Vitreoretinal Surgery

Vitreoretinal Surgery - Scope & Scalpels

• Core Principle: Addresses posterior segment pathologies, typically via a pars plana approach.
• Primary Indications (Scope):
  • Retinal Detachment (RD): Rhegmatogenous (RRD), complex Tractional (TRD).
  • Vitreous Hemorrhage (non-clearing).
  • Macular Pathologies: Macular Hole (MH), Vitreomacular Traction (VMT), Epiretinal Membrane (ERM).
  • Diabetic Retinopathy: Complications like tractional RD, dense vitreous hemorrhage.
  • Infectious/Inflammatory: Endophthalmitis (for diagnostic biopsy & therapeutic vitrectomy).
  • Trauma: Intraocular Foreign Body (IOFB) removal, management of posterior segment trauma.
• Surgical Goals: Remove vitreous opacities, relieve vitreoretinal traction, repair retinal breaks, and facilitate retinal reattachment.
• Key Instruments ("Scalpels" & Tools):
  • Vitrector (high-speed vitreous cutter).
  • Endoilluminator (fiber-optic light source).
  • Laser probes (for endophotocoagulation).
  • Micro-instruments: forceps, scissors, picks, spatulas.

⭐ Rhegmatogenous retinal detachment (RRD) is the most common indication for pars plana vitrectomy (PPV).

Pars Plana Vitrectomy - The Core Cut

Pars Plana Vitrectomy (PPV) is a key surgical technique to access and treat posterior segment pathologies.

• Principle: Controlled removal of vitreous gel to access retina and relieve traction.
• Sclerotomies: Typically 3 ports placed via pars plana (3-4 mm posterior to limbus).
  • Infusion: Maintains intraocular pressure (IOP).
  • Illumination: Provides light.
  • Instrumentation: Vitreous cutter, forceps, laser.
• Gauges: From 20G (sutured) to micro-incision 23G, 25G, 27G (often sutureless).
• Core Vitrectomy: Initial removal of central vitreous.
• Peripheral Vitrectomy: Careful removal near vitreous base.

⭐ Smaller gauge vitrectomy (e.g., 25G, 27G) allows for sutureless surgery, reduced inflammation, and faster visual recovery.

Intraocular Tamponades - Retina's Props

Used to provide internal support and apposition of the retina post-surgery.

⭐ Patients with intraocular gas tamponade must avoid air travel and high altitudes due to risk of gas expansion.

Vitreoretinal Surgery - Post-Op Perils

• Increased Intraocular Pressure (IOP): Common early; manage medically/surgically.
• Cataract Formation: Especially nuclear sclerosis in phakic eyes.
• Endophthalmitis: Rare (~0.05% incidence); requires prompt treatment.
• Retinal Detachment (Recurrent/New): Due to new breaks or PVR.
• Vitreous Hemorrhage: May require observation or washout.
• Corneal Edema: Often transient; can be due to prolonged surgery or high IOP.
• Cystoid Macular Edema (CME): Can cause ↓ vision; treat with NSAIDs/steroids.
• Proliferative Vitreoretinopathy (PVR): Leading cause of surgical failure.
• Hypotony: Low IOP; risk of choroidal detachment, phthisis bulbi.

⭐ Nuclear sclerotic cataract is the most common long-term complication following vitrectomy in phakic eyes, often developing within 2 years post-surgery.

High‑Yield Points - ⚡ Biggest Takeaways

• Pars Plana Vitrectomy (PPV) is key for retinal detachment (RD), vitreous hemorrhage, macular holes, and endophthalmitis.
• Intraocular tamponades like SF6, C3F8 gas, and silicone oil are vital for retinal reattachment.
• Strict postoperative positioning is crucial with gas tamponades.
• Cataract formation is the most common PPV complication; others include ↑IOP and redetachment.
• Scleral buckling is an option for young, phakic RDs; pneumatic retinopexy for superior RDs.