Vitreoretinal Surgery: Strategies and Tactics

Selected wisdoms for the aspiring VR surgeon

Vitreoretinal surgery: the easy thing that is hard to do (paraphrasing Bertold Brecht). Even a journey of a thousand miles begins with a single step (Chinese proverb).

Anyone who has never made a mistake has never tried anything new (Albert Einstein).

The reception of outlandish ideas: First, “it’s completely impossible.” Second, “It’s possible but not worth doing.” Third, “I said all along that it was a good idea”. (Sir Arthur C. Clarke).

If I had had listened to my customers, I would have improved the horse and buggy (Henry Ford).

You can resist an invading army, but no power on earth can stop an idea whose time has come (Victor Hugo).

The important thing is not to stop questioning. Curiosity has its own reason for existing (Albert Einstein).

The difference between good and almost good is like the difference between the lightning bug and lightning (Mark Twain).

Everything should be made as simple as possible, but not simpler (Albert Einstein). Simplicity is the ultimate sophistication. It takes a lot of hard work to make something

simple (Steve Jobs).

What you see is what you get. What you don’t see gets you.

Hobson’s choice is a free choice in which only one option is offered. Decisions are easy when no options are left (Narasimha Rao). Doubt is not a pleasant position but certainty is absurd (Voltaire).

The surest sign of insanity is being certain without having any doubt (Andrew Feldmar). Self-delusion is the first step towards disaster (Raghuram Rajan).

Having a bad strategy is better than not having a strategy at all (Sir Winston Churchill). No battle plan survives the first contact with the enemy (Helmuth von Moltke).

We either find a road or we build one (Hannibal).

They said it couldn’t be done, but that doesn’t always work.

Insanity is doing the same thing over and over again and expecting different outcomes (Albert Einstein).

Do not fear to be eccentric in opinion, for every opinion now accepted was once eccentric (Bertrand Russell).

What was yesterday’s gold standard is today’s dogma; what was yesterday’s craziness is today’s gold.

You are neither right nor wrong because the crowd disagrees with you. You are right because your data and reasoning are right (Benjamin Graham).

You cannot learn to play the piano by going to concerts.

Don’t pay attention to the critics. Don’t even ignore them (Sam Goldwyn).

Care more particularly for the individual patient than the special features of the disease (Sir William Osler).

Ferenc Kuhn

Vitreoretinal Surgery:

Strategies and Tactics

Ferenc Kuhn, MD, PhD

St. Johns, FL

USA

Helen Keller Foundation

for Research and Education

International Society of Ocular Trauma

Birmingham, AL

USA

Consultant and Vitreoretinal Surgeon

Milos Eye Hospital

Belgrade

Serbia

Consultant and Vitreoretinal Surgeon

Zagórskiego Eye Hospital

Cracow

Poland

Library of Congress Control Number: 2015947620

Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2016

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author’s responsibility to describe not only what he does, how he does it, and when he does it; above all, he must explain why he does it. The reader will then have an opportunity to contemplate that “why” and make a conscious decision as to whether he agrees and so will employ it himself or, again based on a conscious thought process, decide against it – just as well, as long as the decision against is not a random one.

This book has no references, only a few important publications are listed as “Further Reading.” References in the internet age are nowhere near as important in a book as they once were. Besides, the statements made, the issues emphasized, the surgical solutions offered in this publication represent a synthesis of the author’s experience. What is described here may have as its birthmother his own brain, that of a colleague during an informal conversation, a publication, or a presentation at some meeting; either way, the original idea has surely evolved over time.

This is a very practical-oriented book, presenting the reader with both strategic and tactical questions about VR surgery (and the surgeon himself). Everything in this publication serves as an agent provocateur to incite the reader to develop his own, individualized approach to each patient, to each surgery. It is not the goal of the book to create copies of the author-surgeon; it is a goal of the book to encourage the reader to make conscious decisions before, during, and after surgery,8 to develop his own, unique method for working as a VR surgeon. The author recommends spending a few minutes by listening to a wonderful song9 that so beautifully, so elegantly describes this singular approach (the lyrics are also published at the end of the Preface).10

The format of this book is rather unusual. The reader will find few lengthy paragraphs; these are mostly replaced by bullet points, tables, and text boxes such as Pearls and Q&A. This format hopefully makes it easier to read the book and find the necessary information fast. Furthermore, the book is partially written in the first person11 and refers to the surgeon and the patients as “he”12 – for no reason other than simplicity.

I tried to mimic as much as possible the most ideal teaching situation: an experienced surgeon actively assisting the fellow. This requires providing specific advice as the fellow progresses with the case and questions/issues arise. My own approach to VR surgery is a very conscious one. This helps me foresee many of the problems

8A good example is a recent lecture the author heard: the speaker described a diabetic patient receiving 36 monthly injections into a single eye with macular edema. Obviously, the treatment became an automated process, and the ophthalmologist forgot to stop at some point during the 3 years to look at the big picture, and ask: Isn’t there something wrong here if the patient must come back for the very same thing every single month for 3 years and the pathology recurs every time?

9https://www.youtube.com/watch?v = 6E2hYDIFDIU

10An honest speaker asks his audience of trainees not to believe a word he (or anybody else) tells them. They should carefully listen to what they are told, test the teaching in their own practice, and then decide whether they accept, reject, or modify it.

11Rather than, as is typical, the author referring to himself in the third person.

12Except the OR nurse, who is a “she.” I have worked, throughout my career, very closely with 17 nurses, each a female.

that emerge as surgery is performed by the fellow (or myself). I tried to construct this book as if addressing these questions while assisting a younger colleague. Naturally, not all situations can be anticipated and thus described in the book, but I believe the most common ones will have been.

I attempted to structure the contents so that they follow a rational order and avoid repetition as much as possible. However, I am aware that this is an impossible task.13 I also made an effort not to present information a well-trained, past-residency- training ophthalmologist (aspiring to be a VR surgeon) is supposed to already know.

The opening part is a rather unique one since it discusses issues that are virtually never raised: who should and who should not be a VR surgeon, and how to train to become one in a country without a formal fellowship. This part is followed by two parts about the basic rules the surgeon must keep in mind before the actual surgery; the fourth part deals with the fundamentals of VR surgery, while the fifth is dedicated to tactical issues per indication.

I do not recommend that the reader go straight to a chapter in the last two parts of the book without reading (all) the prior parts first; the chapters in Parts 4 and 5 were written with the assumption that the reader had gone through all preceding chapters.

The book is based on the “standard 3-port” approach to vitrectomy, using the microscope and the BIOM (macular contact lens) for viewing. One chapter (17) briefly describes the alternative approaches. All issues discussed relate to 23 g transconjunctival vitrectomy, unless otherwise indicated.

The book is not written for fellows residing in any specific country. While VR surgeons in countries with an advanced health-care system may find certain aspects of what is discussed here superfluous,14 young surgeons in many, less advanced countries are likely to have to deal with such issues. Furthermore, even in advanced countries it is still helpful for the fellow to consciously address every possible component of VR surgery, from the correct posture during surgery to using the forceps in the most ideal way.15

The primary target audience of this book is the ophthalmologist who is either contemplating whether to become a VR surgeon or who is already in training, whether as part of a formal fellowship or, more commonly, an informal one. I sincerely hope, however, that the book will also be useful to my very experienced colleagues: the training of the VR surgeon is never complete. Throughout these 3 decades I have visited numerous ORs and without exception found some “trick” that was interesting so that I have decided to try it myself – or something that made me murmur to myself: “thank God I never tried this.” Either way, the visit proved

13Eventually, a choice has to be made between “vertical” and “horizontal” structuring. For example, one cannot group everything that concerns the lens in a single location; the lens has to be mentioned in the chapter on visibility as well as in several chapters dealing with strategy and tactics.

14Describing the characteristics of “the” ideal chair for vitrectomy, setting up the vitrectomy machine etc.

15At what angle should I peel the ILM in an eye with severe macular edema?

useful: whatever it is that forces a surgeon to make conscious, rather than automated, decisions during surgery is a positive thing. The most important is for the surgeon never to be on autopilot; he must avoid making decisions and surgical maneuvers based on reflex or custom.

In summary

Scientific books are impersonal – this book is not. They typically have multiple authors – this book has only one. They contain page after page of references – this book presents none, only a list of “Further Reading”. They usually address larger issues, not technical details – this book attempts to do both.

My Way lyrics:

And now, the end is near;

And so I face the final curtain.

My friend, I’ll say it clear,

I’ll state my case, of which I’m certain.

I’ve lived a life that’s full.

I’ve traveled each and ev’ry highway;

And more, much more than this,

I did it my way.

Regrets, I’ve had a few;

But then again, too few to mention.

I did what I had to do

And saw it through without exemption.

I planned each charted course;

Each careful step along the byway,

And more, much more than this,

I did it my way.

Yes, there were times, I’m sure you knew

When I bit off more than I could chew.

But through it all, when there was doubt,

I ate it up and spit it out.

I faced it all and I stood tall;

And did it my way.

I’ve loved, I’ve laughed and cried.

I’ve had my fill; my share of losing.

And now, as tears subside,

I find it all so amusing.

To think I did all that;

And may I say – not in a shy way, “Oh no, oh no not me,

I did it my way.”

For what is a man, what has he got?

If not himself, then he has naught.

To say the things he truly feels;

And not the words of one who kneels.

The record shows I took the blows –

And did it my way!

Yes, it was my way.

(by Jacques Revaux and Gilles Thibault)

Ferenc Kuhn, MD, PhD

Birmingham, AL, USA

Belgrade, Serbia

Cracow, Poland