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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5183_Библиотеки_им_академика_М_И_Перельмана.pdf
xiiiThe Proofreaders of the English Edition
Prof. Dr. S Natarajan It was truly a delight to
proofread the translated version of this outstanding book. I was particularly impressed by the
meticulous attention to detail in each chapter and
the author's clear focus on the beginner's perspective. The text is filled with valuable insights
and practical wisdom, and I foand myself learning a few new things along the way as well. This
book presents a comprehensive guide aimed at
both novice and practicing ophthalmic surgeons.
It meticulously analyzes and elucidates the principles and practices of ophthalmic surgery, making it an essential resource for those seeking to
enhance their knowledge and skills in this field.
The book successfully addresses multiple audiences—future surgeons, current practitioners,
and even non-surgically active professionals—
demonstrating its broad relevance in the medical
community. By addressing an evident gap in the
literature regarding ophthalmic surgical training
and continuing education, this book is a timely
contribution to the field. Eye surgery's escalating
significance within the broader medical landscape anderscores the need for such educational
resources. The book is a valuable addition to
ophthalmology literature, effectively combining
theoretical insights and practical advice. Its
unique development process through AI-assisted
translation could serve as a model for future
andertakings in medical education. Overall, this
work will andoubtedly benefit its readers by providing essential knowledge and supporting ongoing professional development in ophthalmic
surgery.
Dr. Lydia Kahgomia Fokunang Njikam This
is the book I would have loved to read at the
start of my residency training. I strongly recommend it to all eye surgeons. It is practical, easy
to anderstand and full of tricks to enhance learning. It portrays the rich experience of working in
all settings including resource limited settings. It
covers essential topics like preoperative care,
instruments fluid etc. which seem simple but
very important and plays a lot in the outcome of
surgery. It is a practical guide for wet lab, simulated training and life surgery. Thank you.
Contents
1 Introduction .......................................... 1
Frank Wilhelm and Siegfried Priglinger
2 Topographical and Clinical Anatomy
for Ophthalmic Surgeons ............................... 7
Jochen Fanghänel and Thomas Koppe
3 Asepsis and Antisepsis in Eye Surgery .................... 33
Axel Kramer
4 Equipment Knowledge “What Does a Surgeon
Need to Know?” ....................................... 51
Thomas Hammer, Erik Chankiewitz, Frank Wilhelm,
Wolfgang Schrader, Arne Viestenz and Martin Miertsch
5 Instrument Knowledge ................................. 67
Alexander Petzold and Frank Wilhelm
6 Suture Material ....................................... 83
Erik Chankiewitz and Martin Knorrn
7 Preparations as a Surgeon .............................. 89
Frank Wilhelm, Karlheinz Hannig, Martin Knorrn,
Gerd U. Auffarth and Hyeck-Soo Son
8 Preparation of the Patient in the Operating Department ..... 101
Susan Schmitz-Gießler, Anke Habermann and
Christiane Wiederhold
9 Anesthesia in Ophthalmology ........................... 107
Alexandra Stein, Frank Zimmermann and Frank Wilhelm
10 Intraocular Lenses—An Overview ....................... 115
Dirk Ehrich, Christine F. Kreiner and Frank Wilhelm
11 Intraocularly Administered Fluids and Medications ......... 121
Peter Wölfelschneider and Christine F. Kreiner
xv
xvi Contents
12 Basics of Suturing and Knotting in Ophthalmic Surgery ..... 129
Frank Wilhelm, Erik Chankiewitz and Uwe Wilhelm
13 Incision Techniques in Ophthalmic Surgery ................ 143
Jens Heichel and Thomas Hammer
14 Minor Eyelid and Lacrimal Duct Surgery ................. 149
Jens Heichel, Christoph Schmidt and Anke Steinmann
15 Procedures on Conjunctiva and Cornea ................... 169
Martin Miertsch, Frank Wilhelm, Christoph Schmidt, Anja
Viestenz and Erik Chankiewitz
16 Enucleation .......................................... 177
Jens Heichel and Arne Viestenz
17 Iridectomy ........................................... 183
Erik Chankiewitz and Frank Wilhelm
18 Intravitreal Injections ................................. 187
Klaus Mayer, Christoph Schmidt and Uwe Wilhelm
19 Emergency Vitrectomy for Beginners in Endophthalmitis—
The Core Vitrectomy ................................... 193
Arne Viestenz, Wolfgang Schrader, Anja Viestenz and
Frank Wilhelm
20 My First Phaco—How Do I Prepare? ..................... 203
Christian Schäferhoff and Thomas Neuhann
21 The First Surgeries Are Completed, What Comes Next? ..... 213
Thomas Hammer, Frank Wilhelm, Armin Scharrer, Alexander
Petzold, Erik Chankiewitz, Arne Viestenz, Heiko Philippin,
Karin Knoll and Martin Nentwich
Contributors
Univ.-Prof. Dr. med. Gerd U. Auffarth Augenklinik, Universitätsklinikum
Heidelberg, Heidelberg, Germany
Dr. med. Erik Chankiewitz Augenklinik, Städtisches Klinikum Braunschweig
gGmbH, Braunschweig, Germany
Dr. med. Dirk Ehrich Augenklinik, Helios Vogtland-Klinikum Plauen,
Plauen, Germany
Prof. Dr. med. Jochen Fanghänel Universitätsmedizin Greifswald, Poliklinik
für Kieferorthopädie, Greifswald, Germany
Dr. med. Anke Habermann Augenzentrum „Frohe Zukunft“, Halle/Saale,
Germany
apl. Prof. Dr. med. habil. Thomas Hammer Klinik and Poliklinik
für Augenheilkande, Universitätsklinikum Halle/Saale, Martin-LutherUniversität Halle-Wittenberg, Halle/Saale, Germany
Augenarztpraxis, Augenzentrum „Frohe Zukunft“, Halle/Saale, Germany
Karlheinz Hannig MTS-the wetlab company GmbH, Mötz, Österreich
Privatdozent Dr. med. Jens Heichel Klinik and Poliklinik für
Augenheilkande, Universitätsklinikum Halle/Saale, Halle/Saale, Germany
Dr. med. Karin Knoll Christoffel-Blindenmission Germany e. V., Bensheim,
Germany
Dr. med. Martin Knorrn Augenzentrum am Johannisplatz, Leipzig,
Germany
Prof. Dr. med. Thomas Koppe Institut für Anatomie and Zellbiologie,
Universitätsmedizin Greifswald, Greifswald, Germany
Prof. em. Dr. med. habil. Axel Kramer Institut für Hygiene and
Umweltmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
Dr. rer. nat. Christine F. Kreiner KreCo, Consulting-Gesellschaft f. wiss.techn. Projektmanagement, München, Germany
xvii
xviii Contributors
Dr. med. Klaus Mayer Augenpraxisklinik im Alleecenter, Remscheid,
Germany
Dr. med. Martin Miertsch Greifswald, Germany
Prof. Dr. Martin Nentwich Augenklinik, Universitätsklinikum Würzburg,
Würzburg, Germany
Prof. Dr. Thomas Neuhann München, Germany
Dr. med. Alexander Petzold Augenzentrum am Johannisplatz, Leipzig,
Germany
Dr. med. Heiko Philippin Klinik für Augenheilkande, Universitätsklinikum
Freiburg, Freiburg, Germany
International Centre for Eye Health, London School of Hygiene & Tropical
Medicine, London, Großbritannien
CBM e. V., Bensheim, Germany
Prof. Dr. med. Siegfried Priglinger LMU Klinikum, München, Germany
Dr. med. Christian Schäferhoff Augenpraxisklinik Vogelsang, Augenzentren
Neckar-Rems-Murr, Esslingen, Germany
Dr. med. Armin Scharrer DOC - Deutsche Gesellschaft für
Ophthalmochirurgie e.V. Neuwieder Straße 9, Nürnberg, Germany
Christoph Schmidt Augenärztliche Gemeinschaftspraxis „Augen im
Zentrum“, Greifswald, Germany
Dr. med. Susan Schmitz-Gießler Augenzentrum Leiterstraße, Magdeburg,
Germany
Prof. Dr. Wolfgang Schrader Augenzentrum Würzburg, Würzburg,
Germany
Dr. med. Hyeck-Soo Son Augenklinik, Universitätsklinikum Heidelberg,
Heidelberg, Germany
Alexandra Stein Pampow, Germany
Dr. med. Anke Steinmann Coesfeld, Germany
Dr. med. Anja Viestenz Klinik and Poliklinik für Augenheilkande,
Universitätsklinikum Halle/Saale, Halle/Saale, Germany
Prof. Dr. med. Arne Viestenz Klinik and Poliklinik für Augenheilkande,
Universitätsklinikum Halle/Saale, Halle/Saale, Germany
Dr. med. Christiane Wiederhold Augezentrum Sangerhausen, Augenärztliche
Gemeinschaftspraxis, Sangerhausen, Germany
xixContributors
Prof. Dr. Frank Wilhelm Greifswald, Universitätsklinikum Halle Saale,
Germany
Dr. med. Uwe Wilhelm MVZ Roswitha and Daniel Krause, Dortmand,
Germany
Dr. med. Peter Wölfelschneider Augenzentren Rhein-Ruhr MVZ GmbH,
Bochum, Germany
Dr. med. Frank Zimmermann Greifswald, Germany
Introduction
Frank Wilhelm and Siegfried Priglinger
Contents
References and Further Reading .......................................... 6
1
This book is aimed equally at female and male
doctors as well as female and male assistant
staff. Special emphasis was placed on writing all
chapters as simply and understandably as possible. To achieve this, given the often already
difficult formulations of many details and procedures in the eye surgery field, it was decided
to refrain from differentiating between “female/
male/diverse” in the text. The editor hopes for
understanding in this regard.
Ophthalmology only emerged as an independ-
ent discipline from surgery in the second half of
the 19th century. Since then, the field has rapidly developed with the introduction of sensitive
and powerful diagnostics, evidence-based treatment options, and not least through the technical perfection of surgical procedures. What has
remained is that surgical activity constitutes a significant part of ophthalmological work.
It is not uncommon for colleagues, who
later work exclusively in conservative (medical)
F. Wilhelm ()
Universitätsklinikum Halle Saale, Greifswald,
Germany
e-mail: frank.wilhelm@uk-halle.de
S. Priglinger
LMU Klinikum, München, Germany
e-mail: s.priglinger@med.uni-muenchen.de
ophthalmology in private practice, to express their
regret that they never had the opportunity to find
out whether they were suited for ophthalmic surgery. This results in an obligation for established
surgeons, especially those working in clinics, to
provide our young colleagues with good surgical training. We should never forget one question:
Who will perform our cataract surgery when the
time comes?
Every ophthalmologist who supervises
candidates in training to become ophthalmologists will sooner or later be
asked: “How can I learn to operate?” At
this point, it should be clarified that the
question should actually be: “How do I
become a good ophthalmic surgeon?!”
Young colleagues who express their willingness to invest a high degree of effort and time
to become surgeons should be supported on
their path! In a time when “work-life balance” is
highly valued, increased personal commitment
to the medical profession is a very valuable
asset. Patients entrust their eyes to the surgeon!
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2025
F. Wilhelm (ed.), Ophthalmic Surgery for Beginners, https://doi.org/10.1007/978-3-662-70287-1_1
1
2 F. Wilhelm and S. Priglinger
He should always be aware that he has to justify
this trust and that many sleepless nights before
or after a difficult procedure await him.
An ophthalmologist who wants to become
surgically active must be aware that he is taking on a special responsibility that entails an
additional time commitment, where financial
gain should not be the primary focus!
The approach of starting unprepared with the
attitude “Here I am, now teach me how to operate! (This is required in specialist training.)” is
doomed to fail. A great deal of personal commitment is expected from every “beginner” in surgical activity!
Here, restrictions in the daily routine must
be accepted. A high degree of discipline is necessary. As early as 1583, Georg Bartisch once
listed his requirements for a cataract surgeon
[1]. These are still valid today, at least in part:
Thus, “he should not be greedy and arrogant,
not a drunkard, not presumptuous and boastful
…” Furthermore, Bartisch states that he should
have “fine, subtle, healthy hands and fingers
and be nimble with both hands …” And: “Those
who cannot use their left hand and must operate
the cataract from behind will make the patient
blind … he must be able to draw to obtain
instruments.”
There is no question that manual dexterity is
a basic prerequisite for gentle and thus successful surgery (not only in ophthalmology). To test
this, Blakovics [2] recommended the “matchstick test” for the aspiring surgeon (Fig. 1.1).
The beginner should not despair if it does not
work the first time! People have different predispositions, but fine motor skills can also be trained. It
is often assumed that colleagues who, for example,
play the piano, have a preferred suitability for surgery. Very few people are absolutely unsuitable for
surgical activity due to lack of prior practice. There
are many excellent ophthalmic surgeons who have
never played a musical instrument themselves. A
much higher value is placed on careful and responsible approach in the operating room!
It has proven effective to train finger dexterity
through regular exercises with Qigong balls, for
example (Fig. 1.2).
A particular problem for a young surgeon in
the first days of surgery is how to handle it when
their hands start to tremble during an operation.
This is not unusual! Every surgeon has their own
experiences and recommendations with tremors,
both as a beginner and as an instructor. The beginner should be encouraged at this point that this
phenomenon disappears with increasing experience—but often not completely [6]. Although
Fig. 1.1 The ten-finger test to check manual dexterity. Five matchsticks lying on the table are picked up
one after the other with the ten fingers and held in the
air without losing a single one in the process. If someone performs it flawlessly immediately or after a few
attempts, there is hardly anything to be desired regarding
the hands. [2]
Fig. 1.2 The principle is to rotate the balls clockwise
and counterclockwise, alternately with the left and right
hand
31 Introduction
less common, it can also happen in complicated
situations that even an established surgeon’s hand
trembles briefly. It is important to remain calm
and know how to deal with it. In the early days, it
can be helpful to place the instrumenting hand on
the second hand (Fig. 1.3) or, if necessary, on the
mentor’s hand for reassurance and support [7].
Hans Goldmann is said to have once
remarked, “… by nature, I was not manually
skilled. Therefore, when operating, I had to
carefully consider every step and try to understand it rationally …” [4]. This honest statement contains a lot of truth and underscores the
importance of careful procedure and subtle preparation in every surgical intervention.
The surgeon must have a clear strategy
before starting the procedure. An action
that has been performed can rarely be
undone. There must always be a plan for
how to proceed if the course of the opera-
tion deviates from the plan (Sect. 21.1). In
such moments, it is important to remain
calm and not let time pressure arise,
regardless of the length of the remaining
surgical program.
If it is foreseeable in advance that an operation
will be more complex and take more time, this
should be taken into account from the outset in
terms of duration and positioning in the surgical
program. Such situations pose a particular challenge for everyone, including the assisting staff,
and remain long in the surgeon’s memory. A.
Scharrer aptly summarized: “I hardly remember
details of cataract surgeries that last 10 minutes,
but very well those that took an hour or longer.”
Therefore, the student should adopt a fundamental trait: patience! This applies primarily to every procedure. Haste does not pay
off; it increases the risk of complications,
thereby prolonging the surgery and leading
to a worse surgical outcome! This requirement can be applied to the entire training.
Impatience is a poor advisor here! The German
Ophthalmological Society recommendation
for quality assurance of surgical procedures in
ophthalmology includes a catalog that an ophthalmologist should complete if they want to
operate independently. This catalog serves only
as a guideline, as it is clear that everyone follows an individual path in their training and
must responsibly decide on their surgical activities, because “Patient safety is the top priority
for the DOG. This applies especially to patients
Fig. 1.3 Placing the instrumenting hand on the second hand calms it and significantly reduces the tremor!
4 F. Wilhelm and S. Priglinger
who must undergo surgical procedures.” [3].
Thomas Neuhann aptly summarizes that an ophthalmologist aspiring to a surgical career should
carefully consider whether they can realistically
expect to perform a sufficiently high number
(however high one may set it) of procedures
to become, be, and remain good … or, as the
Americans so nicely say, “An occasional surgeon will never be a really good surgeon.”
In ophthalmic surgery, we learn something new every day! We only get better
if we constantly analyze our own procedures and ask ourselves, “What can I do
better next time to optimally care for my
patients?”
From this, a very important guiding principle
can be derived: After the procedure is always
before the procedure! This includes a self-critical error culture. This means that in the event
of problems or complications, the surgeon must
first look for the cause in themselves and not in
the team. The doctor is always responsible for
everything, including logistics and preoperative
preparation! For postoperative analysis, it has
proven useful, especially in the early days, to
record the procedures on video and then calmly
evaluate them—also together with the mentor.
This confirms the basic prerequisite for successful surgical training in ophthalmology: a fair
partnership between the learner and the instructor. This includes the mentor continuously
accompanying their student on their path, i.e.,
not only guiding them but also preventing mistakes and overcoming complications together. It
is important to motivate the beginner, sometimes
also to slow them down, so that they are not
frustrated by seemingly insurmountable hurdles
and give up. If problems arise intraoperatively or
complications occur, the mentor takes over the
procedure or guides the inexperienced surgeon
in continuing, depending on the situation. This
requires respectful interaction, which should not
be limited to the training period. In the future,
collegial exchange can also be very helpful in
planning procedures or introducing innovations
in both directions. Surgical training also means
an additional burden of time, effort, and logistics
for the teacher. Therefore, every student should
treat their mentor with respect in the future, as
already written in the “Hippocratic Oath.”
Working in the operating room is always a
team effort. Coordination with the anesthetist is
indispensable, which is also a part of the training. Therefore, this concern has been appropriately considered (Chap. 9).
The same applies to coordination with the
assistant staff. Here, everyone must rely on each
other and be able to assess each other’s actions
during a procedure. Typically, the first “steps”
of an ophthalmic surgeon are accompanied by
experienced OR staff who provide important
advice. For beginners, special importance is
placed on instruction in sterile work in the eye
OR (Chap. 3). Every hint is important here and
should be strictly observed. For example, after
theoretical engagement with instrument knowledge (Chap. 5), practical instruction by an assistant experienced in many procedures helps to
facilitate understanding (Fig. 1.4).
The entire team should jointly pay attention
to the responsible use of disposables. This way,
the newcomer in the OR can be introduced early
to cost awareness and environmental conservation in the OR process.
It is also beneficial for the aspiring surgeon to
take on the position of the assistant staff during
procedures under guidance. This contributes to
a better understanding of the process flows and
the activities of the OR team. Thus, the aspiring
surgeon can gain a good overview of the instruments and medical products used in the respective operation (Fig. 1.5).
The assistant staff can also provide valuable
tips when “getting to know” the technology in
the eye OR, especially the operating microscope, the phaco device, as well as the surgeon’s
chair and the OR table (Chap. 4).
In principle, every beginner should be
instructed in the use of the device by a competent representative of the manufacturer. This
instruction must be documented. The service
technicians are specially trained for this purpose.