4.8How Long Do Vitrectomies Take?

Another issue that fellows (as well as inexperienced nurses and anesthesiologists) often ask about is the length of the procedure.

Q and A

Q How long does an average VR surgery last?

AThere is no answer to this question. The duration depends on many factors: The particular indication, the type of equipment used, the quality of the instruments, the experience of the surgeon, the experience and attitude of the nurse, the expected and unexpected complications during the operation, the extra maneuvers that may become necessary etc. If I encounter no surprise, I usually need no more than 10 min for an uncomplicated VH with PVD, a little less than 15 min for an eye with a macular hole, but I have had numerous complex TKP-PPVs that lasted for more than 5 h.

Finishing surgery in the least amount of time should not be a goal of any surgeon for any procedure. The reason to nevertheless try to do so is not for the surgeon to have extra “free” time27 but to reduce the time the patient (and his family) spends worrying about what is happening in the OR.

Pearl

No award is given to finish a VR surgery in record-breaking time. The award goes to those who consistently do a perfect job.

4.9Was Surgery Successful?

Obviously, this is a crucially important and obviously most relevant question; it is, and always should be, asked by the patient, his friends, relatives – and the VR surgeon himself. However, the answer is not as straightforward as it may first seem.

For a cataract surgeon, if no intraoperative complication occurs, the answer is almost always a “yes”: the anatomical success is there for all to see, and the risk of postoperative complications is small; the functional success is virtually never determined by the lens operation28 but by the condition of the posterior retina.29

27Not that there is anything wrong with this concept.

28Except perhaps if an IOL of the wrong power was implanted.

29To avoid the “unexpected outcome of no visual improvement,” the fundus should always be checked prior to cataract surgery: is there an old RD or an end-stage AMD?

For the VR surgeon, however, the issue is much more complex, due to the complexity of the operation and/or to the body’s reaction to the operation; the original condition may also be a progressive one.

•Was the vitrectomy an anatomical success? Often, everything looks perfect at the conclusion of surgery, but by the next morning, there is blood in the AC or in the vitreous, or the retina may be detached.

–Even if complete anatomical success has been achieved, scar formation or some other undesirable complications may later destroy what has been achieved intraoperatively.

•Was the vitrectomy a functional success? Success in restoring the anatomy does not necessarily lead to functional improvement. There are several possibilities.

–The vision may not improve initially but do so subsequently.

–The vision improves initially but deteriorates or is even lost longer term as the anatomical condition of the eye turns for the worse (i.e., the retina detaches).

•The vision does not change substantially – but an otherwise hopeless situation (loss with natural history) has been prevented.

VA drops to 20/40” has no consideration for the individual patient. Several questions immediately come to mind about this:

•Why 20/40, and not some other level of VA (e.g., 20/50)?

–Indeed, the very fact that there is no consensus about the cutoff VA level shows that such an artificial distinction has no merit.

•Is the patient informed that a delay of surgery can cause permanent visual loss?

–The lower the initial VA, the smaller the chance of regaining full vision.

•Are patients robots so that the same artificially chosen cutoff VA is applicable for everybody?

–Some people are extremely bothered by minor visual disturbances while others tolerate much worse ones.4

Pearl

The decision when/whether to operate must not be decided by a random VA value but by the desires of the patient – based on the information he receives from his physician about his condition.

Another example to show the “tissue vs person” thinking is a patient who undergoes cataract surgery and the nucleus is dropped (see Table 9.1). The visual outcomes in the literature are fairly similar whether PPV is performed immediately or delayed by days or even a few weeks.

•The cataract or VR surgeon who leaves the timing up to convenience5 looks at the problem on the “tissue level”: since the outcomes are similar, it does not matter when the PPV will be done.

•The cataract or VR surgeon who wants the PPV to be done immediately6 looks at the problem as one of a person who expected a complication-free cataract operation with a rapid visual rehabilitation. Now that the complication has occurred, this has all changed, and the patient should not be exposed to days or weeks of anxiety about the final outcome.

4If this was not enough to convince the reader why an artificial cutoff VA must never be the deciding factor when indicating or deferring surgery, think about yourself, the VR surgeon, having a vision problem that greatly bothers you during surgery. You go to your colleague who finds that you have 20/25 vision and a barely visible EMP, and he tells you that no surgery is justified because your vision is not yet “bad enough.” Will you accept this verdict?

5Surgeon, OR time availability etc.

6In the same surgical session.