VITRECTOMY 
( Trans Pars Plana Vitrectomy )


Removal of vitreous gel (Vitrectomy) is done to repair many of the retinal disorders, which were previously considered inoperable. The procedure is done through three tiny incisions in the eye for three separate instruments. These incisions are placed in the pars plana of the eye, which is located between the iris and retina. Entering the eye through this location avoids damage to the retina and the crystalline lens.

The instruments, which pass through these incisions, include a light pipe, an infusion port, and the vitreous cutting device. The light pipe is the high-intensity flashlight and is used to illuminate inside of the eye. The infusion port is required to replace fluid in the eye and maintain proper pressure within the eye. The vitrector, or cutting device, works like a tiny guillotine, with an oscillating microscopic cutter to remove the vitreous gel in a slow and controlled fashion. Operating microscope and contact lenses allow a clear view of the vitreous cavity and retina at various magnifications. The procedure is performed in an operating room under local or general anesthesia. 

Trans pars plana vitrectomy (TPPV) is used to treat many retinal disorders such as:

Proliferative diabetic retinopathy (including vitreous hemorrhage) 
Macular hole 
Epiretinal membrane (macular pucker) 
Complicated, tractional or recurrent retinal detachment 
Intraocular infections (endophthalmitis)
Intraocular foreign body 
Retained lens material or dislocated lens implants following cataract surgery
Giant retinal tears 
Age related macular degeneration
Eye injuries
Uveitis 

During vitrectomy, the retinal surgeon may use a variety of special techniques to achieve the desired results: 

Endodrainage: In this an existing retinal hole or a new small hole made in retina (retinotomy) is used to drain out the fluid beneath the retina so that the retina gets attached. The retinal hole is closed by endolaser or outside using trans-scleral cryo.

Intraocular gases: Sterile air or gases usually either perfluropropane (C3F8) or sulfur hexafluoride (SF6)) mixed with sterile air have been used in vitreous surgery. Air remains in the eye for a week while gases remain in the eye for extended periods of time (up to two months). The eyes own natural fluid eventually replaces them. Gas is useful for flattening a detached retina and keeping it attached while healing occurs. Gas is also used to close macular holes. It is frequently necessary to maintain a certain head position following surgery when gas is used. Vision in a gas filled eye is usually rather poor until at least 50% of the gas is absorbed. It may cause glare and double vision, especially when it is about halfway reabsorbed 
Complications of intraocular gas: progression of cataract and glaucoma. 
It is unsafe to fly in a plane while gas remains in the eye. 

Silicone oil: It is a clear viscous fluid, which is sometimes used instead of gas to keep the retina attached postoperatively. 

Advantage: 
Long term support of the retina as is required in the repair of very complicated retinal detachments.
Unlike gas, patients are still able to see through clear silicone oil. 

Positioning is less critical with silicone oil, therefore, it may be used in patients unable to position postoperatively (i.e. children).


Disadvantage:

Silicone remains in the eye until it is removed (necessitating a second surgery at a later date). 

Like gas, silicone oil can promote cataracts, cause glaucoma at times, and may damage the cornea but only if in contact.

Perflurocarbon Liquid: It is used to settle the retina on the operation table in complicated cases as giant retinal tears and helps to visualize traction on the retina. This is removed at the end of surgery and retina is supported by gas or silicone oil.

Endolaser (Endophotocoagulation): It is a procedure wherein laser is done by a probe put in the eye during vitreous surgery. It is used to treat retinal tears in retinal detachment and to do panretinal photocoagulation in proliferative retinopathies. 

Microsurgical instruments: As forceps, scissors and pics may be used to manipulate intraocular structures for the removal of scar tissue and foreign bodies. 

Endoscopy: It allows the surgeon to view the inside of the eye on a television monitor while treating intraocular structures. It is a helpful technique when the cornea or lens are cloudy and do not allow a clear view through the operating microscope. It is rarely used however.

Scleral buckling: It is sometimes combined with a vitrectomy procedure to add additional support to the re-attached retina

Lensectomy: It is removal of the eye's crystalline lens during a vitrectomy procedure. This is sometimes performed when there is a cataract which prevents the surgeon from adequately visualizing the internal structures. A lensectomy may also be necessary to gain access to and remove scar tissue during complicated retinal detachment or diabetic retinopathy procedures. The natural lens can be replaced with a clear lens implant at a later date or during the same surgical procedure. Lensectomy is usually performed using high frequency ultrasound (phacoemulsification) similar to routine cataract surgery.

Relaxing retinectomy: Some times the retina fails to settle after removal of all the scar tissue. This is supposed to be due to shrinkage of retina. The retina is then cut so that it gets attached posteriorly leaving a retina free place anteriorly. The procedure is called relaxing retinectomy. 

Risks of surgery:

Infection, 

Bleeding, 
Cataract, 
Glaucoma, 
Retinal detachment. 

Any of these complications can result in severe visual loss or even loss of the eye itself. 

What to Expect after Vitrectomy?

The lack of vitreous does not affect the functioning of the eye. Rate of recovery depends on many factors; however, the preoperative condition for which the vitrectomy is performed is the most important factor determining the rate of recovery as well as the final outcome. Only your eye surgeon can advise you as to what to expect. 




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