Retina Surgery

The retinal procedures can be divided into diagnostic, laser and intravitreal injections.

Diabetic Retinopathy:

Both adult onset and juvenile onset diabetic patients can, in time, develop diabetic retinopathy. Adult onset patients in general have more problems with macular edema and juvenile onset patients in general have more problems with proliferative disease. Diabetes is the leading cause of blindness in Americans under age 65 (Macular Degeneration is the leading cause for those over age 65). It is recommended that diabetic patients have a dilated fundus exam every year regardless of symptoms, in order to treat people before they start to have irreversible visual loss.

If your doctor sees new blood vessels (proliferative disease), thickening (macular edema), narrowed blood vessels (ischemia) or otherwise suspects that that you may be having problems he will order a fluorescein angiogram (FA) and/or optical coherence tomography (OCT). The FA can determine if there is poor blood flow or rogue blood vessels - these both require peripheral (panretina) laser treatment. While the FA also can determine leakage in the center (the macula) the OCT is better suited to determine whether you have fluid within or even beneath the retina. Depending upon the location of the leakage and the retinal central thickness your doctor will decide whether laser to the macula (around the center), intravitreal medication injection, or both, is indicated.

Laser is done in the office. Macular laser is not painful and only takes about 5 minutes while panretinal laser may hurt somewhat and takes about 10-15 minutes. More than one laser procedure may need to be done depending upon the severity of disease and the response to laser in the affected eye. The most common side effect of laser, permanent loss of peripheral and night vision, is most pronounced after panretinal laser.

Intravitreal injection of steroids or Avastin is used predominantly to reduce the retinal edema (fluid and swelling), thereby improving vision in many cases. Injections are done in the office under topical (eye drop) anesthesia and only take a few seconds once the eye has been cleaned with betadine and antibiotic drops. The needle does cause some pain that usually lasts only a few seconds. Steroids can induce glaucoma and severe inflammation in some patients; these side effects are rarely seen with Avastin, which is why Avastin is more commonly used. These injections may be repeated depending on the amount of residual fluid and the patient's vision. Other uncommon complications from intravitreal injections include retinal detachment and intraocular infection (endophthalmitis).

A few patients with particularly severe diabetic retinopathy will develop bleeding into the vitreous and even scar tissue that can cause the retina to become detached. Panretinal laser is done to prevent these complications. The treatment for bleeding and tractional retinal detachment is vitrectomy surgery. If a patient only has blood to be removed the prognosis is far superior to the patient who has to have adherent membranes removed from the surface of the retina.

Vitrectomy

Vitrectomy is a major surgery that needs to be done either in an ambulatory surgery center or a hospital. It is indicated for many conditions including vitreous hemorrhage, macular pucker (also called epiretinal membrane), macular hole, severe uveitis, complications of cataract surgery, retinal detachment and ocular trauma. Sometimes it is done along with a scleral buckle.

Your doctor will discuss the risks and benefits of your particular surgery and the surgical scheduler will coordinate the timing of surgery and schedule a history and physical as well as medical clearance, if necessary. Vitrectomy is usually done with a local anesthetic injection given behind the eye (retrobulbar block) in combination with heavy sedation, also called MAC ("Monitored Anesthesia Care"). Although the surgery time varies depending upon the condition, most vitrectomies take about an hour. The surgery consists of making three small incisions in the sclera (the white part of the eye) and then correcting the pathology inside the eye. Newer technology has enabled doctors to perform sutureless surgery. Not only does this reduce the surgical time but it is also less uncomfortable in the postoperative period due to the smaller incisions and lack of sutures. You will need to take antibiotic, steroid and dilating drops starting the day after surgery; the antibiotic and dilating drops may be stopped within 2 weeks, while the steroid will be continued until the redness and inflammation subside over the next few weeks.

A gas bubble may be used to replace the vitreous in certain conditions such as macular hole and retinal detachment. Face down positioning to allow the gas to exert pressure against the retina will be necessary for several days. Patients with gas in the eye may not fly for at least 2 weeks. In other cases such as recurrent diabetic hemorrhage and complex retinal detachment silicone oil is used to replace the vitreous.

Scleral Buckle Surgery

Scleral buckles are indicated for retinal detachments caused by peripheral retinal tears. For the most part scleral buckling by itself is done in myopic (nearsighted) patients, younger patients, and patients who have not had cataract surgery. In some cases, especially if the patient has had previous cataract surgery, the buckle surgery is done in conjunction with a vitrectomy. If the detachment is small enough and located in the upper half of the retina it may be amenable to a less invasive procedure consisting of a simple injection of a gas bubble (pneumatic retinopexy); only a small percentage of patients can be safely repaired with this procedure.

Retinal detachments occur as a result of a tear in the retina through which liquified vitreous proceeds to cause a bubble of subretinal fluid that the patient often reports as a" shadow" or "curtain." Risks include a family history of retinal detachment, nearsightedness, previous cataract surgery and a history of retinal detachment in the opposite eye.

Surgery will be done in an ambulatory surgery center or hospital. The surgery can be done either under general anesthesia or under heavy sedation with a local anesthetic injection behind the eye. When there is an area of weakness or a tear that has not yet become detached in the opposite eye, a laser is applied to the non-detached eye in order to prevent a future detachment.

The scleral buckle, which is actually a silicone band that encircles the eyeball, is sutured to the white part of the eye (the sclera) behind the extraocular muscles. Often a hole is made in the sclera to drain the fluid and allow the tear to settle better over the indenting buckle. In order to restore the pressure in the eye and also in order to push the retina against the buckle, a small gas bubble is injected into the vitreous. Your doctor will explain the importance of post-operative head positioning in order to locate the gas bubble over the tear. The gas goes away on its own but the silicone buckle willl remain permanently secured to the eye. Even if the retina successfully reattaches with one surgery other complications such as double vision and macular pucker might require another operation. Also, in spite of successful reattachment the vision may never return to normal. Even some patients who seee 20/20 can have permanent visual distortions.

Your eye will be patched overnight and eye drops will be started the next day. The antibiotic and dilating drop can be stopped in about 2 weeks but the steroid drop may need to be continued for about 6 weeks, as the eye is typically very inflamed and red following surgery.

Diagnostic Procedures are:

• Digital Fundus Photography
• Digital Fluorescein Angiography
• Optical Coherence Tomography
• Ocular Ultrasonography (i.e. B-scan)

Laser Procedures are for:

• Diabetic Macular Edema
• Proliferative Diabetic Retinopathy
• VenousOcclusive Diseases
• Retinal Tears and Lattice Degeneration
• Exudative Macular Degeneration

Intravitreal Injections are:

• Intravitreal drug injections for Exudative Macular Degeneration
• Intravitreal drug injections for Diabetic Macular Edema
• Intravitreal drug injections for Venous Occlusive Disease