Chirurgische indicaties

Indications for a Vitreo-Retinal operation may include:

Dropped nucleus

• Referring without delay.
• The patient will be seen as soon as possible and operated accordingly.

(sub)Luxated IOL

• Referring usually not urgent

Vitreous incarceration in the wound

• May benefit from vitrectomy.

Supra-choroidal hemorrhage

• Rare. Referring after consultation with VR surgeon.
• Telephonic consultation with the VR surgeon to assess urgency and feasibility.

Post-operative macular edema (non responding to medical treatment)

• May benefit from vitrectomy. Referring usually not urgent

Acute post-operative endophthalmitis.

• Referring without delay. See Endophthalmitis (acute).

Chronic or delayed onset post-operative (phaco) endophthalmitis

• Uncommon complication of cataract surgery. Most often due to Propionibacterium acnes. May be due to rare non virulent strain of Staphylococcus or other organism. Occasionally fungal in origin, sometimes as a part of epidemic caused by contamination of irrigating fluids or surgical instruments.Initial good visual results. Late onset of mild decreased vision. Late onset chronic irritation. Ocular pain (not always present). Photophobia.Mild to moderate conjunctival hyperemia. Mild to moderate anterior chamber flare and cell with keratitic precipitates (may become progressively more difficult to suppress with topical steroids. Vitreous cellular infiltrate. Plaque of white infiltrate in capsule characteristic for P. acnes. Anterior chamber tap for culture and sensitivity. Vitreous biopsy for culture and sensitivity. Fungal stains when suspicious. Anaerobic cultures for P. acnes must be held for 2 weeks. Gonioscopy to rule out retained lens fragments.
• Referring as soon as this possibility enters in the differential diagnosis.
• May benefit from an intravitreal injection of antibiotics (rarely effective as stand alone treatment) or a more extensive operation with vitrectomy and removal of the posterior capsule or the IOL itself.

Diagnosis

• Onset usually within the first or second week postoperatively, but may be delayed
• Foreign body sensation; pain in approximately 75% ; redness; vision loss; lid swelling
• Decreased acuity; increased conjunctival hyperemia and chemosis; anterior chamber flare and cell; hypopyon; fibrin, particularly on lens surface; vitreous cellular infiltration and opacification; discharge; lid edema; corneal opacification
• D.D.: Tass -> Rapid onset (usually within 12-24 hours), but can be delayed (rare); lid swelling is rare

When to Refer

Without delay in all cases.

Treatment options

• For eyes with vision of light perception, pars plana vitrectomy and intraocular injection of antibiotics
• For eyes with better than light perception, injection of intraocular antibiotics after tap for vitreous culture or pars plana vitrectomy and intraocular injection of antibiotics

Results

• Visual loss is common even in treated patients.
• Approximately 50% of treated post-cataract patients achieve 20/40 or better vision
• Outcome is dependent on the infecting organism: infections due to Staphylococcus epidermidis have better outcomes than gram-negative micrococci, Staphylococcus aureus, and Streptococcal infections
• Time from presentation to treatment should be minimized for best prognosis

Vitreous and or chorioretinal biospy may be indicated by the following conditions:

• Uveitis where neoplastic or infectious disease are suspected (either due to the clinical appearance or to failure to respond to conventional therapy)
• Primary intraocular (CNS) Lymphoma
• Viral infection (Herpes simplex, herpes zoster, cytomegalovirus, Epstein Barr, human herpesvirus-6)
• Toxoplasmosis
• Mycobacterium tuberculosis
• Whipple disease
• Microbiologic evaluation of endophthalmitis

Alternatives to this procedure:

If lymphoma is suspected, lumbar puncture with cerebrospinal fluid cytology, MRI and brain biopsy may be other options.
Polymerase chain reaction (PCR) analysis of aqueous humor via paracentesis is a reasonable option in the management of herpetic eye disease

Referring if needed.

Procedures options

Vitrectomy with vitreous biopsy.
Vitrectomy with chorio-retinal biopsy.

Blunt trauma

Diagnosis and When to Refer

1. Blunt, closed-globe trauma to the globe produces:

• Commotio retinae; Choroidal rupture; Chorioretinitis Sclopetaria; Traumatic optic neuropathy; Angle recession; Traumatic Maculopathy.
  If a rupture can be excluded referring is not needed
• Vitreous-bleeding; Irido-Cyclodialys; Traumatic cataract; Lens or IOL dislocation.
  If a rupture and a retinal detachment can be excluded referring urgency is dependent on the clinical presentation.

2. Retinal break or retinal detachment often in the form of a Ora’ s tear or avulsion of the vitreous base.

• If no retinal detachment is present prompt laser coagulation of the break is advised. Referring is not needed.
• If a retinal detachment is present referring is urgent but treatment can be usually delayed until the next day. Operating during weekends is also usually not needed.

3. Rupture of the globe

• Rupture most common at limbus or parallel to and under the insertion of the rectus muscles, or previous scleral incision
• Low intraocular pressure (IOP) but normal IOP does not preclude rupture
• Deepened or anterior chamber
• Positive Seidel test may be present
• Hemorrhagic chemosis may obscure and underlying rupture
• Uveal prolapse, hyphema, retinal incarceration, vitreous hemorrhage, retinal detachment (RD), giant retinal tear my be present.

Refer without delay.

Penetrating and Perforating trauma

Diagnosis and When to Refer

1. Perforating globe injury = 2 full thickness scleral defects.

• Usually an entrance plus exit wound. Usually a missile-like injury
• Penetrating globe injury involves entrance wound, no exit wound. Usually a sharp lacerating trauma

Diagnosis

• Pain and decreased vision, decreased visual acuity, decreased intraocular pressure (IOP), scleral or corneal laceration usually visible, shallow anterior chamber (if cornea violated), abnormally deep anterior chamber may suggest scleral injury, hyphema, cataract and/or dislocated lens, vitreous hemorrhage, retinal detachment (RD) and/or choroidal detachment, possible intraocular or intraorbital foreign bodies (IOFB), possible signs of endophthalmitis at time of presentation

Refer without delay.

Vitreous bleeding

Treatment and referring depend on:

the extension and type of the bleeding:

1. If the retina cannot be visualized at all refer without delay. An operation without delay may be the best option (the bleeding may be due to an acute posterior vitreous detachment. Alternatively the cause may be a proliferative diabetic retinopathy: a pan-retinal photocoagulation cannot be performed because of the bleeding)
    
2. If the retina can be visualized and the blood is fresh (red), usually it can spontaneously reabsorb. Close observation and pan-retinal photocoagulation may be the best option. In case of doubt or recurring bleeding just refer the patient without delay.
    
3. If the retina can be visualized but the blood is old (white or yellow), usually it will not reabsorb. Close observation and pan-retinal photocoagulation may be the best option, but if the symptoms are disturbing an operation may be indicated. Referring usually not urgent.

Treatment options

Vitrectomy

Results

If the retina is not damaged for other reason (maculopathy) the prognosis is usually very good with long term stability.

Complications

Re-bleeding can occur, but usually reabsorb spontaneously in few days or weeks.

Proliferative Diabetic Retinopathy

Indications for surgical intervention include:

1. Active neovascularisation or fibrovascular proliferation non responding to pan-retinal laser photocoagulation. Maybe complicated by recurring vitreous bleeding and by progressive tractional retinal detachment.
   * Refer promptly.
   * In the mean time provide pan-retinal photocoagulation if not already present (as complete as possible, up to 2000 spots).
2. Inactive neovascularisation or fibrovascular proliferation. If the vitreous is still attached to the posterior retina this condition maybe complicated by recurring vitreous bleeding because of vitreous traction on the fibro-vascular complexes.
   * Refer promptly.
   * In the mean time provide pan-retinal photocoagulation if not already present (as complete as possible, up to 2000 spots).

Treatment options

Vitrectomy with or without pre-operative anti-VEGF intravitreal injection.

Results

If the retina is not damaged for other reason (maculopathy) the prognosis is usually very good with long term stability.

Complications

Re-bleeding can occur, but usually reabsorb spontaneously in few days or weeks.

Macular edema

Nowadays management of diabetic macular edema consists of intravitreal injection of anti-VEGF drugs and focal/grid laser. Surgical management is recommended when edema is sustained by a tractional epiretinal membrane. Surgical treatment of diffuse non-tractional diabetic macular edema is controversial and often recommended as last option, when irreversible damage of photoreceptors has already occurred. However recent studies suggest that it may benefit from an early vitrectomy with peeling of the internal limiting membrane.

1. Tractional Macular Edema

Referring because of:

• disturbing metamorphopsia and or progressive visual impairment

2. Non-Tractional Macular Edema

Referring because of:

• Insufficient respons to medical treatment
• Progressive visual impairment

Treatment options

Vitrectomy with peeling of the ERM and ILM.

Results

If the retina is not already irreversibly damaged some visual benefit can be expected.

Complications

Recurrence of the edema.

Diagnosis

A vitreous bleeding without a known cause (i.e. proliferative diabetic retinopathy, sickle cells disease…) is most probably caused by a posterior vitreous detachment. In this case if the retinal periphery is not visible, the chance to develop a retinal detachment is significative. For this reason an urgent referral is recommend, as it would be for a macula on retinal detachment.

However, the differential diagnosis of a vitreous bleeding must include:

Posterior vitreous separation: secondary traction at the stronger vitreoretinal interface site, may result in avulsion of a retinal vessel, may result in a retinal tear.

Vitreous traction may also occur in areas of retinal neovascularization

• Proliferative diabetic retinopathy
• Retinal Venous Occlusive Disease
• Sickle cell disease
• Eales disease
• Familial Exudative Vitreoretinopathy (FEVR)
• Retinopathy of prematurity (ROP)
• Vascular tumors of the retina may bleed spontaneously
   
• Choroidal neovascularization
• Tumors of the choroid (i.e. choroidal melanoma)
• Other inflammatory disorders
   
• Sarcoidosis with NV
• Eales disease
   
• Non-accidental trauma in children (i.e. Shaken Baby)
• Trauma
• Terson syndrome (sub-ILM hemorrhage)
• X-linked retinoschisis (young males)
• Retinal macroaneurysm rupture with bleeding into vitreous.

Referring

Without delay in all cases.

Treatment options

• Vitrectomy with gas/oil tamponade
• Laser treatment if possible.

Symptoms due to vitreous floaters may occur in two different settings.

1. Prior to an posterior vitreous detachment: highly subjective. May occur at any age. Symptoms maybe not related to any objective sign. Sometimes may be due to visible floaters: uveitis, complicated cataract surgery, asteroid hyalosis, idiopathic. Referring only after clear discussion of risks and benefits.
2. After a posterior vitreous detachment: symptoms wear usually off after some time because of anterior shift of the vitreous cortex and spontaneous habituation. Referring only after a period of some months (6) after onset of symptoms and after clear discussion of risks and benefits.

Referring because of:

Disturbing floaters

Treatments options

Vitrectomy

Results

Transparent vitreous cavity.

Complications

Endophthalmitis risk is less than 0,1%. Retinal detachment < 0,4%.

Indications for a Vitreo-Retinal operation may include:

Dropped nucleus

• Referring without delay.
• The patient will be seen as soon as possible and operated accordingly.

(sub)Luxated IOL

• Referring usually not urgent

Vitreous incarceration in the wound

• May benefit from vitrectomy.

Supra-choroidal hemorrhage

• Rare. Referring after consultation with VR surgeon.
• Telephonic consultation with the VR surgeon to assess urgency and feasibility.

Post-operative macular edema (non responding to medical treatment)

• May benefit from vitrectomy. Referring usually not urgent

Acute post-operative endophthalmitis.

• Referring without delay. See Endophthalmitis (acute).

Chronic or delayed onset post-operative (phaco) endophthalmitis

• Uncommon complication of cataract surgery. Most often due to Propionibacterium acnes. May be due to rare non virulent strain of Staphylococcus or other organism. Occasionally fungal in origin, sometimes as a part of epidemic caused by contamination of irrigating fluids or surgical instruments.Initial good visual results. Late onset of mild decreased vision. Late onset chronic irritation. Ocular pain (not always present). Photophobia.Mild to moderate conjunctival hyperemia. Mild to moderate anterior chamber flare and cell with keratitic precipitates (may become progressively more difficult to suppress with topical steroids. Vitreous cellular infiltrate. Plaque of white infiltrate in capsule characteristic for P. acnes. Anterior chamber tap for culture and sensitivity. Vitreous biopsy for culture and sensitivity. Fungal stains when suspicious. Anaerobic cultures for P. acnes must be held for 2 weeks. Gonioscopy to rule out retained lens fragments.
• Referring as soon as this possibility enters in the differential diagnosis.
• May benefit from an intravitreal injection of antibiotics (rarely effective as stand alone treatment) or a more extensive operation with vitrectomy and removal of the posterior capsule or the IOL itself.

Diagnosis

Typically idiopathic. May be associated with other ocular conditions including:

• Myopia
• Blunt trauma to globe (i.e. soccer ball)

In idiopathic cases, bilateral macular holes develop in 10% of patients

History includes: Central visual impairment Metamorphopsia Blurred vision Central scotoma

Clinical features of idiopathic macular hole include:

• Stage 1: deep foveal yellow spot or ring, due to outer retinal detachment. 50% chance of spontaneous resolution.
• Stage 2 : full thickness hole, less than 400 microns in diameter. Vision rapidly drops to 0,2-0,3.
• Stage 3: full thickness hole, greater than 400 microns in diameter with or without a cuff of subretinal fluid. Visual acuity often 0,2-0,1.
• Stage 4: same findings as stage 3 plus a complete posterior vitreous detachment (PVD), with or without overlying condensed vitreous. Visual acuity ranges from 0,2 to 0,05.

Possible clinical features associated with traumatic macular hole:

• Choroidal rupture, Retinal pigment epithelial (RPE) alteration in the macula, Epiretinal membrane

Possible clinical features associated with myopic macular hole

• Typically smaller holes, Degenerative macular changes including, Lacquer cracks, Fuchs spot, Posterior pole detachment (particularly if posterior staphyloma), Retinal detachment from idiopathic macular hole (rare)

Referring

• Without delay for recent macular holes (<3 months).
• Short term but without urgency for macular holes older than 3 months.
• Treatment of a old macular hole (>12 months) often results in little improvement of visual acuity but can improve the cooperation between the two eyes.

Treatment options

Vitrectomy with SF6 gas tamponade. The first 5 days after the operation the patient will be asked not to sleep on the back. A post-operative prone positioning is advised only for big and old holes, or holes who fail to close after primary surgery.

Results

Success rate for small hole is virtually 100%. Primary success rate for hole bigger than 400 micron ranges around 90%. Visual acuity can greatly improve, usually between 0,4 and 0,7, sometimes up to 1.0.

Complications

Retinal detachment < 0,4 %; Macular edema <2%, Infection <0,05

Diagnosis

Pucker: Epiretinal membrane (ERM) typically occurs in a patient with a posterior vitreous detachment (PVD) but can be associated with other ocular conditions including:

• Trauma
• Retinal tear
• Retinal venous occlusion
• Diabetic retinopathy
• Uveitis
• Hereditary retinopathy
• Retinal detachment
• Vitreoretinal surgery

May occur at any age, more common in patients over 50 years

Clinical features include:

• Surface of the inner retina has shiny, glistening appearance
• Retinal striae and/ or folds
• Cystoid macular edema/retinal thickening
• Retinal whitening, cotton wool spots or hemorrhage (rare)
• Membrane opacification
• Macular vascular tortuosity / straightening.

A variant is the Pseudohole: the thickness of the fovea is normal while the perifovea is thickened because of the presence of an epiretinal membrane.

The lamellar macular hole is another variant of the pucker. The fovea is here abnormal and the perifovea undermined.

Symtoms include:

• Central vision impairment
• blurred vision
• metamorphopsia

Usually after a rapid (variable: from little to serious) decrease in vision and onset of metamorfospia (not always), visual symptom remain stable for years.

Vitreo-macular traction syndrome (VMT syndrome): Persistent vitreous macular and/or peripapillary traction in an eye with a partial posterior vitreous detachment. Typically idiopathic but be associated with other ocular conditions that cause shrinkage of the vitreous including: inflammatory and metabolic disease, Retinal vein occlusion.

Clinical features include:

• Macula: Localized traction on the retina with or without retinal striae
• Cystoid macular edema (CME)
• Epiretinal membrane often associated
• Localized traction detachment
• Avulsion of a retinal vessel
• Evolution to a full-thickness macular hole

Peripapillary: Blurred disc margins due to retinal elevation, Grey color to peripapillary retina.

Symtoms include:

• Central vision impairment
• blurred vision
• metamorphopsia.

Spontaneous separation of adherent vitreous may occur with resolution of symptoms. How bigger the adherent surface, how smaller the chance that the VMT releases.

Referring because of:

• disturbing metamorphopsia
• progressive visual impairment

Treatments options

• Observation: when visual function is stable and symptoms are not too disturbing.
• Vitrectomy with releasing of the VMT and or peeling of the epiretinal membrane and (if indicated) the internal limiting membrane
• Intravitreal injection of Gas: only for VMT with small adherent surface and no visible epiretinal membrane.

Results

Resolution of metamorphopsia can be expected to a large extent. Cooperation between the two eyes will also improve. Visual acuity will raise in about 65% of eyes. Not always will the OCT show a restitutio ad integrum but vision can nevertheless improve during some months after the operation. Success with Gas occurs in about 70% of treated eyes.

Complications

Endophthalmitis risk is less than 0,1%. Cystoid Macular edema 3-4 %. Retinal detachment < 0,4%.

Retinal detachment (regmatogenous)

Diagnosis and Management

Retinal detachment macula on, outside the vascular arcade

Depending on the number, size and location of the causative breaks the retinal detachment will initially expand relatively quickly to a certain configuration. Afterwards progression will slow down. If not operated, the entire retinal surface will eventually detach and PVR develop.

Referring

Without delay in all cases. Treatment is however not necessary during evening hours or during weekends.
Depending on the extension and location of the detachment, pre-operative head postioning is advised.

Retinal detachment macula on, inside the vascular arcade

The macula can detach at any moment.

Referring

Without delay in all cases. Treatment is recommended even during evening hours or during weekends.
Depending on the extension and location of the detachment, pre-operative head postioning is advised.

Retinal detachment macula off, outside the vascular arcade

A fresh retinal detachment, even if macula off, can achieve good functional outcome after repair. An operation within 8 days (since the detachment of the fovea) is recommended. Afterwards a good result is still possible, however to a lesser extent.

Referring

Without delay in all cases. Treatment is however not necessary during evening hours or during weekends.
No pre-operative head positioning is needed.

Treatment options

Vitrectomy with gas/oil tamponade

Buckle surgery: this option is usually reserved for phakic patients younger than 55 years old with relatively simple detachment configuration, when an Ora’s tear is the causative break or in cases without a posterior vitreous detachmenent.

Results

Reattachment rate after primary surgery ranges from 95 to 90% of cases. Post-operative visual acuity depends on the pre-operative status of the macula. By successfully repaired macula off retinal detachment it ranges from 0,3 to 0,7.

Complications

PVR ensues in about 1-2%. Endophthalmitis risk is less than 0,1%.