Pneumatic Retinopexy
Pneumatic retinopexy is a procedure that retinal specialist can perform to repair certain cases of retinal detachment in the office without taking patient into the operating room. This procedure includes performance of cryotherapy (freezing therapy) around the the retinal break and injection of the gas bubble in the eye to close retinal break and reattach the retina. Laser can be used instead of freezing therapy to seal the retinal break in some instances. The patient must maintain a specific head position for majority of the day and night for about one week to keep the gas bubble floating against the area of retinal tear to provide good seal effect. The physician will instruct positioning (head tilt right, tilt left, face down, or upright) based on location of the tear. As the gas bubble reabsorbs, the patient's vision will improve and the retina will remain reattached. The advantages of the procedure are minimal invasiveness, office - based nature and short duration. Success rates, however, are slightly less than those of the conventional vitrectomy or scleral buckling surgery.
While the gas bubble is in the eye patient can't travel by plane or have significant changes in altitude (eg cross mountain ranges or scuba dive). If a patient undergoes general anesthesia for another surgery, the anesthesiologist must be made aware of the gas bubble, in order to avoid certain dangerous gas anesthetic agents.
Vitrectomy
Vitrectomy is the most common type of retinal surgery performed currently. During vitrectomy the surgeon creates three small entry sites on the surface of the eye through which he introduces different instruments in the eye. One site provides for illumination of the retina (similar to a flashlight), one site is used for active instruments that cut, manipulate, or treat tissue (for example forceps, scissors, laser probe, vitreous cutter), while the third infuses fluid or gas to keep the eye inflated. During the surgery, the vitreous gel that fills the eye is removed and in order to safely perform other portions of the procedure to treat the retina. Vitrectomy is commonly done for many indications, including: reattachment of the retina with the help of laser photocoagulation, freezing treatment and injection of a temporary gas bubble or silicone oil to hold the retina in position in cases of retinal detachment; removal of blood and scar tissue in cases of diabetic retinopathy and tractional retinal detachment; and peeling of membranes from the inner surface of the eye in cases of macular holes and epiretinal membranes.
In cases where a gas bubble is used, the vision will vision will remain poor for several weeks, since the bubble blocks most light from reaching the retina. As the gas bubble reabsorbs the vision improves and the eye gradually fills with fluid naturally produced by the eye to fill the vitreous cavity.
While the gas bubble is in the eye patient can't travel by plane or have significant changes in altitude (eg cross mountain ranges or scuba dive). If a patient undergoes general anesthesia for another surgery, the anesthesiologist must be made aware of the gas bubble, in order to avoid certain dangerous gas anesthetic agents.
When gas or oil are used, the patient will usually be instructed to maintain specific head positions for the first week or more so that the bubble will float to area of retinal pathology. Many times this may be face down. Medical device chairs may be rented (and often reimbursed by commercial insurance) to assist in positioning.
Scleral Buckling
Scleral Buckling surgery is an alternative to a vitrectomy for certain cases of retinal detachment. Instead of entering the inside of the eye to treat the retinal break and reposition the retina (which is done with vitrectomy), scleral buckling technique repairs retinal detachment by doing most of the surgery on the surface of the eye, to push the eyewall against the retina. A piece of soft silicone material is sewn to the outside wall of the eye called the sclera. This creates an indentation that seals the retinal break and causes retina to fall back on its place. The surgeon may occasionally drain fluid which has accumulated behind the retina. Laser or freezing therapy is used to seal the retinal break. The scleral buckle usually stays in place permanently, but rarely may be removed in cases of infection or when eye alignment or motility is affected. Scleral buckles are usually removed from infants, due to increased constriction with eye growth.
Although scleral buckles may cause more discomfort than vitrectomy in the post-operative period, they may in some instances increase success of surgery, particularly when there is large amount of scar tissue towards the front of the eye or when the retinal breaks are at the bottom of the eye (where it may be hard to get bubbles to float). Other advantages of scleral buckle are avoidance of positioning needed with gas and decreased chance of cataract.
Plaque Brachytherapy
Plaque brachytherapy is used to treat certain types of intraocular tumors. It involves suturing a disc shaped radiation source to the eye in an area over the tumor. This is performed as part of an outpatient surgery. The disc is then left in place for 5-7 days, after which an additional surgical procedure is performed to remove it. It allows for direct dosing of radiation to the tumor.
Proton Beam Radiation
Proton beam radiation therapy is used to treat certain types of intraocular tumors. This technique involves the placement of tantalum rings around the base of the tumor as part of an outpatient surgery. These rings serve as reference points to allow the proton beams to be delivered very precisely to only the tumor while avoiding uninvolved parts of the eye. The rings themselves are not radioactive, and because of their biocompatible and inert nature, they do not need to be removed with a second surgery. Protons have an ability to stop in tissue thus allowing radiation to be delivered in a very precise manner. This can be very important in tumors that are in or around critical structures like the eye.
Exam Under Anesthesia
Exam under anesthesia (EUA) is performed when examination, diagnostic procedures, and treatment with laser or injection, is difficult (or unsafe) to perform in the clinic. This is generally applies to young children with significant disease, or occasionally suspected sight or life threatening disease. EUA is generally safe, but there is a small risk of complication. After anesthesia infants (less than 60 weeks PMA) may be required to stay overnight in the hospital for monitoring.
