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ISSN: 2155-9570
Journal of Clinical & Experimental Ophthalmology
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Early Postoperative Intraocular Pressure Elevation after Vitreoretinal Surgery

Pei Xu1, 2, 3, Ting Xia1, 4 and Jianbin Chen1*

1Department of Ophthalmology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China

2Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, Galveston, Texas, 77555, United States

3Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, Texas, 77555, United States

4Department of Ophthalmology, Puai Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China

*Corresponding Author:
Jianbin Chen
Department of Ophthalmology
Tongji Hospital, Huazhong University of Science and Technology
Wuhan, Hubei, 430030, People’s Republic of China
Tel: +8613886112782
E-mail: [email protected]

Received Date: January 16, 2017; Accepted Date: February 16, 2017; Published Date: February 20, 2017

Citation: Xu P, Xia T, Chen J (2017) Early Postoperative Intraocular Pressure Elevation after Vitreoretinal Surgery. J Clin Exp Ophthalmol 8:636.doi: 10.4172/2155-9570.1000636

Copyright: © 2017 Xu P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Objective: The evaluation of intraocular pressure (IOP) after vitreoretinal surgery is critical to ensure the normal function of the eye. The purpose of this study was to determine the incidences and risk factors of early postoperative IOP elevation after vitreoretinal surgery. Method: Data were collected and retrospectively analyzed from 150 patients (150 eyes) who received vitreoretinal surgery from March 2012 to December 2012 in Tongji Hospital. IOP was measured before surgery and on day 1, 2, 3, 4-7 after surgery by Goldmann applanation tonometer. Ocular hypertension was defined as IOP ≥ 24 mmHg. The incidences and risk factors were analyzed. Results: 87 of the 150 patients were male and 63 were female. The IOP was elevated significantly in 54 eyes (36.00%) within 1 week after vitreoretinal surgery. Among them, 31 eyes (57.40%) occurred on day 1; 14 eyes (25.93%) occurred on day 2. The incidences of elevated IOP between different primary diseases had no statistical difference (p>0.05). However, patients with proliferative diabetic retinopathy (PDR), and rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy (PVR) grade ≥ C2, had higher rates of IOP elevation. Vitrectomy combined with cataract surgery or scleral buckling had no significant difference in IOP elevation compared with vitrectomy only (p>0.05). The rate of IOP elevation between 20G pars-plana vitrectomy (41.76%) and 23G pars-plana vitrectomy (27.40%) had statistical difference (p=0.033). The incidence of IOP elevation with intraocular tamponade of C3F8 was significantly higher than simple vitrectomy (chi2=7.723, p=0.005), while with silicone oil, the difference was not significant (chi2=3.627, p>0.05). Conclusion: IOP measurement after vitreoretinal surgery is important to monitor and prevent unintentional high IOP as it is a common complication after vitreoretinal surgery. The risk factors of early IOP elevation include the 20G pars-plana vitrectomy and C3F8 injection. Early treatment of IOP may prevent IOP spike to protect the vison.

Keywords

Intraocular pressure; Vitreoretinal surgery; 20G parsplana vitrectomy; 23G pars-plana vitrectomy; Postoperative complication; C3F8; Silicone oil

Introduction

With the development of novel instruments and techniques, vitreoretinal surgery has been more and more widely used in the recent 50 years to treat a large variety of retinal pathology, such as retinal detachment, macular holes, epiretinal membranes, and proliferative vitreoretinopathy. Despite the accumulation of surgical experience, complications are still not rare in clinical practice, and some of which may have severe consequences. IOP elevation is one of the most common postoperative complications in vitreoretinal surgery. High IOP causes pain and discomfort in patients, more severely, the functionality of the eye may be permanently damaged. Therefore, a close monitor of IOP after vitreoretinal surgery is an important and routine examination in clinic. The incidence of postoperative IOP elevation has been reported as 3.6% to 22.2%; within 48 h, up to 40% of patients experienced an increased IOP [1-3]. Several risk factors have been related with high IOP after vitreoretinal surgery, such as the procedure of the surgery, the application of tamponade and the primary diseases of the patients [1,4,5]. However, these observations were conducted in different clinical studies separately; the data were collected from few hours to 1 day, or 1 month in the postoperative period [1,4-6]. The purpose of this study was to determine the incidence and rick factors of elevated IOP in the early stage (day 1, 2, 3, 4-7) after vitreoretinal surgery.

Methods

Patient cohort

Medical histories obtained from 150 patients (87 males and 63 females) undergoing vitreoretinal surgery between March, 2012 and December 2012 in Tongji Hospital were retrospectively reviewed. The average age was 50.1 ± 6.5 years (age range 3 to 79 years). As to the primary diseases, 14 eyes were oclular injuries, 36 eyes were PDR, 25 eyes were vitreous hemorrhage caused by retinal vascular diseases, 18 eyes were RRD with PVR grade ≥ C2, 88 eyes were RRD with PVR grade <C2. Exclusion criteria include: patients preoperative IOP above 29 mmHg or diagnosed with glaucoma or had family history of glaucoma, iris neovascularization, uveitis, prior intraocular surgery and penetrating eye injuries. All surgeries were performed by a single, experienced vitreoretinal surgeon. All the patients received 20G or 23G pars-plana vitrectomy (PPV). According to the intraoperative situation, additional procedures, such as scleral buckling, phacoemulsification with or without intraocular lens implantation, endolaser retinal photocoagulation, and endotamponades were performed during PPV. Endotamponades included balanced salt solution (BSS), gas (C3F8) and silicone oil. Operations ended up with normal IOP. Informed consent was obtained from all patients in this study.

IOP assessment

IOP was measured by Goldmann applanation tonometry on day 1, 2, 3, 4-7 after vitreoretinal surgery [6]. The average of 3 measurements was recorded.

Definition of IOP elevation

IOP elevation was defined as IOP ≥ 24 mmHg and prospective indication for treatment postoperatively was defined as ≥ 30 mmHg [7,8].

Follow-up and treatment for IOP elevation postoperatively

Patients were followed up at one week, 2 weeks, 4 weeks, 6 weeks, 2 months, 3 months, 6 months and 12 months. Examinations included best-corrected visual acuity (BCVA), IOP, anterior segment detection by slip lamp and fundus examination via indirect ophthalmoscopy. Eyes with IOP ≥ 30 mmHg were treated with topical or systemic antiglaucomatous medication, anterior chamber paracentesis, laser iridoplasty, and inferior iridectomy [9]. Oil removal with or without concurrent glaucoma surgery may be required in eyes with uncontrolled high IOP after silicone oil injection.

Statistical analysis

Statistical analyses were performed with SPSS 19 software (IBM, Armonk, NY, USA). Parametric data were presented as mean ± standard deviation (SD). Chi-square tests were used to compare the categorical data. P<0.05 was accepted as statistically significant.

Results

The incidences of early IOP elevation after vitreoretinal surgery

IOP elevation occurred within one week after vitreoretinal surgery (54 of 150 eyes, 36.00%). As shown in Figure 1, most patients experienced high IOP at day 1 (31 eyes, 57.40%) and day 2 (14 eyes, 25.93%) postoperatively. These data were in accordance with Han’s study [10].

clinical-ophthalmology-vitreoretinal-surgery

Figure 1: IOP elevation within one week after vitreoretinal surgery.

Early IOP elevation after vitreoretinal surgery in patients with different primary diseases

In 36 eyes with PDR, high IOP occurred in 15 eyes (41.76%). In 18 RRD eyes with PVR grade ≥ C2, high IOP occurred in 10 eyes (55.56%). In 38 RRD eyes with PVR grade <C2, high IOP occurred in 13 eyes (34.21%). In 25 eyes with vitreous hemorrhage caused by retinal vascular diseases, high IOP occurred in 7 eyes (28.00%). In 14 eyes with traumatic vitreoretinopathy, high IOP occurred in 4 eyes (28.57%). Among the rest of 19 eyes, 5 experienced high IOP (26.31%). Chi-square tests were used to analyze whether different primary diseases affected the incidences of early elevated IOP after vitreoretinal surgery. The Chi-square value was 5.345 (p=0.375), which indicated the incidences of early IOP elevation in eyes with different primary diseases had no statistical difference.

Early IOP elevation after vitreoretinal surgery in patients with different endotamponades

Endotamponades included BSS, gas (C3F8) and silicone oil. 5 of 30 eyes with BSS experienced high IOP (16.67%); 25 of 53 eyes with C3F8 experienced high IOP (47.17%); 24 of 67 eyes with silicone oil experienced high IOP (35.82%). Chi-square tests were used to analyze whether different endotamponades affected the incidences of early elevated IOP after vitreoretinal surgery. The Chi-square value was 7.738 (p=0.021), which suggested the incidences of early IOP elevation in eyes with different endotamponades had significant difference. Then, we tested the differences between C3F8 and silicone oil group (chi2=1.578, p=0.209), silicone oil and BSS group (chi2=3.627, p=0.057), as well as C3F8 and BSS group (chi2=7.723, p=0.005). The results implicated intraocular tamponade of C3F8 increased the rate of early IOP elevation after vitreoretinal surgery significantly (Tables 1 and 2).

Primary Diseases Total Eye Number High IOP eye number Incidences of IPO (%)
PDR 36 15 41.65
RRD with PVR grade ≥ C2 18 10 55.56
RRD with PVR grade <C2 38 13 34.21
Vitreous hemorrage caused by retinal vascular diseases 25 7 28
Traumatic Vitreoretinopathy 14 4 28.57
Others 19 5 26.31

Table 1: The incidences of early IOP elevation in eyes with different primary diseases.

Endotamponades Total eye number High IOP eye number Incidences of IOP (%)
BSS 30 5 16.67
C3F8 53 25 47.17
Silicone Oil 67 24 35.82

Table 2. The incidences of early IOP elevation in eyes with different endotamponades.

Early IOP elevation after vitrectomy combined with cataract surgery

In 37 eyes performed vitrectomy combined with cataract surgery, high IOP occurred in 18 eyes (48.65%). In 113 eyes underwent only vitreoretinal surgery, high IOP occurred in 36 eyes (31.86%). The Chisquare value was 3.411 (p=0.065), which indicated combined cataract surgery in vitrectomy did not affect the incidence of early postoperative IOP elevation.

Early IOP elevation after vitrectomy combined with scleral buckling

In 19 eyes performed vitreoretinal surgery combined with scleral buckling, high IOP occurred in 9 eyes (47.37%). In 131 eyes underwent only vitreoretinal surgery, high IOP occurred in 45 eyes (34.35%). The Chi-square value was 1.220 (p=0.269), which suggested combined scleral buckling in vitrectomy did not affect the incidence of early postoperative IOP elevation.

Early IOP elevation after 20G or 23G PPV

77 eyes received 20G PPV, 34 of them experienced early postoperative IOP elevation (41.76%). 73 eyes underwent 20G PPV, 20 of them experienced early postoperative IOP elevation (27.40%).

The Chi-square value was 4.568 (p=0.033), which implicated 20G PPV increased the rate of early postoperative IOP elevation.

Discussion

Vitreoretinal surgery is an effective treatment for a large variety of retinal pathology. Despite the application of novel instruments and techniques, as well as the accumulation of surgical experience, complications are still not rare in clinical practice. IOP elevation is a common postoperative complication following vitreoretinal surgery. High IOP not only causes pain and discomfort in patients, but also impair the functionality of the eye. Several risk factors of high IOP after vitreoretinal surgery have been mentioned in different clinical studies separately [1,4,5]. This study systemically analyzed the incidence and rick factors of elevated IOP in the early stage (day 1, 2, 3, 4-7) after vitreoretinal surgery (Tables 3-5).

Procedure Total eye number High IOP eye number Incidences of IOP (%)
PPV 113 36 31.86
PPV combined with cataract surgery 37 18 48.56

Table 3: The incidences of early IOP elevation in eyes performed vitrectomy combined with or without cataract surgery.

Procedure Total eye number High IOP eye number Incidences of IOP (%)
PPV 131 45 34.35
PPV combined with cataract surgery 19 9 47.37

Table 4. The incidences of early IOP elevation in eyes performed vitrectomy combined with or without scleral buckling.

Procedure Total eye number High IOP eye number Incidences of IOP (%)
20G PPV 77 34 41.76
23G PPV 73 20 27.4

Table 5: The incidences of early IOP elevation after 20G or 23G PPV.

We found that most patients experienced high IOP at day 1 (57.40%) and day 2 (25.93%) postoperatively. In Han’s prospective study, around 60% of patients had an acute IOP rise within 2 days of PPV [10]. Possible mechanisms of IOP elevation included inflammation response, pupillary block, ciliary body edema and hemorrhagic complications [10,11]. Prolonged IOP elevation Longstanding increased IOP may occur if patients did not receive appropriate early intervention at this stage.

Several risk factors have been related with high IOP after vitreoretinal surgery, such as the primary diseases of the patients, the application of tamponade, and the procedure of the surgery [1,4,5]. We found that the incidences of elevated IOP between different primary diseases had no statistical difference. However, patients with PDR and RRD with proliferative vitreoretinopathy (PVR) grade ≥ C2, had higher rates of IOP elevation. Actually, Muether’s group reported that patients with PDR traction RD and primary RRD were at high risk for long-standing increased IOP [1].

Emulsification of the silicone oil and gas filling may also lead to early IOP rise [5,12,13]. We found that the incidence of IOP elevation with intraocular tamponade of C3F8 was significantly higher than simple vitrectomy, while with silicone oil, the difference was not significant. Therefore, silicone oil injection did not increase the rate of postoperative IOP elevation in the absence of emulsification. While the use of expanding gas tamponade may lead to increased IOP through iridocorneal apposition or pupillary block.

Hasegawa’s group showed that combined cataract surgery was a risk factor for IOP elevation [4]. However, another study reported that phacoemulsification could easily adjust and control IOP to reduce complications during and after the vitreoretinal surgery [14]. We found that combined cataract surgery in vitrectomy did not affect the incidence of early postoperative IOP elevation. Considering cataract surgery may be more challenging after vitrectomy, removing the lens with or without intraocular lens implantation can be performed if it is needed during surgery.

Placement of a scleral buckle intraoperatively was mentioned as a risk factor in early postoperative IOP elevation of vitreoretinal surgery [10]. However, our data showed that scleral buckling in vitrectomy did not affect the incidence of high IOP. The different results may be explained by the variety of the primary diseases of the patients and the experiences of the vitreoretinal surgeon. We also compare the incidences of early high IOP after 20G and 23G PPV. Results suggested that 20G PPV increased the rate of early postoperative IOP elevation.

In Zhang’s study, IOP was statistically significantly lower in the early stages after 23G PPV because of choroidal detachment [15]. However, we did not detect this complication in the follow-up of our patients. Again, the inconsistence of the results implicated the complex impact factors in early postoperative IOP elevation of vitreoretinal surgery.

In conclusion, early IOP elevation is a common complication after vitreoretinal surgery. IOP measurement after vitreoretinal surgery is important to monitor and prevent unintentional high IOP. The risk factors of early IOP elevation include the 20G pars-plana vitrectomy and C3F8 injection. Early treatment of IOP may prevent IOP spike to protect the vison.

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