Subtotal closed vitrectomy. Restoring vision after vitrectomy

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All recommendations are indicative in nature and are not applicable without consulting a doctor.

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 molecules hyaluronic acid, which 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 jagged line vitreous 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) or 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 the receptors that perceive 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, in case of significant opacities of the cornea or lens, it is possible to perform 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 in blood pressure to normal levels.

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 atrophy optic nerve(the operation 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, general condition patient, 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 of 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

Most modern method Vitrectomy is a method in 25G format. 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 a bathhouse, sauna, do not get close to open fire or other sources of intense heat.
• Wear sunglasses.
• Do not allow water or detergents (soap, shampoo) to get into your eyes.
• 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 a 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, diabetes mellitus, and 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.

In addition, vitrectomy may be performed to eliminate scar tissue in patients with gross opacities or repeated vitreous hemorrhages that do not resolve on their own. To assess the possibility of spontaneous resorption of vitreous hemorrhages, experts usually recommend monitoring the dynamics of hemorrhage regression for six months to a year. In cases where hemorrhage threatens irreversible vision loss, immediate surgery is indicated.

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

How is the operation performed?

Usually, before performing a vitrectomy, the patient is routinely 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 relieve pain during surgery. The duration of the operation to remove the vitreous body is usually 2 – 3 hours.

During the operation, the doctor removes the required amount of vitreous tissue through punctures, after which he carries out the required treatment: he burns 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 procedure in patients with impaired transparency of the vitreous body, developing as a result of hemorrhages or proliferation connective tissue, as well as with neovascularization of the iris. Microinvasive surgery allows you to stop the process of tractional retinal detachment and partially restore lost vision.

At the same time, the procedure for removing the vitreous can be accompanied by various complications, including increased intraocular pressure (especially in patients with glaucoma), severe 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 vision loss.

How is removed vitreous body replaced?

After removal, a special component is introduced into the resulting 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 replaced over time by the eye's own intraocular fluid, so their replacement is not required. PFOS can be used for a period of up to 10 days; a vial of silicone oil can be left in the orbital cavity for up to several years.

To whom and why is vitrectomy performed?

When performing a vitrectomy, the doctor may pursue several goals:

eliminating tissue tension and preventing further detachment of the retina in the area;

providing access in cases requiring surgical intervention in the retinal area;

restoration of vision after heavy intraocular hemorrhages or hemorrhages into the vitreous body, which do not tend to resolve on their own;

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

Prognosis and recovery time after surgery

The prognosis and timing of vision restoration after vitrectomy depend on several factors: the extent of the lesion, the condition of the retina, and the type of vitreous substitute. In case of severe 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 scope of the 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 awaits them or how they cope with the consequences of the operation.

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 of the 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 this, eye plastic surgery 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 size, and 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 does not show the desired result, although this happens in rare cases, surgical intervention is resorted to. In most cases, the operation restores vision and has a positive effect on 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, oncological diseases, 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 of it is removed, and a mixture of gases or silicone oil is injected into the eyeball 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.
• Almost complete lack of 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.

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 pathologies of the retinal region and vitreous body. 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 formation is still a subject of interest to 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.

Along the posterior 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 area of ​​the optic nerve head and macula, peripheral parts 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 trauma 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, 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 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 of the 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 right 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

After positioning on the operating table, the patient is subjected to standard anesthetic cardiorespiratory monitoring: ECG, arterial pressure, respiratory rate and blood oxygen saturation (saturation). A catheter provides peripheral venous access for drug administration.

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 a local anesthetic in the form 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 the 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%).
• Attachment of 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 consumables. 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

The surgical operation during which the vitreous humor is removed is called a vitrectomy of the eye. There are several types of surgery, each with its own indications and objectives. With the help of vitrectomy, it will be possible to completely restore visual function, thanks to which the patient’s life will become the same, while maintaining working capacity. To prevent complications after surgery, it is important to complete the entire course of rehabilitation, strictly following the advice and recommendations of the doctor.

A condition in which a person lacks a gelatinous transparent body is called avitria.

Indications, contraindications

Removal of the vitreous is required in situations where, for one reason or another, its transparency is impaired, and it is impossible to restore vision using more gentle methods. Indications for vitrectomy are such disorders as:

• hemophthalmos, in which blood clots penetrate the transparent body;
• severe injury to the eyeball;
• retinal detachment;
• advanced, complicated inflammation of the mucous membrane;
• deformation or dislocation of the lens;
• macular holes;
• proliferative retinopathy arising from diabetes mellitus;
• epiretinal fibrosis.

However, the procedure has limitations. The contraindications are:

• dysfunction of hematopoiesis;
• infectious disease in the acute period;
• progressive optic atrophy;
• malignant tumor of the eye or brain;
• serious condition of the patient.

Types of surgery

Considering the volume of vitreous to be removed, vitrectomy can be of the following types:

• Total. During the procedure, the transparent body is completely removed.
• Subtotal vitrectomy. The operation involves removing part of the affected gelatinous substance.

In turn, the subtotal type of surgery can be of the following types:

• The back is closed. It is used for damage to the posterior segment of the body of the eye.
• Anterior vitrectomy. It is carried out in cases where the vitreous substance penetrates through the pupil into the anterior segment of the chamber of the organ of vision.

Thanks to the development of ophthalmological surgery, new, more improved techniques are being created that provide low trauma and rapid postoperative recovery. These methods include microinvasive vitrectomy. The essence of the procedure is to provide access to eyeball through micropunctures. Special instruments are inserted into these punctures, after which the necessary manipulations are carried out. At the end of the procedure, no stitches are required and the patient can return home the same day.

How is the preparation going?

Since vitrectomy is a planned operation, it is important to properly prepare for it in order to avoid postoperative complications. To exclude contraindications and restrictions, the patient is given a referral to undergo a series of diagnostic procedures, which includes:

• ophthalmoscopy;
• biomicroscopy;
• electrophysiological examination of the retina;
• Ultrasound, CT or MRI of the eyes.

The patient will also need to undergo a general clinical analysis of urine and blood, biochemistry, undergo a coagulogram, fluorography, and electrocardiography. The day before the operation, the doctor instills eye drops with atropine, which will ensure pupil dilation. For glaucoma, drugs that reduce intraocular pressure must be used, and, if necessary, medications, normalizing blood pressure.

Selection of anesthesia

The type of anesthesia used depends on the extent of the surgery and, accordingly, the duration of the vitrectomy. If the operation is total, preference is given to general anesthesia. When vitreous replacement lasts no longer than 1 hour, use local anesthesia, in which a sedative is injected intramuscularly and a local anesthetic is instilled directly into the eye.

Progress of surgery

The patient is placed on his back, and when the anesthesia takes effect, the eyelids are fixed with a special dilator. The surgeon makes 3 punctures in the right places, where surgical instruments are inserted. First, manipulations are performed on the anterior parts of the organ of vision, slowly moving to the rear areas. To prevent infection, the mucous membrane is constantly washed with an antiseptic.

Next, the damaged vitreous is removed, and in its place a substitute is installed in the form of a sterile saline solution, sterile air with gas, or a specific liquid based on silicone oil. Silicone implants are often used, since after its introduction, visual function is restored almost immediately. Silicone is left in the eye cavity for 4-6 months, sometimes it lasts for a year. After all the manipulations, sutures are placed on the eye shell, and the organ itself is protected from negative external influences with a sterile bandage.

Recovery

After the vitreous substance is removed and silicone, saline solution or gas is installed in its place, restorative rehabilitation will be required, thanks to which it will be possible to quickly return the visual organs to normal functionality. After vitrectomy, the patient needs to visit an ophthalmologist every other day for a week, who will monitor the healing process of the eye.

IN postoperative period appointed drug treatment, which includes the following groups of drugs:

• antibiotics;
• antiseptics;
• painkillers;
• moisturizing;
• strengthening.

It is important to protect the operated organ from ultraviolet rays, dust and wind. Therefore, going outside without sunglasses is prohibited. And also during the recovery period it is worth limiting physical activity, the length of time spent at the computer and TV. You need to be careful during water procedures and ensure that detergents and hygiene products do not come into contact with the mucous membranes of the eyes. For the entire period of rehabilitation, the patient is given sick leave disability. Sometimes membrane peeling is prescribed after vitrectomy. The combination of these manipulations improves the prognosis for the full restoration of visual function.