Ophthalmic Surgery

Each disease with the image that defines it: what it looks like, what the scan shows, and which operation answers it.

Retinal detachment

The film peeling off the camera's back plate.

Mechanism

The ageing vitreous detaches and tugs; a tug can tear the retina; fluid then passes through the tear and lifts the retina off its pigment epithelium, separating it from its oxygen and its pump.

The warning sequence

Flashes (traction), floaters (debris and blood), then the field defect or curtain: the sequence is the public-health message, because a tear lasered at the flashes-and-floaters stage never becomes a detachment.

The macula clock

Macula-on detachments are repaired urgently to protect central vision; macula-off repairs still matter but the tempo changes: the status is the first question in every referral.

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Repair

Close the tear and reattach: vitrectomy with gas or oil tamponade, scleral buckle, or pneumatic retinopexy, with posturing afterwards part of the treatment and air travel forbidden with gas in the eye.

Case: Floaters, flashes, and a curtain

Clinical photo

Compare with a normal retina

• Cataract

  The commonest operation on earth, decided by function.

  The disease

  Lens proteins aggregate and cloud with age (and diabetes, steroids, trauma, congenitally): vision mists, glare scatters, and refraction drifts.

  The decision

  Surgery when the blur costs function the patient values: there is no threshold acuity, and the honest question is what the patient cannot do that they want to.

  The operation

  Phacoemulsification: ultrasound fragments the lens inside its capsule through a tiny incision, and an intraocular lens unfolds into the empty bag, with the refractive target chosen beforehand.

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  Afterwards

  Drops, days of blur clearing, and a famous complication list learned because the operation is so common: posterior capsule opacification (lasered later), and the rare emergencies of endophthalmitis and haemorrhage.

  Phacoemulsification with IOLCase: Losing the reading, and then the road signs

• Glaucoma & angle closure

  The drainage angle, the pressure, and the nerve that pays.

  The plumbing

  Aqueous is made behind the iris and drains through the trabecular meshwork at the angle: obstruct outflow and pressure rises against the optic nerve head.

  Two diseases

  Open-angle glaucoma is chronic, silent field loss over years, managed with drops, laser and surgery; angle closure is the acute, painful, vomiting emergency of a suddenly sealed drain.

  The acute attack

  Mid-dilated fixed pupil, hazy cornea, rock-hard globe, pain and vomiting: pressure is lowered medically within the hour and the anatomy fixed with laser iridotomy, in both eyes.

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  Surgical glaucoma

  When drops and laser fail: trabeculectomy fashions a guarded fistula, tubes shunt aqueous to a plate, and the postoperative art is titrating a wound that must heal exactly partially.

  Case: A red eye and vomiting

• The open globe

  A breached pressurised instrument: surgery's smallest polytrauma.

  Recognition

  Obvious lacerations are the easy ones: the treacherous cases are the quiet penetrations after hammering or grinding, the peaked pupil, the shallow chamber, and the visible dark uveal tissue at a wound.

  First response

  Shield without pressure, nothing by mouth, analgesia and antiemetics, tetanus, no drops or pads, and no examination force: everything that squeezes the globe can extrude its contents.

  Imaging

  CT orbits for the foreign body and the fracture map; MRI forbidden until metal is excluded: the history of metal striking metal is itself an imaging indication.

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  Repair and stakes

  Watertight primary closure in theatre, staged reconstruction after, endophthalmitis prophylaxis, and the counselling registry: final vision tracks the injury more than the repair, and sympathetic ophthalmia is the rare reason the fellow eye is mentioned.

  Primary repair of an open globeCase: A hammer, a chisel, and no goggles