VITREO-RETINAL SERVICES
Vitreoretinal surgery refers to any operation to treat eye problems involving the retina, macula, and vitreous fluid. These include retinal detachment, macular hole, epiretinal membrane, and complications related to diabetic retinopathy. Retinal diseases are often a reflection of the general health of an individual. Retina gets affected by various systemic diseases like diabetes mellitus, hypertension, etc. A large number of diseases affect retina which requires both medical as well as surgical treatment. A wide variety of diagnostic devices as well as treatment equipment is essential to achieve optimum results in retinal diseases.
Dr. Bapaye Hospital has a state of the art Vitreo-retina department well equipped with all the diagnostic and therapeutic instrumentation and expertise necessary to manage any retinal problems. The common diseases managed under this department include:
DIABETIC RETINOPATHY (DR): In diabetic patients the retinal blood vessels become leaky. This leads to an accumulation of fluid and blood in the retina. This causes macular edema, exudates, and hemorrhages on the retinal surface. In advanced stages, improper oxygenation of the retina causes the development of abnormal blood vessels that leak blood into the vitreous cavity in front of the retina (vitreous hemorrhage). The fibrous tissue surrounding these blood vessels pulls the retina leading to tractional retinal detachment. This is a potentially blinding condition, but if detected and treated on time can be kept well under control. This is more common in diabetes is advanced and uncontrolled and of the young-onset type, but can occur even in early well-controlled late-onset diabetics.
At Dr. Bapaye Hospital all diabetic patients are screened for DR with Indirect Ophthalmoscopy and Digital Imaging. If there is no evidence of DR a 6 monthly follow-up is recommended. If there is evidence of DR, Fundus Fluorescein Angiography on the Zeiss Imaging system and OCT is done. If the stage is very early, a 3 monthly watch is recommended with strict control of sugar. If there is macular edema and retinal hemorrhages, Green Laser treatment (Macular grid with Pan-retinal photocoagulation) is done. Generally, 4 sittings are required for each eye. If there is vitreous hemorrhage, B-scan Ultrasonography is done and special injections (generally 3 at monthly interval) of Avastin (Bevacizumab), Lucentis (Ranibizumab), Macugen (Pegaptanib) (Anti-VEGF) are given into the eye, which leads to absorption of the blood. Then the green laser is done to prevent re-bleed. In cases of non-absorbing repeated vitreous hemorrhage and retinal detachment surgery (Vitrectomy) are required. Injections for macular edema like Intravitreal triamcinolone injections are given or Intravitreal Ozurdex Dexamethasone sustained delivery implant is used.
Dr. Bapaye Hospital has the wide-angle viewing lens BIOM and the Accurus Vitrectomy machine with a small gauge that enables excellent surgical results, sutureless surgery, and maximum patient comfort. Sometimes a special substance called Silicone oil is left in the eye for support, which may need to be removed after a few months. Even after treatment strict control of sugar and BP and regular monitoring of the eye, and sometimes retreatment is required.
RETINAL DETACHMENT (RD): The retina which is normally attached to the inner surface of the eye gets separated, leading to blurred vision. This occurs due to fluid seeping under the retina through retinal tears or holes. It is more common in high myopes (near-sighted), after injury or complicated eye surgery, and in relatives of patients having this problem. The patient presents with a sudden decrease in vision, flashes of light, or a shower of black dots (floaters). This is an emergency and immediate examination with Indirect Ophthalmoscopy and B-scan Ultrasonography is done. If there are retinal tears but the retina is attached, only Green Laser is done. But if the retina is detached then early surgery is required. Surgery is of various types depending on the nature of disease:
In Scleral Buckling a flexible silicone band is placed around the eye as support after draining the fluid under the retina.
In Vitrectomy, the gel inside the eye (vitreous) is removed, the retina is re-attached and supported by gas or oil.
AGE-RELATED MACULAR DEGENERATION (ARMD):
The macula is a small area at the center of the retina that allows us to see fine details such as central vision, activities such as reading and writing, and appreciating color vision. Sometimes in old age, the delicate cells of the macula are damaged causing ARMD. It can be of two types:
Dry (Atrophic) type caused by aging and thinning of the tissues of the macula.
Wet (Exudative) type caused by the formation of abnormal blood vessels under the macula which leaks fluid or blood and blurs the central vision.
Straight lines appear distorted or empty areas appear in the center of vision making activities like reading, writing, and recognizing small objects or faces very difficult.
At Dr. Bapaye Hospital ARMD is diagnosed by Slit Lamp examination, Digital Imaging, Fundus Fluorescein Angiography, ICG Angiography, and OCT. The dry type is treated with anti-oxidants and low vision aids. The wet type has the following treatment options:
Photodynamic therapy (PDT): This is a type of laser treatment after injecting a special dye called Verteporfin to localize the abnormal vessels.
Transpupillary thermotherapy (TTT): This is also a type of laser.
Injections of Avastin/Lucentis/Macugen (Anti-VEGF): This is the most path-breaking treatment where generally 3 or more injections are given inside the eye at monthly intervals to cause regression of the abnormal blood vessels. Regular monitoring is required and some patients may experience vision loss in spite of proper treatment.
Children and young people can also suffer from an inherited form of macular degeneration called macular dystrophy, which can sometimes affect several members from the same family.
RETINOPATHY OF PREMATURITY (ROP): In premature infants born before 32 weeks and having birth weight less than 1.5 kg the retinal blood vessels are not fully developed. Due to improper oxygenation, there is the development of abnormal blood vessels that bleed in the vitreous cavity and can cause retinal detachment. This is called ROP and can lead to total blindness if not recognized and treated on time.
So all premature babies with low birth weight, especially those who are kept in an incubator, have had neonatal infections, have received oxygen or blood transfusions are screened for ROP by Indirect ophthalmoscope by a specially trained retina surgeon. The screening is done at 4 weeks after birth and can be done even in the NICU. It is NOT necessary to wait until the systemic condition of the baby stabilizes as it may be too late to save the eye by then. If the blood vessels have not fully developed throughout the retina, but there are no abnormal blood vessels yet, screening is repeated every week until the development is complete. If there is a presence of ROP beyond a certain threshold then retinal laser treatment is done in one or more sittings. Dr. Bapaye hospital is equipped with Portable Diode Laser to perform laser even in the NICU without anesthesia. Advanced cases require intravitreal Anti- VEGF injections and sometimes specialized surgery (Vitrectomy). Dr. Maneesh Bapaye has alone screened close to 3000 babies till now and saved the eyes of hundreds of Babies with laser, injections, and surgery. Laser for ROP is an extremely time and expertise requiring procedure, but Dr. Maneesh takes time out from his busy schedule to do it at a very low cost for babies of less affording patients at civil hospitals every week.
Even after the retina is treated premature babies are examined at one year of age and yearly thereafter for early detection and treatment of other problems like refractive errors and squint, which is then managed by Dr. Charuta Bapaye.
MACULAR HOLE: This affects central vision and requires specialized surgical treatment (Vitrectomy).
CENTRAL SEROUS RETINOPATHY (CSR): There is an accumulation of fluid under the macula in young individuals generally secondary to stress, leading to blurred central vision. It is diagnosed by Digital Imaging, Fundus Fluorescein Angiography, and OCT. It may resolve spontaneously, if not, Green Laser treatment is required especially in recurrent cases.
UVEITIS: Uveitis is an inflammation of the inside of the eye, specifically the layer of the eye called the uvea (comprising of the iris, ciliary body, and the choroid). It may be associated with any of the following:
Systemic problems like rheumatoid arthritis or sarcoidosis
Secondary to external infections like tuberculosis or toxoplasmosis
Secondary to injury
Endogenous (arising within the body)
Without any cause (idiopathic)
Rarely secondary to cancer (Masquerade syndrome)
The patient experiences blurred vision, pain, redness, or floaters. It needs to be investigated with Indirect Ophthalmoscopy, Digital Imaging, and Fundus Fluorescein Angiography if required and certain Blood tests to look for a cause. It is usually treated with topical and/ or oral steroids. Sometimes steroid injections are given in or around the eye or as an intravenous drip. Steroids and the disease itself have the potential to increase the intraocular pressure, so that needs to be monitored. If the cause is infective certain antibiotics may also be required. In non-responsive cases, higher drugs called Antimetabolites may also be required. These can cause serious side effects on the body and so have to be prescribed and monitored by an experienced doctor. Dr. Bapaye Hospital has a specialized experience to manage all types of uveitis.
We have the most advanced technologies in the eyecare industry:
Zeiss FF 450 IR Fundus camera: this state of the art retinal imaging technology is used for various investigations. Besides fluorescein angiography (FA), autofluorescence (FAF), indocyanine green angiography (ICGA), red-free photography of retinal nerve fiber layer analysis is possible with his technology.
Cirrus HD-OCT (Zeiss): High definition spectral domain OCT is capable of assessing minute retinal features that can detect pathology at very early stages. The technology includes the latest features like En-Face OCT, enhanced depth imaging, 3-D retinal analysis. OCT is of immense importance in diagnosis as well as follow up diabetic macular edema, age-related macular degeneration, cystoids macular edema caused by vein occlusion, macular hole, etc various macular pathologies.
Ophthalmic ultrasonography (Quantel Medical- Aviso): Dedicated ophthalmic ultrasonography is important in the assessment of the posterior segment where retina can’t be visualized like in cases of vitreous hemorrhage, mature cataract, ocular trauma and to assess retinal/ choroidal tumors.
Accurus vitrectomy system (Alcon): High-speed vitrectomy as well as transconjunctival sutureless vitrectomy is required for vitreoretinal diseases. The advanced features make it possible to achieve accurate surgical results with minimal surgical time. All types of retinal surgical procedures like macular surgeries, retinal detachment, diabetic vitrectomy, retinopathy of prematurity, etc and many more
Iridex Oculight Gl Green Laser (Iridex Ophthalmic Equipment): Green laser is used for retinal lasers in diabetic retinopathy, peripheral retinal degenerations, certain macular disorders like CSR & extrafoveal CNVM and intraoperative.
Intravitreal Injection therapy: Various intravitreal injections namely Lucentis, Accentrix, Avastin, and Ozurdex is regularly used in retina clinics for various vitreoretinal disorders.