Retinal detachment is a formidable eye disease that, without surgical treatment, most often results in complete loss of vision.

The human eye can be compared with the device of the camera, the lens of which is the cornea with the lens, and the film is the retina, an extremely complex multi-layer structure that is connected to the visual divisions of the brain with the help of nerve fibers. Therefore, we can assume that the retina is a part of the brain.

Retinal detachment most often takes the patient by surprise — before it appears, a person may have excellent vision and may not present any complaints. The speed of propagation of the process is quite rapid, the treatment in the majority of cases is surgical.


The timeliness of the operation gives a chance to preserve vision; in Germany, according to the standard, the operation must be performed within 24 hours after the diagnosis. There are no such standards in Russia. But for each patient, I say that retinal detachment is “like fresh frozen fish” — in a couple of days it’s already “not the first freshness”.

Can you imagine what a person feels who does not see or almost does not see the world around? This condition is called blindness — the inability to perceive visual stimuli due to pathological disorders in the eye itself, in the optic nerves or in the brain. In 1972, the World Health Organization (WHO) adopted the following definition: a person is considered blind if the sharpness of central vision under conditions of maximum correction does not exceed 3/60. With this vision, a person in daylight conditions with maximum optics correction is unable to count fingers from a distance of 3 meters.

So for such cases, the idea of ​​electrical stimulation of the retina or visual cortex was proposed, the creation of a prosthesis that, by the mechanism of action, simulates the actual processes of transmission of electrical signals.


There are several variants of electronic implants, each year new ideas appear, but the term and the Bionic Eye itself were developed by Daniel Palanker, a staff member at Stanford University and his research group Biomedical Physics and Ophthalmic Technologies.

The implantation of the Argus II bionic eye model (by the way, the only model that has an EU brand, but not certified in Russia) was performed in Russia in July 2017 for one patient. And from all sources of television broadcasting we heard — now a person will be able to see the world as before. Hundreds of people are asked to put a bionic eye, and some also ask to “implant” the chips for super-vision.

So what do we have today and can the dream to see the world come true after it has lost sight?

Imagine the situation — you live in peace, nothing hurts and does not blush, wear glasses or lenses, or do not use anything and see perfectly — and you accidentally get an appointment with an ophthalmologist. For example, because of conscription into the army, because of pregnancy, or just for a dispensary examination. And suddenly you will find out that your retina is “full of holes” or stretched and is about to break.

And they recommend you to “sew it on”. And you doubt — and this is exactly what you need? And how safe is it? But nothing bothers — then why? Or maybe they want to earn money on me? And the first thing you start is to read posts on the Internet, what a “independent” expert like Google will say.

And in the future everything depends on your discipline and attention to your own health. You can get to the ophthalmologist-laser specialist, who will be the last resort, and he will do preventive laser coagulation.

Or «forget it» for everything and continue to live as before — nothing bothers you. What is the risk?

Friends, after a break, we resume publications on vision and technology to restore it. The pause was connected with my workload of operations and participation in conferences: in the near future I will publish a review of the most interesting technical innovations in ophthalmology that were presented at them, and today we will talk about astigmatism.


Modern statistics depressing. More than half of the world's population suffers from visual impairment, the most common problems are myopia and hyperopia. But ophthalmologists often diagnose another disease, the name of which is unfamiliar to many. Astigmatism is a defect in the optical system of the eye when the sharpness of the image is asymmetric vertically and horizontally. And the parallel rays of light passing through the eye are focused not into a point, but into the “eight”. For a person, this means that the visibility of the image becomes unsharp, and this often applies to both distant and close objects. As a result, instead of a normal image, a person sees a distorted image, in which some lines are clear, others are blurred. An idea of ​​this can be obtained if you look at your distorted reflection in an oval teaspoon.

Ophthalmologists say that almost two thirds of the world's inhabitants face such a problem. But since the degree of astigmatism may be small, many people practically do not feel any discomfort. It is difficult for doctors to identify a clear list of common symptoms indicating that a patient has astigmatism. In each case, they will differ. In the very early stages, it is often confused with tired eyes.

However, quite a few people need special treatment or correction of this disorder with the help of glasses, contact lenses or even surgery.

We know that nobody is immune to glaucoma.

The number of patients with glaucoma worldwide more than 100 million (!) People. Nine out of ten blind people live in developing countries, and two thirds of them could be cured, they begin to be treated on time.

Glaucoma is the second cause of blindness after cataract — up to 20% of all cases of the disease end with it. Some people do not know about the disease. Glaucoma is often detected at stage 2–3 or at the last, 4th stage, when it is often impossible to help a person. In Russia, glaucoma has recently become the first cause of irreversible blindness, overtaking injury and vascular eye disease.

Despite a serious breakthrough in the understanding of many of the problems of glaucoma over the past few years, it must be admitted that so far no effective methods have been proposed to prevent the disease, its early (fairly cheap method!) Identification and treatment methods that are widely available.

The trouble is that the prevention of this disease, we have long ceased. Previously, after forty, all Soviet people were sure to measure eye pressure once a year. In clinics there were professional examination rooms, people with elevated intraocular pressure were referred to an ophthalmologist. And so revealed about half of patients with glaucoma. Now there is nothing like this. Saving patients was the work of the patients themselves (that is, drowning people).


Since the treatment of glaucoma is just as dangerous as caving — you climb into the dark, and when and what falls on your head, science is unknown. But if you don’t fall, you will drown or suffocate yourself — there are options. When you guess where you are, it will be too late. Let me start with a number of rules described below.

Among the eye diseases are those that are especially dangerous. At first they are asymptomatic — nothing hurts, there are no complaints, they can “disguise” as other “mild” diseases and, most importantly, appear at any age and irrevocably “destroy” their eyesight.

Imagine if you left your left eye accidentally, but with your right, everything is “like a fog”! Read on the Internet how to help yourself or call your friends, and they — do not worry, blink. While they were waiting, it seemed that the fog was really over. This is how periods of anxiety recur, but at first there is little concern. And he (the murderer) began his insidious business. And as a rule, in both eyes, even if the second does not bother! And age is not an obstacle — children are also susceptible to this disease — 10% of children are blind from glaucoma.

Glaucoma is quite common in all countries — in 15% of cases of blindness, it is she who is the cause. This puts her in second place to the causes of incurable blindness!

And all is why — because the human brain very well «replaces» the dips in the field of view, if they arise gradually, adapt, and only when 30-40% of the optic nerve the feeling of «fog» begins. And all — hello, lost non-renewable!

What do you think, how many operations can be done on one eye? A clinical case of one of my patients confirms that more than 20 operations of various kinds are not the limit. Although, no doubt, this case is a record for Russia and the world of ophthalmology.

In 1978, everything was trivial — there was an 18 year old boy (let's call him “A”) who wanted to become a test pilot like his father. This was hampered by weak myopia of the right eye — only minus 1, it did not interfere with life, but the future pilot needed good vision. He decided to correct the optics of one eye by keratotomy — the old “manual” correction method at the Fedorov Institute (of course, through an acquaintance), but something went wrong. This was the first operation. Then four more in Russia, then seven more — in Switzerland. He did not become a pilot, but he became an oligarch, a man who manages serious business projects, but does not control the situation with his vision.

To me, «A» got completely disappointed in the world of ophthalmology, with 10% vision, the impossibility of correction by standard methods and high intraocular pressure. And it was a young 50-year-old businessman, successful in life (this is important — because not everything went further «like that» either). So — the next eight operations are mine. And although we expected that one or two would be enough — we had to go through almost total ophthalmic surgery — all possible types of operations.

By the way, instead of keratotomy, there would be a correction of SMILE (ReLEX SMILE) or, at least, Femto-LASIK — there wouldn’t be anything to write about — it’s impossible to do anything like that!

Практика показывает, что далеко не каждый человек знает, что такое острота зрения. Например, если вы узнаете, что курица видит на 300%, то есть точно лучше каждого из нас, и глаза у нее видят по-разному — то вы удивитесь.

В древние времена остроту зрения проверяли по созвездию Большой Медведицы в ночном небе. Это созвездие напоминает «ковш с ручкой» и практически всегда видно на ночном небе. Так рядом со второй звездой от конца «ручки ковша» (Мицар) находится малозаметная небольшая звезда Алькор («забытая, незначительная»). Способность видеть эту малозаметную звезду считалась традиционным способом проверки зрения, условной нормой. То есть, система была бинарная – «вижу» и «не вижу».


Эра починки зрения началась несколько столетий назад, использовать для этого лазер стали всего пару десятилетий назад и совершили технологический скачок до эндоскопической коррекции зрения ReLEX SMILE, о ней писала здесь.

В мире с 1985 года выполнено более 60 миллионов процедур по лазерной коррекции зрения! И все эти люди счастливы, что получили 100% зрение, спросите вы? А теперь самое интересное – нет, не все счастливы. И уж точно не у всех 100%.

Что может быть причиной не 100% зрения, почему люди «щурятся», как оценивать показатели приборов, которые измеряют параметры глаза, в том числе после лазерной коррекции, можно ли им доверять, как избежать багов при тестировании, какие исследования, зачем и когда необходимы, чтобы прояснить картину?

Поделюсь тем, что должен знать офтальмолог, и как правило, о чем не в курсе пациент.

The last method in our vision correction cycle is hard contact lenses for night use. They are second to safety after points. Conventionally, the safest correction method is definitely glasses (with durable polycarbonate lenses), then ReLEx SMILE and hard night lenses, then femtoLASIK and PRK, then soft one-day lenses, then “barbaric methods” — soft lenses of long-wearing and LASIK. Separately, there are phakic intraocular lenses and artificial lenses — they are best done only by direct medical indications (quite an invasive method for refractive indications).

The main advantage of night lenses is clinically proven to stop progressive myopia. Therefore, they are often prescribed to children when the eye is actively developing. After 20 years, this effect decreases by an order of magnitude, but a couple of other advantages remain.

Payback for the obvious advantages — the high price of such lenses, the need for strict discipline and regular sleep for at least 7 hours.

Nylon 10/0 (to sew the cornea)

For the “last chance” operation or cornea transplant, donor tissue is needed. Specifically, we are interested in tissue with a thickness of 500–600 microns for penetrating keratoplasty. Next you need to work with this film with your hands, sew with a thin nylon thread. Then, when the cornea grows together, remove the suture. No biodegradable materials — their decay products will begin to lysing and can cause inflammation, which will exclude a positive result of the operation. Moreover, the transplant is recommended to flash twice around the perimeter — this increases the chances of its correct and uniform fixation. The second layer of nylon is most often not removed at all, because as long as it does not interfere, we don’t touch it.

But let's start from the beginning. Specifically, from situations where a person may need this difficult for Russia operation, but quite familiar in Germany. It is of three types:

• PKP, that is, the removal of the entire cornea of ​​the patient, for example, with a diameter of 7 to 8.5 mm and sewing on a new one.
• DALK, that is, corneal tissue transplantation with the exception of the Descemet's membrane and endothelium.
• DMEK, that is, the «installation» of only the layer of the Descemet's membrane and endothelial cells instead of the same layer in a patient.

Of course, “we cannot do it ourselves” —the surgery requires another surgeon whom you trust 100%. Answering the question of who the relatives trust — I use mine myself. I did the operation to my mother, aunt, daughter, husband — who needed something “to fix”. Walter operated on his wife and father-in-law.

We can usually do this while shooting or tell how it happens, with the consent of loved ones. We do this when we need to “sacrifice” someone for the sake of science. In our clinic already 6 people after laser vision correction. In the network of clinics SMILE EYES also a few people. The last case — we have 7 years of work in the position of operating nurse-administrator girl Anya, she meets and escorts patients for refractive operations. She is experienced with experience: by the age of 35, fifteen she wore soft contact lenses, sometimes she used glasses. The idea of ​​correction lived in her for all 7 years — as it happens, she saw many times in the form of records from the operating rooms. She saw both Lasik and femtoLasik, and only the operation of vision correction ReLEX SMILE (minimally invasive lenticle extraction) instilled in her confidence in safety and painlessness.

About Anya: I was preparing for the operation as it should be — for a week I honestly took off contact lenses and used glasses. The patients of the clinic were surprised and asked why she was wearing glasses, explaining that she was preparing for a correction. The day was chosen so that she spent the morning in the clinic; in the afternoon, a correction could be made. On this day, I had several SMILE, several SMILE operations — with Walter, who came from Germany. We agreed that Anya will be operated by Professor Sekundo, and I will help camera operators with shooting.

The lens in your eye can change its optical power: when you focus somewhere on the vision, this is what happens. Payback for the «moving parts of the mechanism» — wear with age. At about 40-45 years old, problems usually begin with age-related visual impairment; in 60-70 years, you need up to three pairs of different points. At the same time, the clarity of view is reduced due to the process of sclerosis and lens opacity — it is worth thinking about replacing the lens, until it becomes dim and becomes completely rigid.

To date, the technology of replacing the lens is standardized and well developed. Potential risks are generally somewhat higher than with laser vision correction, but at present this type of surgery is performed even on transparent lenses with refractive purpose (when the patient does not like to wear glasses with thick glasses), that is, it is quite a “household” task for ophthalmology.

This is a model of an intraocular multifocal lens from Carl Zeiss. The real size of such a lens is 11 millimeters, the diameter of the optical zone is 6 mm.

The cataract is, simplifying, age opacification and consolidation of a crystalline lens. According to the classical definition, we are talking about the turbidity of any type. First, something gets in the field of view, a general “fog” appears, you want to wipe dirty glasses, then you do not see the letters in the book, then you want to turn on the light brighter or, on the contrary, you hide from the bright light, and then wake up one fine morning and understand that you can not find slippers. And you see nothing at all — only the shadows. This process sometimes stretches for many years, but slippers are still lost. Mention of clouding that develops in the eyeball, there are still thousands of years before our era.

The treatment procedure has historically been very peculiar — reclination of a cloudy lens. The doctor took the patient with a very dense lens — to that dense stage that the patient is already blind. During the excavations of the settlements of ancient Greece and Rome, the tools used by doctors to remove cataracts were found — sharp needles that pierced the eye and lens, destroying its supporting apparatus. The lens could come off and, by virtue of its gravity, could also fall down from hitting the back of the head with a heavy stick several times. Sometimes the patient died during the emergency eye care, sometimes he had a concussion, and sometimes the lens fell off the ligaments and flew deep into the eye. The patient began to see again — he had a huge lump and vision of about +10 +15 diopters.

Now two news. The bad — people began to live to cataracts more often, and it is inevitable. Good — we have something better than sharp needles and a heavy stick.

— Which is better: glasses, lenses or laser vision correction?
It is best to see without any means of correction. If you are completely satisfied with the glasses — keep calm, no other correction is needed. Lenses — this method of correction requires adherence to clear rules of use, which is ultimately more costly and risky, but it is very popular because the main dangers do not appear immediately after the start of wearing, but years later.

— I decided to stay on the glasses, but I am afraid that the car's pillow will open in my face and they will become contact lenses. What to do?
In my surgical experience, modern airbags do not injure eyeglasses. Eyes and face are usually damaged by windshield fragments. If you are concerned about the safety of glasses, then think about the modern, with polycarbonate lenses, they are incredibly durable, the car drives on crash tests.

— Is it true that all eye disease from the computer?
No, it's not true. The main cause of problems with optics — myopia, hyperopia or astigmatism — is genetics. Adverse environmental conditions, especially during long-term work at close range, are important in childhood, when the development of the organism is not yet complete. And such diseases as cataract, glaucoma, retinal detachment and other diseases occur with the same frequency in those who work at the computer for hours and in those who do not know where the computer has a power button.

In surgery, the term «augmentation» is used for a specific type of intervention, for example, hardening (building) the skeleton of an organ. We will talk about the empowerment of biological vision at the expense of implants.

You can not just take out a piece of tissue from the eye, as during laser correction, but also insert something new there. For example, an implant that allows you to see at night. Or DVR. Or — what is being done now — just an internal contact lens made from a biocompatible polymer.

Therefore, when you read about new opportunities for contact lenses, remember — all this can be built into a person. Of the most promising technologies — transfer images from your eyes to a computer and vice versa. If you are lucky, in 10 years you will be able to search for a given word in a paper book, as you are now looking for on a web page.

But let's still go back to the real world and talk about phakic lisch, corrective vision for those who can not help the laser.

— Are small-invasive laser vision correction operations done in Russia using the Small Incision Lenticule Extraction method?

Yes, about 10 years already. Every year, more and more at conferences of ophthalmologists, questions arise not at the level of “What is this?”, But at specific practical nuances of technology. VisuMax lasers exist in several clinics in Russia, but it is much less used under ReLEx SMILE than under femtoLASIK. Historically, it happened in Russia that this technology is little used in the central part and is actively used beyond the Urals.

— What is the story with licenses for specific operations?

Zeiss sells cones with licenses. A cone — a replacement part adjacent to the eye — is purchased with a license to use a laser procedure, usually in batches of 10 or 100 operations. For example, 10 cones and 10 licenses are received. Licenses are driven through the laser menu, and it allows you to use the appropriate cones for the appropriate program types. Licenses for SMILE separately, for femtoLASIK separately, for FLEX, rings and additional corrections are also separate licenses. Most manufacturers of femtosecond and some excimer lasers have a similar situation. Licenses for excimer operations are not needed, perhaps, except on models of about 5 years old and older.

— And you can not get such a license for SMILE?

Easily. Firstly, this module in the laser is as an expensive option, so the device itself without the SMILE option is cheaper. Secondly, if this option is available, then licenses to carry out the operation ReLEx SMILE can be acquired only after conducting 5–10 test runs on pig eyes, then performing at least 10 femtoLASIK operations on patients, then 50 FLEX operations, and only after that Buy a SMILE license for a specific surgeon.

Today, without the «tin», as you asked

There is already a post about how the laser cuts by creating millions of cavitation bubbles in the cornea layer of the eye, and analyzing telemetry from the real operation in seconds with comments of the surgeon's actions.

Now FAQ about various related things

— If I look away while the laser is running, what will happen?

You simply will not work. In fact, immediately after anesthesia, the eye is pressed against a special pneumocapture. To blink at you too will not leave because of fixing (it is not long and not for long). The only moment where it is possible to seriously disrupt the course of the operation is to pull the head down strongly, pulling it out of the headrest by a serious willed effort. In this case, the operation will instantly stop. More precisely, it will stop even before the loss of capture (details below).

— How should an operating room be prepared?

In general — as a normal operating room, that is, a room with a clean area (air filtration, overpressure to prevent contamination from the outside after cleaning). It is important for the procedure that microparticles of dust flying in the air do not fall between the laser lens and the eye.

Now I will show what doctors usually never show to patients. More precisely, it shows everything in the form of a beautiful render, from which it does not follow at all that a piece of metal will stick up in your cornea for a couple of minutes. Fortunately, you will not feel this because of the anesthetic premedication, you will not know and do not remember, because the piece of iron will be out of focus.



So, watch the video, and I will show the frames with comments. This is a real operation on a patient in a German clinic, the recording was made on a device like the “black box” of the VisuMAX device. In this case, the patient has agreed to use the recording for training purposes, usually access to such records is strictly limited.

The idea — to take and cut a lens in a transparent cornea — is not new. At first it was done manually, with a scalpel directly on the surface (difficult and very rough, with a sea of side effects). The first laser was used in 1979, then it was a pulsed infrared emitter with an effective pulse length of 4 nanoseconds.


Step 1: creating a plasma bubble, in fact — a microburst. Step 2: expansion of the shock and heat waves. Step 3: cavitation bubble (plasma expansion). Step 4: the formation of a parallel slice at the expense of several adjacent laser focus points.

Когда в шарик с гелем, который представляет из себя глаз, что-то попадает – клетки крови или воспаления, инородное тело или нарушается строение оболочек, возникает необходимость в работе внутри глаза в среде стекловидного тела вплотную к сетчатке. Так вот это и есть витрэктомия – работа по «стрижке» волокон витреума (vitreum) – стекловидного тела, удалению его через тонкие трубки и наполнение глаза какой-то средой – водой, маслом или газом. Это выглядит приблизительно как сборка парусника XVII века внутри непрозрачной бутылки с узким горлышком. Только стенками «бутылки» является сетчатка, которую никак нельзя повреждать.

В общем, глаз можно проткнуть в нескольких местах железками, что-то удалить внутри полости и сохранить при этом сам глаз, да еще и зрение улучшить.

Как потом с этим жить и почему от этого никто не застрахован – сегодняшний пост.