*Shortened terms describing a surgeon who applies, pretty much unchanged, his usual approach regardless of the individual circumstances vs a surgeon who changes his approach according to what the individual situation demands.

aTo keep the eye “compartmentalized” was an extremely important issue in the ICCE era when combined surgery was performed but no laser therapy was available – many eyes were lost to neovascular glaucoma. Compartmentalization has lost its significance since.

bSee Table 27.2.

Pearl

Just as it is unwise to initiate therapy without a diagnosis, it is wrong to perform surgery or any surgical manipulation as a reflex or instinct. The surgeon must make conscious decisions concerning all strategic issues and every tissue manipulation prior to any action.

In my many visits to many operating rooms as a trainee, I found surprisingly few surgeons who honestly answered my “why?” questions. Several surgeons were clearly annoyed and did not give an answer at all. Many of those who did answer gave useless ones,11 answers that clearly told me: I do not have a rational explanation for why I’m doing what I’m doing (see Table 2.1).

I encourage every visitor in my operating room to ask me the most fundamental question: “Why did you do that?”12 It is extremely rare that I cannot give a rationale for my action.13

3.5Don’t Start What You Cannot Finish

Typically, the first surgery has the best chance of success, and with each successive operation the prognosis gets poorer. If a surgeon cannot complete the intervention because he reached the limit of his expertise or the equipment is lacking,14 the eye’s condition may have worsened.

Removal of a VH in an eye with complete PVD is perhaps the easiest indication for PPV.

However, if the PVD in incomplete and there is VR adherence in an area of noPVD, even an experienced surgeon can cause a retinal break and even intraoperative RD (see Sect. 58.2).

Q&A

Q Which are the easy cases for the inexperienced fellow to operate on?

AIt is impossible to say. What may look easy preoperatively can quickly turn into a disaster in the hands of a surgeon who lacks the proper expertise. This is why the fellow needs to assist in VR surgery for extended periods before gradually being guided into the surgeon’s role. Unsuccessful surgeries early into one’s career are not “only” harmful for the patients but also for the surgeon’s self-confidence (see Sect. 4.7). This is especially true if the stakes for the patient are exceptionally high, such as when he is monocular (see Sect. 8.4).

11“Because I always do it this way”; “because that’s what I was taught”; “what do you mean?”

12Why did you use a bent needle and not a forceps to lift that membrane? Why did you cut the subretinal strand rather than take it out? Why did you just change the direction of peeling the ILM? The fellow must behave in the OR as a young child who is constantly “pestering” his parents with “why?” questions.

13If I cannot answer a visitor’s “why?”question, it forces me to reconsider the issue in question to either find the rationale for it or look for a more effective option.

14Another evidence in favor of planning all aspects of surgery well in advance.

3.6Common Sense vs Dogma

Common-sense thinking is a must-have attribute of the VR surgeon.15 One’s approach to the treatment of a condition must have a rational basis, and this rational does not tolerate dogmas – even if that dogma seems to have a solid scientific foundation.16 First, not all scientific questions are amenable to an answer by a study with level 1 evidence. Second, even if such a study exists and its results seem to have an obvious answer to a particular problem, it still must pass the “smell test,” that of: “Does it make sense to do this?”17 Third, just because a study’s conclusions are statistically valid, there is great variability in how an individual responds to the same therapy.18 This is another reason for each surgeon to develop his own “my way” philosophy (see Sect. 11.4).

3.7Maximal Concentration During the Entire Operation

•Once you are sitting at the operating table, you must have your undivided attention to be focused on the eye and do so throughout the entire procedure.19

•It can lead to tragedy if you lose concentration, regardless of why.

–External factors (e.g., overhearing two nurses gossiping about a colleague).

–Internal factors (e.g., the manipulations are easy and straightforward,20 and the operation is proceeding smoothly with no apparent risk of intraoperative complications).

Unexpected events can rapidly occur, making a problem of minor significance (e.g., during that “easy” EMP removal the surgeon comes across a small area of strong VR adhesion) into a disaster (the peeling force/direction is not changed in time and an easy-to-avoid retinal tear is caused).

15I recently heard a presentation by a well-known retina specialist about a patient with diabetic macular edema. He received 36 monthly intraocular injections (at ~$2,000 each); the plan was to continue the treatment. Common sense tells you that if a therapy is expensive and does not work, you do not “blindly” follow a study’s blanket recommendation but switch therapy.

16This principle extends to include studies that are “evidence-based.” Just because such proof of the efficacy of a certain treatment option once existed, it does not necessarily mean that years after the publication of that study it still holds water.

17The British Medical Journal published a sarcastic article in December 2003 about the “effectiveness of [the] parachutes,” stating that this “has not been subjected to rigorous evaluation by using randomized controlled trials… everyone might benefit if the most radical protagonists of evidencebased medicine organized and participated in a double-blind, randomized, placebo-controlled, crossover trial of the parachute.”

18In other words, Mr. A. will do fine with therapy X, but Mr. B. is better off with therapy Y.

19The football (soccer) coach’s cliché warning to his players is that the game lasts 90 min; whether the other team wins by scoring in the first or last minute does not matter, you still lose.

20Such as panretinal endolaser treatment, which requires very little “brain work.” A surgeon who delivers over 2,000 spots is at risk of losing focus and venturing too close to the fovea (see Sect. 30.3.2.).