What is Vitreoretinal Surgery?

The Retina is the thin lining of tissue which coats the inner surface of the eye. Light travels through the eye and falls on retinal cells which transmit signals to the optic nerve to produce vision. At the centre of the Retina is the macula. This is where the best retinal cells are located, and is what produces sharp and clear vision.

In front of the retina is the vitreous, which is a gel-like substance composed mainly of water that fills the space in the middle of the eye. There can be diseases of either the vitreous, the vitreo-retinal interface or the retina itself. Because the retina and macula are integral to vision,  diseases affecting these are often sight threatening and require expert care.

Common symptoms of retinal disease include:

  • Floaters in the visual field
  • Flashes of light.
  • Sudden vision loss.
  • Distortion of images and printed words.
  • Distortion or loss of central vision
  • Dimming of vision
  • Photophobia

Examples of Vitreoretinal diseases include:

  • Epiretinal Membrane
  • Macular Hole
  • Vitreomacular Traction
  • Vitreous Floaters
  • Retinal Tear
  • Retinal Detachment
  • Diabetic Retinopathy
  • Macular Degeneration
  • Retinal Vein Occlusion
  • Complex Cataract Conditions

Treatment for Vitreoretinal Disease.

This involves an Argon laser treatment to the retina itself. It is non invasive and should be performed by an expert. The Argon laser uses thermal energy to photocoagulate retinal cells often to form a barrier in the retina against disease processes.

An injection of therapeutic medicine into the vitreous cavity can achieve high concentrations of medicine close to the retinal surface. The injection is largely painless and involves a local anaesthetic on the white part of the eye. This is performed as a day procedure or as part of a course of treatment. 

This has been the cornerstone of diabetic retinal treatment for over half a century. Laser treatment to the retina induces thermal photocoagulation of retinal cells. This can be used to reduce oxygen consumption by the outer retina to preserve central retinal function, and reduce the proliferation of harmful new blood vessels. It is a non invasive procedure which should only be performed by an expert.

As time goes on there is a natural ageing process which affects the vitreous. It results in the structure of the vitreous collapsing causing collagen fibrils  in the vitreous to become stuck together. This results in what we perceive as floaters in our vision. The vitreous commonly separates from the retina in our mid forties and fifties in a process known as a posterior vitreous detachment. This can result in an increase in floaters, which can be obstructive to one’s daily activities. The only way to definitively remove floaters is with a surgical procedure called a vitrectomy to remove the vitreous from the eye. It involves microscopic ‘keyhole’ surgery in the eye and is performed as a day procedure. Once the vitreous is removed a thorough search for any retinal breaks is performed and the vitreous is replaced with either air or gas. The air or gas bubble can take a minimum of two weeks to dissipate from the eye. Post  operative drops are given for a month after surgery.

Technological advances over the last thirty years have led to there being more surgery involved in the care of diabetic eye disease. The surgical removal of the vitreous, especially in the case of vitreous haemorrhage, has meant a once blinding eye condition can now be successfully treated with surgery. In cases of diabetic eye disease a vitrectomy is often combined with internal laser treatment as part of the operation to treat diabetic retinal disease. At the end of the operation either an air or gas bubble is injected in to replace the vitreous which has been removed. This is performed as a day case, and postoperative drops are given for a month after surgery.

An epiretinal membrane is a collection of cells which have formed a layer over the retinal surface. Rather like a sheet of cellophane it can contract to scrunch up the underlying retina. This causes light to unevenly fall on the retina and produces distortion and metamorphopsia. The only way to remove the epiretinal membrane is with a surgical procedure where the membrane is physically peeled away from the retinal surface. To access the membrane safely a vitrectomy is performed to remove the vitreous, and then using very fine instruments the microscopic epiretinal membrane is peeled away. An air or gas bubble is injected into the eye to smooth out the retinal surface. The retina itself has an elastic ‘memory foam’ property which means it can take up to nine months to a year after the membrane has gone for the retina to relax into its natural position. Even after a year often there is residual distortion which may not completely settle with time.

A macular hole is a discontinuity of the central neurosensory retina. It results in a loss of central vision and distortion of vision. It is caused by an ageing process of the vitreous resulting in separation of the vitreous from the retina which leaves a central hole in the retina. This condition until thirty years ago was considered a blinding condition until technological advances involving surgery was developed to treat it. Today up to 95% of macular holes can be closed and vision regained with a day case operation. To access the macular hole a vitrectomy is performed, and then the internal limiting membrane of the retina is peeled away. A gas bubble is injected which then pushes the retinal edges of the hole together. Depending on the size of the hole a postoperative face down position is required for up to five days after the surgery. This gives the best chance of the macular hole closing as it pushes the gas bubble onto the central macula. Post operative drops are required for a month after surgery. 

Retinal detachment is a blinding condition in which the neurosensory retina becomes detached from the wall of the eye, similar to wall paper in a room falling off the wall. It can result in a permanent dark shadow which can rapidly come across the whole of the vision. Without treatment the vision loss is permanent and unfortunately the eye will not see. The causes of retinal detachment can vary, but classic rhegmatogenous retinal detachment results from the vitreous separating from the retina causing a retinal tear, which then develops into a retinal detachment. The only way in which any form of vision can be restored is with an operation. This involves a vitrectomy to remove the offending vitreous, and treatment of the retinal tear either with laser or cryotherapy. A tamponade agent, which is a gas bubble or silicone oil is then injected to push the retina back into its natural position. Post operative positioning is required to push the gas bubble against the tear in the retina. This may be required for up to a week after surgery. Post operative drops are given for a month after surgery. Time delay is critical and once the central macular region of the retina has been detached then vision is often not as good as before even with surgery to put the retina back in place.

Occasionally cataract operations can result in the cataract falling to the back of the eye. This then requires the cataract to be picked up from the vitreous cavity and removed safely. In cases where there has been a difficult first procedure a vitrectomy is required to complete the removal of the cataract from the back of the eye. This is done using key hole microscopic surgery and involves the removal of the vitreous which is often entangled with the cataract. After removal a secondary intraocular lens is placed if there is adequate support for the new lens. If there is not adequate support available for a new lens then a secondary intraocular lens may be required to be placed in the future. 

Sometimes years after a cataract operation the artificial lens in the eye can become dislocated or ‘subluxed’. This can result in glare and a loss of clear vision. In these cases it is often necessary to remove the artificial lens and implant a new lens. This operation is combined with a vitrectomy to remove any vitreous which may be surrounding the artificial lens. Secondary scleral fixated or iris fixated lenses can be placed in the eye to replace the old lens. Post operative drops are given for a month after surgery.

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