique can be performed in the OR combining it with pars plana vitrectomy.


Capsulotomy

Capsulotomy


Known among patients as the need to clean the intraocular lens. What really happens is that some time after cataract surgery with intraocular implant, the sac where it is the lens becomes cloudy resulting in a decrease of visual acuity. To restore vision we use YAG laser to break this capsule by the central area. It is not a painful technique and visual recovery is fast.


Iridoplastia

Iridoplastia


It is done with YAG laser. It is to carry out a laser with thermal effect that retracts the peripheral iris to increase the space of the anterior chamber angle. Its main indication is acute narrow-angle glaucoma and plateau iris.


Trabeculoplasty

Trabeculoplasty


It is a procedure performed with argon laser. It consists in performing thermal laser at trabeculo pigmented level to increase the drainage path


Intravitreal Injections

Intravitreal Injections


Currently the treatment with intravitreal injections is a choice for macular degeneration, some cases of  diabetic retinopathy and  retinal vascular occlusions among other retina problems. It is performed under topical anesthesia, with appropriate aseptic precautions and on an outpatient basis.The main drugs currently used are: Eylea, Lucentis, Avastin i Ozurdex.


Iridotomy

Iridotomy


It is a procedure performed by laser, usually YAG. Surgery consists in making a small hole in the periphery of the iris to connect the posterior and anterior areas (posterior and anterior chambers) of the iris and balance the pressure between them. It is performed in patients with a narrow chamber and therefore more risk of acute glaucoma.


Transscleral Cyclophotocoagulation

Transscleral Cyclophotocoagulation


We do not have this technology


Endocyclophotocoagulation with diode laser

Endocyclophotocoagulation with diode laser


We do not have this technology


Lacrimal Probing

Lacrimal Probing


It involves passing a probe through the tear duct through the punctum previously dilated to explore the tear duct in patients with constant watering. It can be done in the office under topical anesthesia except in children that requires general anesthesia inhalation.


Removing Ocular Samples.

Removing Ocular Samples.





Cryotherapy

Cryotherapy


Cryotherapy is a technique that involves inserting a probe that freeze-burns the intraocular tissue. It is one of the oldest techniques in the treatment of retinal detachment.Currently it is done in some cases associated with other techniques such as scleral buckling. It is done in the operating room under local anesthesia and on an outpatient basis.


Photodynamic Therapy

Photodynamic Therapy


Photodynamic therapy is a treatment that involves the intravenous injection of a photosensitive drug, which is subsequently activated in the retina by applying a special light to the affected area. It is done with the intravitreal administration of verteporfin. Once the drug is distributed by retinal vessels, it proceeds to illuminate the damaged area of the retina with a light source for a few seconds. It is a safe technique performed on an outpatient basis. When administering a drug sensitive to light it is recommended that the patient does not receive direct sunlight for at least 48 hours.


Orbital Fracture

Orbital Fracture


Breaking the continuity of orbital rim so double vision may involve entrapment of eye muscles. Often requires imaging tests and in some cases surgery


Drainage of Abscesses

Drainage of Abscesses





Pharmacological Treatments

Pharmacological Treatments


Some ophthalmic pathologies require the application of drug treatment, in each case the doctor will prescribe the most appropriate according to the pathology.
 
Among which are:
 
BOTULINUM TOXIN
ANTIBIOTICS AND ANTI-INFLAMMATORY
ACETAZOLAMIDE TABLETS
IMMUNOMONDULATORS DRUGS
OTHERS

OPTOMETRY



Optical Correction of Astigmatism with Glasses or Contact Lenses

Optical Correction of Astigmatism with Glasses or Contact Lenses


Astigmatism can be corrected with toric ophthalmic lenses (glasses), as well as contact lenses of the same type (either hydrogel material, silicone hydrogel or rigid gas permeable lenses).




Optical Correction of Presbyopia with Glasses or Contact Lenses

Optical Correction of Presbyopia with Glasses or Contact Lenses


Presbyopia can be corrected with ophthalmic lenses (converging, bifocals or progressive multifocal), as well as contact lenses of the same type (either hydrogel material, silicone hydrogel or rigid gas permeable lenses).


Optical Correction of Myopia with Glasses or Contact Lenses

Optical Correction of Myopia with Glasses or Contact Lenses


Myopia can be corrected with diverging ophthalmic lenses (glasses), as well as contact lenses of the same type (either hydrogel material, silicone hydrogel or rigid gas permeable lenses).


Optical Correction of Hyperopia with Glasses or Contact Lenses

Optical Correction of Hyperopia with Glasses or Contact Lenses


Hyperopia can be corrected with convergent ophthalmic lenses (glasses), as well as contact lenses of the same type (either hydrogel material, silicone hydrogel or rigid gas permeable lenses).


Monovision

Monovision


Monovision is a resource that lets you see in far and near vision without optical correction. It is to focus the dominant eye in far vision, and not dominant in near vision; It can be done with surgery, contact lenses and glasses.


Special Filters

Special Filters


Ophthalmic lenses which allow improved contrast and greater protection against the harmful effects of ultraviolet light; very important in patients with retinal diseases. It is generally used to reduce the sensation of glare.


Low Vision

Low Vision


Optical visual aids for patients that present so low visual acuity  that hinder their normal development of their usual activities. They can be telescopes, magnifiers, filters ...


ORTO-K Treatment

ORTO-K Treatment


Nonsurgical procedure, reversible, that uses gas permeable hard contact lenses at night, in order to reduce myopia and little astigmatism during the day, without using glasses or contact lenses.