VITREORETINAL SURGERY
SERVICE
TRACTIVE MYOPIC MACULOPATHY - RETINA DETACHMENT - EPIRETINAL MEMBRANE - MACULAR HOLE - HEMOVITREUM
DIABETIC RETINOPATHY - SENILE DEGENERATIVE MACULOPATHY or AGE-RELATED - EXUDATIVE ( WET) DEGENERATIVE SENILE MACULOPATHY - ATROPHIC (DRY) SENILE MACULOPATHY - CHOROID DETACHMENT - FLOORING VITREAL BODIES, VITREAL OPACITY, FLOATERS
TRACTIVE MYOPIC MACULOPATHY
In vitreoretinal surgery, high myopia is a condition characterized by a high myopic refractive error. Myopia is a vision disorder in which the eye has excessive axial length or excessive curvature of the cornea, causing light rays to focus at a point anterior to the retina rather than directly on it, making the image blurry.
High myopia occurs when the visual defect is particularly marked, with a high degree of myopia.
In vitreoretinal surgery, the term "high myopia" is often used to describe cases of very advanced or extreme myopia, in which the visual defect is significantly high.
In these cases, the eye may be very abnormally elongated, which can lead to a number of ocular complications, including an increased risk of retinal detachment, myopic macular degeneration, and other retinal conditions.
Vitreoretinal surgery can be used to treat some of the complications associated with high myopia, such as retinal detachment.
This type of surgery involves replacing the vitreous gel inside the eye and repairing or supporting the retina to restore or improve vision.
The specific treatment will depend on the individual characteristics and needs of each patient, and should be evaluated by an ophthalmologist specializing in vitreoretinal surgery.
Fundus profile of a normal eye, collected with widefield OCT
Fundus profile of an eye with high myopia and detached macula, collected with widefield OCT. Axial length 35 mm
Widefield color retinography of an ocular fundus of an eye with high myopia and axial length of 30 mm
SERVICE
Retinal detachment indicates the separation of the retina from its normal position i.e. from the choroid and sclera.
Retinal detachment can be caused by various factors, but the most frequent is the detachment of the vitreous from the retina which first creates a retinal breach (hole or break) through which liquid passes and lifts the retina itself.
The retina can detach even in the absence of a vitreous detachment or due to existing retinal lesions or trauma.
Color retinography of a left eye with normal appearance of the retina and fundus
Widefield OCT exam of the same eye ideally obtained by drawing a horizontal line in the middle of the image as shown on the left. The exam shows the retina well attached to the wall
Widefield OCT exam showing a section of a part of the retina detached from its wall
Color retinography of the right eye of the same patient, showing an inferior retinal detachment
Color retinography of the same eye showing the attached retina after surgery
Widefield OCT examination of the same eye after surgery that returns the retina to its original position
The ophthalmologist specializing in vitreoretinal surgery intervenes to put the retina back in its correct position and repair any damage or anomalies that may have caused the detachment.
During surgery, the surgeon can use micro-instruments and a high-magnification viewing system (the microscope) to access the retina and work with extreme precision.
Vitreoretinal surgery can involve several techniques used individually or in combination, including:
The injection of a bubble of air or gas into the vitreous chamber
Cryotreatment is the creation of a cold weld between the retina and the external wall
Laser or photocoagulation, i.e. the creation of a hot weld between the retina and the external wall
Vitrectomy is the removal of the gel or abnormal tissues that cause traction and detachment
The cerclage and/or the plumbage, i.e. elements to be placed on the external wall of the eye to bring the wall closer to the retina, releasing traction from the outside.
The goal of vitreoretinal surgery is to attach or glue the retina to its natural wall.
This is called ANATOMIC RESULT.
Depending on the damage suffered by the retina during detachment or surgery or the postoperative period, there will be a greater or lesser FUNCTIONAL RESULT, i.e. recovery of sight and visual field
EPIRETINAL MEMBRANE
It is a condition in which a thin layer of fibrous or membranous tissue forms on the surface of the retina, in the macular region of the eye.
The best diagnostic tests to better understand the eye before epiretinal membrane peeling surgery are
Eye exam with refraction for distance and near
Physical examination of the eye with a slit lamp
Color and autofluorescence retinography
The OCT
The angioOCT
Microperimetry
The metamorphopsia test
Color image of the normal macula
Color and black and white Enface image showing the radial folds given by the corrugated premacular membrane
This membrane can cause vision problems, such as distortion of vision and decreased visual acuity.
In vitreoretinal surgery, the epiretinal membrane can be removed via vitrectomy and peeling of the membrane itself.
In some cases, peeling of the membrane from the surface of the retina which is called the internal limiting membrane may also be necessary. The benefits of internal limiting membrane peeling are being studied.
Often at the end of the operation the vitreous is replaced with a bubble of air or gas which is spontaneously reabsorbed within approximately 10 days. Therefore, after surgery, vision is disturbed as long as the air\gas bubble is present inside the eye. The Patient notices that he sees something moving inside the eye, or a level sign that changes from day to day.
OCT showing normal profile of the macula
The results of surgery may vary depending on the severity of the membrane and other individual factors.
After peeling the eye can improve two lines of visual acuity
Image distortion is very difficult or impossible to eliminate, therefore it is advisable to intervene when it occurs before it worsens to have a better recovery after surgery.
OCT showing wrinkled profile of the macula due to the presence of a contracted premacular membrane
The improvement in vision is not immediate. It starts after a month and continues even for two years
OCT of an eye with epiretinal membrane before surgery (left) and after surgery (right). You can see how the macular profile after surgery is smoother and more regular even if it never becomes completely normal
MACULAR HOLE
A macular hole is an ophthalmological condition in which a hole occurs in the macula, which is the central part of the retina responsible for sharp, detailed vision.
The macular hole can cause significant loss of central vision and can affect the ability to carry out daily activities such as reading, driving and recognizing faces.
OCT showing a macular hole
In vitreoretinal surgery, the macular hole can be treated using a procedure called vitrectomy.
Additional maneuvers must be evaluated on a case-by-case basis, such as
Internal limiting membrane (ILM) peeling
Partial peeling of the ILM with maintenance of flap on the hole
Autologous ILM transplant
Autologous retinal transplant
The amniotic membrane implantation
OCT showing the macula before and after vitrectomy surgery, ILM peeling, gas and face down position for 3 days, achieving closure of the hole
At the end of the operation, the eye must be filled with a substance called tamponade which can be air, gas or silicone.
The Patient is asked to maintain a position that allows him to look towards the ground, downwards to ensure that the buffering substance which floats more than the water, goes towards the hole, favoring closure.
The surgeon must explain before the operation which technique and which tamponade he intends to use
Macular hole surgery can improve central vision and reduce symptoms associated with the hole.
Results may vary depending on the type and size of the hole, as well as other individual factors.
10% of macular holes DO NOT close with surgery and require RE-operation.
It is important to consult an ophthalmologist who specializes exclusively in vitreoretinal surgery for an appropriate evaluation and treatment plan for a macular hole.
HEMOVITREUS
SERVICE
DIABETIC RETINOPATHY
It is an ocular complication caused by diabetes mellitus, a chronic disease that affects blood sugar levels.
Diabetic retinopathy occurs when high blood sugar levels damage blood vessels in the retina, the light-sensitive layer of tissue at the back of the eye.
There are two common forms of diabetic retinopathy:
1. Nonproliferative diabetic retinopathy: In this early stage, blood vessels in the retina may develop small abnormalities, such as microaneurysms (small pockets of blood fluid), dilation of blood vessels, or leakage of fluid into surrounding areas. These changes can affect the normal function of the retina and cause accumulation of pockets of fluid in the macula, called MACULAR EDEMA, and more specifically DIABETIC MACULAR EDEMA. Macular edema causes blurred or distorted vision.
In this phase it may be necessary to treat the retina through intravitreal injections of drugs from the ANTIVEGF family, or cortisone-based or suprathreshold (photocoagulation) or subthreshold (micropulsed) laser treatment.
2. Proliferative diabetic retinopathy: In this advanced stage, the blood vessels of the retina become significantly damaged and can cause the formation of new abnormal blood vessels. These new blood vessels are fragile and can cause bleeding inside the eye (vitreous hemorrhage), scarring, and pulling on the retina. This condition can lead to retinal detachment and permanent vision loss if not treated properly.
Vitreoretinal surgery can be used to treat advanced proliferative diabetic retinopathy. The procedure may involve removal of the vitreous gel (vitrectomy), removal of abnormal blood vessels, repair of any retinal detachment, and other techniques to restore normal retinal function.
Management of diabetic retinopathy also involves controlling blood sugar levels, managing blood pressure, and other diabetes care measures. It is important to have regular eye exams for early diagnosis and timely treatment of diabetic retinopathy in order to preserve your vision.
SENILE DEGENERATIVE MACULOPATHY or AGE-RELATED
Senile or age-related degenerative maculopathy is the most frequent form of maculopathy in Western countries and manifests itself from the age of 55 onwards. It has a genetic basis, but like all genetic forms it does not manifest itself in the same way in different generations.
It is often abbreviated to DMS (age-related macular degeneration) or AMD (age-related macular degeneration).
AMD has two broad forms of expression: exudative (wet) or atrophic (dry).
WET MACULOPATHY
This damage to the macula leads to a progressive loss of central vision.
Vitreoretinal surgery may be used to treat wet age-related maculopathy in some situations.
One surgical option is intravitreal injection of anti-VEGF (vascular endothelial growth factor) drugs to reduce the growth of abnormal blood vessels (neovessels) and associated macular edema.
These drugs aim to block the growth factor that stimulates the formation of new abnormal blood vessels in the macula.
This damage to the macula leads to a progressive loss of central vision.
One treatment option is intravitreal injection of anti-VEGF (vascular endothelial growth factor) drugs to reduce the growth of abnormal blood vessels (neovessels) and associated macular edema.
These drugs aim to block the growth factor that stimulates the formation of new abnormal blood vessels in the macula and decrease blood flow in the neovascular membrane.
Intravitreal injection of anti-VEGF drugs is considered the standard treatment for the wet form of age-related macular degeneration.
New drugs are regularly studied and made available for a better and longer lasting effect.
Intravitreal injection of anti-VEGF drugs is considered the standard treatment for the wet form of age-related macular degeneration.
Other treatment approaches may include laser photocoagulation or more invasive surgeries such as subretinal blood removal surgery.
It is essential to consult an ophthalmologist who specializes in the management of wet age-related maculopathy for an accurate evaluation and a personalized treatment plan based on the severity and specific characteristics of the case.
Wet age-related maculopathy, also known as exudative age-related macular degeneration or choroidal neovascularization, is a degenerative eye condition that affects the macula, the central part of the retina responsible for detailed, sharp vision.
It is a form of age-related macular degeneration (AMD).
In exudative senile maculopathy, there is an abnormal growth of new blood vessels from the choroid, a layer of vascular tissue under the retina.
These new blood vessels tend to leak or bleed, causing damage and scarring to the macula.
Exudative maculopathy. Subretinal hemorrhage
Exudative maculopathy before (left) and after (right) treatment with intravitreal injections.
Vitreoretinal surgery is not a standardized treatment for wet maculopathy. Nonetheless, in some cases CHOROID TRANSPLANT surgery can be considered. Choroid transplant involves the surgical removal of the maculopathy, or rather of the neovascular membrane causing the maculopathy, and the replacement of the neovascular membrane with healthy choroid, taken from the peripheral part of the choroid.
Choroid transplant is an extremely complex surgery that is performed in very few centers in the world.
It presents risks and benefits which will be explained separately, in a dedicated section.
Exudative maculopathy before (left) and after (right) treatment with intravitreal injections.
Patient with bilateral submacular bleeding. Vision limited to counting fingers in both eyes
The same patient, after bilateral choroid transplant surgery. Vision in the right eye 2\10 and in the left eye 6\10
DRY MACULOPATHY
Macular drusen
Dry age-related maculopathy, also known as dry or atrophic age-related macular degeneration, is a form of age-related macular degeneration (AMD).
It is the most common form of macular degeneration and mainly affects people aged 55 and older.
In senile dry maculopathy, there is a progressive loss of cells with thinning and deterioration of the macula, the central part of the retina responsible for detailed vision.
In senile dry maculopathy, there is a progressive loss of cells with thinning and deterioration of the macula, the central part of the retina responsible for detailed vision.
The first manifestations are the formation of deposits of waste material that is not eliminated, called drusen in the macula.
Over time, the presence of drusen and damage to the macula can cause a progressive loss of central vision or blurred or distorted vision.
Unlike the wet form of macular degeneration, the growth of new abnormal blood vessels (neovessels) does not occur in dry age-related maculopathy.
Currently, there is no definitive cure for dry senile maculopathy.
Vitreoretinal surgery is not generally used as a treatment for this condition, although some techniques, such as artificial retina and amniotic membrane implantation, are being studied.
Some more common treatment approaches may include taking specific vitamin supplements (such as vitamin C, vitamin E, beta-carotene, zinc, and copper) with the intent of slowing the progression of the disease.
Early diagnosis and appropriate management can help preserve residual vision and address the challenges associated with this condition.
New drugs designed to block the progression of the disease are soon to be available.
The images show the absence of tissue in the macula highlighted by the black autofluorescence image and by the thin layer of macula in OCT
CHOROID DETACHMENT
It is a condition in which the layer of vascular tissue, called the choroid, separates from the retina, which is the light-sensitive layer of tissue located at the back of the eye.
Choroidal detachment can occur spontaneously due to underlying eye conditions or pathologies, such as severe myopia, macular degeneration, Harada disease (pan uveitis), or ocular hypotony (low intraocular pressure).
Choroidal detachment can lead to symptoms such as decreased vision, distorted vision, spots or shadows in the vision, and may be associated with increased pressure in the eye.
Management of choroidal detachment may require surgery to reposition the choroid and restore the eye's normal anatomy.
This surgery may involve vitrectomy, the use of gas, silicone oil to pack the eye, the use of lasers to seal the lesions, or other techniques depending on the severity and specific characteristics of the case.
It is important to consult an ophthalmologist who specializes exclusively in vitreoretinal surgery for an accurate diagnosis and appropriate treatment plan for choroidal detachment.
VITREAL FLOATING BODIES - VITREAL OPACITIES - FLOATERS
Vitreous floaters, also known as floaters or floaters (also commonly called floaters or cobwebs), are thickenings of vitreous body that float in the eye.
The vitreous body is a gelatinous, transparent substance that fills the space between the lens and the retina. This space is called the “glass chamber”.
Vitreous floaters can take different shapes, such as black or grayish dots, filaments or networks.
They become more noticeable when looking at a clear or bright surface, such as a blue sky or a blank page.
They are most common in adults aged 50 and older, but can occur at any age.
If the vitreous floaters cause significant interference with vision or symptoms such as blurred, or disturbed vision, a surgery called a vitrectomy may be considered.
During vitrectomy, the surgeon removes the vitreous body and replaces it with a saline solution, or air, or gas.
This type of procedure eliminates the presence of vitreous floaters and improves the quality of vision.
The decision to undergo a vitrectomy for vitreous floaters must be made based on the severity and persistence of symptoms, balancing against the potential risks of the surgery.
Other procedures such as taking supplements or Yag laser vitreolysis are less effective. The laser is no less dangerous than vitrectomy in my opinion, as it can cause damage to the lens or retina.
It is important to consult an ophthalmologist who specializes exclusively in vitreoretinal surgery for an accurate evaluation and appropriate advice in case of disturbance caused by vitreous floaters.
EYE CARE CLINIC
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24124 - Brescia
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STUDIO DIECIDECIMI
Via Cesare Vivante, 1
95123 - Catania
Telephone 3516449431
