Vision after vitrectomy. Vitrectomy is the removal of the vitreous body or part of it. Use of liquid perfluoroorganic compounds

In addition, victrectomy may be performed to remove scar tissue in patients with gross opacities or repeated vitreous hemorrhages that do not resolve on their own. To assess the possibility of self-resorption of hemorrhages in the vitreous body, experts usually recommend observing the dynamics of hemorrhage regression within six months to a year. In the event that a hemorrhage threatens or irreversible loss of vision, an immediate operation is indicated.

To carry out the manipulation, a special cutting microsurgical instrument vitreotome is used. After removal of part or all of the vitreous body, the resulting cavity is filled with a special filler, which ensures the maintenance of a normal level of intraocular pressure.

How is the operation performed

Usually, before performing a vitrectomy, the patient is planned to be hospitalized, although as an exception, the operation can be performed on an outpatient basis. Both local and parenteral methods of administering anesthetics can be used to anesthetize the operation. The duration of the operation to remove the vitreous body is usually 2 to 3 hours.

During the operation, the doctor removes the necessary volume from the vitreous tissue through punctures, after which he performs the required treatment: cauterizes areas of the retina with a laser, seals the areas of detachment, and restores the integrity of the retina of the affected eye.

Operation efficiency

Vitrectomy is an effective therapeutic manipulation in patients with violations of the transparency of the vitreous body, developing as a result of hemorrhages or proliferation of connective tissue, as well as neovascularization of the iris. Microinvasive surgery allows you to stop the process of traction retinal detachment and partially restore lost vision.

At the same time, the procedure for removing the vitreous body can be accompanied by various complications, among which should be mentioned an increase in intraocular pressure (especially in patients with glaucoma), pronounced edema (corneal edema), retinal detachment, severe neovascular hematoma (due to neovascularization of the iris, the so-called. rubeosisiridis), the addition of a secondary infection with the subsequent development of endophthalmitis. These complications pose a threat in terms of loss of vision.

What is the removed vitreous body replaced with?

After removal, a special component is introduced into the formed cavity of the orbit, which must meet certain requirements: have high transparency, a certain level of viscosity, atoxicity and hypoallergenicity, and, if possible, be used for a long time.

Most often, an artificial polymer (PFOS), balanced salt solutions, a vial of gas or silicone oil are used for this purpose. Vitreous substitutes such as saline solutions and gas are eventually replaced by their own intraocular fluid, so they do not need to be replaced. PFOS can be used for up to 10 days, and a vial of silicone oil can be left in the orbit for up to several years.

Who and why is a vitrectomy performed?

When performing a vitrectomy, a doctor can pursue several goals:

elimination of tissue tension and prevention of further detachment of the retina on the area;

providing access in cases requiring surgical intervention in the area of ​​the retina;

restoration of vision after abundant intraocular hemorrhages or hemorrhages in the vitreous body, which do not show a tendency to self-resorption;

therapy of severe degrees of proliferative retinopathy, accompanied by the formation of gross cicatricial changes or neovascularization (germination of new blood vessels), not amenable to laser treatment;

Forecast and recovery time after surgery

The prognosis and timing of vision recovery after vitrectomy depend on several factors: the extent of the lesion, the condition of the retina, and the type of vitreous substitute. With pronounced severe changes in the retina, complete restoration of vision even after surgery is not possible due to pronounced irreversible changes in the retina.

Price

The cost of vitrectomy in various ophthalmological clinics in Russia ranges from 30,000 to 100,000 rubles, depending on the amount of intervention (microinvasive or subtotal), indications, conditions of the patient's eyes, as well as the clinic where this manipulation is performed.
If you have already undergone surgery, we will be grateful if you leave your feedback about vitrectomy. This will help other people understand what to expect or how they tolerate the consequences of the operation.

All materials on the site are prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative and are not applicable without consulting the attending physician.

Vitrectomy is an operation to remove the vitreous body of the eye. This operation belongs to the most complex, rather young branch of eye microsurgery - vitreoretinal surgery. Thanks to this operation, today it is possible to preserve and restore vision to patients previously doomed to blindness.

Anatomy and physiology of the vitreous body

eye structure

The vitreous body (corpus vitreum) is a gel-like substance that fills the inside of our eyeball. In structure, it is represented by intertwining microscopic collagen fibers. In the cells formed by these fibers, there are hyaluronic acid molecules that retain water well. Water makes up 99% of the composition of the vitreous body.

The vitreous body on the periphery has a denser structure than in the center. The vitreous body is bounded by a dense hyaloid membrane, in front it is adjacent to the lens, behind - to the retina. In the area of ​​the dentate line, the vitreous body is quite tightly soldered to the boundary membrane of the retina. This is the so-called base of the vitreous body.

The vitreous body is the light-conducting structure of the organ of vision. Through it, light rays penetrate from the lens to the retina. Therefore, if a pathology occurs in the vitreous body, leading to a decrease in its transparency, a person's vision will deteriorate.

With age, changes occur in the vitreous body: areas of liquefaction appear and, at the same time, areas of compaction. If a person suffers from chronic diseases associated with metabolic disorders (the most common is diabetes mellitus), these changes occur faster.

retinal detachment

Violation of the structure and transparency of the vitreous body can also occur after injuries (blood ingress into the eyeball), foreign bodies.

When blood cells enter the vitreous body after retinal detachment, proliferation processes begin in it, strands and pathological membranes are formed, closely soldered to the retina. These membranes tend to shrink, which leads to tractional retinal detachment, new vascular microruptures and new proliferative processes. The retina is wrinkled, folds form on it, the torn edge is wrapped.

Since our retina is a receptor that perceives light signals, this state of it leads to significant loss of vision and even blindness.

Especially dangerous is retinal detachment in the area of ​​the macula (this is the area of ​​the retina responsible for color perception and object vision).

Why is it necessary to remove the vitreous body

Based on the foregoing, the removal of the vitreous body is necessary in case of violation of its transparency, as well as to access the retina and carry out the necessary manipulations in case of its detachment.

Main indications for vitrectomy:

1. Entry of blood into the vitreous body (hemophthalmos).
2. Injury to the eye with hemophthalmos, ingress of foreign bodies into the eye, traumatic retinal detachment.
3. Severe inflammation of the eye membranes (endophthalmitis, uveitis).
4. Extensive retinal detachment.
5. Central retinal detachment with a threat of spread to the macula.
6. Severe proliferative retinopathy with the threat of traction detachment.
7. Dislocation of the lens or intraocular lens (artificial lens) into the vitreous body.
8. Macular break.

Examinations and preparation for vitrectomy

To clarify the diagnosis, the following examinations are carried out:

• Ophthalmoscopy - examination of the structures of the eye through the pupil. Ophthalmoscopy can be difficult in severe injuries, corneal opacity, cataracts, hemophthalmos, and severe vitreous opacity. In such cases, the study of light and color perception gives an indirect idea of ​​the functional state of the retina.
• Ophthalmic biomicroscopy (slit lamp examination).
• Ultrasound scanning of the eyeballs. Determines the size of the eyeball, the anatomical ratio of intraocular structures. B-scan allows you to see retinal detachment and vitreous fibrosis.
• Eye CT.
• Electrophysiological examination of the retina (EPS). Registration of potentials from receptors makes it possible to judge the functional state of the retina.

Vitrectomy in most cases is a planned operation. For 10-14 days, a planned preoperative examination is carried out (general and biochemical tests, coagulogram, fluorography, electrocardiography, examination by a therapist).

In case of concomitant chronic diseases, an examination by appropriate specialists is carried out. The bulk of patients referred for vitrectomy are patients with severe diabetes mellitus and concomitant arterial hypertension. They are all examined by an endocrinologist, who must adjust their treatment for maximum compensation of blood glucose levels.

With some pathologies of the light-conducting systems of the eye, vitrectomy is difficult. For example, with significant clouding of the cornea or lens, it is possible to pre-perform or keratoplasty. Phacoemulsification (removal of the clouded lens) with the implantation of an artificial lens can also be performed simultaneously with vitreoretinal surgery.

In glaucoma, instillations of solutions that reduce intraocular pressure are prescribed, as well as the intake of diacarb inside.

It is also very important to achieve a stable decrease in blood pressure to normal levels.

On the eve of the day of surgery, drops with atropine are prescribed to dilate the pupil.

Vitrectomy is contraindicated:

1. In severe general condition of the patient.
2. Violation of blood clotting.
3. Acute infectious diseases.
4. Confirmed atrophy of the optic nerve (the operation will not work).
5. Tumor nature of retinal pathology.

In some cases, an emergency vitrectomy is necessary (for example, hemorrhage due to thrombosis of the central retinal vein). Preparation in such cases is minimal, but it is necessary to achieve adequate reduction in blood pressure and controlled hypotension.

Types of vitrectomy

By volume:

• Total vitrectomy.
• Subtotal vitrectomy (anterior or posterior). With proliferative retinopathy, posterior vitrectomy is most often performed with excision of epiretinal cords and membranes.

Vitrectomy equipment

Vitrectomy is a type of high-tech medical care. When carrying out it, sophisticated equipment is used.

For such operations, a special operating table is used, very stable, with a device for fixing the head. Around the head end is a horseshoe-shaped table for the location of the hands of the surgeon. The surgeon operates sitting on a comfortable chair, hands are located on the table.

All control over the operation is carried out through a powerful operating microscope.

The surgeon's legs are also involved: with one foot he controls the pedal of the microscope (adjusting the magnification), the other foot controls the pedal of the vitreotome.

Vitreotome is a microscopic instrument for dissection of the vitreous body and its aspiration, as well as blood clots, fibrinous membranes, foreign bodies. Vitreotome has the form of a tube with a cutting tip and a hole for suction and irrigation.

To improve the view through the microscope, various contact lenses are used.

Microsurgical instruments are used during the operation - scissors, tweezers, spatulas, diathermocoagulators, laser coagulators.

Vitreous substitutes

In the equipment of microophthalmic surgeons there are special substances that are introduced into the cavity of the eyeball after removal of the altered vitreous body. It is necessary to fill the cavity to maintain normal intraocular pressure, as well as for retinal tamponade after its detachment.

Used for these purposes:

1. Sterile saline solution.
2. Gases (expanding, non-absorbable fluoride compounds for a long time).
3. Liquid perfluoroorganic media (PFOS) (“heavy water”).
4. silicone oil.

Salt solutions and gases do not require surgery to remove them, they are absorbed after a while and replaced by intraocular fluid.

Perfluoroorganic liquid is inert, almost like ordinary water, but has a higher molecular weight. Due to this property, it acts as a pressure on the area of ​​the retina.

The disadvantage of PFOS is that it is undesirable to leave it in the eye for more than 2 weeks. This time is usually sufficient for complete healing of retinal breaks. However, it does not dissolve on its own, and its removal requires a second operation.

Sometimes a longer tamponade of the eyeball is required, then silicone oil is used. It is quite indifferent to the eye structures; after its introduction, the eye begins to see almost immediately. You can leave silicone in the eye cavity for several months, sometimes up to a year.

Anesthesia

The choice of anesthesia depends on the estimated time of surgery, the general condition of the patient, the presence of contraindications, etc. Depending on the volume of the operation, vitrectomy can last from 30 minutes to 2-3 hours.

For long-term surgery, general anesthesia is preferable, since such complex manipulations at the microscopic level require complete immobilization of the patient.

If a shorter duration of intervention is expected (up to 1 hour), as well as in the presence of contraindications to general anesthesia, local anesthesia is performed:

• Intramuscular premedication with a sedative drug.
• Retrobulbar injection of local anesthetic 30-40 minutes before surgery.
• During the entire operation, a mixture of fentanyl and midazolam is periodically administered (neuroleptanalgesia).

Operation progress

After anesthesia proceed directly to the operation. The eyelids are fixed with lid dilators, the surgical field is lined with sterile napkins. The main stages of vitrectomy:

Video: vitrectomy - treatment of retinal detachment

Microinvasive Vitrectomy

The most modern vitrectomy method is the 25G method. This technique uses instruments with a diameter of 0.56 mm. This ensures that the operation is less traumatic, there is no need for suturing.

Incisions are not made, access to the eyeball is carried out with the help of punctures. Through them, ports for instruments are introduced into the eye cavity: an illuminator, an irrigator, and a working instrument. Thanks to these ports, the position of the instruments can be changed one by one. This is an important advantage, providing a complete approach to all areas of the vitreous body.

After extracting the ports, the holes from them are self-sealed, the seams are not applied.

The microinvasive technique expands the indications for vitrectomy, allowing it to be performed in patients previously considered hopeless. Minimally invasive vitrectomy can be performed on an outpatient basis - a few hours after the operation, the patient can be sent home.

The only negative is that such an operation is performed only in some large ophthalmological centers.

Postoperative period

After a conventional vitrectomy, the patient is usually under the supervision of doctors for a week. With microinvasive technique, an outpatient operation is possible.

The pressure bandage can be removed after a day. For several days, it will be necessary to fasten a blindfold over the eye, protecting it from dust, dirt and bright light. Of the sensations, pain is possible, which can be relieved by taking painkillers.

• Limit heavy lifting (limit - 5 kg).
• Read, write, watch TV for no more than half an hour, then you need to take a break.
• Limit physical activity, head tilts.
• Do not rub your eyes, do not put pressure on it.
• Do not visit a bath, sauna, do not come close to open fire and other sources of intense heat.
• Wear sunglasses.
• Do not allow water or detergents (soap, shampoo) to get into the eye.
• When introducing a gas mixture, keep a certain position of the head for several days, do not fly on airplanes, do not climb high into the mountains.
• With the introduction of "heavy water" do not sleep on your stomach, do not bend over.
• Apply anti-inflammatory and antibacterial drops prescribed by a doctor. Drops are prescribed for several weeks in a decreasing pattern.

Vision after the operation is not restored immediately. According to the reviews of patients who underwent surgery, immediately after the procedure, a veil is felt in the eyes, when filled with gas - blackness. Doubling, distortion of lines is possible. Within 1-2 weeks, the "fog" usually dissipates and vision gradually returns.

The terms of restoration of vision are different for different patients, ranging from several weeks to six months. They will be longer in patients with myopia, with diabetes, in the elderly. For this period, it may be necessary to select a temporary correction. The final spectacle correction is performed at the end of the rehabilitation period.

The degree of restoration of vision depends on the functional state of the retina.

The period of disability after vitrectomy is about 40 days.

Possible Complications

1. Bleeding.
2. damage to the posterior lens capsule.
3. Increased intraocular pressure.
4. Development of a cataract.
5. Iridocyclitis, uveitis.
6. Blockade of the anterior chamber with silicone.
7. Clouding of the cornea.
8. Emulsification and haze of silicone.
9. Recurrent retinal detachment.

Operation cost

The operation of vitrectomy refers to the types of high-tech medical care. In each region there are quotas for such medical care free of charge.

However, the situation does not always allow waiting in line for a quota. The cost of the operation varies depending on the category of complexity, the rank of the clinic, the type of equipment used (25G technology is more expensive). The price of a vitrectomy operation ranges from 45 to 100 thousand rubles.

A few decades ago, the problems of the eye organs in the form of: severe injuries of the visual analyzer, hemorrhages in the vitreous body of an organ or process, were classified as serious diseases. It was not possible to cure them, and as a result, the person completely lost his sight. To date, these diseases are effectively cured with the help of a special operation - vitrectomy. The saved eye organ is fully restored and continues to perform its anatomical functions.

Vitrectomy of the eye is successfully performed by both foreign and domestic ophthalmologists. Modern methods of conducting and special equipment make it possible to restore the eye organ even on an outpatient basis. This article will help you understand the features of this surgical intervention, as well as talk about possible complications and measures to help avoid them.

Vitrectomy of the eye

Vitrectomy of the eye is a surgical intervention, during which the ocular organ is removed from the ocular organ, which occupies most of the organ. Depending on the affected area, the body may be removed partially or completely. Partial removal is called subtotal vitrectomy. Complete removal of the vitreous body - total vitrectomy.

Removal of the vitreous allows the ophthalmologist to access the retinal tissues and perform:

• photocoagulation (a kind of soldering of the retina);
• reproduce the restoration of the integrity of the shell, which could be broken when receiving a serious injury;
• move the resulting scar tissue from the surface of the retina, interfering with the eye organ.

Simultaneously with these procedures, additional ones can be carried out (we will consider further).

The removed vitreous body is replaced with silicone oil or a gas mixture - special tools that ensure close contact between the retina and choroid, and also minimize the risk of postoperative complications.

Important: To date, vitrectomy is the only way to solve problems associated with the disease of the eye organ. These are various hemorrhages, retinal detachment or injury to the visual analyzer.

Such an operation requires not only the use of high-tech equipment, but also a highly qualified doctor.

What is the indication for vitrectomy?

Vitrectomy has opened up new possibilities in ophthalmology for the treatment of many diseases that were considered complex and previously untreatable. A person had to go blind with no hope of recovery. Among these diseases:

• the presence of an eye infection, which manifests itself in a severe form;
• cases of retinal detachment due to: penetrating injury to the eye organ as a result of diabetes mellitus, with a high degree of myopia (nearsightedness), in the presence of sickle cell anemia, and also due to physiological obsolescence of the vitreous body in the eyeball;
• penetration into the eye organ of an otherworldly object;
• a hole or tear in the macula (yellow spot);
• large sizes;
• significant clouding occurred in the structure of the vitreous body;
• - the vitreous body is partially or completely saturated with blood;
• the presence of diabetes mellitus often causes the formation - damage to the vessels of the eye organ, which disrupts the process of blood supply to the retina;
• in cases of dislocation of the lens or intraocular lens, which was replaced during the surgical treatment of cataracts.

Repeated hemorrhages and gross opacities lead to scarring of the retinal tissues. These scars make it difficult for a person to see clearly. The goal of surgery is to remove them.

What can be a contraindication to vitrectomy?

Vitrectomy is one of the modern and unique methods of surgical intervention, but not all patients can use it. Among the contraindications are: significant clouding of the cornea, allergic reactions to medications, the general serious condition of the patient, as well as problems with blood clotting, which can provoke serious complications at the time of surgery and the postoperative period.

How is the operation carried out?

Initially, the specialist decides that a vitrectomy will be performed under local or general anesthesia. Preliminary analyzes can play a big role in this decision. If the surgical intervention involves a large amount of various manipulations, the patient has concomitant diseases, and if local anesthesia cannot be performed due to the patient's special condition, the operation will be performed under general anesthesia. With small volumes of surgical intervention, local anesthesia with the use of anesthetic drops is most often used.

The patient is placed on the operating table. After the anesthesia takes effect, the specialist spreads the eyelids with a special device and fixes them in this position.

Read also: The reasons . Very often, patients complain of flies floating before their eyes, dark dots, cobwebs.

The surgeon performs several incisions on the sclera with a special instrument. They will be required to introduce the necessary tools into the eye organ. Further, for the operation, the specialist will need: a lighting device, vitreotome, as well as an infusion cannula. With their help, the vitreous body is separated from the eye organ and “sucked out”. The cavity formed in its place is filled with special means (we will consider below), which press the retina to the underlying layers and then hold it in the desired position.

The average time to complete the operation is one and a half hours. But if the pathological process is in a severe degree or additional manipulations are required, the execution time may increase significantly.

Compounds that replace the vitreous body

In ophthalmology, to replace the vitreous body, liquid perfluoroorganic compounds, silicone oils, gas mixtures are used. Each of these compositions differs in its structure and requires compliance with certain rules in the postoperative period, but all of them are designed for close contact and fixation of the retina to the choroid, as well as to prevent possible complications. Learn more about these compounds.

1. Use of silicone oil. This substance has a unique structure, characterized by chemical and biological inertness, which contributes to the easy tolerance of the oil by the body. The substance contributes to the correct anatomical position of the retina and the rapid restoration of all its functions. The risk of an allergic reaction is minimal. If we consider the refractive index of light using this filler, then it coincides by 90% with the natural refraction, which is reproduced by the eye organ. Unlike other types of vitreous body substitutes, silicone oils are used with the longest service life (about a year).
2. Application of perfluororganic liquid compounds. The second name of these fillers is "heavy water". This name was obtained due to the molecular weight of these compounds, which has a weight of 2 times that of ordinary water. After filling the resulting cavity due to the removal of the vitreous body, the patient does not need to follow special regimens in the postoperative period. The filler keeps the retina in the desired position for 3-4 months, after which it is removed by a specialist.
3. The use of gas mixtures. The resulting cavity is filled with a gas bubble. Of the main advantages of such a filler, I would like to note that the gas bubble completely dissolves on its own in 2-3 weeks. Its composition is gradually replaced by anatomic intraocular fluid. Of course, there are also significant disadvantages. The patient has to follow certain rules in the postoperative period. One of them is that the head must be in a certain position for a long time.

Important: With the use of gas mixtures, the patient is prohibited from flying in the postoperative period. Changes in atmospheric pressure cause expansion of the gas, resulting in an uncontrolled increase in .

Basic rules after vitrectomy, which will shorten the rehabilitation period

If the surgical intervention was not associated with an extremely serious condition of the patient, he is allowed to go home on the same day. Previously, the specialist gives recommendations necessary for a speedy recovery, which will also help to avoid postoperative complications.

• do not overwork the visual apparatus (read, write, sit at the monitor, etc. for more than half an hour);
• the first 2 weeks it is forbidden to lift weight over 3 kg.
• physical activity with sharp movements to the side and forward bends is contraindicated;
• mandatory use of eye drops, which were prescribed by an ophthalmologist to heal the eye organ and prevent an increase in intraocular pressure;
• in the first month after vitrectomy, visiting saunas or baths is excluded;
• you can not bend over the fire (it can be an oven, a gas stove or just an open fire).

Particularly severe cases may require the patient to stay in bed for several weeks. Also, special behavior will be required from the patient if a gas bubble was used to hold the retina during surgery. The recommendations of the specialist in this case will also apply to the special position of the head during the rehabilitation period, which is about three weeks. For example, during sleep, a person will need to sleep on one specific side or face down. In some cases, the patient is advised to rent a special system, which is designed to ensure that the head is constantly in the face down position. It was specially developed for the rehabilitation period after vitrectomy and is designed for use within 5 days and up to 3 weeks.

Failure to follow the recommendations often leads to bleeding, the return of the original state of the eye organ, postoperative infection, and much more. At best, this is an additional treatment, and at worst, irreversible processes of vision loss.

Compliance with all the rules will affect the timing of vision recovery in the postoperative period.

How long does it take for vision to recover after surgery?

The terms of rehabilitation and restoration of the visual functions of the eye organ depend on:

• from the applied filler, which was used instead of the vitreous body;
• the number of additional surgical steps;
• from the volume of the operation;
• on the degree of transparency of the optical medium of the eye organ;
• initial and postoperative state of the retina and optic nerve.

For example, if an anterior vitrectomy was performed, in which a small volume of the vitreous body was removed, positive results with the return of vision are observed within the first week. Advanced stages are often accompanied by irreversible changes in the tissues of the visual organ. The goal of the operation is to prevent complications, and noticeable improvements in visual acuity in this case may not be observed.

Features of rehabilitation associated with vitreous body substitutes are manifested in the following. Substitutes based on saline solutions have a low viscosity, and in the cavity of the ocular organ there is blood and cellular elements that take several weeks to resolve. In this case, restoration of vision does not occur immediately.

Patients who have had their cavity filled with silicone oils during surgery are often prescribed to wear plus glasses for correction.

The use of gas mixtures is manifested by the presence of black, but this negative rehabilitation moment is corrected during the first week - the veil leaves.

When the retina is detached, its function is impaired. If the patient asked for help in a timely manner and the operation went without complications, these functions will recover quickly. But with the delay of the problem, these changes become irreversible. There are disturbances in the optic nerve and in the functioning of the retina. Rehabilitation is greatly complicated, even if during the operation the most positive result in retinal fit was achieved.

Any postoperative results are recorded by an ophthalmologist for a long time, so the patient is registered.

Additional steps in surgery

During a vitrectomy, a specialist may perform additional surgical steps, which include:

1. Air injection. It is performed in order to extract intraocular fluid located in the posterior segment of the eyeball. This procedure allows you to save intraocular pressure, which is necessary to seal the existing holes in the retina and hold it in place. The pressure formed from the air soon passes, and the back begins to fill with liquid again.
2. Sclera tightening procedure. A kind of support “belt” is installed around the eyeball, which, after fixing the retina, maintains it in the proper position.
3. Removal of the lens - lensectomy. Often such an intervention is required if there is a cataract on it, as well as when it is fastened to the tissues of an existing scar.
4. Laser treatment - photocoagulation. It is performed when blood vessels are damaged to close them. Often such damage occurs due to diabetes in the patient. Also, the procedure does an excellent job of sealing the resulting hole in the retina.

These additional stages of surgical interventions can significantly extend the rehabilitation period.

What postoperative complications can occur?

Vitrectomy complications include:

1. The presence of a cataract at the time of surgery often results in its progression in the first year after surgery. This is especially true in cases where the vitreous body was replaced with silicone oil.
2. If during the operation an excessive amount of substitutes was introduced into the eye cavity, the patient's intraocular pressure increases. To eliminate this side effect, the specialist must prescribe special drugs against glaucoma.
3. Relapses with retinal detachment are possible.
4. Complications in the form of endophthalmitis is an infectious and inflammatory process.

Important: The toxic effects of substitutes can contribute to clouding of the cornea.

Microinvasive vitrectomy is considered less traumatic.

Features of microinvasive vitrectomy

The essence of the operation remains the same - partial or complete replacement of the vitreous body with fixation of the retina, but the intervention itself is carried out through three punctures with a hole diameter of 0.3–0.5 mm. Such microscopic punctures require the use of a small instrument. This allows:

• to achieve less traumatization of healthy tissues;
• reduce the risk of possible bleeding, which often occurs due to pathological proliferation of blood vessels;
• the rehabilitation period is significantly reduced;
• this operation is often performed on an outpatient basis.

Microinvasive vitrectomy requires special equipment and highly qualified specialist, so the method is not used in all clinics for the restoration of vision.

10.10.2017

Vitrectomy is a surgical procedure to remove the vitreous body. It looks like a transparent gel-like substance that is located in the cavity of the eyeball. Consists of 99% water, also contains collagen fibers, proteins and hyaluronic acid.

Such an operation is associated, as a rule, not with its changes. It is often necessary to gain access to the posterior segment of the eye in various pathological conditions of the retina. This microsurgical intervention was first performed in 1970. Since then, vitrectomy has undergone many changes, but has not lost its relevance in modern ophthalmic surgery.

There are 2 types of vitrectomy based on the surgical approach used to remove the vitreous, namely anterior and posterior.

The most common method of intervention is the posterior or pars plana. This operation is sometimes the only way to restore a person's vision.

When is vitrectomy surgery indicated?

Microsurgical removal of the vitreous body of the eye is performed in the following pathological conditions:

Proliferative diabetic retinopathy (including vitreous hemorrhages).

Macular breaks.

epiretinal fibrosis.

Complicated, traction or recurrent retinal detachment.

Intraocular foreign body.

Displacement of the artificial lens after its implantation for cataract.

Giant retinal tears.

Age-related macular degeneration.

Traumatic injuries.

Vitrectomy is often performed in emergency clinical situations. It may be contraindicated in a certain category of patients, for example, with a reliably known lack of light perception or the inability to restore vision. The presence or suspicion of active retinoblastoma or choroidal melanoma of the eye calls into question the operation due to the high risk of dissemination of a malignant tumor.

When removing the epiretinal membrane or treating macular holes, the use of drugs from the group of systemic anticoagulants and antiplatelet agents (for example, aspirin or warfarin) is a relative contraindication for vitrectomy surgery. Severe systemic coagulopathy also requires close attention from the doctor, therefore, during the operation of vitrectomy, it is necessary to monitor the state of the coagulation and anticoagulation systems, and, if necessary, make corrections.

Technical features of the operation

Vitrectomy is an outpatient intervention, that is, after its completion, a short observation and receiving recommendations, the patient can leave the clinic. Anesthesia is usually local with eye drops supplemented with intravenous sedation. During the intervention, the patient is conscious, but does not feel pain, there may be slight discomfort. Sometimes during vitrectomy surgery, a retrobulbar blockade is used as an anesthetic.

During surgery, vital signs such as pulse, blood pressure, and ECG are closely monitored.

Microscopic incisions are made in the area of ​​the eyeball, in Latin called pars plana, and three trocars with a diameter of 27G are placed. These devices are conductors through which special surgical instruments are delivered inside the eye.

One of the ports is used for the infusion line needed to inject a special solution into the eye cavity during surgery. The second port during vitrectomy is necessary for a video camera with an illuminator, thanks to which the ophthalmic surgeon can monitor the progress of work on a special monitor. The third trocar is used for vitreotome - an instrument that performs the main actions with the vitreous body. All manipulations on the eye during vitrectomy are performed by a microsurgeon using a high-precision microscope.

A surgical microscope equipped with a special powerful lens provides a clear and magnified view of the inside of the eye.

During the vitrectomy operation, the vitreous body of the eye is aspirated, and the vacated cavity is filled with sterile silicone oil or a special gas-air mixture. The vitreous body does not retract and the eye can function normally without it.

If there is no retinal detachment, air or saline (which is absorbed after a couple of days) may be used. However, if the patient has a retinal detachment, then either sulfur hexafluoride (which remains in the eye for 10-14 days) is used to tamponade it, or in more complex cases, another gas is used, such as fluorohexane or fluoropropane.

Recovery period

The duration of the vitrectomy operation depends on the underlying eye disease, the presence of concomitant ophthalmic pathology and averages from 1 to 3 hours. After the vitrectomy has been performed, the patient goes home with a bandage, which the ophthalmologist removes from the eyes at the first postoperative visit. Sometimes eye drops with glucocorticosteroids are prescribed to minimize inflammatory changes, as well as local antibiotics to reduce the risk of bacterial complications.

Doctors sometimes recommend postoperative positioning to patients. This means that after the operation has been completed, the patient will have to spend some time "head down" or lying on his stomach. This position helps to press the gas bubble against the back wall of the eye, which prevents retinal detachment. A certain head position must be held for at least 45 minutes every 60 minutes. These 15 minutes are for eating, visiting the rest room.

If the eye cavity was filled with an air-gas mixture during the vitrectomy operation, vision in the early postoperative period will be sharply reduced. The doctor must warn the patient about this in advance. Recovery of visual function is observed as the gas is resorbed. Double vision and glare after surgery are also acceptable.

In the postoperative period, one should not lift weights and, if possible, avoid psycho-emotional stress, as this can lead to an increase in intraocular pressure and the development of various complications.

Complications

Although vitrectomy has revolutionized the treatment of posterior segment disorders and significantly improves vision in patients with retinal diseases requiring surgery, it is also associated with comorbidities and complications.

Complications after vitrectomy:

• Bleeding.

  Infection.

  Retinal disinsertion.

  The formation of scar tissue.

  Loss of vision.

  Increased eye pressure or glaucoma.

  Cataract progression requiring surgical removal of the cataract at a later stage.

It is believed that the formation or progression of cataracts is the most common complication associated with vitrectomy.

Often nuclear sclerotic cataracts that develop after vitrectomy reduce visual acuity to the extent that it will lead to surgical removal. The exact pathogenesis of cataract formation or acceleration of the pathological process in the lens after vitrectomy is still unknown.

If the surgery was performed by a professional ophthalmic surgeon and the patient strictly followed all the doctor's recommendations, then the risk of complications is minimized.

Vitrectomy is an integral part of many manipulations aimed at treating diseases of the retina and restoring vision. Modern technologies and equipment make vitrectomy less traumatic for the eyes and comfortable for patients.

Prices for vitrectomy surgery


№	Service name	Price in rubles
2011039	Vitrectomy for uncomplicated hemophthalmia or grade 2 vitreous opacification	53 750

Vitrectomy was first performed about 30 years ago for the treatment of retinal detachment. Since then, the technology has undergone many changes, became much less traumatic and much more comfortable for the patient. Today, this manipulation is performed to treat the pathology of the retinal region and the vitreous body. As a rule, vitrectomy or vitreous removal is performed in combination with other surgical interventions - laser photocoagulation or episcleral filling, for example.

Anatomy and physiology of the vitreous body

The vitreous body occupies about 80% of the volume of the eyeball and is a transparent medium consisting of collagen, hyaluronic acid and water. The approximate volume in an adult is 4.4 ml. On the anterior surface, the vitreal cavity is delimited by the lens, on the posterior surface it is attached to the retina. It is an acellular, highly hydrated, gel-like substance, composed of 99% water. The transparent nature of this anatomical formation is still a subject of interest for scientists.

The structure of the eye

The gel-like structure is formed by a dissolved network of unbranched collagen fibrils. There are several varieties of these fibers, some of which form the cortex or the core of the vitreous body, others form its outer part. The space between the fibrils is mainly filled with glycosaminoglycans, mainly hyaluronic acid.

On the posterior surface, the vitreous body is in contact with the inner limiting membrane of the retina. The nature of the interaction of these two anatomical structures is also a subject of interest for scientists to this day. It is known that the main role in the described interaction is played by laminin, fibronectin, and type VI collagen. The most densely the vitreous body is adjacent to the retina in places where the inner limiting membrane is the thinnest - the region of the optic disc and macula, the peripheral parts of the retina. In the described areas, collagen fibers penetrate the membrane and interact with retinal collagen.

It is noticed that after 40 years the vitreous body undergoes changes– there is a significant increase in the volume of the liquid component and vice versa, a decrease in the gel component. As a result, large delimited spaces with liquid content are formed - lacunae, while the disorganization of the relationship between hyaluron and collagen leads to spontaneous aggregation of collagen structures into bundles of parallel fibrils. More enhanced formation of fibrils occurs in a number of ophthalmic diseases and blood entering the vitreous body in case of eye injury or diabetes mellitus, which leads to the formation of connective tissue strands and membranes that are firmly soldered to the retina and exert a traction effect on the retina, causing it to break and subsequent retinal detachment. This condition leads to a significant decrease in vision, and in advanced cases, to irreversible blindness.

Why is it necessary to remove the vitreous body

A number of ophthalmic diseases require the intervention of a vitreoretinal surgeon. Here are the main indications for vitrectomy surgery:

1. Hemorrhage in the vitreous body. Occurs when blood enters the described transparent medium. As a result, light transmission is disturbed and, depending on the amount of hemorrhage, vision is impaired to one degree or another. Vitrectomy is indicated for massive hemophthalmos, as well as for difficult visualization of the retina to identify the source of bleeding and select adequate treatment.
2. Primary retinal detachment. In this case, the removal of the vitreous can be supplemented by episcleral filling.
3. Vasoproliferative conditions, diabetic retinopathy and its complications. Microangiopathies as a result of impaired glucose tolerance lead to hemorrhages, angiogenesis of defective blood vessels, and the formation of connective tissue. All these conditions can be complicated, for example, by retinal detachment, which requires vitrectomy.
4. epiretinal membrane. The only way to remove the transparent connective tissue membrane that has formed on the surface of the retina is to perform a vitreous removal. After that, the membrane itself is mechanically removed.
5. Infectious processes - endophthalmitis sometimes require the described manipulation, followed by local administration of antibacterial drugs.
6. dislocation of the lens. Sometimes during cataract surgery, your own lens can move into the vitreous cavity. This is fraught with infectious processes and a pronounced increase in intraocular pressure. This situation can be corrected only with the help of vitrectomy.
7. Eye injuries - non-penetrating and penetrating, may require this operation. The volume depends on the area of ​​damage and complications.

Indications for any operation, including the one discussed in this article, are determined by the attending physician, while explaining in detail to the patient the need for intervention, its advantages, risks and complications.

Examinations and preparation for vitrectomy

Preoperative preparation involves a thorough examination of the organ of vision, as well as an assessment of the general condition and the presence of concomitant diseases in the patient. The diagnostic algorithm depends on the pathological condition for which the operation is planned and may include:

• Inspection with a slit lamp.
• Ophthalmoscopy with dilated pupil.
• Optical coherence tomography.
• Fluorescent angiography.
• Ultrasound examination of the retina.

An extended diagnostic spectrum is necessary when planning the involvement of the anterior segment of the eye, lens or cornea during the operation. If there has been a traumatic injury to the organ of vision, computed tomography or magnetic resonance imaging may be needed. These imaging modalities are necessary to assess the extent of the injury.

After diagnosing a disease requiring vitrectomy, the attending physician explains to the patient the indications, risks and alternatives to surgery. After that, the person signs an informed consent for surgery.

It is recommended to stop eating and drinking 8 hours before the operation. This minimizes the risk of aspiration of gastric contents during anesthesia. If you use any drugs constantly, their preoperative intake must be agreed with a specialist in advance. Medications such as injectable insulin, anticoagulants, or antiarrhythmic drugs should be discussed in more detail with the anesthesiologist or surgeon.

Types of vitrectomy

Depending on the scope of intervention, it can be:

• Total, when the entire volume of the vitreous body is removed.
• Subtotal - one of the segments is removed. For example, in the presence of vitreoretinal traction, the posterior vitreous segment is removed.

Equipment for the operation of vitrectomy and the course of the operation

Manipulation is carried out in the operating room in compliance with all the rules of asepsis and antisepsis. The patient changes into clean clothes. During the intervention, he lies on a special operating table.

Access after dilation of the pupil is carried out in a special safe zone of the sclera, in Latin called the pars plana. A surgical microscope with a high magnification lens is used for detailed examination and work in the cavity of the eyeball. The surgeon makes several incisions of the minimum size, which are used to introduce trocars or conductors into the eye cavity. Through them, surgical instruments are introduced into the vitreous cavity, namely:

• Light guide (endo-illuminator) for illumination and visualization of the internal structures of the eye.
• Vitreotome - a tool for the selection and delicate removal of the vitreous body.
• Delicate forceps for excision of membranes or scar tissue.
• Drainage needles for aspiration of contents.
• Laser probe (endolaser) for coagulation of retinal tears or areas of vascular proliferation.

At the end of the intervention, the patient is observed in the clinic for some time, after which he is allowed to go home with appropriate recommendations.

Vitreous substitutes

After removal of the vitreous body, the vacant cavity needs to be filled. To do this, experts use a number of substitutes. Their selection is carried out depending on the disease for which the operation was performed. Let's take a closer look at vitreous substitutes:

1. intraocular gases. One of the specialized gases is mixed with sterile air. These gas-air mixtures tend to dissolve slowly and persist for a long time (up to two months) in the eye. Over time, the gas bubble is gradually replaced by its own intraocular fluid. This method is good for pressing areas of retinal detachment or breaks. The tight fit of the gas bubble to the retinal area for a certain period of time promotes the healing of the defect. To achieve the proper therapeutic effect, it is necessary to adhere to a special postoperative positioning. Within 7-10 days, the patient should be predominantly face down, that is, lying on his back or pressing his head to his chin. Vision after the introduction of such a substitute, as a rule, worsens, as normal light transmission is disturbed. Recovery is observed after resorption of 50% of the volume of the mixture.
2. Sterile silicone oil sometimes used as an alternative to gas mixture for the treatment of retinal detachment. The silicone is not resorbable, but remains in the eye until it is removed during a second surgical intervention. This technology is relevant when there is a need for long-term support (tamponade) of the retina, for example, in case of complicated or massive detachment. In such a situation, postoperative positioning is not so critical, so the technique is also relevant for patients who are unable to fulfill the described conditions, including children.
3. Perfluoroorganic liquid, which is also called "heavy". The purpose of introducing this substitute is also the surgical treatment of detachment or retinal tears due to mechanical pressure. This filler does not dissolve on its own and requires the second stage of the operation for removal.

Anesthesia

After positioning on the operating table, the patient is subjected to standard anesthetic cardiorespiratory monitoring: ECG, blood pressure, respiratory rate and blood oxygen saturation (saturation). Through the catheter, peripheral venous access is carried out for the administration of drugs.

Modern vitrectomy techniques are minimally invasive and comfortable for the patient. Due to this, anesthesia management is limited to intravenous sedation in combination with the use of a local anesthetic in the form of eye drops. General anesthesia and periocular anesthesia are commonly used in children, patients with severe injuries, and those with increased levels of anxiety.

Microinvasive Vitrectomy

As mentioned above, ophthalmic microsurgery at the present stage allows you to perform operations quickly and almost painlessly. This also applies to vitrectomy. The microinvasive technique consists in using trocars with a diameter of 23, 25 and even 27G. Surgical access is not an incision, but a puncture through all layers of the eyeball. Such manipulation takes from 30-40 minutes to an hour, depending on the initial state of the organ of vision and the need to use other technologies (laser coagulation, for example).

This technique does not require sutures. The puncture sites heal on their own, which significantly reduces the recovery period. Such an intervention is also well tolerated by the elderly due to its speed, painlessness and the possibility of early activation.

Postoperative period

At the end of the operation, a protective sterile bandage is applied to the eye. When an air-gas mixture or sterile silicone is introduced into the cavity, the surgeon gives appropriate recommendations on postoperative positioning and its timing. Hyperemia, swelling or soreness in the eye area within 1-3 days after the manipulation is the norm. Your doctor will release you from the clinic with appropriate instructions for using drops with antibiotics or anti-inflammatories. For relief of pain, oral administration of non-steroidal anti-inflammatory drugs (nimesulide, ketorolac) or paracetamol is suitable.

During the recovery period, heavy lifting and intense physical activity should be avoided. As vision recovers, short periods of reading or computer work can be introduced. You can drive a car only with the permission of the attending physician.

Possible Complications

According to statistics, in 82% of patients after vitrectomy, there is a significant improvement both clinically and after diagnostic tests. But, like any surgical manipulation, this type of operation has its complications. The most frequent of them:

• Bleeding (0.14-0.17%).
• Attachment of a bacterial infection (0.039-0.07%).
• Retinal detachment (5.5-10%).

For prevention, it is necessary to be attentive to the intake of anticoagulants and antiplatelet agents in the preoperative period. Infectious complications are prevented by careful processing by the surgeon of the hands and the surgical field. Detachment occurs when the retina is damaged and is treated with standard approaches.

Operation cost

The cost of vitrectomy is determined by the need to use high-precision optical equipment and modern consumables. Specialists performing such an operation, as a rule, are highly qualified and have extensive experience. The price depends on the reputation of the clinic, the initial condition of the patient and varies from 50 to 100 thousand rubles.

Video: vitrectomy - treatment of retinal detachment