Vitrectomy surgery removes the gel inside the eye through tiny openings to repair the retina, treating retinal detachment, macular hole, epiretinal membrane and diabetic bleeding. The eye is then filled with air, gas or silicone oil while the retina heals. Our retina surgeons plan the operation, head positioning and your length of stay around the gas bubble, since flying is safe only once it has cleared.
About This Department
Ophthalmology
Vitrectomy removes the gel inside the eye to reach and repair the retina. Surgery then treats detachments, macular holes and bleeding that would otherwise cost sight.
Vitrectomy surgery, or pars plana vitrectomy, is an operation in which a retinal surgeon removes the vitreous, the clear gel that fills the back of the eye, through three openings smaller than a millimeter, and then repairs the retina underneath. It treats retinal detachment, macular hole, epiretinal membrane, bleeding into the eye from diabetes, infection, injury and a lens that has slipped into the back of the eye. At the end of the operation the surgeon fills the eye with saline, a gas bubble or silicone oil to hold the retina in place while it heals. In a European trial of retinal detachment in eyes that had already had cataract surgery, vitrectomy reattached the retina with a single operation in 72 percent against 53 percent with a scleral buckle (Heimann and colleagues, Ophthalmology, 2007). This page explains what vitrectomy is, the conditions it treats and the results, the operation, the gas bubble and head positioning, recovery, risks, and how patients from abroad plan treatment and travel at Biruni Hospital in Istanbul.
72
Percent of detachments in eyes after cataract surgery repaired with one vitrectomy, against 53 percent with a scleral buckle
9
Times higher odds of macular hole closure with a single operation when the inner retinal membrane is peeled
20/40
Average vision two years after treatment for diabetic bleeding into the eye, from 20/200 at the start
Free
Review of your eye scans and reports by our retina team
The vitreous is a clear gel that fills the back two thirds of the eye. In youth it is firmly attached to the retina, the light-sensitive layer that lines the eye. With age it liquefies and pulls away, and where it tugs too hard it can tear the retina, wrinkle it or open a hole in its center. Removing the gel relieves the pull and gives the surgeon direct access to the retina.
The parts of the eye involved
Part
What it does
What can go wrong
Vitreous
Clear gel filling the eye
Clouding with blood, pulling on the retina, floaters
Retina
Turns light into nerve signals
Tears, detachment, scarring
Macula
Center of the retina, for reading and faces
Hole, wrinkled membrane, swelling
The eye does not need the vitreous once it is removed. The space fills with the eye's own fluid within days to weeks.
Reasons for vitrectomy
1
Problems of the retina
Retinal detachment, scar tissue that pulls the retina after a detachment, and damage from injury.
Each condition has its own urgency. A detachment threatening the center of vision needs surgery within days, while a slowly worsening membrane can be operated when it starts to affect daily life.
2
Problems of the macula
Macular hole, epiretinal membrane, and pull on the macula by the vitreous, called vitreomacular traction.
Conditions treated with vitrectomy
Condition
Symptoms
Urgency
Retinal detachment
Shadow or curtain, flashes, many new floaters
Days
Macular hole
Dark spot in the center, distorted reading
Weeks
Epiretinal membrane
Wavy lines, blurred central vision
Elective
Diabetic bleeding or traction
Sudden cloudy vision, dark streaks
Weeks, sooner if the retina is pulled
Infection inside the eye, endophthalmitis
Pain, redness, rapid loss of vision
Hours
Lens fragment or lens implant in the vitreous
Blur, inflammation after cataract surgery
Days to weeks
Retinal detachment
1
Warning signs
A sudden shower of floaters, flashes of light, or a shadow spreading from the edge of vision. These need examination by an eye doctor the same day.
Scleral buckle against vitrectomy, 681 patients in five European countries
Measure
Scleral buckle
Vitrectomy
Reattached with one operation, eyes after cataract surgery
53.4 percent
72.0 percent
Redetachment, eyes after cataract surgery
39.8 percent
20.4 percent
Vision gain, eyes with their natural lens
Greater
Smaller, and cataract progressed faster
For eyes that have already had cataract surgery, vitrectomy is now the usual choice. In younger patients with their natural lens and simpler detachments, a scleral buckle, a silicone band stitched to the outside of the eye, remains a strong option because it avoids cataract. Some detachments are repaired with an injected gas bubble and freezing treatment in the clinic, called pneumatic retinopexy.
No difference in vision was demonstrated in eyes after cataract surgery, and based on a better anatomical outcome, the investigators recommended vitrectomy in these patients (Heimann and colleagues, 2007).
Why timing matters
The macula decides the outcome.
While the center of the retina is still attached, prompt surgery gives the best chance of keeping reading vision. Surgeons schedule it within a day or two. Once the macula has come off, the cells that give sharp central vision start to suffer, and although surgery the same week still reattaches the retina, the final reading vision depends on how long the macula was detached. Days count. A detachment that has lasted weeks can also develop scar tissue, which makes repair harder and raises the chance of a second operation. For a patient abroad who notices a shadow in the vision, the first step is an eye examination at home the same day, and travel for surgery makes sense only if it does not delay treatment.
Macular hole and epiretinal membrane
1
Macular hole
A small full-thickness opening in the center of the retina, caused by the vitreous pulling as it separates. Reading becomes difficult and a dark spot appears in the center of vision.
Peeling the inner membrane in macular hole surgery, four randomized trials
Outcome
Result
Meaning
Hole closure with one operation
Odds ratio 9.27 in favor of peeling
Far more holes close the first time
Need for another operation
Odds ratio 0.11
Repeat surgery much less often
Vision at 3 months
Better with peeling
Faster recovery
An epiretinal membrane is a thin layer of scar tissue on the surface of the macula that wrinkles it, bending straight lines and blurring central vision. Surgery removes the membrane with fine forceps. Vision improves over months, and distortion lessens though it may not vanish completely.
The evidence for peeling
Available evidence supports internal limiting membrane peeling as the treatment of choice for patients with idiopathic stage 2, 3 and 4 full-thickness macular hole (Spiteri Cornish and colleagues, Ophthalmology, 2014).
Diabetic eye disease
Among eyes with vitreous hemorrhage from proliferative diabetic retinopathy, there was no statistically significant difference in vision over 24 weeks between initial aflibercept injections and vitrectomy with laser, and both groups reached an average of 20/40 at two years (Antoszyk and colleagues, JAMA, 2020).
1
Faster clearing with surgery
Vitrectomy cleared the blood sooner, and vision at four weeks was better in the surgery group. Injections avoided an operation for two thirds of patients.
In diabetes, abnormal new vessels grow on the retina and bleed into the vitreous or contract and pull the retina off. Vitrectomy removes the blood and scar tissue, and laser treatment during the same operation calms the vessels. The choice between injections first and surgery first depends on how much the retina is pulled, whether the other eye sees well, and how quickly the patient needs vision back, for work or driving.
Injections or surgery first
Situation
Usual first choice
Reason
Bleeding without pull on the retina
Either, discussed with the patient
Similar results at two years
Retina pulled off at the center
Vitrectomy
Only surgery releases the traction
Only seeing eye, vision needed quickly
Vitrectomy
Faster clearing
Unfit for surgery
Injections
Avoids an operation
Other reasons
Infection inside the eye, severe injury and a lens fragment left behind after cataract surgery also call for vitrectomy. Several need emergency care.
Floaters
Most floaters need no surgery.
Floaters come from clumps in the vitreous that cast shadows on the retina, and they grow more common with age and short-sightedness. The brain learns to ignore most of them within months. Some fade on their own. Vitrectomy for floaters is offered only when they seriously disrupt reading, work or driving for a long time, since the small risks of the operation, including cataract and retinal detachment, must be weighed against a symptom that is not dangerous in itself.
The operation
What fills the eye after surgery
Tamponade
How long it lasts
Main uses
Air or saline
Days
Membrane peeling, bleeding
SF6 gas
About two weeks
Macular hole, many detachments
C3F8 gas
Six to eight weeks
Complex detachments
Silicone oil
Until removed in a second operation, after months
Severe or repeated detachments, scar tissue
1
Step by step
Local anesthesia with an injection around the eye, sometimes with sedation, or general anesthesia for long or complex cases. Three tiny ports are placed in the white of the eye. A light pipe, an infusion line and a fine cutter enter through them, and the surgeon removes the gel under a microscope, peels membranes, applies laser to tears and flattens the retina. The ports are usually self-sealing. The operation takes 30 minutes to two hours.
Modern vitrectomy uses instruments of 25 or 27 gauge, about half a millimeter across. The openings heal without stitches. When a cataract is present, the surgeon can remove it and place a lens implant in the same session.
The gas bubble and positioning
A gas bubble presses the retina into place from inside while it heals. It rises, so the head position decides where it presses.
After macular hole surgery or some detachment repairs, the surgeon asks the patient to keep the head in a set position, face down or to one side, for several days. The instructions differ by case. Special pillows and a mirror make face-down positioning bearable. Vision through a gas bubble is very blurred, and it clears from the top down as the gas is absorbed.
Can I fly or travel to the mountains with gas in my eye?
No. Air travel and high altitude make the bubble expand, which can raise the eye pressure dangerously and cause permanent loss of sight. Flying is safe only once the surgeon confirms the gas has gone, about two weeks for SF6 and six to eight weeks for C3F8. Nitrous oxide anesthesia must also be avoided, and patients wear a wristband stating that gas is in the eye.
Silicone oil does not expand, so patients with oil can fly.
1
Sleeping
Patients with gas must not sleep flat on their back, since the bubble can press on the lens and cause cataract or raise the pressure.
Recovery
Recovery after vitrectomy
Time
What to expect
Activities
Day 1
Check-up, eye pressure measured, patch removed
Positioning if instructed, drops start
Week 1 to 2
Gas bubble shrinking, vision blurred
Light activity, reading limited by the bubble
Weeks 2 to 8
Gas gone, vision improving
Most normal activity, flying once cleared
Months 3 to 6
Final vision after macular surgery
Glasses prescription updated
Drops continue for about a month. Heavy lifting, swimming and dusty environments are avoided for two weeks. Vision recovers faster after membrane peeling with air than after detachment repair with long-acting gas, and a new glasses prescription is checked once the eye settles.
Risks
Cataract, the commonest consequence, developing within one to two years in most eyes that still have their natural lens.
Raised eye pressure in the first days, treated with drops.
A second operation, needed when the retina detaches again or a hole fails to close.
Less common complications
Complication
How common
Treatment
Retinal detachment after other vitrectomy
A few percent
Further surgery
Bleeding inside the eye
Uncommon
Clears or is washed out
Serious infection, endophthalmitis
Rare, well under 1 in 1,000
Same-day antibiotics injected into the eye
Cataract after vitrectomy is removed with routine cataract surgery once it affects vision, and the result is usually good.
For patients from abroad
The gas bubble decides the length of stay. You cannot fly until it has gone.
1
Length of stay and fitness to fly
For membrane peeling with air, about one week. For macular hole or detachment repair with SF6 gas, two to three weeks in Istanbul until the gas clears. For C3F8, six to eight weeks, and for many patients silicone oil is the practical alternative, since patients with oil are fit to fly within days. The surgeon discusses the choice before surgery.
Before traveling, send recent OCT scans, retinal photographs and your eye doctor's report. For a fresh retinal detachment, surgery at home without delay usually serves the eye better than traveling, and we say so honestly. Planned surgery, such as for an epiretinal membrane, macular hole or diabetic bleeding, suits travel well.
One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number once you are back home. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages, and it arranges the visa invitation letter, airport transfers, daily transport and accommodation near the hospital. Halal, vegetarian and diabetic meals, a prayer room on site, and a female physician on request wherever the rota allows.
Planning travel around the tamponade
Tamponade
Earliest flight
Note
Air
About one week
Surgeon confirms air has cleared
SF6 gas
About two weeks
Confirmed at a check-up
C3F8 gas
Six to eight weeks
Long stay, oil considered instead
Silicone oil
Within days
Second operation to remove oil, here or at home
Plan the return flight only after the surgeon confirms the eye is ready.
Cost
The price depends on the condition, the complexity of the operation, the tamponade used, whether cataract surgery is combined, and the anesthesia. Silicone oil means a second operation to remove it later. Quotes are given per eye.
What a quote for vitrectomy covers
Item
Included
Priced separately
Before surgery
Consultation, OCT and ultrasound scans
Additional imaging such as angiography
Surgery
Operation, anesthesia, gas or oil, day-case or one-night stay
Combined cataract surgery and lens, silicone oil removal
Aftercare
Drops, check-ups during the stay
Accommodation during a long gas stay
References
Heimann H, Bartz-Schmidt KU, Bornfeld N, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment. A prospective randomized multicenter clinical study. Ophthalmology. 2007;114(12):2142-2154.
Spiteri Cornish K, Lois N, Scott NW, et al. Vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole. Ophthalmology. 2014;121(3):649-655.
Antoszyk AN, Glassman AR, Beaulieu WT, et al. Effect of intravitreous aflibercept vs vitrectomy with panretinal photocoagulation on visual acuity in patients with vitreous hemorrhage from proliferative diabetic retinopathy. A randomized clinical trial. JAMA. 2020;324(23):2383-2395.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Assistant Professor Selin ŞİMŞEK ALKAN, Ophthalmology.
