Counselling in Cornea Clinic

It is a transparent watch - glass like membraneous tissue which forms the front 1/6 the of the eye ball.

It lacks blood vessels (avascular) and thus is transparent i.e. allows light rays to pass through unhindered for good vision. Hence it can be transplanted with out fear of rejection.

Diseases of cornea

Corneal ulcers
Pterygium
Corneal opacity
Injuries
Conjunctivitis (Red eye)
Dystrophies
Corneal shape disorders – keratonconus, cornea plana

Common corneal diseases

Corneal ulcer

It is an infective or sterile breach in the corneal surface
It is caused by injury and infection by microorganisms (bacteria, fungi, viruses)
Exposure to dust and even contact lenses see to be common sources of infection
It causes pain, defective vision, redness and discomfort to the patients. Needs urgent treatment by the ophthalmologist.
Can be easily cured if seen and treated earlier by medications only. However in late stages and severe cases, it may require surgery.
Scarring following the healing can cause white opacity on the cornea and defective vision especially following late stages of ulcer healing. (Fig. 8.1)

Role of the counsellor

To reassure a patient and stress on the need for proper compliance with medications and appropriate review as advised by the doctor
The do’s and don’ts like wearing sun glasses for glare (photophobia) and not taking a head shower etc. should also be stressed

Frequently asked questions

1. When will the pain decrease?

Once the ulcer starts healing with medication the pain will decrease. Pain killer tablets would also temporarily reduce the pain.

2. When will I get back my vision?

After the ulcer heals, you might require glasses or surgery at a later date, to get better vision

3. When will the ulcer heal and how long will I have to apply the medicines?

Depending on the size of the ulcer; larger ulcers take longer to heal. Some ulcers like fungal ulcer take longer to heal. But it is important to keep diabetes under control and apply eye drops as advised.

4. When should I come back for review?

As advised by the doctor

5. When can I take head bath?

Once the ulcer heals almost completely and as advised by the doctor

6. Can any surgery be done and will I get full vision if done?

Surgery is the last resort when the ulcer is active. Once it heals for gaining vision we might have to do surgery or if the ulcer does not heal with medicines we might have to do corneal transplantation.

7. My eye has become shrunk will it become normal?

Yes, once the ulcer heals it will be alright

Pterygium

This is a fleshy growth on the white of the eye (conjunctiva) on either side of the cornea which occurs in people exposed to excess wind, heat sun and dust and can grow over the cornea (black of the eye), when it causes loss of vision.
In addition to being cosmetically disfiguring. It can cause pain redness and discomfort (Fig. 8.2).

Role of the counsellor

It should be stressed that permanent vision loss may occur if it grows very large over the cornea even if surgery is done at this stage.
The only permanent treatment is surgery, ideally with an autograft from the same eye.
Topical medication only can temporarily allay the symptoms.
Wearing sun glasses would help mitigate the growth in the eye if the growth is very small.
However the patient would require regular follow up to assess the extent of the growth.

Frequently asked question

1. Why do we get pterygium?

Due to excess exposure to dust, wind and heat (UV radiation)

2. Can we correct the problem by medication?

No, surgery is the only option for permanent cure

3. How many days do I have to stay in the hospital after the surgery?

1 day only

4. Will the eye get a recurrent growth after the surgery?

No, we do a specialized surgery with conjunctival autograft

5. How many days do I have to apply the medication?

For 3 weeks

6. When do I have to come for review?

After 3 weeks

7. Will I get the full vision after the surgery?

The surgery is not for improving vision but only to prevent the loss of vision. Would require glasses to get full vision.

Corneal opacity

The clear cornea becomes white following scarring. The causes can be congenital (from birth) or acquired from a healed ulcer. It can result in visual loss and can be cosmetically disfiguring.
Penetrating keratoplasty is a surgery where the opaque cornea of the patient is transplanted with the clear cornea from the eye of the deceased individual (donor) to provide vision for the patient. It can be done if the scar is not very long standing (Fig. 8.3).

Role of the counsellor

Should explain the advice of the doctor whether it is tattooing, cosmetic contact lenses or penetrating keratoplasty (PKP)
The need for regular follow-up and proper compliance with treatment for a long duration especially after PKP also has to be stressed
The chances for graft rejection after PKP and the necessity for glasses for good vision after surgery also should be explained

Frequently asked questions

1. Why should the cornea be transplanted?

Because there is a corneal opacity due to which you have lost vision, which should be replaced by a clear cornea from a donor.

2. After the surgery, will I have pain, irritation and how long it will take to become alright?

You will have only minimal pain for a couple of days after the surgery which will be taken care of by pain killers. There will not be any irritation.

3. How many days do I have to stay in the hospital?

For 1 week

4. After how many days of the surgery, will I get back full vision?

After 3 months of the surgery if required with the glasses you will get back good vision.

5. How many months do I have to use the medications?

For atleast 6 months after the surgery and thereafter on the doctor’s advice.

6. When do I have to come for a review?

You will have to come at 1, 3 and 6 months for a routine follow up. In between if the doctor advises and if there is any irritation for suture removal.

7. When can I take head bath after the surgery?

Usually after 1 month if the wound has healed.

Injuries

There are ocular emergencies which can vary in severity from mild damage to potentially blinding conditions
The causes can be chemical or mechanical.
They affect any age group especially children and working adults
They can have severe pain, glare and loss of vision.

Role of the counsellor

Stressing the necessity for urgent treatment
Reassuring and insisting the need for proper follow up and compliance with medication. The possibility of scarring and its management will also have to be explained
Counselling on protective measures and care to prevent such recurrent episodes

Frequently asked questions

1. When will my pain decrease?

Once the injury wound heals

2. If I undergo surgery, will I get full vision?

We cannot give any guarantee in an injured eye but definitely the vision will be better and we can save the eye

3. When will the sutures be removed?

Atleast 3 months or as per doctor’s advice only if required

Conjunctivitis (red eye)

Contagious, infective condition of the conjunctiva (white of the eye)
The patient has redness, discharge and discomfort
Usually there is no visual loss and it is treated with eye drops
Rarely the cornea can be involved in viral conjunctivitis (Madras eye) and (EKC - Epidemic kerato conjunctivitis) and causes defective vision
Allergic type: Allergy to dust, contact lens or pollen, animal dander and is a non – contagious type of conjunctivitis, but causes lot of itching and discomfort (Fig. 8.4).

Role of the counsellor

Have to explain that symptoms can be relieved by eye drops but the condition tends to be recurrent and needs prolonged treatment
Stress should be laid on misuse or over use of steroid eye drops which can result in visual loss due to cataract or glaucoma
Should stress personal hygiene like frequent washing of hands and not touching the eyes and keeping their face towels, cosmetics, soaps etc., separately

Frequently asked questions

1. How many days will the redness remain?

For about a week

2. Is it contagious?

Yes, good hygiene & frequent hand washing is a must to prevent spread to others

3. When do I have to come for review?

If required as per the doctor advice

4. Why do I get it frequently? (Allergic conjunctivitis)

If it is a allergic conjunctivitis due to repeated exposure to the causative factor one can get it repeatedly.

Corneal dystrophies

Hereditary, affecting the cornea from within, without any external source of affliction.
Cause defective vision in some which may require keratoplasty (corneal transplant). E.g.: Fuchs and CHED (congenital hereditary endothelial dystrophies) Macular, granular and lattice – stromal dystrophies.

Symptoms

Progressive loss of vision and pain.

Investigations

Detailed anterior segment (including pupils of both eyes] and posterior segment evaluation.
Urine sugar, blood pressure and relevant investigations for general anesthesia if surgery is planned

Treatment

Glasses or contact lenses at the initial stages, with relevant eye drops for example hyperosmotics and lubricants
Surgery (PKP, Lamellar, keratoplasty)

Role of counsellor

To explain the hereditary nature of the disease and get the siblings examined for the same.
To stress that it can be transmitted to future generations

Corneal shape disorders (Keratoconus, cornea plana)

These conditions cause defective vision due to abnormal shape of the cornea

Keratoconus

The cornea bulges forward due to an integral weakness in its structure
Causes could be eye rubbing, hereditary causes, systemic diseases or unknown causes
Results in defective vision, which can be corrected by glasses, contact lens or in severe cases, may require corneal transplantation (Fig. 8.5).

Role of counselling

To explain the chance of progression and to avoid eye rubbing
To stress on the necessity of periodical review to rule out progression and to assess the present condition and give the appropriate management

Cornea plana

It is a hereditary condition where the cornea is flat and causes defective vision

Symptoms

Defective vision

Investigations

Corneal topography for example orb scan orbscan

Treatment

Glasses, contact lens or in severe cases may require corneal transplantation

Lasik – procedure

Definition

LASIK (Laser assisted in-situ keratomileusis) is the high tech outpatient surgical technique for permanent corrections of refractive errors - myopia, astigmatism and hypermetropia.

Procedure

Utilising the accuracy and precision of the computer controlled excimer laser, LASIK changes the shape of the cornea and corrects refractive errors.

The counsellor should be able

To explain how LASIK gives normal high quality vision with a fast recovery time.
To educate the willing people who come for refractive treatment through transparent counselling.
To identify the deserving persons, who seek advanced technology for treatment by social marketing.
To clear confusions and contradictory messages in the minds of the patients.
To help people to have realistic expectations and not get carried away by exaggerated advertisements done elsewhere.

Advantages of lasik

Improves the cosmetics.
Freedom from the time-consuming, day-to-day hassle of glasses or contact lens.
Freedom to play sports without the inconvenience of glasses or contact lens.
Some institutions stipulate “minimum vision requirements” like police services, navy, drivers, railways etc., Some studies require good eye sight like engineering, computer science, microbiology etc., Those opting for these services can benefit from Lasik.

Who can benefit from Lasik?

The ideal candidate for LASIK is anybody between 20 to below 40 years of age without any other eye disease. In addition to having a healthy cornea, patients must not have had a significant change in their glass prescription in the last 12 months and they should have realistic expectation.

Who cannot benefit from LASIK?

People with certain eye conditions like steep cornea, opaque cornea, diabetic retinopathy, glaucoma, cataract and systemic conditions like pregnancy, and hypertension, those who are in contact sports and military, where the flap can lift up even years after Lasik on sustaining an injury. These people may not be good candidates for Lasik.

Role of counsellors

1. To educate the patient about the surgery, its benefits, side- effects and the types.
2. To clear the doubts and misconceptions of the patient about the procedure.
3. To give a realistic picture of the postoperative vision, so that he if not carried away by the aggressive marketing.
4. To explain unsuitable patients, the reasons why they are not suitable for lasik.

Pre-operative counselling instruction

Discontinue wearing soft contact lenses one week prior to the laser procedure. Do not wear rigid gas permeable or hard contact lenses once you have scheduled your laser surgery.
Wear your eyeglasses on the day of your surgery.
Wear loose, comfortable clothing on the day of your laser vision correction procedure. You will be going home in protective shields; Wear something with zippers or buttons, nothing that is pulled over the head.
Eat a light meal prior to your appointment and do not wear any make-up or scented facial lotion on the day of your laser vision correction procedure. Make certain all make-up, including mascara, is removed from your eyes and eyelashes. Do not wear earrings or facial jewelry.
The Excimer Laser is extremely sensitive to odors of all kinds.
Do not wear any perfumes, cologne, scented body lotion, hairspray on the day of LASIK procedure.
Arrange for a friend or relative to drive you home on the day of your procedure and your first postoperative visit.
Be at the LASIK centre sufficiently before the scheduled time. Duration of the procedure is approximately 60-90 minutes.

Preoperative evaluations before doing lasik

Refraction: A detailed subjective refraction is performed to determine the precise refractive error (Tests that you usually undergo when glasses are being prescribed).
Keratometry: it is a test performed to measure the corneal curvature and is especially useful for patients with astigmatism.
Pachymetry: it is a test used to measure thickness of the cornea, which is performed to ascertain whether the cornea is thick enough to withstand laser treatment.
A complete eye examination is performed.If the retina is found to be having any degenerative changes, the same is treated first using a barrage laser and after a month, lasik laser is performed.

Frequently asked question‘s (pre -operative)

1. Are my eyes suitable for the procedure?

After a detailed evaluation by the ophthalmologist and specialised tests including an orbscan and retina evaluation, we can decide whether lasik is suitable for you.

2. I am using contact lens; I want to go for laser treatment, when can I have it?

First you have to discontinue your contact lens atleast for 2 weeks. After the pre-operative evaluation, if you are found fit you can go for the laser treatment.

3. When can I go back to my routine work?

It depends upon the work – usually 1 week rest is sufficient.

4. Is there a 100% guarantee for 6/6 vision?

No, but you can avoid your dependency on glasses .You may have some minimal residual power like 0.5 or so.

5. What will be the long term side effects?

Dry eyes, glare, haloes, ghost images, decrease in contrast etc., are possible temporary side- effects, which may last 6 months.

6. How much residual power will I have after surgery?

Based on the existing refraction and availability of your corneal thickness very minimal residual power is possible but it is unlikely.

7. After surgery can I donate my eyes?

Yes – but they will be used for research purposes only.

8. Why do I get presbyopia after LASIK?

Presbyopia is nothing to do with cornea. It is related to the inner lens whose accommodating capability gets decreased due to normal aging phenomenon after 40 years of age and it is not a disease. Similarly one can get cataract also due to aging.

9. If I am a diabetic or hypertensive patient or if I am pregnant, can I have LASIK?

LASIK is not advisable.

10. What is the usual age limit for LASIK?

Minimum age 20 years and upper age limit is 40 years.

11. Can you explain the surgical procedure?

Using Excimer laser, we reshape the cornea.

12. Whether the LASIK procedure is painful?

No, we numb the eyes with anaesthetic eye drops.

13. What are the two types of laser treatment?

LASIK and Zyoptix

14. What is the difference between these two types of treatment?

Zyoptix is a customised procedure for an individuals’ eyes to correct all the aberrations on the corneas and give supposedly super vision i.e. aberrations free vision

15. Will my eyes become entirely normal after Lasik? And should I come for regular follow up after the surgery?

Your eyes will still be myopic even after the surgery since we only reshape the cornea. The rest of the eye example the retina, would definitely be myopic and hence require regular follow up

Surgical procedure

The procedure is generally painless. Anaesthetic eye drops are instilled half an hour prior to surgery. There are essentially, three steps to LASIK surgery.

A thin layer of the cornea of uniform thickness is created using a special device called microkeratome. This corneal flap is then raised to expose the inner layers of the cornea.
The excimer laser is then used to reshape the bed of the cornea, with exact precision sculpting, to make the required correction.
After sculpting, the corneal flap is repositioned with out any suturing.
The whole procedure requires only fifteen minutes. No bandage is applied. The patient need not be hospitalised. Thus, LASIK surgery is performed on both the eyes in same sitting.

Postoperative care

It is best to keep both eyes closed and at rest as much as possible for the remainder of the day following the surgery. Sleep will speed up your recovery.

Read and watch TV in moderation for the first few days.
Shower and baths are fine, but try to keep your eyes closed and avoid getting water directly in the eye for two weeks. When drying off, never directly rub or wipe your eye.
No swimming, hot tubs for at least 2 weeks.
The majority of our patients feel safe to drive the next day, however discuss the matter with your ophthalmologist.
Most of our patients resume work the next day.
Do not wear eye makeup, lotions or aftershave for 1 week.
Due to light sensitivity, wear sunglasses for comfort as needed. We recommend that all individuals should wear sunglasses for a month.
Avoid dirty and dusty environment for 2 weeks.
Most patients can return to their normal exercise routine after 1 to 2 weeks. Avoid for 1 month contact sports that could result in eye injury. Protective goggles or eyewear is recommended once contact sports are resumed.
Do not vigorously rub eye for 3 months after the surgery. Do not wear a contact lens in the eye which is operated on, unless instructed by your doctor.

Frequently asked questions (post operative)

1. For how many days do I have to take rest?

Avoid watching T.V, reading books, working with computers and heavy work for a week.

2. For how long do I have to use glasses?

Sun glasses are for protection from dust, for at least a month.

3. When can I take a shower bath?

After a week, use shampoo and avoid taking oil bath.

4. What shall I do if I get irritation or itching?

Don’t use any drops without doctor’s knowledge. You can call or come in person to meet the doctor.

5. When shall I take bath in the river, sea or waterfalls?

Avoid taking bath in the river, sea or waterfalls for at least a year and avoid swimming too.

6. When can I go to the gym or do strenuous exercise?

Avoid strenuous exercise at least for 6 months.

Medications

Antibiotics with steroid combination eye drops 4 times per day for 10 days.
Analgesic tablets to alleviate pain.

Follow up

First post operative day
After one month follow up from the date of surgery
After one year follow up from the date of surgery. (for especially retina evaluation)
Grief counselling (Eye donation)and Genetic counselling
- Support family and share their sorrow
- Slowly talk to them about the gift of sight that they can give to others
- Usually done in a place where a death has occurred

Methodology (two methods)

1. Post death counselling

In all cases the pre-death counselling is not possible. Most of the time/95% of the cases) it will happen that counselling the relative has to be done only after the death of a patient.

2. Pre-death counselling

Enquiring doctors and nurses about the patients condition in the particular ICU.
Collect all information and details about the patients family background
Try to identify the decision maker of the family
Try to give an idea about the eye donation. Counsellor only passes on the information about eye donation and is very cautious that the feelings of relatives should not be hurt.
Try to get a good rapport with the family members

Approach

Identify the decision maker of the family
Talk only to limited number of family members, when there are in a relaxed mental state and not hurry up things
Provide comfort and moral support & sympathy to the family members while attempting to motivate them.
Respect their feelings and try not to compel or force them
Should address their queries and fears patiently and assure them.
Express gratitude to the family on acceptance and get a written consent.

Genetic counselling

Corneal dystrophies and keratoconus occur in some families
So other family members and siblings should be screened for the disease and appropriate genetic history obtained
Explain the risk of transmission to subsequent generations in future
Blood samples may be required to confirm the problem and its chances of transmission

Key points to remember

Cornea is clear front portion of the eye.

Corneal diseases are common causes of defective vision and discomfort to patient.

Corneal ulcers require early diagnosis and appropriate treatment for good visual come.

Corneal injuries are ocular emergencies which require urgent treatment.

Conjunctivitis is contagious but easy to treat.

Corneal transplantation (PKP) gives hope to those with loss of vision due to opacity or ulcers.

Corneal dystrophies are untreated and need genetic counselling.

Pterygium needs symptomatic treatment but the only definite treatment is surgery.

The counsellor should have a basic understanding of the above diseases and should be able to counsel patients and attenders regarding the same.

LASIK counsellor should not be a marketing strategy but should give a clear picture about the surgery with realistic expectation on the part of the patient.

Grief counselling is a must to improve the eye donation.

Genetic counselling goes a long way in predicting the future generations getting the disease.

Student exercise