Intruduction
Modern vitreoretinal surgery is safe and effective in treating various retinal disorders, including rhegmatogenous retinal detachment (RRD), [
1] complications of diabetic retinopathy, [
2] macular hole (MH), [
3] and epiretinal membrane (ERM) [
4]. However, since vitreoretinal surgery is invasive, postoperative complications, such as increased (2.5–61.5%) or decreased (1.8–13.1%) intraocular pressure (IOP), [
5‐
10] corneal edema (0.80–1.1%) [
7,
11], intraocular inflammation (0.25–26%) [
5,
12], or retinal detachments (1.2–1.7%) may occur in patients [
11]. Therefore, the postoperative care plan for patients may be changed according to the type and severity of these complications [
12].
The incidence of postoperative complications varies substantially among patients who undergo different surgical procedures [
13]. Accordingly, the incidence of changes in treatment plans may also differ. Information regarding these changes may be useful when discussing postoperative treatment plans for patients. In addition, it may help establish a standardized postoperative care system [
14]. To date, there is limited knowledge regarding this topic.
Herein, we investigated the incidence of early complications requiring changes in the treatment plan in patients who had undergone vitreoretinal surgery. Additionally, the factors associated with the risk of plan changes were evaluated.
Patients
We secured a list of patients who underwent vitrectomy with or without gas or silicone oil tamponade, scleral buckling, scleral encircling, or scleral fixation of intraocular lens (IOL) at our institution between January 2021 and December 2021. Patients with the following diagnoses were included: RRD, ERM, MH, DR, vitreous hemorrhage (VH) other than DR, IOL dislocation, or lens dislocation. All vitrectomies were performed with transconjunctival sutureless vitrectomy technique using 23-gauge or 25-gauge device.
Outcome measures
Patients who experienced changes in the treatment plan within 14 days after surgery due to postoperative complications were identified. The timing, reasons, and details of these changes were also identified. The incidence of the changes in treatment plan was compared among the following categories: (1) age; (2) sex; (3) diabetes mellitus; (4) hypertension; (5) surgeon’s experience in vitreoretinal surgery (≥ 6 vs. < 6 years); (6) diagnosis: RRD vs. ERM vs. MH vs. DR vs. VH other than DR vs. IOL dislocation or lens dislocation; (7) type of surgery: vitrectomy without tamponade vs. vitrectomy with tamponade vs. scleral buckling or encircling only vs. scleral fixation; and (8) combined cataract surgery. When there was more than one episode of plan change, only the first episode of plan change was included in this study.
Statistical analysis
Data are presented as the mean ± standard deviation or number (%), where applicable. Statistical analyses were performed using the IBM SPSS Statistics for Windows (version 21.0; IBM Corp., Armonk, NY, USA). The visual acuities were represented as logarithm of the minimum angle of resolution (logMAR) values. The visual acuities for counting finger and hand motion were converted to logMAR values of 2 and 3, respectively. Between patients with and without treatment plan changes, the age was compared using the independent samples t-test. Diabetes mellitus, hypertension, history of vitreoretinal surgery, surgeon’s experience in vitreoretinal surgery, diagnosis, type of surgery, and combined cataract surgery were compared between the two groups using the chi-square test. The incidence of complications among patients requiring treatment plan changes according to the type of surgery and the timing at which the complications occurred was analyzed using the chi-square or Fisher’s exact test. Statistical significance was set at P < 0.05.
Discussion
In the present study, changes in the treatment plan after vitreoretinal surgery were noted in 16.3% of patients at a mean of 4.0 days after surgery. The most prevalent reason was an increase in IOP, followed by intraocular inflammation, hypotony due to leakage from the sclerotomy wound, and corneal edema. In most patients, the events causing plan changes were well-controlled with the modulation of topical or systemic drug administration.
Increase in IOP is a frequently noted phenomenon after vitreoretinal surgery [
15]. Various mechanisms, including gas expansion, anterior chamber inflammation, and iris-lens diaphragm shifting, are suspected causes of acute increase in IOP [
15]. In the present study, increase in IOP was the primary reason of treatment plan changes. This was most frequently observed after vitrectomy with tamponade. Similar to previous studies, [
8,
16] most increases in IOP were noted within one week after the surgery. Although most cases were well-controlled after administration of IOP-lowering agents, an increase in IOP was the most prevalent reason for prolonged hospitalization. Patients in whom tamponade is planned should be informed that the treatment plan can be changed because of a postoperative increase in IOP.
Sutureless vitrectomy has revolutionized vitreoretinal surgery. Compared to previous technique, it provided more convenient surgery with shortening of operating time and minimizing surgically induced trauma [
17]. However, one limitation of this technique is that tight wound apposition is sometimes not made [
18]. Therefore, leakage of vitreous fluid from unclosed wound lead postoperative IOP decrease [
18]. In some instances, additional procedures, such as sclerotomy sutures, were necessary to control the leakage [
12]. In the present study, hypotony was noted in 3 of the patients who underwent vitrectomy and leakage from sclerotomy wound was noted in one of them. Although the incidence was low, discharge was postponed in one-third of patients with hypotony.
Intraocular inflammation is a rare but important complication of vitreoretinal surgeries. In particular, postoperative endophthalmitis is a grave condition that may lead severe vision loss [
19]. In the present study, treatment plan was changed in four patients because of intraocular inflammation, and the date of discharge was postponed in three (75.0%) of them for close follow-up.
An interesting finding of the present study is that the surgeon’s experience can influence treatment plan changes. It is well-known that there is a learning curve in vitreoretinal surgery. [
20] In the study by Mazinani et al., a learning effect was noted in most surgeons. The learning effect was correlated with the total number of procedures, suggesting the importance of the surgeon’s experience in successful surgery [
21]. In a more recent study investigating the redetachment rates after retinal detachment surgery, the rate was approximately 20% in beginners. The redetachment rates steadily decreased and stabilized under 10% after approximately 200 surgeries [
20]. In the study of Yamakiri et al., surgeons with a higher average annual number of surgeries had significantly better surgical outcomes in scleral buckling procedure [
22]. In the present study, we first evaluated the influence of the surgeon’s experience on the incidence of treatment plan changes. We observed that the incidence was higher in less experienced surgeons than in experienced surgeons, suggesting that inexperienced surgeons should anticipate treatment plan changes before surgery.
The previously reported types and incidence of postoperative complications in patients who had undergone vitreoretinal surgery are summarized in Table
5. The incidence of postoperative complications reported in our study were generally lower than those reportedly [
5‐
25]. However, this study only analyzed cases where treatment plan changes were deemed necessary. Therefore, the incidence of actual complications might have been higher.
Table 5
Summary of previously reported types and incidence of postoperative complications following vitreoretinal surgery
| 2018 | RRD, PDR with tRD, MH | 254 | 48 ~ 61.5% within POD 7 | N/A | N/A | N/A |
| 2011 | Floater, macular pucker, MH, RD, etc. (VH, retained lens fragments, lens subluxation) | 122 | N/A | N/A | 13.1% on POD 1 | N/A |
| 2016 | ERM, VH, MH, RD, VMT | 306 | 15%~25% on POD 1 | 5 ~ 26% exhibited more than + 2 AC cells on POD 1 | 1.8 ~ 2.7% on POD 1 | N/A |
| 2021 | RRD or tRD | 418 | IOP > 21 mm Hg, 69 eyes (16.5%); IOP > 30 mm Hg, 11 eyes (2.6%) | N/A | N/A | N/A |
| 2023 | Pseudophakic RRD | 456 | IOP ≥ 22: 28.0 ~ 49.6%, IOP ≥ 25: 13.6 ~ 30.3% on POD 1 | N/A | 0 ~ 0.8% on POD 1 | N/A |
| 2008 | RD, VH, MH, ERM, retained lens fragments, endophthalmitis, floaters | 100 | 2.5 ~ 12% required IOP control on POD 1 | N/A | N/A | N/A |
| 2016 | PDR, MH, ERM, RRD, VH, IOL or lens dislocation, aphakia, SO removal | 460 | 11.5% | N/A | N/A | ≥ 1.1% |
| 2020 | ERM, MH | 152,034 | N/A | 0.25% for suspected endophthalmitis | N/A | N/A |
| 2017 | N/A | 121 | N/A | N/A | N/A | 0.80% |
The strengths of the present study are as follows. Firstly, we first evaluated the incidence of changes in the duration of hospitalization after vitreoretinal surgery owing to treatment plan changes. Although hospitalization was prolonged in only a limited number of patients, the postoperative care plan and subsequent cost of treatment could be markedly changed in these patients. Recently, the number of centers accredited by the Joint Commission International has increased worldwide, [
26] suggesting an increasing need for standardization of patient care. In the treatment of a certain disease, predicting the hospitalization period is an important part of establishing a standardized care plan for a patient. Second, we identified incidence, timing, and factors related to changes in treatment plans, which can provide valuable information for establishing treatment plans and discussing them with patients in advance.
The present study had some limitations. Firstly, this retrospective study was conducted at a single institution. Secondly, since patients with certain diagnoses were included, the results of the present study may not be valid for patients who underwent vitreoretinal surgery for other reasons. Thirdly, analysis was performed based on the data obtained within 2 weeks after surgery. Thus, complications that may occur after a longer period, such as open-angle glaucoma, [
27] could not be evaluated. Fourth, no strict guidelines were available for surgery, and our results included surgeries performed by multiple surgeons. Therefore, the results of this study require confirmation via further studies with a more controlled design. Finally, detailed postoperative anatomical or functional changes [
28] were not evaluated. Subsequent evaluations may be necessary to assess the impact of such changes on the risk of treatment plan changes.
In summary, treatment plan were changed due to postoperative complications in 16.3% of patients within 14 days following vitreoretinal surgery. The most prevalent complication was an increase in IOP. The incidence was higher in patients who underwent gas or oil tamponade and those who underwent surgery performed by less experienced surgeons. In some patients, the discharge date was delayed because of changes in the treatment plan. When establishing a standardized care plan for patients requiring vitreoretinal surgery, the possibility of treatment plan changes and subsequent prolongation of hospitalization should be considered. Further studies are needed to elucidate the specific burdens that treatment plan changes may impose on individual patients.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.