Various vitreoretinal surgical and laser approaches can restore, preserve and enhance vision for many eye conditions such as certain types of age-related macular degeneration , diabetic retinopathy , diabetic vitreous hemorrhage, macular hole , a detached retina , epiretinal membrane and CMV retinitis. General ophthalmologists, other ophthalmologist sub-specialists and optometrists usually refer patients in need of vitreoretinal management to a specialist. This type of specialist trains first as a general ophthalmologist and subsequently specializes in the medical and surgical management of vitreoretinal disorders.
A vitreoretinal specialist performs nearly all of the surgical procedures listed here, although general ophthalmologists and other ophthalmologist sub-specialists commonly handle procedures involving lasers. Procedures mentioned here are the more common of many surgical approaches to specific conditions requiring vitreoretinal surgery.
A vitrectomy procedure removes the vitreous humor or gel-like substance in the eye. This approach can address vision problems caused when foreign matter invades this usually pristine area of the eye's interior. One example of foreign matter is blood, from conditions such as diabetic vitreous hemorrhage.
Light rays passing through the eye cause the foreign matter to cast shadows on the retina, resulting in distorted or greatly reduced vision. A vitrectomy can restore vision in diabetic retinopathy by removing the natural vitreous that has become clouded by leaking blood vessels and replacing it with clear fluid. Once the surgeon removes the vitreous humor and clears the area, he or she usually injects a saline liquid to replace the vitreous humor that ordinarily fills up the inner chambers of the eye.
However, a vitrectomy is considered inappropriate and extreme for addressing most ordinary spots and floaters that occur with vitreous detachments affecting almost everyone to some degree as they grow older. Usually vitrectomies require general anesthesia. However, local anesthesia is used in certain situations, especially when general anesthesia would be inappropriate, such as for people with breathing problems. Your surgeon will make three tiny incisions in the eye to create openings for the various instruments that will be inserted to complete the vitrectomy. These incisions are placed in the pars plana of the eye, located just behind the iris but in front of the retina.
The instruments that pass through these incisions include:. Because so many variables are involved, only your eye surgeon familiar with your condition can give you a realistic idea of what to expect following a vitrectomy. But the underlying reason for the procedure usually is a major factor in determining how fast you will recover as well as the ultimate outcome. After a procedure, you likely will use antibiotic eye drops for about the first week and anti-inflammatory eye drop medications for several weeks.
Follow your surgeon's advice carefully. In general, don't expect to know your final visual outcome for at least a few weeks. Again, your surgeon or attending ophthalmologist will be the best judge of your individual recovery. Vitrectomies have a very high success rate. Bleeding, infection, progression of cataract and retinal detachment are potential problems, but these complications are relatively unusual.
For most patients who undergo a vitrectomy, sight is restored or significantly improved. The procedure is a marvel of modern medicine for people with conditions that might be blinding otherwise. Epiretinal membrane ERM , also known as macular pucker and cellophane retinopathy, involves growth of a membrane similar to scar tissue across the macula. This type of growth interferes with central vision by shrinking or contracting, which distorts the central retina. If you have this condition, you likely will see straight objects appearing wavy and crooked.
Also, you could experience reduced central vision, depending on the condition's severity. Epiretinal membranes may be associated with other eye conditions, but the cause of most ERMs is unknown. Some disorders occasionally associated with ERMs include previous retinal detachments and related surgery, inflammatory conditions uveitis , retinal tears, branch retinal vein occlusion BRVO and central retinal vein occlusion CRVO.
Your surgeon will help you decide if an epiretinal membrane peeling procedure is appropriate for you.
Vitrectomy for Floaters
But the decision will depend on the extent of preoperative vision loss and distortions. The eye is prepared with antiseptic solution and a sterile drape is applied. An eyelid speculum is used to keep the operative eye open. The other eye is covered and protected. Patients generally close their non-operative eye and rest during the surgery.
A surgical microscope with a special lens allows a wide view of the inside of the eye as well as a magnified and detailed view. Figure 1.
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The surgeon uses a vitrectomy probe vitrector to cut and delicately remove the gel-like vitreous. A wide-angle image of the retina following successful retinal detachment surgery by vitrectomy, scleral buckle, laser, and a small gas bubble. Image Figure 2. Vitreous hemorrhage, pre-retinal, and sub-retinal hemorrhages block vision and are indications for vitrectomy. When blood is cleared by surgery, vision will improve, but improvement is limited by the underlying health of the retina. Separate openings are used to light the eye and to place various other instruments that assist in surgery.
These include:. The eye is left filled with sterile saline salt water or with a vitreous substitute such as a gas bubble or silicone oil. When a vitreous substitute is used, a period of post-operative positioning typically face-down by the patient helps the retina heal. Complications of surgery are rare, but include infection, bleeding, high or low eye pressure, cataract, retinal detachment , and loss of vision. Surgical Goals: Vitrectomy or vitreous surgery can treat a number of conditions.
Surgery is indicated only when these 4 conditions are met:. Very few conditions are cured by vitrectomy alone. Most vitrectomies have at least one additional associated procedure. For example, a patient with longstanding diabetes develops sudden painless loss of vision that has not gotten better with observation alone. Bleeding in the vitreous, a vitreous hemorrhage, is diagnosed. A pars plana vitrectomy removes the hemorrhage and restores vision.
However, if the cause of the bleeding is not addressed, vitreous hemorrhage is likely to recur. Adding endolaser treatment to the vitrectomy surgery treats both the vitreous hemorrhage and areas of diabetic retinopathy —and the patient is much more likely to have an excellent long-term result. When is a Vitrectomy Recommended?
There are 5 major reasons to perform vitrectomy, or a vitrectomy plus other procedures:. Vision-blocking vitreous opacity clouding : When the vitreous cavity becomes cloudy, patients experience hazy vision. This indication is the most straightforward of the 5 categories. Conditions caused by abnormal pulling on the retina: Most vitrectomy surgery is performed to address abnormal pulling traction by the vitreous on the retina.
Vitreoretinal traction is a common causative finding associated with aging, nearsightedness, severe diabetes, severely premature infants, head or eye trauma, following YAG laser capsulotomy , and after complex anterior segment surgery. These conditions may result in:. Treatment consists of vitrectomy to remove vitreous opacities clouding , separation of the vitreous from the retina, membrane peeling to remove retinal traction, and placement of a gas bubble or laser as needed to prevent recurrence. Removing membranes or scar tissue from the surface of the retina is delicate and exacting work, requiring many techniques in addition to vitrectomy.
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Figure 3a. Vitreous fluid flows through a retinal tear to cause a partial retinal detachment involving the macula. The optic nerve and nasal retina, or portion of the retina closest to the nose, are normal and uninvolved. Vitrectomy surgery is indicated to restore vision. Figure 3b. An epiretinal membrane wrinkles the surface of the retina and blocks the macular photoreceptors light-sensing cells at the center of the retina. This causes blurry and distorted vision.
Vitrectomy - diagnosis and treatment
Vitrectomy and retinal membrane removal allow the retina to resume its normal shape and improve vision. Figure 3c. The macula is pulled apart by traction on the surface of the retina. The dark areas represent swelling retinal edema from tissue damage. Jason Calhoun. Figures 3d and 3e. Abnormal blood vessels retinal neovascularization, Figure 3d can be found as a blinding condition in many diseases including diabetic retinopathy, branch retinal vein occlusion, and retinopathy of prematurity.
When vessels contract, they may bleed, causing vitreous hemorrhage bleeding Figure 3a or cause the retina to detach as shown here, causing a traction retinal detachment Figure 3e. In advanced cases, only vitrectomy surgery can help restore vision. Figure 3f.
A fragment of metal upper photo punctures the eye and impales pierces the retina near the optic nerve. Vitrectomy surgery was performed to remove the intraocular in-the-eye foreign body and laser was placed to prevent retinal detachment black spots surrounding the white scar in lower photo. Figure 3g. Contracture of abnormal blood vessels forms an elevated ridge of scar tissue in an infant with severe prematurity.
Sometimes in eyes with retinal detachment, vitrectomy is combined with scleral buckling, a procedure involving sewing a piece of silicone sponge, rubber, or semi-hard plastic onto the sclera or placing a band encircling the eye to relieve retinal traction.
Performing vitrectomy in eyes that are disordered from trauma Figure 3f or in severely premature infants with retinopathy of prematurity Figure 3g can be very challenging. These are some of the most complex surgical procedures in all of ophthalmology. Conditions needing retinal or other eye surgery: As noted previously, the vitreous humor and traction on the retina can cause a wide variety of problems.
For this reason, vitrectomy is also performed to prevent complications or to improve the outcome of the primary surgery. For example, during anterior-segment surgery cataract, glaucoma, cornea, intraocular [in-the-eye] lens , sometimes vitreous comes forward through the pupil and an anterior vitrectomy is performed. Similarly, when a cataract fragment, intraocular lens, or other foreign body dislocates and falls back into the vitreous, a vitrectomy is performed to fully free the object, which can then be removed or repositioned. A pars plana seton valve inserted into the pars plana to control the intraocular pressure in an eye with glaucoma.
A vitrectomy sometimes is performed as part of placing a pars plana glaucoma implant see illustration. This device lowers eye pressure by allowing excess fluid to escape the eye. A vitrectomy removes the vitreous that might otherwise plug the drainage tube. In each example, a vitrectomy improves the outcome of the procedure and reduces the likelihood of retinal tear, retinal detachment, macular edema swelling , and other complications.
To diagnose a vitreoretinal condition diagnostic vitrectomy : This special indication for vitrectomy is employed when removing or sampling the vitreous is needed to help make a diagnosis. A diagnostic vitrectomy is performed in severe eye infections, when the eye is inflamed, and for certain kinds of cancer that can spread to the eye. Examination of the vitreous helps ensure that the most appropriate treatment is being used.
When placing a therapeutic device or drug delivery: Vitrectomy is also performed when placing a therapeutic device in the eye. Devices may include extended-drug-delivery devices to deliver steroid or anti-viral drugs, a glaucoma drainage device Figure 3h , a retinal prosthesis, and gene therapy where the therapeutic products are placed under the retina. New technologies offer the promise of directed treatment to the retina.
Vitrectomy may be one way to accomplish this. Before Surgery Pre-Op —What to Expect: Prior to surgery, your doctor will carefully examine your eye and assess your general health.
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Other tests may be performed if the surgery is likely to involve the anterior front segment, cornea, or lens.