Vitrectomy is one of the most complex surgical procedures in ophthalmology. The goal of this surgery is the reconstruction of the posterior segment of the eye, often in combination with cataract surgery.
Indications for Vitrectomy:
Complex Procedures of Retinal Detachment
The classic surgical procedure of retinal detachment, i.e. “scleral buckling” is indicated in most cases of the retinal detachment. However, there are cases when the primary vitrectomy is indicated: multiple ruptures in more than two quadrants, posterior retinal ruptures, retinal detachments with proliferative vitreoretinopathy (PVR) and inability to see the complete retinal periphery (cataract, pseudophakia, secondary cataract, etc.).
In these cases, it is important to clean the vitreous body as much as possible, because it is the cause of retinal detachment. It is necessary to detach retina of all tractions, so it is mobile, and the base of the vitreous body to be cleared in detail. If the retina is not mobile after the doctor performs detailed grasp and gently peels away the epiretinal membrane from the retina, he can cut the retina – do the retinectomy and remove possible subretinal membranes. Then the subretinal fluid around the ruptures is drained and laser photocoagulation (LFK) of the retina is performed with the whole circumference. The surgery is finished with intraocular gas tamponade or silicone oil.
A special problem is re-proliferation which requires further surgeries in PVR cases despite the retina perfectly clean from epiretinal membranes. Therefore, the success of vitrectomy is much bigger than if the retinal detachment is new.
Diabetic Retinopathy
This indication is one of the most frequent in Serbia because the underlying disease in most cases is treated badly and the preventive LFK of the retina is not done on time. It is of utmost value to understand the importance of well-done pan-retinal LFK because later the vitrectomy has much greater chances to succeed, and further proliferation can be stopped this way.
The most frequent indication for vitrectomy in diabetics is hemophthalmos. If we have the data that an extensive LFK has been done, and if the echography shows that the retina lies without visible traction, it is possible to prolong the surgery. It is almost a rule that the surgery starts with phaco surgery and the necessary lens implant.
If LFK hasn’t been done before, the doctor must perform vitrectomy as soon as possible. During the surgery, he should do LFK as well. Also, if there is a Tractional retinal detachment, he should perform vitrectomy, even though there is a small chance of significant functional recovery. Unlike PVR, here the doctor mustn’t peel away the membrane because it results in iatrogenic posterior ruptures of the retina. They have to be cut instead. After the complete cut of all tractions and cleaning, the membrane is completed with pan-retinal LFK.
The Trauma of the Posterior Segment of the Eye
The most frequent mechanism of the trauma of the posterior segment of the eye is penetrating injury with the presence of an intratubular foreign body. Vitrectomy itself is difficult because it is usually followed first by the reconstruction of the anterior segment, and the extraction of the foreign body and processing of the place it hit both require the extensive experience of a surgeon. The results and visual function after correctly done surgeries can be surprisingly good.
Giant Retinal Tears
Most usually these conditions look catastrophically bad for a general ophthalmologist because the retina is usually folded or wrinkled. However, if the process is new, the results are excellent with vitrectomy accompanied by necessary phaco surgery, lens implant, and finally silicone oil tamponade.
After the Complications of Phaco Surgery
The most important is anterior vitrectomy during the phaco surgery where the posterior capsule tore. If the anterior segment is solved well, it is possible to implant a three-component or hard lens on the anterior capsule and send the patient to a vitreoretinal surgeon. If the intraocular pressure is corneal-compensated, there is no need to rush.
Rupture of the Macula
This surgery presents a hit in vitreoretinal surgery in the last few years because, as it turns out, if the rupture of the macula is recent, in the phase 2-4, vitrectomy leads to rupture closing and improvement of the vision. It is best to undergo surgery as soon as possible! The surgery usually finishes with gas tamponade, by the positioning of the patient, and rarely with tamponade with silicone oil.
We should point out that nowadays, as vitreoretinal surgery has progressed, negative outcomes are very rare and every eye which has well-kept light projection stands a chance. Therefore, if a patient with a sudden vision impairment comes to a general ophthalmologist, sometimes if he has only the loss of the visual field, it is necessary to send him to a vitreoretinal surgeon as soon as possible. It is of vital importance to explain to the patients they should undergo the surgery because, without it, they are doomed to blindness.