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Keratoconus
Keratoconus often results in monocular double-vision, in which a person sees multiple images in each eye. Keratoconus, or KC for short, is a thinning disorder of the cornea that causes distortion and reduced vision.
Keratoconus, often abbreviated to "KC", is a non-inflammatory eye condition in which the normally round dome-shaped cornea progressively thins causing a cone-like bulge to develop. This results in significant visual impairment. The cornea is the clear window of the eye and is responsible for refracting most of the light coming into the eye. Therefore, abnormalities of the cornea severely affect the way we see the world making simple tasks, like driving, watching TV or reading a book difficult.
In its earliest stages, keratoconus causes slight blurring and distortion of vision and increased sensitivity to glare and light. These symptoms usually first appear in the late teens and early twenties. Keratoconus may progress for 10-20 years and then slow or stabilize. Each eye may be affected differently.
Keratoconus, often abbreviated to "KC", is a non-inflammatory eye condition in which the normally round dome-shaped cornea progressively thins causing a cone-like bulge to develop. This results in significant visual impairment. The cornea is the clear window of the eye and is responsible for refracting most of the light coming into the eye. Therefore, abnormalities of the cornea severely affect the way we see the world making simple tasks, like driving, watching TV or reading a book difficult.
In its earliest stages, keratoconus causes slight blurring and distortion of vision and increased sensitivity to glare and light. These symptoms usually first appear in the late teens and early twenties. Keratoconus may progress for 10-20 years and then slow or stabilize. Each eye may be affected differently.
Eyeglasses or soft contact lenses may be used to correct the mild nearsightedness and astigmatism caused in the early stages of keratoconus. As the disorder progresses and the cornea continue to thin and change shape, rigid gas permeable contact lenses are generally prescribed to correct vision more adequately. The contact lenses must be carefully fitted and frequent checkups and lens changes may be needed to achieve and maintain good vision.
In severe cases, a corneal transplant may be needed due to scarring, extreme thinning or contact lens intolerance. This is a surgical procedure that replaces the keratoconus cornea with healthy donor tissue.
Keratoconus Information & Treatment
Keratoconus or conical cornea is a disorder of the human eye that rarely causes blindness but can significantly interfere with vision. It is a condition in which the rounded shape of the cornea is distorted and a conical shaped prominence is developed. The word keratoconus derive from Greek: kerato- horn, cornea; and konos cone.
Given the cornea is the main eye lens; vision diminishes significantly when it is distorted in this way. Keratoconus evolution is generally slow and can stop its development in any phase: from mild to severe. If the keratoconus progresses, the cornea takes a round shape and becomes thinner and irregular, sometimes producing scarring. Usually it appears bilaterally and the phases are asymmetrical.
What are Instrastromal rings?
It is an orthesic treatment consisting of two semi-circular segments of acrylic material (Perspex CQ) with variable density and diameter. This material has been used for more than 20 years when manufacturing intraocular lenses. It is perfectly tolerated by the body and there is no risk of rejection. It is the most modern and safest treatment for Keratoconus.
How many types of rings are there?
There are two commercial brands of intrastromal rings, KeraRings and Intacs. The diameters, shape, placement technique and surgery instructions are completely different. Even though both are placed in the keratoconus, KeraRings and Intacts are placed according to the evolution of the disease. The criteria or the choice for using one or the other is up to the doctor.
Which are the steps of the medical procedures?
Surgery of Intrastromal Segments is performed in operating rooms especially designed for ophthalmologic surgery. Anaesthesia is only local, just drops. After cleaning the area, a sterile pad is placed covering the eyes, nose, mouth and head. It is performed this way in order to keep sterile the area where surgery is going to be performed, clean from any contamination. It is not a painful procedure and lasts approximately 15 minutes. The use of collyrium, antibiotics, anti-inflammatory and lubricants make the post-surgery period more comfortable and safer. In general after three days you can go back to your habitual routine.
Which are the risks of the surgery?
There are minimum risks. Like in any other surgery, infection is one of the possible complications. In this case, implants need to be removed.
There is no risk of rejection. There are few complications and the most important thing is that surgery is reversible, which means that the ring can be removed and the cornea goes back to its original curvature.
After surgery, when is vision restored?
Modifications in vision are fast and they take place the day after the surgery. Vision does not always improve on the first stage, the percentage of improvement is high, but is not the same in every patient given the cornea speed response to the surgery is not the same in every patient. In all cases, the procedure is very well tolerated by the corneal tissue, but the recovery speed cannot be predicted.
It is normal to have daily vision fluctuations. Especially in the morning, vision is better and may become slightly blurry during the day.
This is not a plastic surgery procedure therefore the use of eyeglasses or lenses might be needed to complete the correction of vision. However, as time goes by visual quality will be better than before the surgery even if you have to use residual correction.
Preparation for surgery
The day of the surgery: there are no diet restrictions, unless total anaesthesia has been planned. In that case, fast should not be inferior to 6 hours. It is advisable to take a shower that includes hair washing. The patient should be in the clinic 30 minutes before the operation.
Before going into the operating theatre, your clothes will be changed so you will be more comfortable. You will receive some anaesthetic drops at regular intervals until you go into the operating theatre.
Post - surgery instructions
Right after the surgery, you might experience these symptoms: pain, tears, photophobia (aversion to light) and red eyes. These symptoms are normal during the post-surgery period. However, it is not normal if the symptoms appear later and in that case you must report it to your doctor immediately. Should you have any doubts, call or go to the clinic.
Post - surgery medication
Antibiotics, anti-inflammatory, lubricants and local analgesic (collyrium).
A minimum interval of 15 minutes between each application is necessary.
The patient should avoid bathing (swimming pool, beach, Jacuzzi), sauna, physical activity, rubbing your eyes, and using make-up.
The cleaning should be done very carefully with saline physiological solution and sterilized gas to avoid any kind of traumatism.
It is important that the patient washes his/her hands carefully with liquid soap, similar to Pervinox, and then dries them with disposable towels before washing his/her face and put the medication in his/her eyes.
While sleeping, the patient should lean on the opposite side of the operated eye. The dropper should touch neither the eye nor the skin.
Scheduled controls
Controls should start the day after the surgery and continue on the 1st, 3rd, 6th and 12th months.
Which are the advantages and disadvantages as opposed to the corneal graft?
• Advantages of the intrastromal segments over the corneal graft are:
• Fast visual recover
• No rejection
• Easy and fast tolerance to the use of contact lenses (if necessary)
• Reversibility
• Keratoconus evolution is stopped or reduced
Can a corneal transplant offer better results than the intrastromal ring?
The corneal transplant needs a long period of visual recuperation around 3 to 12 months and the possibility of rejection exists. It does not warrantee recurring of keratoconus and in most cases the use of eyeglasses or contact lenses is needed to correct the residual optic defect.
Can the ring replace the corneal transplant?
No. The main purpose of the intrastromal segment is visual rehabilitation. However, the implant can delay keratoconus evolution, thus postponing for undetermined time the necessity of a corneal transplant.
What is the corneal collagen cross linking?
It is a process used to generate new unions, or bridges, among the existing collagen chains that are altering the keratoconus.
This process consists in saturating the tissue with a substance that makes it more sensible to collagen, rivoflavin. Then the creation of new bridges or unions among the long chains of collagen are stimulated with irradiation of a special light within the range of ultraviolet light with certain wave length (UVA 375 mm).This light delivers a known energy to a certain distance (3m/cm2), during a certain amount of time (30 min).
What is the surgical procedure?
The procedure is performed with the patient lying down, slightly sedated, and with local anaesthesia. After giving the anaesthesia in drops, a small part of the corneal epithelium is cut for the riboflavin to penetrate in the corneal stroma.
It is irrigated with a riboflavin solution, with continual irrigation, reaching a 30 minute exposure to the light.
Which are the surgery risks?
As in every new treatment, although benefits and complications have been studied, there are parameters that need to be checked with time. For de time being, this procedure has already been performed in Germany, USA, Greece, Spain, and England, among other countries.
After surgery, when is vision restored?
Once the ulcer that was caused by the treatment is healed (approximately 24 to 48 hours) vision will be the same as before treatment. Even though sometimes they occur, this treatment does not bring alterations or improvements in vision, but it does bring modifications in corneal structure which shows in an increase of corneal stability. You can continue using contact lenses previously adapted to treatment, as well.
Post - surgery instructions
You will only need antibiotics during 3 to 4 days until the corneal epithelium heals properly, analgesics and anti-inflammatory if necessary, and lots of lubricants.
Rings and cross linking can be combined
It is only natural to combine both procedures, although it might be uncomfortable for the patient to perform them jointly. Usually, cross linking is performed 30 to 40 days before or after the ring procedure, and it is performed in both eyes.
Given it is not a very invasive procedure, it can be performed as first treatment as well in eyes with small changes and that have never been operated on, or in eyes that have undergone rings surgery, even many years later.
How is the corneal transplant performed?
In recent years, eyes surgery has shown a high level of effectiveness and relative comfort. Corneal transplant surgery is the most successful of every transplant procedure and techniques are developed constantly.
The objective of this procedure is to remove the central part of the patient's cornea and replace it with a donor's cornea. Corneal banks are in charge of obtaining healthy corneas and distribute them to surgeons. These are very common procedures with very good results. Rejection probability is lower than in any other organ transplantation, given the cornea does not have blood vessels. The rejection of other organs generally is the result of incompatibility between donor and recipient, and this incompatibility is mediated by blood cells.
Local or general anaesthesia is used in this procedure and in general hospitalization is not needed after surgery. Given at first vision will be blurry, you will need someone to drive you home. Once you are there, you should lead a quiet lifestyle for several days. Some people experience pain and discomfort after the surgery. Inability to work depends on each person job. Usually, in a sedentary job, the person can return to work in one or two weeks.
The surgeon uses an instrument called drill bit to remove the distorted cornea and to cut a similar portion in the donor's cornea. Then the donor's cornea is placed in the whole of the recipient's cornea and then suture is performed. The whole procedure is performed under microscopic vision. The suture used is thinner than a human's hair.
Bandages are removed usually one or two weeks after the surgery, but the patient is not going to see clearly immediately. Several months will pass by before your vision is stabilized and eyeglasses or contact lenses can be prescribed to you. There are big differences among different cases; therefore the time periods mentioned above should be regarded as general.
Even though there is a 95% probability of success in corneal transplants for keratoconus, this procedure, just as any other surgery, involves potentially serious risks. In cases where the first transplant is unsatisfactory, a second transplant might be the solution. Recurrence of keratoconus in the transplanted cornea has happened but it is extremely rare. Although permanent loss of vision is not frequent, it might occur. Corneal transplant is considered only in those cases where corneal rings are not advisable.
Keratoconus medical treatment
The irregular nature of astigmatism caused by keratoconus forces doctors to optimize the ways of diagnosis and treatment. The corneal printer, a non-aggressive and highly qualified instrument used for keratoconus evaluation, allows doctor to know the shape of the cornea and to design CUSTOMIZED contact lenses. The materials used are silicon polymers, which are highly permeable to oxygen, and the adaptation and design of contact lenses is guaranteed by doctors, who can solve successfully the difficulties that may arise from adaptation.
Use of contact lenses after the surgery of intrastromal rings
In some cases the implant of intrastromal rings should be compensated with contact lenses, in some cases temporally, in others in a more definite basis.
The lenses used in these conditions are specifically designed, and soft, siliconized materials or permeable polymer gas. In every case, the adaptation and design of lenses is CUSTOMIZED with help of sophisticated instruments of diagnosis and measurement.
Accelerated Orthokeratology
It consists in using during the NIGHT rigid contact lenses permeable polymer gas of inverse geometry. When used at night, these lenses, offer an excellent vision during the day, WITHOUT the help of contact lenses or eyeglasses!
This technique is used in myopias of 6 dioptres, with or without astigmatism of up to 1, 50 dioptres.
It is perfect for children and teenagers between 8 and 20 years, for sportspeople, for every person that for some reason cannot afford refractive surgery, and also for people suffering myopia with some level of presbytia. [x] _____________________________________________________________________________________
_________________________________________________________________________________________
Astigmatism is a vision condition that causes blurred vision due either to the irregular shape of the cornea, the clear front cover of the eye, or sometimes the curvature of the lens inside the eye. An irregular shaped cornea or lens prevents light from focusing properly on the retina, the light sensitive surface at the back of the eye. As a result, vision becomes blurred at any distance.
Astigmatism is a very common vision condition. Most people have some degree of astigmatism. Slight amounts of astigmatism usually don't affect vision and don't require treatment. However, larger amounts cause distorted or blurred vision, eye discomfort and headaches.
Astigmatism frequently occurs with other vision conditions like nearsightedness (myopia) and farsightedness (hyperopia). Together these vision conditions are referred to as refractive errors because they affect how the eyes bend or "refract" light.
The specific cause of astigmatism is unknown. It can be hereditary and is usually present from birth. It can change as a child grows and may decrease or worsen over time.
A comprehensive optometric examination will include testing for astigmatism. Depending on the amount present, your optometrist can provide eyeglasses or contact lenses that correct the astigmatism by altering the way light enters your eyes.
Another option for treating astigmatism uses a corneal modification procedure called orthokeratology (ortho-k). It is a painless, non-invasive procedure that involves wearing a series of specially designed rigid contact lenses to gradually reshape the curvature of the cornea.
Laser surgery is also a possible treatment option for some types of astigmatism. It changes the shape of the cornea by removing a small amount of eye tissue. This is done using a highly focused laser beam on the surface of the eye.
Astigmatism Information & Treatment
It is difficult to define astigmatism, but to begin with we have to imagine that in a normal eye parallel light rays coming from the infinite and passing through a transparent and spherical surface (as the one in the eye cornea) converge as they refract and they join in one point called principal focus. Even though this is normal, it is not always like this, and it might happen that rays do not converge in one stigmatic focal point. These deviations are called aberrations. One of these aberrations is astigmatism. Generally, an astigmatic cornea is compared to a lens with the shape of a rugby ball. Parallel rays coming from the infinite and passing through the main curve will converge in a point different from the one passing through the ball flattest curve. These two will be very different points.
What are Intracorneal Rings or Intrastromal segments?
It is an orthic treatment consisting of two semicircular segments with variable thickness, arch and diameter, made of acrylic material (Perspex CQ), which has been used for more than 20 years to manufacture intraocular lenses. It is perfectly tolerated by the body without any rejection whatsoever.
Which are the advantages of treat them with rings?
It is a reversible procedure, which means that we can remove or change the segment without causing any tissue alterations or modifications in the pre-surgical keratomy amounts. It keeps the prolacticidad corneal positive because this is not a tissue ablation method but a addition tissue method. It is not very invasive, or intracamerular, it is itracorneal and it is performed with a 1mm incision, with 400 micron depth approximately. It stabilizes the cornea, in case it was unstable (ectasia). The procedure is performed with topic anaesthesia.
The procedure can be reproduced; in a series of 7 eyes, with 5.6 pre-surgical dioptres, a post-surgical 1.2 dioptres was achieved. In figures 9 and 10 we can see the changes in dioptres and in visual acuity with pre-surgical correction vs. visual acuity without post-surgical correction.
Can they be treated with conventional segments?
Certain types of astigmatism can be treated with conventional segments, but in most of them the arch has been modified at 90º and 120º degrees so they have less coupling effect. In figure 11 (see picture) we can see the segments used to treat these astigmatisms.
Which are the steps of the surgical procedure?
The procedure is performed with the patient lying down, slightly sedated and with local anaesthesia. After putting the anaesthesia in drops in the cornea, a small portion of the corneal epithelium is cut for the riboflavin to penetrate into the corneal stroma.
The corneal tissue is irrigated several times with a riboflavin solution, until the saturation is enough to irradiate the corneal tissue with the necessary source of energy to create these unions.
Every 5 minutes, the cornea is irrigated with the riboflavin substance, but irradiating at the same time, until reaching a 30 minutes exposure to light.
Which are the surgery risks?
Risks are minimal. Like in any other surgery, infection is one of the complications. In this case, implants have to be removed.
There is no risk of rejection. There are few complications, and the most important thing is that surgery is reversible, which means the ring can be removed and the cornea goes back to its old curve.
After surgery, when is vision restored?
Modifications in vision are fast and they take place the day after the surgery. Vision does not always improve on the first stage, the percentage of improvement is high, but is not the same in every patient given the cornea speed response to the surgery is not the same in every patient. In all cases, the procedure is very well tolerated by the corneal tissue, but the recovery speed cannot be predicted.
It is normal to have daily vision fluctuations. Especially in the morning, vision is better and may become slightly blurry during the day.
This is not a plastic surgery therefore the use of eyeglasses or lenses might be needed to complete the correction of vision. However, as time goes by visual quality will be better than before the surgery even if you have to use residual correction.
Preparation for surgery
The day of the surgery: there are no diet restrictions, unless total anaesthesia has been planned. In that case, fast should not be inferior to 6 hours. It is advisable to take a shower that includes hair washing. The patient should be in the clinic 30 minutes before the operation.
Before going into the operating theatre, your clothes will be changed so you will be more comfortable. You will receive some anaesthetic drops at regular intervals until you go into the operating theatre.
Post - surgery instructions
Right after the surgery, you might experience these symptoms: pain, tears, photophobia (aversion to light) and red eyes. These symptoms are normal during the post-surgery period. However, it is not normal if the symptoms appear later and in that case you must report it to your doctor immediately. Should you have any doubts, call or go to the clinic.
Post - surgery medication
Antibiotics, anti-inflammatory, lubricants and local analgesic (collyrium).
A minimum interval of 15 minutes between each application is necessary.
The patient should avoid bathing (swimming pool, beach, Jacuzzi), sauna, physical activity, rubbing your eyes, and using make-up.
The cleaning should be done very carefully with saline physiological solution and sterilized gas to avoid any kind of traumatism.
It is important that the patient washes his/her hands carefully with liquid soap, similar to Pervinox, and then dries them with disposable towels before washing his/her face and put the medication in his/her eyes.
While sleeping, the patient should lean on the opposite side of the operated eye. The dropper should touch neither the eye nor the skin.
Scheduled controls
Controls should start the day after the surgery and continue on the 1st, 3rd, 6th and 12th months.
Excimer Laser (Lasik - Lasek)
Excimer Laser delivers energy with the capacity of ablating corneal tissue with cold, in a precise form, and without solid waste. It breaks up the unions that keep the atoms together, thus volatilizing the tissue exposed to energy. This energy can be handled in a way that tissue can be reached with precision and can be delivered in different parts of the cornea. If the delivery (ablation) is performed on the anterior surface of the cornea, removing only the epithelium that covers it, this will be what we call PRK (Photo Refractive Keratectomy). If we use diluted alcohol to remove the epithelium and then replace it after the ablation, it will be a Lasik.
Which are the steps of the surgical procedure?
Either performing one technique or the other, the procedure is fast, effective, and is performed with local anaesthesia, with a slight sedation.
Usually, Lasek and PKR are performed one at a time and sequentially, because the post-surgical period is not very pleasant; it presents discomfort for a couple of days during re-epithelization of the wound; Lasik is usually performed bilaterally and simultaneously since the post-surgical period is more comfortable.
Which are the surgery risks?
As in every surgical procedure, infection is a serious but unusual complication. Most frequent complications are easily dealt with, these are some: flap alterations, hypo or hipercorrections, desepithelization and epithelium.
If the patient follows strictly these indications and, specially, does not rub his/her eyes, there are minimum chances for the complications to occur.
If the procedure performed was a Lasik, rehabilitation is going to be faster: within 24 to 48 hours the patient is in levels of pre-surgical correction.
If the procedure was a PRK or Lasek, rehabilitation is going to be slower and evolution difficult, because as the corneal surface suffers re-epithelization, the patient does not see properly, and feels discomfort as if there was a strange body in his/her eye. Rehabilitation will be progressive from the 5 or 7 day onwards.
Preparation for surgery
The day of the surgery: there are no diet restrictions, unless total anaesthesia has been planned. In that case, fast should not be inferior to 6 hours. It is advisable to take a shower that includes hair washing. The patient should be in the clinic 30 minutes before the operation.
Before going into the operating theatre, some anaesthetic drops will be given to you at regular intervals until entering into the operation theatre, as well as a sublingual sedative.
Post - surgery instructions
In both techniques visual rest during the first hours is needed, which means lying on your back in a room with poor light, where you can relax until you fall asleep, without forgetting to put on the collyrium.
With Lasik, you will have a post-surgical period that is more comfortable, and after that short rest you will feel better, maybe with a slight sensation of a strange "body" in you eye, which lubricants can ease.
With Lasek or PRK evolution will be different, because discomfort will persist and it might be necessary to give oral analgesics, even to put cold gel or compresses on the area.
Although discomfort will persist with Lasek or PKR during the first couple of days, it will decrease until it completely disappears, usually in day 4 or 5.
Post - surgical medication
For both procedures, medication will be antibiotics, analgesics, steroidal anti-inflammatory, and lubricants of the eye surface.
Antibiotics will be used during 5 to 7 days; same thing happens with the analgesics, and the steroidal anti-inflammatory should be used for three months in the case of Lasek or PKR, and less time for the Lasik.
The use of steroidal anti inflammatory for such a long period of time will be monitored each three or four weeks, and it could be modified according to evolution.
In both cases, lubricants are recommended for at least 6 months after surgery.
Scheduled controls
Usually controls are made 24 to 72 hours after the surgery, and afterwards once a month during the first three months, where results are more stable. Until that period, vision might suffer fluctuant alterations, which are normal in scarring periods.
What are the Intraocular Fakir Lenses?
These are intraocular lenses that are placed in front or behind the iris without removing the crystalline lens. They are transparent, very well tolerated by the body, effective, precise, and have the ability to correct high graduations of astigmatism.
How many types are there?
There are several types, according to placement and design.
There are some with anterior chamber, with angular support (Kelman Model or Kelman Duet) or with iridian support (Artisian or Antiflex model).
Others have posterior chamber (ICL model).
Indications for one or the other are different, and they vary according to the surgeon's experience with them.
We have precise indications for each of them and we use one or the other according to the case.
Which are the steps of the surgical procedure?
All procedures are variable according to model and where they are placed, but all of them have one thing in common: a pre-surgical prophylactic iridectomy usually performed with Yag-laser needs to be done a couple of days before surgery.
The procedure itself can be performed with general or local anaesthetics, according to patient's tolerance to the stress of the surgery.
These surgeries last around 20 to 30 minutes and for collocation of anterior chamber lenses drops will be given to close the pupil, whereas for posterior chamber lenses we need to dilate it.
Which are the surgery risks?
Even though the most common risks are related to increase of eye tension in the immediate post-surgical period and they rarely occur, nobody is exempt from that complication, therefore you should be very strict with the application of the collyrium prescribed. Other complication that is common to every model but is extremely rare is the post-surgical infection, which might appear during controls.
These are the risks of each lens model in particular:
Kelman and Kelman-Duet Model: As these lenses are placed with angle support, complications that may arise are strictly related to the place of support, the pupil can rotate or acquire and oval form. Any condition of the pupil will be noticed by the doctor, who will advise to change that lens for another one with a different size or a different model altogether.
In the Kelman-Duet model haptics and lenses can be interchanged separately.
Artisan and Artiflex model: These are lenses of iridian support that rarely bring along any late or immediate complications. Complications are related to the chronic inflammation of the iris, which can bring complications to patients with predisposition to Uvea inflammation, a condition that will be studied prior surgery.
ICL Model: This lens is injectable and it consists of a material called Collamer, which is very thin and it is placed right behind the iris, where it remains separated from the crystalline lens anterior side. As years go by, partial depigmentation of the iris posterior side may appear, as well as some opacity of the crystalline lens anterior capsule; if any of these conditions exist, they will appear in controls.
After surgery, when is vision restored?
Rehabilitation is fast, usually during the first days, the patient achieves a good visual acuity, which may vary depending if the wound has suture or not, which is going to provide a small corneal astigmatism that will produce a variation in your visual acuity, and will modify gradually until it disappears.
Preparation for surgery
The day of the surgery: there are no diet restrictions, unless total anaesthesia has been planned. In that case, fast should not be inferior to 8 hours. It is advisable to take a shower that includes hair washing. The patient should be in the clinic 30 minutes before the operation.
Before going into the operating theatre, you will receive some anaesthetic drops at regular intervals until you go into the operating theatre, and a sublingual sedative will be given to you.
Post-surgical instructions
In both techniques visual rest during the first hours is needed, which means lying on your back in a room with poor light, where you can relax until you fall asleep, without forgetting to put on the collyrium.
You should inform the professional in case you experience any pain other than a passing discomfort; the procedure is not painful, you may feel a slight sensation of strange body in your eye but not intense pain; if so, you should let the doctor know immediately.
Post - surgical medication
For both procedures, medication will be antibiotics, analgesics, steroidal anti-inflammatory, lubricants of the eye surface, and medication to decrease eye tension. Antibiotics and analgesics will be used during 5 to 7 days, and the steroidal anti-inflammatory should be used for a longer period.
Scheduled controls
Usually controls are made 24 to 72 hours after the surgery, afterwards after 7 days, and then once a month during the first three months.[x] _____________________________________________________________________________________
Equipment Used
SOURCE: Ophthalmological Society of South Africa
http://www.ossa.co.za/
SOURCE: American Academy of Ophthalmology
http://www.aao.org/
SOURCE: The Foundation of the American Academy of Ophthalmology
http://www.eyecareamerica.org/
SOURCE: International Council of Ophthalmology
http://www.icoph.org/med/resources.html
2 Slit Lamps - Haags Streit
2 Snelenn Charts - Nidek
1 Refraction Station - Nidek
1 Corneal Topographer - Tomey
1 Corneal Parquímeter - Tomey
1 Biometric Rule - Tomey
1 Frontofocometer - Nidek
2 Tono meter
1 Oftalmoscope
[x] _____________________________________________________________________________________
In severe cases, a corneal transplant may be needed due to scarring, extreme thinning or contact lens intolerance. This is a surgical procedure that replaces the keratoconus cornea with healthy donor tissue.
Keratoconus Information & Treatment
What is Keratoconus?
Keratoconus or conical cornea is a disorder of the human eye that rarely causes blindness but can significantly interfere with vision. It is a condition in which the rounded shape of the cornea is distorted and a conical shaped prominence is developed. The word keratoconus derive from Greek: kerato- horn, cornea; and konos cone.
Given the cornea is the main eye lens; vision diminishes significantly when it is distorted in this way. Keratoconus evolution is generally slow and can stop its development in any phase: from mild to severe. If the keratoconus progresses, the cornea takes a round shape and becomes thinner and irregular, sometimes producing scarring. Usually it appears bilaterally and the phases are asymmetrical.
Instratromal Rings
What are Instrastromal rings?
It is an orthesic treatment consisting of two semi-circular segments of acrylic material (Perspex CQ) with variable density and diameter. This material has been used for more than 20 years when manufacturing intraocular lenses. It is perfectly tolerated by the body and there is no risk of rejection. It is the most modern and safest treatment for Keratoconus.
How many types of rings are there?
There are two commercial brands of intrastromal rings, KeraRings and Intacs. The diameters, shape, placement technique and surgery instructions are completely different. Even though both are placed in the keratoconus, KeraRings and Intacts are placed according to the evolution of the disease. The criteria or the choice for using one or the other is up to the doctor.
Which are the steps of the medical procedures?
Surgery of Intrastromal Segments is performed in operating rooms especially designed for ophthalmologic surgery. Anaesthesia is only local, just drops. After cleaning the area, a sterile pad is placed covering the eyes, nose, mouth and head. It is performed this way in order to keep sterile the area where surgery is going to be performed, clean from any contamination. It is not a painful procedure and lasts approximately 15 minutes. The use of collyrium, antibiotics, anti-inflammatory and lubricants make the post-surgery period more comfortable and safer. In general after three days you can go back to your habitual routine.
Which are the risks of the surgery?
There are minimum risks. Like in any other surgery, infection is one of the possible complications. In this case, implants need to be removed.
There is no risk of rejection. There are few complications and the most important thing is that surgery is reversible, which means that the ring can be removed and the cornea goes back to its original curvature.
After surgery, when is vision restored?
Modifications in vision are fast and they take place the day after the surgery. Vision does not always improve on the first stage, the percentage of improvement is high, but is not the same in every patient given the cornea speed response to the surgery is not the same in every patient. In all cases, the procedure is very well tolerated by the corneal tissue, but the recovery speed cannot be predicted.
It is normal to have daily vision fluctuations. Especially in the morning, vision is better and may become slightly blurry during the day.
This is not a plastic surgery procedure therefore the use of eyeglasses or lenses might be needed to complete the correction of vision. However, as time goes by visual quality will be better than before the surgery even if you have to use residual correction.
Preparation for surgery
The day of the surgery: there are no diet restrictions, unless total anaesthesia has been planned. In that case, fast should not be inferior to 6 hours. It is advisable to take a shower that includes hair washing. The patient should be in the clinic 30 minutes before the operation.
Before going into the operating theatre, your clothes will be changed so you will be more comfortable. You will receive some anaesthetic drops at regular intervals until you go into the operating theatre.
Post - surgery instructions
Right after the surgery, you might experience these symptoms: pain, tears, photophobia (aversion to light) and red eyes. These symptoms are normal during the post-surgery period. However, it is not normal if the symptoms appear later and in that case you must report it to your doctor immediately. Should you have any doubts, call or go to the clinic.
Post - surgery medication
Antibiotics, anti-inflammatory, lubricants and local analgesic (collyrium).
A minimum interval of 15 minutes between each application is necessary.
The patient should avoid bathing (swimming pool, beach, Jacuzzi), sauna, physical activity, rubbing your eyes, and using make-up.
The cleaning should be done very carefully with saline physiological solution and sterilized gas to avoid any kind of traumatism.
It is important that the patient washes his/her hands carefully with liquid soap, similar to Pervinox, and then dries them with disposable towels before washing his/her face and put the medication in his/her eyes.
While sleeping, the patient should lean on the opposite side of the operated eye. The dropper should touch neither the eye nor the skin.
Scheduled controls
Controls should start the day after the surgery and continue on the 1st, 3rd, 6th and 12th months.
Which are the advantages and disadvantages as opposed to the corneal graft?
• Advantages of the intrastromal segments over the corneal graft are:
• Fast visual recover
• No rejection
• Easy and fast tolerance to the use of contact lenses (if necessary)
• Reversibility
• Keratoconus evolution is stopped or reduced
Can a corneal transplant offer better results than the intrastromal ring?
The corneal transplant needs a long period of visual recuperation around 3 to 12 months and the possibility of rejection exists. It does not warrantee recurring of keratoconus and in most cases the use of eyeglasses or contact lenses is needed to correct the residual optic defect.
Can the ring replace the corneal transplant?
No. The main purpose of the intrastromal segment is visual rehabilitation. However, the implant can delay keratoconus evolution, thus postponing for undetermined time the necessity of a corneal transplant.
Corneal Collagen cross linking with Riboflavin:
What is the corneal collagen cross linking?
It is a process used to generate new unions, or bridges, among the existing collagen chains that are altering the keratoconus.
This process consists in saturating the tissue with a substance that makes it more sensible to collagen, rivoflavin. Then the creation of new bridges or unions among the long chains of collagen are stimulated with irradiation of a special light within the range of ultraviolet light with certain wave length (UVA 375 mm).This light delivers a known energy to a certain distance (3m/cm2), during a certain amount of time (30 min).
What is the surgical procedure?
The procedure is performed with the patient lying down, slightly sedated, and with local anaesthesia. After giving the anaesthesia in drops, a small part of the corneal epithelium is cut for the riboflavin to penetrate in the corneal stroma.
It is irrigated with a riboflavin solution, with continual irrigation, reaching a 30 minute exposure to the light.
Which are the surgery risks?
As in every new treatment, although benefits and complications have been studied, there are parameters that need to be checked with time. For de time being, this procedure has already been performed in Germany, USA, Greece, Spain, and England, among other countries.
After surgery, when is vision restored?
Once the ulcer that was caused by the treatment is healed (approximately 24 to 48 hours) vision will be the same as before treatment. Even though sometimes they occur, this treatment does not bring alterations or improvements in vision, but it does bring modifications in corneal structure which shows in an increase of corneal stability. You can continue using contact lenses previously adapted to treatment, as well.
Post - surgery instructions
You will only need antibiotics during 3 to 4 days until the corneal epithelium heals properly, analgesics and anti-inflammatory if necessary, and lots of lubricants.
Rings and cross linking can be combined
It is only natural to combine both procedures, although it might be uncomfortable for the patient to perform them jointly. Usually, cross linking is performed 30 to 40 days before or after the ring procedure, and it is performed in both eyes.
Given it is not a very invasive procedure, it can be performed as first treatment as well in eyes with small changes and that have never been operated on, or in eyes that have undergone rings surgery, even many years later.
Corneal Transplant
How is the corneal transplant performed?
In recent years, eyes surgery has shown a high level of effectiveness and relative comfort. Corneal transplant surgery is the most successful of every transplant procedure and techniques are developed constantly.
The objective of this procedure is to remove the central part of the patient's cornea and replace it with a donor's cornea. Corneal banks are in charge of obtaining healthy corneas and distribute them to surgeons. These are very common procedures with very good results. Rejection probability is lower than in any other organ transplantation, given the cornea does not have blood vessels. The rejection of other organs generally is the result of incompatibility between donor and recipient, and this incompatibility is mediated by blood cells.
Local or general anaesthesia is used in this procedure and in general hospitalization is not needed after surgery. Given at first vision will be blurry, you will need someone to drive you home. Once you are there, you should lead a quiet lifestyle for several days. Some people experience pain and discomfort after the surgery. Inability to work depends on each person job. Usually, in a sedentary job, the person can return to work in one or two weeks.
The surgeon uses an instrument called drill bit to remove the distorted cornea and to cut a similar portion in the donor's cornea. Then the donor's cornea is placed in the whole of the recipient's cornea and then suture is performed. The whole procedure is performed under microscopic vision. The suture used is thinner than a human's hair.
Bandages are removed usually one or two weeks after the surgery, but the patient is not going to see clearly immediately. Several months will pass by before your vision is stabilized and eyeglasses or contact lenses can be prescribed to you. There are big differences among different cases; therefore the time periods mentioned above should be regarded as general.
Even though there is a 95% probability of success in corneal transplants for keratoconus, this procedure, just as any other surgery, involves potentially serious risks. In cases where the first transplant is unsatisfactory, a second transplant might be the solution. Recurrence of keratoconus in the transplanted cornea has happened but it is extremely rare. Although permanent loss of vision is not frequent, it might occur. Corneal transplant is considered only in those cases where corneal rings are not advisable.
News regarding contact lenses
Keratoconus medical treatment
The irregular nature of astigmatism caused by keratoconus forces doctors to optimize the ways of diagnosis and treatment. The corneal printer, a non-aggressive and highly qualified instrument used for keratoconus evaluation, allows doctor to know the shape of the cornea and to design CUSTOMIZED contact lenses. The materials used are silicon polymers, which are highly permeable to oxygen, and the adaptation and design of contact lenses is guaranteed by doctors, who can solve successfully the difficulties that may arise from adaptation.
Use of contact lenses after the surgery of intrastromal rings
In some cases the implant of intrastromal rings should be compensated with contact lenses, in some cases temporally, in others in a more definite basis.
The lenses used in these conditions are specifically designed, and soft, siliconized materials or permeable polymer gas. In every case, the adaptation and design of lenses is CUSTOMIZED with help of sophisticated instruments of diagnosis and measurement.
Accelerated Orthokeratology
It consists in using during the NIGHT rigid contact lenses permeable polymer gas of inverse geometry. When used at night, these lenses, offer an excellent vision during the day, WITHOUT the help of contact lenses or eyeglasses!
This technique is used in myopias of 6 dioptres, with or without astigmatism of up to 1, 50 dioptres.
It is perfect for children and teenagers between 8 and 20 years, for sportspeople, for every person that for some reason cannot afford refractive surgery, and also for people suffering myopia with some level of presbytia. [x] _____________________________________________________________________________________
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Astigmatism
Astigmatism is a vision condition that causes blurred vision due either to the irregular shape of the cornea, the clear front cover of the eye, or sometimes the curvature of the lens inside the eye. An irregular shaped cornea or lens prevents light from focusing properly on the retina, the light sensitive surface at the back of the eye. As a result, vision becomes blurred at any distance.
Astigmatism is a very common vision condition. Most people have some degree of astigmatism. Slight amounts of astigmatism usually don't affect vision and don't require treatment. However, larger amounts cause distorted or blurred vision, eye discomfort and headaches.
Astigmatism frequently occurs with other vision conditions like nearsightedness (myopia) and farsightedness (hyperopia). Together these vision conditions are referred to as refractive errors because they affect how the eyes bend or "refract" light.
The specific cause of astigmatism is unknown. It can be hereditary and is usually present from birth. It can change as a child grows and may decrease or worsen over time.
A comprehensive optometric examination will include testing for astigmatism. Depending on the amount present, your optometrist can provide eyeglasses or contact lenses that correct the astigmatism by altering the way light enters your eyes.
Another option for treating astigmatism uses a corneal modification procedure called orthokeratology (ortho-k). It is a painless, non-invasive procedure that involves wearing a series of specially designed rigid contact lenses to gradually reshape the curvature of the cornea.
Laser surgery is also a possible treatment option for some types of astigmatism. It changes the shape of the cornea by removing a small amount of eye tissue. This is done using a highly focused laser beam on the surface of the eye.
Astigmatism Information & Treatment. What is Astigmatism?
It is difficult to define astigmatism, but to begin with we have to imagine that in a normal eye parallel light rays coming from the infinite and passing through a transparent and spherical surface (as the one in the eye cornea) converge as they refract and they join in one point called principal focus. Even though this is normal, it is not always like this, and it might happen that rays do not converge in one stigmatic focal point. These deviations are called aberrations. One of these aberrations is astigmatism. Generally, an astigmatic cornea is compared to a lens with the shape of a rugby ball. Parallel rays coming from the infinite and passing through the main curve will converge in a point different from the one passing through the ball flattest curve. These two will be very different points.
. Intracorneal Ring
What are Intracorneal Rings or Intrastromal segments?
It is an orthic treatment consisting of two semicircular segments with variable thickness, arch and diameter, made of acrylic material (Perspex CQ), which has been used for more than 20 years to manufacture intraocular lenses. It is perfectly tolerated by the body without any rejection whatsoever.
Which are the advantages of treat them with rings?
It is a reversible procedure, which means that we can remove or change the segment without causing any tissue alterations or modifications in the pre-surgical keratomy amounts. It keeps the prolacticidad corneal positive because this is not a tissue ablation method but a addition tissue method. It is not very invasive, or intracamerular, it is itracorneal and it is performed with a 1mm incision, with 400 micron depth approximately. It stabilizes the cornea, in case it was unstable (ectasia). The procedure is performed with topic anaesthesia.
The procedure can be reproduced; in a series of 7 eyes, with 5.6 pre-surgical dioptres, a post-surgical 1.2 dioptres was achieved. In figures 9 and 10 we can see the changes in dioptres and in visual acuity with pre-surgical correction vs. visual acuity without post-surgical correction.
Can they be treated with conventional segments?
Certain types of astigmatism can be treated with conventional segments, but in most of them the arch has been modified at 90º and 120º degrees so they have less coupling effect. In figure 11 (see picture) we can see the segments used to treat these astigmatisms.
Which are the steps of the surgical procedure?
The procedure is performed with the patient lying down, slightly sedated and with local anaesthesia. After putting the anaesthesia in drops in the cornea, a small portion of the corneal epithelium is cut for the riboflavin to penetrate into the corneal stroma.
The corneal tissue is irrigated several times with a riboflavin solution, until the saturation is enough to irradiate the corneal tissue with the necessary source of energy to create these unions.
Every 5 minutes, the cornea is irrigated with the riboflavin substance, but irradiating at the same time, until reaching a 30 minutes exposure to light.
Which are the surgery risks?
Risks are minimal. Like in any other surgery, infection is one of the complications. In this case, implants have to be removed.
There is no risk of rejection. There are few complications, and the most important thing is that surgery is reversible, which means the ring can be removed and the cornea goes back to its old curve.
After surgery, when is vision restored?
Modifications in vision are fast and they take place the day after the surgery. Vision does not always improve on the first stage, the percentage of improvement is high, but is not the same in every patient given the cornea speed response to the surgery is not the same in every patient. In all cases, the procedure is very well tolerated by the corneal tissue, but the recovery speed cannot be predicted.
It is normal to have daily vision fluctuations. Especially in the morning, vision is better and may become slightly blurry during the day.
This is not a plastic surgery therefore the use of eyeglasses or lenses might be needed to complete the correction of vision. However, as time goes by visual quality will be better than before the surgery even if you have to use residual correction.
Preparation for surgery
The day of the surgery: there are no diet restrictions, unless total anaesthesia has been planned. In that case, fast should not be inferior to 6 hours. It is advisable to take a shower that includes hair washing. The patient should be in the clinic 30 minutes before the operation.
Before going into the operating theatre, your clothes will be changed so you will be more comfortable. You will receive some anaesthetic drops at regular intervals until you go into the operating theatre.
Post - surgery instructions
Right after the surgery, you might experience these symptoms: pain, tears, photophobia (aversion to light) and red eyes. These symptoms are normal during the post-surgery period. However, it is not normal if the symptoms appear later and in that case you must report it to your doctor immediately. Should you have any doubts, call or go to the clinic.
Post - surgery medication
Antibiotics, anti-inflammatory, lubricants and local analgesic (collyrium).
A minimum interval of 15 minutes between each application is necessary.
The patient should avoid bathing (swimming pool, beach, Jacuzzi), sauna, physical activity, rubbing your eyes, and using make-up.
The cleaning should be done very carefully with saline physiological solution and sterilized gas to avoid any kind of traumatism.
It is important that the patient washes his/her hands carefully with liquid soap, similar to Pervinox, and then dries them with disposable towels before washing his/her face and put the medication in his/her eyes.
While sleeping, the patient should lean on the opposite side of the operated eye. The dropper should touch neither the eye nor the skin.
Scheduled controls
Controls should start the day after the surgery and continue on the 1st, 3rd, 6th and 12th months.
Excimer Laser (Lasik - Lasek)
. What is the surgery with Excimer Laser (Lasik-Lasek)?
Excimer Laser delivers energy with the capacity of ablating corneal tissue with cold, in a precise form, and without solid waste. It breaks up the unions that keep the atoms together, thus volatilizing the tissue exposed to energy. This energy can be handled in a way that tissue can be reached with precision and can be delivered in different parts of the cornea. If the delivery (ablation) is performed on the anterior surface of the cornea, removing only the epithelium that covers it, this will be what we call PRK (Photo Refractive Keratectomy). If we use diluted alcohol to remove the epithelium and then replace it after the ablation, it will be a Lasik.
Which are the steps of the surgical procedure?
Either performing one technique or the other, the procedure is fast, effective, and is performed with local anaesthesia, with a slight sedation.
Usually, Lasek and PKR are performed one at a time and sequentially, because the post-surgical period is not very pleasant; it presents discomfort for a couple of days during re-epithelization of the wound; Lasik is usually performed bilaterally and simultaneously since the post-surgical period is more comfortable.
Which are the surgery risks?
As in every surgical procedure, infection is a serious but unusual complication. Most frequent complications are easily dealt with, these are some: flap alterations, hypo or hipercorrections, desepithelization and epithelium.
If the patient follows strictly these indications and, specially, does not rub his/her eyes, there are minimum chances for the complications to occur.
If the procedure performed was a Lasik, rehabilitation is going to be faster: within 24 to 48 hours the patient is in levels of pre-surgical correction.
If the procedure was a PRK or Lasek, rehabilitation is going to be slower and evolution difficult, because as the corneal surface suffers re-epithelization, the patient does not see properly, and feels discomfort as if there was a strange body in his/her eye. Rehabilitation will be progressive from the 5 or 7 day onwards.
Preparation for surgery
The day of the surgery: there are no diet restrictions, unless total anaesthesia has been planned. In that case, fast should not be inferior to 6 hours. It is advisable to take a shower that includes hair washing. The patient should be in the clinic 30 minutes before the operation.
Before going into the operating theatre, some anaesthetic drops will be given to you at regular intervals until entering into the operation theatre, as well as a sublingual sedative.
Post - surgery instructions
In both techniques visual rest during the first hours is needed, which means lying on your back in a room with poor light, where you can relax until you fall asleep, without forgetting to put on the collyrium.
With Lasik, you will have a post-surgical period that is more comfortable, and after that short rest you will feel better, maybe with a slight sensation of a strange "body" in you eye, which lubricants can ease.
With Lasek or PRK evolution will be different, because discomfort will persist and it might be necessary to give oral analgesics, even to put cold gel or compresses on the area.
Although discomfort will persist with Lasek or PKR during the first couple of days, it will decrease until it completely disappears, usually in day 4 or 5.
Post - surgical medication
For both procedures, medication will be antibiotics, analgesics, steroidal anti-inflammatory, and lubricants of the eye surface.
Antibiotics will be used during 5 to 7 days; same thing happens with the analgesics, and the steroidal anti-inflammatory should be used for three months in the case of Lasek or PKR, and less time for the Lasik.
The use of steroidal anti inflammatory for such a long period of time will be monitored each three or four weeks, and it could be modified according to evolution.
In both cases, lubricants are recommended for at least 6 months after surgery.
Scheduled controls
Usually controls are made 24 to 72 hours after the surgery, and afterwards once a month during the first three months, where results are more stable. Until that period, vision might suffer fluctuant alterations, which are normal in scarring periods.
. Intraocular Fakir Lenses
What are the Intraocular Fakir Lenses?
These are intraocular lenses that are placed in front or behind the iris without removing the crystalline lens. They are transparent, very well tolerated by the body, effective, precise, and have the ability to correct high graduations of astigmatism.
How many types are there?
There are several types, according to placement and design.
There are some with anterior chamber, with angular support (Kelman Model or Kelman Duet) or with iridian support (Artisian or Antiflex model).
Others have posterior chamber (ICL model).
Indications for one or the other are different, and they vary according to the surgeon's experience with them.
We have precise indications for each of them and we use one or the other according to the case.
Which are the steps of the surgical procedure?
All procedures are variable according to model and where they are placed, but all of them have one thing in common: a pre-surgical prophylactic iridectomy usually performed with Yag-laser needs to be done a couple of days before surgery.
The procedure itself can be performed with general or local anaesthetics, according to patient's tolerance to the stress of the surgery.
These surgeries last around 20 to 30 minutes and for collocation of anterior chamber lenses drops will be given to close the pupil, whereas for posterior chamber lenses we need to dilate it.
Which are the surgery risks?
Even though the most common risks are related to increase of eye tension in the immediate post-surgical period and they rarely occur, nobody is exempt from that complication, therefore you should be very strict with the application of the collyrium prescribed. Other complication that is common to every model but is extremely rare is the post-surgical infection, which might appear during controls.
These are the risks of each lens model in particular:
Kelman and Kelman-Duet Model: As these lenses are placed with angle support, complications that may arise are strictly related to the place of support, the pupil can rotate or acquire and oval form. Any condition of the pupil will be noticed by the doctor, who will advise to change that lens for another one with a different size or a different model altogether.
In the Kelman-Duet model haptics and lenses can be interchanged separately.
Artisan and Artiflex model: These are lenses of iridian support that rarely bring along any late or immediate complications. Complications are related to the chronic inflammation of the iris, which can bring complications to patients with predisposition to Uvea inflammation, a condition that will be studied prior surgery.
ICL Model: This lens is injectable and it consists of a material called Collamer, which is very thin and it is placed right behind the iris, where it remains separated from the crystalline lens anterior side. As years go by, partial depigmentation of the iris posterior side may appear, as well as some opacity of the crystalline lens anterior capsule; if any of these conditions exist, they will appear in controls.
After surgery, when is vision restored?
Rehabilitation is fast, usually during the first days, the patient achieves a good visual acuity, which may vary depending if the wound has suture or not, which is going to provide a small corneal astigmatism that will produce a variation in your visual acuity, and will modify gradually until it disappears.
Preparation for surgery
The day of the surgery: there are no diet restrictions, unless total anaesthesia has been planned. In that case, fast should not be inferior to 8 hours. It is advisable to take a shower that includes hair washing. The patient should be in the clinic 30 minutes before the operation.
Before going into the operating theatre, you will receive some anaesthetic drops at regular intervals until you go into the operating theatre, and a sublingual sedative will be given to you.
Post-surgical instructions
In both techniques visual rest during the first hours is needed, which means lying on your back in a room with poor light, where you can relax until you fall asleep, without forgetting to put on the collyrium.
You should inform the professional in case you experience any pain other than a passing discomfort; the procedure is not painful, you may feel a slight sensation of strange body in your eye but not intense pain; if so, you should let the doctor know immediately.
Post - surgical medication
For both procedures, medication will be antibiotics, analgesics, steroidal anti-inflammatory, lubricants of the eye surface, and medication to decrease eye tension. Antibiotics and analgesics will be used during 5 to 7 days, and the steroidal anti-inflammatory should be used for a longer period.
Scheduled controls
Usually controls are made 24 to 72 hours after the surgery, afterwards after 7 days, and then once a month during the first three months.[x] _____________________________________________________________________________________
Equipment UsedSOURCE: Ophthalmological Society of South Africa
http://www.ossa.co.za/
SOURCE: American Academy of Ophthalmology
http://www.aao.org/
SOURCE: The Foundation of the American Academy of Ophthalmology
http://www.eyecareamerica.org/
SOURCE: International Council of Ophthalmology
http://www.icoph.org/med/resources.html
2 Slit Lamps - Haags Streit
2 Snelenn Charts - Nidek
1 Refraction Station - Nidek
1 Corneal Topographer - Tomey
1 Corneal Parquímeter - Tomey
1 Biometric Rule - Tomey
1 Frontofocometer - Nidek
2 Tono meter
1 Oftalmoscope
[x] _____________________________________________________________________________________
