The correspondent

Within last decade we hear a lot about different operations which are carried out for the short-sightedness treatment. And so often we hear about different complications after such operations or about their not efficiency Shell we quit such operations? And what kind of operations shall we perform? This question we have addressed to the director of the Crimean Republic center of vision rehabilitation, the doctor of medical sciences, the doctor - ophthalmologist of the supreme category, a member of the International society of studying of an eye, the winner of the State premium, the honored doctor of the Republic of Crimea to Dembsky Leonid Konstantinovich.

Dembsky L.K.

You have absolutely correctly mentioned such term, as operations which are applied for the short-sightedness treatment. But before I tell you about it, it is necessary to know that the operations performed on a short-sighted eye are divided on medical and cosmetic.

Medical are directed to stop progressing the short-sightedness, to break deterioration of sight.

Cosmetic operations should be performed only when short-sightedness has ceased to progress, the eye has stopped in the growth and deterioration of sight does not occur at least within two years. To such operations are referred making incisions on a cornea which for the first time have been offered by Japanese surgeon Sato and later widely implemented by well-known Russian surgeon S.N.Fedorov.

With development of lasers from notches one has proceeded on more modern methods, so-called Eximer or Lasik - to technologies with evaporation of a part of thickness of a cornea by this laser.

Both at making notches, and at Eximer - operations optical force of a cornea changes and in case of successful operation the patient gets 100 % sight without glasses. However, as each operation it bears carries in itself the certain risk both the most terrible is a postoperative turbidity of a cornea.

The correspondent

So if such danger exists, whether it is necessary to risk? And if to risk, in what cases?

Dembsky L.K.

Let's imagine the young man or girl with short-sightedness of 2 - 3 or 4 dioptries. It is short-sightedness of a weak or average degree. We suppose they have wanted to get rid of glasses. They have gone to the operation and after operation they have got a complication - turbidity of a cornea at which any glasses will not help to see. Whether it was better to live and be pleased in glasses in this case as it is done by Japanese. What for was a risk?

Another case when a person has a big difference between refraction, i.e. optical force of both eyes:

We suppose that one eye sees 100 % without glasses, and another one sees these 100 % in glasses of 5 dioptries. Such difference between optical force of eyes and glasses is not borne by the brain; a person will feel unpleasant sensations, headaches, fatigue. Such operation is justified in this case. It is justified and in case of expressed astigmatism - some kind of deformations, i.e. a wrong structure of a cornea.

The correspondent

Leonid Konstantinovich we would like to hear your opinion relatively not cosmetic but medical operations. Especially because you have just returned from long trip to Germany, Holland and it would be interesting to us to know not only as they are performed by us but also as they operate this short-sightedness there.

Dembsky L.K.

The countries of Europe have completely refused from operations at short-sightedness which was widespread in the past - scleroplasty. I had interesting meetings with leading ophthalmologists of Germany which have found out with the big surprise that in Ukraine are still performed scleroplasty operations. I have expressed my opinion concerning absurdity, uselessness and inefficiency of scleroplastic operations to the German colleagues. Though our point of view was known to German colleagues from the materials placed on our site.

I want to turn your attention that absurdity of these operations is so obvious that these operations are not mentioned neither in the program of German medical high schools nor in the system of последипломного education.

In the CIS countries including Ukraine and now Crimea the book "Children's ophthalmology" written by authors David Taylor and Creig Hoyt well-known in the ophthalmologic world and translated into English went on sale. The purpose of this book edition is rendering of the qualified help to children, suffering the most various diseases of the organ of sight. In this book it is precisely said that effectiveness, i.e. efficiency of sclerostrengthening injections and sclerostrengthening operations is not proved.

The correspondent

Leonid Konstantinovich, can you tell our readers in detail why there is no necessity to perform scleroplasty?

Dembsky L.K.

Why does short-sightedness develop? What is a principal cause?

There are many reasons causing occurrence of short-sightedness. But main of them scientists count the following:

• The weakened sclera which does not render due resistance to excessive growth of an eye;
• Excessive visual job on close distance from a subject (without rest for eyes and by the bad illumination);
• Hereditary predisposition to development of short-sightedness at which weakness of sclera is inherited;
• Weakness and as consequence, an overstrain of the accommodative muscles, responsible for the "adjustment" of the crystalline lens to different distances

Apparently there are many reasons of short-sightedness development, but nevertheless what is main reason, underlying cause? Why does short-sightedness develop at equally heavy visual stress on one child, on other one - no? The answer is very simple. The strong organism is capable to stand such stress, weak accordingly - no.

Short-sightedness develops at weak children.

There are a number of factors being the reason of weakness of an organism:

• Birth injuries of a cervical spine and a spinal cord;
• Rachitis
• Diseases of epipharynx and oral cavities: a tonsillitis, an antritis, adenoids;
• Allergic and infectious diseases: measles, a scarlet fever, a diphtheria, a tuberculosis, an infectious hepatitis and so forth;
• Immunity reduction

All listed factors at excessive visual stress in the overwhelming percent are able to cause a spasm of accommodation, having begun development of short-sightedness, and further to promote its progressing.

It is clear that if there is a hereditary factor when one or both parents are short-sighted, process of myopia i.e. developments of short-sightedness begins earlier and proceeds more rapidly.

We should to be aware that short-sightedness is not simply infringement in the optical apparatus of an eye, consequently sight afar fails. No, this is infringement in all organism at a level of metabolism processes. Because of infringement of a protein and mineral metabolism of sclera - that retina that holds its round form, weakens and eye is stretched at length getting the wrong pear-shaped form. Most of all suffers thus a back part of an eye. The retina which provides visual perception is also stretched, its function is broken. In heavy cases detachment of retina from a sustentacular tissue or even ruptures are possible. Thus sight is lost. This is the most serious and dangerous complication. When the short-sighted eye is stretched (it is visible at special examination) ophthalmologists say that on fundus of eye is a myopic cone (it is an initial degree of change) or posterior staphyloma (and it already manifestation of developed process). Sight thus is rapidly reduced, the patient does not see even the first line all of the known table for check of visual acuity and experiences difficulty at twilight illumination and in darkness.

It is important to know that miopia alta is contra-indication to a number of professions demanding especially good sight. It limits the person also in private life. Heavy exercise stress, weight-lifting, to stay in position with the lowered head are contra-indicated for such people. For the woman it is a problem of childbirth - natural delivery is excluded, the alternative is cesarean section.

So we have approached to the main reason of occurrence and development of short-sightedness - weakness of sclera, to be exact a connective tissue of which it consists. What is in the conception of "connective tissue"? It turned out that it is almost everything of what we consist. The connective tissue in an organism exists in 4 states:

• Fibrous - sinews, fascia, ligaments, joint bursa;
• Solid - bones;
• Gel - cartilages;
• Liquid - blood, lymph.

Connective tissue supports a skeleton of any organ, connects cells among themselves, and is part of walls of all capillaries - it is ubiquitous. Our body consists on 85 % of a connective tissue. Scientists and doctors named a condition when because of weakness of a connective tissue arise preconditions to disease and diseases themselves as a syndrome of connective tissue insufficiency.

New term occurred in the world: syndrome of displasia of connective tissue or syndrome of collagenoses i.e. impaired collagen that is basis of the connective tissue.

Collagen is as armature in ferro-concrete determines its durability.

What do you think is it possible that the connective tissue can be weak in an eye and strong in a spinal column which keeps straight due to extremely strong connective tissue? Certainly, no. Oculists often do not pay attention to the general regularity and treat exclusively only an eye and this patient has if not a spinal curvature as a scoliosis, lordosis can have platypodia, splanchnoptosis as again the reason is a weak connective tissue but mostly no one reveals it

If we depart from the stereotypes, obsolete rules, it will be easy to make a conclusion that short-sightedness is one of the symptoms of the collagenoses syndrome and should be treated not only by the oculists but also by orthopedists, pediatrists, therapeutists; it means that the whole of organism shall be treated. What is the treatment of short-sightedness, how is it treated and how shall be treated, is it necessary to perform an operation?

For the stabilization of the short-sightedness you and your child can be offered besides above listed measures the scleroplasty operation.

Often doctors easily direct a patient at scleroplasty operation, not having tried before it to do something to stop progressing of short-sightedness without a knife.

As any operation it always, we emphasize it especially, always conceals danger and risk. It should understand and realize both a doctor and a patient.

So you are directed at operation that is called scleroplasty. What is this operation?

First a little bit of anatomy: the eye of the person is in an eye-socket. The eye-socket is osseous structure. Contents of an eye-socket consists of actually eyeball, fatty tissue, located behind of an eyeball between it and bone eye-socket walls, fascia, muscles, vessels, nerves (fig. 1).

Fatty tissue serves as the powerful shock-absorber of an eye, preserving it from rupture at direct impact.

At the posterior pole of eyeball the surface of fatty tissue, i.e. fat is covered by dense fascia - Tenon's fascia or a capsule. She begins at the posterior pole of eyeball grows together with the sheath covering an optic nerve and, surrounding an eyeball, reaches equator of an eye.

Surrounding an eye, Tenon's fascia represents a bursa which and is called Tenon's bursa. This bursa with its masses suspends an eye in an eye-socket, keeping it in the certain position, not hampering its movement. Between Tenon's fascia and sclera is Tenon's space in which there is a loose tissue with a liquid that carries out a role of grease for reduction of friction at rotation of an eye. The eyeball in the Tenon's capsule rotates similarly to a spheroidal joint. This analogy is supported with clinical supervision over tenonits - inflammatory processes of Tenon's space similar to arthropathy because of causes, complaints and clinical manifestations

In the eye-socket there are 8 muscles, from them 6 moving an eyeball: four rectus muscles - top, bottom, internal and external, two oblique - top and bottom, a muscle lifting a upper eyelid and an orbital muscle. Thus, external muscles of an eye rotate it in all sides on vertical, horizontal and slanting directions.

The muscles themselves go through Tenon's fascia and are covered with it. Hence, as Tenon's capsule, so eye muscles have complex functional relationship, are interconnected and have the great physiological value in joint movements of an eye, the important component of binocular sight.

Binocular sight means sight two eyes. The perception of depth, relief, stereoscopy - is possible only in the presence of binocular sight, what, in turn, is possible only at synchronous movements of eyes.

The core of scleroplastic operations comes to strengthening of weakened by it thin sites of sclera with help of different materials.

There are many methods. In one cases they put bandage on the posterior mostly thin part of an eye in the circumference of the outlet of optic nerve to prevent further stretching of an eye, in other cases they strengthen the equatorial zone of sclera. Sometimes sclera is being incised half of its thickness making tunnels in sclera and after that introducing bands of strengthening tissue in these tunnels. It is clear to everyone that incision of thin sclera weakens it even greater. Where is logic in performing such operations?

There are methods of introduction of liquid polymers under Tenon's capsule in postero-external part of an eye which after introduction harden. It provokes an inflammation in posterior pole of eyeball, that should strengthen scleral capsule and stabilization of myopia but it does not occur, instead of a positive effect we have terrible complication - this hardened polymer squeezes an optic nerve with the subsequent atrophy of it and loss of sight.

Besides, when doing scleroplasty there can be such complications as inflammatory disease of an eye (uveitis, tenonitis, endophthalmitis), increase of intraocular pressure, detachment of retina, partial atrophy of optic nerve, paresis of oculomotorius muscle.

Besides, when estimating scleroplastic operations, their outcomes and complications doctors often do not take into account changes in the muscular and ligamentous apparatus of an eye connected with scleroplasty. As is known through Tenon's space to sclera there are attached all external eye muscles between which and also between them, eyeball and eye-socket are established complex anatomic and functional relations with the help of Tenon's capsule, muscular membranes and ligaments.

Implantation of scleral flaps into Tenon's space, being a basis of scleroplastic operations, makes changes in complex structure of muscular and ligamentous apparatus of an eye and is the reason of various infringements on the part of oculomotorius apparatus functions.

Normal functioning of oculomotorius apparatus is a necessary condition of correct functioning of the visual analyzer of a person. Representing a paired organ, the visual analyzer can carry out its full-value function under condition of full synchronization of movement of both eyeballs. Any infringements arising in the motional sphere of eyeballs, conduct to disorganization of functions of the visual analyzer and frustration of binocular sight. It naturally follows from Goering's thesis that "for binocular sight, in addition to other conditions, normal functioning of oculomotorius apparatus of both eyes is necessary". Oculomotorius infringements can substantially limit professional suitability and reduce visual efficiency. (According to materials of the scientific job devoted to complications at scleroplastic operations, scientists - ophthalmologists of faculty of ophthalmology, the Ukrainian Kharkov institute of advanced training of doctors, under the direction of Professor Cherednichenko V.M.)

So you are operated however after a while you have again felt deterioration of sight and have addressed to the doctor. The doctor made a helpless gesture and established a fact that despite the performed operation, short-sightedness continues to progress. Certainly, you have misfortune. And, certainly, you can not be pleased with the phrase so often said by doctors - "Well, what you want, my dear, not all operations have positive result, you are not lucky... ". So effect from such operations is so insignificant that they are rejected by the majority of countries about what it was spoken at 2-nd international conference of children's ophthalmologists. (Chief ophthalmologist of Ministry of Health of Ukraine, the professor, Doctor of Medicine Sergienko N.M., Sudak, 2003) And what clinical effect can be if we direct efforts on creation of a mechanical obstacle in a way to a stretched eye while should think of an original cause - progressing of weakness of sclera and, first of all, of a connective tissue with all complex of diagnostics and pharmacotherapy.

The correspondent

Is scleroplasty till now widely applied in Crimea and Ukraine?

Dembsky L.K.

Unfortunately, yes, but it is not in all eye hospitals. From eleven eye hospitals which are situated on our peninsula, continue to perform scleroplasty in Republic children's clinical hospital (Simferopol) and in the Center of health protection of mother and the child (Sevastopol), thus being retarded from progress in ophthalmology. In other eye centers and branches, including first of all the Republic Center of microsurgery of an eye, sclerostrengthening injections and operations are not performed for a long time as inefficient.

Meeting ophthalmologists of Ukraine, I happen to hear that scleroplasty is necessary to perform to increase the surgical activity of a doctor and surgical department. Is it not blasphemy, not cynicism?

And, taking into account, that Ukraine strive for the European structures, doctors need to apply to international experience more often and not to make similar mistakes, breaking key rule of Hippocrat "do not harm". I think that scientists of faculty of eye diseases for a long time it was necessary to raise a question on inexpediency of similar operations and to supervise a situation in Crimea.

The correspondent

I think that it is clear now to all readers that short-sightedness is to be treated not with a knife but with other methods. What methods do you consider first of all?

Dembsky L.K.

It is very pleasant for me to tell all the Crimeans that scientists of the Crimean state medical university together with scientists of the Crimean Republic center of vision rehabilitation - Professor Kubyshkin V.F., Zagorulko A.K., Kryuchkova O.N., Doctor of Medicine is planned establishment of problem laboratory on studying a connective tissue. With creation of such laboratory in Crimea there will be an opportunity to determine infringement in a connective tissue easily and quickly. This is waited by cardiologists, surgeons, pediatrists and certainly us, ophthalmologists. Thus we can "catch" the reason of weakness of collagen or other component of a connective tissue and hence to determine correctness of treatment. Such approach exists in all civilized countries.

The correspondent

Leonid Konstantinovich, how does Ukraine think about the innovations of Crimea?

Dembsky L.K.

Crimea is the part of our big country - Ukraine. We have many clever, talented and intellectual ophthalmologists. But to unit all them in the solution of the common problem we have taken the initiative to create ophthalmologic debating society on problems of ophthalmology. We do the first step already - in a week on our site will appear the project - the concept of creation of debating society on the problem of myopia, in particular on the expediency or inexpediency of sclerostrengthening injections and operations. I think that our Crimean experience will be certainly positively appreciated by all Ukraine.

The correspondent

Thanks, I think that the opinion of the scientist will be useful not only to patients but also to doctors.