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Les dernières actualités de la chirurgie réfractive et de nos autres domaines de compétence ophtalmologique

Le LASIK pour l’hypermètropie

Généralités *

Lorsqu’un ou une patiente hypermètrope vient consulter pour retirer sa correction lunettes, deux situations se présentent à nous. Jeune, il aura derrière lui un long passé de fatigue oculaire (on parle d’asthénopie), de séances chez l’orthoptiste, voire de strabisme (qualifié d’accomodatif). Mêmes si les indications sont historiquement moins larges que pour la myopie, les progrès liés à la généralisation du laser femtosecond dans la découpe du volet autorisent la réintroduction de cette chirurgie. A la quarantaine – si tant est que l’on ne soit plus jeune à quarante ans :siffle: – la situation s’inverse et les indications opératoire se facilitent, devenant un des traitement les plus aisé de la presbytie.

L’oeil hypermètrope *

Anatomie *

Quel que soit son âge l’oeil hypermètrope est un oeil trop court. Il n’est pas assez convergent: l’image focalisée par nos lentilles, la cornée, et le cristallin, se retrouve en arrière de la rétine. Floue.

Conséquences visuelles *

Avant quarante ans *

Si l’on compare l’oeil à un appareil photo, la cornée, l’iris et le cristallin en formeraient l’objectif, alors que la rétine en serait le capteur CCD (ça fait longtemps qu’on ne met plus de pellicule! ). Pour l’amateur éclairé, la cornée serait une focale fixe, l’iris le diaphragme, et le cristallin un formidable autofocus. Et oui: contrairement à la cornée, le cristallin est déformable. De la véritable « jelly » ! Sous l’action du muscle ciliaire, il devient plus convexe, plus puissant: il accomode l’image sur la rétine. L’hypermètrope jeune, le plus souvent vois bien!

Cette contraction permanente a malheureusement un prix: des maux de tête. Typiques: une barre horizontale sur le front en fin de journée. Du CP ou après une journée sur l’ordinateur, c’est toujours la même. Pire: si, épuisé, le muscle ciliaire se relâche, le cristallin s’aplatit. L’image s’éloigne de nouveau de la rétine. Le flou visuel apparait: l’hypermètropie est décompensée.

On pourrait en rester là mais le fort hypermètrope peut souffrir d’autres maux: cet effort d’accomodation réalisé en permanence, tout à chacun (l’emmètrope) le réalise dans une situation bien particulière: lorsqu’il regarde de près pour lire. L’accomodation s’associe alors par réflexe à une contraction de la pupille -un myosis- et surtout à une convergence du regard. Vous avez compris: il faut loucher pour voir de près.

Aie aie aie, mais on vient pas de voir que le fort hypermètrope accomode tout le temps?Il va loucher! 😕

Oui c’est même comme ça que se développe le strabisme accomodatif. Et c’est aussi pour ça que l’on traite ce type de strabisme simplement par la prescription de lunettes: la suppression du facteur accomodatif permet de dire au cerveau :  » pas besoin de me faire loucher, j’suis pas en train de regarder de près là! »

On m’a encore changé les lunettes! Mais c’est quoi ma vraie correction?

En fonction de notre état de fatigue, de notre mode de vie, on va plus ou moins solliciter notre accomodation. Il est évident qu’on a beaucoup moins mal à la tête après une journée de farniente qu’après une nuit sur l’ordinateur. Votre formule de correction va se balader entre le nul pour une hypermètrope qui voit bien et qui n’a pas mal à la tête, à la correction optique totale chez le strabique. La variabilité de cette mesure est la principale cause de cet adage: l’hypermètrope de moins de 40 ans reste (mais moins qu’avant) le parent pauvre de la chirurgie réfractive 🙁 .

A l’aurore de la presbytie *

Tout change avec les golfes qui s’approfondissent et les tempes qui grisonnent  😉 . La cornée est toujours aussi solide. Par contre, le cristallin, lui, ça fait bien longtemps qu’il a commencé a changer: il se rigidifie. Le petit chewing gum de l’enfance s’est transformé en pastille Valda® (il finira en Pulmol®, mais ça, c’est une autre histoire 😯 ). Avec cette transformation il perd ses capacités accomodatives.

Oui mais mon muscle ciliaire est très fort ! Il va bien réussir à la déformer cette Valda?? Je ne veux pas que mon puntum proximum s’éloigne moi! JE NE VEUX PAS DE PROGRESSIFS docteur! 😈

Bien sûr qu’il est fort votre muscle! Mais ça fait quarante ans qu’il est contracté en permanence. Alors quand on lui demande un effort supplémentaire, il n’y arrive pas. Rappelez vous de votre première 2CV à fond dans les tours à 100 sur l’autoroute et puis d’un coup le drame: une montée! La file de gauche qui se gausse… 😛 Votre muscle ciliare, à 40 ans, c’est une dodoche partie pour faire l’Alpes d’Huez.

Et c’est grave docteur?

Et non!! C’est une bénédiction pour vous, hypermètropes murissants. Adieu hypermètropie latente: votre correction s’est enfin stabilisée. On va pouvoir opérer. Et c’est une des meilleures indication de la chirurgie réfractive.

Particularités chirurgicales *

 

J’espère que vous ne serez pas trop embêté pour m’opérer avec mes petits yeux, docteur…

Hum. Comment dire? C’est ainsi: vous avez un petit œil. Et ceci va avoir de multiples conséquences.

La succion *

Le premier temps opératoire, la phase de blocage de l’œil par la machine, ne sera pas vraiment affectée par sa petite taille. Ce qui va nettement plus nous embêter, c’est qu’un petit œil est souvent plus enfoncé dans l’orbite: il est enophtalme. Ce sera notre dur labeur que d’aller faire glisser l’anneau de succion jusque là.

Le profil d’ablation *

Pour corriger votre cornée trop plate ( on dit qu’elle est oblate), il n’y a pas 36 solutions. Il n’y en a qu’une. Il faut la rendre plus puissante. Plus convergente: il faut augmenter sa convexité (la rendre prolate).

Ok j’ai tout compris: les myopes on les aplati et les hypermétropes, on les cambre. Fastoche. Mais ça change quoi?

La zone de transition *

Ça change tout!

Lorsqu’on traite une cornée, on ne le fait pas sur toute sa surface. On se débrouille pour que la zone traitée efficace (on parle de zone optique) soit la plus grande possible (au moins plus grande que votre pupille dilatée la nuit); mais pour autant, il y aura toujours un anneau périphérique non traité. La jonction entre cet anneau et la zone optique s’appelle la zone de transition. Sa pente est naturellement très douce lorsque l’on a aminci la grande cornée du myope. Elle est par contre abrupte lorsque l’on traite l’hypermètrope.

Et alors?

La taille du capot *

Alors pour ne pas vous faire souffrir des aberrations induites par ces changements aigus de pente, nous allons l’affaiblir en augmentant la zone de transition

Ca  veut dire que vous allez traiter une surface plus grande non? On peut faire ça?

C’est la grande victoire du laser Femtosecond sur le microkeratome pour la découpe du volet.

D’une, le laser ne fait pas cas de la platitude de votre cornée. Mais surtout, on peut faire des volet ENORMES, tout ce qu’il y a de plus adapté à l’hypermétropie.

Le centrage et l’angle kappa *

Le pourcentage de tissu altéré *

La régression *

La multifocalité *

Ca vous fait bien des complications tout ça docteur. Pourquoi vous m’avez dit que c’était une des meilleures indication de LASIK?

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