The Medical Practice of Ray M. Balyeat, MD: Limited to Medical & Surgical Management
of Diseases of the Macula, Retina & Vitreous

Vitrectomy is the surgical removal of the vitreous gel from the middle of the eye. It
may be done when there is a retinal detachment, as removing the vitreous gel may
provide the surgeon with enhanced ability to manipulate the detached retina. The
vitreous gel may also be removed if blood in the vitreous gel (vitreous hemorrhage)
does not clear on its own.  Other common indications for vitrectomy include
management of macular holes, removal of epimacular membranes ("macular
puckers") and dislocated lens fragments following complicated cataract surgery.

During a vitrectomy, the surgeon inserts small instruments (20, 23 or 25 gauge) into
the eye, cuts the vitreous gel into tiny portions at high speed which are then
removed by suction. After removing the vitreous gel, the surgeon may treat the retina
with a laser (photocoagulation), cut or remove fibrous or scar tissue from the retina,
flatten areas where the retina has become detached, or repair tears or holes in the
retina or macula.









At the end of the surgery, silicone oil or a gas (sulfur hexafluoride (SF6)or
perfluoropropane (C3F8)) is injected into the eye as a temporary vitreous substitute.  
These agents temporarily prevent clear aqueous fluid (which is naturally formed
inside the eye) from gaining access to retinal tears and holes which could lead to
recurrent retinal detachment.  Silicone oil may be removed weeks to months later
(sometimes never) in the operating room; gases resorb ("evaporate") by themselves
over a period of two to six weeks.

Vitrectomy is usually done by an ophthalmologist (vitreoretinal surgeon) who has
special training in treating problems of the retina.



Vitrectomy may require an overnight hospital stay, but it may sometimes be done as
outpatient surgery. The surgery lasts 2 to 4 hours. Vitrectomy can be done with local
or general anesthesia.  After uncomplicated vitrectomy, pain is typically very mild to
moderately severe and is usually well controlled with the short term use of non-
narcotic and/or narcotic pain relieving medications.  The eye may be puffy and blood-
shot in appearance; a mucous and/or blood tinged discharge is common.  These
changes usually resolve fairly rapidly over a two to four week time frame although it
may take several months or more for an eye to become "white" again.  Eyelid
swelling and droop often accompany these changes to  variable degrees and mostly
resolve during the first two to four weeks after surgery.  Rarely, eyelid repositioning
surgery may be required to correct a droopy eyelid.



Vitrectomy has been shown to greatly improve visual acuity in many people who
have severe vitreous hemorrhage that has not cleared on its own. A vitrectomy can
decrease the risk of severe bleeding in people who have retinal vascular problems
which predispose them to this problem.  Most commonly, such individuals are
diabetics with new retinal blood vessel growth (retinal neovascularization) known as
proliferative diabetic retinopathy.  Less commonly, vitreous hemorrhage can
complicate retinal tears and retinal tears with retinal detachment.  Vitreous
hemorrhage may also occur in the eyes of patients with partial loss of the retinal
blood supply (retinal vein occlusion or obstruction) and secondary retinal
neovascularization.  

In general, vitrectomy can restore some vision lost as a result of retinal detachment
and may help prevent further detachment. But the results tend to be better when the
detachment has not affected the center of the retina (macula) and the central vision it
provides.














Vitrectomy may cause elevated pressure inside the eye (intraocular pressure, or
IOP), especially in people who have glaucoma.  This problem is usually temporary
and controlled with the use of additional glaucoma medications.  Vitrectomy has a 1
in 1500 risk of inciting an intraocular ("inside the eye") infection which although
potentially a devastating complication is less than the often stated risk of infection
from cataract surgery (about 1 in 1000).  Such infections may be controlled with
antibiotic injections.  Vitrectomy when performed on patients older than 50 years of
age promotes more rapid cataract formation (lens clouding).

There are several other serious, vision-threatening risks associated with vitrectomy.
These include:
  • bleeding (or recurrent bleeding) into the vitreous cavity and anterior (front)
    chamber of the eye
  • retinal detachment (or recurrent retinal detachment)
  • swelling of the clear "watch crystal" front structure of the eye (corneal edema)



One of the main uses of vitrectomy is to remove blood from the middle of the eye, a
condition called vitreous hemorrhage. When vitreous hemorrhage occurs, some
doctors may recommend waiting several months to see whether the vitreous gel will
clear on its own before performing surgery that can have serious complications.

But if the hemorrhage is causing severe vision loss or is preventing treatment of
severe retinal disease, surgery may be performed sooner rather than later. Some
studies have shown that long-term results are better with early vitrectomy.

    Patient who undergo vitrectomy for management of
    retinal detachment or macular hole may be
    instructed to maintain certain head positions ("face
    down", "right ear down", or "left ear down") at night
    when they attempt to sleep and through major
    portions of the day when they are awake in order to
    position the injected gas bubbles over the macula
    (central retina) or peripheral retina.  Such head
    positioning aids in closure of macular holes and
    prevention of early post-operative retinal re-
    detachment while laser treatment around retinal
    tears is "healing".  The comfort of face down
    positioning may be greatly enhanced by use of
    equipment that can be leased from durable medical
    goods vendors at a reasonable charge.
What To Expect After Surgery
What To Think About
Risks
Vitrectomy
A.  fiberoptic light pipe
and forceps inserted
into the vitreous
cavity during repair of
a retinal detachment
B.  removing an epiretinal
membrane ("macular
pucker")
Dr. Balyeat performs a
vitrectomy in the St. John
Medical Center Outpatient
Surgery Center.
Gas bubble in vitreous cavity floating
up toward the optic nervehead and
macula (the eye is positioned with the
pupil "looking" down).
bubble