Eye vitrectomy surgery: how to do it. Vitrectomy: indications, preparation, possible complications. Indications for use

The first operation, vitrectomy, was performed about 30 years ago to treat retinal detachment. Since then, technology has undergone many changes, has become much less traumatic and much more comfortable for the patient. Today, this manipulation is performed to treat pathology of the retinal area and vitreous. As a rule, vitrectomy or removal of the vitreous body 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 for an adult is 4.4 ml. Along the anterior surface, the vitreal cavity is delimited by the lens, and along the posterior surface it is attached to the retina. The consistency is acellular, highly hydrated, gel-like substance, consisting of 99% water. The transparent nature of this anatomical education is still a subject of interest for scientists.

Structure of the eye

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

By back surface The vitreous body is in contact with the internal limiting membrane of the retina. The nature of the interaction between these two anatomical structures is also a subject of interest to scientists to this day. It is known that laminin, fibronectin and collagen type VI play the main role in the described interaction. The vitreous body is closest to the retina in places where the internal limiting membrane is thinnest - the disc area optic nerve and macula, peripheral parts of the retina. In the described areas, collagen fibers penetrate the membrane and interact with retinal collagen.

It has been noticed that after 40 years the vitreous body undergoes changes– there is a significant increase in the volume of the liquid component and, conversely, 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 intense formation of fibrils occurs in a number of ophthalmological diseases and blood entering the vitreous body during eye injury or diabetes mellitus, which leads to the formation of connective tissue cords and membranes, firmly fused to the retina, and exerting a traction effect on the retina, causing its ruptures and subsequent retinal detachment. This condition leads to a significant decrease in vision, and in advanced cases, to irreversible blindness.

Why do you need to remove the vitreous?

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

1. Hemorrhage into the vitreous body. Occurs when blood enters the described transparent medium. As a result, light transmission is disrupted and, depending on the volume of hemorrhage, vision is impaired to varying degrees. 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, removal of the vitreous body can be supplemented with 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, education 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 remove the vitreous body. After which the membrane itself is mechanically removed.
5. Infectious processes - endophthalmitis sometimes require the described manipulation followed by local administration of antibacterial drugs.
6. Lens dislocation. Sometimes, during cataract surgery, the lens of the eye may move into the vitreous cavity. This is fraught with infectious processes and a pronounced increase in intraocular pressure. This situation can only be corrected with the help of vitrectomy.
7. Eye injuries – non-penetrating and penetrating – may require this surgery. 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, 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 general condition and the presence of concomitant diseases in the patient. The diagnostic algorithm depends on the pathological condition for which surgery is planned and may include:

• Slit lamp examination.
• Ophthalmoscopy with a dilated pupil.
• Optical coherence tomography.
• Fluorescein angiography.
• Ultrasound examination of the retina.

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

After diagnosing a disease that requires vitrectomy, the attending physician tells the patient the indications, risks and alternatives to surgery. After this the person signs informed consent for surgery.

It is recommended to stop eating and drinking 8 hours before surgery. This minimizes the risk of aspiration of gastric contents during anesthesia. If you use any medications constantly, their preoperative use must be agreed with a specialist in advance. Medicines 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 the intervention, it can be:

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

Equipment for vitrectomy surgery and the course of the operation

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

Access after pupil dilation is carried out in a special safe zone of the sclera, called pars plana in Latin. 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 minimally sized incisions, which are used to insert 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 is a tool for isolating and delicately removing the vitreous.
• 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 for some time in the clinic, after which he is sent home with appropriate recommendations.

Vitreous substitutes

After removal of the vitreous, the vacated cavity requires filling. 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 in the eye for a long time (up to two months). Over time, the gas bubble is gradually replaced by the eye's own intraocular fluid. This method is good for applying pressure to areas of retinal detachment or tears. The tight fit of the gas bubble to the retinal area for a certain period of time promotes healing of the defect. To achieve the proper therapeutic effect, it is necessary to adhere to special postoperative positioning. For 7-10 days, the patient should be predominantly face down, that is, lying on his back or with his head pressed to his chin. Vision after the introduction of such a substitute, as a rule, worsens, as normal light transmission is disrupted. Recovery is observed after resorption of 50% of the mixture volume.
2. Sterile silicone oil sometimes used as an alternative to gas mixture to treat retinal detachment. Silicone does not dissolve, but remains in the eye until it is removed during repeated surgical intervention. This technology is relevant if 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 through mechanical pressure. This filler does not dissolve on its own and requires a second stage of surgery for removal.

Anesthesia

Once positioned on the operating table, the patient is subject to standard anesthetic cardiorespiratory monitoring: ECG, blood pressure, respiratory rate and blood oxygen saturation (saturation). Peripheral venous access for administering medications.

Modern vitrectomy techniques are minimally invasive and comfortable for the patient. Due to this, anesthetic management is limited to intravenous sedation in combination with the use of local anesthetic in the form of eye drops. General anesthesia and periocular anesthesia are usually used in children, patients with severe trauma, and elevated level anxiety.

Microinvasive vitrectomy

As mentioned above, ophthalmic microsurgery at the present stage allows operations to be performed quickly and practically painlessly. This also applies to vitrectomy. The microinvasive technique involves the use of trocars with a diameter of 23, 25 and even 27G. The surgical approach is not an incision, but a puncture through all layers of the eyeball. This 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 shortens the recovery period. This intervention is also well tolerated by older people 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 introducing a gas-air mixture or sterile silicone into the cavity, the surgeon gives appropriate recommendations on postoperative positioning and its timing. Hyperemia, swelling or pain in the eye area for 1-3 days after the procedure is normal. The doctor will release you from the clinic with appropriate recommendations for the use of antibiotic or anti-inflammatory drops. For cupping pain syndrome Oral administration of non-steroidal anti-inflammatory drugs (nimesulide, ketorolac) or paracetamol is suitable.

During recovery period It is necessary to avoid heavy lifting and intense physical activity. As vision recovers, short periods of reading or computer work can be introduced. You can drive a car only with the permission of your doctor.

Possible complications

According to statistics, 82% of patients after vitrectomy experience significant improvement both clinically and after diagnostic tests. But, like any surgical procedure, this type of operation has its complications. The most common of them:

• Bleeding (0.14-0.17%).
• Accession bacterial infection (0,039-0,07%).
• Retinal detachment (5.5-10%).

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

Cost of the operation

The cost of vitrectomy is determined by the need to use high-precision optical equipment and modern Supplies. The specialists performing this operation are usually 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

Vitrectomy is a surgical operation to partially or complete removal vitreous body of the eye. This may be necessary when various pathologies visual organs or in the treatment of eye injuries. Modern methods allow the procedure to be carried out as efficiently as possible and with virtually no complications. Read more in the article.

In what cases is eye vitrectomy prescribed?

Here are the diseases that this surgical intervention can be prescribed for:

• peeling retina;
• diabetic retinopathy;
• epiretinal fibrosis;
• macular hole;
• vascular diseases retina;
• post-traumatic changes in the visual organs;
• vitreous opacification due to hemorrhage;
• vitreomacular traction syndrome;
• intraocular bleeding;
• when restoring vision after complete or subtotal hemophthalmos.

The vitreous body is a substance resembling gel or gelatin, a gelatinous mass consisting of 99% water with protein compounds. It is located in the space between the lens and the retina, to which it is attached at several points. This structure of the eyeball occupies 2/3 of its total volume. The vitreous body is an optical medium that ensures the correct refraction of light rays upon entering the retina and is responsible for tissue turgor and the incompressibility of the eye.

During vitrectomy, this structure of the eye is partially or completely removed. This allows you to gain access to the affected area of ​​the retina and perform the necessary actions to restore the viability of the visual organ.

The procedure also helps eliminate the destruction of the vitreous body, restore its optical functions, returning transparency, and significantly improve the quality of vision. In addition, vitrectomy is needed to ensure sufficient access when performing surgical interventions on the posterior segment of the eyeball.

Types of vitrectomy

This procedure is divided into several types, depending on the area where it is carried out and the volume of work performed.

In vitreoretinal surgery there is the following classification:

• anterior subtotal vitrectomy - removal of part of the vitreous in its anterior sections;

• subtotal posterior vitrectomy - removal of part of the vitreous body closer to the posterior segment of the eye;

• total vitrectomy - complete removal of the vitreous.

The freed space in the eyeball is then filled with a special composition - these can be gas bubbles and silicone oil, saline solutions, or special synthetic polymers. At the same time, they are subject to strict requirements: substitutes must be perfectly transparent, biocompatible, hypoallergenic, durable, viscosity must correspond to the removed vitreous, and in general, ensure normal functioning of the eye without discomfort or rejection.

What symptoms may indicate retinal disease?

Each eye disease has specific symptoms. Often we do not pay attention to them, attributing them to fatigue, visual strain, while the diseases progress. Doctors say that complete loss of vision could have been avoided in 80% of cases if the patient had sought help from specialists in time.

Here are some symptoms that may indicate changes in the retina:

• the contours of objects seem distorted, and straight lines are curved;
• with close visual work, the eyes quickly get tired, a veil appears, “spots”, gray spots, flashes, lightning;
• there is a decrease in visual acuity at long distances;
• narrowing and loss of lateral fields of vision, double vision;
• migraine and dizziness.

If even one or two of the listed symptoms appear, you should immediately visit an ophthalmologist. He will conduct a diagnosis of the visual organs and detect any existing disorders.

What tests need to be done before eye vitrectomy surgery?

Before the operation, the doctor will prescribe full examination which includes several procedures. Only based on the diagnostic results will he make the final decision on minimally invasive vitrectomy. Contraindications may include serious damage to the optic nerve or retina, severe clouding of the cornea, a tendency to allergic reactions, oncological diseases, hemophilia. Here are the tests the patient will need to undergo:

• general analysis blood;
• hemoglobin test (for patients with type 1 and type 2 diabetes);
• total protein, creatinine, bilirubin;
• Duke or Sukharev test for blood clotting time;
• HIV tests;
• electrocardiogram, radiography chest;
• health reports from an otolaryngologist, dentist, endocrinologist (in the presence of diabetes and thyroid diseases).

Only after the doctor receives all the test results and conclusions from other specialists will he make a final decision on the procedure.

How is microinvasive vitrectomy performed?

Vitrectomy is a minimally traumatic method of penetration into any organ in order to exclude wide abdominal access. It is because of this that subsequent complications often arise. The eye vitrectomy operation is performed under general or local anesthesia - at the discretion of the attending physician. The eyelids are spread apart and fixed with an eyelid expander. Then three small punctures are made on the sclera of the eyeball, through which instruments will be subsequently introduced into the vitreous cavity - a trocar and an infusion cannula.

Vitrectomy is an operation that requires great skill of the surgeon. The retina of the eye is highly sensitive nerve tissue, and almost every part of it is responsible for some area of ​​vision, so you need to be extremely careful when operating with it. At the time of the procedure, the doctor looks inside the eye through the pupil, and this requires absolute transparency of the optical media of the eye - the cornea and lens. If the patient has cataracts, the clouded lens is first replaced with an intraocular lens, then vitrectomy is performed directly.

The vitreous body is separated and sucked out through punctures, pathologically altered tissues that cause tension on the retina are removed, scars and fibrous cords are dissected. After the surface of the retina has been cleaned in this way, it is straightened and applied to the choroid - as it should be anatomically correct. Next, the ophthalmic surgeon performs laser coagulation of the retina - strengthening its damaged areas with a laser for a reliable connection with the choroid.

Then the so-called “heavy water” - a liquid organic substance - is introduced into the resulting cavity. Due to its large molecular weight, it acts on the surface of the retina like a press, smoothing and pressing it. This component is absolutely transparent, so the eye can see immediately after the operation is completed. However, this measure is temporary: “heavy water” cannot be left in the eyeball for a long time. After 7-14 days it is replaced with silicone oil. This is a viscous transparent liquid, the tissues of the eye almost do not react to it, and it can remain inside the eye for much longer - up to several months. Silicone is great for securing the achieved effect. The functions of the retina are gradually restored, and the adhesions in the areas of laser exposure acquire high strength over time. One of the features of silicone oil is an increase in the optical power of the eye by 4-5 diopters. Patients with myopia see much better during this period.

Typically, the silicone remains inside the eyeball for up to 2-3 months, after which it can be safely removed - the retina no longer needs to be pressed. This process is also a separate operation, although not so complicated. However, with some pronounced changes in the eye, doctors leave silicone - it can stay there for 10 or even 15 years.

Gases or air are sometimes used to fill the cavity after removal of the vitreous. The principle of their influence remains the same: pressing the retina for a while until the adhesions heal and strengthen. Over time, the gas or air gradually dissolves in the intraocular fluid - this takes from 2 weeks to one month. Unlike silicone filler, when they are introduced, the quality of vision deteriorates - the patient sees only light or bright large objects. This effect gradually wears off as the gas dissolves. But this method There are also advantages: it will not be necessary to perform a second operation to extract these components, as is the case with silicone oil.

After all the steps are completed, the punctures are covered with thread sutures, which will soon dissolve on their own.

Vitrectomy is carried out in a clinic on a “one-day” basis - already six hours after its completion, the patient can be discharged home. The procedure itself takes approximately one and a half to three hours, depending on the severity of the eye pathology.

Results of eye surgery. Vision after vitrectomy.

In general, the effectiveness of minimally invasive vitrectomy is very high. Often this intraocular procedure is the only possible way out of a difficult clinical situation.

Each case of retinal detachment is individual; only the surgeon decides which method of treatment to choose. IN medical practice combination is widely used in various ways, for example, vitrectomy + lensectomy, vitrectomy + laser coagulation and other combined techniques. This approach allows you to cope with almost any retinal detachment that occurs for various reasons. Another question is how badly her cells were damaged and how long they were down. The degree of vision restoration after surgery depends on this. Dead cells, of course, will no longer be able to function.

Usually, the doctor undertakes vitrectomy if no more than a year has passed since the destructive processes in the retina and the eyes can still see light well - in such a situation there is a chance to improve vision.

If the patient sees very poorly, then, alas, in this case the operation will not help - most of the retinal cells have already died. Each situation is considered individually - great importance diagnosis also plays a role. Sometimes it is possible to help even in difficult situations.

What is forbidden to do during the first 24 hours after vitrectomy surgery?

• Driving is prohibited. According to individual indications, this period can be extended.
• You cannot rub your eyes or press on them.
• You should take all prescribed medications - they accelerate tissue regeneration.
• Discharge from the eyes should be carefully blotted using clean, dry wipes, without touching the eyes with your hands or the wipe.
• After the operation, a feeling of burning, tingling, or a feeling of “sand” in the eyes may remain for some time - this is normal. Medicines will help
• eliminate these symptoms.
• It is strictly forbidden to engage in physical labor, jumping, running, making sudden head movements, lifting weights, visiting bathhouses and swimming pools, and getting hypothermic.

During the month after vitrectomy, you should also follow certain rules that will help keep your eyes safe.

You can take a shower on the third day, but you need to do it with your eyes closed. When going outside, your eyes should be protected from the bright sun with dark glasses. Women should stop using decorative cosmetics during this period.

You should limit activities associated with visual strain: spending long periods of time with gadgets, watching movies, reading. It is also prohibited to lift weights over 5 kg. It should be understood that violation of the prescribed rules can lead to re-detachment of the retina while it is healing - and the operation will have to be repeated.

If the cavity in the eye is filled with gas after the procedure, then it is strictly forbidden to fly on airplanes for two months after the operation. Pressure changes can negatively affect the condition of the gas.

Call your doctor immediately if the following signs appear:

• blurred vision;
• itching and irritation;
• profuse lacrimation;
• eyelid swelling and hyperemia;
• discharge from the eyes that does not stop for a long time.

These signs may indicate that for some reason the retina is not taking root well or that the eye is reacting to components introduced after removal of the vitreous. The doctor examines the visual organs to determine the cause.

Upon completion of the operation, the specialist prescribes a schedule of follow-up visits. You should not miss such visits - during the examination, the ophthalmologist examines the condition of the operated eye and, if there are any deviations, will be able to take timely measures. We must remember that only we ourselves are primarily responsible for our own health.

In the human eyeballs there is a vitreous body, which in its structure resembles a gel: it is this that gives the eye its spherical shape. In addition, there are other functions of this component human eye, for example, the refraction of light entering the retina. However, in the event of certain pathologies, it becomes necessary to remove the vitreous body or part of it. This operation is called vitrectomy.

Vitrectomy is a complex surgical procedure that should only be performed by an ophthalmic surgeon.

Vitrectomy became possible approximately 50 years ago when Robert Machemer invented a device that could reach the back of the eyeball and absorb the vitreous. Moreover, the scientist provided the ability to regulate during the procedure. This was the device with which the world's first vitrectomy was performed.

Initially, this procedure was aimed only at ridding the vitreous of opacities. However, subsequently the removed gel-like substance began to be filled with other substances, thus returning the eye to its original shape. Currently, the Machemer apparatus has been significantly modified, and now it is possible to set the device cutting parameters, the rate of vitreous absorption, and more accurately regulate the depth of immersion. With the help of this plastic surgery eyes has become more effective.

During this operation, the doctor removes blood clots, scarring or other defects that have arisen from the eyeball that negatively affect the general condition of the eye. However, the removed part of the vitreous is replaced with special fillers. This is done to normalize internal pressure, in order to avoid repeated hemorrhages and pathological neoplasms. When the natural volume of the vitreous body is replenished, the retina returns to its natural position - close to the eye. Thus, removing tumors reduces tension in the retina, and filling it with polymers, a mixture of gases, water or silicone oil allows you to return it to its optimal position: without tension or sagging. Subsequently, these substances are absorbed or removed, the vitreous body grows to normal sizes, the problem goes away.

Indications for use

Currently, it is with the help of vitrectomy that it is possible to cure severe eye pathologies. The following diseases may be the reasons for the operation.

• Retinal pathologies, such as its detachment or disruption of its central part. Vitrectomy allows access to affected tissues for therapeutic surgical procedures.
• Macular hole in the center of the retina, caused by a detachment of the vitreous humor, causes empty spaces inside the eye that fill with unnecessary fluid. This negatively affects vision. The operation allows to partially restore it. After vitrectomy, a membranoectomy is performed to remove excess tissue.
• Vitrectomy is used to treat cloudy eyes.
• Inflammatory eye diseases, in particular, inflammation of the retina and blood vessels in a certain area of ​​the eyeball.
• Destruction of the vitreous body causes visual impairment. If conservative treatment did not show the desired result, although this happens in rare cases, they resort to surgical intervention. In most cases, the operation restores vision and provides positive influence to the vitreous body.
• Complications diabetes mellitus, such as, helps to increase the number of vessels in the retina. This leads to tension and subsequent peeling, which impairs vision.
• Diseases cordially vascular system , such as hypertension, cancer, vascular pathologies, can cause bleeding into the vitreous body.

Types of operations

During vitrectomy, either the entire vitreous body or a certain part of it can be removed. Resection of the area, depending on the location of the intervention, can be posterior or anterior.

Posterior vitrectomy

The vitreous body consists of collagens and hyaluronates - salts of hyaluronic acid. These components give this area a gel-like and plastic structure. However, the vitreous grains can only accept a small portion of the cohesion, so the vitreous may partially migrate to the back of the eye. This causes the retina to tear or a macular spot to form. In this case, posterior vitrectomy is used.

Anterior vitrectomy

An anterior vitrectomy may be indicated if the vitreous fluid leaks into the front of the eye. This can happen with mechanical damage to the eye or pathology of the lens. In some cases, such leakage of the gel-like substance occurs during surgical procedures aimed at eliminating cataracts. Thus, to minimize the danger and damage to the eye, vitrectomy is sometimes performed unscheduled - during the main operation.

Carrying out the operation

Only a qualified ophthalmologist can perform a vitrectomy operation, since the procedure requires precise and careful manipulation. The operation involves the following steps:

• The surgeon makes three small incisions (slightly less than 0.1 cm). Micro incisions are made on the outside of the eyeball to reach the vitreous.
• Devices of the required size are inserted into each of the incisions: a fiber optic light guide for illuminating the retina, a cannula for introducing the necessary polymer and creating the necessary pressure inside the eye, as well as a vitrector, which is designed to suction the vitreous or completely remove it.
• The vitreous body or part thereof is removed, while eyeball a mixture of gases or silicone oil is introduced to fix the retina. The gas is directed to the retinal tissue, promoting its regeneration. Silicone oil must be removed in the future, since it does not dissolve on its own. This will require a second operation. The doctor decides what to use: a mixture of gases or a silicone polymer.

The operation does not require general anesthesia; local anesthesia will suffice. The duration of the procedure depends on the disease; it usually lasts no longer than two hours. In some cases, the operation may be unplanned and performed in combination with another.

Microinvasive vitrectomy

Today, a microinvasive vitrectomy operation is available, which does not require going to the hospital. Microinvasive vitrectomy is performed using three punctures of smaller diameter than during conventional surgery - 0.3 - 0.5 mm. These miniature punctures require appropriate equipment: special thin lamps, an electric or pneumovitreotomy, which sucks out the vitreous body at half the rate compared to a non-microinvasive operation. A microscope is also used.

The procedure is carried out in a similar way to conventional surgery, but the eye tissue is damaged significantly less. Minimizing intervention allows you to do the procedure faster and direct more efforts to eliminate the source of the problem.

• The quality of the procedure improves and access to the lesion becomes more accurate.
• Less traumatic compared to conventional operations.
• Does not require hospitalization.
• Local anesthesia that does not harm the body.
• The blindfold is removed one day after surgery.
• Practically complete absence rehabilitation.
• Can be carried out simultaneously with other interventions.

However, in most clinics, such a procedure costs much more than a conventional operation, since more expensive and high-tech medical equipment is used.

Rehabilitation period after vitrectomy

The rehabilitation period after vitrectomy is accompanied by some difficulties. Immediately after surgery, the eye is fixed with a bandage, which in most cases is removed the next day. It is necessary to use eye drops for a month after surgery. At first it will be uncomfortable to blink: there will be a feeling of a foreign body in the eye.

Aesthetically, the operation will also not pass without a trace: for several days the eyes will be red and swollen. Otherwise, there is a risk of increased intraocular pressure.

You should not exercise or shake your head for the first ten days, but otherwise you can continue to live your normal life.

If a bubble of a gas mixture was placed inside the eye to fix the retina, then recovery will be more difficult: it will require almost constant support of the head in a certain position, for example, sleeping on a certain side of the body or head down. In this case, the ophthalmologist prescribes strict instructions that must be carefully followed. You should not use ground transportation, climb to high floors, or fly by air. Otherwise, intraocular pressure will increase, and the consequences will be disastrous.

The presence of a gas mixture or silicone-based polymer in the eye can partially impair vision, but after removing these substances, it gradually returns to normal. It is important to understand that rehabilitation after such a delicate procedure is long-term, so it will be possible to fully evaluate its results after a month or more.

10.10.2017

Vitrectomy is a surgical procedure aimed at removing the vitreous humor. 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 usually not associated with its changes. It is often necessary to gain access to the posterior segment of the eye for various pathological conditions retina. This microsurgical intervention was first performed in 1970. Vitrectomy has undergone many changes since then, 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 method to restore a person’s vision.

When is eye vitrectomy indicated?

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

Proliferative diabetic retinopathy (including vitreous hemorrhages).

Macular holes.

Epiretinal fibrosis.

Complicated, traction or recurrent retinal detachment.

Intraocular foreign body.

Displacement of the artificial lens after its implantation for cataracts.

Giant retinal tears.

Age-related macular degeneration.

Traumatic injuries.

Vitrectomy is often performed in emergency clinical situations. It may be contraindicated for 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 casts doubt on the operation due to high risk 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. Severe systemic coagulopathies also require close attention from the doctor, therefore, during the vitrectomy operation, it is necessary to monitor the condition of the coagulation and anticoagulation systems, and, if necessary, make corrections.

Technical features of the operation

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

During surgery, vital signs are carefully monitored. important functions such as pulse, blood pressure and ECG.

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

One of the ports is used for the infusion line necessary to introduce a special solution into the eye cavity during surgery. The second port during vitrectomy is necessary for a video camera with a light, thanks to which the ophthalmic surgeon can monitor the progress of the work on a special monitor. The third trocar is used for a vitreotome, an instrument that performs basic operations 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 high-power lens provides a clear and magnified image of the inside of the eye.

During the vitrectomy operation, the vitreous body of the eye is aspirated, and the empty cavity is filled with sterile silicone oil or a special gas-air mixture. The vitreous does not return, 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) can be used. However, if the patient has a retinal detachment, then either sulfur hexafluoride (which stays in the eye for 10-14 days) is used to tamponade it, or in more complex cases, another gas is used, for example, fluorohexane or fluoropropane.

Recovery period

The duration of the vitrectomy operation depends on the underlying eye disease and the presence of concomitant ophthalmological 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 prescribed eye drops with glucocorticosteroids to minimize inflammatory changes, as well as local antibiotics to reduce the risk of developing 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 to the back wall of the eye, which prevents retinal detachment. A certain head position must be maintained for at least 45 minutes every 60 minutes. These 15 minutes are intended for eating and visiting the rest room.

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

In the postoperative period, you should not lift heavy objects 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 surgical intervention, it is also associated with comorbidities and complications.

Complications after vitrectomy:

• Bleeding.

  Infection.

  Retinal disinsertion.

  Formation of scar tissue.

  Loss of vision.

  High blood pressure eye or glaucoma.

  Progression of cataracts requiring cataract surgery at a later stage.

Cataract formation or progression is believed to be the most common complication associated with vitrectomy.

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

If the surgical intervention 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 procedures aimed at treating retinal diseases and restoring vision. Modern technologies and equipment make the vitrectomy operation less traumatic for the eyes and comfortable for patients.

Prices for eye vitrectomy surgery


№	Service name	Price in rubles
2011039	Vitrectomy for uncomplicated hemophthalmos or vitreous opacities of the second category	53 750

Vitrectomy is surgery, which is successfully used for vitreous hemorrhages, retinal detachment, severe injuries to the visual analyzer and diabetes mellitus.

All of these diseases were previously considered incurable and ultimately led to loss of vision. To date modern medicine suggests vitrectomy as effective method correction and treatment of eye diseases.

Vitrectomy is also understood as an operation to remove the vitreous humor from the eye. This structure occupies the largest volume in the eye. The body can be partially removed, i.e. perform a subtotal vitrectomy, or it is possible to perform a complete one.

After vitrectomy, the ophthalmologist gains full access to the retinal tissue. This allows for photocoagulation (“soldering”) of the retina, removing scar tissue from it, or restoring the integrity of the membrane.

When the vitreous humor of the eye is removed, gas or a special liquid is injected instead.

This operation can be performed under local or under general anesthesia.

The main reasons for the operation are:

1. Eye injuries, for example due to penetration of a foreign object;
2. Retinal detachment resulting from severe myopia, diabetes mellitus, or aging of the vitreous. The retina can also detach due to sickle cell anemia or penetrating injury to the eye;
3. Saturation of the vitreous body with blood – hemophthalmos;
4. Severe intraocular infection;
5. Retinopathy - diabetic pathology retina, complicated by traction-type retinal detachment, hemophthalmos, or swelling of the optic spot;
6. Serious stage of vitreous opacification;
7. Large retinal tears;
8. A hole or tear in the macula (macula);
9. Dislocation of the lens or the intraocular lens that replaced it (in the case of surgical treatment cataracts);
10. Removal of scar tissue in case of opacities or multiple hemorrhages. Hemorrhage can cause tissue detachment and emergency measures will be required.

Before the operation, at approximately 18:00, the patient should take his last meal. After this, you cannot eat or drink until the operation. The surgery lasts approximately 2 hours.

Vitrectomy of the eye can be performed after instillation of anesthetic agents into the eye, or under general anesthesia. The decision depends on the patient's condition, the presence of other diseases and the total number of proposed procedures.

The surgery itself is performed on the patient, who is in a supine position. After combined or local anesthesia, a special eyelid dilator is inserted into the eye; it will fix the eye during procedures performed by the surgeon.

After this, 3 small incisions are made in the eye, where instruments are inserted, allowing the surgeon to manipulate the retina and vitreous body.

The surgeon uses the following instruments during the operation:

1. Vitreotome is a special cylinder with a knife,
2. Lighting device,
3. A cannula for regularly delivering sterile saline solution into the eyeball. The substance maintains the apple of the eye in normal tone.

The vitreous must be completely sucked out using a vacuum. After this, scars, pathological tissues, and blood are removed from the body. Next, the doctor performs manipulations on the retina.

The vitreous that has been removed is replaced:

• A mixture of air or sterile air with gas, if the goal is to tamponate the retina, as well as keep it in its normal position (in case of rupture of the macula area. The mixture resolves on its own in 3 weeks. After this time, its own intraocular fluid appears;
• Organofluorine liquid, i.e. water that is saturated with fluoride or silicone oil. The liquid is heavier than water. Silicone oil is much heavier than water, it presses against the retina for 3-4 months, after which the doctor removes it.

Microinvasive vitrectomy

A type of surgical intervention involves extracting the entire vitreous or part of it. The operation is performed in three microscopic punctures measuring 0.3-0.5 mm. Even smaller instruments are inserted into the punctures.

It is characteristic that the frequency of operation of the vitreotome during microinvasive vitrectomy is higher, and is not 2500 per minute, but twice as much. In addition, another type of illuminators is used - self-fixing multipoint ones.

Features of the operation are as follows:

• Low level of trauma;
• Reducing the risk of bleeding, which is important in case of excessive proliferation of blood vessels in the tissue;
• The operation is performed in an outpatient setting, without hospitalization;
• The period of postoperative rehabilitation has been reduced.

Microinvasive vitrectomy is not performed in all ophthalmology centers.

Reviews of vitrectomy directly depend on the qualifications of the doctor and the availability of special instruments.

Features of the postoperative period

After a standard vitrectomy, the patient must stay in a medical facility for 1-3 days, under the strict supervision of doctors.

The patient's vision is restored some time after the operation. The degree of recovery and duration depends on the following factors:

• The presence of severe pathologies of the retina;
• Permeability of the optical media of the eye for the light beam;
• Condition of the optic nerve.

If the vitreous body was replaced with a saline solution, then blood elements will be free in the eye for some time. Reviews from patients indicate that cloudy eyes can persist for several weeks.

If the vitreous was replaced by a gas mixture, a black veil will appear, which will go away within seven days.

In case of delayed treatment, when the retina has already acquired irreversible changes, rehabilitation measures take a long time.

After vitrectomy for 3-6 months it is prohibited:

1. Lift weights weighing more than two kilograms;
2. Read more than 30 minutes;
3. Leaning over the fire of a gas stove or standing over an open fire;
4. Play sports that involve bending;
5. Experience any intense physical activity.

Please note that you do not need to follow a special diet after surgery.

The following complications may occur:

1. Increased eye pressure, which is most dangerous for people suffering from glaucoma;
2. Retinal detachment;
3. Vitreous hemorrhages;
4. Formation of an infectious intraocular process;
5. Damage to the lens;
6. Cataract;
7. Swelling of the areas under the cornea - the outer layer of the eye;
8. The appearance of a mass of new vessels in the iris, which can provoke glaucoma.

The better the preparation for surgery and preoperative studies, the greater the likelihood of avoiding complications.

Vitrectomy is the most common operation when it is necessary to remove the vitreous humor of the eye, especially for type 2 diabetes. Often surgery is the only condition for saving a person’s vision. Currently, vitrectomy is performed on modern equipment in good medical conditions.

Just a few decades ago, problems of the eye organs in the form of: severe injuries to the visual analyzer, hemorrhages in the vitreous body of the organ, or the process of retinal detachment, were considered serious diseases. There was no way to cure them and as a result the person completely lost his sight. Today, these diseases are effectively cured through a special operation - vitrectomy. The rescued eye organ is completely restored and continues to perform its anatomical functions.

Vitrectomy of the eye is successfully performed by both foreign and domestic ophthalmologists. Modern methods 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 procedure, and will also tell you about possible complications and measures that will help you avoid them.

Vitrectomy of the eye

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

Removal of the vitreous body allows the ophthalmologist to gain access to the retinal tissue and perform:

• photocoagulation (a kind of soldering of the retina);
• reproduce the restoration of the integrity of the shell, which could be damaged when receiving a serious injury;
• move the formed scar tissue from the surface of the retina that interferes 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 means that ensure close contact between the retina and choroid, and also minimize the risk of postoperative complications.

Important: Today, vitrectomy is the only way to solve problems associated with eye disease. 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 highly qualified doctors.

What is the indication for vitrectomy?

Vitrectomy has opened up new opportunities 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 severe form;
• cases of retinal detachment due to: penetrating injury to the eye organ, as a result of diabetes mellitus, with high degree myopia (myopia), in the presence of sickle cell anemia, as well as due to physiological aging of the vitreous humor in the eyeball;
• penetration of an otherworldly object into the eye organ;
• a hole or tear in the macula (macula);
• large retinal tear;
• there has been significant clouding in the structure of the vitreous body;
• hemophthalmos - the vitreous body is partially or completely saturated with blood;
• the presence of diabetes mellitus often causes the formation of retinopathy - damage to the blood vessels of the eye organ, which disrupts the blood supply to the retina;
• in cases of dislocation of the lens or intraocular lens, which was replaced during cataract surgery.

Repeated hemorrhages and gross opacities lead to scarring of the retinal tissue. These scars prevent a person from seeing clearly. The purpose of surgery is to remove them.

What can be a contraindication to vitrectomy?

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

How is the operation performed?

First, the specialist decides whether 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 volume 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. For small volumes of surgery, local anesthesia with anesthetic drops is most often used.

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

Using a special instrument, the surgeon makes several incisions on the sclera. They will be needed to insert the necessary instruments into the eye organ. Further, to perform the operation, the specialist will need: a lighting device, a vitreotome, and 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 further), which press the retina to the underlying layers and then hold it in the desired position.

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

Vitreous replacement compounds

In ophthalmology, the following are used to replace the vitreous body: liquid perfluoroorganic compounds, silicone oils, and gas mixtures. 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. Read more about these compounds.

1. Using silicone oil. This substance has a unique structure, characterized by chemical and biological inertness, which makes the oil easily tolerated by the body. The substance promotes 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 is 90% identical to the natural refraction, which is reproduced by the eye organ. Unlike other types of vitreous substitutes, silicone oils have the longest service life (about a year).
2. Application of perfluoroorganic liquid compounds. The second name for these fillers is “heavy water”. This name was obtained due to the molecular weight of these compounds, which weighs 2 times more than ordinary water. After filling the resulting cavity due to removal of the vitreous, the patient does not need to follow special regimes in the postoperative period. The filler holds the retina in the desired position for 3–4 months, after which it is removed by a specialist.
3. Application 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 resolves on its own in 2–3 weeks. Its composition is gradually replaced by anatomical 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 air travel during the postoperative period. Changes in atmospheric pressure cause gas to expand, leading to an uncontrolled increase in intraocular pressure.

Basic rules after vitrectomy that will shorten rehabilitation time

If the surgical intervention was not associated with the patient’s extremely serious condition, he is sent home on the same day. In advance, the specialist gives recommendations necessary for a speedy recovery, which will also help to avoid postoperative complications.

• do not overwork your visual apparatus (reading, writing, sitting at the monitor, etc. for more than half an hour);
• During the first 2 weeks, it is prohibited to lift weights exceeding 3 kg.
• physical activity with sudden movements to the side and bending forward is contraindicated;
• mandatory use of eye drops that were prescribed by an ophthalmologist to heal the eye organ and prevent increased intraocular pressure;
• in the first month after vitrectomy, visiting saunas or steam baths is excluded;
• you cannot lean over the fire (it can be an oven, a gas stove or just an open fire).

Particularly severe cases may require the patient to remain 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 specialist’s recommendations in this case will also concern the special position of the head during the rehabilitation period, which is about three weeks. For example, when sleeping, a person will need to sleep on one specific side or face down. In some cases, it is recommended that the patient rent a special system that is designed to keep the head in a face-down position at all times. It was specially designed for rehabilitation period after vitrectomy and is designed for use from 5 days to 3 weeks.

Failure to follow the recommendations often leads to bleeding, return to the original state of the eye organ, postoperative infection and much more. This is in best case scenario additional treatment, and in the worst case, irreversible processes of vision loss.

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

How long does it take for vision to be restored after surgery?

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

• from the filler used, which was used instead of the vitreous;
• number of additional surgical stages;
• on the volume of the operation;
• on the degree of transparency of the optical environment of the eye organ;
• initial and postoperative condition of the retina and optic nerve.

For example, if an anterior vitrectomy was performed, during which a small amount of the vitreous 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 purpose of the operation is to prevent complications, and in this case, noticeable improvements in visual acuity may not be observed.

Features of rehabilitation associated with vitreous substitutes are as follows. Substitutes based on saline solutions have low viscosity, and the cavity of the eye organ contains blood and cellular elements, which need several weeks to resolve. In this case, vision restoration does not occur immediately.

Patients who had the resulting 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 a black veil before the eyes, but this negative rehabilitation aspect is corrected during the first week - the veil goes away.

When the retina is detached, its function is impaired. If the patient seeks help in a timely manner and the operation proceeds without complications, these functions will be restored quickly. But as the problem drags on, these changes become irreversible. There are disturbances in the optic nerve and in the functioning of the retina. Rehabilitation is greatly complicated, even if the maximum was achieved during the operation. positive result according to the fit of the retina.

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

Additional stages of surgery

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

1. Air injection. It is performed to extract intraocular fluid located in the posterior segment of the eyeball. This procedure maintains intraocular pressure, which is necessary to seal existing holes in the retina and keep it in place. The pressure generated by the air soon disappears, and the back part begins to fill with liquid again.
2. Scleral screed procedure. A kind of support “belt” is installed around the eyeball, which, after fixing the retina, supports it in the proper position.
3. Removal of the lens - lensectomy. Often such intervention is required when there is a cataract on it, as well as when it is attached to the tissues of an existing scar.
4. Laser treatment – ​​photocoagulation. Performed when blood vessels are damaged to close them. Often such damage occurs due to diabetes in the patient. The procedure also 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 may occur?

Among the complications of vitrectomy noted:

1. The presence of cataracts in a patient 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 was replaced with silicone oil.
2. If during surgery an excessive amount of substitutes is introduced into the eye cavity, the patient's intraocular pressure increases. To eliminate this side effect The specialist should prescribe special drugs against glaucoma.
3. Recurrences with retinal detachment are possible.
4. Complications in the form of endophthalmitis are an infectious and inflammatory process.

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

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. These microscopic punctures require the use of a small instrument. This allows:

• achieve less trauma to 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 specialists, so the method is not used in all vision restoration clinics.

Patient reviews of vitrectomy are mostly positive. Everyone talks about different times for vision restoration, but it still happens. And this is already a big plus in favor of vitrectomy.

Vitrectomy is a surgical procedure during which the vitreous body is completely or partially removed. It was first carried out by R. Machemer in 1971.

This is a rather complex operation that requires high-tech equipment and a highly qualified surgeon. But at the same time, it is the only solution to some eye diseases.

Indications and contraindications for surgery

Vitrectomy is advisable in the following cases:

• Hemophthalmos (hemorrhage into the vitreous cavity);
• Exudative, rhegmatogenous or tractional retinal detachment;
• Severe wounds and injuries of the eye, accompanied by hemophthalmos, retinal detachment, penetration of a foreign body into the eye;
• Macular retinal hole;
• Diabetic proliferative retinopathy;
• Vitreous opacification after uveitis;
• Subretinal hemorrhage (bleeding under the retina);
• Severe intraocular infectious diseases(endophthalmitis);
• Macular edema;
• Hardening of the surface layer of the retina (epiretinal fibrosis).

Vitrectomy is not done in the presence of blood diseases (especially if there is a violation of the coagulation system), severe clouding of the cornea and the patient’s serious condition.

Stages of vitrectomy surgery

Today, vitrectomy is performed on an outpatient basis under local anesthesia. The patient is in a supine position, his head is fixed with a special device.

The sequence of actions of the surgeon is as follows:

Infusion cannula

Anesthesia of the eye.

1. Opening and fixing the eyelids using an eyelid expander.
2. Three microscopic incisions are made on the sclera, through which several instruments are inserted into the vitreous cavity: an infusion cannula, a vitreotome and a lighting device.
3. Separation of the vitreous body using a vitreotome.
4. Removal of the vitreous by suction. If necessary, electrocoagulation of bleeding vessels and excision of scars and fibrous cords are additionally performed.
5. Introduction of a vitreous substitute into the eye cavity.

The duration of vitrectomy varies from 2 to 3 hours, depending on the qualifications of the surgeon and the severity of the patient's condition.

Vitreous substitutes

Currently There are several vitreous substitutes available: silicone oil, complex saline solution, liquid perfluoroorganic compound or sterile gas bubble. The use of these substances ensures close contact between the choroid and the retina and prevents the development of complications.

Using silicone oil

The light refractive index of silicone oil is almost the same as the natural refractive media of the eye

Silicone oil is a substance unique in its nature, which is characterized by biological and chemical inertness.

Thanks to this property, the oil is easily tolerated by patients and does not cause allergic reactions. Its refractive index of light is almost the same as the natural refractive media of the eye.

These features allow you to leave silicone oil in the eye cavity for long term(up to 1 year).

Silicone oil ensures the correct anatomical position of the retina and rapid restoration of its function.

Using a gas mixture

The introduction of an air bubble into the eye cavity requires the patient to strictly adhere to certain rules. This mainly concerns long-term holding of the head in a certain position, which is discussed with the doctor and depends on the scope of the operation.

The advantage of the gas bubble is that over time (12-20 days) it completely resolves and is replaced by natural intraocular fluid.

During this period, air travel is strictly contraindicated for a person. This is because changes in atmospheric pressure expand the gas and can cause an uncontrolled increase in intraocular pressure.

Use of liquid perfluoroorganic compounds

They are also known as “heavy water” because their molecular weight is almost twice as heavy as that of ordinary water.

After the introduction of such a substance into the vitreous cavity, the patient is not required to comply with any special regimen.

The only downside to liquid perfluoroorganic compounds is that they need to be changed every two weeks.

Postoperative period after vitrectomy

After the intervention, the patient can go home the same day. For a speedy recovery, you must follow the following recommendations:

• During the first 12-14 days, it is strictly forbidden to lift weights over five kilograms.
• Avoid overworking the visual analyzer.
• Any physical activity accompanied by sudden movements is contraindicated.
• Do not visit the pool, bathhouse or sauna for the first month after surgery.
• Use eye drops prescribed by your ophthalmologist several times a day.

The timing of restoration of visual functions directly depends on the extent of the operation and what kind of vitreous substitute was used.

For example, if only part of the vitreous was removed during vitrectomy, vision improvement may occur within the first week. If the operation was performed on advanced stage diseases when tissue changes have become irreversible, a noticeable improvement in vision may not occur.

Complications that may develop after vitrectomy

Like any surgical intervention, vitrectomy carries a certain risk of developing postoperative complications.

Possible postoperative complications :

• Progression of cataracts. If the patient already had cataracts at the time of the intervention, then there is a possibility of its progression in the first six months or a year after the intervention. This happens more often when silicone oil is used as a vitreous substitute.
• Development of secondary glaucoma.
• Relapse (repetition) of retinal detachment.
• Ocular hypertension, or increased intraocular pressure. This complication occurs when an excess amount of substitute is introduced into the eye cavity. To eliminate this complication, the patient must use anti-glaucoma drops for some time.
• Infectious and inflammatory complications (for example, endophthalmitis).
• Cloudiness of the cornea. It is rare and is caused by the toxic effects of the vitreous substitute.

Reviews about vitrectomy and the postoperative period

We are always glad when site visitors leave their feedback after undergoing operations. Thus, you help countless patients decide to take an important step and regain their health.

You can leave your feedback after undergoing vitrectomy, as well as tell your feelings in the postoperative period in the comments to this article.

Vitrectomy is an operation to remove the vitreous humor of the eye. This operation belongs to the most complex, fairly young branch of eye microsurgery - vitreoretinal surgery. Thanks to this operation, it is now 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 microscopic collagen fibers intertwined with each other. The cells formed by these fibers contain hyaluronic acid molecules that retain water well. Water makes up 99% of the composition of the vitreous body.

The vitreous body at 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, and behind it is adjacent to the retina. In the area of ​​the dentate line, the vitreous body is quite tightly fused to the limiting membrane of the retina. This is the so-called base of the vitreous.

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, the 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), these changes occur faster.

retinal detachment

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

When blood cells enter the vitreous body after retinal detachment, proliferation processes begin in it, cords and pathological membranes are formed, closely fused to the retina. These membranes tend to contract, which leads to tractional retinal detachment, new micro-ruptures of blood vessels and new proliferative processes. The retina wrinkles, folds form on it, and the torn edge curls up.

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

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

Why do you need to remove the vitreous?

Based on the above, removal of the vitreous body is necessary in case of a 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. Eye injury with hemophthalmos, foreign bodies entering the eye, traumatic retinal detachment.
3. Severe inflammation of the eye membranes (endophthalmitis, uveitis).
4. Extensive retinal detachment.
5. Central retinal detachment with threat of extension to the macula.
6. Severe proliferative retinopathy with the threat of tractional detachment.
7. Dislocation of the lens or intraocular lens (artificial lens) into the vitreous body.
8. Macular hole.

Examinations and preparation for vitrectomy

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

• Ophthalmoscopy is an examination of the structures of the eye through the pupil. Ophthalmoscopy can be difficult with severe injuries, with corneal opacification, with cataracts, with hemophthalmos and severe opacification of the vitreous body. In such cases, the study of light and color perception provides 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 and the anatomical relationship of intraocular structures. B-scan allows you to see retinal detachment and fibrosis of the vitreous body.
• CT eye.
• Electrophysiological study of the retina (EPI). Registration of potentials from receptors makes it possible to judge the functional state of the retina.

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

With accompanying chronic diseases inspection by relevant 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 to maximize compensation of blood glucose levels.

In some pathologies of the light-conducting systems of the eye, vitrectomy is difficult. For example, if there is significant opacification of the cornea or lens, it is possible to undergo cataract removal or keratoplasty first. Phacoemulsification (removal of the clouded lens) with implantation of an artificial lens can also be performed simultaneously with vitreoretinal surgery.

For glaucoma, instillation of solutions that reduce intraocular pressure, as well as oral administration of diacarb, are prescribed.

It is also very important to achieve a stable reduction blood pressure to normal numbers.

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

Vitrectomy is contraindicated:

1. In severe general condition of the patient.
2. Blood clotting disorders.
3. Acute infectious diseases.
4. Confirmed optic nerve atrophy (surgery will have no effect).
5. The tumor nature of retinal pathology.

In some cases, 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). For proliferative retinopathy, posterior vitrectomy with excision of epiretinal cords and membranes is most often performed.

Equipment for vitrectomy surgery

Vitrectomy is a type of high-tech medical care. To carry it out, 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 there is a horseshoe-shaped table for positioning the surgeon's hands. The surgeon operates while sitting on a comfortable chair, with his hands 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 leg he controls the pedal of the microscope (adjusting the magnification), the other leg controls the pedal of the vitreotome.

A vitreotome is a microscopic instrument for dissecting the vitreous and its aspiration, as well as blood clots, fibrinous membranes, and foreign bodies. The vitreotome has the form of a tube with a cutting tip and an opening for suction and irrigation.

Various contact lenses are used to improve viewing through a microscope.

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

Vitreous substitutes

Micro-ophthalmic surgeons are equipped with special substances that are injected into the cavity of the eyeball after removal of the altered vitreous body. Filling the cavity is necessary to maintain normal intraocular pressure, as well as to tamponade the retina after retinal detachment.

Used for these purposes:

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

Saline solutions and gases do not require surgery to remove them; after some time they are absorbed and replaced by intraocular fluid.

Perfluoroorganic liquid is inert, almost like ordinary water, but has a higher molecular weight. Thanks to this property, it acts like a press on the retinal area.

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 resolve on its own, and its removal requires repeated surgery.

Sometimes a longer tamponade of the eyeball is required, then silicone oil is used. It is quite indifferent to the ocular structures; after administration, the eye begins to see it 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 expected time of surgery, the general condition of the patient, the presence of contraindications, etc. Depending on the scope of the operation, vitrectomy can last from 30 minutes to 2-3 hours.

During a long operation, 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 if there are contraindications to general anesthesia, local anesthesia is performed:

• Intramuscular premedication with a sedative.
• Retrobulbar administration local anesthetic 30-40 minutes before surgery.
• A mixture of fentanyl and midazolam (neuroleptanalgesia) is periodically administered throughout the operation.

Progress of the operation

After anesthesia, the operation begins directly. The eyelids are fixed with eyelid dilators, and the surgical field is covered with sterile napkins. Main stages of vitrectomy:

Video: vitrectomy - treatment of retinal detachment

Microinvasive vitrectomy

The most modern method of vitrectomy is the 25G method. This technique uses instruments with a diameter of 0.56 mm. This ensures a low-traumatic operation and there is no need for sutures.

No incisions are made; access to the eyeball is carried out using punctures. Through them, ports for instruments are introduced into the eye cavity: an illuminator, an irrigator and for 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 the ports are removed, the holes from them are self-sealed and no stitches are required.

Microinvasive techniques expand the indications for vitrectomy and allow it to be performed in patients previously considered hopeless. Minimally invasive vitrectomy can be performed on an outpatient basis - the patient can be sent home a few hours after the operation.

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 medical supervision for a week. With the microinvasive technique, the operation can be performed on an outpatient basis.

The pressure bandage can be removed after a day. For several days you will need to attach a curtain bandage over your eye to protect it from dust, dirt and bright light. The sensation may include pain, 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 exercise, head tilts.
• Do not rub your eye or put pressure on it.
• Do not visit the bathhouse, sauna, do not approach open fire and other sources of intense heat.
• Wear sunglasses.
• Avoid getting water or detergents(soap, shampoo).
• When introducing the gas mixture, maintain a certain head position for several days, do not fly on airplanes, and do not climb high into the mountains.
• When introducing “heavy water”, do not sleep on your stomach or bend over.
• Use anti-inflammatory and antibacterial drops prescribed by your doctor. Drops are prescribed for several weeks in a decreasing pattern.

Vision does not recover immediately after surgery. According to reviews from patients who have undergone surgery, immediately after the procedure a veil is felt in the eyes, and when filled with gas, blackness is felt. Possible double vision and distortion of lines. Within 1-2 weeks, the “fog” usually dissipates and vision gradually returns.

The time frame for vision restoration varies from patient to patient, ranging from several weeks to six months. They will last longer in patients with myopia, with diabetes mellitus, 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 vision restoration 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 capsule of the lens.
3. Increased intraocular pressure.
4. Development of cataracts.
5. Iridocyclitis, uveitis.
6. Blocking the anterior chamber with silicone.
7. Cloudiness of the cornea.
8. Emulsification and clouding of silicone.
9. Recurrence of retinal detachment.

Cost of the operation

Vitrectomy surgery is a type of high-tech medical care. In each region there are quotas for providing such medical care free of charge.

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