Having finally agreed to a vitrectomy, Professor Nathan Efron’s seeks to calm his anxiety by gathering information on the next step of his personal journey of retinopexy, cryopexy, vitrectomy and IOL surgery.
Being an academic optometrist skilled in techniques for accessing the scientific literature, I was able to fully inform myself about the vitreoretinal surgery to which I was now committed. In particular, I was a little anxious about two aspects of the surgery – the planned epiretinal membrane (ERM) peel, and the decision as to whether my eye would be filled with oil or air at the end of the procedure – and sought to find more information relating to these issues.
The literature wasn’t much help in getting a feel for the likely outcome following an ERM peel, because most of the reported cases involved patients who already had substantially reduced vision prior to surgery. Nevertheless, it was comforting to learn that in the vast majority of those cases, there was a substantial improvement in vision with reduced visual distortions. The literature was silent in respect of my situation, which was removing the ERM from an eye with good visual acuity. Figure 1 shows an OCT scan of my right eye prior to my retinal tear, and 43 months after the tear. The formation of an ERM after the tear is evident, albeit subtle, my wife Suzanne tells me, compared to the pucker and resultant macula oedema she has seen in some of her own optometry patients.
The literature addressing the question of whether to replace my vitreous with oil or air as a tamponade was somewhat equivocal. There appeared to be no clear evidence for superior outcomes with one technique or the other, except that silicone oil is regarded as a more secure tamponade and it can be left in the eye for a few weeks. It is typically used where there is judged to be a greater risk of retinal detachment after surgery. A post-operative increase in intra-ocular pressure was the main risk of oil. Air only has a full tamponade impact for a few days, because it starts resolving immediately, and is fully resolved after about 10 days.
This instruction was emphasised so strongly and repeatedly that I started to wonder if this was really a euphemism for not having sex!
As well as reading the academic literature, I decided to spend some time looking at patient forums on the internet. These turned out to be very revealing, and seemed to be very biased against silicone oil. A number of people complained that following their vitrectomy, some silicone oil remained behind and formed into small silicone balls which would roll around inside their eye, resulting in annoying and distracting entoptic phenomena (not a term they used). The other big disadvantage of using oil is that eventually it has to be surgically removed.
Discussing the Surgical Approach
I had a pre-surgical review visit with Bill one week before the scheduled vitrectomy. I told him that I was a little nervous about the ERM peel, but was happy to accept his preference to proceed with this. On the question of oil versus air, Bill advised that because my retinas were well attached he would probably use air, but would make his final decision on this during surgery. He asked if I had any further questions. I said “no”, to which he replied with a smile, “See you next Friday then”.
Before I left Bill’s office I was handed the usual glossy folder with all the paper work, including informed consent, hospital admission and medical history forms. I was also asked to obtain a letter from my general medical practitioners verifying that I was fit for surgery. A bit of an overkill, I thought, but I went ahead anyway and got my doctor to complete and sign the form.
I was also bombarded with other instructions. I was to instil Systane eye drops three times per day, and Polyvisc eye ointment before bed, for three days prior to the vitrectomy. I suppose Bill likes being presented with a well-lubricated eye at surgery. I was not to have anything to eat or drink for four hours prior to surgery. I was not to get any water near my eyes for two weeks following surgery. I was reminded that I would need to engage in ‘posturing’ (position my head to face the floor) for extended periods for three days following the operation. I was advised that I would receive a phone call around 4.00pm the day before the operation to tell me of the admission time. I registered my preference for an early start. I was given a minim of mydriatic (1 per cent cyclopentolate hydrochloride) to instil in my right eye one hour before my admission time.
One instruction that was stressed verbally and in writing was that for two weeks following surgery I must not engage in anything particularly energetic or lift heavy objects. This instruction was emphasised so strongly and repeatedly that I started to wonder if this was really a euphemism for not having sex!
Here We Go
Admission time was 6.30am, which suited me perfectly. As one of the first procedures of the day, Bill would be fresh, and I wouldn’t have time to get hungry…
I duly presented at the allotted time with a nicely dilated right pupil. All of the pre-surgical formalities were as before: red hair net (allergic to penicillin), dark blue gown, light blue show covers, marker pen cross on my forehead above the eye to be operated (right), more mydriatic and anaesthetic drops and blood pressure taken. I was also given two Panadol tablets.
I had not forgotten the unfortunate incident of a surgical assistant bumping the operating table during my retinopexy procedure three-and-a-half years ago, so I again jotted down the following ‘concerns’ in the open field box on the pre-surgical admission form that invited such comments: “please instruct assisting theatre staff to avoid bumping the operating table during surgery”. The admissions nurse said she would pass on this concern.
I was led through to another pre-surgical room, a pre-heated blanket was placed on my lap, and the anaesthetist appeared and proceeded to insert a cannula in my left arm. After studying my case notes, he looked up and said (with a slight smile), “Professor of Optometry, eh? So you know what’s going on here then”… to which I replied (with a big smile), “Yes, I know exactly what’s going on here”. To which he replied (with an even bigger smile), “Hmmmmm… I’ll give you a nice, deep sedation, then”.
I was led through to the operating theatre, where I was made comfortable on the operating table, which was actually like a large armchair that laid back flat. The anaesthetist connected a syringe to the cannula in my arm… and that’s just about all I remember about the operation. I recall seeing bright lights and shadows, presumably as instruments were inserted and manipulated in my eye, but I couldn’t feel anything and was comfortable throughout.
All of a sudden, or so it seemed, I was wide-awake and upright, and was asked to swing around slowly and step off the operating chair into a wheelchair. My right eye was covered with a gauze patch, which in turn was covered with a protective transparent plastic shield. Bill was still there – it was the first time I had been aware of his presence that day – and he simply said, “All went well, Nathan, and I have put air in your eye”. Great news!
I was wheeled through to the recovery area, and given sandwiches and coffee. Bill’s assistant surgeon appeared after about 20 minutes, removed my eye patch, and had a peer in with his head-mounted indirect ophthalmoscope. “All looks fine… you are going to have a lot of fun with that bubble,” he blurted. I was given a pre-prepared package of eye drops and ointments to administer during the post-operative recovery phase, with a bill for payment to the local chemist. I was also instructed about posturing (more about that in a later blog), and told to sleep with my left cheek against the pillow for the next few nights. And yet again, “no physical exertion” (nudge nudge, wink wink).
Suzanne then appeared in the recovery room, led me to her car, and drove me home. This was all a very slick arrangement, I thought, having been admitted at 6.30am and arriving home by 9.00am.
But I really wasn’t prepared for the drama that was about to unfold…
Professor Nathan Efron is a researcher at the Institute of Health and Biomedical Innovation and School of Optometry and Vision Science, Queensland University of Technology. He is currently President of the Australian College of Optometry and Vice-President of the International Society for Contact Lens Research.