Vitrectomy Surgery for Vitreous Haemorrhage
The type of surgery for vitreous haemorrhage depends on whether it is due to diabetes or not and whether there are signs, on examination and the B-scan ultrasound, of there being complex new vessels and tractional retinal detachment.
If so, it is likely that the vitrectomy will be performed using 20-gauge instruments as this is the safest option and allows for the best instruments available to be used. Otherwise, the vitrectomy will be performed using the smallest, most advanced 25-gauge (using no stitches) surgical technique available.
The surgery, in either case, will begin as an exploratory operation by careful removal of the vitreous with blood. Only after full vitreous removal is it possible to examine the retina properly.
At that stage Dr Chauhan will perform the operation relevant to the cause of the vitreous haemorrhage. It is very common, after a vitrectomy to remove the vitreous haemorrhage, for there to be blood mixed in the fluid inside the eye. The difference here is that the blood is mixed in clear fluid and is cleared quickly over a week or so, compared with months or not at all in the vitreous.
Will I Feel The Operation?
No. This surgery is almost always performed under local anaesthetic as a day case and the method is the same as that used for cataract surgery. It involves some anaesthetic drops being put in your eye, followed by sedation with a drug injected into your vein. This will make you completely unaware of the anaesthetist giving you an injection of anaesthetic fluid around the outside of your eyeball.
The surgery is not painful but you should let the Dr Chauhan know if, as rarely occurs, you do feel any sensation in the eye. This is best done without talking as speaking makes your head (and eye) move. Your anaesthetist will let you know how to signal this before the surgery. It is simple for more anaesthetic to be given straight away and this takes effect almost immediately.
There is no need or benefit to being a martyr about this; the surgery is also easier if you are not in pain or discomfort.You will be lying on your back throughout the anaesthetic and surgery.
How Is The Operation Done?
After the anaesthetic has been given, iodine solution will be used to clean around your eye. After this a plastic sheet (drape) will be used to cover your eye and face. Dr Chauhan and the anaesthetist will ensure that an oxygen and air mixture can flow freely under this sheet and that you can breathe easily. A hole will then be cut in the drape over your eye and a special clip used to hold it open. Dr Chauhan will then sit down and position a microscope above your eye and switch the light on. You may be able to see this light but it usually fades after a little while.
During the surgery itself, you will feel Dr Chauhan’s hands on your forehead and, occasionally, on the bridge of your nose. You may hear the theatre staff talking, as well various sounds made by the vitrectomy machine and possibly, music. You may feel a trickle of watery fluid down the side of your face but, whilst uncomfortable, this is not dangerous.Three tiny holes (ports) will be made in the white (sclera) of your eye, through which instruments are introduced into your eye. One of these has a constant flow of fluid passing into your eye and is known as the “infusion”. One of the other two ports is used to place a fibre-optic “light pipe” into your eye, illuminating it from within; the third port is used for a variety of instruments. The main one is a “cutter” that is used to cut and remove the vitreous.
Only after full vitreous removal is it possible to examine the retina properly. Of all eye operations this is the one that can change course most during the surgery itself, as the next steps are completely dependent on what is seen. At this stage Dr Chauhan will perform the operation relevant to the cause of the vitreous haemorrhage. If there is a retinal tear alone it will be treated with cryo retinopexy. The next step will be to replace the fluid within your eye with a bubble of air. You may hear a whistling sound at this stage.
If there is a retinal detachment then the surgery will end up being a vitrectomy for retinal detachment.
Finally, if the source of the vitreous haemorrhage is new vessels from any cause then Dr Chauhan will perform a delamination, which consists of delicately cutting the base of the abnormal blood vessels so that the vitreous is completely separated from the retina. This can be the most complex eye operation performed.
How Long Is The Operation?
The time taken for this surgery varies hugely. It can take 30 to 45 minutes, for a vitreous haemorrhage due to a single retinal tear without a retinal detachment, and even over two hours if there is a severe tractional retinal detachment. If your vitrectomy is combined with a cataract extraction (phakoemulsification) this will mean your operation is likely to be 15 to 20 minutes longer and that it is even more important that you do not rub your eye afterwards.Unlike cataract surgery on its own, it will take 6 or so weeks for your eye to settle enough to make a visit to the optometrist worthwhile; Dr Chauhan will tell you when to do so.
What Happens After The Operation?
At the end of the operation you will have a pad and shield over your eye. This remains on until the next day when Dr Chauhan will examine your eye.
Immediately after the operation you will enter the recovery area where the nurses will make some routine checks including your pulse and blood pressure. Even though you will have been sedated, by this time you are likely to be fully awake and ready for a drink and a snack.
Once the nurses are happy that you feel fine and are fit to leave, you will be escorted out to meet your friend/relative who will take you straight home. You will be provided with a prescription for drops that will need to be taken to the chemist that day, as you will be asked to bring the drops with you to the clinic the next day; the first drops will be instilled when you are examined.
How Can I Avoid Problems After The Surgery?
Whilst any air or gas is in your eye (about a week for air and up to 6 weeks for some gases), you must not fly in an aeroplane or travel to high altitude as this can make the bubble expand in your eye, making the pressure in your eye go up and cause significant harm as well as pain.
For similar reasons, you must inform the anaesthetist that there is air or gas in your eye before any general anaesthetic you may require afterwards.
Make sure that you wear the shield provided when sleeping. This will prevent inadvertent pressure on the eye and stop you rubbing your eye when asleep.
What Should I Expect After Surgery?
The operated eye should not be very painful after surgery; it is, however, normal to get a little surface irritation (feeling like something is in the eye) and for bright lights to be a little uncomfortable (wearing sunglasses is often helpful).
Your eye may well be red and sometimes a pinkish watery discharge may be noticed on bedclothes. This is caused by tears mixing with some blood on the surface of the eye and is not dangerous.
Immediately after the surgery, and for the first few days or so, you will not be able to see straight ahead or below this with the operated eye. This is because the air in the eye prevents light from focussing on the retina.
Only as the air or gas is slowly absorbed will you notice that the top of your vision becomes clearer and that there is a wobbly black (sometimes silver) line at the top of the area that you cannot see. As time passes, this line will get smaller and lower and you will be able to see directly ahead. When the bubble gets even smaller, it will be seen as one or more balls or circles in the bottom of your vision before disappearing completely.
It is very common, after a vitrectomy to remove the vitreous haemorrhage, for there to be blood mixed in the fluid inside the eye. The difference here is that the blood is mixed in clear fluid and is cleared quickly over a week or so, compared with months or not at all in the vitreous.
What Should I Be Concerned About After Surgery?
If any of the following occur, or if you are concerned about any another matter after an operation on your eye, you should get in touch with your surgeon urgently.
- Pain, particularly aching, deep pain.
- If your eye becomes more uncomfortable or painful than when you last were seen by your surgeon.
- If your vision worsens since your last appointment. In particular, if the top part of your vision, which slowly improves in normal circumstances, gets worse, you ought to be seen urgently.
- If a pus-like discharge develops at any time after the surgery this requires urgent attention.
- If you become aware of new floaters, flashes of light or a shadow in your peripheral vision
Not all problems fit neatly into descriptions in a list like this. Dr Chauhan and his staff prefer that his patients call with questions that might seem minor or ‘silly’ rather than wait until their next appointment. Please call Vision Retinal Institute Eastern on 03 9890 4333 if there is an issue during office hours.
You will also have been given his mobile phone number to call; he will attempt to contact or see you as soon as possible. If he is unable to see you, he will make alternative arrangements for you to be seen by another retinal specialist.
What Are The Risks Of Surgery?
The risks of the surgery are:
- 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
Dr Chauhan will discuss these risks and others with you before your surgery.