Time-sensitive Elective Surgery

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Did you know? – During COVID-19 lockdowns, many doctors and patients have struggled to get authorization from their insurers for medical and surgical procedures because these were deemed “elective”. However, elective simply means that the doctor and patient can “elect” the day, time and place to perform a procedure optimally. That is, in a familiar environment, with familiar staff and instruments, a rested surgeon and a stable, nil per os patient. Elective does not mean that there are no time-sensitive aspects to a procedure. In fact, elective procedures are essential, because they minimize urgent procedures, which in turn minimize emergency procedures.

Take cataract surgery for example. Very elective. We might as well do it 5 years’ time rather than now, under lockdown. Right? Not exactly. First, cataract surgery has been shown to reduce the risk of all-cause mortality; the vulnerable become less vulnerable. Sure, most cases can be delayed to some extent without harm. However, there are many intrinsic time sensitive elements to cataract surgery. The older a patient gets, the harder a cataract becomes, and at some point it can become hard enough to make surgery more difficult. Some cataracts contribute to narrowing of a delicate angle inside the front of the eye and this can cause acute glaucoma. Cataracts can obscure the view of the back of the eye and interfere with the evaluation and treatment of other pathology like nerve thinning and retinal bleeding. Workers delivering essential services now face increased demands in some sectors and risk accidents as their cataracts become more symptomatic. The list goes on.


Remember that the decision to treat or not lies with the patient, a qualified and trusted doctor, and the respectful discussion between them, not with your medical aid or their medical advisers.

Neuro-ophthalmology

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WHAT IS A NEURO-OPHTHALMOLOGIST?

Technically, in South Africa, such a person does not exist. After first becoming a general practitioner or medical officer and then going on to specialize as an ophthalmologist (also called an eye specialist or ophthalmic surgeon), a doctor can go on to specialize even further in a subspeciality (sometimes called super-specialization). This is normally through a very intensive type of residency program called a fellowship and in ophthalmology this is almost always done at an overseas centre. Subspecialities include corneal surgery, glaucoma, neuro-ophthalmology, ocular oncology, oculoplastics, orbital surgery, paediatric ophthalmology, refractive surgery, uveitis, vitreoretinal surgery and medical retina. However, in South Africa not all subspecialities are formally recognized and registered, and these include those that fall under ophthalmology. Eye specialists still indicate their expertise and practice scope by saying that they have a fellowship / extensive experience / special interest in a specific subspeciality. There are also large areas of overlap between the different subspecialities, including neuro-ophthalmology. In short, all ophthalmologists in South Africa have been trained in neuro-ophthalmology, but it is not a separate field of sub-specialist practice recognized by the HPCSA.

Neuro-ophthalmology deals with disorders related to the nerves that travel between the brain and the eye as well as the brain itself with its various visual interpretation, control and integration areas. The nerve tissue of the visual system starts in the eye as the neuroretina. (Most people have at least heard about a condition called retinal detachment. This is a separation of the neuroretina from the rest of the tissue inside the eye. More about this in future.)

Groups of ophthalmic conditions that typically fall within the scope of neuro-ophthalmology are the following:
• Persistent vision loss such as that caused by damage to the optic nerve, strokes or brain tumours.
• Temporary vision loss like the aura some people see before the get a migraine or the curtain-like obscuration caused by a very small stroke in the eye.
• Visual illusions, hallucinations and other so-called higher cortical (located in the brain) visual disorders. This is a very complex group of conditions, including for instance, an inability to recognize familiar faces, an inability to read what one has just written, or being unaware that one is missing half of one’s visual field. Although relatively common in patients with previous strokes, they are easily missed or misinterpreted and it is important to help these patients get proper evaluation for neuro-rehabilitation.
• Double vision and eye movement disorders. Controlling the completely harmonious voluntary and involuntary movement of our eyes is another complex function of the brain and brainstem. When this control breaks down and specifically, when one or more of the three nerves that supply our eye muscles are damaged, we can no longer focus on two identical images for the brain to fuse together, but instead see two different images at the same time, causing tremendous discomfort.
• Other abnormal eye movements including the involuntary, jerky back-and-forth movements called nystagmus.
• Abnormal pupillary reactions, for instance an asymmetry in the sizes or reactivity of one’s pupils.
• Eyelid and/or facial abnormalities like twitching, uncontrollable blinking, eyelid retraction (abnormal staring gaze) and Bell palsy.
• Pain of the eye, the face (“around the eye”) or headache (pain “behind the eye”).
• Non-physiologic or nonorganic eye disorders, in which a patient has visual complaints even though there is nothing wrong with a person’s visual system.
• Systemic (“whole body”) conditions associated with neurological problems. A few big ones are infections (HIV, tuberculosis, syphilis and herpes virus), cardiovascular (diabetic vasculopathy, hypertension, high cholesterol) and auto-immune (including multiple sclerosis, thyroid dysfunction, systemic lupus, sarcoidosis and myasthenia gravis).

Do you know someone who needs neuro-ophthalmic evaluation?

Glaucoma: MIGS and LASERS

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Before I start the counselling process with a newly diagnosed patient, I usually ask them what their current understanding of a specific condition or procedure is. In the context of glaucoma, the answer is usually either “high pressure” or “it causes blindness”.

 

There is so much more to glaucoma. Yes, it CAN cause blindness, but doesn’t have to. Yes, the intra-ocular pressure is often high, but not always. I recently wrote a post for Sandhurst Eye Centre‘s Facebook Page on some of the advances in glaucoma surgery, and in it I mention useful posts by my colleagues on the same page. Have a look, and see our other recent social media posts as well.

Cataracts

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CATARACTS – Globally still the leading cause of blindness despite being fully treatable. In fact, cataracts are preferably treated when they are not too hard and haven’t yet caused total blindness. Contrary to what I’m commonly asked, a cataract isn’t something that grows in or on top of the eye. Rather, it is the eye’s own natural lens that becomes opaque. These opacities are caused by damage to the lens’s crystalline fibers due to aging, metabolic disorders, trauma, etc. Our latest social media feeds focus on some general info and updates related to cataracts. Have a look!

Age-related Macular Degeneration

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AGE-RELATED MACULAR DEGENERATION (AMD) is a major cause of permanent vision loss, affecting the central vision of millions of elderly people worldwide. Despite remarkable advances in recent decades with regards to not only our understanding of the disease process, but also our ability to slow some of the devastating effects thereof, the search is still on for ways to truly halt the progression of AMD and hopefully even reverse it. For more on this, check out some of the most recent links in our social media posts.

Glaucoma

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GLAUCOMA is the leading cause of irreversible blindness in the world (Quigley, 2006). An interesting case comes to mind where a patient presented with high eye pressures and cavernous damage to his optic nerve, both typical of glaucoma. Was this patient genetically destined to develop this problem, or could it have had something to do with the steroid nasal spray that’s been used chronically? This week’s social media posts and reposts focuses on various aspects of the disorder, including the roles of diet and medical steroids.