The new standard in Vitreoretinal surgery

The minimally invasive vitrectomy or MIVs (Vitreoretinal Mini Invasive Surgery) using 27 gauge is the latest development in the field of retinal surgery and the macula.

It seems to be the future for any operation on the retina, and Dr. Panico is one among the first few in Europe to use it since 2011. Click here for more information on Vitrectomy

The macular pucker refers to the wrinkling of the macula or epiretinal membrane. It is a membrane composed of a thin fibrous layer that is formed on the macula which is located in the centre of the retina.

A patient suffering from macular pucker experiences

1. A distortion of the images also known as metamorphopsia, both in the near vision with distortion of characters while reading, and far vision with the deformation of the images while watching television, etc.

2. A reduction of central vision.

Distorted Image

In the early stages, distortion and visual impairment are minimal and tolerable. When the symptoms are persistent, it is important to immediately take action rather than to compromise the reading and or driving. No matter how mild the symptoms, it is necessary to intervene and operate as soon as possible before the problem aggravates. This treatment is exclusively surgical. 

At Dr. Panico’s Clinic we practice a minimally invasive surgery using the latest production technologies, that are practiced only in a few centers in Italy.

How to start a macular pucker?

The vitreous humor is a gel-like substance attached to the retina, which fills the eyeball behind the lens.

During the first years of life, the vitreous has quite a solid consistency. With the passing years it begins to dehydrate, reducing in volume and detaching along the anterior - posterior axis of the surface of the retina in the posterior pole level. In most cases this posterior vitreous detachment, takes place without any negative effect.

The patient may experience the so-called floaters but no significant damage is done to the eye. In some individuals, however, there are areas where the vitreous is more closely attached to the retina. If condensation occurs prior to the displacement, the retina can give in to traction, leading to the formation of microscopic damage of its surface. It forms a thin fibrous layer known as Macular Pucker. 

In most cases, this attempt that the retina adopts to repair itself is slight. It forms a thin transparent layer without tractions, with little or no adverse effect on the visual function. In other cases, however, this process can be excessive, with the formation of an opaque and thick membrane on the surface of the macula. The process is still very slow and tends to restrain itself over time and stop. However, the cells that make the membrane can begin to exhibit contractile properties and to deform the same membrane. Since the pucker is attached to the retina, it also begins to deform, in association with the progression of the disease. 

Macular Pucker

How to diagnose a macular pucker?

The diagnosis of macular pucker can be made only by an ophthalmologist, through:

• An examination of the fundus, after dilation of the pupil.

• An Optical Coherence Tomography (OCT) which is a modern and non-invasive examination process essential in the diagnosis to provide a quantification of the problem. The OCT is an ultrasound which replaced ultrasound with a laser light. The amount of information gathered by the reflected beam of the eye is remarkably higher. It can recognize structures measuring 7 thousandths of a millimeter or 7 microns.

The OCT Heidelberg Spectralis Blue Peak, installed in Dr. Claudio’s clinic, is a UNIQUE instrument for imaging of the retina.

This technology combined with the active Eye tracking and blue laser auto fluorescence provides us the SENZA EQUAL tool for advanced diagnostics of the retina.

1. It can make 40,000 scans per second with measurable detail of each POCHI Micron (histology in vivo).

2. It performs functions from placing the same points of previous examinations, subsequent testing of the same patient, for capturing changes in retinal anatomy with a detail of 1 micron.

3. Autofluorescence

Without the injection of intravenous fluorescence, the light of OCT blue laser Heidelberg Spectralis exploits the spontaneous fluorescence of lipofuscin. It is a product of retinal metabolism that obtains fluorescent images. It follows the trend of the evolution of malattie affecting the macula according to precise patterns.

This helps people understand its usefulness in detecting any deterioration of maculopathy, pucker, edema and macular holes as well as central serous choroiditis and diabetic retinopathy.

 • Finally, a retinal fluorescence angiography (FAG) may be recommended when there are concerns about a disease.

Diagnosis of Macular Pucker
Fundus examination
Minimally invasive Vitectromia

What is macular pucker surgery?

DR. Panico practices a minimally invasive surgery, using cutting-edge technology available in only a few centers in Italy. He uses the method of VITRECTOMY 27G, involving three small cavities of the size of an insulin needle (400 microns) that are introduced in the white part of the eye (sclera). Within this flows micropinze, microforbici, bright fiber and a tool that cuts along the vitreous. This microprobe allows the removal of the vitreous through vitrectomy. With a microscopic clamp the membrane is then "peeled" from the retina, after staining of the same to increase their visibility. This process is called peeling. The crystalline layer is most often removed to provide a final solution post the surgery, else the cataract tends to develop again. The surgery is typically performed under local anesthesia with the injection given near the eye and the patient does not require hospitalization.

What are the results?

Recovery is subjective and is dependent on the degree of retinal impairment prior to surgery. The therapeutic goal is to stabilize the situation, and avoid a further deterioration of vision. If the patient’s eyesight is good before the surgery, then there is higher likelihood of improvement. It takes about 6 months and 25 weeks or more for complete visual recovery. In some cases, visual improvement takes a year.

What is the post-operative procedure for a macular pucker surgery?

The day after the surgery, the operated patient has to visit the doctor to make sure there are no early postoperative infections and if the intraocular pressure is normal. The patient is explained the protocol of postoperative infections.

Here are some precautions one needs to exercise after an operation:

• Carry a pair of sunglasses, because the eyes are more sensitive to light for some time

• Use antibiotic eye drops for 2 weeks

• Do not rub the operated eye for three weeks

• Use a protective plastic shell every night for a week

• Do not partake in strenuous activities for 2-3 days and please refrain from carrying children for a few days

 • Avoid a dusty or unhealthy environment for 2 weeks

• On the 3rd day you can shave, wash your face and take a shower but with caution

It is important that you see the doctor 3 times after the operation: after the day of surgery, after one week and three weeks after the surgery. 

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