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The last frontier of cataract surgery is a surgery without the use of the scalpel (bladeless surgery).
It is performed using a femtosecond laser, or femtolaser, a fast surgical robot, which replaces most of the steps performed manually. If we consider that the numerous maneuvers carried out in rapid succession by a skilled surgeon are fast and extremely precise, then the LASER carries out the process with a repeatable, unsurpassed safety and precision that even the most skilled hand cannot achieve.
The expectations of patients are very high, but contrary to what most people think, a cataract surgery, is a very complex and delicate operation.
The thinness of the tissues a surgeon works with, measuring just a few thousands of a millimeter, are extremely delicate. These tissues are transparent and visible only through the microscope.
Besides the femtolaser that we use for cataracts, there are few other structures present in Italy.
Unfortunately, the cost of the platform, the learning curves and the high specialization that surgeons require for using it causes limitations, particularly in public hospitals.
WHAT ARE THE ADVANTAGES OF femtolaser?
The elimination of needles, scalpel and forceps
The accuracy and presicion
Minimal invasive technique
The patient can soon return to their normal activities
Personalized treatment for each individual patient
HOW DOES A femtosecond laser function in Cataract surgery
The femtolaser, emits the frequency of laser pulses of a millionth of a billionth of a second (femtosecond).
The process is pain free as we do not use a scalpel.
The treatment is carried out under the guidance of an operating microscope combined with femtosecond laser that is controlled by a computer.
This makes it possible to act exclusively on the plan that has been put into action, leaving the crossed tissues intact.
Once reached the level of optimal depth, the laser beam generates a series of thousands of gas microbubbles, close to each other, which, on expanding, gently separate the layers affected by the cutting. There is no production of heat or any cutting. It has been programmed.
What the regular equipment fail to carry out, a femtosecond laser achieves.
In cataract surgery, the femtosecond laser can perform:
1) Corneal incisions using a service entrance tunnel that is less than 2mm, it is always the same size and angle. It has higher precision and forseeability. It can resolve minor astigmatism.
2) Etching the anterior capsule of the capsular bag containing cataracts, which are always centered. Along with improved results in systems of intraocular lenses and progressive TORIC lenses, it helps correct astigmatism. It has better reproducibility and minor complications.
3) It is a less invasive process and involves the fragmentation of the nucleus of the cataract.
In essence, the robotic laser precision removes all the steps and tools such as sharp needles, scalpels and forceps replacing them with maneuvers of a precision.
The patients benefit from this process as they have faster visual recovery and are able to return their normal activities soon. In addition to the absence of pain, there is the possibility of adjusting the treatment, customizing it for each case, increasing the predictability of results, while reducing the complications.
How is the Cataract Surgery Different with Femtosecond Laser?
After topical anesthesia with some anesthetic eye drops, the patient is placed under the femtolaser.
This is driven by an Optical Coherence Tomograph (OCT), a type of high-definition ultrasound system, which employs an ultrasonic diagnostic laser. This allows controlling the thickness of the cornea and the capsule in real time to affect both the size and shape of the lens.
This makes it possible to carry out the operation while leaving the corneal tissue intact.
Once the eye collimated with the TMB has reached the level of optimal depth, the laser beam generates a series of thousands of gas microbubbles, close to each other, which, by expanding, gently separate the tissues. It has been programmed to be able to perform any cutting without production of heat.
It avoids the use of scalpel as it has extreme precision in cutting incisions of the cornea. It avoids the use of needles and forceps as it can open the outer casing of the lens (anterior capsule), and divides the nucleus of the cataract in four or multiple quadrants.
After this phase with the laser, the patient is placed under the operating microscope, where the opaque nucleus cataract is broken with an ultrasound probe called phacoemulsification. This is a necessary step during which the artificial lens is inserted. This intraocular lens previously calculated using biometrics, based on the clinical characteristics of the patient, is able to correct about 80% of pre-existing visual defects and sometimes even presbyopia.
POST - OPERATIVE
At the end of the surgery, please allow the patient to recuperate.
The therapeutic prophylaxis is equal to that of phacoemulsification.
Choice of Patients for a Surgery using Femtosecond Laser
The selection of patients for this process is necessary as only 60% of the eyes are fully compatible with this type of surgery.
Those who fail to meet adequate clinical features and requirements can still be operated with the traditional phacoemulsification ultrasound technique which is very effective and has been in use for over thirty years.
Technological improvements have made modern equipment and processes increasingly safe and reliable. An eye surgery can turn an unfortunate event such as a diagnosis of cataracts, into a chance to significantly improve the quality of the patient’s lives.
The process is completely painless and lasts only for 10-20 minutes. Although it appears as a relatively simple process, actually it requires great expertise, years of scientific research and clinical experience, to know how to operate it and take certain decisions while operating. The process combines the accuracy of the robotic laser with the skill and experience of the surgeon. It creates a mix between technology and competence necessary to complete the service with a phacoemulsification technique. However the last stages of the surgery are carried out with the less use of ultrasound.
The microsurgery with this robotic laser is an excellent procedure for cataract removal and replacement of the lens. It allows to operate without scalpels, blades, pliers or other sharp instruments, it has a course of operative and postoperative procedures which ensures simple and faster healing.
The revolution in this surgical field is represented by the application of robotics as in the femtosecond laser. Guided by a computer, it realizes the most delicate phases of 'intervention in an automated manner/
Unfortunately, the cost of the platform, learning curves and the high specialization required to use them, limits the use of this robotic laser, especially in the public environment. Hopefully, within a few years, this elite surgery technique, gains wide-spread awareness resulting in price reduction and can become accessible at the best hospitals in the National Health Service.
THE CATARACT is a progressive clouding of the lens (the natural lens located behind the iris).
The lens is made up of:
1) A central part called the core
2) A peripheral part called the cortical front and rear
3) A casing also called capsule
It is an ancient disease and constitutes the first cause of blindness.
The name comes from the belief that it was a veil that came down over a person’s eyes, like a waterfall like the cataracts of the Nile
The patient suffering from cataracts will notice the following symptoms:
1. A progressive loss of vision
2. A blurred vision
3. Too much outdoor glare
4. Colors seem less bright
5. In many cases, one may notice the appearance or increase of myopia if it already exists.
The only treatment is surgery.
Cataract surgery implement by Dr. Claudio is a minimum invasive surgery using cutting-edge technology, that is available in a very few centers in Italy.
Click on image to download and view a leaflet on cataract by the Ministry of Health
The lens, after an age of 50 years, just like all the parts of our body, undergoes certain changes. In this case, the lens loses transparency. Cataract mainly affects the elderly, but can also occur in patients with diabetes, and in people who have prolonged use of medications like cortisone, the cordarone and chemotherapy. As a result of injuries or serious eye trauma, people with other eye diseases such as uveitis later exposed to excessive sunlight, may also get affected by cataract. Unfortunately it can be present at birth and that is congenital.
The effect on vision is represented in the attached figure.
The patient complains of a progressive blurring of vision and an outdoor glare. The colors seem less bright and in many cases you notice the appearance of myopia or the increase of it in case it was already present. When the opacity of the crystalline lens becomes very dense, one is no longer able to distinguish objects. In the very advanced stages, this can result in total loss of vision. However this can be fully treated through surgery.
When is the best time to operate cataract?
When a person is no longer able to lead his or her life and when there are limitations in daily activities, then it is time to operate. The decision must be made by the patient after consultation with the ophthalmologist.
What cataract and how can it be treated?
Cataract is a disease that affects vision and is the first cause of blindness.
Presently, there are no medicines, diets or eyeglasses that can reverse it. The only effective treatment is surgery. It is not meant only for emergencies but can be practiced regardless of the degree of opaqueness. When the cataract prevents the patient from performing normal daily activities, he or she must undergo the surgery. It is one of the most performed surgical operations worldwide.
Dr. Cladio has implemented a minimally invasive surgery, which includes:
- IA microsurgery performed with a surgical microscope
- Micro-incisional surgery can be done with 2 small holes that do not require sutures
- Use of artificial lens folding
- The surgery can be done in a few minutes
- Outpatient Regime: an hour after the surgery, you can return home
Technique of intervention: phacoemulsification of the cataract nucleus
It uses a mini ultrasound probe called phacoemulsificator. This breaks the nucleus of the cataract into small pieces, which are removed by a suction line located inside the probe itself.
The lens is surrounded by a thin shell or capsular bag that supports it. The capsule is left in place, since it is necessary as a support for the new artificial lens and because it separates the posterior portion of the eye consisting of the vitreous humor and retina, from the front one.
Introduction of lens intraocular rolled, that unfolds within the capsular bag
The non-transparent natural lens is replaced by an artificial lens. In this technique we exclusively use crystalline foldable intraocular, which can be rolled up like a cigar and inserted into micro-incisions.
Anaesthesia: To avoid pain, we give you a few drops of anesthesia or neighboring injections. In very few cases, we give general anesthesia.
In almost all cases we use topical anesthesia, which gives the opportunity to work when the patients are conscious and yet not suffering from pain. There is no wrap at the end of the intervention. The Intraocular lens will be well placed in the capsular bag, behind the iris.
Care after Cataract Surgery
The day after surgery the operated patient needs to visit the surgeon to check that there are no early postoperative infections, the intraocular pressure is normal and to understand the protocol of postoperative infections that our team will explain.
Here are some precautions to exercise:
• Carry a pair of sunglasses, as the eye is more sensitive to light for some time
• Use an antibiotic eye drops for 2 weeks
• Do not rub the operated eye for 3 weeks
• Use a plastic shell for protection at night for a week
• Do not strain for to 2-3 days, do not take carry children
• Avoid dusty or unhealthy environment for 2 weeks
• On the 3rd day you can shave, wash your face and take a shower with caution.
• Visit the surgeon thrice to monitor progress and changes of postoperative infections: the day after surgery, after one week and three weeks after surgery. This depends on the incubation period of the various germs.
-- A cataract is a veil that covers the front of the eye
Cataract is the changing of the lens from crystalline to opaque.
- Can Cataracts be treated with medication or visual rehabilitation treatments?
There are no medical therapies. The only way to treat cataract is surgery.
- How long does a cataract surgery?
It usually lasts lesser than 10 minutes. In case of more complex cases, it takes up to 20 minutes.
- Is it necessary to be admitted?
It is an outpatient procedure. After a few hours you can return to your home.
- Does the operation require a general anesthesia?
A patient is given only a few anesthetic eye drops and the operation is totally painless.
- Is the surgery performed with a laser?
Normally it uses a mini ultrasound probe called phacoemulsificator, which breaks the nucleus of the cataract into small pieces. These are sucked by a suction line located inside the probe itself.
For some time a femtosecond laser that can perform certain stages of 'cataract surgery, but you still need to associate it with a phacoemulsifier ultrasound.
- Do you have to keep your eye closed after surgery?
At the end of surgery the eye is normally not blindfolded but it is necessary to bring the sunglasses, necessary for a few days, as the eye is sensitive to the intensity of the light.
- Can the surgery correct existing vision defects such as myopia, hyperopia and astigmatism?
The new artificial lenses allow us to fix 80% of pre-existing visual defects in the patient with reliability. The latest generation of intraocular lenses TORIC, and MULTIFOCAL TORIC MULTIFOCAL-can eliminate astigmatism and allow to overcome presbyopia as well.
- Do you need to always wear glasses after surgery?
If it is possible to implant a premium lens, the operated eye is able to see well without the use of corrective glasses in 80% of cases. This depends on the ocular characteristics of each patient.
- Do the most modern surgical techniques require stitches?
In the microsurgical technique we use, (MICS) stands for Micro Incision Cataract Surgery wherein the two necessary incisions are so small in diameter, that they do not require suture.
- Will there be a visible scar?
No, the surgery leaves no visible sign.
- Can people suffering from glaucoma do a cataract surgery?
Usually cataract surgery reduces intraocular pressure induced by glaucoma. It is possible with some frequency to reduce or even suspend it using antiglaucoma eye drops after cataract surgery. However, there are various techniques which allow the simultaneous surgical treatment of both the cataract as well as the glaucoma in serious cases.
- Are women more affected than men?
Cataract affects more women, but we must consider the fact that their life expectancy is significantly higher.
- Does Cataract affect only older people?
Cataracts are also caused by drugs and juvenile diseases. They tend to be congenital and also happen to aged people.
- Is the surgery dangerous?
There is always an element of risk in surgery, but new techniques make this procedure one of the safest. In Italy, this surgery has been carried out on about 500,000 cataract patients in a year, while in the US about three million operations are done. A cataract operation is the most common operation done.
- Do you have to wait for Cataract to mature before operating?
Today the opposite is true. It is advised to do the surgery before the lens becomes too hard to be broken easily by ultrasonic shock. This reduces the duration of the operation and the involved risks. It also improves the postoperative results.
- Is the operation easy and can it be performed in any structure?
The technique is very sophisticated and requires a competent and experienced surgeon, proper equipment and organization to reduce the risks of complications and ensure adequate visual recovery.
More so surgery is minimized, the greater the benefits for the patient being a speedy visual recovery speed. It allows our patient to quickly return to normal and daily activities and there is a reduction of postoperative complaints. On the other hand, it increases the degree of difficulty for the surgeon, who is working on delicate anatomical structures with less available space.
- Can the operation be conducted on those suffering from poor health?
There are few inoperable cases. Each case requires a careful and analytical assessment by the surgeon and anesthesiologist to understand and calculate the level of risk involved based on which they could suggest whether or not to operate.
- Can cataracts return?
A cataract will not return, although, there may be a clouding of the capsular bag that contains the artificial lens. This is called secondary cataract and is caused by the migration of epithelial cells from the equator of the bag itself. This new opacity is treated with the YAG laser.
- Can patients with retinal disorders or maculopathy be treated?
Each associated pathology should be assessed individually by the specialist. In general there are no absolute constraints. However, it should be well understood that the visual recovery would be modest, as a result of the severity of associated diseases.
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