Vitrectomy for retinal detachment

Why Do I Need An Surgery?

If retinal detachment surgery is not performed, you have a very high chance of going blind in the affected eye. The eye may also become painful later. Surgery is recommended to prevent your vision from worsening and also to recover as much sight as possible.

If you have a macula-on retinal detachment, a successful surgery can enable you to maintain good vision for the remainder of your life, while successful surgery for macula-off retinal detachment can help recover nearly all of your central vision and restore normal peripheral vision. Distortion in the central vision can also show improvement in the months after surgery.

When Should I Have My Retina Detachment Surgery?

If you have a macula-on retinal detachment, it is more urgent that you schedule your surgery as soon as possible. However, there are many different types of retinal detachment, each with their own different levels of urgency. I will advise you of the surgery timeframe your retinal detachment requires.

If the surgery is not performed within this timeframe, final vision can often become worse. The surgery can also be less effective, and a higher risk of complications and further surgery can also result.

What Does Retina Detachment Surgery Involve?

The surgery for a retinal detachment consists of a vitrectomy, which is the removal of vitreous gel from the retina. This is usually performed with small 25 gauge equipment and advanced surgical techniques to ensure no stitches are needed. However, there are some cases where the surgery may require a conventional technique that utilises bigger instruments and necessitates stitches. This is known as cryo-buckle surgery and is explained here.

Will I Be Able To Feel The Surgery?

No, you should not feel any part of your retina detachment surgery due to it being performed under local anaesthetic. To ensure no pain, anaesthetic drops will be placed into your eye before you’re sedated with an injected drug. As a result of this, you’ll be completely unaware of the anaesthetist injecting anaesthetic around your eyeball.

The surgery itself is not painful, but you should immediately inform me if you experience any sensation. You should signal this without speaking to avoid moving your head or eyes, and more anaesthetic can be administered straight away to ease any discomfort you may be feeling. There is no need to be afraid to ask for this; the surgery is much easier to do when you’re feeling completely comfortable. The anaesthetic and surgery is also performed while you’re lying down to further aid with your comfort.

After you’ve received anaesthetic, we’ll use an iodine solution to clean your eye area before placing a plastic drape sheet over your eye and face. I will make sure that you’re getting enough oxygen and air flowing in under the sheet to breathe comfortably. Next, a hole is cut in the drape to provide access to your eye, with a special clip used to hold it open so you won’t have to. A microscope will also be placed above your eye and a light will be turned on, and though this may seem bright at first, it will shortly fade.

While the detached retina surgery is being performed, you may feel my hands on your forehead and the bridge of your nose. You may also hear various sounds, including the theatre staff talking together, noises made by the vitrectomy machine, and sometimes even music. You might also feel watery fluid trickling down your face. While this may be uncomfortable, it is nothing to be concerned about.

How Is The Retinal Detachment Surgery Done?

The surgery begins with the making of three small holes (ports) in the white (sclera) of your eye. The first allows for a constant flow of fluid – known as the ‘infusion’ – to pass into your eye. The second port is used to insert a special fibre-optic ‘light pipe’ to provide illumination to your eye, while the third is used for all other instruments that require access to the eye during the surgery, including a ‘cutter’ for the removal of vitreous. After this, you may feel some pressure around the eye area while I examine your retina to locate the tear or tears that have caused the retinal detachment.

Next, a freezing treatment (cryo) will be applied. During this stage of the detached retina surgery, you will hear both myself and the nurse say ‘cryo on’ and ‘cryo off’ many times. After this, the fluid in your eye will be replaced with air and you may hear a whistling sound while this happening. This air will later be replaced with a gas at the end of the operation and is usually either C₃F₈ or SF₆

The duration of a retinal detachment surgery ranges from 20 to 40 minutes, but it is important to understand that the time taken is not an indication of how well the operation has gone. At the conclusion of the operation, a pad and shield will be placed over your eye to provide a protective covering.

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How Does The Surgery Work?

The surgery consists of two main parts. These include the operation that I will perform and the posturing period in the days following the surgery. Both parts are absolutely essential to the surgery’s success.

The retinal detachment surgery involves the removal of vitreous gel from your eye (known as a vitrectomy), as well as pushing the detached retina back into its correct position. The tear or tears (often there is more than one) will be sealed using cryo, a freezing treatment, or laser that’s applied to trigger a scar reaction that will stick the retina to the retinal pigment epithelium (RPE) around each tear. The next step involves gas being injected into your eye to help keep the retina in place while it sticks down and seals around the tear.

What Does Posturing Involve?

Posturing involves keeping your eye in a position that allows the gas bubble to float against the tear (or tears if there is more than one). You won’t know which posturing position you’ll require until after the conclusion of your detached retina surgery, as the position depends on where the tears are located. Below, I’ve detailed several common posturing positions.

UPRIGHT

If the tear is situated at the top of your eye, posturing will be simple, as you will simply need to remain in an upright position. For night, you will be told what the best option is for your particular tear. You will also be told whether or not you can lie on your back.

ON YOUR SIDE

For this posturing position, you will need to lie on one side for 50 minutes out of every hour of the day and night for ten days. While doing this, it is vital to not let your head tilt up. This position is usually used for tears that are situated at one side of the retina.

FACE DOWN

If the tear is located at the bottom of the retina, the only way to get the bubble to press against the tear is to look vertically down towards the floor. This can be easily achieved if you tilt your head forwards and point your face downwards, with the position known as face-down posturing. You will most likely be asked to posture in this position for 50 minutes out of every hour of the day and for ten days. You will be given specific instructions for the position to be adopted whilst asleep.

While this period of face-down posturing is essential, I do recognise that it can be a daunting proposition. Fortunately, it can be made easier with specially designed posturing equipment such as the Retina Rest and through the use of mirrors. These allow you to look down but still see ahead; enabling you to maintain eye contact.

Often, it’s not possible to know what post-operative posturing will be needed until the operation is over, so it’s worth making some arrangements for face-down posturing just in case it’s needed.

HOW SHOULD I PREPARE FOR POSTURING FACE DOWN?

Here are some steps you can take before commencing face-down posturing to make the posturing period easier.

• As soon as you are informed of your retinal detachment surgery date, discuss booking equipment to help you with face-down posturing (such as RetinaRest). Explain that you will not be sure of the posture required until the day of surgery; after, the equipment can be supplied to be picked up the day after your surgery.
• Plan in advance how you will prepare meals, knowing that you will only have ten minutes per hour to both prepare and consume your meal.
• Before your surgery, go shopping for food, toiletries and other essentials. You may also like to purchase audio books and CDs to listen to, as well as large-print books and magazines.
• DVDs can help you keep your eyes in the correct position if you use Retina Rest equipment that includes the purpose-designed mirror. This will allow you to watch TV as well as talk to friends and relatives.
• Position your toiletries and medicines so they’re in easy reach without you having to raise your head.
• Put your kettle, coffee maker and other kitchen appliances somewhere low so you can make food and drinks without help. You should also buy straws to help you drink cold drinks while looking down.
• Ensure you have enough clean and comfortable clothes for the entire posturing period (up to ten days)

FOR FURTHER INFORMATION REGARDING POSTURING FACE DOWN AND PHYSIOTHERAPY, PLEASE CLICK BELOW TO DOWNLOAD A PRINTABLE INFORMATION SHEET:

RetinaDoctor – Post-operative Vitrectomy Care and Physiotherapy

How Can I Avoid Problems With Posturing?

While there is any gas in your eye, you must not travel in an aeroplane or go to a high altitude location. This can make the eye bubble expand, affecting the pressure in your eye and potentially causing harm as well as pain. If you undergo any other procedures in the days following your retinal detachment surgery, you must inform the anaesthetist that there is gas within your eye before you are given any general anaesthetic.

Make sure that you also wear the special eye shield you’re provided with when sleeping. This will prevent you from accidentally rubbing your eye when asleep or applying pressure.

When you’re posturing with your arms placed in front of you, try not to rest the inside area of your elbow on an unpadded area. There are some patients who have acquired an injury to the nerve (also known as the ‘funny bone’) by leaning on it for lengthy periods.

I also recommend that you spend the ten minutes in which you don’t have to posture each hour to stretch and walk. These breaks will help you avoid complications such as deep vein thrombosis and stiff muscles.

What Should I Expect After The Detached Retina Surgery?

While the operated eye should not hurt too much after surgery, it is normal for the surface to be irritated and for some bright lights to feel uncomfortable to look at (wearing sunglasses can often help). Your eye may also look red and seep a pinkish watery discharge that you might notice on your sheets and bedclothes – please note that this is not dangerous.

For the first 2 or 3 weeks after your retina detachment surgery, your operated eye will not be able to see straight ahead or below this. This is due to the gas in the eye preventing light from focusing on the retina. Fortunately, as the gas is absorbed over time, you will begin to notice the top of your vision clearing. During this time, you may notice a wobbly black or silver line near the area you cannot see. Over several weeks, this line will drop, allowing you to see directly in front of you. After the surgery, even when the gas bubble becomes smaller and you can see straight ahead, your vision may still not be very good. This is because the gas in your eye will affect the quality of your vision. Depending on the type of gas that was used and its concentration, it can take between three and ten weeks to be absorbed.

What Should I Be Concerned About After The Retinal Detachment Surgery?

If you notice any of the following signs or symptoms, or if you have any other concerns, you should contact me as soon as possible.

• Pain, especially when it’s deep or aching.
• If your eye gets more uncomfortable or painful since your last appointment.
• If your vision declines since your last appointment, particularly if it’s the top part of your vision, which should be getting better rather than worsening.
• If you notice a pus-like discharge any time after your retina detachment surgery.
• If you start to notice any new floaters, flashes of light or shadows in your vision.

Understandably, not all problems are able to be explained within a description in a list. I urge all patients to call immediately with any questions or concerns, even if they might seem minor or ‘silly’. Call Vision Retinal Institute Eastern on (03) 9890 4333 during office hours, or call me on my mobile number which you should also have been given. I will attempt to get in touch with you or make an appointment as soon as possible. If this is not possible, I will arrange for you to be seen by another retinal specialist.

What Are The Risks Of Vitrectomy For Retinal Detachment?

The risks of a vitrectomy surgery for retinal detachment include:

• Less than 1 in 1000 chance of blindness due to either infection or bleeding
• Less than 1 in 200 lifetime risk of retinal detachment
• 1 in 50 chance of reduced vision

I will discuss these risks and others with you before your surgery.