Vitrectomy is a microsurgical procedure in which specialized instruments and techniques are used to repair various retinal disorders. The initial step in this procedure is the removal of the "vitreous gel" through a very small micro-incision in the wall of the eye, hence the name "vitrectomy". The vitreous is removed with a miniature cutting device and replaced with a special saline solution similar to the fluid being removed from the eye. An endoilluminator provides the light source used to illuminate the inside of the eye for the surgeon to visualize the internal structures as the surgery is being performed. The surgeon uses a specialized operating microscope and contact lenses, which allow a clear view of the vitreous cavity and retina at various magnifications. The procedure is performed in an operating room under local or (occasionally) general anesthesia. It can, and is often done as an ambulatory procedure. This means that barring complications, a patient is discharged and can leave the hospital or surgical facility within 23 hours. With most of our cases the patients are usually discharged and leave the hospital within 3 to 4 hours of completion of the procedure. Although vitrectomy procedures are sometimes performed through incisions made near the front of the eye, most vitreo-retinal surgeons enter the globe through a part of the eye known as the pars plana. This is why the procedure is often referred to as a pars plana vitrectomy (PPV). Entering the eye through this location avoids damage to the retina and the crystalline lens.
Pars plana vitrectomy (PPV) is used to treat many different retinal disorders including
those listed below:
- Proliferative diabetic retinopathy
- Vitreous hemorrhage
- Macular hole
- Macular pucker (epiretinal membrane)
- Certain traction or recurrent retinal detachments
- Intraocular infections (endophthalmitis)
- Intraocular foreign body
- Retained lens fragments or dislocated lens implants (following cataract surgery)
- Giant retinal tears
- Certain traumatic eye injuries
The retinal surgeon has at his disposal a variety of specialized techniques and procedures to maximize the effectiveness of vitrectomy surgery, including:
The use of Intraocular gases, when combined with sterile air, have the necessary properties for remaining in the eye for extended periods of time (up to two months). Eventually, they are replaced by the eye's own natural fluid. Intraocular gases are useful for flattening a detached retina allowing it to remain attached while the healing process takes place. Macular holes (link) are also treated with an intraocular gas injection. An important aspect of gas usage is the requirement for specific head positioning, which varies from case to case, and is discussed with the patient prior to and following surgery. Vision in a gas filled eye is usually rather poor until at least 50% of the gas is absorbed. Possible complications involved in the usage of intraocular gas include an elevation in eye pressure (glaucoma), and the progression of cataracts. It is deemed unsafe to fly in an airplane while intraocular gas remains in the eye as the air bubble will tend to expand.
Silicone oil is sometimes used instead of gas to keep the retina attached post-operatively. The chemical properties of silicone oil allow it to remain in the eye until removed (often requiring a second surgery at a later date). This technique is advantageous when long term support (referred to as "tamponade") of the retina is required. Unlike intraocular gas, patients are able to see through clear silicone oil. The factor of positioning is less critical with silicone oil, and as a result it may be used in patients unable to meet the postoperative positioning requirements (i.e. children). As with gas, silicone oil can promote cataracts, cause glaucoma and cornea damage.
Endophotocoagulation involves the use of laser to treat the eye's intraocular structures. This process is often used to treat the retinal tears that may have precipitated a retinal detachment. Endophotocoagulation is also frequently utilized to treat proliferative diabetic retinopathy as well.
Scleral buckling where an encircling band is sutured into the sclera, is sometimes combined with a vitrectomy procedure to add additional support to the reattached retina.
Lensectomy which involves the removal of the eye's crystalline lens, is usually performed when there is a cataract (a clouding of the lens) preventing the surgeon from adequately visualizing the internal structures. A lensectomy may also prove necessary in gaining access to scar tissue (for its removal) during complicated retinal detachment or diabetic retinopathy procedures. The eye's natural lens can be replaced with a clear lens implant at the time of the surgery. Lensectomy is usually performed using high frequency ultrasound (known as phacoemulsification) and is similar to the process involved in routine cataract surgery.
Vitrectomy surgery represents a major medical advance which allows us to treat certain retinal conditions and diseases. It has proved itself successful in preventing vision loss for patients who, prior to the advent of vitrectomy, may have gone blind without this procedure. A vitrectomy usually takes about 1-3 hours or longer depending on the complexity of the case or the combination of other procedures such as scleral buckle or lensectomy. The risks associated with the surgery include infection, bleeding, cataract, glaucoma, and detachment of re-detachment of the retina. These complications can result in severe visual loss, and it is important that you discuss the potential risks and benefits of this procedure with your surgeon before making a decision regarding treatment.
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