Retina and Macula Surgery in Toulon: Vitrectomy, Retinal Detachment, Epiretinal Membrane

Retinal surgery covers all the procedures that treat diseases of the back of the eye — the vitreous, the retina and the macula (the centre of the retina responsible for fine vision). It treats epiretinal membrane, retinal detachment, macular hole, vitreous haemorrhage and the complications of diabetic retinopathy. The main technique is vitrectomy, performed through micro-incisions of less than 1 mm. Scleral buckling remains preferred for retinal detachment in young patients. The surgeon specialising in these operations is called a retina specialist (vitreoretinal surgeon). Some conditions (wet AMD, macular oedema) are treated medically with intravitreal injections or argon laser. At the Centre Iris – Institut Toulonnais d’Ophtalmologie and the Clinique Saint-Michel ELSAN, Dr Hugo Bourdon manages the main retinal conditions in Toulon and the Var.

Expert insight on retinal surgery

“Retinal operations are among the most meticulous in ophthalmology: they demand micrometric precision and excellent command of the instruments. Fortunately, the evolution of minimally invasive vitrectomy (25 and 27 Gauge) and the latest-generation equipment now allow faster and more comfortable visual recovery. A retinal detachment or a vitreous haemorrhage nonetheless remains an emergency: the earlier the treatment, the better the visual prognosis.”

Dr Hugo Bourdon

What is retinal surgery?

Retinal surgery refers to all the operations treating diseases of the back of the eye — those affecting the vitreous (the transparent gel filling the inside of the eye), the retina (the thin neurosensory membrane lining the back of the eye) and the macula (the centre of the retina responsible for fine vision, detail and colour).

It is performed by specialist ophthalmic surgeons called retina specialists. It is a subspecialty of ophthalmic surgery for which the ophthalmologist completes specific additional training (vitreoretinal surgery diplomas, fellowships).

Retinal operations restore or maintain useful vision in the face of conditions that, untreated, most often lead to severe vision loss or even blindness. It is important to note that retinal surgery does not act on refractive errors (myopia, hyperopia, astigmatism, presbyopia), which fall under refractive surgery.

Which retinal diseases are operated on?

The main retinal conditions requiring surgical treatment are:

• Epiretinal membrane — a thin scar-like “skin” that forms on the surface of the macula and puckers it, distorting vision (metamorphopsia) and blurring it. Treated by micro-forceps peeling during a vitrectomy.
• Macular hole — a full-thickness perforation at the centre of the macula, causing a dark central spot (scotoma) and a marked drop in vision. Treated by vitrectomy with internal limiting membrane peeling and gas tamponade.
• Retinal detachment — fluid accumulating under the retina, caused by a tear. It shows as a black veil or curtain invading the visual field, sometimes preceded by flashes of light or floaters. A surgical emergency to be treated by vitrectomy or scleral buckling within 24 to 72 hours.
• Vitreous haemorrhage — blood in the vitreous body, suddenly blurring vision. It can be caused by a retinal tear, diabetic retinopathy or a complicated posterior vitreous detachment. Treated by vitrectomy if it does not clear on its own.
• Disabling floaters — in selected cases, large and persistent floaters can be removed by vitrectomy.
• Macular haematoma — a complication of exudative AMD that may require vitrectomy with injection of products into the macula.

Conditions treated medically (without surgery)

Some retinal diseases are treated medically (injections or laser) in the office, without going to the operating room:

• Wet AMD — the exudative form of age-related macular degeneration is treated with intravitreal anti-VEGF injections (Lucentis®, Eylea®, Vabysmo®) repeated at regular intervals.
• Retinal vein occlusions (CRVO, BRVO) — thromboses of the retinal veins causing macular oedema. Treated with anti-VEGF or corticosteroid injections (Ozurdex® implants).
• Diabetic retinopathy — vascular complications of diabetes in the retina. Treated with argon laser (panretinal photocoagulation) at advanced stages, and with injections for diabetic macular oedema.
• Retinal tears without detachment — sealed preventively with argon laser to avoid progression to retinal detachment.

Surgical techniques in retinal surgery

Vitrectomy — the gold standard

Vitrectomy is the main technique of retinal surgery. It involves introducing three complementary instruments into the eye through 3 micro-incisions of 0.4 to 0.5 mm (25 or 27 Gauge vitrectomy):

• A vitreous cutter — a rotating instrument that aspirates and cuts the vitreous in a controlled way
• An endo-illumination fibre — lights the inside of the eye so the surgeon can view the retina under the microscope
• An infusion line — maintains the intraocular pressure by replacing the aspirated vitreous volume

The surgeon can then, as needed: peel membranes from the retinal surface with micro-forceps, cauterise the retina with an endolaser around a tear, tamponade the retina by injecting gas (SF6, C2F6, C3F8, absorbed within a few weeks) or silicone oil to keep it pressed against the pigment epithelium, or evacuate blood in case of vitreous haemorrhage. The micrometric incisions are self-sealing and generally need no suture, allowing faster recovery than the historical 20 Gauge techniques.

Scleral buckling — detachment in young patients

Scleral buckling (or “ab externo” surgery) is an alternative to vitrectomy reserved for treating retinal detachment. It is preferred in young patients (under 50) with a clear lens — vitrectomy speeds up the development of a cataract. It is also suited to chronic or limited detachments with an accessible peripheral tear.

The technique involves placing a silicone band (explant) around the eyeball, under the eye muscles, and pressing it against the sclera opposite the tear to seal it. A cryotherapy application (cold) is performed over the tear to create an adhesive scar. The band stays in place permanently.

Medical treatments of the retina (outside the operating room)

Intravitreal injections

Intravitreal injections (IVI) deliver a medication directly into the vitreous. The main products injected are anti-VEGF agents (Lucentis®, Eylea®, Vabysmo®, Beovu®), which block the formation of abnormal new vessels in wet AMD, diabetic retinopathy and macular oedema from vein occlusions, and corticosteroids (Ozurdex®, Iluvien®), which reduce inflammation and macular oedema.

The injections are carried out in the office in a dedicated room under strict aseptic conditions. They are painless (drop anaesthesia), last only a few seconds, but must be repeated at regular intervals (1 to 3 months) and are often continued for life to maintain their effect.

Retinal argon laser

The argon laser cauterises the retina to strengthen it or destroy diseased areas. It is used to wall off a retinal tear (a preventive adhesive scar), for panretinal photocoagulation (PRP) in proliferative diabetic retinopathy, and to treat vein occlusions.

Sessions take place seated, in the office. The pupil is dilated with drops and the cornea anaesthetised to allow a treatment contact lens to be placed. The session lasts a few minutes and causes a strong dazzling sensation during and after treatment, which fades within a few hours.

Conditions and techniques: summary table

Procedure and aftercare

Retinal operations are usually performed on an outpatient basis (or with one night in hospital for complex cases), under locoregional (peribulbar) or general anaesthesia depending on the condition, the expected duration and the patient’s preference. The procedure lasts from 30 minutes to 2 hours depending on complexity.

Post-operative positioning

When surgery requires a gas tamponade (macular hole, retinal detachment), strict face-down positioning may be required for several days to several weeks. This positioning is essential to the success of the operation: it lets the gas rise and press on the treated retinal area. It is often experienced as the most demanding part of the surgery, but it is temporary.

Precautions with intraocular gas

If gas has been injected, two absolute precautions apply until it is absorbed (2 to 8 weeks depending on the gas): no air travel and no stay at altitude (above 1,000 m) — the gas would expand and dangerously raise the intraocular pressure; and no general anaesthesia with nitrous oxide (N₂O) — same consequence. The patient is given an alert bracelet to flag the presence of gas in case of unexpected medical care.

Aftercare and recovery

• Antibiotic and anti-inflammatory eye drops for 1 month
• Protective shield at night for 1 week
• Check-ups at day 1, day 7 and day 30
• Sick leave of 1 to 4 weeks depending on the job and the condition
• Progressive visual recovery over several weeks to several months — final vision may not be reached before 3 to 6 months

Warning signs: when to seek emergency care?

Some symptoms should prompt an emergency eye consultation (within 24 hours), as they may signal a serious retinal condition requiring immediate care:

• Sudden appearance of floaters — may indicate a posterior vitreous detachment with a risk of retinal tear
• Flashes of light (phosphenes) in the visual field — traction on the retina, risk of tear
• Black veil, dark curtain or loss of part of the visual field — signs of retinal detachment — EMERGENCY
• Sudden drop in vision — may indicate a vascular occlusion, a detachment or a vitreous haemorrhage
• Distortion of straight lines (metamorphopsia) — suggests a macular condition (membrane, hole, AMD, oedema)
• Dark central spot (scotoma) — suggests a macular hole or macular damage

Reminder: the earlier a retinal detachment is treated, the better the visual prognosis. Do not wait.

Frequently asked questions about retinal surgery

Sources and references

• American Academy of Ophthalmology — Detached and Torn Retina
• EyeWiki — Pars Plana Vitrectomy
• NHS — Vitrectomy
• QualiDoc — Retina / Toulon

Article written and reviewed by Dr Hugo Bourdon, ophthalmic surgeon at the Clinique Saint-Michel ELSAN and the Centre Iris – Institut Toulonnais d’Ophtalmologie (281 rue Jean Jaurès, Toulon).