Vitrectomy: indications, procedure and postoperative recovery

Vitrectomy is a vitreoretinal microsurgery procedure that involves removing the vitreous — the transparent gel that fills the back of the eye — to treat several retinal conditions. Indications, procedure, postoperative positioning and recovery: what you need to know before a vitrectomy.

UNDERSTANDING

What is the vitreous and why remove it?

The vitreous is a transparent, viscous gel that occupies most of the volume of the eye, between the lens and the retina. Made up of nearly 99% water, it also contains collagen fibres and hyaluronic acid. Its role: to maintain the shape of the eye and transmit light towards the retina.

With age, the vitreous gradually liquefies. It may also detach from the retina (posterior vitreous detachment, often benign) or, conversely, exert pathological traction that causes macular holes, epiretinal membranes or retinal detachments. In certain situations, replacing it with a physiological solution — then with gas or silicone oil — makes it possible to treat the cause and restore the retinal anatomy.

INDICATIONS

The 6 main indications for vitrectomy

• Idiopathic macular hole — a small hole in the centre of the retina causing reduced central vision and metamorphopsia. Vitrectomy combined with peeling of the internal limiting membrane and gas tamponade achieves closure in more than 90% of cases.
• Epiretinal membrane (ERM) — a thin scar-like film that forms on the surface of the macula, pulling on the retina and distorting the image. Vitrectomy + ERM peeling gradually restore vision. Learn more about ERM.
• Rhegmatogenous retinal detachment — the retina separates from the wall of the eye because of one or more tears. A surgical emergency, treated by vitrectomy + laser + tamponade (gas or oil). Recognising a detachment.
• Tractional retinal detachment — typically in patients with advanced diabetes, related to proliferative diabetic retinopathy. Vitrectomy releases the abnormal fibrovascular traction.
• Vitreous haemorrhage — blood in the vitreous that obscures vision, often secondary to diabetic retinopathy, a retinal tear or a venous occlusion. If it does not resolve spontaneously, vitrectomy removes the blood.
• Endophthalmitis — a serious intraocular infection, often postoperative or following an injection. Vitrectomy combined with intravitreal antibiotics is essential in severe forms.

Other, rarer indications exist: dislocation of the lens or of an implant, complications of repeated intravitreal injections, retinal tumours, complicated posterior uveitis.

PROCEDURE

How the procedure is performed

Modern vitrectomy is a minimally invasive surgery, performed on an outpatient basis. It lasts on average 30 to 60 minutes depending on the complexity of the case. I perform it at the Clinique Sainte-Geneviève (Paris 14), which has a room dedicated to vitreoretinal microsurgery.

Anaesthesia and setup

The procedure is performed under locoregional anaesthesia (peribulbar or sub-Tenon’s) in the vast majority of cases. The eye is numb and the eyelid is held open by a small retractor. You remain awake during the procedure, but nothing is visible on your side — only the light of the microscope is perceived. Mild intravenous sedation is offered in case of anxiety.

25G or 27G trocars: self-sealing micro-incisions

Three small openings are made in the white wall of the eye (sclera), about 4 mm from the corneal limbus. Each opening receives an ultra-fine trocar — 25 gauge (0.5 mm) or 27 gauge (0.4 mm). These incisions are self-sealing: they close spontaneously at the end of the procedure, without sutures in most cases.

The three trocars are used to introduce, in turn: a light source (optical fibre), a vitreous cutter (an instrument that aspirates and cuts the vitreous at high frequency), and an infusion line to maintain the pressure of the eye. Other instruments (peeling forceps, laser probe, injection needle) are introduced as needed during the procedure.

Tamponade: gas or silicone oil

At the end of the procedure, the vitreous cavity may be filled with an internal tamponade whose role is to hold the retina against the wall while it heals:

• SF6 gas (sulphur hexafluoride) — resorbs in 2 to 3 weeks. Indicated for macular holes and certain simple detachments.
• C3F8 gas (perfluoropropane) — resorbs in 6 to 8 weeks. Used for more complex or inferior detachments.
• Silicone oil — a permanent tamponade, removed later during a second procedure (3 to 12 months afterwards). Indicated for severe or recurrent detachments and major diabetic traction.

Important: when a gas tamponade is in place, any air travel or trip to high altitude (> 1,000 m) is strictly contraindicated until the bubble has disappeared (risk of major decompensation of the intraocular pressure).

AFTER SURGERY

Postoperative positioning: head down

For certain indications — notably macular holes and superior retinal detachments — a specific position is required in the days following the procedure. The logic: the injected gas or oil is lighter than the physiological fluid. It therefore rises naturally. For it to press on the area that needs to heal (the macula, located at the posterior pole), you must position your head so that this area is at the highest point of the eye.

Most often, this means keeping your head down (chin near the chest) for 3 to 7 days, including at night (with a suitable cushion, lying face down). It is a genuine constraint — I explain it during the preoperative consultation with practical detail: bed adjustments, position for eating, phone use, duration in blocks of 45–50 minutes interspersed with short breaks.

In elderly patients, patients with neck conditions or certain cognitive disorders, this positioning is sometimes adapted (partial side positioning, reduced duration) depending on the context. The goal remains to place the bubble against the area that needs to heal.

RECOVERY

Day-by-day recovery

• Day 0 (procedure) — you go home with a protective shield over the eye. Vision is very blurred, possibly with a black bubble at the bottom of the field (the gas). Simple painkillers are generally enough. The first eye drops are started in the evening or the next day according to the prescription.
• Day 1 — follow-up consultation. Check of the intraocular pressure, examination of the retina, confirmation of the positioning.
• Day 7 — healing of the incisions confirmed. The SF6 gas begins to resorb. Vision is still blurred but improves gradually depending on the type of procedure.
• Month 1 — follow-up OCT. For a macular hole: closure is usually documented. For a detachment: retinal reattachment confirmed.
• Months 3 to 6 — visual stabilisation. Recovery depends heavily on the initial condition and on how long the disease process had been present. A detachment treated early recovers better.

RESULTS

Success rates by condition

• Idiopathic macular hole: closure > 90% at the first procedure, with progressive visual gain over 6 to 12 months.
• Epiretinal membrane: visual improvement in a large majority of patients, proportional to the initial severity and the age of the lesions.
• Primary rhegmatogenous retinal detachment: anatomical reattachment in a single procedure in about 85 to 90% of cases, with possible follow-up surgery for complex detachments.
• Diabetic vitreous haemorrhage: rapid clearing of the visual field, with the visual outcome depending on the underlying retinal status.

These results are orders of magnitude drawn from the literature and from routine practice. The individual prognosis depends on many factors: time before surgery, extent of the lesions, lens status, age, associated conditions.

FAQ

Frequently asked questions about vitrectomy

ADMINISTRATIVE

Administrative coverage

Unlike elective refractive surgery (LASIK, PKR, SMILE, ICL), vitrectomy is a medically necessary procedure: a medical leave certificate can be issued for the duration of convalescence, adapted to your professional activity. Generally allow 2 to 4 weeks depending on the type of surgery, the required positioning and the nature of your work.

A transport voucher is provided for the day of surgery only (the round trip to the Clinique Sainte-Geneviève on the day of the procedure). The prior anaesthesia consultation, which takes place at the clinic, and the postoperative follow-up consultations (Day 1, Day 7, Month 1) are arranged by your own means.

My assistant prepares the surgical file in advance: a quote (financial transparency), the information leaflet from the French Society of Ophthalmology (informed consent document), and the pre-operative prescriptions (dilating eye drops) and post-operative prescriptions (antibiotic, anti-inflammatory, lubricant if needed).

Sources

• Rizzo S, Genovesi-Ebert F, Murri S, et al. 25-gauge, sutureless vitrectomy and standard 20-gauge pars plana vitrectomy in idiopathic epiretinal membrane surgery: a comparative pilot study. Graefes Arch Clin Exp Ophthalmol. Comparative study on minimally invasive vitrectomy.
• Steel DH. Idiopathic macular hole. BMJ Clinical Evidence. Systematic review of closure rates for idiopathic macular holes with vitrectomy + ILM peeling + gas tamponade.
• Lois N, Burr J, Norrie J, et al. Internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole: a pragmatic randomized controlled trial. Invest Ophthalmol Vis Sci. 2011;52(3):1586-92. PMID 21051731.

This content is informational and does not replace a medical consultation. Each indication for vitrectomy is individual and must be assessed by an ophthalmologist after examination and retinal imaging.