(1)
St. Johns, FL, USA
(2)
Helen Keller Foundation for Research and Education, International Society of Ocular Trauma, Birmingham, AL, USA
(3)
Consultant and Vitreoretinal Surgeon, Milos Eye Hospital, Belgrade, Serbia
(4)
Consultant and Vitreoretinal Surgeon, Zagórskiego Eye Hospital, Cracow, Poland
Of all the pieces on the surgeon’s decision-making palette, the easiest to influence is the time when the surgery is to be done. In many conditions delaying the operation means that the vision will gradually worsen, and the worse the visual acuity at the time of the operation, the less likely that the improvement will fully restore what has been lost.1
Pearl
As a general rule (exceptions exist), the earlier surgery is performed, the easier the procedure technically is and the better the prognosis.
Still, it is impossible to issue blanket advice about the urgency of VR surgery,2 and every decision should be an individualized one tailored to the particular circumstances. Table 9.1 shows the decision-making process in various conditions and Fig. 9.1 the strategic thinking in timing decisions.
One issue to consider in each case if the surgery is elective is whether certain systemic medications need to be suspended or modified preoperatively. This is briefly discussed in Sect. 40.1.
Table 9.1
Indication-specific considerations related to timing
Indicationa | Comment |
|---|---|
BRVO | This is mostly a macular edema indication, even if the case is amenable to sheathotomy |
Cataract | True urgency, even emergency, is present if the lens is swelling and causes high IOPb; in the presence of a broken capsule, this is rather common in children and very uncommon in older patients The opaque lens should be removed very early if there is suspicion/confirmed presence of a retinal condition requiring urgent PPV |
Cellophane maculopathy | This is not an urgent indication, the timing is primarily determined by the severity of the patient’s complaints |
CRVO | The rationale for early surgery is to remove the VH so that the retina can be visualized; otherwise, it is basically a macular edema indication |
Dropped nucleus | The issue is less medical than psychological and one of empathy. Delaying the reconstructive vitrectomy increases patient anxiety without any benefit regarding functional outcome. If a VR surgeon is available at the time when the complication during cataract surgery occurs, it is best to perform immediate PPV |
EMP | This is not an urgent indication; the timing is primarily determined by the severity of the patient’s complaints. Increased thickness of the membrane and its tractional consequences can make surgery more urgent |
Endophthalmitis | For me this is an urgent indication: as soon as the diagnosis is made, I prefer performing complete and early PPV (CEVE)c |
Glaucoma
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