This is not a surgical procedure, even though in many countries it must be done in the OR. I nevertheless include a very short to-do list (see Table 43.1) because the procedure is performed in increasingly great quantities.1 The technique is very similar for intraocular implants with slow-release medications, except the use of a special applicator in lieu of the syringe.

Quo vadis, VR surgery?

For the VR surgeon there are additional implications due the rising number of intravitreally injected medications available for an increasing number of diseases. Studies that provide “level 1 evidence” regarding the efficacy of a treatment modality are very expensive; pharmaceutical companies, naturally, tend to support studies testing the drug they are manufacturing. If found effective, “they are in business,” and this is understandable. However, this starts a cascade.

The physician soon finds that once a patient seeks treatment for a condition for which such a drug is available, he no longer has a choice; this drug is now the treatment option. Since companies that manufacture surgical devices can never offer the same level of financial support for a study showing the efficacy of surgery for the same condition, the VR surgeon is increasingly faced with two sad facts. First, diseases that he used to treat (and trained hard to do so) are now treated by colleagues whose expertise in the field is obviously more limited (the general ophthalmologist using intravitreal injections to treat ME caused by EMP). Second, he himself may be forced to slowly transit from being a vitrector to being an injector. Something is wrong with the (big) picture, but this goes beyond the scope of this book.

1 This also puts severe strain on the institutions in terms of logistics, infrastructure, and finances.

F. Kuhn, Vitreoretinal Surgery: Strategies and Tactics,

DOI 10.1007/978-3-319-19479-0_43

aObviously, patients who undergo repeated injections need less explanation.

bShorter duration has no therapeutic benefit but does increase the risk of producing bacterial resistance.

cSterile wipes (e.g., Blephaclean, Labtician Ophthalmics, Oakville, ONT, Canada) to be used by the patient for 3 days prior to the injection to clean the eyelid margins. Moist heat can also be applied, and any infection treated with antibiotic ointment for a sufficiently long period.

dIt is also possible to inject the solution subconjunctivally. However, this requires preinjection drops anyway, and the bubble that forms may make the selecting of the exact location of the intravitreal injection (penetration of the sclera with the needle) more difficult.

eDraping is not mandatory.

fIf the patient still has pain, soak a cotton-tip applicator in a sterile analgesic solution and keep the tip pressed against the conjunctiva at the planned location of the injection. If the solution is not sterile, repeat the irrigation of the conjunctival sac with Betadine.

gCaliper, cotton-tip applicator, pressure plate, or the surgeon’s finger (see Fig. 39.2). hEyes that underwent PPV may require a more firm push with the syringe.

iThe location may be varied, especially if repeated injections are given.

jInjecting TA allows the surgeon to see how strong a jet stream can be created by a too rapid push on the plunger.

Part V

Tissue Tactics in VR Surgery

Introduction

The primary focus of this part is the specific tissue tactics in VR surgery in the most common conditions, including dropped nucleus and IOL, endophthalmitis, retinal detachment of various types, macular disorders ranging from hole to edema, PVR, PDR, and trauma. Certain topics that may appear outside the VR surgeon’s expertise yet are crucially important during his daily practice, such as iris reconstruction and scleroplasty, are also included, as is a summary of the most important issues in postoperative care. Some of the writings in each chapter, grouped per indication, resemble a checklist since the individual maneuvers (such as retinectomy or endolaser cerclage) have been covered in much detail in the previous parts. However – as throughout the entire book – a serious effort is made to provide the rationale why a particular step is recommended, not only how and when it is to be done.