Ophthalmology Unit

Ospedale San Raffaele

key figures 

CLINICAL SERVICES:

  • Cataract Surgery
  • Surgical Retina
  • Ophthalmoplastic, Orbital and Cosmetic Eyelid Surgery
  • Medical Retina
  • Ocular Immunology and Uveitis
  • Ocular Oncology
  • Paediatric and Genetic Ophthalmology
  • Strabismus
  • Glaucoma
  • Neuro-ophthalmology and Electrophysiology
  • Imaging
  • General Ophthalmology

PROCEDURES PERFORMED PER YEAR:

  • 3.000 cataract surgeries with phacoemulsification technology
  • 650 vitreoretinal surgery procedures
  • 150 strabismus surgery procedures
  • 150 paediatric surgery procedures
  • 500 eyelid surgery procedures
  • 100 orbital surgeries
  • 200 lacrimal pathways surgeries
  • 200 incisional surgery for glaucoma
  • 500 laser treatments for glaucoma
  • 1.200 retinal laser treatments
  • 7.000 intravitreal injections
  • 20.000 ocular diagnostic imaging procedures
  • 3.400 ocular functional tests

San Raffaele’s ophthalmology unit is divided into 14 subsections covering the whole field of ophthalmology. The services are linked together with the other operating units of the hospital to ensure a complete response in the case of complex diseases that involve different areas.

The ophthalmology unit is accredited by the European Board of Ophthalmology (EBO). The EBO makes evaluation of the clinical-assistance and teaching-training standards by inspectors from their organization. Thanks to this accreditation the unit can accommodate doctors-specialists and teachers from accredited university hospitals in various European countries.

The ophthalmology unit has also been recognised by the International Council of Ophthalmology as a suitable structure to welcome specialists from all over the world to perform fellowships in various fields of ophthalmology.

The ophthalmology unit is part of the European Vision Institute (EVI.CT.SE). It is a European network of clinical ophthalmological research centres, dedicated to conducting clinical research activities in ophthalmology with the highest quality standards, following the European and international directives for clinical studies. This network has an infrastructure for the management of multi-centre clinical trials through common and harmonised technical and organisational standard operating procedures, quality control and staff training. EVI.CT.SE serves as a fundamental resource for the development of translational research, in particular for industrial innovation for medical and pharmaceutical devices in the European Union.

The ophthalmology unit was chosen by the European School for Advanced Studies in Ophthalmology (ESASO) as a venue for the execution of fellowships in the field of retinal diseases.

 

treatmentS

Cataract Surgery

The unit offers diagnosis and surgical treatment of cataract and lens disorders. Cataract surgery is done on an outpatient basis using the most innovative and least invasive technique: Torsional Phacoemulsification. This technique allows to perform cataract extraction interventions through a lower energy use of ultrasounds, with incisions of minimal size and with a "topical" anaesthesia or, in some cases, "peribulbar".

The service also offers the opportunity to implant next-generation intraocular lenses that both prevent the formation of opacity of the posterior capsule and limit the retinal damage correlated to UVB rays. In relation to the needs of the individual patient, it is possible to implant particular lenses such as multifocal lenses, which allow a near and far vision, and the "toric" lenses which allow to correct astigmatism. This service, in collaboration with the paediatric ophthalmology service, deals with the diagnosis and treatment of congenital cataracts. It is also a reference centre for the study and use of novelties in the field of intraocular lenses and surgical devices.

Treatment of complicated cases such as traumatic cataract, subluxated cataract, uveitis cataract in adults and children and cataract in aniridia are also performed in the unit.

Main Pathologies Treated:

  • Paediatric cataract disorders
  • Congenital cataract disorders
  • Traumatic cataract disorders
  • Subluxated cataract disorders
  • Uveitis cataract disorders
  • Aniridia cataract disorders
  • Astigmatism treatment

Top Procedures:

  • Surgery with phacoemulsification technology
  • Implantation of new-generation intraocular lenses
    • Multifocal lenses
    • “Toric” lenses

Vitreoretinal Surgery Division

This subsection of the ophthalmology unit is engaged in the diagnosis and surgical treatment of retinal diseases. The vitreoretinal surgery team is currently using the most advanced instruments and guarantees the most innovative therapeutic solutions currently available such as: ultra-high speed vitrectors, minimally invasive surgery, intravitreal ocriplasmin injection, new dyes, 3D surgery, intraoperative OCT. The division provides laser treatment of peripheral retinal degenerations (Pascal and Argon laser devices are available).

The vitreoretinal surgery division is currently involved in several clinical research fields with multicentre international trials and randomized studies.  

The team has performed the first Italian subretinal-implant of artificial retina, designed to restore partial vision in blind subjects affected by inherited retinal dystrophies.

Main Pathologies Treated:

  • Primary retinal detachment and complex cases
  • Vitreoretinal interface disorders including:
    • Idiopatic and secondary macular hole
    • Idiopatic and secondary epiretinal membrane
    • Vitreoretinal traction syndrome
    • Complications of diabetic retinopathy including vitreous haemorrhage, traction retinal detachment, diabetic macular oedema
  • Retinoschisis
  • Endophthalmitis
  • Intraocular lens dislocations
  • Traumatic disorders, including foreign body extraction
  • Peripheral retinal degenerations

Top Procedures:

  • Scleral buckling
  • Vitrectomy (20-gauge, 23-gauge and 25-gauge and 27-gauge with endotamponade)
  • Retinal cryotherapy
  • Artificial retina implant

Ophthalmoplastic, Orbital, and Cosmetic Eyelid Surgery

The ophthalmoplastic, orbital and cosmetic surgery division specialises in the diagnosis and treatment of eyelid, orbital and tear system disorders. Particular attention is paid to the diagnosis and surgical treatment of congenital and acquired anomalies of the eyelid position: entropion, ectropion, trichiasis, eyelid ptosis, eyelid retraction. The subdivision is also a reference centre for the diagnosis and treatment of lymphoma of the orbit. Most of the surgery is performed as an outpatient procedure while the most complex surgical cases can be done through ordinary hospitalization.

Main pathologies treated of ophthalmoplastic and orbital diseases:

  • Acquired and congenital anomaly of the position of the eyelid and lacrimal drainage system obstructions
  • Lacrimal system and orbital infections
  • Malignant and benign tumours of conjunctiva, eyelid, orbit, and lacrimal system
  • Anophthalmic cavity reconstruction
  • Silicon and hydroxyapatite endo-prosthesis
  • Eyelid, lacrimal system and orbital trauma
  • Optic nerve diseases

Main pathologies treated of cosmetic eye surgery interest:

  • Blepharoplasty
  • Aesthetic ptosis
  • Xanthelmas
  • Benign superficial neoformations

Medical Retina

Macular diseases have always been one of the main fields of interest of the department. It particularly dedicates attention to age-related macular degeneration, pathological myopia, and central serous chorioretinopathy, as well as other less frequently observed problems such as angioid streaks and white dot syndromes, together with some even rarer and more unusual cases. Patient work-up begins in a specifically dedicated section with a diagnostic track that is based on the latest multimodal-tool examinations. Upon diagnosis, the treatment, when required, is given in real-time. Intravitreal therapy can be carried out in the surgical area where about 7,000 injections/year are performed. Moreover, the department’s reputation results in them hosting the principal RCT experimental protocols testing new treatments for every kind of macular disease. Notably, the unit is a referral centre for many local and international colleagues, which gives it the chance to observe numerous rare and intriguing cases.

The retinal vasculopathies subsection has a long-standing clinical experience and is one of the most important divisions of the unit. The most frequently managed pathologies are diabetic retinopathy and retinal occlusions (Arterial and Venous Thrombosis) for which the service continues to constitute a national reference centre. The subdivision carries out treatments mainly on an outpatient basis. All the medical, nursing and technical staff are actively involved in the patient’s clinical pathway, research and teaching activities, with the aim of combining scientific and professional quality for optimal outcomes. The organization of the division foresees that, in the same session, the patient is subjected to the necessary diagnostic tests and, where possible, to the most appropriate treatments.

Chorioretinal dystrophies represent a heterogeneous group of hereditary diseases, whose diagnosis and management requires integrated collaboration with various specialists. After the diagnostic path, based on the most recent techniques, follows a therapeutic and possibly rehabilitative path. The division collaborates with San Raffaele’s medical genetics department working in an integrated way to ensure efficient and high-quality treatments to patients.

Main Pathologies Treated:

  • Vascular diseases:
    • Diabetic retinopathy
    • Retinal vein and arterial occlusion
    • Retinal angiomatosis
    • Retinal arterial macroaneurysm
  • Macular diseases including:
    • Age-related macular degeneration
    • Myopic macular degeneration
    • Central serous chorioretinopathy
  • Corioretinal dystrophies:
    • Cone dystrophy
    • Stargardt macular dystrophy
    • Vitelliform macular dystrophy
    • Pattern dystrophy
    • Juvenile X-linked retinoschisis
    • Retinitis pigmentosa

Top Procedures:

  • Laser treatment with innovative technology
  • Intravitreal injection of therapeutic agents
  • Photodynamic therapy
  • Diagnostic examinations:
    • Optical coherence tomography (OCT)
    • OCT angiography
    • B-Scan ocular ultrasound
    • Ophthalmic ultrasound bio microscope
    • Multimodal imaging colour retinography, blue-light and near infrared auto fluorescence fundus image, fluorescein and indocyanine green angiography, ultra-wide-fluorescein angiography
    • Ocular electro functional exams (ERG, m-ERG, EOG, PEV)
    • Microperimetry
    • Perimetry
    • Genetic investigation (NGS)

Ocular Immunology and Uveitis

This section is dedicated to diagnosis and treatment of inflammatory and infectious ocular diseases and its activity is oriented both in clinical and research fields. Among the various diagnostic techniques, the division uses Polymerase Chain Reaction (PCR) on corneal tissue, on aqueous and vitreous humour for the differential diagnosis of viral, bacterial or fungal infections. For the treatment of inflammatory uveitis, multiple therapies are used from local to intravitreal to systemic drugs.

The division is also specialised in the care of young patients, suffering from ocular involvement in Juvenile Idiopathic Arthritis (JIA). The clinical activity employs a group of doctors dedicated to these pathologies for both medical management and surgical procedures.

The ocular immunology and uveitis division is also dedicated to the diagnosis and treatment of Ocular Surface Disfunction (Dry Eye Syndrome). In addition to basic diagnostic techniques, conjunctival impression cytology and tear osmolarity measures are available, if needed. Particular attention is given to patients affected by Sjögren Syndrome, Graft Versus Host Disease (GVHD), and systemic autoimmune pathologies.

Main Pathologies Treated:

  • Anterior, intermediate and posterior uveitis
  • Viral, bacterial and fungal infections
  • Dry eye syndrome and ocular surface dysfunction
  • Sjögren syndrome and GVHD
  • HIV related ocular disease
  • Major ocular inflammations

Top Procedures:

  • Polymerase chain reaction (PCR)
  • Intravitreal steroid implants
  • Systemic treatments (steroid, cyclosporine, methotrexate, biological drugs, interferon)
  • Conjunctival impression cytology
  • Tear osmolarity measure
  • Surgical treatments

Ocular Oncology

The ocular oncology section carries out clinical and research activities in the field of ocular tumours. In conjunctival neoplasia the diagnosis work includes surgical biopsies. Regarding the therapy of conjunctival tumours, in addition to traditional surgery, treatments with local chemotherapy are performed. In the treatment of conjunctival lymphomas intralesional injections of interferon or rituximab are performed. As part of the surgical treatment of conjunctival melanoma, the "sentinel lymph node" technique can be applied. The division is also specialised in intraocular tumour diagnosis and treatments. In intraocular lymphoma in addition to external radiotherapy and in selected cases intravitreal injections of chemotherapy are used. Uveal metastases are treated by external radiotherapy with "lens sparing" technique or with Gamma Knife radiosurgery.

In uveal melanoma, as an alternative to enucleation, the conservative treatment used is radiotherapy by means of Gamma Knife radiosurgery. Transpupillary laser thermotherapy (TTT) is currently applied only for selected cases of small uveal melanomas. In choroidal haemangioma, the standard treatment is currently photodynamic therapy (PDT) that has replaced radiotherapy in most cases.

Main Pathologies Treated:

  • Conjunctival tumours
  • Intraocular neoplasia
  • Intraocular lymphoma
  • Uveal melanoma
  • Choroidal haemangioma

Top Procedures:

  • Surgical treatment
  • Topical or local chemotherapy
    • Mitomycin C, 5-FU, Rituximab, Interferon
  • Diagnostic examinations:
    • A- B scan ocular ultrasound
    • Ophthalmic ultrasound bio microscopy
    • Multimodal imaging (optical coherence tomography OCT, ultra-wide field fundus photography, fluorescein and indocyanine green angiography)
    • Magnetic resonance imaging (MRI)
    • Computed tomography (CT)
    • Radioimmunoscintigraphy using monoclonal antibody
    • Positron emission tomography (PET)
  • Gamma Knife radiosurgery  
  • Photodynamic therapy

Paediatric Ophthalmology

The paediatric ophthalmology service takes care of infant eyes for the diagnosis and treatment of ocular disorders in the age group from 0 to 14 years. Screening and complete ocular examinations are performed for all children in the "plastic period" of visual development (0-6 years), even in the absence of disturbances. Early onset ocular pathologies are followed, from the annexes to the posterior segment which, for greater accuracy, are managed in direct collaboration with the other ophthalmology divisions. The paediatric division provides outpatient services (with a complete visit to cycloplegia and orthoptic evaluation) and, using a multidisciplinary approach, guarantees the surgical and patient management in this area.

Main Pathologies Treated:

  • Refractive defects
  • Amblyopia
  • Congenital obstruction of the nasolacrimal duct
  • Congenital ocular anomalies
  • Allergic conjunctivitis

Genetic Ophthalmology

The genetic ophthalmology division deals with the diagnosis and management of genetically-determined eye diseases, in paediatric and adult patients. The division works in collaboration with the geneticist’s department at the San Raffaele Hospital, in order to promote and carry out research in genetic eye diseases through multicentre studies. Because this direct collaboration with geneticist there is also the possibility of carrying out biomolecular studies, in selected cases.

The most frequently-treated diseases are Down's syndrome, neurofibromatosis, Marfan's syndrome, ocular albinism and hereditary retinopathies as retinitis pigmentosa and juvenile macular degeneration. The division provides outpatient services and, using the collaboration of other ophthalmology subsections, allows the clinical and instrumental classification of the patient (electrophysiology, fluorescein angiography, OCT).

Main Pathologies Treated:

  • Retinal dystrophies
  • Genetic syndromes with ocular involvement

Strabismus

Strabismus service works on clinical, diagnostic and therapeutic aspects in paediatric and adult ocular motility disorders. The division is composed of a team of doctors, surgeons, and orthoptists, experts in the field of strabismus.

With regard to paediatric patients, the division is particularly interested in congenital, infantile, acquired paralytic strabismus and those forms of ocular deviation associated with syndromic and systemic diseases, in direct collaboration with the paediatric and genetic ophthalmology division. The aims are having a correct clinical diagnosis, routine follow-up, clinical treatment and, when necessary, surgical approach.

In adult patients, the division manages long-established congenital strabismus, with or without previous treatment, secondary strabismus with neurological and neurosurgical disorders, thyroid, post traumatic, restrictive and others.

Diplopia is also treated, by conservative or surgical approach, under topical or general anaesthesia, based on the origin of the deviation. The diagnosis and treatments are provided in close collaboration with the paediatric-genetic, oculoplastic, neuro ophthalmology and neurophysiology services.

Main Pathologies Treated:

  • Strabismus
  • Diplopia

Top Procedures:

  • Surgical treatments
  • Diagnostic examinations:
    • Cycloplegia including orthoptic examination
    • Prismatic tests

Glaucoma

The glaucoma division guarantees excellent diagnosis and treatment to glaucoma patients, through the performance of diagnostic services, the prescription of medical treatments and the execution of laser and surgical treatments, according to the most updated guidelines thanks to the experience and continuous updating of the team. It is the reference centre at a regional and national level for the diagnosis and treatment of the disease. The service collaborates with the most prestigious national and international glaucoma centres, participates in multi-centre studies for the research of new drugs and for the development of new laser and surgical techniques, independently conducts study protocols and performs a lively activity teaching and in congresses.

The division provides a complete medical assistance to patients suffering from all forms of glaucoma, primary and secondary, thanks to top-level skills and tools, while ensuring full and empathic personal availability. The innovative diagnostic activity allows the team to identify and follow the disease, not only in its established forms, but also in those extremely initial, or in the cases where it is a question of assessing the presence of simple risk factors for the future development of the disease. Patients are offered the most up-to-date pharmacological treatments, defining the most appropriate therapeutic scheme for each individual case. Laser treatments are carried out, if necessary, which are more suitable in various forms, such as iridotomies, trabeculoplasty, gonioplasty and cyclophotocoagulations.

The cases in which the medical and laser therapies are not sufficient to guarantee the stability of the disease are tackled with the most effective and safe surgical procedures, both in hospitalization and day-surgery, using all the latest filtering surgery techniques: trabeculectomy, viscocanalostomy, deep sclerectomy, drainage implants and MIGS, among others.

Main pathologies Treated:

  • Glaucoma

Top Procedures:

  • Diagnostic examinations and early risk factors detection:
    • Tonometry
    • Tonometry curves
    • Gonioscopy
    • Pachymetry
    • Anterior segment Imaging
    • Optic nerve head imaging exams
    • Conventional/nonconventional perimetry
  • Laser treatments:
    • Trabeculoplasty
    • Iridotomy
    • Iridoplasty
    • Cyclophotocoagulation
    • Laser approach for malignant glaucoma
  • Surgical Procedures:
    • Trabeculectomy
    • Nonpenetrating surgeries
    • Minimally invasive glaucoma procedures (MIGS)
    • Mini-drainage devices
    • Major drainage implants
    • Complicated cataracts
    • Management of concomitant cataract and glaucoma
    • Antimetabolite implementation
    • Repeat surgeries
  • Complete postoperative management:
    • Antimetabolite injection
    • Needling and revisions
    • Goniopuncture
    • Choroidal taps
    • Management of hypotony

Neurophthalmology and Clinical Electrophysiology

Neurophthalmology is a clinical-scientific discipline that deals with the physiology and pathology of neurological structures related to the visual system.

The integration between neuro-ophthalmological skills and those of neurological, neuroradiological, neurosurgical, endocrinological, immunological and otoneurologic relevance is of fundamental importance. For this purpose, the clinical activity of the division takes place within a multidisciplinary team that concerns in particular the following clinical areas: thyroid diseases, basicranial pathologies, inherited degenerative diseases of the central nervous system, demyelinating pathologies of the central nervous system, immunological diseases of the nervous system. The division is a reference centre for optic neuropathies for international clinical and therapeutic trials.

Clinical electrophysiology uses instrumental investigations such as electroretinography (ERG), multifocal ERG, visual evoked potential (VEP), and pattern electroretinogram (PERG), for the diagnostic classification and monitoring of retinal pathologies and those affecting the structures responsible for nerve conduction to the primary visual cortex. The division pays particular attention to the diagnosis and monitoring of retina-inherited degenerative diseases or acquired, and the pathologies regarding the optical nerve.  

Main Pathologies Treated:

  • Optic neuropathies
    • Idiopathic or arteritic ischemic optic neuropathies
    • Toxic and ethereal optic neuropathies
    • Inherited optic neuropathies
    • Inflammatory idiopathic neuropathies
    • Multiple Sclerosis associated neuropathies and dysimmune neuropathies
  • Optic nerve tumours and compressive cerebral pathologies of the sellar region
  • Pseudotumor cerebral and intracranial hypertension complications
  • Cranial nerve paralysis (III, IV, VI)
  • Ocular motility alterations secondary to cerebral diseases
  • Pupillary alterations
  • Ocular myopathies and ocular gravis myasthenia
  • Inflammatory and infiltrative orbitopathies
  • Thyroid associated orbitopathy
  • Complications of cranial trauma
  • Intracranial and intra-orbital arteriovenous malformations (MAV)
  • Eyelid spasm
    • Blepharospasm
    • Hemifacial spasm
  • Correction surgery of adult strabismus
    •  Paralytic, sensory, restrictive

Imaging

The diseases affecting this division include all fields of ophthalmology. The division guarantees the latest generation of equipment, which are continuously updated, in particular the OCTs of which all the latest models currently available on the market are offered.

Spectral Domain OCT (SD-OCT), with a wavelength of near 800nm, or a swept-source OCT (SS-OCT), which utilizes a longer wavelength, close to 1050nm, use light waves to take cross-section pictures of the retina and the choroid and of anterior segment. They allow to evaluate both the morphology and the thickness of the macular region, of the optic nerve and of the anterior segment with a resolution of 5 micrometres. Recently Optical Coherence Tomography Angiography (OCT-A) emerged as a non-invasive technique for imaging the microvasculature of the retina and choroid. OCT-A technology uses laser light reflectance of the surface of moving red blood cells to accurately depict vessels through different segmented areas of the eye, thus eliminating the need for intravascular dyes, as fluorescein and indocyanine-green angiography. Ultrasound with contact and immersion technique, B-scan, Standardized A-scan and linear A-scan for biometric measurements is also available at the division. Ocular ultrasound is of maximum clinical utility in the presence of opacity of the dioptric media, such as advanced cataracts, internal bleeding, corneal opacities that prevent the exploration of the ocular fundus. The orbital ultrasound allows the study of retrobulbar structures, such as the lacrimal gland, oculomotor muscles, and the optic nerve. Meanwhile, the Ultrasound Biomicroscopy (UBM), is a high-resolution ultrasound, with which it is possible to visualize structures of the anterior segment and of the most peripheral (now tightened) ocular districts. UBM allows three-dimensional images of the anterior segment to be obtained. It is very useful for the study of corneal pathologies, iris and iridocorneal angle and important for the evaluation of the success of numerous surgical interventions.

General Ophthalmology

The general ophthalmology subsection addresses ocular and systemic diseases which affect directly visual acuity and can generate eye complications. It performs different exams and procedures depending on the ocular pathology with a super-specialised approach. The division is able to refer patients to all other sections of the ophthalmology department, ensuring the best possible clinical pathway for patients. One main field of interest is the correction of refractive problems. The refractive defects may require different evaluations and solutions (contact lenses, high index lenses or progressive lenses) according to the extent of the defect and working activities that the patient performs. A specific field of interest is that of the so-called "occupational" ophthalmology, that is, problems related to the use of display screen equipment (such as decrease in visual acuity, poor posture, irritative symptoms) or other eye diseases correlated with work activity. An important subsection is the visual suitability to guide for renewal or release of guide license addressed to sanitary commissions; the evaluation includes specific exams, all carried out in one visit: contrast test, dazzle test, colours test, dazzle recovery test, best corrected visual acuity and visual field.

Main Pathologies Treated:

  • Ocular refraction defects

Top Procedures:

  • Prescription of ocular lenses (contact, high-index, progressive)