Post Vitrectomy Recovery and Posturing

Modern eye surgery is in most cases a painless procedure, with discomfort generally minimised both during and after the operation.

Local anaesthetic ensures that there is no pain experienced through the course of the operation, whilst a slight eye ache and mild eye surface irritation (similar to the sensation of having something in your eye) is common afterwards. This irritation gradually improves during the post-operative period and, importantly, with no expectation of worsening pain or discomfort at any stage following the surgery.

Whilst this experience is true for most eye surgeries, there are some eye conditions that require specific post-operative care to help ensure a successful outcome. ‘Posturing’ is sometimes required following vitrectomy surgery, and can cause significant disruption to both a patient’s daily activities, as well as challenges to comfort. Good organisation and planning, as well as strategies to address any potential issues, is essential prior to having vitrectomy surgery with posturing.

What Is A Vitrectomy Done For?

The eye works similarly to a camera, where light passes through a lens at the front of the eye, which then focusses onto the ‘film’ (or retina) at the back. Between the lens and the retina, the back part of the eye is filled vitreous humour, which is transparent and gel like in consistency.

A vitrectomy procedure involves removing the vitreous through surgery, and this is done for a number of reasons. In some circumstances, the vitreous is removed in order to treat the condition itself, such as when there are abnormal attachments of the vitreous to the retina e.g. vitreomacular traction.

At other times, a vitrectomy is done as part of an operation to access areas of the retina that require treatment. This can include conditions such as epiretinal membrane (macular pucker), macular hole and retinal detachment. Following the surgery, the eye is either filled with an air or gas bubble, and this is dependent upon the condition being treated.

What is posturing and why is it necessary?

‘Posturing’ refers to after surgery care that involves a patient keeping their head in a specific position to aid the success of their operation. This posturing of the head can involve both waking hours, as well as sleeping positions, and how a patient is required to posture is dependent upon the condition being treated.

At the end of a vitrectomy operation, the eye is partially filled with air. For conditions such as retinal detachment or macular hole the eye is completely filled with air, which is then replaced with a gas; its purpose is to press against the area that is being treated. If you have had a macular hole surgery, the area being treated is at the back of the eye.

This gas forms a bubble in your eye and floats upwards, similar to a bubble in a carbonated drink. If you remain upright, this gas bubble won’t fully press against the macular hole at the back of your eye and the macular hole may not close.

The only way to get the gas bubble to press against the macula is to look vertically down towards the floor. One of the easiest ways in which to do this is to tilt your head slightly forwards and look straight down to towards the floor. This is known as face-down posturing, but I prefer the term “eyes-down” as this gets the eyes pointing in the correct direction and does not mean that you have to strain your neck by bending your head down all the way forwards. I usually request that posturing is done for 50 minutes out of every hour for five days whilst you’re awake.

Daily Activities and Sleeping

Face down (“eyes down”) posturing is only required during waking hours, not when you’re sleeping.

It is recommended to sleep on either side or even your front, but not sleep on your back as that would make the bubble move away from the macular hole. One tip to help you avoid this is to place pillows behind you, or even to pin a tennis ball in a sock behind your back to prevent you from rolling onto your back during sleep.

Walking during the after surgery period is allowed and encouraged for its health benefits; this is done by looking vertically downwards when walking, whilst trying to keep your head up as upright as possible.

Most seated activities should be possible during this period, and likely made easier with the use of specialised posturing equipment such as a RetinaRest (retinarest.com or 1300 66 80 59) or Summit (vitrectomy.com.au or 1300 133 116). This equipment supports the user’s face during face-down posturing, helping to relieve neck strain. As the face cushion has a hole in the middle (similar to a massage table), it allows activities such as reading and near work to be done. Additionally the RetinaRest includes a mirror which reflects an image of what’s in front of you, meaning television can also be watched using this equipment.

How Can I Best Prepare Myself for Posturing?

Here are some top tips to help ready yourself for posturing:

Consider arranging hire of equipment that will assist you with posturing (RetinaRest or Summit) as soon as you become aware of the date of your operation. If you choose to do so, it’s best to hire the equipment several days beforehand to help you prepare.
Work out how you are going to prepare and eat meals. Often, assistance from others will be necessary, as you will only have 10 minutes available out of each hour.
Make sure you do a shop for food, toiletries, entertainment and other essentials before your macular hole surgery. Audio books and CDs are highly recommended, as you can listen to these without moving your eyes. While you may not feel like reading within the first few days after surgery, large-print books and magazines are good to have on hand for later.
DVDs can be watched as long as you keep your eyes in the correct position with the use of a RetinaRest mirror. This will enable you to watch TV, talk to friends, and look ahead of you.
Organise all of your toiletries and medications so they’re easily accessible without raising your eyes or head.
Make sure your kitchen appliances (e.g. kettle, toaster and coffee machine) are stored low so you can prepare foods and drinks without help.
Ensure you have straws on hand to help you sip cold drinks. Prepare plenty of clean, comfortable clothing for the posturing period.

Post-operative Exercises

As posturing following a macular hole surgery involves maintaining a face down position for long periods of time, this can understandably cause issues involving strain and discomfort.

Exercises can help alleviate some of these problems, and prevent unnecessary compensation at the neck and shoulders.

In conjunction with Balwyn Sports and Physiotherapy Centre, I have recommended a number of exercises that address these affected areas. These exercises should be completed as often as is required during the 10 minute break from every hour of posturing. A printable version of these exercises can be found here.

Stiffness and discomfort may occur due to posturing. If this is the case, assessment and appropriate treatment from a physiotherapist experienced with post-operative vitrectomy care is recommended to alleviate symptoms and restore mobility.

1. Head rotations

In standing, do circles with your head in both directions
Do not go all the way back into extension as you rotate

Repetition: 10 Frequency: 2x/day

2. Assisted neck rotations

Stand or sit tall
Slowly rotate head to bring chin over shoulder and look to the side
Apply gentle pressure to opposite cheek bone with your hand to assist movement
Return to a neutral position

Repetition: 10 Frequency: 2x/day

3. Stretching side bending

Lift one arm and bring it up and across your head
Sit straight and place the palm of your hand on your head
Use your hand to pull your head gently down towards your shoulder until a stretch is felt on the opposite side of the neck
Maintain the position
Do not turn your head or tilt it forwards or backwards while you perform this stretch

Sets: 2 Repetition: 30 Frequency: 2x/day

4. Stretching levator scapula

Sit tall on a straight chair
grab the bottom of your seat with your hand on the injured side to lower the shoulder by pulling down
Tilt and turn your head to the opposite side
Nod head forward until a stretch is felt along side and back of neck
Apply extra pressure (gently) with your hand to increase the stretch if needed
Hold the stretch and relax

Sets: 2 Repetition: 30 Frequency: 2x/day

5. Stretching SCM

Sit and place both hands over the collarbone on the affected side
Pull it down towards the floor gently with hands
Raise your chin and lean your head sideways away from hands until a stretch is felt along the side of the neck
Maintain the stretch

Sets: 2 Repetition: 30 Frequency: 2x/day