The current standard of care following vitreoretinal (VR) surgery is to examine patients on postoperative (PO) day 1. This practice dates back to when the majority of VR surgery patients were admitted as inpatients. In 1988, Isernhagen et al. performed a prospective study and concluded that 52% of patients had PO events that were best treated in the inpatient setting.1 However, most of these side effects were related to general anesthesia rather than the VR surgery itself. Since this study, use of local anesthesia and improvements in surgical technique and instrumentation have led to a significant decrease in PO adverse events.2,3 Therefore, most VR surgeries are now performed as outpatient surgery with a PO day 1 visit.
PO day 1 visits can be inconvenient for certain patients who may need to travel long distances to access VR surgical care. In 2015, Alexander et al. found that following pars plana vitrectomy (PPV), the overall PO day 1 intervention rate for hypotony or elevated intraocular pressure (IOP) was 3.7% (n = 273).4 The authors concluded, “day 1 postoperative review can be safely omitted in the majority of patients undergoing vitrectomy.” More recently, Ho and Shah reviewed outcomes for a series of nonrandomized, nonconsecutive patients who had their first PO visit at day 3 or greater (mean = 4.5) after VR surgery.5 They found that at the first PO visit, 3.3% eyes had an IOP of 5 mm Hg or less and 3.3% had an IOP of 30 mm Hg or higher. The results of these recent studies are intriguing, but the PO day 1 visit remains popular among VR surgeons and provides an excellent opportunity for the surgeon to review surgical details and important PO instructions with the patient. Furthermore, this appointment is used to monitor for IOP extremes, pain, or early complications such as choroidals, vitreous hemorrhage, hyphema, or endophthalmitis.
For many years, it has been common practice for anterior segment surgeons to see patients on PO day 0 following phacoemulsification. A 2009 study exhibited no significant long-term difference in patient outcomes when PO day 0 was compared with PO day 1 following phacoemulsification.6 Recently, attitudes regarding PO day 0 have shifted for many VR surgeons. A 2011 survey of United Kingdom VR surgeons (n = 135) found that 12% of providers assess the patient on PO day 0.7 To our knowledge, a comparison of PO day 0 and PO day 1 outcomes following modern VR surgery has not been published. Herein, we present the results of a nonrandomized, consecutive, comparative series reporting the rates of elevated IOP and hypotony following VR surgery when patients are examined on PO day 0 compared with PO day 1.
Patients and Methods
A nonrandomized, comparative series of a single VR surgeon (DWP) at a single tertiary referral center was conducted on 594 VR surgeries that had either a PO day 0 visit (166 patients) or a PO day 1 visit (428 patients). The surgeon operated at two locations: an eye hospital and an ambulatory surgery center. Patients were assigned surgery at one of the two places based on schedule, availability, and occasionally some payer or patient health limitations. The eye hospital patients received the standard PO day 1 visit the next day. The ambulatory surgery center patients received the PO day 0 visit at the end of afternoon clinic with no PO day 1 visit. The surgery there began any time between 7:30 am and 12:00 pm, and the PO day 0 visit any time between 3:30 pm and 5:30 pm, although at least 5 hours separated the surgery and visit in all cases. In both groups, the second PO visit was at 1 to 2 weeks after surgery, unless scheduled earlier due to a specific concern. Institutional review board (IRB) approval through Salus IRB was obtained. Various procedures for a large variety of retinal conditions were analyzed to identify which eyes developed hypotony (IOP ≤ 5 mm Hg) or required intervention for elevated IOP (IOP ≥ 30 mm Hg) (Fisher exact test, two-tailed, statistically significant if P < .05).
All cases involving PPV utilized the Constellation Vision System (Alcon, Fort Worth, TX) with 25-gauge instrumentation. No combined cases including cataract extraction were included in this study. Trocars were inserted obliquely in standard fashion. If gas tamponade or silicone oil were utilized, patients received a drop of topical timolol 0.5% / dorzolamide 2.0% at the end of the case. Scleral buckles, when utilized, were secured using either sutures or scleral belt loops. Small air or gas bubbles were injected with some of the primary scleral buckles.
Data collected included patient's age, eye involved, preoperative diagnoses, and PO findings / complications. Examinations for PO day 0 patients occurred at 5 hours or more following the conclusion of the VR surgery. Examinations for PO day 1 patients occurred generally between 24 and 30 hours following the conclusion of the VR surgery. No eyes during the study period were excluded from this study.
In this 16-month study, 594 VR surgeries were performed. Patient characteristics of both study groups were similar and are listed in Table 1. The PO day 0 group included 166 surgeries, and the PO day 1 group included 428 surgeries. The PO day 0 group had a mean age of 61.5 years, was 59% male, was 39% right eyes, and had preexisting glaucoma in 16.3% of patients. The PO day 1 group had a mean age of 63.2 years, was 61.7% male, was 45.1% right eyes, and had preexisting glaucoma in 17.8% of patients. Surgical indications and the surgical procedures performed are listed in Table 2.
Types of Vitreoretinal Surgery Performed
The PO day 0 visit occurred a mean of 7 hours after the surgery (range: 5 hours to 9.5 hours).
Notable findings included an increased rate of hypotony (IOP ≤ 5 mm Hg) on PO day 0 (4.6%) when compared with PO day 1 (1.6%) (Fisher exact test P = .039) and a lower rate of increased IOP (IOP ≥ 30 mm Hg) on PO day 0 (1.8%) compared with PO day 1 (4.0%) (Fisher exact test P = .31) (Table 3). The mean preoperative IOP in the PO day 0 and PO day 1 groups was 15.2 mm Hg and 16.0 mm Hg, respectively. The mean change in IOP from the preoperative visit to the first PO visit was −2.5 mm Hg for PO day 0 cases and −1.1 mm Hg for PO day 1 cases.
Incidence of Intraocular Pressure Extremes
Among the eyes involving vitrectomy with suturing of at least one sclerotomy, the mean change in IOP from the preoperative visit was −0.3 mm Hg for PO day 0 cases and −0.2 mm Hg for PO day 1 cases. There were no cases of hypotony when at least one sclerotomy was sutured.
In those eyes without sclerotomy sutures, the PO day 0 group had a mean IOP change of −4.1 mm Hg, and the PO day 1 group had a mean IOP change of −1.7 mm Hg. The hypotony rate was 5.3% among the sutureless PO day 0 group and 1.8% among the sutureless PO day 1 group.
Eyes with preexisting glaucoma were analyzed, and there was no statistically significant difference in mean IOP, hypotony, or high IOP rates between the PO day 0 and PO day 1 groups.
This study confirms that with modern VR surgery, the overall incidence of IOP extremes following VR surgery is low. In this report, the overall percentage of patients who exhibited an IOP extreme at their PO visit was 6.4% in the PO day 0 group and 5.6% in the PO day 1 group. There was a statistically significant incidence of hypotony with PO day 0 patients when compared with PO day 1 patients, and there was a trend toward a higher rate of patients with elevated IOP on PO day 1.
There are advantages of the PO day 0 visit when compared with a traditional PO day 1 visit or omission of the early PO visit in favor of a more than 3 days primary PO visit. Foremost, the discussion in the PO suite with the patient and / or caretakers, when the patient is frequently still sedated, need not be as comprehensive as the surgeon will reconvene with the patient and family in only a few hours to address activity restrictions, medications, and sleep, and to encourage adherence to positioning requirements. Positioning instructions can often be modified or lightened at the PO day 0 visit, depending on the examination findings, potentially easing the patient's first night after surgery. For patients with logistical concerns such as the need to travel a long-distance home or difficulty securing transportation, a PO day 0 visit can alleviate these issues. Additionally, there is also the potential for optical coherence tomography-guided positioning for macular hole repair as described in the literature to be utilized at the PO day 0 visit.8,9
Hypotony following sutureless vitrectomy has been reported in 0% to 25% of cases, with most recent papers reporting a hypotony rate of approximately 5%.10–15 This is typically transient and resolves with conservative measures. The literature suggests that angled or biplanar entry during trocar placement can reduce wound leak and hypotony by effectively lengthening the wound tract and maximizing scleral reapposition.16,17 In our study, all trocars were inserted using oblique entry, and an overall low rate of hypotony (2.5%) was found in the early PO period. For patients found to have hypotony at the PO day 0 visit, reapplication of the pressure patch for approximately 12 hours was an effective method to ensure wound closure and raise the IOP back to physiologic levels.
Increased IOP following VR surgery has historically been of high concern to VR surgeons. With smaller-gauge surgery, recent studies have shown a low incidence of elevated IOP following VR surgery.10–15 In our study, an overall low rate of elevated IOP (IOP ≥ 30 mm Hg) (3.3%) was found in the early PO period. Patients noted to have an elevated IOP at the PO visit were treated with topical therapy. A trend toward more patients with elevated IOP was seen on PO day 1 compared with PO day 0, although this was not statistically significant. Fortunately, most episodes of elevated IOP following VR surgery are transient and can be controlled with medical therapy. Appropriate management of elevated IOP is needed to avoid PO pain and other complications that may arise from elevated IOP, such as optic nerve damage or central retinal artery occlusion. One concern regarding the evaluation of patients on PO day 0 is the potential to miss an IOP spike in patients who received expansile C3F8 during their VR surgery, as the visit might occur before peak expansion of the gas.
There are limitations to our retrospective study. It was nonrandomized, and results from only one VR surgeon were included. Practice patterns such as this surgeon's use of prophylactic IOP medication and use of only 25-gauge vitrectomy instrumentation are not applicable to all surgeons or practices. IOP extremes were only measured in the PO day 0 or PO day 1 period, and therefore patients presenting with hypotony or increased IOP at a later date were not analyzed or included in the study.
Based on the results of our study, we conclude that substituting a PO day 0 examination in place of the traditional PO day 1 examination following VR surgery is a safe practice and can effectively identify common PO complications including hypotony and elevated IOP. The modern VR surgeon could implement this method of PO care for patients with travel or caretaker constraints to best serve his or her patients.
- Isernhagen RD, Michels RG, Glaser BM, de Bustros S, Enger C. Hospitalization requirements after vitreoretinal surgery. Arch Ophthalmol. 1988;106(6):767–770. doi:10.1001/archopht.1988.01060130837035 [CrossRef]
- Newsom RS, Wainwright AC, Canning CR. Local anaesthesia for 1221 vitreoretinal procedures. Br J Ophthalmol. 2001;85(2):225–227. doi:10.1136/bjo.85.2.225 [CrossRef]
- Wong R, Gupta B, Williamson TH, Laidlaw DA. Day 1 postoperative intraocular pressure spike in vitreoretinal surgery (VDOP1). Acta Ophthalmol. 2011;89(4):365–368. doi:10.1111/j.1755-3768.2009.01703.x [CrossRef]
- Alexander P, Michaels L, Newsom R. Is day-1 postoperative review necessary after pars plana vitrectomy?Eye (Lond). 2015;29(11):1489–1494. doi:10.1038/eye.2015.134 [CrossRef]
- Ho VH, Shah GK. Short- and long-term outcomes of vitreoretinal surgeries with deferred first postoperative visits at day 3 or later. J Vitreoretin Dis. 2017;1(2):126–132. doi:10.1177/2474126416685632 [CrossRef]
- Blatt SA, Perlman JI, Stubbs EB Jr, . Comparison of cataract outcomes when the initial post-operative evaluation is performed on post-operative day # 0 versus post-operative day # 1. Invest Ophthalmol Vis Sci. 2009;50:5583.
- Hussain R, Matare T, Zambarakji H. National survey of day-case vitreoretinal surgery in the United Kingdom. Eur J Ophthalmol. 2011;21(2):183–188. doi:10.5301/EJO.2010.1441 [CrossRef]
- Shah SP, Manjunath V, Rogers AH, Baumal CR, Reichel E, Duker JS. Optical coherence tomography-guided facedown positioning for macular hole surgery. Retina. 2013;33(2):356–362. doi:10.1097/IAE.0b013e318263d0e8 [CrossRef]
- Chow DR, Chaudhary KM. Optical coherence tomography-based positioning regimen for macular hole surgery. Retina. 2015;35(5):899–907. doi:10.1097/IAE.0000000000000410 [CrossRef]
- O'Reilly P, Beatty S. Transconjunctival sutureless vitrectomy: Initial experience and surgical tips. Eye (Lond). 2007;21(4):518–521. doi:10.1038/sj.eye.6702255 [CrossRef]
- Kusuhara S, Ooto S, Kimura D, et al. Outcomes of 23- and 25-gauge transconjunctival sutureless vitrectomies for idiopathic macular holes. Br J Ophthalmol. 2008;92(9):1261–1264. doi:10.1136/bjo.2008.140533 [CrossRef]
- Khan MA, Shahlaee A, Toussaint B, et al. Outcomes of 27 gauge microincision vitrectomy surgery for posterior segment disease. Am J Ophthalmol. 2016;161:36–43.e2. doi:10.1016/j.ajo.2015.09.024 [CrossRef]
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|PO Day 0 Group||PO Day 1 Group|
|Number of Cases||166||428|
|Mean Age, Years||61.5||63.2|
|Male, n (%)||98 (59.0)||264 (61.7)|
|Female, n (%)||68 (41.0)||164 (38.3)|
|Right Eyes, n (%)||65 (39.2)||193 (45.1)|
|Left Eyes, n (%)||101 (60.8)||235 (54.9)|
|Preexisting Glaucoma, n (%)||27 (16.3)||76 (17.8)|
Types of Vitreoretinal Surgery Performed
|Procedures||PO Day 0 Group||PO Day 1 Group|
|n = 166 (%)||n = 428 (%)|
|Rhegmatogenous Retinal Detachment Repair||42 (25.3)||171 (40.0)|
|Pars Plana Vitrectomy||24 (14.5)||97 (22.7)|
|Pars Plana Vitrectomy / Scleral Buckle||10 (6.0)||47 (11.0)|
|Scleral Buckle||8 (5.0)||27 (6.3)|
|Epiretinal Membrane or Vitreomacular Traction, n (%)||42 (25.3)||104 (24.3)|
|Macular Hole||22 (13.1)||39 (9.1)|
|Tractional Retinal Detachment||20 (12.0)||48 (11.3)|
|Vitreous Hemorrhage||12 (7.2)||20 (4.7)|
|Secondary Intraocular Lens||7 (4.2)||19 (4.4)|
|Proliferative Vitreoretinopathy Retinal Detachment||4 (2.4)||14 (3.3)|
|Other||17 (10.2)||13 (3.0)|
Incidence of Intraocular Pressure Extremes
|PO Day 0 Group, n = 166 (%)||PO Day 1 Group, n = 428 (%)||P Value|
|Elevated IOP (IOP ≥ 30 mm Hg)||3 (1.8)||17 (4.0)||P = .31|
|Hypotony (IOP ≤ 5 mm Hg)||8 (4.6)||7 (1.6)||P = .04|