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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6023_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Foreword 1
- •Foreword 2
- •Preface
- •Contents
- •Abbreviations
- •1.1.1 Pre-Jules Gonin Era
- •1.1.2 Post-Jules Gonin Era
- •2.3 Poiseuille Equation
- •1.6 Summary
- •2.1 Bernoulli’s Principle
- •2.4.1 Surface Tension
- •2.4.2 Interfacial Tension
- •2.5 Boyle’s Law
- •2.6 Fick’s Diffusion Law
- •2.7 Other Physical Principles
- •2.8 Summary
- •3.2.1 Density
- •3.2.2 Buoyancy
- •3.2.3 Interfacial Tension
- •3.2.4 Viscosity
- •3.3 Gases
- •3.3.2 Pneumatic Retinopexy
- •3.3.4 Gas Injection Techniques
- •3.3.6 Precautions After Intravitreal Gas Injection
- •3.4 Silicone Oil
- •3.4.2 Silicone Oil Usage Rate
- •3.5 Heavy Liquid
- •3.6 Summary
- •4.1 Doctor-Patient Interaction
- •4.3.1 Local Anesthesia
- •4.3.2 General Anesthesia
- •4.4 Summary
- •5.1.1 Instrument Diameter
- •5.1.2 Trocar-Cannula System
- •5.1.3 Vitrectomy Machine
- •5.2 Basic Steps
- •5.3.3 Posterior Vitreous Detachment (PVD)
- •5.4 Summary
- •6.3.2 Lincoff’s Rules
- •6.5.2 Subretinal Fluid Drainage
- •6.5.3 Scleral Encircling
- •6.6.1 Persistent Subretinal Fluid
- •6.6.2 Recurrent Retinal Detachment
- •6.6.3 Elevated Intraocular Pressure
- •6.6.4 Anterior Segment Ischemia
- •6.6.6 Extraocular Muscle Dysfunction
- •6.6.7 Refractive Changes
- •6.7 Summary
- •7.3.1 Cutting Central Vitreous
- •7.3.2 Confirming or Creating Posterior Vitreous Detachment
- •7.3.5 Removing Peripheral Vitreous
- •7.3.7 Sealing Retinal Breaks
- •7.3.9 Adjusting Intraocular Pressure
- •7.6.1 Pathological Basis
- •7.6.2 Surgical Principles
- •7.6.3 Surgical Strategies
- •7.9.1 360° Laser Encircling
- •7.9.2 Scleral Buckling
- •7.11 Summary
- •8.1.1 Retinal Proliferative Changes
- •8.1.2 Vitreous Status
- •8.5.1 Segmentation Technique
- •8.5.2 Delamination Technique
- •8.5.3 En Bloc Technique
- •8.6.1 Staining Agents
- •8.6.2 Tamponades
- •8.7.1 Corneal Edema
- •8.7.2 Lens Opacity
- •8.7.3 Pupillary Constriction
- •8.7.4 Iatrogenic Retinal Tears
- •8.7.5 Intraoperative Bleeding
- •8.8.1 Elevated Intraocular Pressure
- •8.8.3 Lens Opacity
- •8.8.5 Anterior Hyaloidal Fibrovascular Proliferation
- •8.8.6 Intraocular Fibrin Syndrome
- •8.8.7 Vitreous Hemorrhage
- •8.9 Summary
- •9.1 Clinical Characteristics
- •9.4.1 Surgical Timing
- •9.4.2 Prognostic Factors
- •9.5 Standard Surgical Steps
- •9.6.1 Triamcinolone Acetonide (TA)
- •9.6.2 Indocyanine Green (ICG)
- •9.6.3 Brilliant Blue G (BBG)
- •9.7.1 Preparation
- •9.7.2 Flap Initiation Methods
- •9.8 Complications
- •9.8.1 Intraoperative Complications
- •9.8.2 Postoperative Complications
- •9.9 Summary
- •10.2.1 Classification
- •10.4 Routine Surgical Procedures
- •10.5.1 Commonly Used Dyes
- •11.1.1.2 Glial Cells
- •11.1.1.3 Macrophages
- •11.1.3 Extracellular Matrix Remodeling
- •11.1.4 Susceptibility Genes
- •11.2.1 Clinical Manifestations
- •11.2.1.1 Characteristic Retinal Changes
- •10.6.2 Flap Initiation Techniques
- •10.6.4 ILM Flap Techniques
- •10.7 Complications
- •10.8 Summary
- •11.1 Etiology
- •11.1.1.1 RPE Cells
- •11.2.1.2 Anterior Segment Manifestations
- •11.2.2 Grading
- •11.4.2.2 Retinotomy
- •11.4.2.3 Retinectomy
- •11.4.3 Radial Retinotomy
- •11.5 Summary
- •12.2.2 Anti-VEGF Intraocular Injection
- •12.2.3 Retinal Laser Photocoagulation
- •12.2.4 Vitreoretinal Surgery
- •12.3.1 Overview
- •12.5 Summary
- •13.8 Showcase Your Art Works
- •13.9 Summary
- •15: Combined Phaco/Vitrectomy
- •15.1 The Surgery
- •15.2 Main Surgical Steps
- •15.3.2 Phacoemulsification
- •15.3.10 Fluid Against Air Exchange
- •15.3.13 Tamponade
- •15.3.14.1 Postoperative Posture
- •15.3.14.2 Complications
- •15.3.14.5 Fractionized PFCL Injection
- •15.3.15 FAQ
- •16.1 Surgery
- •16.2 Main Surgical Steps
- •16.4 FAQ
- •17: Easy Diabetic Retinopathy
- •17.1 Introduction
- •17.3 Vitrectomy
- •17.3.1 The Surgery Step-by-Step
- •17.3.2 Complications
- •17.4 FAQ
- •19.1 Introduction
- •19.3 The Surgery Step-by-Step
- •19.4.1 Encircling Band (cerclage)
- •19.4.3 Pars Plana Vitrectomy
- •19.4.5 Vitreous Base Shaving
- •19.4.6 Membrane Dissection
- •19.4.9 Retinotomy
- •19.4.11 Laser Photocoagulation
- •19.4.13 Tamponade
- •20: Difficult Proliferative Diabetic Retinopathy
- •20.1 Introduction
- •20.2 General Introduction
- •20.3.5 Hemostasis
- •20.3.9 Intravitreal Avastin
- •20.3.10 Internal Postoperative Tamponade
- •20.4 Complications
- •20.5 FAQ
- •Bibliography

Vitreoretinal
Surgery
Underlying Logic and Basic
Skill
ZhaotianZhang
UlrichSpandau
123

Vitreoretinal Surgery

An oil painting by Zao Wou-Ki embodies the harmonious coexistence of tranquility and passion,
as well as the boundless vitality born from their fusion. For us as vitreoretinal surgeons, these same
qualities are essential to our craft.
ZAO Wou-Ki (1920–2013)
25.04.88, 1988
Oil on canvas, 200 × 162cm
Private collection
© Zao Wou-Ki, ProLitteris, Zurich– Reserved rights

ZhaotianZhang • UlrichSpandau
Vitreoretinal Surgery
Underlying Logic andBasic Skill

ZhaotianZhang
Zhongshan Ophthalmic Center
Sun Yat-Sen University
Guangzhou, China
UlrichSpandau
Ophthalmology
University of Uppsala
Uppsala, Uppsala Län, Sweden
ISBN 978-3-032-25270-8 ISBN 978-3-032-25271-5 (eBook)
https://doi.org/10.1007/978-3-032-25271-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2026
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specic statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
If disposing of this product, please recycle the paper.

This book is dedicated to my mentor,
Professor Shaochong Zhang, with thanks for
his kindness and motivation; to my idols, the
painter Zao Wou-Ki and the architect
I.M. Pei, for their inspiration in bridging
East and West; to my dear friends Ulrich
Spandau and Geoffrey Emerson for their
great encouragement; to every colleague at
Zhongshan Ophthalmic Center for their
constant support; and to my family, for their
unfading love.
—Zhaotian Zhang, MD, FASRS

Foreword 1
It is a pleasure to introduce this textbook of retinal surgery techniques for my friends
and colleagues, Zhaotian Zhang and Ulrich Spandau.
This book offers introspective guidance for aspiring retina surgeons as they
embark on and mature in their careers, emphasizing continuous learning, resilience,
and composure. Retina surgery is a eld that blends profound reward with frequent
challenge and periodic failure.
Learning and mastering vitreoretinal surgery requires both solid theoretical
knowledge and extensive practical training. There is no substitute for surgical experience and great mentors. Surgeons must cultivate deep understanding, humility,
and patience—prioritizing careful judgment over speed.
The learning curve of a retinal surgeon is steep. Even steps that seem simple at
rst can hide complexity and risk. An open-minded and pragmatic attitude is essential in surgery, so that we may adapt to new techniques in an ever-changing eld.
Nevertheless, surgical situations are not always predictable. Sometimes a surgeon
can surmount a tricky situation by remembering an old technique, or a case they saw
or heard of from a predecessor.
Vitreoretinal surgery remains a growing and demanding eld. The authors
encourage approaching it with optimism, respect, and a commitment to technical
excellence as well as compassion for patients. As an aspiring surgeon myself, I
appreciate this philosophy and take it to heart. I am also grateful to have this insightful and comprehensive text at my side for moments when I need a suggestion or
even a quick review of the basics. Thank you and bravo, Zhaotian and Ulrich.
GeoffreyG.Emerson, MD, PhD Minneapolis, MN, USA
vii

Foreword 2
In the intricate microcosm of the eye, vitreoretinal surgery represents one of medicine’s most profound intersections of art and science. It is a discipline in constant
ux, where technological innovation and rened clinical wisdom converge to restore
not just sight, but hope for millions. This book, a collaborative endeavor between
leading experts from Uppsala University Hospital and the Zhongshan Ophthalmic
Center (ZOC), is conceived in this very spirit of dynamic evolution.
It is a natural extension of the Bright-X—a cultural and strategic philosophy I
have distilled to guide our mission at ZOC.The name Bright-X encapsulates a dual
commitment: intellectually, it stands for Borrow & Build, Road & Reach,
Intelligence & Integration, Global & Governance, Health & Happy, Technology &
Talent, and Cross & Unknown. Politically, it resonates with a broader vision: Belt &
Road Initiative: Great Health Together. It is our belief that by illuminating the path
for global ophthalmology, we can advance the health of nations along the Belt and
Road and beyond, fostering a world where shared knowledge leads to shared
well-being.
As the largest public ophthalmic hospital in China, the sole ophthalmic specialty
hospital administered by China’s National Health Commission, and the World
Health Organization Collaborating Center for Eye Care and Vision in China, ZOC
has long been recognized as a leader in ophthalmic care. In November 2024, we
took another historic step forward with the ofcial inauguration of the International
Ophthalmology Medical Center, a landmark initiative designed to serve as a global
platform for cutting-edge research, talent cultivation, and cross-border collaboration in eye health.
Our commitment to research excellence is reected in our sustained global
impact. According to the Nature Index annual rankings, ZOC has ranked rst in the
world among all ophthalmic institutions for three consecutive years since 2023.
This unprecedented achievement in both Health Sciences and Biological Sciences
underscores our dedication to advancing the frontiers of ophthalmic science and
translating discovery into clinical impact on a global scale.
ix

x
Foreword 2
Beyond our research and clinical achievements, ZOC takes pride in its role as a
bridge connecting ophthalmic communities across continents. As the headquarters
of the Asia-Pacic Academy of Ophthalmology and the President Ofce of the
Afro-Asian Council of Ophthalmology, we have long served as a convening force
for dialogue and collaboration among eye care professionals across Asia, Africa,
Europe, and the Americas.
The foundation of this work is rooted in Borrow & Build. It respectfully borrows
from the foundational knowledge laid by pioneers while building upon it with the
rich, collective clinical experience of both Chinese and European masters. By weaving together the vast surgical volumes seen at ZOC with the rened techniques of
Uppsala, we have built a guide that transcends any single institution’s perspective.
This book, therefore, paves a new Road & Reach. It charts a clear educational
pathway for surgeons at every level, from the novice grasping the underlying logic
of vitrectomy to the seasoned expert navigating complex pathologies. Our reach
extends from our operating rooms in Guangzhou and Uppsala to the global community, embodying the “Road” in our philosophy—connecting colleagues and
patients across continents in a shared pursuit of excellence.
This endeavor is powered by Intelligence & Integration. The book integrates core
physical principles with cutting-edge surgical methodologies. But more than that, it
reects a deep integration of minds—combining European rigor with Asian innovation to foster the clinical intelligence that denes wise, adaptable surgeons.
As a World Health Organization Collaborating Center and the headquarters of
leading international ophthalmic societies, ZOC bears a profound responsibility in
the realm of Global & Governance. This book is a tangible expression of our commitment to global eye health governance. By sharing knowledge and setting educational benchmarks, we actively contribute to the “Great Health Together” vision,
fostering the cross-border collaboration essential to addressing the universal challenge of blindness.
Ultimately, our goal is Health & Happy. Every principle detailed, every technique analyzed, is in service of this singular outcome: restoring healthy vision and,
with it, the happiness and quality of life for patients worldwide.
This achievement would not be possible without our most valuable asset: our
people. It underscores the critical importance of Technology & Talent. While we
embrace technological advancement, we rmly believe it is most powerful when
wielded by talented, well-trained hands—the very hands this book seeks to cultivate.
Finally, this project is a venture into the Cross & Unknown. It is a cross-cultural
partnership that enriches us all. By venturing into the unknown territories of complex diseases together, we model the very collaboration that will unlock the future
of medicine.
Published with Springer Nature, this book marks a signicant milestone in
ZOC’s journey as a global leader in ophthalmology. It is our hope that Vitreoretinal
Surgery: Underlying Logic and Basic Skill serves not as an endpoint, but as a

Foreword 2
xi
catalyst for future discoveries. At ZOC, we stand ready to deepen these global partnerships, to share Chinese wisdom and Asian solutions, and to continue our shared
journey toward a world where no one is needlessly blind.
Hao-tianLin, MDDirector, Zhongshan Ophthalmic Center (ZOC)
President, Zhongshan Ophthalmic Center Hospital
Sun Yat-sen University
Guangzhou, China
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