What is presbyopia?

Presbyopia is the condition in which the lens of the eye loses its ability to focus. It is a common condition that could accompany cataracts and impair your ability to see objects that are close up. Have you ever found yourself holding a menu or book farther away to read it? the need for reading glasses is usually a sign of presbyopia. This aging of the eyes eventually affects everyone. If you have cataracts with presbyopia, the lens can correct both conditions.

What is a multifocal lens?

Multifocal lens is a breakthrough lens for cataract surgery that lets patient see from near to far, usually without glasses. It is effective when placed in both eyes. Most of the multifocal lens patients find that they can read a book, work on the computer, drive a car – day or night – and play golf or tennis with an increased freedom from glasses. You my experience visual disturbances in low lighting conditions, therefore increased care should be taken when driving at night

Normal Vision	Vision with Cataract(simulated)

Besides conventional extracapsular cataract extraction,this centre is also performing world class small incision sutureless cataract surgery (phaco),with foldable IOL including multi focal leading to greater patient satisfaction.well experienced and highly skilled cataract surgeons of this hospital have changed the lives of thousands of patients who underwent cataract surgery in this centre

A cataract occurs when the normally clear lens of the eye becomes cloudy and interferes with light passing through the eye. Cataracts are a process of aging and usually begin developing around midlife. Approximately 70% of people over the age of 60 and 90% of people over 70 will develop cataracts. The process is generally gradual, and people often do not realize what is happening until they have an eye exam. Common symptoms of cataracts may include blurry vision, glare and reduced vision in bright light, halos around light, poor night vision or fading of colors. Untreated, cataracts are a common cause of blindness.

How is a Cataract Removed?

Modern surgical techniques have made cataract removal one of the safest and most successful surgeries today. The virtually painless procedure takes about 10 minutes and is usually performed in a hospital on an outpatient basis. The eye is anesthetized using eyedrops, and a small incision (about one-eighth of an inch) is made in the white of the eye or through the outer edge of the cornea. An ultrasonic instrument is inserted and used to emulsify, or break up, the cataract and then vacuum away the damaged material. After the cataract has been removed, the surgeon inserts an intraocular lens to replace the natural lens that was removed. The day after surgery you will return for a checkup and your doctor may ask you to return later for one or more follow-up examinations and vision tests. Most patients notice an improvement in their vision during the first few days after surgery.

What is an Intraocular Lens?

An intraocular lens (IOL) is usually implanted during cataract surgery to replace the clouded natural lens that is being removed. A comprehensive eye examination prior to surgery and discussion with your doctor will determine what type, size and power of IOL is needed. The prescription lens implants are made from a flexible plastic that can be folded and inserted into the same small incision used to remove the cataract. The IOL is held in place inside the eye by tiny wires attached to the implant. Once the lens is implanted, it functions similarly to a natural lens and usually is not detectable to the patient.

A cataract occurs when the normally clear lens of the eye becomes cloudy and interferes with light passing through the eye. Cataracts are a process of aging and usually begin developing around midlife. Approximately 70% of people over the age of 60 and 90% of people over 70 will develop cataracts. The process is generally gradual, and people often do not realize what is happening until they have an eye exam. Common symptoms of cataracts may include blurry vision, glare and reduced vision in bright light, halos around light, poor night vision or fading of colors. Untreated, cataracts are a common cause of blindness.

What is Astigmatism?

Sometimes the surface of the cornea is curved in such a way that vision becomes distorted or blurred. A person who has both cataracts and a corneal astigmatism will not regain high – quality distance vision after cataract surgery unless the astigmatism is also corrected.

How does TORIC IOL give better result in cataract surgery?

The toric intraocular lens (IOL) replaces your eye’s natural clouded lens during cataract surger. It has the ability to reduce or eliminate corneal astigmatism at the same time it corrects cataracts. The result is typically improved distance vision and less dependence on spectacles . however , most patients still need corrective lenses for near and intermediate tasks. With the toric lens, your distance vision can be clear and vibrant, giving you the power to see your best and be your best.

Vision with Cataract	traditional replacement	Vision with Toric IOL

Diabetic eye disease is a leading cause for blindness registration among working age adults in India. It is caused by changes to the tiny blood vessels of the retina (the light sensitive layer at the back of the eye). Proliferative diabetic retinopathy is caused by abnormal new blood vessels that grow on the surface of the retina. This is the most advanced stage of diabetic retinopathy. At this stage, you may not have symptoms but are at high risk for vision loss.

How does proliferative diabetic retinopathy cause vision loss?

In proliferative diabetic retinopathy, the blood vessels that nourish the retina are blocked. The retina sends signals that trigger the growth of new abnormal blood vessels. These vessels are thin and fragile. By themselves, they do not cause vision loss. However, vision loss occurs when they bleed into the retina and gel-like fluid fills the eye.

In advanced stages of proliferative diabetic retinopathy, scar tissue pulls the retina away from the back of the eye (retinal detachment). Abnormal blood vessels can also increase the pressure within the eye (rubeotic glaucoma). If left untreated,severe vision loss and even blindness will occur.

Who is at risk of proliferative diabetic retinopathy?

All people with type 1 and type 2 diabetes are at risk of proliferative diabetic retinopathy. The longer you have had diabetes, the more likely you are to develop this condition. However, large studies have shown that the people who have good control of their blood sugar levels, cholesterol, and blood pressure are less likely to develop proliferative diabetic retinopathy.

How is proliferative diabetic retinopathyfound?

Proliferative diabetic retinopathycan be found during your yearly visit to your ophthalmologist.You may not notice
any changes in your vision at this stage but digital photographs of your eye may show signs of proliferative diabetic retinopathy.It is important you carry on going to your regular diabetic eye screening appointments.

What happens when I go to the medical retina clinic?

You will have a comprehensive eye examination that includes:

•  Visual acuity test: A sight test that measures how well you see at different distances
•  Eye pressure test: We check the pressure of your eyes. Numbing drops may be used as part of this test.
•  Dilated eye examination: Drops are place in your eyes to widen (dilate) your pupils so that we can examine the back of your eyes.You may also undergotests such as:
•  Optical coherence tomography (OCT): This test is similar to having a photograph taken of your eye. Pictures are taken using light reflected from the back of your eye. This test allows the eye care practitioner to identify fluid collecting in the macula and plan your treatment.
•  Widefield retinal photography: This test is also similar to having a photograph taken of your eye. It takes only a few seconds to take a wide-angled image of the retina. This test allows the eye care practitioner to assess and monitor the severity of diabetes in your eye.
•  Fluorescein angiography: In this test, dye is injected into a vein in your arm. Pictures are taken as the dye passes through blood vessels in theeye. This test allows the eye care practitioner to identify leaking blood vessels in the eye and plan your treatment.

How isproliferative diabetic retinopathy treated?

Proliferative diabetic retinopathy is treated with laser therapy. This is done together with improving thecontrol of your blood sugar, blood pressure, and cholesterol levels.

If you have very advanced proliferative diabetic retinopathy, you may require surgery.The treatments for proliferative diabetic retinopathy are:

1. lasertherapy
2. surgery

What is laser therapy?

This treatment uses laser to produce small areas of heat on the retina. This creates small laser burns scattered across the retina. Usually a thousand laser burns are applied in one session. Usually two to three sessions will be required to achieve this.The goal of laser therapy is to cause the abnormal blood vessels to shrink and disappear.
Laser therapy does not improve your vision. The aim is to prevent severe vision loss.

What happens duringlaser therapy?

Laser therapy takes place in the outpatient medical retina clinic. You will have drops to widen your pupils and numb your eye. The lights in the room will be dim. You will sit facing the laser machine and the doctor will place a contact lens on your eye. This will allow the doctor to see to the back of the eye and prevent you from blinking. During laser therapy, you will see flashes of light. You may feel a stinging sensation that can be uncomfortable. After laser therapy, your vision will be a little blurry for the rest of the day. You will need someone to accompany you home after the treatment. You may wish to bring a pair of sunglasses as your eyes will be sensitive to bright lights.

What are the side effects of laser therapy?

You may experience temporary worsening of vision on the day of laser therapy. This is caused by the bright flashing lights from laser treatment. This usually recovers by the next day. There is a small risk of loss of side vision (visual field) because of laser therapy. More than 90% of persons who receive laser will retain enough side vision for driving. In proliferative diabetic retinopathy, the risk of vision loss from no treatment is much higher than laser therapy. Sometimes laser therapy does not workand yourvision can still get worse despite treatment.

Can I drive after laser therapy?

The driver and vehicle licensing authority makes the decision on whether you will be able to drive. You should inform the Licensing authority when you have had laser therapy. They will arrange to have your side vision (visual field) tested at your local optometrist before making a decision.

What is retinal surgery for proliferative diabetic retinopathy?

In proliferative diabeticretinopathy, bleeding can occur in the retina and gel-like fluid that fills the eye. This blood usually clears on its own within three to six months. If this fails to clear you may need surgery to remove the blood. In advancedproliferative diabetic retinopathy,scar tissue can form in the retina. This causes the retina to pull away from the back of the eye (retinal detachment). Surgery will be required to remove the scar tissue and repair the retina.

What is conjunctivitis?

The surface membrane of your eye is known as the conjunctiva. It forms a thin transparent layer over the white of your eye and under your eyelids. Conjunctivitis means inflammation of the conjunctiva. It has several causes:

•  An infection (bacteria or viruses, usually flu or cold viruses)-infective conjunctivitis.
•  An allergy-allergic conjunctivitis.

What are the symptoms of infective conjunctivitis?

Infective conjunctivitis can affect one eye or both eyes. The whites of your eyes can look inflamed, swollen and red. Your eyes may feel gritty, watery or sticky and your eyelids may become swollen and get stuck together, especially in the mornings. Your vision may be blurred due to tears or sticky discharge. You may also get flu-like symptoms such as a sore throat, fever, muscle ache, and feel generally unwell.

What are the treatment options for infective conjunctivitis?

•  No treatment–most infections clear up on their own within a few days to a few weeks.
•  Antibiotic eye drops or ointment–viral infections do not respond to antibiotics and the infection may last for two to three weeks before your natural immunity is able to build up enough to clear the virus. Antibiotic drops or ointment may be helpful in conjunctivitis caused by bacteria.
•  Lubricant eye drops, gel or ointment–these may help reduce discomfort and grittiness, but will not reduce the duration of the illness.
•  Simple painkillers such as paracetamol or ibuprofen tablets can ease the discomfort and flu-like symptoms.
•  Regular lid cleaning–you can clean sticky discharge or secretions from your eyes with a clean flannel soaked in warm water.
•  Steroid eye drops are occasionally used in severe cases.

What is the infection risk to others?

Viral conjunctivitis is contagious and spreads very easily through water droplets (coughs and sneezes) or contact with tissues, flannels, towels, pillowcases and even door handles. They can also be caught through droplets spread by sneezing and coughing. Not sharing towels/pillows and encouraging your child to wash their hands often is important to reduce the spread.

Frequent hand-washing and proper disposal of used tissues is important in preventing the spread of the condition to other family members or work colleagues.

Advice for contact lens wear. Contact lenses should not be worn until symptoms have completely cleared.

Are there any complications?

Occasionally, viral conjunctivitis can cause inflammation on the cornea, the front window of the eye, or scarring of the conjunctiva, which can affect the sight, however this usually responds well to treatment.

When to seek advice?

If you develop further blurred vision or noticeable eye pain, or if you see any blisters or spots on your eyelids, you should call for advice.

What is diabetic macular oedema?

Diabetic eye disease is a leading cause of blindness registration among working age adults in India. It is caused by changes to the tiny blood vessels of the retina (the light sensitive layer at the back of the eye). In diabetic macular oedema, blood vessels leak fluid into the retina.

How does diabetic macular oedema cause vision loss?

Vision loss occurs when the fluid reaches the macula (the centre of the retina that provides sharp vision) and builds up, causing swelling. At first, you may not notice changes to your vision. Over time, diabetic macular oedema can cause your central vision to become blurred. A healthy macula is essential for good vision.

Who is at risk of diabetic macular oedema?All people with type 1 and type 2 diabetes are at risk of diabetic macular oedema. You are at greater risk if you:

• •  Have had diabetes for a long time–about one in three people living with diabetes for 20 years or more will develop diabetic macular oedema
  •  Have poorly controlled blood sugars
  •  Havehigh blood pressure
  •  Have high cholesterol levels
  •  Smoking
  •  Pregnancy

Large studies have shown that people who have well-controlled blood sugar, blood pressure and cholesterol levels, and do not smoke are less likely to develop diabetic macular oedema.

How to reduce the risks of diabetic macula oedema?

To reduce the risk of diabetic macular oedema, it is important not to smoke and to ensure that your blood sugar, blood pressure, and cholesterol levels are well controlled.

How is diabetic macular oedema detected?

Diabetic macula oedema may be detected during your annual eye screening visits, which are offered to all patients with diabetes. Digital photographs of your retina may show signs of early diabetic macular oedema. You may not notice any changes in your vision at this stage. If diabetic macular oedema is detected, you will be referred to the retina clinic.

What happens when I attend the medical retina clinic? You will have a comprehensive eye examination that includes:

• •  Visual acuity test: A sight test that measures how well you see at different distances
  •  Eye pressure test: A test that measures the pressure of your eyes –numbing drops may be used as part of this test
  •  Dilated eye examination: Drops are placed in your eyes to dilate (widen) your pupils so that the back of your eyes can be examined You may also undergo tests such as a:
    •  Fluorescein angiography, a diagnostic test which involves the injection of fluorescein (yellow) dye into your bloodstream via a vein in your hand or arm, followed by a series of retinal photographs taken over several minutes. The test gives your doctor more information about the condition of your retina and this helps decide which treatment is most appropriate.
    •  Optical coherence tomography (OCT) measures the amount of retinal swelling (macular oedema) which, like fluorescein angiography, helps decide which treatment is most appropriate. OCT is also used to monitor your retina over time and to show how effective treatment may have been. It is effectively ‘optical ultrasound’, a non-invasive test, using reflections from within your retina to provide a cross-sectional picture of the retina.

This leaflet is written for patients who might have treatment with anti-angiogenic (anti-VEGF) drugs via an injection into the eye. This treats certain retinal conditions which cause abnormal blood vessels to grow and leak under the retina.

Patients with these retinal conditions can lose central vision when abnormal blood vessels bleed or leak fluid under the retina at the back of the eye. A series of injections of anti-VEGF medicines are given into the back of the eye to stop these blood vessels growing and help control the leakage. This treatment is highly effective in preserving central vision in many people.

In which common conditions might this occur?

• Wet age-related macular degeneration.
• Myopic choroidal neovascularization.
• Diabetic macular oedema.
• Retinal vein occlusion.
• Any other retinal condition causing fluid to leak under the retina.

What is age-related macular degeneration (AMD)?

Age-related macular degeneration (AMD) is the leading cause of vision loss in people aged 50 years or older. It involves damage to the part of the eye called the macula. The macula is a small, but extremely important area located at the centre of the retina, the light-sensing tissue that lines the back of the eye.

Sub-retinal bleeding at the macula in wetmacular degenerationThe macula is responsible for seeing fine details clearly. A person with AMD loses the ability to see fine details, both close-up and at a distance. This affects only the central vision, with the side, or peripheral, vision usually remaining normal. For example, when people with AMD look at a clock, they can see the clock’s outline but cannot tell what time it is. In a similar way, those with AMD will also lose the ability to recognise people.

What is ‘wet’ AMD?

There are two types of AMD. Most people (about 75%) have a form called ‘early’ or ‘dry’ AMD, which develops when there is a waste build-up under the macula. This is usually seen in those with normal or partially reduced vision. A minority of patients with early AMD can progress to the vision-threatening forms of AMD called late AMD. The most common form of late AMD is ‘exudative’ or ‘wet’ AMD. Wet AMD occurs when abnormal blood vessels grow underneath the retina.These unhealthy vessels leak blood and fluid, which can prevent the retina from working properly. Severe damage leads to severe permanent loss of central vision, but the eye is not usually at risk of losing all vision (going ‘blind’) as the ability to see in the periphery (side) remains. There is a less common form of late AMD called geographic atrophy, where vision is lost through the macular tissue becoming completely worn out, with no leaking blood vessels. Unfortunately, anti-angiogenic medicines cannot help this form of lateAMD.

What is myopic choroidal neovascularization?

This condition occurs in people who are highly myopic (short-sighted). When someone is highly short-sighted, the retina at the back of the eye is stretched due to the increased size of the eye. This stretching can make the retina thinner and prone to splitting. When this occurs, blood vessels from the choroid (the layer of the eye behind the retina) can grow underneath the retina. These new vessels (neovascularisation) leak blood and fluid, which can prevent the retina from working properly. Severe damage leads to severe permanent loss of centralvision.

What is diabetic macular oedema (DMO)?

Diabetic macular oedema is an eye condition occurring in people with both type 1 and type 2 diabetes. Macular oedema is swelling and thickening of the macula. The macula is a small area in the centre of the retina which contains a rich collection of nerve cells sensitive to light, fine detail, and colour DMO occurs as a result of changes in retinal blood vessels in people with diabetes. Diabetes is characterised by increased levels of sugar (glucose) in the blood stream. Consistently high blood sugar can damage blood vessels, with the first signs appearing in the smallest vessels, called capillaries. The damaged blood vessels will leak, causing the build-up of excess fluid (oedema) and blood in the macula. It can lead to severe impairment of central vision in the affected eye.

What is retinal vein occlusion (RVO)?

RVO occurs when one of the retinal veins is blocked. The retina is thelight sensitive tissue that lines the back of the eye and is responsible for eyesight. RVO usually occurs when:A retinal vein is ‘pinched off’ through the pressure of an artery lying on top of the vein; or is clogged with a blood clot or atherosclerotic plaque (fatty deposit in the wall of the artery); or is blocked by some inflammatory conditions. The block can occur in the main retinal vein-central retinal vein occlusion (CRVO), or in one of the branches of the main vein-branch retinal vein occlusion (BRVO). Macular oedema is swelling and thickening of the macula. The macula is a small area in the centre of the retina that contains a rich collection of nerve cells sensitive to light, fine detail, and colour. The vein block causes the blood pressure to increase in the small retinal blood vessels which causes them to bleed and leak fluid into the retina, forming a macular oedema. The retina may also be affected by poor blood flow and inflammation. All these processes lead to decrease/loss of vision in the affected eye.

Can I have treatment with anti-angiogenic (anti-VEGF) drugs if I am pregnant or breast-feeding?

If you are pregnant or planning to become pregnant, please discuss this with your doctor before your intravitreal injection treatment. Anti-VEGF medicines should be used with caution during pregnancy. Women of child-bearing potential should use effective contraception during their treatment and for at least three months after the last intravitreal injection. If you do become pregnant whilst undergoing intravitreal injections, please inform your doctor immediately. Anti-VEGF medicines are not recommended during breast-feeding because it is not known whether the medicine passes into human milk. Ask your doctor for advice before treatment.

Who else should not be treated with anti-VEGF?

You should not be given anti-VEGF treatment if you have any of the following:

•  Allergy to anti-VEGF or any of its ingredients.
•  An infection in or around either eye or severeinfectionanywhere in your body.Anti-VEGF should be used with caution in patients who have had a heart attack or stroke in the last three months, or who have uncontrolled angina or uncontrolled high blood pressure. Please ensure you inform the doctor if there are any changes in your medical condition.

How does an anti-VEGF injection prevent sight loss?

Anti-VEGF medicines stop the abnormal blood vessels growing, then leaking and bleeding under the retina. This prevents or limits damage to the retinal light receptors and loss of central vision. These medicines are effective in preventing further central vision loss in up to 90% of treated eyes.

Is anti-VEGF treatment right for me?

Your ophthalmologist will advise if the treatment is appropriate for you and which anti-VEGF medicine will be used. Only patients with active leaking of blood and fluid can benefit from it. The treatment that’s right for you will depend on the specific condition of your central retina (macula), your vision and whether there is scarring at the macula. We perform scans and photographs of the eye which show us the different layers of the retina. These scans can show us if there is blood or fluid present within the retinal layers and help us decide on your treatment.

How is the treatment given?

The drug is injected into your eye with a fine needle. Minimal discomfort is to be expected (equivalent to having blood taken from your arm). The procedure takes five to seven minutes, but the injection itself is over in less than 20 seconds. The injection is given with you lying down comfortably on the couch.Firstly, local anaesthetic drops are applied to numb your eye and minimise discomfort. Then, your eyelids and surface of the eye are cleaned to prevent infection. Your face and the area around your eye will be covered by a small surgical sheet (a drape) to keep the area sterile. A small clip (speculum) will be used to keep the eye open (see picture below). The injection site is marked with callipers and your eye is stabilised with forceps or a cotton bud. A few seconds later, the injection is given. The injecting clinician will use lubricating drops after your injection. Your vision is assessed post injection by checking you can see hand movementsor can countfingers.The image on the next page shows an eye draped with a speculum in place. The cotton bud is stabilising the eye while the injection is being given.

Who will give the injection?

These injections will be given either by an ophthalmologist or a registered nurse practitioner.

What are the side effects of injections?

As with any medical procedure, there is a small risk of complications following anti-VEGF treatment.
Some common side effects that could occur include:

• Red eye (there is usually a bleed or bruise on the white part of the eye at the site of injection, which clears in a week ortwo).
• Sore and gritty eye (slight ache and discomfort lasting a day or two).
• ‘Blobs’ or ‘small specks’ in your vision (‘floaters’) might be seen for a few days after the injection. You may also experience transient flashing lights or swirls of light immediately after the injection. It is important to note that most of the discomfort relating to injections is due to the use of Povidone Iodine antiseptic. This is a vital part of the injection process and reduces the risk of infection. Rare risks of anti-VEGF injections:
  • serious eye infection (one in 2,000 cases).
  • detached retina.
  • increased eyepressure.
  • blood clots and bleeding in theeye.
  • inflammation inside theeye.There are no special precautions following intravitreal injections and you will be able to travel, but please avoid getting water into your eye or swimming for the first few days afterwards.