Vitrectomy eye surgery is done for conditions like retinal detachment, diabetic retinopathy and for complications of cataract surgery like infection or retained lens matter. This involves removing the vitreous gel in your eye with tiny keyhole incisions. Vitrectomy surgery is usually done under local anesthetic and takes less than 30 minutes to do.
Happy new year! I hope you have had a good break over the Christmas and New Year holidays and are ready to face 2013. I am quite excited as there will be a couple of new medicines for retinal diseases that will soon be available in Malaysia for my patients. Both drugs have to be injected into the eyeball as an intravitreal injection.
Eyelea (Aflibercept) blocks VEGF
Eyelea is a new type of Anti-VEGF drug that binds to VEGF molecules in the eye. VEGF is one of the factors involved in common eyes diseases like AMD, diabetic retinopathy, and retinal vein occlusion. Drugs that can reduce VEGF in the eye like Avastin and Lucentis are now widely used to treat these retinal diseases. The main problem is that we have to inject the current drugs into the eyeball every month as current medicines only last about one month in the eye and the disease recurs. Eyelea is unique in that it can stay in the eye for more than two months. This means that patients will need less frequent injections. I am looking forward to Eyelea being approved in Malaysia as I have many patients that require monthly injections and it becomes a big burden for them to come to clinic every month for their injection. So, rather then needing an injection every month for your retina disease, you will probably only need an injection every 2 months if you choose to have Eyelea.
Jetrea (Ocriplasmin) is an enzyme that helps the vitreous to detach from the retina
In our eyes, the vitreous jelly is attached to the retina inside the eye. Sometimes if the vitreous is too tightly attached to the macula, this can lead to conditions like macula hole which is normally treated with vitrectomy surgery. During vitrectomy surgery, retina surgeons aim to release the vitreous from the retina and this can be sometimes very difficult. Studies have shown that Jetrea can help release the vitreous from the retina if injected before vitrectomy surgery. In some cases, the macula hole was actually closed with the injection of Jetrea alone and the patient did not require surgery! This is very exciting. This new drug may also be used for cases of diabetic retinopathy requiring vitrectomy surgery as detaching the vitreous from the retina is often required for such cases. Children with retina diseases like retinopathy of prematurity (ROP) or retina detachment, may also benefit from having an injection of Jetrea prior to vitrectomy surgery. In children, the vitreous jelly is very stuck to the retina and it is extremely difficult to separate the vitreous from the retina with surgery. This new drug is a breakthrough and earned a publication in the prestigious New England Journal of Medicine for the discovery.
Have a happy and healthy year ahead!
Kuala Lumpur, Malaysia
When you have bleeding inside your eye (vitreous haemorrhage, VH), it can affect your vision because the blood blocks any light from entering your eye. There are many causes of bleeding in your eye including diabetic retinopathy, retinal detachment, and retinal vein occlusion. Retina specialists normally would perform laser treatment to the retina in diabetic patients to prevent VH. If there is already VH present, laser cannot be done as the laser beam cannot reach the retina. Bleeding in the eye is due to new blood vessels growing on the surface of the retina. New blood vessels grow due to lack of oxygen in conditions like diabetes and retinal vein occlusion. Laser will improve the oxygen supply to the retina and stop growth of new blood vessels.
Vitrectomy surgery to remove blood in the eye
The vitreous gel in your eye traps blood and prevents it from coming out. VH can take up to 6 months to clear and if your vision is affected, vitrectomy surgery can be done to remove the blood trapped in the vitreous gel. Surgery normally takes about 30 mins and after all the blood is removed, more laser can be done to the retina. Recovery after surgery is very quick but your vision may take a few weeks to improve. This is because there is always some blood left in the corner of the eye that cannot be removed. With the vitreous gel removed, this blood will clear out from the eye much quicker.
Rebleeding after surgery
In diabetic patients, repeated episodes of bleeding is common even after vitrectomy surgery. This is usually due to poorly controlled diabetes, or if , the patient is taking blood thinning medications like aspirin, plavix, warfarin, or ticlodipine. I would normally then wait two to three months and if there is still blood present, repeat vitrectomy surgery can be done.
We are approaching the end of Ramadan holiday break in Malaysia this weekend and I would like to wish all my readers and patients “Selamat Hari Raya” and drive safely!
All patients with diabetes should have their retina examined once a year to look for signs of retinopathy. Early laser treatment can prevent progression of retinopathy and prevent loss of vision.
Vitrectomy Eye Surgery for Diabetes
Unfortunately, many patients with diabetes are unaware of this and only seek help when the have lost their eye sight. I have come across many young patients with severe diabetic retinopathy in both eyes that cannot be treated with laser.
This is because there is blood in the eye that prevents the laser beam from entering the eye or there is retinal detachment present. The only option left to try to save the eye sight is to carry out vitrectomy surgery.
Surgery for diabetic retinopathy is very challenging. This is because the retina of these patients are already damaged and have poor potential for vision. I often give an injection of Avastin (an anti-VEGF drug) into the eyeball of the patients 1 week before their operation.
This wonder drug causes rapid shrinking of any new blood vessels in the eye and reduces the chance of bleeding during surgery.
Advantages of Small Gauge Vitrectomy Surgery
I feel that the best approach for diabetic vitrectomy is to use the latest modern sutureless small gauge vitrectomy machines. Although the cost is slightly more expensive, it really makes my life as a surgeon easier.
It is also more comfortable for the patient post op as there are no sutures in the eye and recovery is quicker. Surgery aims to remove all blood in the eye and any scar tissue. This is easier said than done!
Very often, the scar tissue is very tightly stuck to the retina and you can easily cause damage to the retina. It is like trying to peel away two wet pieces of tissue paper that are stuck together. Surgery can often take more than 1 hour.
Surgery to Prevent or Repair Retinal Detachment
Once all scar tissue is removed, I often try to flatten the retina by putting air into the eye ball. I then perform extensive laser treatment to try to stick the retina down.
Sometimes, despite all my best efforts and the retina is reattached, the patient fails to see any improvement in vision. This is probably due to the fact that the eye has been deprived of oxygen and nutrients for too long.
It is of course much better to prevent severe diabetic retinopathy from occurring in the first place. A well organized local screening program for all diabetics is key to this as well as good control of the diabetes, lipids and blood pressure.