Advances in ophthalmic microsurgery have helped make cataract surgery an ambulatory procedure.1 Vitreo-retinal surgeries, the most complicated of ocular surgeries, are commonly conducted on inpatient basis. They require prolonged surgical time, general anesthesia in a few patients, stringent postoperative positioning and prolonged recovery. Socio-economically it leads to loss of working days and their cost is higher, especially due to longer hospital stay.2 Advances in retinal surgery and anesthesia techniques have improved their outcome and made their postoperative course predictable. We present the results of ambulatory vitreo-retinal surgery performed at our center between January 2005 and July 2005.
All the patients within a 20 km radius and having easy public transport accessibility were included in the study. Patients requiring general anesthesia were excluded. All patients were discharged 30 min after the procedure. They were prescribed postoperative analgesics (Ibuprofen + Paracetamol combination) and sustained release acetazolamide capsules, continued for at least seven days postoperatively based on surgeons' clinical expectations postoperatively. It was confirmed preoperatively that patients did not have any medical contraindication or known allergy to the drugs. All the patients were informed about the prophylactic nature of the treatment. They were given the list containing post surgery instructions, the possible complications and remedial measures to be taken. A 24h helpline number (surgeons') was given to them in case of any unexpected complications. The relative of the patient was trained to remove the patch and initiate topical treatment. A combination of topical ofloxacin and prednisolone acetate six times a day, along with homatropine eye drops three times daily was prescribed in all patients. In those with injection of intravitreal gas, topical timolol 0.5% in combination with dorzolamide twice daily was given. Patients were reviewed directly on the seventh day of surgery and then at one month. All the patients and their caretakers were thoroughly explained about the disease, the uncertainties of results, antecedent complications and deviation from normal postoperative care in their case. Patients were given a choice to opt out of the study if there was any disagreement with the protocol of the study. However, all the patients agreed after signing a special informed written consent.
We operated 30 eyes of 30 patients (24 males, six females) within the study period. Of these 6/30(20%) underwent scleral buckling with gas injection (SF6), 12/30(40%) underwent vitrectomy with gas (C3F8) or silicone oil insertion for advanced diabetic retinopathy with traction retinal detachment and 12/30(40%) patients underwent vitrectomy with belt buckling, membrane peeling, fluid air exchange, endolaser and silicone oil injection, for proliferative vitreo-retinopathy (PVR). Surgeries and the postoperative course were uneventful in all the patients.
Although 27/30 patients (90%) had headache and 12/30 (40%) nausea/vomiting during the first 24h of surgery it was however, relieved with routine postoperative analgesia and/or ocular hypotensive agents already prescribed. When first observed on the seventh postoperative day all the patients were symptomatically comfortable. Apart from slit-lamp examination, intraocular pressure was measured with applanation tonometer. All patients except 1/30 (3%) had prolonged elevation of IOP and required topical medical management of glaucoma (timolol maleate eye drops 0.5% twice daily and dorzolamide eye drops thrice daily). Twenty-seven out of thirty (90%) patients had anatomical success at three months of follow-up. Resurgery was required in three patients (10%) of PVR with oil injection done. The re-detachment was noted beyond three to four weeks when the patient had incidentally followed up for unrelated complaints. The retina remained reattached after a silicone oil exchange, which was again performed on ambulatory basis.
Routine postoperative care, but for the current study, after vitreo-retinal surgery in our setup would include one to three days of hospital stay. In addition, after discharge the patient follows up on the seventh day of surgery. This increases medical care costs as well as the load on a tertiary care center.2 Currently, when retinal surgery is the only inpatient surgery, an ambulation concept may relieve the inpatient burden of the eye care center and help stringent postoperative positioning at home. This is probably the first step towards transition into daycare concept. As also studied by Cannon et al.3 the postoperative symptomatology was predictive. All patients were relieved of major postoperative symptoms, which obviated their visit to our center. Overall anatomical success of 90% (27/30) was comparable to that (88%) of our non-ambulatory patients. With the introduction of sutureless (23/25 gauge) vitrectomy probably many of our patients would be symptom-free than currently. This would definitely help a smooth transition towards ambulatory patient care in selected patients. However, it cannot be applied to patients coming from a long distance with inadequate transport facilities.
This is an attempt made on the part of the author to study the practicality of an ambulatory concept in retina surgery. This could probably help plan future studies based on improvisation of the current design.
1. Fedorowicz Z, Lawrence D, Gutierrez P. Day care versus in-patient surgery for age-related cataract Cochrane Database Syst Rev. 2005;1:CD004242
2. Sulkes DJ, Scott IU, Flynn HW Jr, Feuer WJ. Evaluating outpatient versus inpatient costs in endophthalmitis management Retina. 2002;22:747–51
3. Cannon CS, Gross JG, Abramson I, Mazzei WJ, Freeman WR. Evaluation of outpatient experience with vitreoretinal surgery Br J Ophthalmol. 1992;76:68–71