*Please note that this information is for illustrative purposes only, providing a general overview on the topics listed. For any specific questions or concerns regarding your condition, please contact our office so that you can consult with the appropriate person or department to address your needs.
POSTERIOR VITREOUS DETACHMENT (PVD) Overview
A posterior vitreous detachment (PVD) is a condition, related to aging, that is caused by the separation of the vitreous gel from the retina. Early in life the vitreous gel (analogous to the yolk of an egg) fills the entire inner cavity of the eye (like the yolk fills the eggshell). When you are young the vitreous gel is firmly adherent to the retina (the retina is analogous to the thin membrane on the inside of an eggshell). As you age the vitreous gel changes in composition from thick Jello-like gel to a more thin fluid-like gel. This change eventually leads to spontaneous separation of the vitreous gel from the retina.
In some patients the vitreous gel will begin to separate from the retina and cause a retinal tear, retinal hole or macular hole at an area of increased vitreoretinal adhesion.
During the development of a typical PVD, the vitreous will suddenly separate from the retina and optic nerve and continue to separate without tearing the retina, over the next few days to weeks. This is called an uncomplicated PVD.
In other patients the vitreous gel will begin to separate from the retina and optic nerve and there will be an incidental rupture of a blood vessel on the optic nerve or retina, without tearing the retina, that will lead to the development of bleeding into the vitreous cavity. This is called a hemorrhagic PVD.
In less than 5% of patients, the vitreous gel will begin to separate from the retina and optic nerve and the strong adhesion between the retina and vitreous will cause a retinal tear, operculated hole or retinal detachment (see link to that section) or a macular hole (see link to that section).
Symptoms
The development of a posterior vitreous detachment (PVD) causes symptoms such as the sudden onset of floaters, flashing lights, an arc of light, or a shadow in your peripheral vision.
Treatment
The development of an uncomplicated posterior vitreous detachment is a normal part of the aging process and, in most cases, requires no treatment other then repeated dilated retinal exams during the weeks or months the patient remains symptomatic (complaining of flashing light sensations).
The development of a hemorrhagic posterior vitreous detachment does not require treatment unless the vitreous hemorrhage is very dense and the entire retina cannot be visualized. In these cases, your surgeon may choose to perform a vitrectomy procedure to remove the vitreous hemorrhage and evaluate the retina to treat any potential retinal tears and to prevent retinal detachments from occurring from untreated retinal tears.
The vast majority of PVDs are benign and require no treatment. A small percentage of patients will develop a retinal tear or operculated hole, a macular hole or a retinal detachment. These conditions do require surgical treatment.
Surgical Treatment Options
Vitrectomy surgery with physical removal of the vitreous gel (and vitreous hemorrhage when present) is the treatment for a PVD with a dense vitreous hemorrhage when there is a suspicion that the patient may have a hidden retinal tear or possibly a retinal detachment hidden by overlying hemorrhage. The procedure is performed under local anesthesia, in either our outpatient surgical center (see link to ESSI) or local hospital (see link to our hospitals). The surgery usually takes 15-25 minutes (unless a scleral buckle is needed which adds 30 minutes to the surgery) and can be viewed by clicking on the following link (attach link). The surgery is performed through three 25-gauge ports (about the width of a wire paper clip). The surgery begins by placing an infusion canula, a light pipe & a vitrectomy cutter through each of the 3 ports. The infusion cannula keeps a constant pressure in the eye while the vitrectomy cutter removes the vitreous gel and vitreous hemorrhage. As the gel is removed, balance salt solution replaces the gel in the vitreous cavity. The gel that is adherent to the retina is gently lifted off the optic nerve and macula to separate the vitreomacular adhesions. The light pipe is used by the surgeon to see the vitreous being removed inside the eye. After the hemorrhage and gel are removed, your physician will identify any retinal breaks, tears or detachments and surround them with laser. If a detachment is present, the surgeon will drain out the fluid below the retina, to repair the detachment, and laser around any tears or holes. In these cases, an intravitreal gas bubble (C3F8 or SF6) will be used to hold the retina in place until the laser treatment forms a scar and adhesion around the tear(s) that caused the detachment. After enough vitreous is removed the surgeon removes the surgical instruments and trocars (3 ports) and the operation is complete. No sutures are typically needed in up to 95% of cases. Antibiotic ointment and a patch are placed over the eye for one night and removed the following day by the technician in our office.
Risks and Benefits of Surgery
The benefits of vitrectomy surgery, in general, are the potential for improved vision, reduced distortion of straight lines (when present pre-operatively), and reduction or elimination of floaters.
In the case of a hemorrhagic PVD with a retinal tear or detachment, hidden by overlying blood, the benefit of early surgery is to prevent the tear from progessing into a detachment or to prevent a small detachment from enlarging which can make the eventual repair more difficult or complicated.
Some of the risks of vitrectomy surgery include:
-More rapid cataract progression (in up to 20% of patients the lens may harden or become cloudy more rapidly after the vitreous gel is removed) that may require cataract surgery 1-2 years after the vitrectomy procedure.
- Vitreous (less than 5%) or choroidal (less than 1%) hemorrhage
- Retinal break or tear (less than 5%) or Retinal Detachment (less than 1%)
- Infection/Endophthalmitis (less than 1 in 500 patients)
-Permanent loss of vision/Blindness (approx. 1 in 10,000)
-These are some of the more common and serious side effects of surgery but there are additional risks of surgery not listed above
Post Operative Care
Patients are typically started on antibiotic and steroid eyedrops the day after surgery. The frequency of these drops will be determined by your surgeon on the first post-operative day. Some patients have a temporary increase in intraocular pressure after even uncomplicated surgery and may require additional pressure lowering drops or oral medication.
Post Operative Expectations
Vision is usually blurry the first day after surgery but typically improves to equal or better than your pre-operative vision about a week after surgery. Continued visual improvement often occurs over the first 6-8 weeks but some patients experience improvement even up to 6 months after surgery.
Patients typically experience little to no pain following surgery. Surface or external irritation (feeling of having something in your eye) is common. A deeper or more intense eye pain in not typical and may signal a more serious issue such as high intraocular pressure, serous or hemorrhagic choroidals or infection. A deeper or more intense eye pain needs to be reported to your physician immediately.
Post Operative Restrictions
Post-operative restrictions are for 4 weeks after surgery and include:
-Anything that creates a Valsalva Maneuvers such as coughing, sneezing, blowing your nose, straining with bowel movements or exertion, and some of the following:
-Bending at the waist putting your head below your belt line (such as bending to tie your shoes). Bending at the knees with your head up is allowed.
-Heavy lifting greater than 15-20 lbs.
-Strenuous activity (including lifting weights, running, yoga, pilates, aerobics, yard work, snow shoveling, laundry, housecleaning, sexual intercourse) is not recomended as it will increase your risk of developing a retina tear or detachment. Walking, for exercise, after surgery is allowed (in patients who do not require post-operative head down position).
-Showering is allowed immediately after surgery but be sure to keep your eyes closed to prevent shower water from entering your eye.
-Swimming after surgery should be avoided for 4 weeks. You may go into a pool (not under water for the first 4 weeks).
-Working restrictions are job dependent. Patients with desk jobs or who perform light stationary office work may sometimes resume work 2-3 days after surgery. Patients with jobs that require heavy lifting or strenuous activity may be required to be out of work for 2-4 weeks. Ask your physician about your individual work restrictions. We will be happy to provide you with a doctor’s note for your work and/or complete your temporary disability paperwork.
-Driving restrictions will be dependent on your post-operative vision and should be discussed with your physician after surgery.
*Please note that this information is for illustrative purposes only, providing a general overview on the topics listed. For any specific questions or concerns regarding your condition, please contact our office so that you can consult with the appropriate person or department to address your needs.