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Strabismus
Strabismus is a visual disorder where the eyes are misaligned and point in different directions. This misalignment may be constantly present, or it may come and go. Sometimes, only one eye may be affected - turning inward (esotropia), outward (exotropia) or downward - while the other eye is directed straight ahead.
Strabismus is a common condition among children. Normal alignment of both eyes during childhood allows the brain to fuse the two pictures into a single 3-dimensional image. Strabismus or abnormal alignment can cause amblyopia or reduced vision. If vision is reduced, the brain of the child will learn to recognize the stronger image and ignore the weaker image of the amblyopic eye. This will eventually cause a loss of depth perception. If strabismus develops in an adult, they will often experience double vision because the brain has been trained to receive images from both eyes.
The treatment goal for strabismus is to preserve vision, to straighten the eyes, and to restore 3-dimensional vision. If amblyopia is detected in the first few years of life, treatment is often successful. If treatment is delayed until later, amblyopia or reduced vision generally becomes permanent. Covering or patching the better seeing eye can strengthen the eye muscles and improve vision in the amblyopic eye. Depending on the cause of the strabismus, treatment may involve repositioning the unbalanced eye muscles, removing a cataract, or correcting other conditions which are causing the eyes to turn. After a complete eye examination, including a detailed study of the inner parts of the eye, an ophthalmologist can recommend appropriate optical, medical or surgical treatment.

Lasik Eye Surgery - Refractive Surgery
The refractive surgery refers to a series of procedures – surgical and laser – used for correcting the refractive errors – far-sightedness, near-sightedness and astigmatism. It eliminates the dependence on the conventional accessories such as contact lenses and spectacles. The potential of refractive surgery is enormous, for both small and large optical aberrations including astigmatism as well, by selecting the most adequate method.
Excimer laser is certainly the most popular and the least invasive method. It represents a computer guided and well controlled appliance of a laser beam – actually the high frequency ‘flying’ laser spots, used to reshape the corneal surface according to a desired one and therefore change its refractive power into a desired one. The dioptric range planned to be "taken" off by a laser is defined in advance by the specific parameters established during an examination. Very important is the corneal thickness , its shape and stability prior the laser procedure. It is used for correction of a low- and medium level of near-sightedness , up to – 10 diopter (with astigmatism) in the case of normal corneal thickness, and lower level in thinner corneas. For far-sightedness, these values are round plus 2, with small astigmatism.
This is an essential condition for the safety of the procedure. For the higher range of dioptria, the suggestion is surgical treatment regarding following possibilities:

a) Surgical procedure with refractive intraocular lens implants, without the removal of the natural, biological lens, with accommodative power saved. That is so-called PHAKIC INTRAOCULAR LENS (IOL) for high myopia and high hyperopia and PHAKIC TORIC IOL for mentioned sphere aberration combined with a certain (high) range of astigmatism. The method is applied on patients that still have the accommodation, up to 35-40 years of age. Currently, the quality of these lenses is exceptional, and the aberration field covered with this surgery is wide: for the near-sightedness up to – 25Dsph and far-sightedness up to plus 10 /plus 12 Dsph, with the cylindrical correction of up to plus 7 D, depending on the type of the lens. There are different types available – angle support and iris – claw lens , flexible for small incision implantation. The results are brilliant.
b) In older myopic or hyperopic patients , when the natural human lens lost its accommodative power and therefore another spectacle dependence is needed, well known as “reading glasses”, the method of choice would not be laser, or phakic iol implantation, but Lens Exchange surgery with the type of the lens implant especially selected to fit the patient’s needs, and professional or other requirements. A large number of patients are extremely happy with the selection of the multifocal foldable intraocular lens with a comfort of near vision for close objects (imitation of accommodation), medium distances (computer) and far distances vision.
Thus a multifocal foldable lens practically removes the double dependence on spectacles, giving opportunity of having good quality of vision at different distances (imitation of accommodation). All procedures require appropriate surgical skill and performance, since surgical precision is a very important premise, in order to use the best potential of the refractive surgery. Therefore, it is very important that the surgeon who performs refractive surgery is an expert in this field, and offers the maximum to his patients.
Today Excimer laser is a software type, with the advantages of adjusting the procedures to each individual eye. It has reached its developmental culmination. A long time ago assigned aim has finally been achieved. A dream of the millions has become a reality! Precision, predictability, safety and satisfaction of the millions of patients underwent the operation worldwide influenced the highest authorities of ophthalmology to make the laser procedures official.
The goal of refractive surgery is to provide a comfortable, functional visual acuity without contact lenses or spectacles, and to quit the dependence on the conventional helping devices.
The other reason for choosing refractive surgery is impossibility to correct the refractive error with spectacles , because of the type of error or big diopter differences between both eyes (anisometropia), even if they have nothing personally against the glasses.
Financial aspect is of great importance. Refractive surgery is done ones for a life, while the contact lenses are a lifelong dependence.
People over 18 years of age, with a stable dioptry. Certain age is a desired condition.
Cornea is to be healthy. Its quality and thickness, as well as the size of the pupil, measured under dark conditions define the dioptric range suitable for treatment. These parameters set the safety limits of laser correction.
In the case of large refractive difference between the eyes(anisometropia), refractive surgery is of great importance , as well as for need of only one eye correction.
For younger than18 years of age, laser can be used in case of a stable dioptry, in the last three years, with a strong motivation due to the dedication to sports or fine arts, where the classic adjuncts are not the best solution.
Large difference in dioptry not corrected in time , or presence of astigmatism is the reason for amblyopia from young age. The place of excimer laser here is to help correcting the refractive error in the best way and prevent strong amblyopia if used properly in certain age.
EXCIMER laser is successfully used not only for refractive procedures , but also for therapeutic treatments-for better healing in cases of recidivant (‘repeated’) erosions of cornea – the PTK method.

WHAT DOES THE LASER PROCEDURE LOOK LIKE, HOW LONG DOES IT TAKE, WHICH ANESTHETIC IS USED?

The task of the computer-controlled apply of a ‘cold’ laser beam is to change the refractive power of cornea into a desired one by remodeling the cornea. This can be achieved by direct effect of the laser beam on the surface of the cornea (PRK method) that lasts for 1-2 minutes, for the purpose of creating an erosion zone on the cornea. During the epithelisation of this eroded area, the patient wears a therapeutic contact lens in order to protect the cornea and reduce the discomfort caused by the targeted ‘erosion’. This discomfort, which is usually expected the next day following the intervention, is a common reaction and is overcome successfully with given eye drops and pills .Immediately after the intervention, the patients notice a dramatic improvement of vision, in spite of the temporary blur that lasts for a few days.
Another modality is LASIK, a combination of the microsurgical and the laser procedure. Lifting the epithelial flap is achieved using a microkeratom (a special instrument), and is then followed by the laser treatment of deeper layers, after which the epithelial flap returns to its position. This method is more invasive. The healing period of the cornea lasts longer than for the PRK, although the discomfort is here reduced to only a few hours following the intervention.
In both cases, the anesthesia is topical , with drops, and the patient returns home immediately after the intervention, and can go back to work in 5-6 days.
The other modalities of the basic principles are Lasek and Epi lasik (variants between the PRK and Lasik).

HOW SHOULD THE EXAMINATION BE PLANNED IN CONTACT LENS WEARERS?

If the patient is a contact lens wearer, it is required to stop with the lens before the laser procedure in order to give time for cornea to ‘reconfigure- between 10 and 15 days for soft, and 4 -6weeks for GP lenses-approximately one month of stopping for 10 years of wearing. Corneal topography can plastically showed what happened with cornea under contact lens- an ‘imprint’ of the contact lens on cornea can be seen.
The surgery performed here, represents the highest level of ophthalmic surgery.

Cataract
Phacoemulsification allows cataract surgery to be performed in the earliest stage of the disease, at the very onset of the first symptoms, instead of troublesome waiting for cataract to be mature .Waiting for cataract to be mature is actually passing through the dark period of ‘ temporary blindness’. Furthermore, mature cataract by itself, is a risk of inducing possible complications-glaucoma, or inflammatory reactions due to disintegration of altered human lens materials (uveitis), or make difficulties in discovering serious diabetic changes in posterior segment of the eye, such as bleeding or retinal detachments.
It is not unusual that patients their loss of the vision connect only with the cataract, without idea of other possible causes, from posterior segment, and that is why early operation is of great importance.
Phacoemulsification means small incision surgery, today less than 2 mm, use of ultrasound power in emulsifying the lens material and aspiration, applying a foldable lens in the place of capsular bag through a small incision, and therefore finishing surgery without stitches, except in children where the stitches are demanded. The choice of the lens type depends on the case, special patient’s need, wish for correcting refractive error or special ophthalmic problem. Patients are particularly happy with a selection of the multifocal implants, which provides comfortable far distance and intermediate vision, independent of glasses. Special advantage of multifocals is comfort in looking the objects from every side with the same quality of given picture, not as in multifocal spectacles putting effort to find picture under the certain angle.
The aim of refractive surgery to beat the presbyiopia has finally been achieved, mainly in presbyopic hyperopic patients.
For the patients with the damaged macula the intraocular lens with blue filter is specially suggested for protecting from harmful blue light.
Just opposite from mentioned above, the old, classic approach require mature cataract, what means completely blurred lens, with functional “blindness” prior to operation and a large incision, great mechanical trauma for the eye, many sutures at the end. That could lead to accompanying problems in some cataract cases combined with glaucoma, or diabetic changes posteriorly, or big changes in macula, what mostly made “classic doctors “ to announce such cases as inoperable having fear of making situation worse with the classical approach to surgery. Since there are enormous numbers of combined problems in the eye, the safer surgical approach was required and that is why phacoemupsification was born.
The point is that the refining and perfecting the surgical technique needs virtuosity in performing the surgery, and such skilled surgeons dictate the guidelines for modelling of the technique. Therefore, owing to one of them, who won special awards and merits for his contributions to the modern ophthalmology, Prof. Dr. Pavel Rozl (who has also introduced the method in Serbia), we now have the opportunity to follow the phenomenal possibilities of the phacoemulsification nowadays. This method has already entered the new epoch of existing, now in completely new appearance and new instrumentation, with three different energy platforms integrated in one device, INFINITY. Now we have three different types of probes, to be used in specific case each. One is completely new approach without the use of ultrasound-at all- AQUALASE. Aqualase became a new term in refractive lens exchange procedures where ‘gentle lens rinsing’ is achieved by water-jet phenomenon without a roughly mechanical impact. It is ideal for the minimally blurred lenses or clear lens exchange in refractive corrective procedures.
The other two platforms are refined, more balanced ultrasound and neosonix-ultrasound and oscillatory energy in one platform, far more powerful in the cases of ‘hard, mature’ cataracts, with an exceptional degree of control and shorter apply of ultrasound energy.
This new technology requires the great knowledge of technique of phacoemulsification, the experts in this method, and currently exists only in the few leading world centers, performed by the best surgeons of great experience in phacoemulsification. Top-quality eye surgery is here in Belgrade.

Mystery called Glaucoma
In general, GLAUCOMA is a diverse group of eye conditions with optic nerve impairment and loss of vision. Unless treated the blindness is a final outcome. The disease is MULTIFACTORIAL optic neuropathy with characteristic acquired loss of optic nerve fibers. It has a wide range of risk factors expressed, with the increased eye pressure at the first place.
Glaucoma is mostly a chronic disease, with concealed onset, without clear symptoms, hardly recognized by the patient on time. Still this deceitful disease leaves alarming number of blind people of different age in our country.
Contemporary ophthalmology has conceived and demystified this phenomenon, and has offered the OFFICIAL survey about the early discovery and treatment of glaucoma, the disease that leads into darkness – blindness, if not recognized in time. The earliest stage are changes at the level of the retinal ganglion cells, before appearance of symptoms, and it could last for a while, before disease goes on progressively thereafter. The therapy starts immediately when the subtle changes are discovered. The choice of an adequate surgical method or a combination of methods for each patient individually is very important precondition, and the most delicate moment during the battle against this monster.
For an eye evidently impaired, “normal, desired “eye pressure certainly has to be lower than the standard normal levels of healthy eyes.
In collaboration with the distinguished names of the European ophthalmology, the new more refined surgical approaches are cherished, with the unpenetrating deep sclerectomy among them with gel implants. The first reaction of a patient after being brought face to face with the glaucoma diagnosis is disbelief. Apart from having the values of IOP twice as high as normal, the increased eye pressure, as the most common manifestation of glaucoma, doesn’t make pain. There are specific defects in peripheral visual field, while the central vision remains intact for a long time, and the patient does not recognize the first symptoms. When the pain and the evident defects in the visual field appear, the damage is irreversible, with the certain part of optic nerve already destroyed. The aim of the therapy is to keep the disease at that stage, and the intraocular pressure under control.
The increased IOP is considered to be the most common risk factor, but not the only one. The increased IOP will certainly speed the appearance of glaucoma impairments, but glaucoma is not “equal the high eye pressure.” In some cases very fine changes have been noted in papilla of optic nerve in the conditions of ‘relatively’ normal or even lower IOP. This is a so-called normal or low-tension glaucoma. It is agreed to take the IOP values between 9-21 mm Hg as normal. However, in approximately 25of people with “relatively normal“ IOP has certain glaucomatous changes.
This means that the assessment of the IOP value must be connected to serious evaluation of many other risk factors and presence of predisposition for disease, not separately. If optic disk is already impaired, or there is a visual field defect, with positive family history, the value of IOP should be kept lower than usual to the value that would not lead to further impairments. Like in coronary disease, when we tend to have the value of blood pressure and level of serum lipid lower more than in healthy people, without risk factors.
Looking in the IOP value, even when it is for example. 22 mmHg, it should be glaucoma suspect, until we confirmed the other changes or exclude the risk.
Difference in the eye pressure in both eyes, as well as large daily oscillations of IOP, the asymmetry in the look of papilla of both eyes, is an alarm for complete examination with computerized visual field and immediate therapy if diagnosis is confirmed.
The increased intraocular pressure ("hard eye") is generating in the imbalance between the production and outflow of aqueous humor,- either an excess of aqueous production or impede aqueous egress. Every major category of pathology is represented in one form of glaucoma or another. If the eye anatomy is “normal, with normal look of anterior chamber angle and anterior chamber depth, that is so-called open angle glaucoma. If there are some changes in anterior structure, hereditary, or acquired, that is called narrow-angle or angle-closure glaucoma. In some predisposition with aging process, the anterior chamber angle becomes narrow and that is risk of acute glaucoma attack, especially under dilated pupil (in the darkness or with mydriaticum!). That is why first inspection of chamber angle is of great importance before dilatation of pupil!!!
High hyperopia with shallow anterior chamber is a predisposition for glaucoma, as well.
Glaucoma as a secondary appearance (‘consequently’) develops in inflammatory processes in the eye (uveitis), post –traumatic, because of adhesions in the chamber angle. It could be also complication of the ‘maturing’ cataract, when a swollen lens pushes the iris forward and narrows the anterior chamber and the chamber angle, or blocks the communication of fluid from posterior to anterior part by blocking pupil’s area. A long waiting for operation of mature cataract is a threat for lens disintegration with uveitis inflammatory reaction as complication or closing of the angle and acute attack of glaucoma.
Early changes in glaucoma develop at the level of retinal ganglion cells, before the clear clinical sign of disorder. Tissue nourishment is basically impaired due to perfusion disturbances in very delicate sensitive ganglion cell and optic nerve (axons) tissue. Its sensitivity is higher in the increased IOP or daily oscillations in the IOP more than 6 mm Hg. Perfusion disturbances present in general diseases: carotid artery occlusion, low blood pressure, diabetes mellitus, certainly have great impact on changes in optic nerve axons, as well as local predisposition, such as high myopia.
These risk factors can make the impairment worse, but that does not mean that everyone with some circulatory disturbances has to develop glaucoma.
The genetics determine the sensitivity of the delicate tissues to the risk factor exposure.
The disease could be expressed in early childhood, solitary or combined with some other congenital disorder, such as cataract or aniridia. It is important to look for glaucomatous appearance after discovery of congenital cataract, and even if not expressed at the same time, to be aware of possible delayed onset.
The aim of the therapy is to protect the optic nerve and keep the eye pressure under reasonable value. The first step is eye drops, but in the case of an imminent threat of glaucoma attack in angle-closure glaucoma the laser is applied. If the maximum therapy does not stop progression of glaucomatous changing in optic disc and visual field, surgery is the method of choice.
Uncritical assessment of the intraocular pressure values and unrecognized first signs of disorder leads to a catastrophic outcome. Maximum therapy means all available resources for controlling the disease by medication, having in mind the age of the patient. In younger patients (30-40 years of age) with the apparent deterioration after two different medications, one should seriously consider the surgery. These people are facing many years of battle against glaucoma and application of these medicaments for many years certainly is not harmless. Though powerful, these medications have side effects, and in some cases they are contraindicated, as well. After many years of using drops, the tissue loses characteristics of its “nature biology“, what reduces the effects of the late surgery.
The decision when to operate and which method or a combination of methods to use depends on many factors: the type of glaucoma, lasting of disease, degree of damages, and value of IOP. Those factors determine the value of desired IOP level, and of course the type of surgery.
Concerning all delicacy of this disorder, the decision about surgery should be brought by the top experts who are familiar with all the details, and all the advantages and disadvantages of the available surgical options, and who are the masters in these surgical techniques.

Vitreoretinal surgery
Operation in the posterior eye segment – on retina and vitreous body is performed in collaboration with a Swedish University in Uppsala, lead by Dr Zoran Tomic. The patients who undergo this kind of surgery are mostly diabetic patients, the patients with long lasting retinal detachment and patients with injuries to the eye, as well.
This surgery can be considered as a kind of the “neurosurgery” of the eye. It is very complex and demanding, dependent on technological conditions and support of an experienced and skilled surgeon.
Special Eye Hospitals in Belgrade became some of the leading European centres in both, anterior and posterior eye surgery.
Not only the quality of surgery and complete treatment with world experts, but some other advantages like the lower operation costs. Like it was in anterior segment surgery (cataract and refractive), the vitreoretinal surgery also tremendously developed to the today’s possibilities in smaller incision (23 and 25 gauge) without stitching. Visualization of the posterior eye segment is advantage of new generations of devices, as well as precision of cutting the vitreous membranes with vitrectoms - small rotary high speed cutting disposable instruments of 2500 cuttings per minute is amazing. Modern vitrectomy today is far above the past standards and gives to those who underwent this surgery the new quality and faith in life.