|Year : 1981 | Volume
| Issue : 4 | Page : 359-362
Chandran Abraham, SS Badrinath
Sankara Nethralaya, Medical Research Foundation, Madras, India
Sankara Nethralaya; Medical Research foundation, 18, College Road, Madras
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Abraham C, Badrinath S S. Vitrectomy. Indian J Ophthalmol 1981;29:359-62
This is a presentation of 61 patients who underwent vitreous surgery and surgery of the lens, iris and membranes in the pupillary area using the Peyman type vitreophage with the Vijaya Sukut vitrectomy unit. The procedure, the results obtained, the complications encountered and the need for such a procedure will be discussed.
| Material and methods|| |
47 of the patients were males and 14 females. The youngest patient was 2 years old and the oldest 76 years of age. Eales disease and diabetic retinopathy were the most common causes of vitreous haemorrhage among the 24 patients who underwent vitrectomy. The haemorrhage had existed for more than 6 months in 14 patients, and less than 6 months in 8. 10 of the fellow-eyes with vitreous haemorrhage were normal ; 4 had Eales' disease and 4 had vitreous haemorrhage. 2fpatients had diabetic retinopathy and 2 a detached retina. 4 patients with endophthalmitis and 2 with hyperplastic primary vitreous were also subjected to this procedure [Table - 1]. Anterior segment surgery comprised of lensectomies, membranectomies, iridectomies and anterior vitrectomies and anterior vitrectomies in different combinations. [Table - 2].
Pre-operative examination included a careful history, recording of visual acuity, and intra ocular tension. Slit lamp examination and Binocular indirect ophthalmnoscopy completed the work up. Scleral depression was avoided. Surgery was performed under local anaesthesia after a pre-medication suited to the patients' needs. Maximum pupillary dilatation is essential. After the initial preparation and draping of the patient, the lids were kept apart by sutures. The four recti were tagged through the conjunctiva in order to control the movement of the globe. The conjunctiva was incised forming a `T' at the limbus in the chosen quadrant (usually the temporal for the right eye and superior nasal for the left). The sclera was carefully incised concentric to and about 4.5 mm. from the limbus. Mattress sutures were placed in the lips of the scleral incision. For posterior segment surgery, a Graefe knife was thrust in to the pars plana, the tip being directed towards the centre of the globe avoiding damage to the lens in phakic eyes and to the retina.
The vitreophage (connected to the Vijaya Sukut unit) was then intoduced into the vitreous cavity through the tract created until the tip was seen in the centre of the vitreous cavity. The sutures at the scleral wound were temporarily knotted to hold the instrument snugly to the globe. The cutter and suction were then worked on and bits of cut vitreous removed. The vitreous cavity was infused with Saline containing Garamycin to replace the tissue removed and maintain the intraocular pressure. The tip of the instrument was always kept visualised. When the central part of the vitreous had been cleared, the tip was maneuvered posteriorly to work in the mid and posterior vitreous cavity. Indirect ophthalmoscopy was performed at this stage and all further manipulation carried out under ophthalmoscopic control. The instrument was withdrawn when the region of the posterior pole and the region up to the equator was cleared, the assistant simultaneously pulling on the suture in the scleral wound. The retina was evaluated and retinal breaks looked for. The conjunctival wound was then closed.
While performing lensectomies, the knife was plunged into the lens through its equator. The fragmentation of the lens was commenced in the central part and great care taken to avoid the posterior capsule. When all the lens matter was removed, the anterior capsule was cut.
17 patients have been followed up for more than 6 months; the rest have had a follow up of less than 6 months.
| Observations|| |
44 patients had a good clearing of the media permitting a clear view of the fundus. The clarity was only moderate in 8 patients. This helped us in employing further modalities of treatment in 8 cases. 4 patients had a scleral buckling, 3 had photocoagulation and 1 had cryo therapy [Table - 3].
The visual acuity improved in 30 patients and deteriorated in 11. The improvement was substantial in 22 patients - where the final visual acuity was 6/60 or more from just perception of hand movements close to face. In the remaining 8, when visual acuity was less than 6/60, 5 had a vision (of about 1/60 to 3/60) with which they could look after themselves. [Table - 4] Better visual results could not be achieved because of the presence of a detached retina in (13), non clearing of media in 6, cataracts in 3, and other retinal changes in 3. [Table - 5].
Intraocular bleeding occurred in 10 patients during the procedure. This was not of much significance as it either stopped spontaneously or after raising the intraocular pressure. 2 retinal breaks were suspected to be iatrogenic. The loss of vitreous in 2 patients and injury to the iris in 2 were not of any consequence. However, the injury to the lens in 5 was significant. Important postoperative complications were panophthalmitis in one and hyphaema and glaucoma in another. The retinal detachment which occurred in one was successfully buckled. [Table - 6].
| Discussion|| |
Though the procedure of vitrectomy requires considerable skill on the part of the surgeon, good instrumentation and carries complications, it definitely has an important place in the treatment of vitreous haemorrhage because of i) absence of any other mode of therapy to relieve the condition, ii) the good likelihood in regaining a fair amount of visual acuity and iii) the possibility of applying other modalities of therapy if need be. Almost all the patients had a visual acuity of only hand movements close to face or light perception. An improvement in vision to even 3/60 will enable a person to move around by himself. Even if grave complications occur, the patient has very little to lose. Performing anterior segment surgery though the pars plana appears to give good results as the problems of iris tissue, capsular remnants and worst of all vitreous adhering to the classical sclero-corneal section do not arise. If the vitreous is distrubed, an anterior vitrectomy can be easily performed with the very same instrument.
8 of our patients were subject to vitrectomy though the duration of haemorrhage was less than 6 months. Most of the pioneers in this field emphasize the fact that one should wait for atleast 6 months before performing the surgery and that the retinal pathology should have 'burntout'. It is very difficult to say when the disease process is really queiscent in an eye where the retina is obscured by a vitreous haemorrhage. Moreover, as the duration increases, the greater the chance for fibro vascular membranes to develop, and the greater the chances for a traction retinal detachment to occur. Early interference will definitely be beneficial in these cases. This has been aptly pointed out by Rodman Irvine and Robert Stone. Electro retinography and ultra sonography will be two important tools in helping us to choose patients who have a greater chance for having their visual acuity improved.
Only 3 eyes out of 26 with vitreous haemorrhage needed photocoagulation after vitrectomy. The fundi in the remaining cases showed no area from which the blood occurred. Whether this denotes a complete dying out of the disease process is a question to be answered.
| Summary|| |
The procedure of vitrectomies and surgery of the lens, iris and pupillary membranes through the pars plana on 61 patients followed up for a period of less than 3 months to more than a year the visual results obtained, the complications encountered and the need for such a procedure are discussed.
| References|| |
Asberg, Thomas - Controversy in ophthalmology, 1977, Pars plana vitrectomy Page 478.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]