• Cataract Surgery
• Retinal Detachment Surgery
• Macular Hole Surgery
• PRK

Cataract Surgery

The eye has a natural lens, which lies behind the iris and the pupil and focuses light onto the retina at the back of the eye. It works in much the same way as a camera lens, adjusting the eye’s focus. A cataract occurs when this lens becomes cloudy as part of the natural aging process or as a result of complications from other conditions. About half the population has a cataract by age 65, and nearly everyone over 75 has at least one.

Cataracts remain one of the leading causes of blindness in the undeveloped countries. In Europe and in the U.S.A., corrective surgery is recommended whenever a cataract is bad enough to impair vision.

Cataract surgery is one of the most commonly performed eye surgeries. During the last decades, it underwent dramatic improvements due to the introduction of a new surgical technique called “facoemulsification”, based on the use of ultrasound technologies. Today cataract surgery is generally performed on a day hospital basis. The patient generally undergoes cataract surgery by means of topical anaesthesia with or without mild sedation, which simply serves to decrease the psychological stress related to any type of surgery.

During the procedure, the surgeon will make a small incision into the eye. He will then remove the cloudy lens using an ultrasound probe to break it up and simultaneously remove the fragments. Normally, an artificial intraocular lens (IOL) is inserted, which acts as a replacement lens. The artificial IOL will never get cloudy again; it will last forever. In order to maintain clear vision after surgery, a single laser treatment of the capsular bag supporting the implanted IOL may be necessary due to its progressive fibrosis.

Like all surgical procedures, cataract surgery is not without risk, but it is commonly performed all over the world and generally safe, especially when done by a very experienced surgeon. Dr. Cusumano’s applied theory is “no compromise about safety”.

Dr. Cusumano considers mandatory:

• the use the latest ultrasound technologies;
• the intraocular injection of the best viscoelastic substances in order to better preserve the patient’s cornea during surgery;
• and the implantation of IOLs proven over years for superior biocompatibility and refractive properties.

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Retinal Detachment Surgery

The retina is the neurosensory tissue lining the internal back wall of the eye that is responsible for creating the images that we see. The centre of the retina is called the macula. It is the portion responsible for fine detailed vision like that used in reading and recognizing facial features. The rest of the retina is called the peripheral retina and is used for side vision.

When the retina becomes “detached”, it separates from the back wall of the eye, losing its blood supply and source of nutrients. If the retina remains detached, it will degenerate and lose its ability to function. There are three main types of retinal detachment:

• Rhegmatogenous retinal detachment is the most common form. It occurs when a tear or hole in the retina allows vitreous fluid to enter the potential space beneath the retina, separating the retina from the layer beneath. This type of detachment generally requires urgent surgery, within 24 hours of diagnosis, in order to regain postoperative good visual acuity.
• Exudative retinal detachment is caused by leakage from under the retina, which creates fluid that detaches the retina. Tumours and inflammatory disorders are two common causes of exudative detachment.
• Traction retinal detachments are caused by a pulling on the retina, usually from fibro-vascular tissue within the vitreous cavity. Proliferative diabetic retinopathy is the most common cause.

In relation to the specific features of the detachment there are three types of surgery to reattach the retina:

• Pneumatic retinopexy uses an intraocular injection of an expandable gas followed by cryotherapy application in order to close a retinal tear or hole located in one of the superior retinal quadrants. This type of surgery can be performed on an outpatient basis but requires careful positioning of a patient’s head in the first postoperative days.
• Scleral buckle surgery uses a flexible band to pull the retina to the back wall of the eye; the doctor often drains off the fluid that is trapped under the retina. The buckle is usually a piece of silicone sponge or solid silicone. Often, scleral buckle surgery can be done with local anaesthetic and on an outpatient basis. This procedure has been successfully used for more than 30 years.
• Vitrectomy is a slightly newer procedure that involves removing the vitreous gel and replacing it with a gas bubble, which the body’s fluids will gradually replace. It is most commonly used for traction retinal detachments, but is also used for rhegmatogenous detachments. It can also usually be done as same-day surgery and with local anaesthesia. In the most complicated cases, the simultaneous use of binocular imaging ophthalmo-microscope (BIOM) combined with wide angle observation and multiportal illumination systems (MIS) may dramatically reduce time of surgery, improving the safety and success rate.

As with other ophthalmic surgical procedures Dr. Cusumano strongly believes that retinal detachment surgery requires the utmost skill and rigorous safety standards. An adequate pre-operative examination, with the support of the most advanced diagnostic instrumentation, combined with optimal surgical planning and skilled surgery using the latest “cutting edge technologies” permits him to achieve the most successful postoperative anatomical and functional results.

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Macular Hole Surgery

A macular hole is a small tear in the macula, the centre portion of the light-sensitive, neurosensory tissue known as the retina. The macula is the only part of the retina capable of fine detailed vision we need for reading, driving, facial recognition, and fine detail.

Macular holes happen when the vitreous, a gel-like substance that fills about 80 percent of the eye, begins to shrink and pull away from the retinal surface. This is a normal part of the aging process, but in cases where the vitreous is firmly attached to the retina when it pulls away, it can tear the retina and create a macular hole. The fluid that has replaced the shrunken vitreous can then seep through the hole onto the macula, blurring and distorting central vision.

A macular hole has three stages. Stage I is known as foveal detachment. Without treatment, approximately half of stage I macular holes will progress. Stage II is characterized by partial-thickness holes. Without treatment, about 70% of stage II holes will progress. A full-thickness hole is described as Stage III. Most central and detailed vision can be lost when a Stage III macular hole develops.

Treatment of a macular hole involves a surgical procedure called a pars-plana vitrectomy. In a vitrectomy, the vitreous gel is removed to prevent it from pulling on the retina, and is replaced with a bubble containing a mixture of air and expandable gas. The bubble holds the edges of the macular hole in place as it heals and acts as an internal, temporary bandage. The procedure is generally performed under local anaesthesia and often on an outpatient basis. Careful post-operative head positioning (face down) is generally necessary for one week, more or less, in order to achieve the best visual results after surgery.

Like any surgical procedure, a vitrectomy involves a certain degree of risk. However, the treatment is fairly common and generally very safe, especially when performed by an experienced surgeon. Once again, careful pre-operative examination of a patient’s eye by means of advanced diagnostic instruments like Optic Coherence Tomography (OCT), fluorescence angiography (FAG), ultrasound B-scan, microperimetry, etc. is necessary in order to optimize surgical planning. This also reduces the rate of unexpected intra- or post-operative complications.

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PRK

Photorefractive keratectomy, or PRK, is a type of laser refractive surgery that gently reshapes the cornea by removing microscopic amounts (microns) of tissue from the outer surface with a cool, computer-controlled ultraviolet beam of light. The excimer laser used is so precise that it can cut notches in a strand of human hair without breaking it.

PRK is an outpatient procedure that is performed with local anaesthetic, and is used to treat nearsightedness, farsightedness, and astigmatism.

Nowadays, in selected and motivated patients suffering from presbyopia, laser refractive surgery can provide a new post-operative status (“blended vision”) in which a predominant eye is best corrected for long distance vision and the fellow one slightly prevails for near vision. Due to this type of surgery, patients do not need spectacles during most of their daily activities (excluding car driving and extensive reading).

LASIK is a newer form of laser eye surgery, but many surgeons, including Dr. Cusumano, prefer PRK because of its longer track record and reputation for safety. Customized ablations for patients with larger pupils or tissue saving techniques for patients with thin corneas represent two of the latest advances of this revolutionary surgical technique.

In order to know if the patient might be a good candidate for PRK, it is necessary to perform a large series of diagnostic examinations before planning surgery. If the eye features (corneal thickness, pupil size) and the number of dioptres to be corrected are within the internationally required standards, this technique remains one of the safest surgical eye procedures ever performed.

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