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Part I

Becoming a VR Surgeon

Introduction

This part deals with the two most fundamental issues an aspiring VR surgeon faces. An ophthalmology resident should choose to become a specialist in VR surgery only if he truly understands what such a career entails – otherwise he will not live a happy life as a VR surgeon. He must have a personality that feels comfortable with the daily challenges and more-than-occasional failures the VR surgeon faces, but also be able to recharge his often-depleted emotional batteries by the daily miracles in restoring sight in diseases that not so long ago would have led to blindness. The

ﬁrst chapter offers guidelines for the aspiring resident in making the right choice. Many of those who, after careful consideration, made the conscious choice to

indeed become a VR surgeon will not be able to join a formal training program because the country’s health care system does not offer one. The second chapter provides a road map on how to train “on your own.”

Should You Become a VR Surgeon?	1

The simpliﬁed answer is: it primarily depends on your personality. Most people prefer living a life that is mostly a series of routine activities and feel uncomfortable if they are constantly exposed to challenges, especially if these vary in nature and severity. Such people would have an unhappy life as a VR surgeon.1 Table 1.1 compares the life of the cataract surgeon with that of the VR surgeon.

In a classic joke, a car dies and the owner visits the mechanic. The mechanic opens the hood, takes a lengthy look around, then picks a hammer and whacks something under the hood – and the engine roars back to life. When asked how much his intervention costs, he says: “$100.” The owner becomes agitated, how can you charge $100 for a hammer blow? “No”, the mechanic says, “that’s $1. But to know what to whack, that’s $99.”

VR surgery is rather similar. When an experienced surgeon operates, everything looks easy and straightforward to the observer, but when it is the beginner who is sitting at the operating table and tries to proceed with the case, even the simplest maneuvers appear complex and difﬁcult. It is crucial for the ophthalmologist who is considering becoming a VR surgeon to understand that the learning curve is steep2 and long – in fact, the learning process never stops. New indications, techniques, and technologies keep emerging, and even the experienced surgeon must constantly adapt. For those considering the VR subspecialty, it is therefore highly advisable to understand all its implications for their professional and personal lives before they enter the training program.

I remember a colleague with exceptional dexterity in removing cataracts and implanting IOLs but no regard for the rest of the eyeball.3 He once asked me to assist him in surgery: he wanted to perform vitrectomy for a macular hole on his former cataract patient. He saw ILM removal in a couple of videos and assumed that

1Even worse, their patients will be unhappy: a chronically unhappy surgeon is not able to perform.

2When I completed my fellowship with my initial mentor, the late Klaus Heimann, his farewell message was: “Don’t be discouraged, but your ﬁrst 50 surgeries will end up as failures.”

3The typical phacologist.

F. Kuhn, Vitreoretinal Surgery: Strategies and Tactics,

DOI 10.1007/978-3-319-19479-0_1

4		1 Should You Become a VR Surgeon?

Table 1.1 Life as a cataract vs as a VR surgeon*
Variable	Cataract surgeon	VR surgeon	Comment
Learning curve	Moderate	Very steep	For a VR surgeon the learning
			process is intense and it
			remains forever so
Sleepless nights	Almost nevera	Occasionally	Preoperatively because the
before or after			surgeon is not sure what the
surgery			best surgical approach
			would be
			Postoperatively because the
			surgeon now knows he made
			the wrong choice and it
			resulted in an irreversibly
			poor outcome
Difﬁculty in	Minimal	Moderate to	For the cataract surgeon, the
preoperative		extreme	diagnosis brings an almost
decision-making			automatic solution, phaco
			and IOL implantation, and
			the timing is also obvious:
			as soon as feasible.
			For the VR surgeon, this can
			raise extremely difﬁcult
			questions; just think about a
			one-eyed patient who has
			retinitis pigmentosa and
			develops an EMP. If
			something goes wrong
			during surgery, the patient
			instantly loses (some)
			central vision in an eye that
			is already losing its visual
			ﬁeld; then there is the risk of
			postoperative
			complications. Conversely,
			if surgery is not done, the
			central vision will gradually
			and irreversibly decrease
Consequences if the	None to minimal	None to extreme	Just think of a patient with an
preoperative			injury that has a high risk of
decision-making			endophthalmitis; you decide
was erroneous			to do early PPV but a
			catastrophic ECH occurs
			intraoperatively
Physical challenge	Minimal; mainly	Can be	My longest case (TKP-PPV for
intraoperatively	determined by	signiﬁcant	a severe injury in a young
	how many cases		boy) lasted 6 h and 23 min
	the surgeon
	decides to
	perform on a
	given day
			(continued)

1 Should You Become a VR Surgeon?			5

Table 1.1 (continued)
Variable	Cataract surgeon	VR surgeon	Comment
Mental challenge	Moderate	Moderate to	During cataract surgery the
intraoperatively		intense	need to make a unique,
			major decision relatively
			rarely emerges, but in certain
			instances real challenges do
			exist (children,
			pseudoexfoliation etc.).
			In VR surgery, even in “easy”
			cases (VH, see Sect. 62.1),
			many decisions are
			required, and some of them,
			if they prove to have been
			wrong, result in irreversibly
			negative consequences
Difﬁculty in	Minimal to	Minimal to	Cataract surgery has to a large
intraoperative	moderate	severe	extent been standardized.
decision-making			The inter-case variability is
			typically limited, and even
			if the tissue reacts
			differently to that expected,
			the solution is usually a
			readily available one.
			Even in an “easy” case, the VR
			surgeon must make several
			decisions that are
			individualized to that
			particular patient/eyeball.
			In more difﬁcult cases the
			number of decisions can be
			almost inﬁnite
Tissue reaction to the	Typically as	As expected or	The nucleus may be as soft as
surgeon’s action	expected	very different	predicted or much harder.
			During vitreoretinal separation
			the retina may prove as
			resistant to traction as
			assumed – or it may tear at
			the weakest traction force
Consequences if the	Minimal to	Minimal to	Certain errors can easily be
intraoperative	moderateb	extreme	corrected (an equatorial
decision-making			retinal tear has been caused
was erroneous			during too forceful PVD);
			others can result in
			irreversible loss of vision
			(tearing the fovea during
			EMP removal)
			(continued)

6		1 Should You Become a VR Surgeon?

Table 1.1 (continued)
Variable	Cataract surgeon	VR surgeon	Comment
Expected success	Very high/excellent	Low to	The cataract surgeon is
rate/prognosis		high/good to	disappointed if full vision is
		poor	not restorede or not restored
			rapidlyf
			In certain pathologies (macular
			hole, EMP etc.) excellent
			visual recovery can be
			expected if surgery is done
			well and early. In others
			(PVR, submacular
			hemorrhage etc.) the success
			rate is low and/or the
			recurrence or complication
			rate high (see Fig. 11.1)
Apparent success rate	Very high	Low	This is a bias, although it may
			not be obvious to the VR
			surgeon: his patients are
			much less likely to come
			back for longer-term
			follow-up if surgery was
			successful. His failures, on
			the other hand, keep
			returning
Intraoperative	None to low	None to	For the cataract surgeon, these
complication rate		moderate	complications are rare and
			mild, and even if they occur,
			the solution is usually at
			hand
			The VR surgeon faces an
			endless list of potential
			complications, some of
			which may be rare or severe
			enough not to have a readily
			available solution
Postoperative	None to low	None to inﬁnite	A stand-alone booklet can be
complication rate			written about the list of
			potential complications
			following VR surgery
			(see Chap. 64)
Severity of early	None to lowc	None to extreme For the cataract surgeon, the
postoperative			only truly vision-threatening
complication(s)			risk is endophthalmitis
			The list of even the very serious
			complications after VR
			surgery is rather long:
			endophthalmitis, high IOP
			due to gas expansion, severe
			VH, RD, PVR etc.
			(continued)

1 Should You Become a VR Surgeon?			7

Table 1.1 (continued)
Variable	Cataract surgeon	VR surgeon	Comment
Reoperation(s)	Very rared	Rather common	For the VR surgeon, this is true
			even if his initial job was
			well done
Patient satisfaction	High	Low to high	For the VR surgeon, this is one
			of the reasons why
			preoperative counseling is
			so imperative: the patient
			should know before surgery
			what to reasonably expect
			and why his cooperation
			with the surgeon’s
			instructions is so crucial
Threat of lawsuit	Very low	Low to moderate	For the VR surgeon, this is one
against the surgeon			of the reasons why
			preoperative counseling is
			so imperative: the patient
			should know before surgery
			what to reasonably expect
			and why his cooperation
			with the surgeon’s
			instructions is so crucial; he
			must also understand and
			appreciate how difﬁcult the
			surgeon’s task is
Intellectual reward	None to high	None to extreme This is a personality-dependent
			issue. The phacologist looks
			at how many cases he did
			during the day; the cataract
			surgeon proudly looks at
			how many patients had their
			sight restored by him
			Saving vision even in “routine”
			VR cases means great
			satisfaction. Nothing is as
			rewarding for the VR
			surgeon than improving the
			patient’s chances for being
			able to see (or even keeping
			the eyeball) in cases where
			everybody has given up hope
			(continued)

8		1	Should You Become a VR Surgeon?

Table 1.1 (continued)
Variable	Cataract surgeon	VR surgeon	Comment
Financial reward	Decent	Lower then	This, of course, depends on
		decent	many factors: health care
			system in the country, the
			type of practice, the number
			of cases performed etc.
			The VR surgeon may be more
			rewarded than his cataract
			colleague per case, but his
			caseload is much lower

*Nothing in this book implies that the VR surgeon has any type of supremacy over the cataract surgeon; cataract removal with IOL implantation is the most successful surgery on the human body and with good reason: great cataract surgeons have perfected it beyond expectation. My already high personal appreciation was only increased when I underwent, on both eyes, cataract surgery myself, done by an excellent cataract surgeon. Conversely, I do harbor hard feelings for that minority of cataract surgeons whom some call “phacologist”: those for whom the patient is a lens walking on two legs, waiting for extraction and in-the-bag IOL placement. Such phacologists do not recognize that “there is life behind the posterior capsule” and thus have no respect for the retina or the eye in general (see the Appendix, Part 2).

aOne of the exceptions is a major intraoperative bleeding from the choroid (ECH) and consequent loss of the eye.

bProvided the cataract surgeon makes the correct choice: he does not ﬁsh for lens particles (see Sect. 44.1.1) lost into the vitreous or he does not carry on with the surgery even though a choroidal hemorrhage is occurring (see Sect. 40.1).

cExcept: endophthalmitis.

dYAG capsulectomy is not considered as a reoperation.

eWhich is rarely the result of the cataract surgery but due to some VR pathology such as AMD. fCorneal edema due to increased phaco time because of a hard nucleus.

this is exactly like a capsulorhexis: you take a forceps and tear off a membrane.4 What he did not understand is that success in VR surgery is primarily determined not by the hand (dexterity) but by the brain, which gives instructions to the hand (see Sect. 4.2).

Pearl

Whatever instruction the brain gives to a trained VR surgeon’s hands, it is very likely that the hands will be able to execute that decision and without causing signiﬁcant iatrogenic mechanical damage. Conversely, one may have the most delicate hands, but if the instruction is false, failure is inevitable. An obvious example is ILM removal: the surgeon must be aware of how to grab the membrane, recognize via visual feedback how deep the jaws are biting, how to pull on the membrane (vectors), at what speed etc. (see Sect. 32.1). All trained VR surgeons should possess the hands to carry out any maneuver with relatively little difﬁculty.

4 Similarly, an inexperienced VR surgeon should not, unless assisted by an experienced mentor, undertake removal of an EMP – I have seen eyes after such attempts with an intact EMP but with central retinal tears as the inexperienced surgeon grabbed retina instead of epiretinal tissue.

1 Should You Become a VR Surgeon?	9

Aspiring VR surgeons must understand what their future life will be like, but also how complex the training is (see Chap. 2), and not embark on this road unless they are prepared to accept the hardship.5

One of the peculiarities of the VR surgeon’s life is the relatively high number of returning patients. They usually come back because of a complication. (Those, and this is the majority, who had been cured forever with one operation are much less likely to return.) The VR surgeon is therefore exposed to a “selection bias” on his outpatient (clinic) days: there will many more patients to be seen with “a problem” than without.

The VR surgeon occasionally sees patients who arrive with a condition that other colleagues deemed inoperable, but the patient does not want to give up hope and keeps searching for a surgeon who is willing to try. Successful intervention in such a case is what helps the surgeon recharge his drained emotional battery.

A VR surgeon is not a surgeon of the retina and vitreous; he is a surgeon of the eyeball.6 To be able to properly deal with posterior segment problems, he must also be able to treat corneal diseases, perform a PK, suture the iris, remove the lens and implant an IOL, recognize the causes of secondary glaucoma etc.7

Ophthalmologists who understand these caveats and accept their implications will have a richly rewarded emotional and spiritual life as VR surgeons. If they do not, will they be very unhappy – and so will their patients.

5I know of several fellows who entered into a program only to give up after a few months; more was lost for them than the time wasted.

6More precisely, surgeon of a person (see Chap. 5).

7Some, although not all, of these are therefore discussed in this book, even if such topics do not regularly get detailed in publications dedicated to VR surgery.

How to Train as a VR Surgeon Outside	2
a Formal Fellowship

Ophthalmology residents who decide to become a VR surgeon have at least some experience in performing anterior segment surgery, mainly cataract extraction. Such a background provides a good basis for specializing in posterior segment work – but no more than a foundation for it.

Training for VR surgery is a long, indeed never-ending, process. If the ophthalmologist is fortunate enough to live in one of the few countries in which formal schooling (fellowship) is available, his path to becoming a trained VR surgeon is charted. Most residents, however, will not have access to such tried-and-tested programs and must design their training program themselves. This chapter provides guidelines for such an endeavor.1

Pearl

For someone aspiring to become a VR surgeon, the importance of proper training cannot be overemphasized. Without such training many operations will end in failure for the surgeon and visual loss for the patient. Repeating the same erroneous intravitreal maneuvers will predictably result in the same tragic outcome. Facing failure after failure, these surgeons will eventually give up VR surgery, at the cost of blind patients and the loss of self-conﬁdence.

1 All trainees are called fellow in this book.
© Springer International Publishing Switzerland 2016	11
F. Kuhn, Vitreoretinal Surgery: Strategies and Tactics,
DOI 10.1007/978-3-319-19479-0_2

12	2 How to Train as a VR Surgeon Outside a Formal Fellowship

2.1The “To-Do” List2

The fellow should do all of the following:

•Select an experienced and willing VR surgeon3 at the fellow’s institution, who will serve as a mentor for the entire training period (see the Appendix, Part 1).

•Read the most important books and articles on VR surgery – the mentor should help with the selection process.

•Attend meetings where peers, preferably from the international community, discuss the latest development in the VR ﬁeld.4

•Spend the maximum possible time with the mentor,5 examining patients in the outpatient department. Many a pathology will be seen and you should understand how the decision whether the condition in that particular patient is amenable for surgery is made.6

–Follow the patient after PPV, preferably long term. This helps recognizing complications and their treatment, and also, in retrospect, to see whether the decision to go to surgery was correct.

•Assist in surgery as often as possible.7 Assisting, again, must never be spent by passively staring at the microscope or monitor (see Table 2.1). As always, the more experience gained, the easier and more useful such observing/assisting becomes.8

•It is highly advisable to learn from more than a single surgeon, however good he is. Different surgeons have different approaches to the same problem, and, optimally, the fellow is exposed to a variety of options. Even when the fellow sees something “horrifying,” it is helpful: he now deﬁnitely knows that he will never do this in his own practice.

2Taking notes throughout the entire training process is crucial, for two reasons. (1) The human brain is not a storage facility. Instead of trying to memorize the received information, whether major strategy-related issues or useful surgical tricks, it is best to preserve them electronically, in an organized system that best suits the fellow’s own logic and allows searching. (2) There is a huge difference between active and passive knowledge; taking notes makes the learning process active, as opposed to just listening or reading, both of which are passive.

3Do not expect that everybody around you will treat you well (see the Appendix, Part 2).

4Obviously, some of the lectures will at the beginning be way above the level of the fellow. This difﬁcult initial period will not last very long, and the fellow should not be discouraged if he has problems understanding all he hears (or reads). If the information is conﬂicting, it may simply be due to the complexity of the ﬁeld, not a sign of his incompetence.

5Shadowing. You should bombard him with questions, and while remaining respectful, do not hesitate to challenge him (see the Appendix, Part 2).

6The mentor’s decision is to some extent subjective; others may choose a different option in the same situation (see the Preface, Sect. 11.4, and Chaps. 8, 9, and 10).

7If this is not allowed or possible during a visit, at least observe closely, as if you were assisting.

8Imagine two people being taken by a football fan to a game: one of them understands it, the other has never seen one. Even though these two people will see exactly the same events unfolding in front of their eyes, one will be able to share exciting moments after the game with the fan (“Did you see how player X passed the ball in the 40th min with his heel?” – “Yes, it was fantastic”). The inexperienced person will have no idea what the other two are talking about. The image of that heel-pass was cast on his retina, but his brain did not register it.

2.1 The “To-Do” List	13

Table 2.1 The rules of assisting/observing in VR surgerya
Element	Comment
Talk to the surgeon	Explain to him that you came to learn and that you are very interested
before the	in what he is going to do; ask him if he is comfortable with you
operation	asking lots of questionsb
The condition of the	Note the anatomical relationships; formulate a strategic goal (what the
eye	eye’s condition at the end of the operation should be) and then the
	tactical goals (the tissue manipulations needed to achieve that ﬁnal
	anatomical condition). Of these two basic categories, initially the
	second is more obvious; as the experience grows, the strategic issues
	will gain importancec
The surgeon’s next	Try to expect what this move will be (what you would do in this
move	situation). There are two possibilities, detailed next
Move is what you	Be proud of yourself
expected
Move is not what you	This is the moment of truth: if you are able to ﬁgure out why his move
expected	was not what you expected, you learned something
	If you cannot determine why the surgeon acted differently from your
	expectation, you must ask him why he did what he didd
Asking the surgeon	Most surgeons will not be willing to answer you during the operation.
“why”	You must make a mental note (if you are assisting) or a quick written
	one (if you are observing) about the exact situation and how the
	surgeon’s action diverged from your expectation, and ask him after
	the operation
	A few surgeons are willing to answer the question right there and then.
	These are the surgeons you will beneﬁt from the most since you can
	instantly learn something
	A few surgeons actually encourage you to comment, not simply answer
	your questions; this is the absolute best option since it makes your
	newly gained experience a truly active one. These are the surgeons
	you should often revisit
	Conversely, some surgeons will not answer you at all or give you an
	obviously bogus answer. Leave him

aThe distinction is that during observation the fellow follows the surgery on the monitor or, if he is able to have access to it, through the microscope. If he is allowed to scrub in and actually act as an assistant, the experience is enhanced.

bMake sure you select your words very carefully if the patient is awake during the operation (see

Chap. 15).

cThese goals are discussed in Parts IV and V. dSee Sect. 3.4.

•The best possible scenario is to visit numerous surgeons/institutions over time.9 The fellow does not have to spend a lot of time with/at each; a week or 2 usually sufﬁces. Ideally, he arrives with lots of questions, gets answers, goes home, and continues the learning process in his own practice; with time he will have more questions and then visit another surgeon for answers and for a different experience.

9 See Sect. 3.4 about the behavior of the fellow in the ORs he is visiting.

14	2 How to Train as a VR Surgeon Outside a Formal Fellowship

Q&A

Q How should the fellow select which other surgeons to visit and observe?

AThe surgeon should obviously be knowledgeable – but it is equally important for him to be willing to help, answer all questions, and explain things; in short, he must not only be an experienced surgeon but also be a decent person.

The process of observing is not restricted to what is happening inside the eye. It is also crucial to take note, among others, of the following:

–The surgeon’s posture and seating arrangement (see Chap. 16).

–How he holds the instruments with three, not with two, ﬁngers (see Sect. 20.1).

–How he hands instruments to, and accepts instruments from, the nurse while he never looks outside the microscope (see Fig. 35.1).

–How he supports the actions of the hand performing the maneuver with his other hand (see Fig. 2.1).

•Watching unedited videotapes of surgeries performed by the fellow himself as well as by other surgeons is a great teaching tool (see Sect. 11.3).

•Once you gained some experience performing surgery yourself, ﬁnd a mentor who is willing to observe you (ideally, assist you), serving as your coach. Nothing is as valuable as an experienced surgeon who shares his practical expertise with you this way – as long as he does it in optimally (see the Appendix, Part 1).

Fig. 2.1 One hand supported by the other. The surgeon is performing maneuvers in the AC: the probe must be inserted through a temporal paracentesis because it has to be held in the horizontal plane. In this particular case it means that the probe is held in the surgeon’s nondominant hand; his dominant hand is used to provide extra stability and increased precision for maneuvering with the probe

2.1 The “To-Do” List	15

Table 2.2 provides a brief summary to help the fellow design his own training program.

Table 2.2 The elements of a self-designed VR fellowship program*

Element	Comment
Books, articles	These represent a readily available source that should often be
	consulted
Internet	It is useful to know “what’s out there”; however, websites that are not
	written by professionals for professionals in a veriﬁable manner
	should never be used as a source for learning
Attending VR	The usefulness of such meetings increases as the fellow gains
meetings	experience. The meetings, even at the onset of the training
	program, however, provide physical access to, meeting with,
	potential mentors. Exchange of ideas with peers is another beneﬁt,
	whether related to information/knowledge about VR surgery or the
	training process
Active participation in	Examining patients, assisting in surgery, following patients who
own institution’s	underwent PPV, postgraduate courses, clinical research
VR activities
Observing/assisting in	This should never be a passive observation but an active one: the
surgery	fellow should think along and try to predict the surgeon’s next step
	(see Table 2.1). Furthermore, observation is not restricted to
	intraocular manipulations; everything must be noticed from
	anesthesia to how the nurses assist the surgeon or how the surgeon
	holds the instruments in his hand
“Why?”	The fellow must develop an attitude so that he never accepts anything
	he is told without consciously contemplating it, and, if he has
	doubts or disagreements, is ready to voice these – regardless of
	who the “authority” that told him that particular thing is (see the
	Appendix, Part 2)
Note-taking	This is a nonstop process; the notes must be kept in a single place
	(one electronic ﬁle, one booklet) and be arranged logically and
	constantly updated. The electronic version has the advantage of
	being searchable
The messenger	It is a common problem that speakers/tutors are unable to place
	themselves in the shoes of the audience or the fellow, and try to
	explain things on a level that is far above the one that the audience/
	fellow is able to perceive. Even if the fellow ﬁnds a knowledgeable
	and helpful surgeon, if this person is unable to communicate in a
	manner that is “on level,” the fellow is better off not spending time
	with him
Visiting other surgeons	To select which surgeon to visit is not an easy task. The surgeon must
	not only be a respectable expert but one who is willing to help; one
	who explains things and does so on a level that the fellow actually
	understands (see above); one who does not give bogus answers to
	the fellow’s questions just so that all questions are answered,
	regardless of the answers’ truthfulness; and one who is willing to
	maintain a long-term relationship with the fellow: he remains
	available to be consulted via email, SMS, or the telephone (Skype)
	(continued)

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Introduction

Should You Become a VR Surgeon?