Fundamental Rules for the VR Surgeon

aThe surgeon must also have a rough idea about what that most optimal outcome can be, both anatomically and functionally (prognosis).

bWhich is the majority of the cases.

cThere are other, less crucial steps, which are not listed here.

dIt can range from the high teens to literally hundreds during a complex trauma case. eThis is rather common in VR surgery, see Table 1.1.

Pearl

Just as a driver who encounters a roadblock or traffic sign that forces him to alter his planned route, a surgeon who finds an unexpected pathology or tissue behavior must change his original plan according to what the new findings dictate.

As in the driving example, the surgical plan cannot be formulated without the surgeon having a clear idea about the desired anatomical outcome of that particular operation. Instead of making ad hoc decisions as pathologies emerge, the surgeon’s tactical decisions are in harmony with the strategy.5 This long-term thinking has multiple advantages (see Table 3.2).

Table 3.2 Long-term vs short-term planning for a patient requiring VR surgery

A 48-year-old male presents with a 6-day history of vision loss; he has 3 D of myopia. He has a macula-off RD with a large tear at the equator inferotemporally. The vitreous is full of pigmented cells, and the tear’s edge is curled

•It requires careful consideration whether an eye that is likely to develop PVR requires primary in-the-bag IOL implantation.

–An eye at high PVR risk may be better off with removal of both lens capsules during the primary surgery, especially if the patient is young (see Sect. 38.5). The implantation of an iris-claw IOL is the last step of the management process (see Sect. 38.6).6

5Another analogy to describe the difference between the two approaches is the example of two football coaches who have the purse to buy new players. One coach buys famous players with the hope that their talent will naturally give birth to a team system; the other one buys players who he thinks will fit his existing coaching philosophy. The second coach should have a higher chance of creating a winning team.

6The implantation is performed months after the silicone oil has been removed.

•Suture-constricting a pupil too early makes subsequent VR surgery more difficult (see Sect. 48.1.2).7

•The surgeon should try to anticipate complications such as PVR, which may arise due to the condition itself or as a result of his own intervention. He must try to reduce the risk (prophylactic chorioretinectomy; see Sect. 33.3).

Pearl

A good surgeon is akin to a defensive driver who not only drives carefully but is constantly on alert: keeping watch over all the other drivers around him and trying to anticipate what those drivers may do. A surgeon must never be on autopilot and never do maneuvers as a matter of reflex or custom – there must be a reason for everything he does (or does not do).

•A pseudophakic eye requires a capsulectomy.

–With the probe it is possible to create a capsulectomy regardless of the thickness of the capsule and without the risk of damaging the IOL; in addition, the capsulectomy is precisely of the desired size.

–Performing capsulectomy assures instant and permanently excellent visibility for both patient and ophthalmologist.

–True, YAG laser will probably also allow opening the posterior capsule at any time postoperatively, but the opacified capsule will interfere with visualization until then. The laser also produces a large, permanent floater that may be bothersome to the patient, a consequence that could easily have been avoided by planning ahead.

–Leaving the posterior capsule intact has one, intraoperative, advantage: no risk of IOL fogging during F-A-X (see Sect. 25.2.3.4).

Finally, it must be emphasized that as technology evolves, surgical techniques improve, new materials become available etc., the surgeon must also change. The same condition that a few years ago would have required a certain plan to treat may require a very different plan today.8

Figure 3.1. is an illustrative example of planning. It is from “civilian life,” outside ophthalmology, but it shows the mindset that the VR should develop to replace “instinct” with thinking ahead.

7Another example of long-term thinking is a patient with PDR: the VA is full but the tractional detachment is progressively approaching the fovea. A surgeon with short-term thinking simply hopes that the TRD never progresses that far and defers surgery until the fovea does detach. A surgeon with long-term thinking explains to the patient what is likely to unfold, but also the risks of the surgery, and, with the patient’s informed consent, operates before the fovea detaches.

8One illustrative example: In severely injured eyes I used to preserve the anterior capsule and implant, as the very last step of the treatment process, a sulcus-fixated IOL. In recent years I switched to removing both capsules and implanting an iris-claw IOL (usually possible even if the iris had also been injured and required suturing; see Sect. 38.6).

a

P1

P2

Y X

b

X

X

Y

Fig. 3.1 Planning to park a car. (a) All cars are parked in a way that reflects their owners’ lack of planning before they had parked their vehicle (peer pressure may also have played a role for those who arrived later). The question is: how will the driver of car X, just arriving, park? This parking lot provides the opportunity to pull through (leaving the car in space P1 instead of P2). Space P1 has numerous advantages: upon leaving, there will be no need to first go in reverse. (b) Backing out not only wastes fuel and wears out the breaks and the gear mechanism earlier, it also makes it impossible for the driver to see, at least initially, whether there is oncoming traffic (such as car Y). If that driver does not pay attention, a crash can easily occur. Furthermore, driver X will be forced to wait until all traffic clears before he can proceed. Parking in space P2, in short, has absolutely no advantage. A VR surgeon, planning ahead, should immediately pull through to space P1

3.2Control (as Opposed to Playing Russian Roulette)9

By carefully planning the treatment on levels one and two, it is the surgeon, not chance, that controls the strategic aspects of the treatment. Control intraoperatively10 is also very important; it means that the surgeon has a clear idea about the consequences of each of his maneuvers, how the tissue will (should) react. Instead of “let’s cut into the retina and hope it will not bleed,” control translates to “I will diathermize the retina before cutting into it so that there will be no bleeding.”

Pearl

Ideally, everything that unfolds inside the eye during VR surgery does so because of choice, not chance. Grabbing an EMP in the center and pulling it away from the retina translates into a traction force that acts on the retina at each location where there is adhesion between scar tissue and retina – and the surgeon has no way of knowing where these adhesion points are. By attacking the membrane at its center, the surgeon gives up control over subsequent events and replaces it with hope (centrifugal peeling; see Sect. 32.2.2.5).

3.3Do Not Try to Adapt the Eye to Your Own Preferences

Certain conditions permit, even encourage, a cure by employing against them exactly the same type of surgery, performed in an identical fashion and repeating the same surgical steps; VR pathologies must never be in this category. Each case deserves individual attention and management, on all three levels of planning and executing the plan. Table 3.3 shows the differences between the two approaches.

Trying to force the surgeon’s favorite technique on the eye irrespective of the condition’s unique attributes is wrong and dangerous. The surgeon must adapt to the eye’s condition and not the other way around. He must be able to see the forest, not just the tree, and develop the best possible treatment option in the particular situation. If he is unable or unwilling to modify his approach based on what the eye’s condition demands, he must forego surgery and refer the patient.

3.4The “What, When, How – and Why” Questions

The VR surgeon must always know what he is doing or planning to do, when he plans to do it (timing), and how he intends to do it (tissue tactics). It is equally important for him to always know why he does it, and this is true for all three levels of planning, including every single tissue maneuver during surgery.

9A corollary to this issue is a surgeon who never had binocular vision. In real life it is not a problem: he may not even know this, and no binocularity test is required of a potential VR surgeon. Those who used to have binocular vision but then lost it should not be discouraged either: EAV proves that the human brain is able to cope, even if the learning curve must be respected (see Sect. 17.3).

10Level three, tissue tactics.