Vitrectomy in Turkey

Vitrectomy is an eye surgery in which the gel-like fluid called the “vitreous,” which fills the back cavity of the eye, is removed with microsurgical instruments to treat diseases of the retina. This method, used to repair structural problems that carry a risk of vision loss, is performed by entering the eye with very fine instruments. The main goal of the surgery is to clear bleeding or opacities that block the visual axis and eliminate adhesions that pull on the retina. Removing the vitreous gel, whose natural structure has been disrupted due to various health problems, from the eye helps light reach the retina properly again and supports the preservation of visual function.

What is vitrectomy and why is it performed in the back part of the eye?

The vitreous, which is the gel-like fluid inside the eye, has a very homogeneous and firm structure during youth, but with advancing age it enters a natural process of change. Fluid-filled spaces form in its center and its overall volume decreases. As the gel shrinks, it tends to separate from the retina that lines the inner wall of the eye. In most people, this separation occurs without problems, but sometimes the gel may be more firmly attached to the retina than normal. As the gel attempts to separate, it pulls on the retina like a sheet of paper.

Some of the main factors that may predispose this structural change and separation process to become problematic are as follows:

• Aging process
• High myopia
• Eye trauma
• Diabetes
• Intraocular inflammation

If this pulling results in a retinal tear or if bleeding occurs inside the eye due to conditions such as diabetes, visual quality can decrease significantly. The main purpose of vitrectomy surgery is to remove this altered gel that damages the retina or obstructs vision from inside the eye. After the gel is removed, the eye continues to maintain its shape by filling this space with the natural fluids it produces. In this way, stress on the retina is reduced.

What are sutureless vitrectomy methods and how do they make surgery easier?

In classical posterior eye surgeries performed in the past, wider incisions had to be made in the sclera, the white part of the eye, and these incisions had to be closed one by one with sutures at the end of the surgery. Sutured methods could cause complaints such as stinging, burning, redness, and a foreign body sensation in the eye to last longer during the healing process. However, in modern medicine today, highly advanced sutureless methods called microincisional vitrectomy are widely used.

Some of the main measurements used to indicate the thickness of microsurgical instruments are as follows:

• 23-gauge
• 25-gauge
• 27-gauge

These measurements refer to guide tubes with diameters of fractions of a millimeter, almost resembling a very fine needle tip. During surgery, these very thin tubes called trocars are placed through the conjunctiva (the membrane of the eye) and the scleral layer. The entire surgical procedure is performed through these millimetric tunnels. When the surgery is completed and these tubes are removed, the small tunnels that have been created behave like a self-sealing valve. The absence of sutures helps preserve the natural vascular structure of the eye while making the process of returning to daily life after surgery more comfortable for patients.

How are transparent structures made visible during vitrectomy?

One of the most challenging aspects of this delicate surgery is that transparent structures are arranged one after another. The cortical vitreous gel inside the eye and the thin membranes covering the retina are completely transparent. Like trying to find a transparent gelatin in water, the surgeon needs additional assistance to detect these membranes without damaging the retina.

At this point, special staining techniques that make tissues visible come into play. Certain special molecules injected into the eye adhere to the fibers of the transparent gel like snowflakes. Thanks to these dyes, invisible structures extending to the very back wall of the eye and pulling on the retina become visible. Because the surgeon can clearly see the areas that need to be cleaned, protecting the retinal tissue becomes much easier. If the operated eye also has a cataract problem, cataract surgery and intraocular lens implantation may be combined with vitrectomy in the same session to maximize visual clarity.

In which eye diseases is vitrectomy surgery used?

Vitrectomy surgery is preferred as a primary method in the treatment of many conditions that occur in the back part of the eye, disrupt the structure of the retina, and threaten visual function. The main goal is to clear fluids that block the visual axis, sever adhesions that pull on the tissue, and reposition the detached nerve layer to where it belongs.

The main conditions requiring surgical intervention are as follows:

• Retinal detachment
• Vitreous hemorrhage
• Macular hole
• Epiretinal membrane
• Intraocular infections
• Eye trauma
• Intraocular foreign bodies

Each of these diseases prevents the retina from maintaining its normal function. A microsurgical intervention performed at the right time can play a major role in preserving visual potential.

How does vitrectomy provide a repair process in retinal detachment?

Retinal detachment is the separation of the retina, which lines the inner surface of the eye, from the nourishing tissue beneath it and its movement toward the cavity of the eye. We can think of this condition like wallpaper on a wall becoming wet, swelling, and peeling away from its place. Patients usually experience complaints such as sudden flashes of light in the eye, floating black spots resembling soot, or a black curtain descending over their field of vision.

When the retina becomes detached, it cannot receive proper nourishment and loses its ability to function. During the surgical repair process, all vitreous tissue pulling on the retina is removed. If there are membranes on the retinal surface that have contracted and shortened the tissue, these membranes are gently peeled away from the retina using very fine instruments. Heavy liquids are then introduced into the eye, allowing the elevated retina to slowly settle back into its original position. The areas around the tears are then sealed circumferentially using intraocular laser treatment to secure them. These procedures are performed to allow the retina to regain its former structure and continue detecting light.

For what purpose is vitrectomy used in eye damage caused by advanced diabetes?

Diabetes affects the structure of many blood vessels throughout the body over time, and it also damages the fine vessels in the retinal layer of the eye. In the advanced stages of the disease, when the retina does not receive sufficient nourishment, the eye attempts to form new blood vessels in order to compensate for the lack of oxygen. However, these new vessels are extremely weak and fragile. Even a slight fluctuation in blood pressure can cause them to bleed easily, turning the transparent fluid that fills the eye into a dense layer of blood.

These dense hemorrhages that do not resolve on their own are one of the main conditions requiring vitrectomy surgery. Moreover, the problem is not limited to bleeding alone. Over time, the bleeding vessels turn into thick membrane layers that adhere tightly to the retina. As these thick membranes dry and contract, they begin to pull the retina away from its position. During surgery, the surgeon first clears the blood inside the eye to restore visibility. Then, with the help of microscopic scissors and instruments, these membranes that are tightly attached to the retina are meticulously removed, much like peeling tape from a thin sheet of paper. After the membranes are removed, laser treatment is applied to the affected areas to slow the formation of new bleeding.

How does the treatment process with vitrectomy work for a macular hole?

The macula is the most sensitive point located at the very center of the retina, enabling us to read, recognize faces, distinguish colors, and see fine details. In some cases, usually due to age-related changes, as the vitreous gel contracts it may pull on the very center of this sensitive area and cause a millimetric hole to form. In this condition, people see a dark or blurred spot in the exact center of where they are looking, and sometimes they may perceive straight lines as distorted or wavy.

Since there is no treatment for a macular hole with drops or medication, a surgical approach is preferred. During vitrectomy surgery, the vitreous gel is first removed. Then, a transparent and extremely thin membrane covering the innermost surface of the retina and mechanically preventing the hole from closing is identified. This membrane is gently peeled in a circular manner around the hole using micro-instruments. This peeling procedure not only eliminates the pulling force but also stimulates repair cells within the tissue, triggering the eye’s own self-repair mechanism. These activated cells support the biomechanical closure of the opening by pulling the edges of the hole toward each other.

Which tamponade agents are placed inside the eye after vitrectomy?

After the gel-like structure inside the eye is removed, tamponade agents are injected into the eye to help keep the retina attached to the back wall, prevent fluid from leaking again through the tears, and stabilize the tissue until the laser-treated areas heal. We can compare this application to keeping a broken bone in a cast or splint until it heals.

The main tamponade agents selected according to the requirements of the surgery are as follows:

• Sterile air
• Sulfur hexafluoride gas
• Perfluoropropane gas
• Standard silicone oil
• Heavy silicone oil

These substances have different characteristics. Sterile air is naturally absorbed within a short period. Gases, depending on their type, remain in the eye and perform their function for several weeks to several months, after which they are naturally absorbed by the body. Silicone oils are used in cases requiring much heavier and longer-term support. Since silicone oils are not absorbed by the body, they must be removed from the eye through a second surgical procedure several months after the retina has healed.

Why is face-down positioning so important after vitrectomy?

Gases injected into the eye work according to the principle of “buoyancy,” which is a basic law of physics. Just as an air bubble in water always rises toward the surface, the gas bubble inside the eye also applies upward pressure in the direction opposite to gravity. The logic of head positioning after surgery is entirely based on this principle.

Especially when gas is used to close a hole in the visual center, the patient is generally asked to lie face down or keep the head tilted forward. The macula, which is the sensitive point of our eye, is located on the very back wall of the eyeball. When you turn your face toward the ground, the back wall of your eye faces the ceiling. In this way, the gas bubble rises upward and applies perfect pressure exactly to the targeted area. This position, usually recommended for a period of around three days, aims to keep the edges of the hole dry by protecting them from intraocular fluid and to accelerate healing. Lying on the back, on the other hand, should be avoided because it may cause the gas to move toward the front of the eye, place pressure on the lens and cornea, and increase intraocular pressure.

What are the restrictions on air travel for people who have undergone vitrectomy?

The most critical environmental factor that people who receive gas tamponade in the eye after surgery must pay attention to is changes in atmospheric pressure. People who have a gas bubble in the eye face very serious risks if they travel by air or go to high-altitude mountain roads.

The reason for this is pressure differences. As an aircraft climbs or a person ascends to a high mountain, the external air pressure decreases. When the external pressure drops, the gas bubble inside the closed system of the eye rapidly expands and attempts to increase in volume. This expansion can raise the pressure inside the eyeball, that is, the intraocular pressure, to very high levels within seconds. This severe increase in internal pressure can mechanically compress the main vessel that brings oxygenated blood to the eye and stop blood flow. When the retinal tissue is deprived of oxygen in this way, there is a risk of permanent vision loss. Therefore, air travel or going to high-altitude areas should be avoided until the doctor confirms that the gas has been completely absorbed.

What can the outcomes and risks to be considered after vitrectomy surgery be?

The success of vitrectomy surgery is evaluated both by whether the retina remains structurally attached in place and by how clearly the patient is able to see again. The rate at which surgery succeeds in keeping the retina in place is generally quite high. However, the retina settling back into position does not always mean that the previous level of perfect vision will return. Factors such as how long the visual center remained affected and how much the cells were damaged by oxygen deprivation determine the final level of vision. Functional outcomes are expected to be more favorable in cases treated early.

As with every major surgical intervention, some potential risks that need to be closely monitored during the recovery process are as follows:

• Development of membrane formation
• Secondary tears
• Cataract formation
• Elevated intraocular pressure
• Intraocular inflammation

Some eyes may react excessively to surgical trauma and develop new cellular membrane formation, which can lead to renewed pulling on the retina. Especially in people who have not undergone cataract surgery, the gas or silicone placed inside the eye may affect the nourishment of the natural lens and accelerate the development of cataracts; therefore, cataract surgery may become necessary in the following months. Fluctuations in intraocular pressure are generally managed with eye drops. Strict adherence to the prescribed postoperative drop treatments and following the physician’s instructions provide the greatest assurance in protecting the retina.